2015 Prescription Drug Formular and Network Pharmacies

Transcription

2015
Prescription Drug Formulary
and Network Pharmacies
Offered by
H5826_MA_047_2015_v_02_FormularyPharmacy3tier Accepted
Community HealthFirst™ Medicare Advantage Plans
2015 Prescription Drug Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
HPMS approved formulary file submission, ID 00015060, version 6, approved
08/08/2014
This formulary was updated on 08/22/2014. For more recent information or other
questions, please contact Community Health Plan of Washington at 1-800-944-1247 or
for TTY users, Dial 7-1-1, 7 days a week, 8am – 8pm or visit www.healthfirst.chpw.org.
Note to existing members: This formulary has changed since last year. Please review
this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Community Health
Plan of Washington.. When it refers to “plan” or “our plan,” it means Community
HealthFirst™ Medicare Advantage Plans.
This document includes a list of the drugs (formulary) for our plan which is current as of
October 1, 2014. For an updated formulary, please contact us. Our contact information,
along with the date we last updated the formulary, appears on the front and back cover
pages.
You must generally use network pharmacies to use your prescription drug benefit.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on
January 1, 2015 and from time to time during the year.
Community Health Plan of Washington is a Coordinated Care Plan with a Medicare
Advantage contract. Enrollment in Community Health Plan of Washington depends
on contract renewal.
H5826_MA_047_2015_v_02_FormularyPharmacy3tier Accepted
H5826_MA_047_2015_V_03_FormularyPharmacy3Tier
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What is the Community HealthFirst Medicare Advantage Plans
Formulary?
A formulary is a list of covered drugs selected by our plan in consultation with a team of
health care providers, which represents the prescription therapies believed to be a
necessary part of a quality treatment program. Our plan will generally cover the drugs
listed in our formulary as long as the drug is medically necessary, the prescription is
filled at a Community HealthFirst Medicare Advantage Plans network pharmacy, and
other plan rules are followed. For more information on how to fill your prescriptions,
please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the
beginning of the year, we will not discontinue or reduce coverage of the drug during the
2015 coverage year except when a new, less expensive generic drug becomes
available or when new adverse information about the safety or effectiveness of a drug is
released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain
available at the same cost-sharing for those members taking it for the remainder of the
coverage year. We feel it is important that you have continued access for the remainder
of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your
safety.
If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or
step therapy restrictions on a drug [or move a drug to a higher cost-sharing tier], we
must notify affected members of the change at least 60 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time
the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer
removes the drug from the market, we will immediately remove the drug from our
formulary and provide notice to members who take the drug. The enclosed formulary is
current as of October 1, 2014. To get updated information about the drugs covered by
Community HealthFirst Medicare Advantage Plans, please contact us. Our contact
information appears on the front and back cover pages.
We regularly review and update the formulary. The notice of these changes is posted
monthly at www
www.healthfirst.chpw
.healthfirst.chpw.org/for-members-prescription-coverage/formulary
.org/for-members-prescription-coverage/formulary..
How do I use the Formulary?
There are two ways to find your drug within the formulary:
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Medical Condition
The formulary begins on page 14.The drugs in this formulary are grouped into
categories depending on the type of medical conditions that they are used to treat.
For example, drugs used to treat a heart condition are listed under the category,
“Cardiovascular, Hypertension/ Lipids”. If you know what your drug is used for, look
for the category name in the list that begins on page number 14. Then look under
the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the
Index that begins on page 67. The Index provides an alphabetical list of all of the
drugs included in this document. Both brand name drugs and generic drugs are
listed in the Index. Look in the Index and find your drug. Next to your drug, you will
see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Community HealthFirst Medicare Advantage Plans cover both brand name drugs
and generic drugs. A generic drug is approved by the FDA as having the same
active ingredient as the brand name drug. Generally, generic drugs cost less than
brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These
requirements and limits may include:
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Prior Authorization: Community HealthFirst Medicare Advantage Plans require
you or your physician to get prior authorization for certain drugs. This means that
you will need to get approval from our plan before you fill your prescriptions. If
you don’t get approval, our plan may not cover the drug.
•
Quantity Limits: For certain drugs, Community HealthFirst Medicare Advantage
Plans limit the amount of the drug that our plan will cover. For example, our plan
provides 68 tablets per prescription for bupropion hcl. This may be in addition to
a standard one-month or three-month supply.
•
Step Therapy: In some cases, Community HealthFirst Medicare Advantage
Plans require you to first try certain drugs to treat your medical condition before
we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, our plan may not cover Drug B unless you try
Drug A first. If Drug A does not work for you, we will then cover Drug B.
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You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 14. You can also get more information about the
restrictions applied to specific covered drugs by visiting our Web site. We have posted
on line documents that explain our prior authorization and step therapy restrictions. You
may also ask us to send you a copy. Our contact information, along with the date we
last updated the formulary, appears on the front and back cover pages.
You can ask Community HealthFirst Medicare Advantage Plans to make an exception
to these restrictions or limits or for a list of other, similar drugs that may treat your health
condition. See the section, “How do I request an exception to the Community
HealthFirst Medicare Advantage Plans’ formulary?” on page 4 for information about how
to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first
contact Member Services and ask if your drug is covered.
If you learn that our plan does not cover your drug, you have two options:
•
You can ask Member Services for a list of similar drugs that are covered by
Community HealthFirst Medicare Advantage Plans. When you receive the list,
show it to your doctor and ask him or her to prescribe a similar drug that is
covered by our plan.
•
You can ask Community HealthFirst Medicare Advantage Plans to make an
exception and cover your drug. See below for information about how to request
an exception.
How do I request an exception to the Community HealthFirst
Medicare Advantage Plans’ Formulary?
You can ask us to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
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You can ask us to cover a drug even if it is not on our formulary. If approved, this
drug will be covered at a pre-determined cost-sharing level, and you would not
be able to ask us to provide the drug at a lower cost-sharing level.
You can ask us to waive coverage restrictions or limits on your drug. For
example, for certain drugs, our plan limits the amount of the drug that we will
cover. If your drug has a quantity limit, you can ask us to waive the limit and
cover a greater amount.
Generally, Community HealthFirst Medicare Advantage Plans will only approve your
request for an exception if the alternative drugs included on the plan’s formulary or
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additional utilization restrictions would not be as effective in treating your condition
and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or
utilization restriction exception. When you request a formulary or utilization
restriction exception you should submit a statement from your prescriber or
physician supporting your request. Generally, we must make our decision within 72
hours of getting your prescriber’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously harmed
by waiting up to 72 hours for a decision. If your request to expedite is granted, we must
give you a decision no later than 24 hours after we get a supporting statement from your
doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs
or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on our formulary but your ability to get it
is limited. For example, you may need a prior authorization from us before you can fill
your prescription. You should talk to your doctor to decide if you should switch to an
appropriate drug that we cover or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action
for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is
limited, we will cover a temporary 34-day supply (unless you have a prescription written
for fewer days) when you go to a network pharmacy. After your first 34-day supply, we
will not pay for these drugs, even if you have been a member of the plan less than 90
days.
If you are a resident of a long-term care facility, we will allow you to refill your
prescription until we have provided you with a 91 and may be up to 98-day transition
supply, consistent with dispensing increment, (unless you have a prescription written for
fewer days). We will cover more than one refill of these drugs for the first 90 days you
are a member of our plan. If you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90days of membership in our
plan, we will cover a 34-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
Community HealthFirst Medicare Advantage Plans will extend an override to current
enrollees who experience level of care changes, such as a change in treatment
settings. This allowance will be made for the 30-day period following the level of care
change.
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For more information
For more detailed information about your Community HealthFirst Medicare Advantage
Plans prescription drug coverage, please review your Evidence of Coverage and other
plan materials.
If you have questions about Community HealthFirst Medicare Advantage Plans, please
contact us. Our contact information, along with the date we last updated the formulary,
appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call
Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY
users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Community HealthFirst Medicare Advantage Plans Formulary
The formulary that begins on page14 provides coverage information about the drugs
covered by our plan. If you have trouble finding your drug in the list, turn to the Index
that begins on page 67.
The first column of the chart lists the drug name. Brand name drugs are capitalized
(e.g., CRESTOR and generic drugs are listed in lower-case italics (e.g., simvastatin.)
The information in the Requirements/Limits column tells you if Community HealthFirst
Medicare Advantage Plans have any special requirements for coverage of your drug.
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Formulario de medicamentos recetados para el año 2015
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN
SOBRE ALGUNOS DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Este formulario se actualizó el 08/22/2014. Si desea obtener información más reciente
o si tiene otras preguntas, póngase en contacto con Community Health Plan of
Washington llamando al número 1-800-944-1247 (para usuarios de TTY, marque 7-1-1)
de 8 a. m. a 8 p. m., los 7 días de la semana, o visitando www.healthfirst.chpw.org.
Nota para los miembros actuales: Este formulario ha cambiado con respecto al año
pasado. Revise este documento para asegurarse de que aún contiene los
medicamentos que toma.
Cuando esta lista de medicamentos (formulario) hace referencia a “nosotros” “nos” o
“nuestro”, se refiere a Community Health Plan of Washington. Cuando se menciona “el
plan” o “nuestro plan”, se hace referencia a Community HealthFirst™ Medicare
Advantage Plans.
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la
cual entrará en vigencia el 1.º de octubre de 2014. Para obtener un formulario
actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la
fecha de la última actualización del formulario, aparece en las páginas de la portada y
la contraportada.
Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de
medicamentos recetados. Los beneficios, el formulario, la red de farmacias o los
copagos/el coseguro podrían cambiar el 1.º de enero de 2015 y algunas veces durante
el año.
Community Health Plan of Washington es un plan de atención coordinada que tiene un
contrato con Medicare Advantage. La inscripción en Community Health Plan of
Washington depende de la renovación del contrato.
¿Qué es el formulario de Community HealthFirst Medicare Advantage
Plans?
Un formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan
con la colaboración de un equipo de proveedores de cuidado médico, que representa
los tratamientos con medicamentos recetados que se consideran necesarios en un
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programa de tratamiento de calidad. Por lo general, nuestro plan cubrirá los
medicamentos incluidos en el formulario siempre que el medicamento recetado sea
médicamente necesario, se surta en una farmacia de la red de Community HealthFirst
Medicare Advantage Plans y se respeten otras normas del plan. Si desea más
información sobre cómo surtir sus medicamentos recetados, consulte la Evidencia de
cobertura.
¿Puede cambiar el formulario (lista de medicamentos)?
Por lo general, si toma un medicamento de nuestro formulario durante el año 2015 que
estaba cubierto al comienzo del año, no discontinuaremos ni reduciremos la cobertura
del medicamento durante el año de cobertura 2015, excepto cuando esté disponible un
nuevo medicamento genérico de menor costo o cuando se dé a conocer nueva
información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de
cambios en el formulario, como por ejemplo, la eliminación de un medicamento de
nuestro formulario, no afectarán a los miembros que actualmente estén tomando el
medicamento. Continuará disponible al mismo costo compartido para aquellos
miembros que estén tomándolo por el resto del año de cobertura. Consideramos que
es importante que tenga acceso continuo a los medicamentos del formulario que
estaban disponibles cuando eligió nuestro plan durante el resto del año de cobertura,
salvo en los casos en los que usted podría ahorrar más dinero o que nosotros
podríamos garantizarle su seguridad.
Si retiramos medicamentos de nuestro formulario, [o] agregamos autorizaciones
previas, límites de cantidad o restricciones en tratamientos escalonados en relación con
un medicamento [o si pasamos un medicamento a un nivel superior de costo
compartido], debemos notificar sobre el cambio a los miembros afectados al menos
60 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite un
resurtido del medicamento, momento en el cual el miembro recibirá un suministro del
medicamento para 60 días. Si la Administración de Drogas y Alimentos (Food and Drug
Administration, FDA) considera que un medicamento de nuestro formulario es inseguro
o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho
medicamento de nuestro formulario y notificaremos a los miembros que lo estén
tomando. El formulario adjunto estará vigente a partir del 1.º de octubre de 2014.Si
desea recibir información actualizada sobre los medicamentos cubiertos por
Community HealthFirst Medicare Advantage Plans, comuníquese con nosotros.Nuestra
información de contacto figura en las páginas de la portada y la contraportada de este
folleto.
El formulario se revisa y actualiza con regularidad. Las notificaciones de cambios se
publican mensualmente en www.healthfirst.chpw.org/for-members-prescriptioncoverage/formulary.
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¿Cómo se utiliza el formulario?
Hay dos maneras de encontrar un medicamento en el formulario:
Afección médica
El formulario comienza en la página 14. Los medicamentos en este formulario se
agrupan en categorías según el tipo de afección médica para cuyo tratamiento se
los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección
cardíaca se incluyen en la categoría “Cardiovascular, hipertensión/lípidos”. Si sabe
para qué se utiliza un medicamento, busque el nombre de la categoría en la lista
que comienza en la página 14. Luego, busque el medicamento por nombre de
categoría.
Listado alfabético
Si no está seguro de qué categoría debe consultar, busque el medicamento en el
Índice que comienza en la página 67. Allí encontrará una lista alfabética de todos
los medicamentos incluidos en este documento. En el Índice figuran tanto los
medicamentos de marca como los genéricos. Revise el Índice y busque el
medicamento. Junto al medicamento, verá el número de página donde puede
encontrar información acerca de la cobertura. Vaya a la página que figura en el
Índice y busque el nombre del medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Community HealthFirst Medicare Advantage Plans cubre tanto medicamentos de
marca como genéricos. Un medicamento genérico está aprobado por la FDA, dado
que se considera que tiene el mismo principio activo que el medicamento de marca.
Por lo general, los medicamentos genéricos cuestan menos que los medicamentos
de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de
cobertura. Estos requisitos y límites pueden incluir:
•
Autorización previa: Community HealthFirst Medicare Advantage Plans exige
que usted o su médico obtengan una autorización previa para determinados
medicamentos. Esto significa que necesitará contar con la aprobación de
nuestro plan antes de surtir sus medicamentos recetados. Si no consigue la
autorización, es posible que nuestro plan no cubra el medicamento.
•
Límites de cantidad: Para ciertos medicamentos,
Community HealthFirst Medicare Advantage Plans limitan la cantidad del
medicamento que cubrirán. Por ejemplo, nuestro plan proporciona
68 comprimidos por receta para clorhidrato de bupropión. Esto puede ser
complementario a un suministro estándar para uno o tres meses.
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Tratamiento escalonado: En algunos casos,
Community HealthFirst Medicare Advantage Plans requieren que usted pruebe
primero ciertos medicamentos para tratar su enfermedad antes de que cubramos
otro medicamento para esa enfermedad. Por ejemplo, si tanto el medicamento A
como el medicamento B tratan su afección médica, es posible que nuestro plan
no cubra el medicamento B a menos que usted pruebe primero el
medicamento A. Si el medicamento A no funciona para usted, entonces
cubriremos el medicamento B.
Puede averiguar si su medicamento tiene requisitos o límites adicionales buscando en
el formulario que comienza en la página 14. También puede obtener más información
sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro
sitio web. Hemos publicado documentos en línea donde se explican nuestras
restricciones para los tratamientos escalonados y el proceso de autorización previa.
También puede solicitar que le enviemos una copia. Nuestra información de contacto,
junto con la fecha de la última actualización del formulario, aparece en las páginas de la
portada y la contraportada.
Puede pedir a Community HealthFirst Medicare Advantage Plans que haga una
excepción a estas restricciones o límites, o puede solicitar una lista de otros
medicamentos similares que podrían tratar su afección médica. Para obtener
información sobre cómo solicitar una excepción, consulte la sección titulada “¿Cómo
puedo solicitar que se haga una excepción al formulario de Community HealthFirst
Medicare Advantage Plans?” en la página 4.
¿Qué pasa si mi medicamento no está en el formulario?
Si el medicamento que toma no está incluido en este formulario (lista de medicamentos
cubiertos), primero debe ponerse en contacto con el Servicio para los miembros y
preguntar si su medicamento está cubierto.
Si resulta que nuestro plan no cubre el medicamento que toma, tiene dos alternativas:
•
Puede solicitar al Servicio para los miembros una lista de medicamentos
similares cubiertos por Community HealthFirst Medicare Advantage Plans.
Cuando reciba la lista, muéstresela a su médico y pídale que le recete un
medicamento similar que esté cubierto por nuestro plan.
•
Puede solicitarle a Community HealthFirst Medicare Advantage Plans que haga
una excepción y cubra el medicamento. Consulte más abajo para obtener
información sobre cómo solicitar una excepción.
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¿Cómo puedo solicitar que se haga una excepción al formulario de
Community HealthFirst Medicare Advantage Plans?
Puede solicitar que hagamos una excepción a nuestras normas de cobertura. Hay
varios tipos de excepciones que puede solicitar.
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Puede pedir que cubramos un medicamento, incluso si no está en nuestro
formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo
compartido predeterminado, y usted no podrá pedir que proporcionemos el
medicamento a un nivel de costo compartido menor.
Puede pedir que no apliquemos restricciones o límites de cobertura al
medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la
cantidad del medicamento que cubriremos. Si el medicamento tiene un límite de
cantidad, puede pedir que hagamos una excepción al límite y cubramos una
cantidad mayor.
Por lo general, Community HealthFirst Medicare Advantage Plans solo aprobará su
solicitud de excepción si los medicamentos alternativos incluidos en el formulario del
plan o las restricciones de uso adicionales no fueran tan efectivos para tratar su
afección o le provocarán efectos médicos adversos.
Comuníquese con nosotros para solicitar una decisión de cobertura inicial para una
excepción al formulario o a las restricciones de utilización. Cuando solicita una
excepción al formulario o a la restricción de uso, debe presentar una declaración
de su médico o de la persona autorizada a dar recetas que respalde su solicitud.
Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha
de haber recibido la declaración que respalde su solicitud por parte de la persona
autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su
médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar
gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos
comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber
recibido la declaración de respaldo de la persona autorizada a dar recetas.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de
los medicamentos que tomo o la solicitud de excepción?
Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando
medicamentos que no están incluidos en el formulario. También es posible que esté
tomando un medicamento incluido en el formulario, pero que su capacidad de
conseguirlo sea limitada. Por ejemplo, podría necesitar nuestra autorización previa
antes de poder surtir un medicamento recetado. Consulte con su médico para decidir si
debe cambiar el medicamento por uno adecuado que cubramos o solicitar una
excepción al formulario para que cubramos el medicamento que toma. Mientras evalúa
con el médico el procedimiento adecuado a seguir en su caso, podemos cubrir el
medicamento en determinadas situaciones durante los primeros 90 días en que usted
sea miembro de nuestro plan.
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Para cada uno de los medicamentos que no están incluidos en el formulario, o si su
capacidad para conseguirlos es limitada, cubriremos un suministro temporal para
34 días (a menos que tenga una receta para menos días) cuando acuda a una farmacia
de la red. Después del primer suministro para 34 días, no seguiremos pagando este
medicamento, incluso si ha sido miembro del plan durante menos de 90 días.
Si reside en un centro de atención a largo plazo, le permitiremos resurtir su receta
hasta que le hayamos provisto un suministro de transición de entre 91 y 98 días como
máximo, de manera coherente con el incremento de provisión (a menos que tenga una
receta para menos días). Cubriremos más de un resurtido de estos medicamentos
durante los primeros 90 días en que usted sea miembro del plan. Si necesita un
medicamento que no está en el formulario, o si su capacidad para conseguirlo es
limitada, pero ya pasaron los primeros 90 días de afiliación en nuestro plan, cubriremos
un suministro de emergencia del medicamento para 34 días (a menos que tenga una
receta para menos días) mientras solicita una excepción al formulario.
Community HealthFirst Medicare Advantage Plans otorgará una anulación a los
inscritos actuales que experimenten cambios en su nivel de atención, como un cambio
en los entornos de tratamiento. Este recurso se mantendrá durante el período de
30 días posterior al cambio en el nivel de atención.
Si desea más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados
de Community HealthFirst Medicare Advantage Plans, consulte la Evidencia de
cobertura y el resto de la documentación del plan.
Si tiene alguna pregunta sobre Community HealthFirst Medicare Advantage Plans,
comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la
última actualización del formulario, aparece en las páginas de la portada y la
contraportada.
Si tiene preguntas generales sobre su cobertura para medicamentos recetados de
Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), durante las
24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-4862048. O visite http://www.medicare.gov.
Formulario de Community HealthFirst Medicare Advantage Plans
El formulario que comienza en la página 14 proporciona información de cobertura sobre
los medicamentos cubiertos por nuestro plan. Si tiene alguna dificultad para encontrar
un medicamento en la lista, consulte el Índice que comienza en la página 67.
En la primera columna de la tabla se menciona el nombre del medicamento. Los
medicamentos de marca están en letra mayúscula (p. ej., CRESTOR), y los
medicamentos genéricos están en letra minúscula y cursiva (p. ej., simvastatina).
La información incluida en la columna Requisitos/límites indica si
Community HealthFirst Medicare Advantage Plans tiene algún requisito especial para la
cobertura del medicamento.
12
Below is a list of abbreviations that may appear on the following pages in the
Requirements/Limits column that tells you if there are any special requirements for
coverage of your drug.
List of Abbreviations
B/D PA: This prescription drug may be covered under Medicare Part B or D depending
upon the circumstances. Information may need to be submitted describing the use and
setting of the drug to make the determination.
LA: Limited Availability. This prescription may be available only at certain pharmacies.
For more information, please call Customer Service.
MO: Mail-Order Drug. This prescription drug is available through our mail-order service,
as well as through our retail network pharmacies. Consider using mail order for your
long-term (maintenance) medications (such as high blood pressure medications). Retail
network pharmacies may be more appropriate for short-term prescriptions (such as
antibiotics).
PA: Prior Authorization. The Plan requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval before you
fill your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will
cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, we may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover
Drug B.
13
13
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
ANTI - INFECTIVES
nystatin oral tablet
1
MO
ANTIFUNGAL AGENTS
SPORANOX ORAL
SOLUTION
2
MO
terbinafine oral
1
MO
voriconazole
intravenous
1
MO
3
MO
ABELCET
3
B/D PA; MO
AMBISOME
3
B/D PA; MO
amphotericin b
1
B/D PA; MO
CANCIDAS
3
B/D PA; MO
clotrimazole mucous
membrane
1
MO
voriconazole oral
suspension for
reconstitution
fluconazole
1
MO
3
MO
fluconazole in
dextrose(iso-o)
intravenous
piggyback 400
mg/200 ml
1
voriconazole oral
tablet 200 mg
voriconazole oral
tablet 50 mg
1
MO
flucytosine
3
MO
abacavir
1
MO
griseofulvin
microsize
1
MO
abacavirlamivudinezidovudine
3
MO
griseofulvin
ultramicrosize
1
MO
acyclovir oral
1
MO
itraconazole
1
MO; QL (120
per 30 days)
acyclovir sodium
intravenous solution
1
B/D PA
ketoconazole oral
1
MO
adefovir
3
MO
LAMISIL ORAL
GRANULES IN
PACKET
2
MO
amantadine hcl oral
1
MO
APTIVUS ORAL
CAPSULE
3
MO
MYCAMINE
INTRAVENOUS
RECON SOLN 100
MG
3
MO
APTIVUS ORAL
SOLUTION
3
ATRIPLA
3
MO
MYCAMINE
INTRAVENOUS
RECON SOLN 50
MG
2
BARACLUDE
ORAL SOLUTION
2
MO
BARACLUDE
ORAL TABLET
3
MO
NOXAFIL ORAL
3
MO
cidofovir
3
B/D PA; MO
nystatin oral
suspension
1
MO
COMPLERA
3
MO
CRIXIVAN
2
MO
ANTIVIRALS
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
14
14
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
didanosine
Drug
Tier
Requirements
/Limits
1
MO
2
MO
EDURANT
3
MO
EMTRIVA
2
MO
KALETRA ORAL
TABLET 100-25
MG
EPIVIR ORAL
SOLUTION
2
MO
KALETRA ORAL
TABLET 200-50
MG
3
MO
EPIVIR HBV
ORAL SOLUTION
2
MO
lamivudine
1
MO
EPZICOM
3
MO
lamivudinezidovudine
1
MO
famciclovir
1
MO
2
MO
foscarnet
1
B/D PA; MO
LEXIVA ORAL
SUSPENSION
FUZEON
3
MO
3
MO
ganciclovir sodium
1
MO
LEXIVA ORAL
TABLET
INTELENCE ORAL
TABLET 100 MG,
200 MG
3
MO
MODERIBA
1
MO
1
MO
INTELENCE ORAL
TABLET 25 MG
2
MODERIBA DOSE
PACK ORAL
TABLETS,DOSE
PACK 400 MG (7)400 MG (7)
INVIRASE ORAL
CAPSULE
2
MO
3
MO
INVIRASE ORAL
TABLET
3
MO
ISENTRESS ORAL
POWDER IN
PACKET
2
MODERIBA DOSE
PACK ORAL
TABLETS,DOSE
PACK 600 MG (7)600 MG (7)
nevirapine
1
MO
NORVIR
2
MO
ISENTRESS ORAL
TABLET
3
MO
OLYSIO
3
PA; MO
ISENTRESS ORAL
TABLET,CHEWAB
LE 100 MG
3
MO
PREZISTA ORAL
SUSPENSION
3
MO
2
MO
ISENTRESS ORAL
TABLET,CHEWAB
LE 25 MG
2
MO
PREZISTA ORAL
TABLET 150 MG,
75 MG
3
MO
KALETRA ORAL
SOLUTION
3
MO
PREZISTA ORAL
TABLET 600 MG,
800 MG
RELENZA
DISKHALER
2
MO; QL (60
per 180 days)
RESCRIPTOR
2
MO
of this table.
15
15
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTIO
N
2
MO; QL (600
per 180 days)
TIVICAY
3
MO
TRUVADA
3
MO
TYZEKA
3
MO
valacyclovir
1
MO; QL (30
per 30 days)
VALCYTE
3
MO
VICTRELIS
3
MO
VIDEX 2 GRAM
PEDIATRIC
2
MO
VIRACEPT
3
MO
VIRAMUNE XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
100 MG
2
MO
VIRAZOLE
3
MO
RETROVIR
INTRAVENOUS
2
REYATAZ
3
MO
RIBAPAK DOSE
PACK ORAL
TABLETS,DOSE
PACK 400-400 MG
(28)-MG (28), 600400 MG (28)-MG
(28), 600-600 MG
(28)-MG (28)
3
MO
RIBASPHERE
ORAL CAPSULE
1
MO
RIBASPHERE
ORAL TABLET
200 MG
1
MO
RIBASPHERE
ORAL TABLET
400 MG
1
RIBASPHERE
ORAL TABLET
600 MG
3
ribavirin
1
MO
VIREAD
3
MO
rimantadine
1
MO
2
MO
SELZENTRY
3
MO
ZIAGEN ORAL
SOLUTION
SOVALDI
3
PA; MO
zidovudine
1
MO
stavudine
1
MO
STRIBILD
3
MO
cefaclor
1
MO
SUSTIVA
2
MO
cefadroxil
1
MO
SYNAGIS
INTRAMUSCULA
R SOLUTION 50
MG/0.5 ML
3
MO; LA
cefazolin injection
recon soln 1 gram
1
MO
1
TAMIFLU ORAL
CAPSULE 30 MG
2
MO; QL (84
per 180 days)
cefazolin injection
recon soln 10 gram,
500 mg
1
TAMIFLU ORAL
CAPSULE 45 MG,
75 MG
2
MO; QL (42
per 180 days)
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml
MO
CEPHALOSPORINS
MO
of this table.
16
16
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO
SUPRAX ORAL
CAPSULE
2
MO
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 100 MG/5 ML,
200 MG/5 ML
2
MO
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 500 MG/5 ML
2
SUPRAX ORAL
TABLET
2
MO
SUPRAX ORAL
TABLET,CHEWAB
LE
2
MO
TEFLARO
2
MO
cefdinir
1
cefditoren pivoxil
1
cefepime
1
cefotaxime injection
recon soln 1 gram, 2
gram, 500 mg
1
cefotaxime injection
recon soln 10 gram
1
cefotetan
1
cefoxitin intravenous
recon soln 1 gram
1
cefoxitin intravenous
recon soln 10 gram,
2 gram
1
cefoxitin in dextrose,
iso-osm
1
cefpodoxime
1
MO
cefprozil
1
MO
ceftazidime injection
recon soln 1 gram, 6
gram
1
ceftazidime injection
recon soln 2 gram
1
ceftriaxone injection
recon soln 10 gram
1
ceftriaxone injection
recon soln 250 mg,
500 mg
1
ceftriaxone
intravenous
1
MO
cefuroxime axetil
1
MO
cefuroxime sodium
injection
1
MO
cefuroxime sodium
intravenous
1
cephalexin
1
MO
MO
MO
MO
MO
MO
Drug
Tier
Requirements
/Limits
ERYTHROMYCINS / OTHER
MACROLIDES
azithromycin
1
MO
clarithromycin
1
MO
E.E.S. 400
1
MO
E.E.S. GRANULES
2
MO
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 250 MG,
333 MG
1
MO
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
2
MO
ERYPED 200
2
MO
ERYPED 400
2
MO
ERYTHROCIN
INTRAVENOUS
RECON SOLN 500
MG
2
of this table.
17
17
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
ERYTHROCIN (AS
STEARATE)
1
MO
CLINDAMYCIN
PEDIATRIC
1
erythromycin oral
tablet
1
MO
1
MO
erythromycin
ethylsuccinate oral
1
MO
clindamycin
phosphate
600 mg/4 ml
erythromycinsulfisoxazole
1
MO
COARTEM
2
MO
colistin
(colistimethate na)
1
MO
CUBICIN
3
MO
dapsone
2
MO
DARAPRIM
2
MO
DORIBAX
INTRAVENOUS
SUSPENSION FOR
RECONSTITUTIO
N 500 MG
2
ethambutol
1
MO
gentamicin injection
solution 40 mg/ml
1
MO
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml, 60 mg/50
ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
1
gentamicin sulfate
(pf) intravenous
solution 80 mg/8 ml
1
hydroxychloroquine
oral
1
MO
imipenem-cilastatin
1
MO
INVANZ
INJECTION
2
MO
isoniazid injection
1
isoniazid oral
1
MISCELLANEOUS ANTIINFECTIVES
ALBENZA
2
MO
ALINIA
2
MO
amikacin injection
solution 500 mg/2 ml
1
MO
atovaquone
3
MO
atovaquoneproguanil
1
MO
aztreonam injection
recon soln 1 gram
1
MO
BACIIM
1
bacitracin
intramuscular
1
MO
BETHKIS
3
B/D PA; MO;
QL (224 per
28 days)
CAPASTAT
2
CAYSTON
3
chloramphenicol sod
succinate
1
chloroquine
phosphate oral
1
MO
clindamycin hcl
1
MO
clindamycin in
dextrose 5 %
1
MO
MO; LA; QL
(84 per 28
days)
MO
of this table.
18
18
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
mefloquine
Drug
Tier
Requirements
/Limits
1
MO
1
MO
meropenem
intravenous recon
soln 500 mg
1
MO
tobramycin in 0.9 %
nacl intravenous
piggyback 80
mg/100 ml
metronidazole oral
capsule
1
tobramycin sulfate
injection solution
1
MO
metronidazole oral
tablet
1
MO
TRECATOR
2
MO
TYGACIL
2
MO
metronidazole in
nacl (iso-os)
1
MO
XIFAXAN ORAL
TABLET 200 MG
2
MO
NEBUPENT
2
B/D PA; MO;
QL (6 per 28
days)
XIFAXAN ORAL
TABLET 550 MG
3
MO
neomycin
1
MO
3
MO
paromomycin
1
MO
PASER
2
MO
ZYVOX
INTRAVENOUS
PARENTERAL
SOLUTION 600
MG/300 ML
PENTAM
2
MO
ZYVOX ORAL
3
MO
polymyxin b sulfate
1
MO
PENICILLINS
PRIFTIN
2
MO
amoxicillin
1
MO
primaquine
2
MO
1
MO
pyrazinamide
1
MO
amoxicillin-pot
clavulanate
quinine sulfate
1
MO
ampicillin
1
MO
rifabutin
1
MO
1
MO
rifampin
1
MO
SIRTURO
3
MO; LA
ampicillin sodium
injection recon soln
1 gram, 10 gram,
125 mg
streptomycin
intramuscular
2
MO
1
STROMECTOL
2
MO
ampicillin-sulbactam
15 gram
SYNERCID
3
1
tinidazole
1
MO
ampicillin-sulbactam
3 gram
tobramycin in 0.225
% nacl
3
B/D PA; MO;
QL (280 per
28 days)
MO
of this table.
19
19
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
penicillin g sodium
1
MO
penicillin v
potassium
1
MO
PFIZERPEN-G
INJECTION
RECON SOLN 5
MILLION UNIT
1
piperacillintazobactam
intravenous recon
soln 3.375 gram, 4.5
gram
1
MO
AVELOX IN NACL
(ISO-OSMOTIC)
2
MO
ciprofloxacin
400 mg/40 ml
1
1
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
2
BICILLIN C-R
2
MO
BICILLIN L-A
2
MO
dicloxacillin
1
MO
nafcillin injection
recon soln 1 gram
1
MO
nafcillin injection
recon soln 10 gram
3
MO
nafcillin in dextrose
iso-osm intravenous
piggyback 1 gram/50
ml
1
oxacillin injection
recon soln 10 gram
3
oxacillin intravenous
recon soln 2 gram
1
ciprofloxacin oral
suspension,microcap
sule recon
oxacillin in
dextrose(iso-osm)
intravenous
piggyback 1 gram/50
ml
1
ciprofloxacin oral
tablet
1
MO
ciprofloxacin
(mixture)
1
MO
oxacillin in
dextrose(iso-osm)
intravenous
piggyback 2 gram/50
ml
3
ciprofloxacin in 5 %
dextrose intravenous
piggyback 200
mg/100 ml
1
MO
1
MO
penicillin g
potassium injection
recon soln 5 million
unit
1
levofloxacin
intravenous
levofloxacin oral
1
MO
1
penicillin g procaine
intramuscular
syringe 1.2 million
unit/2 ml
1
levofloxacin in d5w
intravenous
piggyback 500
mg/100 ml
moxifloxacin
1
MO
ofloxacin oral
1
MO
MO
MO
MO
QUINOLONES
of this table.
20
20
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
SULFA'S / RELATED AGENTS
trimethoprim
1
MO
sulfadiazine oral
1
MO
VANCOMYCIN
sulfamethoxazoletrimethoprim
1
MO
1
MO
demeclocycline
1
MO
vancomycin
intravenous recon
soln 1,000 mg, 10
gram, 500 mg
doxycycline hyclate
intravenous
1
vancomycin oral
3
MO
doxycycline hyclate
oral
1
MO
doxycycline
monohydrate oral
capsule 150 mg, 75
mg
1
MO
doxycycline
monohydrate oral
suspension for
reconstitution
1
doxycycline
monohydrate oral
tablet 150 mg, 50
mg, 75 mg
1
minocycline oral
1
MO
tetracycline
1
MO
TETRACYCLINES
Requirements
/Limits
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine
crystalline
3
3
MO
dexrazoxane
intravenous recon
soln 250 mg
3
MO
ELITEK
INTRAVENOUS
RECON SOLN 1.5
MG
FUSILEV
3
KEPIVANCE
3
leucovorin calcium
100 mg, 350 mg
1
MO
leucovorin calcium
oral
1
MO
mesna
1
MO
MESNEX ORAL
3
MO
XGEVA
3
MO
URINARY TRACT AGENTS
MO
MO
MO
MACRODANTIN
ORAL CAPSULE
25 MG
2
methenamine
hippurate
1
MO
nitrofurantoin oral
1
MO
nitrofurantoin
macrocrystal oral
capsule 50 mg
1
MO
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
ABRAXANE
3
MO
nitrofurantoin
monohyd/m-cryst
1
MO
AFINITOR ORAL
TABLET 10 MG
3
PA; MO; QL
(60 per 30
days)
PRIMSOL
2
MO
of this table.
21
21
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
CELLCEPT ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
B/D PA; MO
CELLCEPT
INTRAVENOUS
2
B/D PA
cisplatin
1
MO
cladribine
3
MO
CLOLAR
3
MO
COMETRIQ
3
PA; MO
cyclophosphamide
oral capsule
2
B/D PA
cyclophosphamide
oral tablet
1
B/D PA; MO
cyclosporine
intravenous
1
B/D PA
cyclosporine oral
1
B/D PA; MO
cyclosporine
modified
1
B/D PA; MO
cytarabine
1
MO
cytarabine (pf)
injection solution 2
gram/20 ml (100
mg/ml)
1
MO
dacarbazine
intravenous recon
soln 200 mg
1
MO
daunorubicin
1
decitabine
3
DOCEFREZ
3
docetaxel
80 mg/4 ml (20
mg/ml)
3
AFINITOR ORAL
TABLET 2.5 MG, 5
MG, 7.5 MG
3
PA; MO
AFINITOR
DISPERZ
3
PA; MO
ALIMTA
INTRAVENOUS
RECON SOLN 500
MG
3
MO
anastrozole
1
ARRANON
3
ARZERRA
INTRAVENOUS
SOLUTION 100
MG/5 ML
3
AVASTIN
2
MO
azacitidine
3
MO
AZASAN
2
B/D PA; MO
azathioprine
1
B/D PA; MO
bicalutamide
1
MO
BICNU
2
MO
bleomycin injection
recon soln 30 unit
1
MO
BOSULIF ORAL
TABLET 100 MG
3
PA; MO
BOSULIF ORAL
TABLET 500 MG
3
PA; MO; QL
(30 per 30
days)
BUSULFEX
3
CAPRELSA ORAL
TABLET 100 MG
3
MO; LA
CAPRELSA ORAL
TABLET 300 MG
3
MO; LA; QL
(30 per 30
days)
carboplatin
1
MO
MO
B/D PA; MO
Drug
Tier
Requirements
/Limits
MO
MO
of this table.
22
22
Drug Name
Drug
Tier
Requirements
/Limits
docetaxel
80 mg/8 ml (10
mg/ml)
3
DOXIL
3
MO
doxorubicin
50 mg/25 ml
1
MO
DROXIA
2
MO
ELIGARD
2
PA; MO
EMCYT
2
MO
epirubicin
50 mg/25 ml
1
MO
ERBITUX
INTRAVENOUS
SOLUTION 100
MG/50 ML
3
ERIVEDGE
3
ERWINAZE
3
ETOPOPHOS
2
MO
etoposide
intravenous
1
MO
exemestane
1
MO
FARESTON
2
MO
FASLODEX
3
MO
FIRMAGON KIT W
DILUENT
SYRINGE
2
MO
fludarabine
intravenous recon
soln
1
MO
fluorouracil
2.5 gram/50 ml
1
MO
MO
PA; MO; QL
(30 per 30
days)
Drug Name
Drug
Tier
Requirements
/Limits
flutamide
1
MO
FOLOTYN
INTRAVENOUS
SOLUTION 40
MG/2 ML (20
MG/ML)
3
MO
gemcitabine
intravenous recon
soln 1 gram
3
MO
GENGRAF
1
B/D PA; MO
GILOTRIF ORAL
TABLET 20 MG
3
PA; MO; QL
(60 per 30
days)
GILOTRIF ORAL
TABLET 30 MG
3
PA; MO; QL
(40 per 30
days)
GILOTRIF ORAL
TABLET 40 MG
3
PA; MO; QL
(30 per 30
days)
GLEEVEC ORAL
TABLET 100 MG
3
PA; MO
GLEEVEC ORAL
TABLET 400 MG
3
PA; MO; QL
(60 per 30
days)
HALAVEN
3
MO
HERCEPTIN
3
MO
HEXALEN
3
MO
hydroxyurea
1
MO
idarubicin
1
ifosfamide
intravenous recon
soln 1 gram
1
MO
IMBRUVICA
3
PA; MO; QL
(120 per 30
days)
INLYTA ORAL
TABLET 1 MG
3
PA; MO
of this table.
23
23
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
PA; MO; QL
(120 per 30
days)
LYSODREN
2
MO
MATULANE
3
MO
megestrol oral
suspension 400
mg/10 ml (40 mg/ml)
1
MO
megestrol oral tablet
1
MO
MEKINIST ORAL
TABLET 0.5 MG
3
PA; MO; QL
(120 per 30
days)
MEKINIST ORAL
TABLET 2 MG
3
PA; MO; QL
(30 per 30
days)
melphalan
3
PA; MO; QL
(60 per 30
days)
mercaptopurine
1
MO
methotrexate sodium
oral
1
B/D PA; MO
methotrexate sodium
(pf) injection recon
soln
1
B/D PA
methotrexate sodium
(pf) injection
solution
1
B/D PA; MO
mitomycin
intravenous recon
soln 20 mg
1
MO
mitoxantrone
1
MO
MUSTARGEN
2
MO
mycophenolate
mofetil
1
B/D PA; MO
mycophenolate
sodium
1
B/D PA; MO
NEXAVAR
3
PA; MO; LA
NILANDRON
2
MO
NULOJIX
3
B/D PA; MO
INLYTA ORAL
TABLET 5 MG
3
irinotecan
100 mg/5 ml
3
MO
ISTODAX
3
MO
IXEMPRA
INTRAVENOUS
RECON SOLN 45
MG
3
MO
JAKAFI ORAL
TABLET 10 MG, 15
MG, 20 MG, 5 MG
3
JAKAFI ORAL
TABLET 25 MG
3
JEVTANA
3
MO
KADCYLA
INTRAVENOUS
RECON SOLN 100
MG
3
MO
letrozole
1
MO
LEUKERAN
2
MO
leuprolide
1
MO
lomustine
2
MO
LUPRON DEPOT
3
PA; MO
LUPRON DEPOT
(3 MONTH)
3
PA; MO
LUPRON DEPOT
(4 MONTH)
3
PA; MO
LUPRON DEPOT
(6 MONTH)
3
PA; MO
LUPRON DEPOTPED
INTRAMUSCULA
R KIT 11.25 MG, 15
MG
3
PA; MO
PA; MO
Requirements
/Limits
of this table.
24
24
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
octreotide acetate
injection solution
1,000 mcg/ml, 500
mcg/ml
3
MO
SPRYCEL ORAL
TABLET 100 MG,
20 MG, 50 MG, 80
MG
3
PA; MO
octreotide acetate
injection solution
100 mcg/ml, 200
mcg/ml, 50 mcg/ml
1
MO
SPRYCEL ORAL
TABLET 140 MG
3
PA; MO; QL
(30 per 30
days)
ONCASPAR
3
MO
SPRYCEL ORAL
TABLET 70 MG
3
oxaliplatin
100 mg/20 ml
3
MO
PA; MO; QL
(60 per 30
days)
STIVARGA
3
paclitaxel
1
MO
PA; MO; QL
(84 per 28
days)
PERJETA
3
MO
3
PA; MO
POMALYST
3
MO
SUTENT ORAL
CAPSULE 12.5 MG
PROGRAF
INTRAVENOUS
2
B/D PA; MO
SUTENT ORAL
CAPSULE 25 MG
3
PA; MO; QL
(60 per 30
days)
RAPAMUNE
ORAL SOLUTION
2
B/D PA; MO
SUTENT ORAL
CAPSULE 50 MG
3
RAPAMUNE
ORAL TABLET 1
MG
2
B/D PA; MO
PA; MO; QL
(30 per 30
days)
3
MO
RAPAMUNE
ORAL TABLET 2
MG
3
B/D PA; MO
SYLVANT
INTRAVENOUS
RECON SOLN 100
MG
SYNRIBO
3
MO
REVLIMID
3
PA; MO; LA
TABLOID
2
MO
RITUXAN
3
PA; MO
1
B/D PA; MO
SANDOSTATIN
LAR DEPOT
3
MO
tacrolimus oral
capsule 0.5 mg, 1 mg
3
B/D PA; MO
SIGNIFOR
3
PA; MO
tacrolimus oral
capsule 5 mg
SIMULECT
INTRAVENOUS
RECON SOLN 20
MG
2
B/D PA; MO
TAFINLAR ORAL
CAPSULE 50 MG
3
PA; MO; QL
(180 per 30
days)
3
sirolimus
1
B/D PA; MO
TAFINLAR ORAL
CAPSULE 75 MG
SOLTAMOX
2
MO
PA; MO; QL
(120 per 30
days)
tamoxifen
1
MO
of this table.
25
25
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
PA; MO
VELCADE
3
MO
vinblastine
1
MO
vincristine
1 mg/ml
1
MO
vinorelbine
50 mg/5 ml
1
MO
TARCEVA ORAL
TABLET 100 MG,
25 MG
3
TARCEVA ORAL
TABLET 150 MG
3
PA; MO; QL
(30 per 30
days)
TARGRETIN
3
MO
TASIGNA ORAL
CAPSULE 150 MG
3
PA; MO
TASIGNA ORAL
CAPSULE 200 MG
3
PA; MO; QL
(112 per 28
days)
VOTRIENT
3
PA; MO; QL
(120 per 30
days)
THALOMID
3
PA; MO
3
PA; MO
TOPOSAR
1
MO
XALKORI ORAL
CAPSULE 200 MG
topotecan
intravenous recon
soln
3
MO
XALKORI ORAL
CAPSULE 250 MG
3
PA; MO; QL
(60 per 30
days)
TORISEL
3
MO
XTANDI
3
TREANDA
INTRAVENOUS
RECON SOLN 100
MG
3
MO
PA; MO; QL
(120 per 30
days)
3
MO
TRELSTAR
3
TRELSTAR
DEPOT
3
YERVOY
INTRAVENOUS
SOLUTION 50
MG/10 ML (5
MG/ML)
3
MO
TRELSTAR LA
3
tretinoin
(chemotherapy)
3
MO
ZALTRAP
INTRAVENOUS
SOLUTION 100
MG/4 ML (25
MG/ML)
TRISENOX
3
MO
ZANOSAR
2
MO
TYKERB
3
PA; MO; LA;
QL (180 per
30 days)
ZELBORAF
3
PA; MO; QL
(240 per 30
days)
VECTIBIX
INTRAVENOUS
SOLUTION 100
MG/5 ML (20
MG/ML)
3
B/D PA; MO
ZOLINZA
3
MO
ZORTRESS ORAL
TABLET 0.25 MG
2
B/D PA; MO
MO
of this table.
26
26
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
B/D PA; MO
FYCOMPA
2
MO
gabapentin oral
capsule
1
MO
gabapentin oral
1
MO
gabapentin oral
tablet
1
MO
GABITRIL ORAL
TABLET 12 MG, 16
MG
2
MO
lamotrigine oral
tablet
1
MO
ZORTRESS ORAL
TABLET 0.5 MG,
0.75 MG
3
ZYKADIA
3
PA; MO; QL
(150 per 30
days)
ZYTIGA
3
PA; MO; QL
(120 per 30
days)
AUTONOMIC / CNS DRUGS,
NEUROLOGY / PSYCH
ANTICONVULSANTS
Requirements
/Limits
APTIOM ORAL
TABLET 200 MG,
400 MG, 800 MG
2
MO
lamotrigine oral
tablet extended
release 24hr
1
MO
APTIOM ORAL
TABLET 600 MG
3
MO
1
MO
BANZEL ORAL
SUSPENSION
2
MO
lamotrigine oral
tablet, chewable
dispersible
1
MO
BANZEL ORAL
TABLET 200 MG
2
MO
levetiracetam
intravenous
1
MO
BANZEL ORAL
TABLET 400 MG
3
MO
levetiracetam oral
solution 100 mg/ml
1
MO
carbamazepine
1
MO
levetiracetam oral
tablet
CELONTIN
2
MO
1
MO
clonazepam
1
PA; MO
levetiracetam oral
tablet extended
release 24 hr
diazepam rectal
1
PA; MO
LYRICA
2
PA; MO
DILANTIN
2
MO
ONFI
2
PA; MO
divalproex
1
MO
oxcarbazepine
1
MO
EPITOL
1
MO
PEGANONE
2
MO
ethosuximide
1
MO
phenobarbital
1
MO
felbamate
1
MO
1
MO
fosphenytoin
injection solution
100 mg pe/2 ml
1
MO
phenytoin oral
suspension 125 mg/5
ml
phenytoin oral
tablet,chewable
1
MO
of this table.
27
27
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
entacapone
1
MO
NEUPRO
2
MO
pramipexole
1
MO
ropinirole
1
MO
selegiline hcl
1
MO
phenytoin sodium
1
MO
phenytoin sodium
extended
1
MO
POTIGA
2
MO
primidone
1
MO
SABRIL
3
MO; LA
TEGRETOL XR
ORAL TABLET
EXTENDED
RELEASE 12 HR
100 MG
2
MO
tiagabine
1
MO
topiramate oral
capsule, sprinkle
1
PA; MO
topiramate oral
tablet
1
PA; MO
valproate sodium
1
MO
valproic acid
1
MO
valproic acid (as
sodium salt) oral
1
MO
VIMPAT
INTRAVENOUS
2
VIMPAT ORAL
2
MO
zonisamide
1
PA; MO
ANTIPARKINSONISM AGENTS
APOKYN
3
MO; LA
AZILECT
2
MO
benztropine
1
MO
bromocriptine
1
MO
carbidopa
1
MO
carbidopa-levodopa
1
MO
carbidopa-levodopaentacapone
1
MO
Requirements
/Limits
MIGRAINE / CLUSTER HEADACHE
THERAPY
dihydroergotamine
injection
1
MO
ERGOMAR
2
MO
MIGERGOT
1
MO
naratriptan
1
MO; QL (18
per 28 days)
rizatriptan
1
MO; QL (36
per 28 days)
sumatriptan nasal
spray,non-aerosol
20 mg/actuation
1
MO; QL (18
per 28 days)
sumatriptan nasal
spray,non-aerosol 5
mg/actuation
1
MO; QL (36
per 28 days)
sumatriptan
succinate oral
1
MO; QL (18
per 28 days)
sumatriptan
succinate
subcutaneous pen
injector 6 mg/0.5 ml
1
MO; QL (16
per 28 days)
sumatriptan
succinate
subcutaneous
solution
1
MO; QL (16
per 28 days)
zolmitriptan
1
MO; QL (18
per 28 days)
MISCELLANEOUS NEUROLOGICAL
THERAPY
AMPYRA
3
PA; MO; LA
of this table.
28
28
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
LIORESAL
INTRATHECAL
SOLUTION 50
MCG/ML
2
B/D PA
COPAXONE
SUBCUTANEOUS
SYRINGE KIT
3
PA; MO; QL
(30 per 30
days)
donepezil
1
MO
EXELON
TRANSDERMAL
2
ST; MO
MESTINON ORAL
SYRUP
2
MO
galantamine
1
MO
2
MO
GILENYA
3
PA; MO
MESTINON
TIMESPAN
NAMENDA
2
PA; MO
pyridostigmine
bromide
1
MO
NAMENDA
TITRATION PAK
2
PA; MO
tizanidine
1
MO
NUEDEXTA
2
MO
rivastigmine tartrate
1
MO
TECFIDERA
3
PA; MO
TYSABRI
3
PA; MO; LA
XENAZINE
3
PA; MO; LA
MUSCLE RELAXANTS /
ANTISPASMODIC THERAPY
baclofen
1
MO
cyclobenzaprine
1
PA; MO
dantrolene
1
MO
GABLOFEN
INTRATHECAL
SOLUTION 10,000
MCG/20ML (500
MCG/ML), 40,000
MCG/20ML (2,000
MCG/ML)
2
B/D PA; MO
GABLOFEN
INTRATHECAL
SYRINGE 50
MCG/ML (1 ML)
2
LIORESAL
INTRATHECAL
SOLUTION 2,000
MCG/ML, 500
MCG/ML
2
B/D PA; MO
B/D PA; MO
NARCOTIC ANALGESICS
acetaminophencodeine oral solution
300 mg-30 mg /12.5
ml
1
QL (4500 per
30 days)
acetaminophencodeine oral tablet
300-15 mg, 300-30
mg
1
MO; QL (360
per 30 days)
acetaminophencodeine oral tablet
300-60 mg
1
MO; QL (180
per 30 days)
buprenorphine
injection syringe
1
QL (267 per
30 days)
buprenorphine
sublingual tablet,
sublingual 2 mg
1
MO; QL (300
per 30 days)
buprenorphine
sublingual tablet,
sublingual 8 mg
1
MO; QL (75
per 30 days)
codeine sulfate oral
tablet
1
MO; QL (180
per 30 days)
DURAMORPH (PF)
INJECTION
SOLUTION 0.5
MG/ML
1
MO; QL (4000
per 30 days)
of this table.
29
29
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
DURAMORPH (PF)
INJECTION
SOLUTION 1
MG/ML
1
QL (2000 per
30 days)
ENDOCET ORAL
TABLET 10-325
MG, 5-325 MG, 7.5325 MG
1
MO; QL (360
per 30 days)
ENDODAN
1
MO; QL (360
per 30 days)
fentanyl citrate
buccal lozenge on a
handle 1,200 mcg
3
PA; MO; QL
(39 per 30
days)
fentanyl citrate
buccal lozenge on a
handle 1,600 mcg
3
PA; MO; QL
(29 per 30
days)
fentanyl citrate
buccal lozenge on a
handle 200 mcg
3
PA; MO; QL
(120 per 30
days)
fentanyl citrate
buccal lozenge on a
handle 400 mcg
3
PA; MO; QL
(116 per 30
days)
fentanyl citrate
buccal lozenge on a
handle 600 mcg
3
PA; MO; QL
(77 per 30
days)
fentanyl citrate
buccal lozenge on a
handle 800 mcg
3
PA; MO; QL
(58 per 30
days)
fentanyl patches
transdermal patch
72 hour 100 mcg/hr
1
fentanyl patches
transdermal patch
72 hour 12 mcg/hr,
25 mcg/hr, 50
mcg/hr, 75 mcg/hr
1
hydrocodoneacetaminophen oral
solution 7.5-325
mg/15 ml
1
MO; QL (9 per
30 days)
MO; QL (10
per 30 days)
MO; QL (5550
per 30 days)
Drug
Tier
Requirements
/Limits
hydrocodoneacetaminophen oral
tablet 10-300 mg,
10-325 mg, 5-300
mg, 5-325 mg, 7.5300 mg, 7.5-325 mg
1
MO; QL (360
per 30 days)
hydrocodoneibuprofen oral tablet
7.5-200 mg
1
MO; QL (50
per 30 days)
hydromorphone oral
liquid
1
MO; QL (300
per 30 days)
hydromorphone oral
tablet
1
MO; QL (180
per 30 days)
hydromorphone oral
tablet extended
release 24 hr 12 mg,
8 mg
1
MO; QL (60
per 30 days)
hydromorphone oral
tablet extended
release 24 hr 16 mg
3
MO; QL (60
per 30 days)
hydromorphone (pf)
mg/ml
1
MO; QL (120
per 30 days)
ibuprofen-oxycodone
1
MO; QL (28
per 30 days)
levorphanol tartrate
1
MO; QL (120
per 30 days)
LORCET
(HYDROCODONE)
1
QL (360 per
30 days)
LORCET HD
1
MO; QL (360
per 30 days)
LORCET PLUS
1
QL (360 per
30 days)
LORTAB 10-325
1
MO; QL (360
per 30 days)
LORTAB 5-325
1
MO; QL (360
per 30 days)
LORTAB 7.5-325
1
MO; QL (360
per 30 days)
of this table.
30
30
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
methadone injection
1
QL (160 per
30 days)
morphine oral tablet
1
MO; QL (180
per 30 days)
methadone oral
solution 10 mg/5 ml
1
MO; QL (600
per 30 days)
1
MO; QL (60
per 30 days)
methadone oral
solution 5 mg/5 ml
1
MO; QL (1200
per 30 days)
extended release 100
mg
1
methadone oral
tablet 10 mg
1
MO; QL (120
per 30 days)
extended release 15
mg, 30 mg
MO; QL (120
per 30 days)
methadone oral
tablet 5 mg
1
MO; QL (240
per 30 days)
1
MO; QL (30
per 30 days)
morphine
intravenous syringe
2 mg/ml
1
QL (1000 per
30 days)
extended release 200
mg
1
MO; QL (100
per 30 days)
morphine
intravenous syringe
4 mg/ml
1
QL (500 per
30 days)
extended release 60
mg
1
MO; QL (300
per 30 days)
morphine oral
capsule, er
multiphase 24 hr
120 mg
1
MO; QL (50
per 30 days)
morphine
concentrate oral
solution
oxycodone oral
capsule
1
MO; QL (360
per 30 days)
1
morphine oral
capsule, er
multiphase 24 hr 30
mg, 45 mg, 60 mg,
75 mg, 90 mg
1
oxycodone oral
concentrate
MO; QL (180
per 30 days)
oxycodone oral
solution
1
MO; QL (1200
per 30 days)
1
morphine oral
capsule,extend.relea
se pellets 10 mg, 20
mg, 30 mg, 50 mg,
60 mg
1
oxycodone oral
tablet 10 mg, 15 mg,
20 mg
MO; QL (180
per 30 days)
oxycodone oral
tablet 30 mg
1
MO; QL (134
per 30 days)
1
morphine oral
se pellets 100 mg
1
MO; QL (60
per 30 days)
oxycodone oral
tablet 5 mg
MO; QL (360
per 30 days)
oxycodoneacetaminophen
1
MO; QL (360
per 30 days)
morphine oral
se pellets 80 mg
1
MO; QL (75
per 30 days)
oxycodone-aspirin
1
MO; QL (360
per 30 days)
morphine oral
solution
1
MO; QL (900
per 30 days)
oxymorphone oral
tablet 10 mg
1
MO; QL (200
per 30 days)
oxymorphone oral
tablet 5 mg
1
MO; QL (180
per 30 days)
MO; QL (60
per 30 days)
MO; QL (90
per 30 days)
of this table.
31
31
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO; QL (90
per 30 days)
diclofenac sodium
topical drops
1
MO
diclofenacmisoprostol
1
MO
diflunisal
1
MO
etodolac
1
MO
fenoprofen oral
tablet
1
MO
flurbiprofen
1
MO
ibuprofen oral
suspension
1
MO
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
1
MO
ketoprofen
1
MO
meclofenamate oral
1
MO
mefenamic acid
1
MO
meloxicam oral
suspension
1
MO
meloxicam oral
tablet 15 mg
1
MO
meloxicam oral
tablet 7.5 mg
1
MO; QL (30
per 30 days)
oxymorphone oral
tablet extended
release 12 hr 10 mg,
15 mg, 20 mg, 5 mg,
7.5 mg
1
oxymorphone oral
tablet extended
release 12 hr 30 mg
1
oxymorphone oral
tablet extended
release 12 hr 40 mg
1
REPREXAIN
1
MO; QL (50
per 30 days)
VICODIN
1
MO; QL (360
per 30 days)
VICODIN ES
1
MO; QL (360
per 30 days)
VICODIN HP
1
MO; QL (360
per 30 days)
ZAMICET
1
MO; QL (5550
per 30 days)
MO; QL (67
per 30 days)
MO; QL (50
per 30 days)
NON-NARCOTIC ANALGESICS
Drug
Tier
Requirements
/Limits
buprenorphinenaloxone
1
PA; MO; QL
(90 per 30
days)
butorphanol tartrate
mg/ml
1
MO; QL (720
per 30 days)
nabumetone
1
MO
nalbuphine injection
solution 10 mg/ml
1
MO; QL (200
per 30 days)
mg/ml
1
MO; QL (360
per 30 days)
nalbuphine injection
solution 20 mg/ml
1
MO; QL (100
per 30 days)
nasal
1
MO; QL (40
per 30 days)
naloxone injection
syringe 1 mg/ml
1
MO
CELEBREX
2
MO
naltrexone
1
MO
diclofenac potassium
1
MO
naproxen
1
MO
diclofenac sodium
oral
1
MO
naproxen sodium
oral tablet 275 mg,
550 mg
1
MO
of this table.
32
32
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
ABILIFY
DISCMELT ORAL
TABLET,DISINTE
GRATING 10 MG
2
MO; QL (90
per 30 days)
ABILIFY
DISCMELT ORAL
TABLET,DISINTE
GRATING 15 MG
2
MO; QL (60
per 30 days)
ABILIFY
MAINTENA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON 300 MG
3
MO
alprazolam oral
tablet
1
MO
amitriptyline
1
PA; MO
amoxapine
1
MO
PSYCHOTHERAPEUTIC DRUGS
AMPHETAMINE
SALT COMBO
1
MO
ABILIFY
INTRAMUSCULA
R
2
MO
BRINTELLIX
ORAL TABLET 10
MG
2
MO; QL (60
per 30 days)
ABILIFY ORAL
SOLUTION
2
MO
2
MO; QL (30
per 30 days)
ABILIFY ORAL
TABLET 10 MG
2
MO; QL (90
per 30 days)
BRINTELLIX
ORAL TABLET 20
MG
2
ABILIFY ORAL
TABLET 15 MG
2
MO; QL (60
per 30 days)
BRINTELLIX
ORAL TABLET 5
MG
MO; QL (120
per 30 days)
ABILIFY ORAL
TABLET 2 MG
2
MO; QL (450
per 30 days)
bupropion hcl oral
tablet
1
MO
ABILIFY ORAL
TABLET 20 MG
3
MO; QL (60
per 30 days)
1
MO; QL (120
per 30 days)
ABILIFY ORAL
TABLET 30 MG
3
MO; QL (30
per 30 days)
bupropion hcl oral
tablet extended
release 100 mg
1
ABILIFY ORAL
TABLET 5 MG
2
MO; QL (180
per 30 days)
bupropion hcl oral
tablet extended
release 150 mg
MO; QL (90
per 30 days)
oxaprozin
1
MO
piroxicam
1
MO
sulindac oral
1
MO
tolmetin
1
MO
tramadol oral tablet
1
MO; QL (240
per 30 days)
tramadol oral tablet
extended release 24
hr 100 mg, 200 mg
1
MO; QL (30
per 30 days)
tramadol oral tablet,
er multiphase 24 hr
300 mg
1
MO; QL (30
per 30 days)
tramadolacetaminophen
1
MO; QL (240
per 30 days)
VOLTAREN GEL
2
ST; MO
ZUBSOLV
2
PA; MO; QL
(90 per 30
days)
Drug
Tier
Requirements
/Limits
of this table.
33
33
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO; QL (60
per 30 days)
diazepam oral tablet
1
PA; MO
DIAZEPAM
INTENSOL
1
PA; MO
doxepin oral
1
PA; MO
duloxetine oral
capsule,delayed
release(dr/ec) 20 mg
1
MO; QL (180
per 30 days)
duloxetine oral
capsule,delayed
1
MO; QL (120
per 30 days)
duloxetine oral
capsule,delayed
1
MO; QL (60
per 30 days)
EMSAM
2
MO
ergoloid
1
MO
escitalopram oxalate
oral solution
1
MO
oral tablet 10 mg
1
MO; QL (60
per 30 days)
oral tablet 20 mg
1
MO; QL (30
per 30 days)
oral tablet 5 mg
1
MO; QL (120
per 30 days)
eszopiclone
1
ST; MO; QL
(30 per 30
days)
FANAPT ORAL
TABLET 1 MG
2
MO; QL (720
per 30 days)
FANAPT ORAL
TABLET 10 MG, 8
MG
2
MO; QL (90
per 30 days)
bupropion hcl oral
tablet extended
release 200 mg
1
bupropion hcl oral
tablet extended
release 24 hr 150 mg
1
bupropion hcl oral
tablet extended
1
buspirone
1
MO
chlorpromazine
1
MO
citalopram oral
solution
1
MO
citalopram oral
tablet 10 mg
1
MO; QL (120
per 30 days)
citalopram oral
tablet 20 mg
1
MO; QL (60
per 30 days)
citalopram oral
tablet 40 mg
1
MO; QL (30
per 30 days)
clomipramine
1
PA; MO
clonidine hcl oral
tablet extended
release 12 hr
1
MO
clorazepate
dipotassium
1
clozapine oral tablet
1
desipramine oral
1
MO
dexmethylphenidate
1
MO
dextroamphetamine
oral capsule,
extended release
1
MO
dextroamphetamine
oral tablet
1
MO
FANAPT ORAL
TABLET 12 MG
2
MO; QL (60
per 30 days)
dextroamphetamineamphetamine
1
MO
FANAPT ORAL
TABLET 2 MG
2
MO; QL (360
per 30 days)
diazepam oral
solution 5 mg/5 ml
1
PA; MO
FANAPT ORAL
TABLET 4 MG
2
MO; QL (180
per 30 days)
MO; QL (90
per 30 days)
MO; QL (60
per 30 days)
PA; MO
of this table.
34
34
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
FANAPT ORAL
TABLET 6 MG
2
MO; QL (120
per 30 days)
fluoxetine oral tablet
10 mg
1
MO; QL (240
per 30 days)
FANAPT ORAL
TABLETS,DOSE
PACK
2
QL (8 per 28
days)
fluoxetine oral tablet
20 mg
1
MO
FAZACLO ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
2
fluphenazine
decanoate
1
MO
fluphenazine hcl
1
MO
fluvoxamine oral
capsule,extended
release 24hr 100 mg
1
MO; QL (90
per 30 days)
FETZIMA ORAL
CAPSULE,EXT
REL 24HR DOSE
PACK
2
fluvoxamine oral
capsule,extended
release 24hr 150 mg
1
MO; QL (60
per 30 days)
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 120 MG
2
ST; MO; QL
(30 per 30
days)
fluvoxamine oral
tablet 100 mg
1
MO; QL (90
per 30 days)
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 20 MG
2
ST; MO; QL
(180 per 30
days)
fluvoxamine oral
tablet 25 mg
1
MO; QL (360
per 30 days)
fluvoxamine oral
tablet 50 mg
1
MO; QL (180
per 30 days)
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 40 MG
2
GEODON
INTRAMUSCULA
R
2
MO
guanidine
1
MO
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 80 MG
2
haloperidol
1
MO
haloperidol
decanoate
1
MO
fluoxetine oral
capsule 10 mg
1
MO; QL (240
per 30 days)
haloperidol lactate
1
MO
imipramine hcl
1
PA; MO
fluoxetine oral
capsule 20 mg
1
MO
imipramine pamoate
1
PA; MO
2
1
MO; QL (60
per 30 days)
MO; QL (240
per 30 days)
fluoxetine oral
capsule,delayed
release(dr/ec)
1
MO; QL (4 per
28 days)
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR
1.5 MG
fluoxetine oral
capsule 40 mg
fluoxetine oral
solution
1
MO
ST; MO; QL
(28 per 28
days)
ST; MO; QL
(90 per 30
days)
ST; MO; QL
(45 per 30
days)
of this table.
35
35
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR 3
MG
2
MO; QL (120
per 30 days)
lorazepam oral
tablet
1
PA; MO
LORAZEPAM
INTENSOL
1
PA; MO
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR 6
MG
2
loxapine succinate
1
MO
maprotiline
1
MO
MARPLAN
2
MO
METADATE ER
1
MO
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR 9
MG
2
MO; QL (41
per 30 days)
methamphetamine
1
MO
1
MO
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 117
MG/0.75 ML, 156
MG/ML, 234
MG/1.5 ML
3
MO
methylphenidate
oral capsule, er
biphasic 30-70 10
mg, 50 mg, 60 mg
methylphenidate
oral capsule,er
biphasic 50-50
1
MO
methylphenidate
oral solution
1
MO
1
MO
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 39
MG/0.25 ML, 78
MG/0.5 ML
2
methylphenidate
oral tablet
methylphenidate
oral tablet extended
release
1
MO
1
MO
LATUDA ORAL
TABLET 120 MG
3
MO; QL (30
per 30 days)
methylphenidate
release 24hr
LATUDA ORAL
TABLET 20 MG
2
MO; QL (240
per 30 days)
mirtazapine
1
MO
modafinil
1
PA; MO
LATUDA ORAL
TABLET 40 MG
2
MO; QL (120
per 30 days)
nefazodone
1
MO
nortriptyline
1
MO
LATUDA ORAL
TABLET 60 MG, 80
MG
2
MO; QL (60
per 30 days)
olanzapine
intramuscular
1
MO
lithium carbonate
1
MO
olanzapine oral
tablet 10 mg
1
MO; QL (60
per 30 days)
lithium citrate
1
MO
olanzapine oral
tablet 15 mg, 20 mg
1
MO; QL (30
per 30 days)
MO; QL (60
per 30 days)
MO
Drug
Tier
Requirements
/Limits
of this table.
36
36
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
olanzapine oral
tablet 2.5 mg
1
MO; QL (240
per 30 days)
PAXIL ORAL
SUSPENSION
2
MO
olanzapine oral
tablet 5 mg
1
MO; QL (120
per 30 days)
perphenazine
1
MO
olanzapine oral
tablet 7.5 mg
1
MO; QL (81
per 30 days)
perphenazineamitriptyline
1
PA; MO
olanzapine oral
tablet,disintegrating
10 mg
1
MO; QL (60
per 30 days)
phenelzine
1
MO
2
olanzapine oral
15 mg, 20 mg
1
MO; QL (30
per 30 days)
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
100 MG
ST; MO; QL
(120 per 30
days)
olanzapine oral
5 mg
1
MO; QL (120
per 30 days)
2
ST; MO; QL
(240 per 30
days)
olanzapinefluoxetine
1
MO
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
50 MG
PROCENTRA
1
MO
ORAP
2
MO
protriptyline
1
MO
oxazepam
1
PA; MO
1
paroxetine hcl oral
tablet 10 mg
1
MO; QL (180
per 30 days)
quetiapine oral
tablet 100 mg
MO; QL (240
per 30 days)
1
paroxetine hcl oral
tablet 20 mg
1
MO; QL (90
per 30 days)
quetiapine oral
tablet 200 mg
MO; QL (120
per 30 days)
1
paroxetine hcl oral
tablet 30 mg
1
MO; QL (60
per 30 days)
quetiapine oral
tablet 25 mg
MO; QL (902
per 30 days)
1
paroxetine hcl oral
tablet 40 mg
1
MO; QL (45
per 30 days)
quetiapine oral
tablet 300 mg
MO; QL (81
per 30 days)
1
paroxetine hcl oral
tablet extended
release 24 hr 12.5
mg
1
MO; QL (180
per 30 days)
quetiapine oral
tablet 400 mg
MO; QL (60
per 30 days)
quetiapine oral
tablet 50 mg
1
MO; QL (480
per 30 days)
paroxetine hcl oral
tablet extended
release 24 hr 25 mg
1
MO; QL (90
per 30 days)
2
MO
paroxetine hcl oral
tablet extended
release 24 hr 37.5
mg
1
MO; QL (60
per 30 days)
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 12.5
MG/2 ML, 25 MG/2
ML
of this table.
37
37
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
MO
ROZEREM
2
MO; QL (30
per 30 days)
SAPHRIS
SUBLINGUAL
TABLET,
SUBLINGUAL 10
MG
2
MO; QL (60
per 30 days)
SAPHRIS
SUBLINGUAL
TABLET,
SUBLINGUAL 5
MG
2
MO; QL (120
per 30 days)
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET,
SUBLINGUAL 10
MG
2
MO; QL (60
per 30 days)
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET,
SUBLINGUAL 5
MG
2
MO; QL (120
per 30 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
150 MG
2
MO; QL (161
per 30 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
200 MG
2
MO; QL (120
per 30 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
300 MG
2
MO; QL (81
per 30 days)
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 37.5
MG/2 ML, 50 MG/2
ML
3
risperidone oral
solution
1
MO; QL (480
per 30 days)
risperidone oral
tablet 0.25 mg
1
MO; QL (1920
per 30 days)
risperidone oral
tablet 0.5 mg
1
MO; QL (960
per 30 days)
risperidone oral
tablet 1 mg
1
MO; QL (480
per 30 days)
risperidone oral
tablet 2 mg
1
MO; QL (240
per 30 days)
risperidone oral
tablet 3 mg
1
MO; QL (161
per 30 days)
risperidone oral
tablet 4 mg
1
MO; QL (120
per 30 days)
risperidone oral
0.25 mg
1
MO; QL (1920
per 30 days)
risperidone oral
0.5 mg
1
MO; QL (960
per 30 days)
risperidone oral
1 mg
1
MO; QL (480
per 30 days)
risperidone oral
2 mg
1
MO; QL (240
per 30 days)
risperidone oral
3 mg
1
MO; QL (161
per 30 days)
risperidone oral
4 mg
1
MO; QL (120
per 30 days)
Requirements
/Limits
of this table.
38
38
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MO; QL (60
per 30 days)
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
400 MG
2
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
50 MG
2
sertraline oral
concentrate
1
MO
sertraline oral tablet
100 mg
1
MO; QL (60
per 30 days)
25 mg
1
MO; QL (240
per 30 days)
50 mg
1
MO; QL (120
per 30 days)
STRATTERA
2
MO
SURMONTIL
2
PA; MO
temazepam
1
PA; MO
thioridazine
1
MO
thiothixene
1
MO
tranylcypromine
1
MO
trazodone
1
MO
trifluoperazine
1
MO
venlafaxine oral
capsule,extended
release 24hr 150 mg
1
MO; QL (60
per 30 days)
venlafaxine oral
capsule,extended
release 24hr 37.5 mg
1
MO; QL (180
per 30 days)
venlafaxine oral
capsule,extended
release 24hr 75 mg
1
MO; QL (90
per 30 days)
venlafaxine oral
tablet 100 mg, 75 mg
1
MO; QL (480
per 30 days)
MO; QL (90
per 30 days)
Drug
Tier
Requirements
/Limits
venlafaxine oral
tablet 25 mg
1
MO; QL (270
per 30 days)
venlafaxine oral
tablet 37.5 mg
1
MO; QL (180
per 30 days)
venlafaxine oral
tablet 50 mg
1
MO; QL (150
per 30 days)
VERSACLOZ
3
LA
VIIBRYD ORAL
TABLET 10 MG
2
MO; QL (120
per 30 days)
VIIBRYD ORAL
TABLET 20 MG
2
MO; QL (60
per 30 days)
VIIBRYD ORAL
TABLET 40 MG
2
MO; QL (30
per 30 days)
VIIBRYD ORAL
TABLETS,DOSE
PACK
2
MO; QL (30
per 30 days)
XYREM
3
MO; LA
zaleplon oral
capsule 10 mg
1
ST; MO; QL
(60 per 30
days)
zaleplon oral
capsule 5 mg
1
ST; MO; QL
(30 per 30
days)
ZENZEDI ORAL
TABLET 10 MG, 5
MG
1
MO
ziprasidone hcl oral
capsule 20 mg
1
MO; QL (240
per 30 days)
capsule 40 mg
1
MO; QL (120
per 30 days)
capsule 60 mg
1
MO; QL (80
per 30 days)
capsule 80 mg
1
MO; QL (60
per 30 days)
zolpidem
1
ST; MO; QL
(30 per 30
days)
of this table.
39
39
Drug Name
Drug
Tier
Requirements
/Limits
CARDIOVASCULAR,
HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Drug Name
Drug
Tier
Requirements
/Limits
amiloride
1
MO
amiloridehydrochlorothiazide
1
MO
amlodipine
1
MO
amlodipinebenazepril
1
MO
atenolol
1
MO
1
MO
amiodarone
1
B/D PA; MO
amiodarone oral
tablet 200 mg, 400
mg
1
MO
flecainide
1
MO
atenololchlorthalidone
mexiletine
1
MO
benazepril
1
MO
PACERONE
1
MO
1
MO
procainamide
injection solution
100 mg/ml
1
MO
benazeprilhydrochlorothiazide
betaxolol oral
1
MO
procainamide
injection solution
500 mg/ml
1
bisoprolol fumarate
1
MO
bisoprololhydrochlorothiazide
1
MO
propafenone
1
MO
bumetanide
1
MO
quinidine gluconate
1
MO
candesartan
1
MO
quinidine sulfate
1
MO
1
MO
SORINE ORAL
TABLET 120 MG,
160 MG, 80 MG
1
MO
candesartanhydrochlorothiazid
captopril
1
MO
1
MO
SORINE ORAL
TABLET 240 MG
1
captoprilhydrochlorothiazide
CARTIA XT
1
MO
sotalol oral tablet
160 mg, 240 mg, 80
mg
1
carvedilol
1
MO
chlorothiazide
1
MO
SOTALOL AF
ORAL TABLET
120 MG
1
chlorothiazide
sodium
1
MO
chlorthalidone
1
MO
TIKOSYN
2
clonidine
1
MO; QL (4 per
28 days)
clonidine hcl oral
tablet
1
MO
MO
MO
MO
ANTIHYPERTENSIVE THERAPY
acebutolol oral
1
MO
AFEDITAB CR
1
MO
of this table.
40
40
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO
fosinoprilhydrochlorothiazide
1
MO
furosemide injection
solution
1
MO
furosemide oral
1
MO
hydralazine
1
MO
hydrochlorothiazide
1
MO
indapamide
1
MO
irbesartan
1
MO
irbesartanhydrochlorothiazide
1
MO
isradipine
1
MO
labetalol
1
MO
labetalol oral
1
MO
lisinopril
1
MO
lisinoprilhydrochlorothiazide
1
MO
losartan
1
MO
losartanhydrochlorothiazide
1
MO
MATZIM LA
1
MO
methyclothiazide
1
MO
CLORPRES ORAL
TABLET 0.1-15
MG
1
CLORPRES ORAL
TABLET 0.3-15
MG
2
DEMSER
2
MO
DIBENZYLINE
2
MO
DILT-XR
1
MO
diltiazem hcl
intravenous
1
diltiazem hcl oral
capsule, extended
release 180 mg, 360
mg, 420 mg
1
diltiazem hcl oral
capsule,extended
release 12 hr
1
diltiazem hcl oral
capsule,extended
release 24hr 120 mg,
240 mg, 300 mg
1
diltiazem hcl oral
tablet
1
MO
doxazosin oral tablet
1 mg, 2 mg, 4 mg
1
MO; QL (30
per 30 days)
doxazosin oral tablet
8 mg
1
MO; QL (60
per 30 days)
methyldopa
1
MO
metolazone
1
MO
DUTOPROL
2
MO
metoprolol succinate
1
MO
enalapril maleate
1
MO
1
MO
enalaprilhydrochlorothiazide
1
MO
metoprolol tahydrochlorothiaz
1
MO
eplerenone
1
MO
metoprolol tartrate
eprosartan
1
MO
1
MO
felodipine
1
MO
metoprolol tartrate
oral
fosinopril
1
MO
minoxidil oral
1
MO
moexipril
1
MO
MO
MO
MO
MO
of this table.
41
41
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
moexiprilhydrochlorothiazide
1
MO
telmisartanhydrochlorothiazid
1
MO
nadolol
1
MO
1
nadololbendroflumethiazide
1
MO
terazosin oral
capsule 1 mg, 2 mg,
5 mg
MO; QL (30
per 30 days)
nicardipine
1
MO
1
NIFEDICAL XL
1
MO
terazosin oral
capsule 10 mg
MO; QL (60
per 30 days)
nifedipine oral tablet
extended release
24hr
1
MO
timolol maleate oral
1
MO
1
nimodipine
1
MO
torsemide
20 mg/2 ml (10
mg/ml)
nisoldipine
1
MO
torsemide oral
1
MO
perindopril
erbumine
1
MO
trandolapril
1
MO
pindolol
1
MO
triamterenehydrochlorothiazid
1
MO
prazosin
1
MO
1
MO
propranolol
intravenous
1
valsartanhydrochlorothiazide
1
MO
propranolol oral
1
MO
verapamil
propranololhydrochlorothiazid
1
MO
verapamil oral
1
MO
quinapril
1
MO
digoxin oral
1
quinaprilhydrochlorothiazide
1
MO
2
ramipril
1
MO
LANOXIN ORAL
TABLET 187.5
MCG
REMODULIN
3
PA; MO; LA
2
spironolactonhydrochlorothiaz
1
MO
LANOXIN ORAL
TABLET 62.5 MCG
spironolactone
1
MO
AGGRENOX
2
MO
TAZTIA XT
1
MO
BRILINTA
2
MO
telmisartan
1
MO
cilostazol
1
MO
telmisartanamlodipine
1
MO
clopidogrel
1
MO
dipyridamole oral
1
MO
EFFIENT
2
MO
CARDIAC GLYCOSIDES
MO
MO
COAGULATION THERAPY
of this table.
42
42
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
ELIQUIS
2
MO
JANTOVEN
1
MO
enoxaparin
subcutaneous
solution
1
MO
pentoxifylline
1
MO
PROMACTA
3
PA; MO; LA
enoxaparin
subcutaneous
syringe 100 mg/ml,
30 mg/0.3 ml, 40
mg/0.4 ml, 60 mg/0.6
ml, 80 mg/0.8 ml
1
tranexamic acid
intravenous
1
MO
warfarin
1
MO
XARELTO
2
MO
enoxaparin
subcutaneous
syringe 120 mg/0.8
ml, 150 mg/ml
3
MO
fondaparinux
subcutaneous
syringe 10 mg/0.8
ml, 5 mg/0.4 ml, 7.5
mg/0.6 ml
3
MO
fondaparinux
subcutaneous
syringe 2.5 mg/0.5
ml
1
heparin (porcine)
injection solution
1
heparin (porcine) in
5 % dex intravenous
parenteral solution
20,000 unit/500 ml
(40 unit/ml), 25,000
unit/250 ml(100
unit/ml)
1
5 % dex intravenous
parenteral solution
25,000 unit/500 ml
(50 unit/ml)
1
nacl (pf) intravenous
parenteral solution
1,000 unit/500 ml
1
MO
MO
MO
MO
LIPID/CHOLESTEROL LOWERING
AGENTS
ADVICOR ORAL
TABLET, ER
MULTIPHASE 24
HR 1,000-20 MG,
750-20 MG
2
MO; QL (60
per 30 days)
ADVICOR ORAL
TABLET, ER
MULTIPHASE 24
HR 1,000-40 MG,
500-20 MG
2
MO; QL (30
per 30 days)
amlodipineatorvastatin
1
MO; QL (30
per 30 days)
atorvastatin
1
MO; QL (30
per 30 days)
CHOLESTYRAMI
NE LIGHT ORAL
POWDER IN
PACKET
1
MO
colestipol oral
granules
1
MO
colestipol oral tablet
1
MO
fenofibrate oral
tablet
1
MO
fenofibrate
micronized
1
MO
fenofibrate
nanocrystallized
1
MO
of this table.
43
43
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
fenofibric acid
(choline)
1
MO
nitroglycerin
intravenous
1
B/D PA
fluvastatin oral
capsule 20 mg
1
MO; QL (30
per 30 days)
nitroglycerin
transdermal
1
MO
fluvastatin oral
capsule 40 mg
1
MO; QL (60
per 30 days)
1
MO
gemfibrozil oral
1
MO
nitroglycerin
translingual
spray,non-aerosol
JUXTAPID
3
MO; LA
NITROSTAT
2
MO
KYNAMRO
3
MO; LA
lovastatin oral tablet
10 mg
1
MO; QL (30
per 30 days)
lovastatin oral tablet
20 mg, 40 mg
1
MO; QL (60
per 30 days)
acitretin oral
capsule 10 mg
1
MO
niacin oral tablet
extended release 24
hr
1
MO
acitretin oral
capsule 17.5 mg, 25
mg
3
MO
omega-3 acid ethyl
esters
1
MO
calcipotriene
1
MO
pravastatin
1
MO; QL (30
per 30 days)
calcipotrienebetamethasone
1
MO
PREVALITE ORAL
POWDER
1
MO
calcitriol topical
1
MO
1
MO
simvastatin
1
MO; QL (30
per 30 days)
selenium sulfide
topical suspension
WELCHOL
2
MO
silver sulfadiazine
1
MO
ZETIA
2
MO
SSD
1
MO
MISCELLANEOUS
CARDIOVASCULAR AGENTS
RANEXA
2
VECAMYL
3
MO
NITRATES
isosorbide dinitrate
1
MO
isosorbide
mononitrate
1
MO
NITRO-BID
1
MO
DERMATOLOGICALS/TOPICAL
THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
BURN THERAPY
MISCELLANEOUS
DERMATOLOGICALS
8-MOP
2
MO
ammonium lactate
1
MO
CARAC
2
MO
diclofenac sodium
topical gel
1
MO
fluorouracil topical
1
MO
imiquimod
1
MO
of this table.
44
44
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
MYORISAN
1
Requirements
/Limits
methoxsalen rapid
3
OXSORALEN
2
MO
TAZORAC
2
PA; MO
PANRETIN
3
MO
tretinoin topical
1
PA; MO
podofilox
1
MO
ZENATANE
1
MO
PROTOPIC
2
PA; MO
TOPICAL ANESTHETICS
PRUDOXIN
1
MO
1
PA; MO
REGRANEX
2
MO; QL (15
per 30 days)
lidocaine topical
adhesive
patch,medicated
UVADEX
2
1
MO
ZYCLARA
2
lidocaine topical
ointment
lidocaine (pf)
mg/ml (1 %), 5
mg/ml (0.5 %)
1
MO
lidocaine hcl
mg/ml (2 %)
1
MO
lidocaine hcl mucous
membrane gel
1
MO
membrane jelly in
applicator
1
MO
membrane solution 2
%
1
MO
THERAPY FOR ACNE
adapalene
1
PA; MO
AMNESTEEM
1
MO
AVITA TOPICAL
CREAM
1
PA; MO
CLARAVIS
1
MO
clindamycin
phosphate topical
1
MO
clindamycin-benzoyl
peroxide topical gel
1
MO
ERY PADS
1
MO
erythromycin with
ethanol topical gel
1
MO
erythromycin with
ethanol topical
solution
1
MO
membrane solution 4
%
1
MO
erythromycinbenzoyl peroxide
1
MO
lidocaine-prilocaine
topical cream
1
MO
metronidazole
topical cream
1
MO
metronidazole
topical gel
1
MO
metronidazole
topical lotion
1
MO
TOPICAL ANTIBACTERIALS
gentamicin topical
1
MO
mafenide acetate
1
MO
mupirocin
1
MO
mupirocin calcium
1
MO
of this table.
45
45
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
sulfacetamide
sodium (acne)
1
MO
betamethasone,
augmented
1
MO
SULFAMYLON
TOPICAL CREAM
2
MO
clobetasol topical
foam
1
MO
clobetasol topical
gel
1
MO
clobetasol topical
lotion
1
MO
clobetasol topical
ointment
1
MO
clobetasol topical
shampoo
1
MO
clobetasol topical
solution
1
MO
clobetasol-emollient
topical cream
1
MO
desonide
1
MO
desoximetasone
1
MO
diflorasone
1
MO
fluocinolone
1
MO
fluocinonide topical
cream 0.1 %
1
MO
gel
1
MO
ointment
1
MO
solution
1
MO
FLUOCINONIDE-E
1
MO
fluticasone topical
1
MO
TOPICAL ANTIFUNGALS
ciclopirox
1
MO
clotrimazole topical
1
MO
clotrimazolebetamethasone
1
MO
econazole topical
1
MO
ketoconazole topical
1
MO
KETODAN KIT
1
MO
NYAMYC
1
MO
nystatin topical
1
MO
nystatintriamcinolone
1
MO
NYSTOP
1
MO
PEDI-DRI
1
MO
TOPICAL ANTIVIRALS
acyclovir topical
1
MO
DENAVIR
2
MO
ZOVIRAX
TOPICAL CREAM
2
MO
TOPICAL CORTICOSTEROIDS
ALA-CORT
1
MO
alclometasone
1
MO
amcinonide
1
MO
APEXICON E
1
MO
betamethasone
dipropionate
1
MO
halobetasol
propionate
1
MO
betamethasone
valerate
1
MO
hydrocortisone
topical cream 1 %,
2.5 %
1
MO
of this table.
46
46
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
hydrocortisone
topical lotion 2.5 %
1
MO
neomycin-polymyxin
b gu
1
MO
hydrocortisone
topical ointment 1
%, 2.5 %
1
MO
ringers irrigation
1
MO
hydrocortisone
butyr-emollient
1
MO
hydrocortisone
butyrate topical
ointment
1
MO
hydrocortisone
butyrate topical
solution
1
MO
hydrocortisone
valerate
1
MO
mometasone
1
MO
prednicarbate
1
MO
triamcinolone
acetonide topical
1
MO
TRIDERM
1
MO
MISCELLANEOUS AGENTS
TOPICAL ENZYMES
SANTYL
2
MO
TOPICAL SCABICIDES /
PEDICULICIDES
lindane
1
MO
malathion
1
MO
permethrin topical
cream
1
MO
spinosad
1
MO
DIAGNOSTICS /
IRRIGATING SOLUTIONS
lactated ringers
irrigation
1
MO
acamprosate
1
MO
ADAGEN
3
MO
alendronate oral
tablet 40 mg
1
MO; QL (30
per 30 days)
anagrelide
1
MO
ARALAST NP
INTRAVENOUS
RECON SOLN 500
MG
3
MO; LA
CARBAGLU
3
MO; LA
cevimeline
1
MO
CHEMET
2
MO
CLINIMIX
4.25%/D5W
SULFIT FREE
2
B/D PA
CLINIMIX E
2.75%/D10W SUL
FREE
2
CLINIMIX E
2.75%/D5W SULF
FREE
2
d10 % & 0.45 %
sodium chloride
1
d2.5 %-0.45 %
sodium chloride
1
d5 % and 0.9 %
sodium chloride
1
MO
d5 %-0.45 % sodium
chloride
1
MO
dextrose 10 % & 0.2
% nacl
1
of this table.
47
47
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
dextrose 10 % in
water (d10w)
1
MO
RAVICTI
3
MO
dextrose 5 % in
water (d5w)
intravenous
parenteral solution
1
MO
RENVELA ORAL
TABLET
2
MO
riluzole
3
MO
1
MO
dextrose 5 %lactated ringers
1
sodium chloride
irrigation
1
MO
dextrose 5%-0.2 %
sod chloride
1
sodium chloride 0.9
% intravenous
parenteral solution
dextrose 5%-0.3 %
sod.chloride
1
sodium
phenylbutyrate
3
MO
disulfiram
1
MO
1
etidronate disodium
1
MO
SODIUM
POLYSTYRENE
(SORB FREE)
EXJADE ORAL
TABLET,
DISPERSIBLE 125
MG
2
MO; LA
SYPRINE
3
MO
THIOLA
2
MO
1
MO
EXJADE ORAL
TABLET,
DISPERSIBLE 250
MG, 500 MG
3
MO; LA
water for irrigation,
sterile
zoledronic acidmannitol-water
1
PA; MO
FERRIPROX
3
MO
SMOKING DETERRENTS
INCRELEX
3
MO; LA
BUPROBAN
1
MO
KIONEX ORAL
POWDER
1
MO
CHANTIX
2
MO
levocarnitine
intravenous
1
MO
CHANTIX
CONTINUING
MONTH BOX
2
MO
levocarnitine oral
tablet
1
MO
2
levocarnitine (with
sugar)
1
MO
CHANTIX
CONTINUING
MONTH PAK
2
midodrine
1
MO
ORFADIN
3
MO; LA
CHANTIX
STARTING
MONTH BOX
pilocarpine hcl oral
1
MO
2
PROLASTIN-C
3
MO; LA
CHANTIX
STARTING
MONTH PAK
NICOTROL
2
MO
MO
MO
of this table.
48
48
Drug Name
NICOTROL NS
Drug
Tier
2
Requirements
/Limits
Drug Name
MO
dexamethasone oral
elixir
1
MO
dexamethasone oral
tablet
1
MO
DEXAMETHASON
E INTENSOL
1
MO
dexamethasone
sodium phosphate
injection
1
MO
fludrocortisone
1
MO
hydrocortisone oral
1
MO
methylprednisolone
oral tablet
1
B/D PA; MO
methylprednisolone
oral tablets,dose
pack
1
MO
methylprednisolone
acetate
1
MO
methylprednisolone
sodium succ
125 mg
1
MO
methylprednisolone
sodium succ
40 mg
1
MILLIPRED ORAL
TABLET
1
B/D PA; MO
prednisolone sodium
phosphate oral
solution 15 mg/5 ml,
5 mg base/5 ml (6.7
mg/5 ml)
1
MO
prednisolone sodium
phosphate oral
solution 25 mg/5 ml
(5 mg/ml)
1
prednisone oral
solution
1
EAR, NOSE / THROAT
MEDICATIONS
azelastine nasal
1
MO; QL (60
per 30 days)
chlorhexidine
gluconate mucous
membrane
1
ipratropium bromide
nasal
1
MO; QL (30
per 30 days)
PERIOGARD
1
MO
triamcinolone
acetonide dental
1
MO
TYZINE NASAL
DROPS 0.05 %
2
MO
MO
MISCELLANEOUS OTIC
PREPARATIONS
ACETASOL HC
1
MO
acetic acid otic
1
MO
fluocinolone
acetonide oil
1
MO
hydrocortisoneacetic acid
1
MO
ofloxacin otic
1
MO
OTIC STEROID / ANTIBIOTIC
CIPRODEX
2
MO
neomycinpolymyxin-hc otic
1
MO
ENDOCRINE/DIABETES
ADRENAL HORMONES
A-HYDROCORT
1
MO
cortisone
1
MO
Drug
Tier
Requirements
/Limits
MO
of this table.
49
49
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO; QL (180
per 30 days)
prednisone oral
tablet
1
B/D PA; MO
CYCLOSET
2
PREDNISONE
INTENSOL
1
MO
gauze pads 2 x 2
2
triamcinolone
acetonide injection
suspension 10 mg/ml
1
MO
glimepiride oral
tablet 1 mg
1
MO; QL (240
per 30 days)
1
triamcinolone
acetonide injection
suspension 40 mg/ml
1
glimepiride oral
tablet 2 mg
MO; QL (120
per 30 days)
glimepiride oral
tablet 4 mg
1
MO; QL (60
per 30 days)
VERIPRED 20
1
glipizide oral tablet
10 mg
1
MO; QL (120
per 30 days)
5 mg
1
MO; QL (240
per 30 days)
extended release
24hr 10 mg
1
MO; QL (60
per 30 days)
extended release
24hr 2.5 mg
1
MO; QL (240
per 30 days)
extended release
24hr 5 mg
1
MO; QL (120
per 30 days)
glipizide-metformin
oral tablet 2.5-250
mg
1
MO; QL (240
per 30 days)
glipizide-metformin
oral tablet 2.5-500
mg, 5-500 mg
1
MO; QL (120
per 30 days)
GLUCAGEN
2
GLUCAGEN
HYPOKIT
2
MO
GLUCAGON
EMERGENCY
2
MO
HUMALOG
2
MO
HUMALOG
KWIKPEN
2
MO
MO
ANTITHYROID AGENTS
methimazole
1
MO
propylthiouracil
1
MO
DIABETES THERAPY
acarbose oral tablet
100 mg
1
MO; QL (90
per 30 days)
25 mg
1
MO; QL (360
per 30 days)
50 mg
1
ALCOHOL PADS
2
BYDUREON
SUBCUTANEOUS
SUSPENSION,EXT
ENDED REL
RECON
2
BYETTA
SUBCUTANEOUS
PEN INJECTOR 10
MCG/DOSE(250
MCG/ML) 2.4 ML
2
BYETTA
SUBCUTANEOUS
PEN INJECTOR 5
MCG/DOSE (250
MCG/ML) 1.2 ML
2
MO; QL (180
per 30 days)
PA; MO; QL
(4 per 28 days)
PA; MO; QL
(2.4 per 30
days)
PA; MO; QL
(1.2 per 30
days)
of this table.
50
50
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 50-1,000 MG
2
MO; QL (60
per 30 days)
JANUVIA
2
MO; QL (30
per 30 days)
JENTADUETO
2
MO; QL (60
per 30 days)
LANTUS
2
MO
LANTUS
SOLOSTAR
2
MO
LEVEMIR
2
MO
LEVEMIR
FLEXPEN
2
MO
HUMALOG MIX
50-50
2
MO
HUMALOG MIX
50-50 KWIKPEN
2
MO
HUMALOG MIX
75-25
2
MO
HUMALOG MIX
75-25 KWIKPEN
2
MO
HUMULIN 70/30
2
MO
HUMULIN 70/30
KWIKPEN
2
MO
HUMULIN 70/30
PEN
2
MO
HUMULIN N
2
MO
HUMULIN N
KWIKPEN
2
MO
LEVEMIR
FLEXTOUCH
2
MO
HUMULIN N PEN
2
MO
1
HUMULIN R
2
MO
metformin oral
tablet 1,000 mg
MO; QL (75
per 30 days)
HUMULIN R U-500
"CONCENTRATED
"
2
MO
metformin oral
tablet 500 mg
1
MO; QL (150
per 30 days)
1
insulin pen needle
2
MO
metformin oral
tablet 850 mg
MO; QL (90
per 30 days)
insulin syringe (disp)
u-100 0.3 ml
2
MO
metformin oral
tablet extended
1
MO; QL (120
per 30 days)
u-100 1 ml
2
1
MO; QL (75
per 30 days)
u-100 1/2 ml
2
MO
metformin oral
tablet extended
1
INVOKANA
2
MO; QL (30
per 30 days)
MO; QL (75
per 30 days)
JANUMET
2
MO; QL (60
per 30 days)
metformin oral
tablet extended
release 24hr 1,000
mg
1
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 100-1,000
MG, 50-500 MG
2
MO; QL (30
per 30 days)
nateglinide oral
tablet 120 mg
MO; QL (90
per 30 days)
nateglinide oral
tablet 60 mg
1
MO; QL (180
per 30 days)
needles, insulin
disp.,safety
2
of this table.
51
51
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
NOVOLOG
Drug
Tier
Requirements
/Limits
2
MO
TRADJENTA
2
NOVOLOG
FLEXPEN
2
MO
MO; QL (30
per 30 days)
VGO 20
2
MO
NOVOLOG MIX
70-30
2
MO
VGO 30
2
MO
NOVOLOG MIX
70-30 FLEXPEN
2
MO
VGO 40
2
MO
NOVOLOG
PENFILL
2
MO
pioglitazone
1
MO; QL (30
per 30 days)
pioglitazoneglimepiride
1
MO; QL (30
per 30 days)
pioglitazonemetformin
1
MO; QL (90
per 30 days)
PROGLYCEM
2
MO
repaglinide oral
tablet 0.5 mg
1
MO; QL (960
per 30 days)
repaglinide oral
tablet 1 mg
1
MO; QL (480
per 30 days)
repaglinide oral
tablet 2 mg
1
MO; QL (240
per 30 days)
RIOMET
2
MO; QL (765
per 30 days)
SYMLINPEN 120
2
PA; MO; QL
(18.9 per 30
days)
SYMLINPEN 60
2
MISCELLANEOUS HORMONES
ALDURAZYME
3
MO
ANADROL-50
3
PA; MO
ANDROGEL
2
PA; MO
ANDROXY
1
MO
cabergoline
1
MO; QL (16
per 28 days)
calcitonin (salmon)
1
MO
calcitriol
intravenous
1
MO
calcitriol oral
1
MO
CEREZYME
3
MO
chorionic
gonadotropin,
human
1
PA; MO
danazol oral
1
MO
desmopressin
injection
1
MO
desmopressin nasal
spray,non-aerosol
1
MO
PA; MO; QL
(10.5 per 30
days)
desmopressin oral
1
MO
doxercalciferol
intravenous
1
doxercalciferol oral
1
MO
ELAPRASE
3
MO
ELELYSO
3
MO
tolazamide oral
tablet 250 mg
1
MO; QL (120
per 30 days)
tolazamide oral
tablet 500 mg
1
MO; QL (60
per 30 days)
tolbutamide
1
MO; QL (180
per 30 days)
of this table.
52
52
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
MO
testosterone
cypionate
1
MO
testosterone
enanthate
1
MO
VPRIV
3
MO
ZAVESCA
3
MO; LA
ZEMPLAR
INTRAVENOUS
2
MO
zoledronic acid
1
MO
FABRAZYME
INTRAVENOUS
RECON SOLN 35
MG
3
FORTICAL
1
MO
KUVAN ORAL
TABLET,SOLUBL
E
3
MO; LA
LUMIZYME
3
MO; LA
METHITEST
2
MO
MIACALCIN
INJECTION
2
MO
MYALEPT
3
PA; MO; LA
MYOZYME
3
MO
NAGLAZYME
3
MO; LA
NOVAREL
1
PA; MO
oxandrolone oral
tablet 10 mg
3
PA; MO
oxandrolone oral
tablet 2.5 mg
1
PA; MO
pamidronate
1
MO
paricalcitol
1
MO
SAMSCA ORAL
TABLET 15 MG
3
PA; MO; QL
(30 per 30
days)
SAMSCA ORAL
TABLET 30 MG
3
PA; MO; QL
(60 per 30
days)
SENSIPAR ORAL
TABLET 30 MG
2
MO
SENSIPAR ORAL
TABLET 60 MG, 90
MG
3
MO
SOMAVERT
3
MO; LA
SYNAREL
3
MO
Requirements
/Limits
THYROID HORMONES
levothyroxine oral
1
MO
LEVOXYL
1
MO
liothyronine
intravenous
1
liothyronine oral
1
MO
THYROLAR-1
2
MO
THYROLAR-1/2
2
MO
THYROLAR-1/4
2
MO
THYROLAR-2
2
MO
THYROLAR-3
2
MO
UNITHROID
ORAL TABLET
100 MCG, 112
MCG, 125 MCG,
150 MCG, 175
MCG, 200 MCG, 25
MCG, 300 MCG, 50
MCG, 75 MCG, 88
MCG
1
MO
GASTROENTEROLOGY
ANTIDIARRHEALS /
ANTISPASMODICS
atropine injection
syringe
1
of this table.
53
53
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
dicyclomine
1
MO
GAVILYTE-G
1
MO
diphenoxylateatropine
1
MO
GAVILYTE-N
1
MO
glycopyrrolate
1
MO
GENERLAC
1
MO
loperamide oral
capsule
1
MO
granisetron
1 mg/ml (1 ml)
1
MO
granisetron oral
1
B/D PA; MO
1
MISCELLANEOUS
GASTROINTESTINAL AGENTS
Drug
Tier
Requirements
/Limits
ALOXI
2
MO; QL (10
per 30 days)
granisetron (pf)
100 mcg/ml
AMITIZA
2
MO
GRANISOL
1
B/D PA; MO
balsalazide
1
MO
1
MO
budesonide oral
3
MO
hydrocortisone
rectal
CANASA
2
MO
1
MO
CESAMET
3
B/D PA; MO
lactulose oral
solution 10 gram/15
ml
CHENODAL
3
PA; MO; LA
LIALDA
2
MO
COLOCORT
1
MO
LINZESS
2
MO
COMPRO
1
MO
LOTRONEX
3
MO
CONSTULOSE
1
MO
meclizine oral tablet
1
MO
CORTIFOAM
2
MO
1
MO
CREON
2
MO
mesalamine with
cleansing wipe
cromolyn oral
1
MO
1
MO
CYSTADANE
3
MO
metoclopramide hcl
injection solution
DIPENTUM
2
MO
metoclopramide hcl
oral
1
MO
dronabinol oral
capsule 10 mg
3
B/D PA; MO
ondansetron
1
B/D PA; MO
dronabinol oral
capsule 2.5 mg, 5 mg
1
B/D PA; MO
ondansetron hcl oral
solution
1
B/D PA; MO
EMEND
INTRAVENOUS
2
MO
tablet 24 mg
1
B/D PA
EMEND ORAL
2
B/D PA; MO
tablet 4 mg, 8 mg
1
B/D PA; MO
ENULOSE
1
MO
1
MO
GAVILYTE-C
1
MO
ondansetron hcl (pf)
injection solution
of this table.
54
54
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-34,000 55,000 UNIT,
15,000-51,000 82,000 UNIT,
20,000-68,000 109,000 UNIT,
25,000-85,000136,000 UNIT,
3,000-10,00016,000 UNIT
peg 3350electrolytes oral
recon soln 23622.74-6.74 gram
1
MO
PENTASA
2
MO
polyethylene glycol
3350 oral powder
1
MO
prochlorperazine
1
MO
prochlorperazine
edisylate injection
solution 10 mg/2 ml
(5 mg/ml)
1
MO
prochlorperazine
maleate oral
1
MO
ULCER THERAPY
PROCTO-PAK
1
MO
PROCTOZONE-HC
1
MO
RECTIV
2
MO
RELISTOR
2
MO
REMICADE
3
PA; MO
SUCRAID
3
MO
sulfasalazine oral
tablet
1
SULFAZINE EC
Drug
Tier
Requirements
/Limits
2
MO
amoxicilclarithromylansopraz
1
MO; QL (112
per 30 days)
CARAFATE ORAL
SUSPENSION
1
MO
cimetidine
1
MO
esomeprazole
sodium
1
MO
famotidine oral
suspension
1
MO
1
MO
1
MO
TRANSDERMSCOP
2
MO
famotidine oral
tablet 20 mg, 40 mg
famotidine (pf)
1
MO
TRILYTE WITH
FLAVOR
PACKETS
1
MO
famotidine (pf)-nacl
(iso-os)
1
UCERIS
3
MO
1
MO; QL (30
per 30 days)
ursodiol
1
MO
lansoprazole oral
capsule,delayed
VIOKACE
2
MO
lansoprazole oral
capsule,delayed
1
MO
misoprostol
1
MO
nizatidine
1
MO
of this table.
55
55
Drug Name
Drug
Tier
omeprazole oral
capsule,delayed
release(dr/ec) 10
mg, 20 mg
1
omeprazole oral
capsule,delayed
1
omeprazole-sodium
bicarbonate oral
capsule 20-1.1 mggram
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MO; QL (30
per 30 days)
BIOTECHNOLOGY DRUGS
ACTIMMUNE
3
MO
ARCALYST
3
PA; MO
MO
AVONEX
INTRAMUSCULA
R KIT
3
PA; MO; QL
(4 per 28 days)
1
MO; QL (30
per 30 days)
AVONEX
INTRAMUSCULA
R PEN INJECTOR
KIT
3
PA; MO; QL
(4 per 28 days)
omeprazole-sodium
bicarbonate oral
capsule 40-1.1 mggram
1
MO
AVONEX
INTRAMUSCULA
R SYRINGE
3
PA; MO; QL
(4 per 28 days)
pantoprazole
intravenous
1
MO
AVONEX
ADMINISTRATIO
N PACK
3
PA; MO; QL
(4 per 28 days)
pantoprazole oral
tablet,delayed
release (dr/ec) 20
mg
1
MO; QL (30
per 30 days)
BETASERON
SUBCUTANEOUS
KIT
3
PA; MO; QL
(15 per 28
days)
pantoprazole oral
tablet,delayed
release (dr/ec) 40
mg
1
EGRIFTA
3
PA; MO
ILARIS (PF)
3
PA; MO; LA
2
MO
rabeprazole
1
MO
ranitidine hcl
mg/ml
1
MO
INTRON A
INJECTION
RECON SOLN 10
MILLION UNIT (1
ML)
2
MO
ranitidine hcl oral
capsule
1
MO
ranitidine hcl oral
syrup
1
MO
INTRON A
INJECTION
SOLUTION 6
MILLION
UNIT/ML
LEUKINE
3
MO
ranitidine hcl oral
tablet 150 mg, 300
mg
1
MO
MOZOBIL
3
MO
NEULASTA
3
sucralfate oral tablet
1
PA; MO; QL
(2 per 30 days)
NEUMEGA
3
MO
MO
MO
IMMUNOLOGY, VACCINES /
BIOTECHNOLOGY
of this table.
56
56
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
NEUPOGEN
INJECTION
SOLUTION 480
MCG/1.6 ML
3
PA; MO
NEUPOGEN
INJECTION
SYRINGE
3
PA; MO
OMNITROPE
SUBCUTANEOUS
CARTRIDGE
2
PA; MO
OMNITROPE
SUBCUTANEOUS
RECON SOLN
3
PA; MO
PEGASYS
3
MO; QL (4 per
28 days)
PEGASYS
CONVENIENCE
PACK
3
MO; QL (4 per
28 days)
PEGASYS
PROCLICK
3
MO; QL (4 per
28 days)
PEGINTRON
3
MO; QL (4 per
28 days)
PEGINTRON
REDIPEN
3
MO; QL (4 per
28 days)
PROCRIT
INJECTION
SOLUTION 10,000
UNIT/ML, 2,000
UNIT/ML, 20,000
UNIT/2 ML, 3,000
UNIT/ML, 4,000
UNIT/ML
2
PA; MO
PROCRIT
INJECTION
SOLUTION 20,000
UNIT/ML, 40,000
UNIT/ML
3
PROLEUKIN
REBIF (WITH
ALBUMIN)
Drug
Tier
Requirements
/Limits
REBIF REBIDOSE
SUBCUTANEOUS
PEN INJECTOR 22
MCG/0.5 ML, 44
MCG/0.5 ML
3
PA; MO; QL
(6 per 28 days)
REBIF REBIDOSE
SUBCUTANEOUS
PEN INJECTOR
8.8MCG/0.2ML-22
MCG/0.5ML (6)
3
PA; MO; QL
(12 per 28
days)
REBIF TITRATION
PACK
3
PA; MO; QL
(12 per 28
days)
SAIZEN
3
PA; MO
SAIZEN
CLICK.EASY
3
PA; MO
SYLATRON
3
MO
VACCINES / MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF)
2
MO
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
INTRAMUSCULA
R SUSPENSION
2
MO
ATGAM
3
B/D PA
bcg vaccine, live (pf)
2
BOOSTRIX TDAP
2
MO
2
PA; MO
PA; MO
BOTOX
INJECTION
RECON SOLN 100
UNIT
3
PA
3
MO
CARIMUNE NF
NANOFILTERED
INTRAVENOUS
RECON SOLN 3
GRAM
3
PA; MO; QL
(6 per 28 days)
CERVARIX
VACCINE (PF)
2
MO
of this table.
57
57
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
IPOL INJECTION
SUSPENSION
2
MO
IXIARO (PF)
2
MO
M-M-R II (PF)
2
MO
MENACTRA (PF)
2
MO
MENOMUNE A/C/Y/W-135 (PF)
2
MO
MENVEO A-C-YW-135-DIP (PF)
2
MO
PEDVAX HIB (PF)
2
MO
PRIVIGEN
3
PA; MO
PROQUAD (PF)
2
COMVAX (PF)
2
MO
DAPTACEL (DTAP
PEDIATRIC) (PF)
2
MO
ENGERIX-B (PF)
INTRAMUSCULA
R SYRINGE
2
B/D PA; MO
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SUSPENSION
2
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SYRINGE
2
fomepizole
1
MO
RABAVERT (PF)
2
MO
GAMASTAN S/D
2
MO
RAGWITEK
2
MO
GAMUNEX-C
INJECTION
SOLUTION 1
GRAM/10 ML (10
%)
2
PA; MO
2
B/D PA; MO
GARDASIL (PF)
INTRAMUSCULA
R SUSPENSION
2
MO
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SUSPENSION 10
MCG/ML, 40
MCG/ML
ROTARIX
2
HAVRIX (PF)
INTRAMUSCULA
R SUSPENSION
1,440 ELISA
UNIT/ML
2
ROTATEQ
VACCINE
2
tetanus
toxoid,adsorbed (pf)
1
MO
2
MO
HAVRIX (PF)
INTRAMUSCULA
R SYRINGE 720
ELISA UNIT/0.5
ML
2
tetanus-diphtheria
toxoids-td
TWINRIX (PF)
INTRAMUSCULA
R SUSPENSION
2
MO
2
IMOVAX RABIES
VACCINE (PF)
2
TYPHIM VI
INTRAMUSCULA
R SOLUTION
INFANRIX (DTAP)
(PF)
INTRAMUSCULA
R SUSPENSION
2
VAQTA (PF)
INTRAMUSCULA
R SUSPENSION 25
UNIT/0.5 ML
2
B/D PA; MO
B/D PA
MO
MO
MO
of this table.
58
58
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
BENLYSTA
INTRAVENOUS
RECON SOLN 120
MG
2
MO
CUPRIMINE
3
MO
DEPEN
TITRATABS
2
MO
ENBREL
SUBCUTANEOUS
KIT
3
PA; MO; QL
(8 per 28 days)
ENBREL
SUBCUTANEOUS
SYRINGE 25
MG/0.5ML (0.51)
3
PA; MO; QL
(8 per 28 days)
ENBREL
SUBCUTANEOUS
SYRINGE 50
MG/ML (0.98 ML)
3
PA; MO; QL
(4 per 28 days)
ENBREL
SURECLICK
3
PA; MO; QL
(4 per 28 days)
HUMIRA
SUBCUTANEOUS
KIT 20 MG/0.4 ML
3
PA; MO; QL
(2 per 28 days)
HUMIRA
SUBCUTANEOUS
KIT 40 MG/0.8 ML
3
PA; MO; QL
(3.2 per 28
days)
HUMIRA
CROHN'S DIS
START PCK
3
PA; MO; QL
(4.8 per 180
days)
HUMIRA PEN
3
PA; MO; QL
(3.2 per 28
days)
HUMIRA
PSORIASIS
STARTER PACK
3
PA; MO; QL
(3.2 per 180
days)
leflunomide
1
MO; QL (30
per 30 days)
ORENCIA
3
PA; MO
VARIVAX (PF)
2
MO
YF-VAX (PF)
2
MO
ZOSTAVAX (PF)
2
MO
MUSCULOSKELETAL /
RHEUMATOLOGY
GOUT THERAPY
allopurinol
1
ALOPRIM
1
colchicineprobenecid
1
MO
COLCRYS
2
MO
probenecid
1
MO
ULORIC
2
ST; MO
MO
OSTEOPOROSIS THERAPY
alendronate oral
solution
1
MO; QL (1286
per 30 days)
alendronate oral
tablet 10 mg, 5 mg
1
MO; QL (30
per 30 days)
alendronate oral
tablet 35 mg, 70 mg
1
MO; QL (4 per
28 days)
FORTEO
3
PA; MO; QL
(2.4 per 28
days)
ibandronate
intravenous
2
PA; MO
ibandronate oral
1
MO; QL (1 per
30 days)
PROLIA
2
PA; MO
raloxifene
1
MO
risedronate
1
MO; QL (1 per
30 days)
OTHER RHEUMATOLOGICALS
ACTEMRA
3
PA; MO
Drug
Tier
Requirements
/Limits
of this table.
59
59
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
ORENCIA (WITH
MALTOSE)
3
PA; MO
norethindrone
(contraceptive)
1
MO
OTEZLA
3
PA; MO
1
MO
OTEZLA
STARTER
3
PA; MO
norethindrone
acetate
1
MO
RIDAURA
2
MO
progesterone
micronized
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
MISCELLANEOUS OB/GYN
clindamycin
phosphate vaginal
1
MO
1
MO
CAMILA
1
MO
DEPO-PROVERA
INTRAMUSCULA
R SOLUTION
2
MO
metronidazole
vaginal
1
MO
ERRIN
1
MO
MICONAZOLE-3
VAGINAL
SUPPOSITORY
ESTRACE
VAGINAL
2
MO
terconazole
1
MO
tranexamic acid oral
1
MO
estradiol oral
1
MO
VANDAZOLE
1
MO
estradiol
transdermal
1
MO; QL (4 per
28 days)
XULANE
1
MO
estradiol valerate
1
MO
estradiolnorethindrone acet
1
MO
estropipate
1
MO
JOLIVETTE
1
MO
LYZA
1
medroxyprogesteron
e intramuscular
suspension
1
MO
medroxyprogesteron
e oral
1
MO
MENEST
2
MO
MIMVEY
1
MO
MIMVEY LO
1
MO
NORA-BE
1
MO
ORAL CONTRACEPTIVES / RELATED
AGENTS
AMETHIA
1
MO
AMETHYST
1
MO
APRI
1
MO
ARANELLE (28)
1
MO
AVIANE
1
MO
BALZIVA (28)
1
MO
BRIELLYN
1
MO
CRYSELLE (28)
1
MO
CYCLAFEM 1/35
(28)
1
MO
CYCLAFEM 7/7/7
(28)
1
MO
drospirenone-ethinyl
estradiol
1
of this table.
60
60
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
MICROGESTIN FE
1.5/30 (28)
1
MO
MICROGESTIN FE
1/20 (28)
1
MO
MONONESSA (28)
1
MO
NECON 0.5/35 (28)
1
MO
NECON 1/35 (28)
1
MO
NECON 1/50 (28)
1
MO
NECON 10/11 (28)
1
MO
NECON 7/7/7 (28)
1
MO
NORTREL 0.5/35
(28)
1
MO
ELLA
2
MO
EMOQUETTE
1
MO
ENPRESSE
1
MO
GIANVI (28)
1
MO
GILDAGIA
1
MO
INTROVALE
1
MO
JUNEL 1.5/30 (21)
1
MO
JUNEL 1/20 (21)
1
MO
JUNEL FE 1.5/30
(28)
1
MO
JUNEL FE 1/20 (28)
1
MO
KARIVA (28)
1
MO
KELNOR 1/35 (28)
1
MO
NORTREL 1/35
(21)
1
MO
LARIN 1/20 (21)
1
1
MO
LARIN FE
1
MO
NORTREL 1/35
(28)
LEENA 28
1
MO
1
MO
LESSINA
1
MO
NORTREL 7/7/7
(28)
LEVONEST (28)
1
MO
OCELLA
1
MO
levonorgestrelethinyl estrad oral
tablets,dose pack,3
month
1
MO
OGESTREL (28)
1
MO
ORSYTHIA
1
MO
PIMTREA (28)
1
MO
LEVORA-28
1
MO
1
MO
LOMEDIA 24 FE
1
MO
PIRMELLA ORAL
TABLET 1-35 MGMCG
LORYNA (28)
1
MO
PORTIA
1
MO
LOW-OGESTREL
(28)
1
MO
PREVIFEM
1
MO
QUASENSE
1
MO
LUTERA (28)
1
MO
RECLIPSEN (28)
1
MO
MARLISSA
1
MO
SPRINTEC (28)
1
MO
MICROGESTIN
1.5/30 (21)
1
MO
SRONYX
1
MO
MICROGESTIN
1/20 (21)
1
MO
TRI-LEGEST FE
1
MO
TRI-PREVIFEM
(28)
1
MO
of this table.
61
61
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
Requirements
/Limits
TRI-SPRINTEC
(28)
1
MO
levofloxacin
ophthalmic
1
MO
TRINESSA (28)
1
MO
NATACYN
2
MO
TRIVORA (28)
1
MO
1
MO
VELIVET
TRIPHASIC
REGIMEN (28)
1
MO
neomycinbacitracinpolymyxin
1
MO
VESTURA (28)
1
MO
VYFEMLA (28)
1
MO
neomycinpolymyxingramicidin
ZENCHENT (28)
1
MO
ofloxacin ophthalmic
1
MO
ZENCHENT FE
1
MO
polymyxin b sulftrimethoprim
1
MO
ZOVIA 1/35E (28)
1
MO
tobramycin
1
MO
ZOVIA 1/50E (28)
1
MO
ANTIVIRALS
trifluridine
1
MO
ZIRGAN
2
MO
betaxolol ophthalmic
1
MO
carteolol
1
MO
levobunolol
ophthalmic drops
0.5 %
1
MO
metipranolol
1
MO
1
MO
OXYTOCICS
methylergonovine
oral
1
MO
BETA-BLOCKERS
OPHTHALMOLOGY
ANTIBIOTICS
bacitracin
ophthalmic
1
MO
bacitracinpolymyxin b
ophthalmic
1
MO
ciprofloxacin
ophthalmic
1
MO
timolol maleate
ophthalmic
erythromycin
ophthalmic
1
MO
CHOLINESTERASE INHIBITOR
MIOTICS
gatifloxacin
1
MO
GENTAK
OPHTHALMIC
OINTMENT
1
MO
PHOSPHOLINE
IODIDE
gentamicin
ophthalmic drops
1
gentamicin
ophthalmic ointment
1
MO
2
MO
DIRECT ACTING MIOTICS
pilocarpine hcl
ophthalmic
1
MO
MISCELLANEOUS
OPHTHALMOLOGICS
of this table.
62
62
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
Drug
Tier
azelastine
ophthalmic
1
MO
1
MO
cromolyn
ophthalmic
1
MO
neomycinpolymyxin-hc
ophthalmic
1
MO
CYSTARAN
3
MO
tobramycindexamethasone
epinastine
1
MO
RESTASIS
2
MO; QL (60
per 30 days)
dexamethasone
sodium phosphate
ophthalmic
1
MO
FML S.O.P.
2
MO
PRED MILD
2
MO
prednisolone acetate
1
MO
prednisolone sodium
phosphate
ophthalmic
1
MO
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
bromfenac
1
MO
diclofenac sodium
ophthalmic
1
MO
flurbiprofen sodium
1
MO
ketorolac
ophthalmic
1
MO
ORAL DRUGS FOR GLAUCOMA
Requirements
/Limits
STEROIDS
STEROID-SULFONAMIDE
COMBINATIONS
BLEPHAMIDE
2
MO
1
BLEPHAMIDE
S.O.P.
2
MO
1
sulfacetamideprednisolone
1
MO
1
MO
acetazolamide oral
1
acetazolamide
sodium
methazolamide oral
MO
MO
OTHER GLAUCOMA DRUGS
SULFONAMIDES
dorzolamide
1
MO
dorzolamide-timolol
1
MO
sulfacetamide
sodium ophthalmic
latanoprost
1
MO
SYMPATHOMIMETICS
travoprost
(benzalkonium)
1
MO
ALPHAGAN P
OPHTHALMIC
DROPS 0.1 %
2
MO
apraclonidine
1
MO
brimonidine
1
MO
STEROID-ANTIBIOTIC
COMBINATIONS
neomycinbacitracin-poly-hc
1
MO
neomycinpolymyxin-dexameth
1
MO
VASOCONSTRICTOR
DECONGESTANTS
naphazoline
1
MO
RESPIRATORY AND ALLERGY
of this table.
63
63
Drug Name
Drug
Tier
Requirements
/Limits
ANTIHISTAMINE /
ANTIALLERGENIC AGENTS
ADRENALIN
INJECTION
SOLUTION 1
MG/ML (1:1,000)
(1ML)
1
cetirizine oral
solution 1 mg/ml
1
MO
desloratadine
1
MO; QL (30
per 30 days)
diphenhydramine hcl
injection solution
1
MO
diphenhydramine hcl
oral elixir
1
PA; MO
EPIPEN
2
QL (4 per 30
days)
EPIPEN 2-PAK
2
MO; QL (4 per
30 days)
EPIPEN JR
2
QL (4 per 30
days)
EPIPEN JR 2-PAK
2
MO; QL (4 per
30 days)
hydroxyzine hcl oral
tablet
1
PA; MO
levocetirizine oral
solution
1
MO
levocetirizine oral
tablet
1
MO; QL (30
per 30 days)
promethazine
injection solution
1
MO
PULMONARY AGENTS
acetylcysteine
solution
1
ADEMPAS
3
B/D PA; MO
PA; MO; LA
Drug Name
Drug
Tier
Requirements
/Limits
albuterol sulfate
inhalation solution
for nebulization 0.63
mg/3 ml, 1.25 mg/3
ml, 2.5 mg /3 ml
(0.083 %), 5 mg/ml
1
B/D PA; MO
albuterol sulfate oral
1
MO
aminophylline
250 mg/10 ml
1
MO
ARCAPTA
NEOHALER
2
MO; QL (30
per 30 days)
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 110
MCG (30 DOSES),
220 MCG (30
DOSES)
2
MO; QL (30
per 30 days)
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 220
MCG (120 DOSES)
2
MO; QL (240
per 30 days)
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 220
MCG (60 DOSES)
2
MO; QL (60
per 30 days)
ATROVENT HFA
2
MO; QL (25.8
per 30 days)
budesonide
inhalation
1
B/D PA; MO
budesonide nasal
1
MO; QL (17.2
per 30 days)
of this table.
64
64
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
CINRYZE
3
PA; MO
COMBIVENT
RESPIMAT
2
MO; QL (8 per
30 days)
cromolyn inhalation
1
B/D PA; MO
DALIRESP
2
PA; MO
DULERA
2
PA; MO; QL
(13 per 30
days)
FIRAZYR
3
PA; MO
flunisolide
1
MO; QL (50
per 30 days)
fluticasone nasal
1
MO; QL (16
per 30 days)
ipratropium bromide
inhalation
1
B/D PA; MO
ipratropiumalbuterol
1
B/D PA; MO
KALYDECO
3
MO
LETAIRIS
3
PA; MO; LA
levalbuterol hcl
inhalation solution
for nebulization 0.31
mg/3 ml, 0.63 mg/3
ml, 1.25 mg/0.5 ml
1
B/D PA; MO
metaproterenol
1
MO
montelukast
1
MO
OPSUMIT
3
PA; MO; LA
PERFOROMIST
2
B/D PA; MO
PROAIR HFA
2
MO; QL (17
per 30 days)
PULMICORT
INHALATION
SUSPENSION FOR
NEBULIZATION 1
MG/2 ML
2
B/D PA; MO
PULMOZYME
3
Drug
Tier
Requirements
/Limits
QVAR
2
MO; QL (17.4
per 30 days)
REVATIO
INTRAVENOUS
3
PA; MO
SEREVENT
DISKUS
2
MO; QL (60
per 30 days)
sildenafil
1
PA; MO; QL
(90 per 30
days)
SPIRIVA WITH
HANDIHALER
2
MO; QL (90
per 30 days)
SYMBICORT
INHALATION HFA
AEROSOL
INHALER 160-4.5
MCG/ACTUATION
2
PA; MO; QL
(10.2 per 30
days)
SYMBICORT
INHALATION HFA
AEROSOL
INHALER 80-4.5
MCG/ACTUATION
2
PA; MO; QL
(6.9 per 30
days)
terbutaline oral
1
MO
terbutaline
subcutaneous
1
MO
theophylline oral
solution
1
theophylline oral
tablet extended
release
1
MO
theophylline oral
tablet extended
release 12 hr
1
MO
TRACLEER
3
PA; MO; LA
triamcinolone
acetonide nasal
1
MO; QL (16.5
per 30 days)
TYVASO
3
B/D PA; MO
B/D PA; MO
of this table.
65
65
Drug Name
XOLAIR
zafirlukast
Drug
Tier
Requirements
/Limits
Drug Name
3
PA; MO; LA;
QL (6 per 28
days)
KLOR-CON 10
1
MO
KLOR-CON 8
1
MO
KLOR-CON M15
1
MO
KLOR-CON M20
1
MO
lactated ringers
intravenous
1
MO
magnesium sulfate
injection syringe
1
1
MO
UROLOGICALS
ANTICHOLINERGICS /
ANTISPASMODICS
Drug
Tier
Requirements
/Limits
flavoxate
1
MO
oxybutynin chloride
oral
1
MO
NORMOSOL-R IN
5 % DEXTROSE
2
tolterodine
1
MO
1
trospium
1
MO
potassium chloridd5-0.45%nacl
intravenous
parenteral solution
10 meq/l, 30 meq/l,
40 meq/l
potassium chloridd5-0.45%nacl
intravenous
parenteral solution
20 meq/l
1
MO
potassium chloride
intravenous
parenteral solution
1
MO
potassium chloride
intravenous
piggyback 10
meq/100 ml, 20
meq/100 ml, 40
meq/100 ml
1
potassium chloride
oral capsule,
extended release
1
MO
potassium chloride
oral tablet,er
particles/crystals
1
MO
potassium chloride
in 0.9%nacl
1
BENIGN PROSTATIC
HYPERPLASIA(BPH) THERAPY
alfuzosin
1
MO
finasteride oral
tablet 5 mg
1
MO
tamsulosin
1
MO
CHOLINERGIC STIMULANTS
bethanechol chloride
1
MO
MISCELLANEOUS UROLOGICALS
ammonium chloride
2
CYSTAGON
2
MO; LA
ELMIRON
2
MO
potassium citrate
release 10 meq, 5
meq
1
MO
VITAMINS, HEMATINICS /
ELECTROLYTES
ELECTROLYTES
calcium acetate oral
capsule
1
MO
ELIPHOS
1
MO
of this table.
66
66
Drug Name
Drug
Tier
Requirements
/Limits
potassium chloride
in 5 % dex
intravenous
parenteral solution
20 meq/l, 40 meq/l
1
potassium chloride
in lr-d5 intravenous
parenteral solution
20 meq/l
1
potassium chloride0.45 % nacl
1
potassium chlorided5-0.2%nacl
intravenous
parenteral solution
20 meq/l
1
1
1
ringers intravenous
1
sodium chloride
intravenous
parenteral solution
2.5 meq/ml
1
MO
sodium chloride 0.45
% intravenous
parenteral solution
1
MO
sodium chloride 3 %
1
sodium chloride 5 %
1
sodium lactate
intravenous
1
MO
MO
MO
MISCELLANEOUS NUTRITION
PRODUCTS
AMINOSYN 8.5 %ELECTROLYTES
2
B/D PA
AMINOSYN II 10
%
2
B/D PA
Drug Name
Drug
Tier
Requirements
/Limits
AMINOSYN II 15
%
2
B/D PA
AMINOSYN II 7 %
2
B/D PA
AMINOSYN II 8.5
%
2
B/D PA
AMINOSYN II 8.5
%ELECTROLYTES
2
B/D PA
AMINOSYN M 3.5
%
2
B/D PA
AMINOSYN-PF 10
%
2
B/D PA
AMINOSYN-PF 7
% (SULFITEFREE)
2
B/D PA
CLINIMIX
5%/D15W
SULFITE FREE
2
B/D PA
CLINIMIX
5%/D25W
SULFITE-FREE
2
B/D PA
CLINIMIX
2.75%/D5W
SULFIT FREE
2
B/D PA
CLINIMIX 4.25%D20W SULF-FREE
2
B/D PA
CLINIMIX 4.25%D25W SULF-FREE
2
B/D PA
CLINIMIX
4.25%/D10W SULF
FREE
2
B/D PA
CLINIMIX 5%D20W(SULFITEFREE)
2
B/D PA
CLINIMIX E
4.25%/D25W SUL
FREE
2
of this table.
67
67
Drug Name
Drug
Tier
Requirements
/Limits
CLINIMIX E
4.25%/D5W SULF
FREE
2
CLINIMIX E
5%/D15W SULFIT
FREE
2
CLINIMIX E
5%/D20W SULFIT
FREE
2
CLINIMIX E
5%/D25W SULFIT
FREE
2
HEPATAMINE 8%
2
B/D PA
HEPATASOL 8 %
2
B/D PA
INTRALIPID
INTRAVENOUS
EMULSION 20 %
1
B/D PA; MO
IONOSOL-B IN
D5W
2
IONOSOL-MB IN
D5W
2
ISOLYTE-P IN 5 %
DEXTROSE
2
ISOLYTE-S
2
LIPOSYN III
INTRAVENOUS
EMULSION 10 %,
20 %
1
B/D PA
NEPHRAMINE 5.4
%
2
B/D PA
NORMOSOL-M IN
5 % DEXTROSE
2
NORMOSOL-R PH
7.4
2
PLASMA-LYTE
148
2
PLASMA-LYTE A
2
Drug Name
Drug
Tier
Requirements
/Limits
PLASMA-LYTE-56
IN 5 % DEXTROSE
2
PREMASOL 10 %
1
B/D PA
PREMASOL 6 %
2
B/D PA
PROCALAMINE
3%
2
B/D PA
TRAVASOL 10 %
1
B/D PA
TROPHAMINE 10
%
2
B/D PA
TROPHAMINE 6%
2
B/D PA
VITAMINS / HEMATINICS
PRENATAL
VITAMIN
1
sodium fluoride oral
tablet
1
of this table.
68
68
Index
AMPHETAMINE SALT
alfuzosin ...............................66
8
COMBO ...........................33
ALIMTA ..............................22
8-MOP..................................44
amphotericin b ......................14
ALINIA ................................18
A
ampicillin..............................19
allopurinol ............................59
abacavir ................................14
ampicillin sodium .................19
ALOPRIM ............................59
abacavir-lamivudineampicillin-sulbactam ............19
ALOXI..................................54
zidovudine ........................14
AMPYRA .............................28
ALPHAGAN P.....................63
ABELCET............................14
ANADROL-50 .....................52
alprazolam ............................33
ABILIFY ..............................33
anagrelide .............................47
amantadine hcl......................14
ABILIFY DISCMELT .........33
anastrozole............................22
AMBISOME ........................14
ABILIFY MAINTENA........33
ANDROGEL ........................52
amcinonide ...........................46
ABRAXANE........................21
ANDROXY ..........................52
AMETHIA............................60
acamprosate..........................47
APEXICON E ......................46
AMETHYST
........................60
acarbose................................50
APOKYN .............................28
amifostine crystalline ...........21
acebutolol .............................40
apraclonidine ........................63
amikacin
...............................18
acetaminophen-codeine........29
APRI .....................................60
amiloride...............................40
ACETASOL HC ..................49
APTIOM...............................27
amiloride-hydrochlorothiazide
acetazolamide .......................63
APTIVUS .............................14
..........................................40
acetazolamide sodium ..........63
ARALAST NP......................47
aminophylline.......................64
acetic acid.............................49
ARANELLE (28) .................60
AMINOSYN 8.5 %acetylcysteine .......................64
ARCALYST .........................56
ELECTROLYTES............67
acitretin.................................44
ARCAPTA NEOHALER.....64
AMINOSYN II 10 % ...........67
ACTEMRA ..........................59
ARRANON ..........................22
AMINOSYN II 15 % ...........67
ACTHIB (PF).......................57
ARZERRA ...........................22
AMINOSYN
II
7
%
.............67
ACTIMMUNE .....................56
ASMANEX TWISTHALER 64
AMINOSYN II 8.5 % ..........67
acyclovir .........................14, 46
atenolol .................................40
AMINOSYN II 8.5 %acyclovir sodium ..................14
atenolol-chlorthalidone.........40
ELECTROLYTES............67
ADACEL(TDAP
ATGAM ...............................57
AMINOSYN M 3.5 %..........67
ADOLESN/ADULT)(PF) 57
atorvastatin ...........................43
AMINOSYN-PF 10 % .........67
ADAGEN .............................47
atovaquone............................18
AMINOSYN-PF 7 %
adapalene..............................45
atovaquone-proguanil ...........18
(SULFITE-FREE) ............67
adefovir.................................14
ATRIPLA .............................14
amiodarone ...........................40
ADEMPAS...........................64
atropine .................................53
AMITIZA
.............................54
ADRENALIN.......................64
ATROVENT HFA................64
amitriptyline .........................33
ADVICOR............................43
AUGMENTIN ......................20
amlodipine
............................40
AFEDITAB CR....................40
AVASTIN.............................22
amlodipine-atorvastatin ........43
AFINITOR .....................21, 22
AVELOX IN NACL (ISOamlodipine-benazepril ..........40
AFINITOR DISPERZ ..........22
OSMOTIC).......................20
ammonium chloride..............66
AGGRENOX .......................42
AVIANE...............................60
ammonium lactate ................44
A-HYDROCORT.................49
AVITA..................................45
AMNESTEEM .....................45
ALA-CORT..........................46
AVONEX .............................56
amoxapine ............................33
ALBENZA ...........................18
AVONEX
amoxicil-clarithromy-lansopraz
albuterol sulfate ....................64
ADMINISTRATION PACK
..........................................55
alclometasone .......................46
..........................................56
amoxicillin............................19
ALCOHOL PADS................50
azacitidine.............................22
amoxicillin-pot clavulanate ..19
ALDURAZYME..................52
AZASAN..............................22
alendronate .....................47, 59
of this table.
69
69
azathioprine ..........................22
azelastine ........................49, 63
AZILECT .............................28
azithromycin.........................17
aztreonam .............................18
B
BACIIM ...............................18
bacitracin ........................18, 62
bacitracin-polymyxin b ........62
baclofen ................................29
balsalazide ............................54
BALZIVA (28).....................60
BANZEL ..............................27
BARACLUDE .....................14
bcg vaccine, live (pf)............57
benazepril .............................40
benazepril-hydrochlorothiazide
..........................................40
BENLYSTA .........................59
benztropine ...........................28
betamethasone dipropionate.46
betamethasone valerate ........46
betamethasone, augmented...46
BETASERON ......................56
betaxolol .........................40, 62
bethanechol chloride ............66
BETHKIS .............................18
bicalutamide .........................22
BICILLIN C-R .....................20
BICILLIN L-A .....................20
BICNU .................................22
bisoprolol fumarate ..............40
bisoprolol-hydrochlorothiazide
..........................................40
bleomycin .............................22
BLEPHAMIDE ....................63
BLEPHAMIDE S.O.P..........63
BOOSTRIX TDAP ..............57
BOSULIF .............................22
BOTOX ................................57
BRIELLYN ..........................60
BRILINTA ...........................42
brimonidine ..........................63
BRINTELLIX ......................33
bromfenac.............................63
bromocriptine .......................28
budesonide......................54, 64
bumetanide ...........................40
buprenorphine.......................29
buprenorphine-naloxone.......32
BUPROBAN ........................48
bupropion hcl..................33, 34
buspirone ..............................34
BUSULFEX .........................22
butorphanol tartrate ..............32
BYDUREON........................50
BYETTA ..............................50
C
cabergoline ...........................52
calcipotriene .........................44
calcipotriene-betamethasone 44
calcitonin (salmon) ...............52
calcitriol..........................44, 52
calcium acetate .....................66
CAMILA ..............................60
CANASA..............................54
CANCIDAS..........................14
candesartan ...........................40
candesartan-hydrochlorothiazid
..........................................40
CAPASTAT .........................18
CAPRELSA..........................22
captopril................................40
captopril-hydrochlorothiazide
..........................................40
CARAC ................................44
CARAFATE.........................55
CARBAGLU ........................47
carbamazepine ......................27
carbidopa ..............................28
carbidopa-levodopa ..............28
carbidopa-levodopaentacapone ........................28
carboplatin ............................22
CARIMUNE NF
NANOFILTERED............57
carteolol ................................62
CARTIA XT.........................40
carvedilol ..............................40
CAYSTON ...........................18
cefaclor .................................16
cefadroxil..............................16
cefazolin ...............................16
cefazolin in dextrose (iso-os)16
cefdinir..................................17
cefditoren pivoxil .................17
cefepime ...............................17
cefotaxime ............................17
cefotetan ...............................17
cefoxitin................................17
70
70
cefoxitin in dextrose, iso-osm
..........................................17
cefpodoxime .........................17
cefprozil ................................17
ceftazidime ...........................17
ceftriaxone ............................17
cefuroxime axetil ..................17
cefuroxime sodium ...............17
CELEBREX .........................32
CELLCEPT ..........................22
CELLCEPT INTRAVENOUS
..........................................22
CELONTIN ..........................27
cephalexin.............................17
CEREZYME.........................52
CERVARIX VACCINE (PF)
..........................................57
CESAMET ...........................54
cetirizine ...............................64
cevimeline.............................47
CHANTIX ............................48
CHANTIX CONTINUING
MONTH BOX ..................48
CHANTIX CONTINUING
MONTH PAK ..................48
CHANTIX STARTING
MONTH BOX ..................48
CHANTIX STARTING
MONTH PAK ..................48
CHEMET..............................47
CHENODAL ........................54
chloramphenicol sod succinate
..........................................18
chlorhexidine gluconate........49
chloroquine phosphate..........18
chlorothiazide .......................40
chlorothiazide sodium ..........40
chlorpromazine .....................34
chlorthalidone .......................40
CHOLESTYRAMINE LIGHT
..........................................43
chorionic gonadotropin, human
..........................................52
ciclopirox..............................46
cidofovir ...............................14
cilostazol...............................42
cimetidine .............................55
CINRYZE.............................65
CIPRODEX ..........................49
ciprofloxacin...................20, 62
ciprofloxacin (mixture) ........20
ciprofloxacin in 5 % dextrose
..........................................20
cisplatin ................................22
citalopram.............................34
cladribine..............................22
CLARAVIS..........................45
clarithromycin ......................17
clindamycin hcl ....................18
clindamycin in dextrose 5 % 18
CLINDAMYCIN PEDIATRIC
..........................................18
clindamycin phosphate..18, 45,
60
clindamycin-benzoyl peroxide
..........................................45
CLINIMIX 5%/D15W
SULFITE FREE ...............67
CLINIMIX 5%/D25W
SULFITE-FREE...............67
CLINIMIX 2.75%/D5W
SULFIT FREE..................67
CLINIMIX 4.25%/D10W
SULF FREE .....................67
CLINIMIX 4.25%/D5W
SULFIT FREE..................47
CLINIMIX 4.25%-D20W
SULF-FREE .....................67
CLINIMIX 4.25%-D25W
SULF-FREE .....................67
CLINIMIX 5%D20W(SULFITE-FREE) .67
CLINIMIX E 2.75%/D10W
SUL FREE........................47
SULF FREE .....................47
SUL FREE........................67
SULF FREE .....................68
CLINIMIX E 5%/D15W
SULFIT FREE..................68
CLINIMIX E 5%/D20W
SULFIT FREE..................68
CLINIMIX E 5%/D25W
SULFIT FREE..................68
clobetasol..............................46
clobetasol-emollient .............46
CLOLAR..............................22
clomipramine........................34
clonazepam...........................27
clonidine ...............................40
clonidine hcl ...................34, 40
clopidogrel............................42
clorazepate dipotassium .......34
CLORPRES..........................41
clotrimazole ....................14, 46
clotrimazole-betamethasone.46
clozapine...............................34
COARTEM ..........................18
codeine sulfate......................29
colchicine-probenecid ..........59
COLCRYS............................59
colestipol ..............................43
colistin (colistimethate na) ...18
COLOCORT ........................54
COMBIVENT RESPIMAT .65
COMETRIQ .........................22
COMPLERA ........................14
COMPRO .............................54
COMVAX (PF) ....................58
CONSTULOSE ....................54
COPAXONE ........................29
CORTIFOAM ......................54
cortisone ...............................49
CREON ................................54
CRIXIVAN ..........................14
cromolyn...................54, 63, 65
CRYSELLE (28) ..................60
CUBICIN..............................18
CUPRIMINE ........................59
CYCLAFEM 1/35 (28) ........60
CYCLAFEM 7/7/7 (28) .......60
cyclobenzaprine....................29
cyclophosphamide ................22
CYCLOSET .........................50
cyclosporine..........................22
cyclosporine modified ..........22
CYSTADANE......................54
CYSTAGON ........................66
CYSTARAN ........................63
cytarabine .............................22
cytarabine (pf) ......................22
D
d10 % & 0.45 % sodium
chloride.............................47
d2.5 %-0.45 % sodium
chloride.............................47
d5 % and 0.9 % sodium
chloride.............................47
71
71
d5 %-0.45 % sodium chloride
..........................................47
dacarbazine ...........................22
DALIRESP ...........................65
danazol..................................52
dantrolene .............................29
dapsone .................................18
DAPTACEL (DTAP
PEDIATRIC) (PF)............58
DARAPRIM .........................18
daunorubicin .........................22
decitabine..............................22
demeclocycline .....................21
DEMSER..............................41
DENAVIR ............................46
DEPEN TITRATABS ..........59
DEPO-PROVERA................60
desipramine...........................34
desloratadine.........................64
desmopressin ........................52
desonide................................46
desoximetasone.....................46
dexamethasone .....................49
DEXAMETHASONE
INTENSOL.......................49
dexamethasone sodium
phosphate....................49, 63
dexmethylphenidate..............34
dexrazoxane..........................21
dextroamphetamine ..............34
dextroamphetamineamphetamine.....................34
dextrose 10 % & 0.2 % nacl .47
dextrose 10 % in water (d10w)
..........................................48
dextrose 5 % in water (d5w).48
dextrose 5 %-lactated ringers48
dextrose 5%-0.2 % sod
chloride .............................48
dextrose 5%-0.3 %
sod.chloride ......................48
diazepam.........................27, 34
DIAZEPAM INTENSOL.....34
DIBENZYLINE ...................41
diclofenac potassium ............32
diclofenac sodium.....32, 44, 63
diclofenac-misoprostol .........32
dicloxacillin ..........................20
dicyclomine ..........................54
didanosine.............................15
diflorasone............................46
diflunisal...............................32
digoxin..................................42
dihydroergotamine ...............28
DILANTIN...........................27
diltiazem hcl .........................41
DILT-XR..............................41
DIPENTUM .........................54
diphenhydramine hcl ............64
diphenoxylate-atropine.........54
dipyridamole.........................42
disulfiram .............................48
divalproex.............................27
DOCEFREZ .........................22
docetaxel.........................22, 23
donepezil ..............................29
DORIBAX............................18
dorzolamide..........................63
dorzolamide-timolol .............63
doxazosin..............................41
doxepin .................................34
doxercalciferol......................52
DOXIL .................................23
doxorubicin...........................23
doxycycline hyclate..............21
doxycycline monohydrate ....21
dronabinol.............................54
drospirenone-ethinyl estradiol
..........................................60
DROXIA ..............................23
DULERA..............................65
duloxetine.............................34
DURAMORPH (PF) ......29, 30
DUTOPROL.........................41
E
E.E.S. 400.............................17
E.E.S. GRANULES .............17
econazole..............................46
EDURANT...........................15
EFFIENT..............................42
EGRIFTA .............................56
ELAPRASE..........................52
ELELYSO ............................52
ELIGARD ............................23
ELIPHOS .............................66
ELIQUIS ..............................43
ELITEK................................21
ELLA....................................61
ELMIRON............................66
EMCYT................................23
EMEND................................54
EMOQUETTE......................61
EMSAM ...............................34
EMTRIVA............................15
enalapril maleate...................41
enalapril-hydrochlorothiazide
..........................................41
ENBREL ..............................59
ENBREL SURECLICK .......59
ENDOCET ...........................30
ENDODAN ..........................30
ENGERIX-B (PF) ................58
ENGERIX-B PEDIATRIC
(PF)...................................58
enoxaparin ............................43
ENPRESSE ..........................61
entacapone ............................28
ENULOSE............................54
epinastine..............................63
EPIPEN ................................64
EPIPEN 2-PAK ....................64
EPIPEN JR ...........................64
EPIPEN JR 2-PAK...............64
epirubicin..............................23
EPITOL ................................27
EPIVIR .................................15
EPIVIR HBV........................15
eplerenone ............................41
eprosartan .............................41
EPZICOM ............................15
ERBITUX.............................23
ergoloid.................................34
ERGOMAR ..........................28
ERIVEDGE ..........................23
ERRIN ..................................60
ERWINAZE .........................23
ERY PADS...........................45
ERYPED 200 .......................17
ERYPED 400 .......................17
ERY-TAB.............................17
ERYTHROCIN ....................17
ERYTHROCIN (AS
STEARATE) ....................18
erythromycin ..................18, 62
erythromycin ethylsuccinate.18
erythromycin with ethanol....45
erythromycin-benzoyl peroxide
..........................................45
erythromycin-sulfisoxazole ..18
escitalopram oxalate .............34
72
72
esomeprazole sodium ...........55
ESTRACE ............................60
estradiol ................................60
estradiol valerate...................60
estradiol-norethindrone acet .60
estropipate.............................60
eszopiclone ...........................34
ethambutol ............................18
ethosuximide.........................27
etidronate disodium ..............48
etodolac.................................32
ETOPOPHOS .......................23
etoposide...............................23
EXELON ..............................29
exemestane ...........................23
EXJADE ...............................48
F
FABRAZYME .....................53
famciclovir............................15
famotidine.............................55
famotidine (pf)......................55
famotidine (pf)-nacl (iso-os)55
FANAPT.........................34, 35
FARESTON .........................23
FASLODEX .........................23
FAZACLO............................35
felbamate ..............................27
felodipine..............................41
fenofibrate.............................43
fenofibrate micronized..........43
fenofibrate nanocrystallized .43
fenofibric acid (choline) .......44
fenoprofen.............................32
fentanyl citrate ......................30
fentanyl patches ....................30
FERRIPROX ........................48
FETZIMA.............................35
finasteride .............................66
FIRAZYR .............................65
FIRMAGON KIT W
DILUENT SYRINGE ......23
flavoxate ...............................66
flecainide ..............................40
fluconazole ...........................14
fluconazole in dextrose(iso-o)
..........................................14
flucytosine ............................14
fludarabine ............................23
fludrocortisone......................49
flunisolide .............................65
fluocinolone..........................46
fluocinolone acetonide oil ....49
fluocinonide..........................46
FLUOCINONIDE-E ............46
fluorouracil .....................23, 44
fluoxetine..............................35
fluphenazine decanoate ........35
fluphenazine hcl ...................35
flurbiprofen...........................32
flurbiprofen sodium..............63
flutamide...............................23
fluticasone ......................46, 65
fluvastatin .............................44
fluvoxamine..........................35
FML S.O.P. ..........................63
FOLOTYN ...........................23
fomepizole............................58
fondaparinux.........................43
FORTEO ..............................59
FORTICAL ..........................53
foscarnet ...............................15
fosinopril ..............................41
fosinopril-hydrochlorothiazide
..........................................41
fosphenytoin .........................27
furosemide............................41
FUSILEV .............................21
FUZEON ..............................15
FYCOMPA ..........................27
G
gabapentin ............................27
GABITRIL ...........................27
GABLOFEN.........................29
galantamine ..........................29
GAMASTAN S/D ................58
GAMUNEX-C .....................58
ganciclovir sodium ...............15
GARDASIL (PF)..................58
gatifloxacin...........................62
gauze pads 2 x 2 ...................50
GAVILYTE-C......................54
GAVILYTE-G .....................54
GAVILYTE-N .....................54
gemcitabine ..........................23
gemfibrozil ...........................44
GENERLAC.........................54
GENGRAF ...........................23
GENTAK .............................62
gentamicin ................18, 45, 62
gentamicin in nacl (iso-osm) 18
gentamicin sulfate (pf)..........18
GEODON .............................35
GIANVI (28) ........................61
GILDAGIA ..........................61
GILENYA ............................29
GILOTRIF............................23
GLEEVEC............................23
glimepiride............................50
glipizide ................................50
glipizide-metformin..............50
GLUCAGEN ........................50
GLUCAGEN HYPOKIT .....50
GLUCAGON EMERGENCY
..........................................50
glycopyrrolate.......................54
granisetron ............................54
granisetron (pf) .....................54
GRANISOL..........................54
griseofulvin microsize ..........14
griseofulvin ultramicrosize...14
guanidine ..............................35
H
HALAVEN...........................23
halobetasol propionate..........46
haloperidol............................35
haloperidol decanoate...........35
haloperidol lactate ................35
HAVRIX (PF) ......................58
heparin (porcine) ..................43
heparin (porcine) in 5 % dex 43
heparin (porcine) in nacl (pf)43
HEPATAMINE 8%..............68
HEPATASOL 8 % ...............68
HERCEPTIN ........................23
HEXALEN ...........................23
HUMALOG..........................50
HUMALOG KWIKPEN ......50
HUMALOG MIX 50-50 ......51
HUMALOG MIX 50-50
KWIKPEN........................51
HUMALOG MIX 75-25 ......51
HUMALOG MIX 75-25
KWIKPEN........................51
HUMIRA..............................59
HUMIRA CROHN'S DIS
START PCK.....................59
HUMIRA PEN .....................59
HUMIRA PSORIASIS
STARTER PACK.............59
HUMULIN 70/30 .................51
73
73
HUMULIN 70/30 KWIKPEN
..........................................51
HUMULIN 70/30 PEN.........51
HUMULIN N .......................51
HUMULIN N KWIKPEN....51
HUMULIN N PEN...............51
HUMULIN R........................51
HUMULIN R U-500 ............51
hydralazine ...........................41
hydrochlorothiazide..............41
hydrocodone-acetaminophen30
hydrocodone-ibuprofen ........30
hydrocortisone ....46, 47, 49, 54
hydrocortisone butyrate ........47
hydrocortisone butyr-emollient
..........................................47
hydrocortisone valerate ........47
hydrocortisone-acetic acid....49
hydromorphone.....................30
hydromorphone (pf)..............30
hydroxychloroquine..............18
hydroxyurea ..........................23
hydroxyzine hcl ....................64
I
ibandronate ...........................59
ibuprofen...............................32
ibuprofen-oxycodone............30
idarubicin..............................23
ifosfamide .............................23
ILARIS (PF) .........................56
IMBRUVICA .......................23
imipenem-cilastatin ..............18
imipramine hcl......................35
imipramine pamoate .............35
imiquimod.............................44
IMOVAX RABIES VACCINE
(PF) ...................................58
INCRELEX ..........................48
indapamide ...........................41
INFANRIX (DTAP) (PF).....58
INLYTA .........................23, 24
insulin pen needle .................51
insulin syringe (disp) u-100 0.3
ml......................................51
insulin syringe (disp) u-100 1
ml......................................51
insulin syringe (disp) u-100 1/2
ml......................................51
INTELENCE ........................15
INTRALIPID........................68
INTRON A...........................56
INTROVALE .......................61
INVANZ...............................18
INVEGA.........................35, 36
INVEGA SUSTENNA.........36
INVIRASE ...........................15
INVOKANA ........................51
IONOSOL-B IN D5W .........68
IONOSOL-MB IN D5W......68
IPOL .....................................58
ipratropium bromide.......49, 65
ipratropium-albuterol ...........65
irbesartan ..............................41
irbesartan-hydrochlorothiazide
..........................................41
irinotecan..............................24
ISENTRESS .........................15
ISOLYTE-P IN 5 %
DEXTROSE .....................68
ISOLYTE-S..........................68
isoniazid ...............................18
isosorbide dinitrate ...............44
isosorbide mononitrate .........44
isradipine ..............................41
ISTODAX ............................24
itraconazole ..........................14
IXEMPRA............................24
IXIARO (PF)........................58
J
JAKAFI ................................24
JANTOVEN .........................43
JANUMET ...........................51
JANUMET XR.....................51
JANUVIA.............................51
JENTADUETO ....................51
JEVTANA............................24
JOLIVETTE .........................60
JUNEL 1.5/30 (21)...............61
JUNEL 1/20 (21)..................61
JUNEL FE 1.5/30 (28) .........61
JUNEL FE 1/20 (28) ............61
JUXTAPID...........................44
K
KADCYLA ..........................24
KALETRA ...........................15
KALYDECO........................65
KARIVA (28).......................61
KELNOR 1/35 (28)..............61
KEPIVANCE .......................21
ketoconazole...................14, 46
KETODAN KIT ...................46
ketoprofen.............................32
ketorolac ...............................63
KIONEX...............................48
KLOR-CON 10 ....................66
KLOR-CON 8 ......................66
KLOR-CON M15.................66
KLOR-CON M20.................66
KUVAN................................53
KYNAMRO .........................44
L
labetalol ................................41
lactated ringers ...............47, 66
lactulose................................54
LAMISIL..............................14
lamivudine ............................15
lamivudine-zidovudine.........15
lamotrigine............................27
LANOXIN............................42
lansoprazole..........................55
LANTUS ..............................51
LANTUS SOLOSTAR.........51
LARIN 1/20 (21) ..................61
LARIN FE ............................61
latanoprost ............................63
LATUDA..............................36
LEENA 28............................61
leflunomide...........................59
LESSINA..............................61
LETAIRIS ............................65
letrozole ................................24
leucovorin calcium ...............21
LEUKERAN ........................24
LEUKINE.............................56
leuprolide..............................24
levalbuterol hcl .....................65
LEVEMIR ............................51
LEVEMIR FLEXPEN..........51
LEVEMIR FLEXTOUCH ...51
levetiracetam ........................27
levobunolol...........................62
levocarnitine .........................48
levocarnitine (with sugar).....48
levocetirizine ........................64
levofloxacin ....................20, 62
levofloxacin in d5w ..............20
LEVONEST (28)..................61
levonorgestrel-ethinyl estrad 61
LEVORA-28 ........................61
levorphanol tartrate...............30
74
74
levothyroxine........................53
LEVOXYL ...........................53
LEXIVA ...............................15
LIALDA ...............................54
lidocaine ...............................45
lidocaine (pf) ........................45
lidocaine hcl..........................45
lidocaine-prilocaine ..............45
lindane ..................................47
LINZESS ..............................54
LIORESAL...........................29
liothyronine...........................53
LIPOSYN III ........................68
lisinopril................................41
lisinopril-hydrochlorothiazide
..........................................41
lithium carbonate ..................36
lithium citrate........................36
LOMEDIA 24 FE .................61
lomustine ..............................24
loperamide ............................54
lorazepam .............................36
LORAZEPAM INTENSOL .36
LORCET (HYDROCODONE)
..........................................30
LORCET HD........................30
LORCET PLUS....................30
LORTAB 10-325..................30
LORTAB 5-325....................30
LORTAB 7.5-325.................30
LORYNA (28)......................61
losartan .................................41
losartan-hydrochlorothiazide 41
LOTRONEX.........................54
lovastatin...............................44
LOW-OGESTREL (28)........61
loxapine succinate ................36
LUMIZYME.........................53
LUPRON DEPOT ................24
LUPRON DEPOT (3
MONTH) ..........................24
LUPRON DEPOT (4
MONTH) ..........................24
LUPRON DEPOT (6
MONTH) ..........................24
LUPRON DEPOT-PED .......24
LUTERA (28).......................61
LYRICA ...............................27
LYSODREN.........................24
LYZA ...................................60
M
MACRODANTIN................21
mafenide acetate...................45
magnesium sulfate................66
malathion..............................47
maprotiline ...........................36
MARLISSA..........................61
MARPLAN ..........................36
MATULANE .......................24
MATZIM LA .......................41
meclizine ..............................54
meclofenamate .....................32
medroxyprogesterone ...........60
mefenamic acid ....................32
mefloquine............................19
megestrol ..............................24
MEKINIST...........................24
meloxicam ............................32
melphalan .............................24
MENACTRA (PF) ...............58
MENEST..............................60
MENOMUNE - A/C/Y/W-135
(PF)...................................58
MENVEO A-C-Y-W-135-DIP
(PF)...................................58
mercaptopurine.....................24
meropenem ...........................19
mesalamine with cleansing
wipe ..................................54
mesna....................................21
MESNEX .............................21
MESTINON .........................29
MESTINON TIMESPAN ....29
METADATE ER..................36
metaproterenol......................65
metformin .............................51
methadone ............................31
methamphetamine ................36
methazolamide .....................63
methenamine hippurate ........21
methimazole .........................50
METHITEST........................53
methotrexate sodium ............24
methotrexate sodium (pf) .....24
methoxsalen rapid ................45
methyclothiazide ..................41
methyldopa ...........................41
methylergonovine.................62
methylphenidate ...................36
methylprednisolone ..............49
methylprednisolone acetate ..49
methylprednisolone sodium
succ...................................49
metipranolol..........................62
metoclopramide hcl ..............54
metolazone............................41
metoprolol succinate.............41
metoprolol ta-hydrochlorothiaz
..........................................41
metoprolol tartrate ................41
metronidazole ...........19, 45, 60
metronidazole in nacl (iso-os)
..........................................19
mexiletine .............................40
MIACALCIN .......................53
MICONAZOLE-3 ................60
MICROGESTIN 1.5/30 (21) 61
MICROGESTIN 1/20 (21)...61
MICROGESTIN FE 1.5/30
(28) ...................................61
MICROGESTIN FE 1/20 (28)
..........................................61
midodrine..............................48
MIGERGOT.........................28
MILLIPRED.........................49
MIMVEY .............................60
MIMVEY LO .......................60
minocycline ..........................21
minoxidil ..............................41
mirtazapine ...........................36
misoprostol ...........................55
mitomycin.............................24
mitoxantrone.........................24
M-M-R II (PF)......................58
modafinil ..............................36
MODERIBA.........................15
MODERIBA DOSE PACK..15
moexipril ..............................41
moexipril-hydrochlorothiazide
..........................................42
mometasone..........................47
MONONESSA (28) .............61
montelukast ..........................65
morphine...............................31
morphine concentrate ...........31
moxifloxacin.........................20
MOZOBIL............................56
mupirocin..............................45
mupirocin calcium................45
MUSTARGEN .....................24
75
75
MYALEPT ...........................53
MYCAMINE........................14
mycophenolate mofetil .........24
mycophenolate sodium .........24
MYORISAN.........................45
MYOZYME .........................53
N
nabumetone...........................32
nadolol ..................................42
nadolol-bendroflumethiazide42
nafcillin.................................20
nafcillin in dextrose iso-osm 20
NAGLAZYME.....................53
nalbuphine ............................32
naloxone ...............................32
naltrexone .............................32
NAMENDA..........................29
NAMENDA TITRATION
PAK ..................................29
naphazoline...........................63
naproxen ...............................32
naproxen sodium ..................32
naratriptan.............................28
NATACYN...........................62
nateglinide ............................51
NEBUPENT .........................19
NECON 0.5/35 (28)..............61
NECON 1/35 (28).................61
NECON 1/50 (28).................61
NECON 10/11 (28)...............61
NECON 7/7/7 (28) ...............61
needles, insulin disp.,safety ..51
nefazodone............................36
neomycin ..............................19
neomycin-bacitracin-poly-hc63
neomycin-bacitracinpolymyxin.........................62
neomycin-polymyxin b gu....47
neomycin-polymyxindexameth...........................63
neomycin-polymyxingramicidin.........................62
neomycin-polymyxin-hc.49, 63
NEPHRAMINE 5.4 %..........68
NEULASTA .........................56
NEUMEGA ..........................56
NEUPOGEN.........................57
NEUPRO ..............................28
nevirapine .............................15
NEXAVAR...........................24
niacin ....................................44
nicardipine............................42
NICOTROL..........................48
NICOTROL NS....................49
NIFEDICAL XL ..................42
nifedipine..............................42
NILANDRON ......................24
nimodipine............................42
nisoldipine ............................42
NITRO-BID .........................44
nitrofurantoin........................21
nitrofurantoin macrocrystal ..21
nitrofurantoin monohyd/mcryst ..................................21
nitroglycerin .........................44
NITROSTAT........................44
nizatidine ..............................55
NORA-BE ............................60
norethindrone (contraceptive)
..........................................60
norethindrone acetate ...........60
NORMOSOL-M IN 5 %
DEXTROSE .....................68
NORMOSOL-R IN 5 %
DEXTROSE .....................66
NORMOSOL-R PH 7.4 .......68
NORTREL 0.5/35 (28).........61
NORTREL 1/35 (21)............61
NORTREL 1/35 (28)............61
NORTREL 7/7/7 (28)...........61
nortriptyline..........................36
NORVIR...............................15
NOVAREL...........................53
NOVOLOG ..........................52
NOVOLOG FLEXPEN........52
NOVOLOG MIX 70-30 .......52
NOVOLOG MIX 70-30
FLEXPEN ........................52
NOVOLOG PENFILL .........52
NOXAFIL ............................14
NUEDEXTA ........................29
NULOJIX .............................24
NYAMYC ............................46
nystatin ...........................14, 46
nystatin-triamcinolone..........46
NYSTOP ..............................46
O
OCELLA ..............................61
octreotide acetate..................25
ofloxacin...................20, 49, 62
OGESTREL (28)..................61
olanzapine.......................36, 37
olanzapine-fluoxetine ...........37
OLYSIO ...............................15
omega-3 acid ethyl esters .....44
omeprazole ...........................56
omeprazole-sodium
bicarbonate .......................56
OMNITROPE.......................57
ONCASPAR.........................25
ondansetron ..........................54
ondansetron hcl.....................54
ondansetron hcl (pf)..............54
ONFI.....................................27
OPSUMIT ............................65
ORAP ...................................37
ORENCIA ............................59
ORENCIA (WITH
MALTOSE)......................60
ORFADIN ............................48
ORSYTHIA..........................61
OTEZLA ..............................60
OTEZLA STARTER............60
oxacillin................................20
oxacillin in dextrose(iso-osm)
..........................................20
oxaliplatin.............................25
oxandrolone ..........................53
oxaprozin..............................33
oxazepam..............................37
oxcarbazepine.......................27
OXSORALEN......................45
oxybutynin chloride..............66
oxycodone ............................31
oxycodone-acetaminophen...31
oxycodone-aspirin ................31
oxymorphone..................31, 32
P
PACERONE.........................40
paclitaxel ..............................25
pamidronate ..........................53
PANRETIN ..........................45
pantoprazole .........................56
paricalcitol ............................53
paromomycin........................19
paroxetine hcl .......................37
PASER..................................19
PAXIL ..................................37
PEDI-DRI.............................46
PEDVAX HIB (PF)..............58
76
76
peg 3350-electrolytes............55
PEGANONE.........................27
PEGASYS ............................57
PEGASYS CONVENIENCE
PACK ...............................57
PEGASYS PROCLICK........57
PEGINTRON .......................57
PEGINTRON REDIPEN......57
penicillin g potassium...........20
penicillin g procaine .............20
penicillin g sodium ...............20
penicillin v potassium...........20
PENTAM..............................19
PENTASA ............................55
pentoxifylline........................43
PERFOROMIST...................65
perindopril erbumine ............42
PERIOGARD .......................49
PERJETA .............................25
permethrin.............................47
perphenazine.........................37
perphenazine-amitriptyline...37
PFIZERPEN-G .....................20
phenelzine.............................37
phenobarbital ........................27
phenytoin ..............................27
phenytoin sodium .................28
phenytoin sodium extended ..28
PHOSPHOLINE IODIDE ....62
pilocarpine hcl ................48, 62
PIMTREA (28).....................61
pindolol.................................42
pioglitazone ..........................52
pioglitazone-glimepiride.......52
pioglitazone-metformin ........52
piperacillin-tazobactam ........20
PIRMELLA ..........................61
piroxicam..............................33
PLASMA-LYTE 148 ...........68
PLASMA-LYTE A ..............68
PLASMA-LYTE-56 IN 5 %
DEXTROSE .....................68
podofilox...............................45
polyethylene glycol 3350 .....55
polymyxin b sulfate ..............19
polymyxin b sulf-trimethoprim
..........................................62
POMALYST.........................25
PORTIA................................61
potassium chlorid-d50.45%nacl.........................66
potassium chloride................66
potassium chloride in 0.9%nacl
..........................................66
potassium chloride in 5 % dex
..........................................67
potassium chloride in lr-d5...67
potassium chloride-0.45 % nacl
..........................................67
potassium chloride-d50.2%nacl...........................67
potassium citrate...................66
POTIGA ...............................28
pramipexole..........................28
pravastatin ............................44
prazosin ................................42
PRED MILD ........................63
prednicarbate ........................47
prednisolone acetate .............63
prednisolone sodium phosphate
....................................49, 63
prednisone ......................49, 50
PREDNISONE INTENSOL 50
PREMASOL 10 % ...............68
PREMASOL 6 % .................68
PRENATAL VITAMIN.......68
PREVALITE ........................44
PREVIFEM ..........................61
PREZISTA ...........................15
PRIFTIN...............................19
primaquine............................19
primidone .............................28
PRIMSOL.............................21
PRISTIQ...............................37
PRIVIGEN ...........................58
PROAIR HFA ......................65
probenecid ............................59
procainamide ........................40
PROCALAMINE 3%...........68
PROCENTRA ......................37
prochlorperazine...................55
prochlorperazine edisylate....55
prochlorperazine maleate .....55
PROCRIT .............................57
PROCTO-PAK.....................55
PROCTOZONE-HC.............55
progesterone micronized ......60
PROGLYCEM .....................52
PROGRAF............................25
PROLASTIN-C ....................48
PROLEUKIN .......................57
PROLIA................................59
PROMACTA........................43
promethazine ........................64
propafenone ..........................40
propranolol ...........................42
propranolol-hydrochlorothiazid
..........................................42
propylthiouracil ....................50
PROQUAD (PF)...................58
PROTOPIC...........................45
protriptyline ..........................37
PRUDOXIN .........................45
PULMICORT.......................65
PULMOZYME.....................65
pyrazinamide ........................19
pyridostigmine bromide .......29
Q
QUASENSE .........................61
quetiapine .............................37
quinapril................................42
quinapril-hydrochlorothiazide
..........................................42
quinidine gluconate ..............40
quinidine sulfate ...................40
quinine sulfate ......................19
QVAR...................................65
R
RABAVERT (PF) ................58
rabeprazole ...........................56
RAGWITEK.........................58
raloxifene..............................59
ramipril .................................42
RANEXA .............................44
ranitidine hcl.........................56
RAPAMUNE........................25
RAVICTI..............................48
REBIF (WITH ALBUMIN).57
REBIF REBIDOSE ..............57
REBIF TITRATION PACK.57
RECLIPSEN (28) .................61
RECOMBIVAX HB (PF) ....58
RECTIV................................55
REGRANEX ........................45
RELENZA DISKHALER ....15
77
77
RELISTOR ...........................55
REMICADE .........................55
REMODULIN ......................42
RENVELA ...........................48
repaglinide ............................52
REPREXAIN........................32
RESCRIPTOR ......................15
RESTASIS............................63
RETROVIR ..........................16
REVATIO.............................65
REVLIMID...........................25
REYATAZ ...........................16
RIBAPAK DOSE PACK .....16
RIBASPHERE......................16
ribavirin ................................16
RIDAURA............................60
rifabutin ................................19
rifampin ................................19
riluzole..................................48
rimantadine ...........................16
ringers .............................47, 67
RIOMET...............................52
risedronate ............................59
RISPERDAL CONSTA .37, 38
risperidone ............................38
RITUXAN ............................25
rivastigmine tartrate..............29
rizatriptan..............................28
ropinirole ..............................28
ROTARIX ............................58
ROTATEQ VACCINE.........58
ROZEREM ...........................38
S
SABRIL................................28
SAIZEN................................57
SAIZEN CLICK.EASY .......57
SAMSCA..............................53
SANDOSTATIN LAR
DEPOT .............................25
SANTYL ..............................47
SAPHRIS..............................38
SAPHRIS (BLACK
CHERRY).........................38
selegiline hcl .........................28
selenium sulfide....................44
SELZENTRY .......................16
SENSIPAR ...........................53
SEREVENT DISKUS ..........65
SEROQUEL XR.............38, 39
sertraline ...............................39
SIGNIFOR ...........................25
sildenafil ...............................65
silver sulfadiazine.................44
SIMULECT..........................25
simvastatin............................44
sirolimus ...............................25
SIRTURO.............................19
sodium chloride ..............48, 67
sodium chloride 0.45 %........67
sodium chloride 0.9 %..........48
sodium chloride 3 %.............67
sodium chloride 5 %.............67
sodium fluoride ....................68
sodium lactate.......................67
sodium phenylbutyrate .........48
SODIUM POLYSTYRENE
(SORB FREE) ..................48
SOLTAMOX........................25
SOMAVERT........................53
SORINE ...............................40
sotalol ...................................40
SOTALOL AF......................40
SOVALDI ............................16
spinosad................................47
SPIRIVA WITH
HANDIHALER................65
spironolactone ......................42
spironolacton-hydrochlorothiaz
..........................................42
SPORANOX ........................14
SPRINTEC (28) ...................61
SPRYCEL ............................25
SRONYX .............................61
SSD.......................................44
stavudine...............................16
STIVARGA..........................25
STRATTERA.......................39
streptomycin .........................19
STRIBILD............................16
STROMECTOL ...................19
SUCRAID ............................55
sucralfate ..............................56
sulfacetamide sodium...........63
sulfacetamide sodium (acne) 46
sulfacetamide-prednisolone..63
sulfadiazine...........................21
sulfamethoxazole-trimethoprim
..........................................21
SULFAMYLON...................46
sulfasalazine .........................55
SULFAZINE EC ..................55
sulindac.................................33
sumatriptan ...........................28
sumatriptan succinate ...........28
SUPRAX ..............................17
SURMONTIL.......................39
SUSTIVA .............................16
SUTENT...............................25
SYLATRON.........................57
SYLVANT ...........................25
SYMBICORT.......................65
SYMLINPEN 120 ................52
SYMLINPEN 60 ..................52
SYNAGIS.............................16
SYNAREL............................53
SYNERCID ..........................19
SYNRIBO ............................25
SYPRINE .............................48
T
TABLOID ............................25
tacrolimus .............................25
TAFINLAR ..........................25
TAMIFLU ............................16
tamoxifen..............................25
tamsulosin.............................66
TARCEVA ...........................26
TARGRETIN .......................26
TASIGNA ............................26
TAZORAC ...........................45
TAZTIA XT .........................42
TECFIDERA ........................29
TEFLARO ............................17
TEGRETOL XR...................28
telmisartan ............................42
telmisartan-amlodipine.........42
telmisartan-hydrochlorothiazid
..........................................42
temazepam............................39
terazosin................................42
terbinafine.............................14
terbutaline.............................65
terconazole............................60
testosterone cypionate ..........53
testosterone enanthate...........53
tetanus toxoid,adsorbed (pf) .58
tetanus-diphtheria toxoids-td 58
tetracycline ...........................21
THALOMID.........................26
theophylline ..........................65
THIOLA ...............................48
78
78
thioridazine ...........................39
thiothixene ............................39
THYROLAR-1 .....................53
THYROLAR-1/2 ..................53
THYROLAR-1/4 ..................53
THYROLAR-2 .....................53
THYROLAR-3 .....................53
tiagabine ...............................28
TIKOSYN.............................40
timolol maleate ...............42, 62
tinidazole ..............................19
TIVICAY..............................16
tizanidine ..............................29
tobramycin ............................62
tobramycin in 0.225 % nacl..19
tobramycin in 0.9 % nacl......19
tobramycin sulfate ................19
tobramycin-dexamethasone..63
tolazamide.............................52
tolbutamide ...........................52
tolmetin.................................33
tolterodine.............................66
topiramate .............................28
TOPOSAR............................26
topotecan...............................26
TORISEL..............................26
torsemide ..............................42
TRACLEER .........................65
TRADJENTA .......................52
tramadol ................................33
tramadol-acetaminophen ......33
trandolapril ...........................42
tranexamic acid...............43, 60
TRANSDERM-SCOP ..........55
tranylcypromine....................39
TRAVASOL 10 % ...............68
travoprost (benzalkonium)....63
trazodone ..............................39
TREANDA ...........................26
TRECATOR .........................19
TRELSTAR ..........................26
TRELSTAR DEPOT ............26
TRELSTAR LA....................26
tretinoin.................................45
tretinoin (chemotherapy) ......26
triamcinolone acetonide.47, 49,
50, 65
triamterene-hydrochlorothiazid
..........................................42
TRIDERM ............................47
trifluoperazine ......................39
trifluridine.............................62
TRI-LEGEST FE..................61
TRILYTE WITH FLAVOR
PACKETS ........................55
trimethoprim.........................21
TRINESSA (28) ...................62
TRI-PREVIFEM (28)...........61
TRISENOX ..........................26
TRI-SPRINTEC (28)............62
TRIVORA (28) ....................62
TROPHAMINE 10 % ..........68
TROPHAMINE 6% .............68
trospium................................66
TRUVADA ..........................16
TWINRIX (PF) ....................58
TYGACIL ............................19
TYKERB..............................26
TYPHIM VI .........................58
TYSABRI.............................29
TYVASO..............................65
TYZEKA..............................16
TYZINE ...............................49
U
UCERIS................................55
ULORIC ...............................59
UNITHROID........................53
ursodiol.................................55
UVADEX .............................45
V
valacyclovir ..........................16
VALCYTE ...........................16
valproate sodium ..................28
valproic acid .........................28
valproic acid (as sodium salt)
..........................................28
valsartan-hydrochlorothiazide
..........................................42
vancomycin ..........................21
VANDAZOLE .....................60
VAQTA (PF)........................58
VARIVAX (PF) ...................59
VECAMYL ..........................44
VECTIBIX ...........................26
VELCADE ...........................26
VELIVET TRIPHASIC
REGIMEN (28) ................62
venlafaxine ...........................39
verapamil ..............................42
VERIPRED 20 .....................50
VERSACLOZ ......................39
VESTURA (28)....................62
VGO 20 ................................52
VGO 30 ................................52
VGO 40 ................................52
VICODIN .............................32
VICODIN ES .......................32
VICODIN HP .......................32
VICTRELIS..........................16
VIDEX 2 GRAM PEDIATRIC
..........................................16
VIIBRYD .............................39
VIMPAT...............................28
vinblastine ............................26
vincristine .............................26
vinorelbine............................26
VIOKACE ............................55
VIRACEPT ..........................16
VIRAMUNE XR..................16
VIRAZOLE ..........................16
VIREAD...............................16
VOLTAREN GEL................33
voriconazole .........................14
VOTRIENT ..........................26
VPRIV ..................................53
VYFEMLA (28) ...................62
W
warfarin ................................43
water for irrigation, sterile....48
WELCHOL ..........................44
X
XALKORI ............................26
XARELTO ...........................43
XENAZINE..........................29
XGEVA ................................21
XIFAXAN ............................19
79
79
XOLAIR ...............................66
XTANDI...............................26
XULANE..............................60
XYREM................................39
Y
YERVOY .............................26
YF-VAX (PF).......................59
Z
zafirlukast .............................66
zaleplon.................................39
ZALTRAP ............................26
ZAMICET ............................32
ZANOSAR ...........................26
ZAVESCA............................53
ZELBORAF .........................26
ZEMPLAR ...........................53
ZENATANE.........................45
ZENCHENT (28) .................62
ZENCHENT FE ...................62
ZENPEP ...............................55
ZENZEDI .............................39
ZETIA...................................44
ZIAGEN ...............................16
zidovudine ............................16
ziprasidone hcl......................39
ZIRGAN ...............................62
zoledronic acid......................53
zoledronic acid-mannitol-water
..........................................48
ZOLINZA.............................26
zolmitriptan...........................28
zolpidem ...............................39
zonisamide............................28
ZORTRESS ....................26, 27
ZOSTAVAX (PF) ................59
ZOVIA 1/35E (28) ...............62
ZOVIA 1/50E (28) ...............62
ZOVIRAX ............................46
ZUBSOLV............................33
ZYCLARA ...........................45
ZYKADIA ............................27
ZYTIGA ...............................27
ZYVOX ................................19
Community HealthFirst™ Medicare Advantage Plans
2015 Pharmacy Directory
This pharmacy directory was updated on 08/22/2014. For more recent information or other questions,
please contact Community Health Plan of Washington at 1-800-944-1247 or for TTY users, Dial 7-1-1, 7
days a week, 8am – 8pm or visit www.healthfirst.chpw.org.
Introduction
This booklet provides a list of Community HealthFirst™ Medicare Advantage Plans’s network
pharmacies. To get a complete description of your prescription coverage, including how to fill your
prescriptions, please review the Evidence of Coverage and Community HealthFirst™ Medicare
Advantage Plans’s formulary.
When this pharmacy directory refers to “we,” “us”, or “our,” it means Community Health Plan of
Washington. When it refers to “plan” or “our plan,” it means Community HealthFirst™ Medicare
Advantage Plans.
We call the pharmacies on this list our “network pharmacies” because we have made arrangements with
them to provide prescription drugs to Plan members. In most cases, your prescriptions are covered
under our plan only if they are filled at a network pharmacy or through our mail order pharmacy service.
Once you go to one pharmacy, you are not required to continue going to the same pharmacy to fill your
prescription but can switch to any other of our network pharmacies. We will fill prescriptions at nonnetwork pharmacies under certain circumstances as described in your Evidence of Coverage.
All network pharmacies may not be listed in this directory. Pharmacies may have been added or
removed from the list after this directory was printed. This means the pharmacies listed here may no
longer be in our network, or there may be newer pharmacies in our network that are not listed. This list is
current as of 10/21/2014. For the most current list, please contact us. Our contact information appears
on the front and back cover pages.
You can get prescription drugs shipped to your home through our network mail order delivery program.
For more information, please contact us or see the mail order section of this pharmacy directory.
If you have questions about any of the above, please see the first and last cover pages of this directory
for information on how to contact us.
78
80
Can the list of network pharmacies change?
Yes, our plan may add or remove pharmacies from our pharmacy directory. To get current information
about Community HealthFirst™ Medicare Advantage Plans network pharmacies in your area, please
visit our web site at www.healthfirst.chpw.org or call Customer Service.
How do I find a Community HealthFirst Medicare Advantage Plans network pharmacy in my
area?
You can visit our web site at www.healthfirst.chpw.org
.org or call Customer Service during the hours of
8:00 a.m. to 8:00 p.m., 7 days a week. Current members should call 1-800-942-0247 and
prospective members should call 1-800-944-1247 (TTY Relay: Dial 7-1-1).
How do I fill a prescription at a network pharmacy?
To fill your prescription at a network pharmacy, you must show your Community HealthFirst Medicare
Advantage Plans Member ID card. If you do not have your ID card with you when you fill your
prescription, you may have to pay the full cost of the prescription (rather than paying just your copay).
If this happens, you can ask us to reimburse you for our share of the cost by submitting a claim to us.
To find out how to submit a claim, look in your Evidence of Coverage or call our Customer Service.
How do I fill a prescription through Community HealthFirst MA Special Needs Plan’s mail-order
pharmacy service?
To get order forms and information about filling your prescriptions by mail, please call 1-888-823-1968.
Please note that you must use our mail-order service. Prescription drugs that you get through any other
mail-order service are not covered.
You can use our plan’s mail-order service to fill prescriptions for any drug that is on the formulary list.
Our plan’s mail-order service requires you to order at least a 30-day supply of the drug and no more
than a 90-day supply.
You are not required to use mail-order service to obtain an extended supply of maintenance
medications. Instead, you have the option of using a retail pharmacy in our network to obtain a supply
of maintenance medications. Some retail pharmacies may agree to accept the mail-order
reimbursement rate for an extended supply of medications for up to 90 days per dispensing, which may
result in no out-of-pocket payment difference to you. Other retail pharmacies may not agree to accept
the mail-order reimbursement rate for an extended supply of medication. In this case, you will be
responsible for the difference in price. Please look in the pharmacy directory below for retail pharmacies
in our network at which you can obtain an extended supply of maintenance medications or call our
Customer Service for more information.
After you’ve sent your order, you should receive your prescription within 14 days. If for some reason
your order cannot be delivered within 14 days, a mail-order representative may contact you. For more
information about mail-order, visit Community HealthFirst’s web site at www
www..healthfirst.chpw
healthfirst.chpw..org or call
our Customer Service during the hours of 8:00 a.m. to 8:00 p.m., 7 days a week. Current members
should call 1-800-942-0247 and prospective members should call 1-800- 944-1247 (TTY Relay:
Dial 7-1-1).
Filling prescriptions outside the network
Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine
circumstances when a network pharmacy is not available. Below are some circumstances when we
would cover prescriptions filled at an out-of- network pharmacy. Before you fill your prescription in
these situations, call Customer Service to see if there is a network pharmacy in your area where
79
81
you can fill your prescription. If you must use an out-of-network pharmacy, you will generally have to
pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask
us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to
us if you fill a prescription at an out-of-network pharmacy as any amount you pay will help you qualify
for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims
process described next.
You will be allowed a total of three fills at an out-of-network pharmacy within a plan year. If you fill a
prescription out-of- network, you will receive a message on your monthly Explanation of Benefits (EOB)
that will state “Non-network pharmacy.” If you request a fourth fill at an out-of-network pharmacy, your
request for coverage will be denied. If you feel that the out-of-network claim should have been covered,
contact our Customer Service during the hours of 8:00 a.m. to 8:00 p.m., 7 days a week. Current
members should call 1-800-942-0247 and prospective members should call 1-800- 944-1247 (TTY
Relay: Dial 7-1-1).
How do I submit a paper claim?
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy.
However, if you go to an out-of-network pharmacy the pharmacy may not be able to submit the claim
directly to us. When that happens, you will have to pay the full cost of your prescription.
To submit a paper claim, you must send a copy of the receipt for the prescription drugs from the
pharmacy where you bought them and a completed Prescription Drug Claim Form. Please send the
completed Prescription Drug Claim Form and the receipts to the following address:
Express Scripts
Attn: Med D Accts.
PO Box 2858
Clinton, IA 52733-2858
www.healthfirst.chpw
If you do not have a Prescription Drug Claim Form visit our web site at www.
healthfirst.chpw..org or
call Customer Service.
Community HealthFirst Medicare Advantage Plans Retail Pharmacies Offering Extended Supplies
of Medications
You are not required to use mail-order service to obtain an extended supply of maintenance
medications. Instead, you have the option of using a retail pharmacy in our network to obtain an
extended supply of maintenance medications. Some retail pharmacies may agree to accept the
mail-order reimbursement rate for an extended supply of medications for up to 90 days per
dispensing, which may result in no out-of-pocket payment difference to you. Other retail
pharmacies may not agree to accept the mail-order reimbursement rate for an extended supply of
medication. In this case, you will be responsible for the difference in price. In the pharmacy
directory below, you will find identified those retail pharmacies in our network that offer extended
supplies of maintenance medications.
For more information
For more detailed information about your Community HealthFirst Medicare Advantage Plans
prescription drug coverage, please review the Evidence of Coverage and Community HealthFirst
Medicare Advantage Plans’ formulary.
80
82
If you
haveCommunity
questions about
Community
HealthFirst
Medicare
If you have questions
about
HealthFirst
Medicare
Advantage
Plans, Advantage
please visit Plans,
our please visit o
web
site
at
www.healthfirst.chpw.org
or
call
Customer
Service
during
the
hours
of 8:00 a.m. t
www
.
healthfirst.chpw
.
org
or call Customer Service during the hours of 8:00 a.m. to 8:00
web site at www healthfirst.chpw.
p.m.,
7 daysmembers
a week. Current
members
should
call and
1-800-9420247members
and prospective membe
p.m., 7 days a week.
Current
should call
1-800-9420247
prospective
should call(TTY
1-800-944-1247
(TTY Relay: Dial 7-1-1).
should call 1-800-944-1247
Relay: Dial 7-1-1).
Listing Table of Contents
Pharmacy ListingPharmacy
Table of Contents
Retail PharmaciesRetail Pharmacies
page 92
Mail-Order Pharmacies
Mail-Order Pharmacies
page 151
Home Infusion Pharmacies page 152
Home Infusion Pharmacies
Long Term Care Pharmacies page 154
Long Term Care Pharmacies
Indian Health Service/Tribal/
Indian Health Service/Tribal/
Urban
IndianPharmacies
Health Programpage
Pharmacies
Urban Indian Health
Program
160
83 81
page 92
page 151
page 152
page 154
page 160
81
Directorio de farmacias para el año 2015
Este directorio de farmacias se actualizó el 08/22/2014. Para obtener información más reciente o si
tiene otras preguntas, póngase en contacto con Community Health Plan of Washington llamando al
1-800-944-1247 (los usuarios de TTY deben marcar 7-1-1), de 8 a. m. a 8 p. m., los 7 días de la
semana, o visitando www.healthfirst.chpw.org.
Introducción
Este folleto ofrece un listado de las farmacias de la red de
Community HealthFirst™ Medicare Advantage Plans. Si desea una descripción completa de la
cobertura de medicamentos recetados, incluido cómo surtir las recetas, revise la Evidencia de
cobertura y el formulario de Community HealthFirst™ Medicare Advantage Plans.
Cuando en este directorio de farmacias se menciona “nosotros” “nos” o “nuestro”, se refiere a
Community Health Plan of Washington. Cuando se menciona “el plan” o “nuestro plan”, se hace
referencia a Community HealthFirst™ Medicare Advantage Plans.
Llamamos “farmacias de la red” a las farmacias que aparecen en este listado porque tenemos con
ellas acuerdos para que proporcionen a los miembros del plan los medicamentos recetados. En la
mayoría de los casos, los medicamentos recetados están cubiertos por nuestro plan únicamente si
los surte en una farmacia de la red o a través de nuestro servicio farmacéutico de pedidos por
correo. Cuando vaya a una farmacia, no se le exigirá que continúe usando la misma farmacia para
surtir sus recetas, sino que puede ir a cualquiera de nuestras farmacias de la red. En determinadas
circunstancias, según se describe en la Evidencia de cobertura, surtiremos las recetas en farmacias
que no pertenecen a la red.
Es posible que en este directorio no aparezcan todas las farmacias de la red y que se hayan
agregado o eliminado farmacias a la lista después de su impresión. En otras palabras, las farmacias
que figuran en esta lista podrían no pertenecer más a la red, o bien podría haber nuevas farmacias
incorporadas a la red que no aparezcan en la lista. Esta lista está vigente a partir del 10/21/2014. Si
desea una lista más reciente, comuníquese con nosotros. Nuestra información de contacto figura en
las páginas de la portada y la contraportada.
Puede pedir que le envíen por correo los medicamentos recetados a través del programa de pedidos
por correo de nuestra red.Si desea más información, comuníquese con nosotros o consulte la
sección de pedidos por correo en este directorio de farmacias.
Si tiene preguntas acerca de las secciones anteriores, consulte las primeras y últimas páginas del
directorio para obtener información sobre cómo comunicarse con nosotros.
¿Puede cambiar la lista de farmacias de la red?
Sí, nuestro plan puede agregar o eliminar farmacias del directorio de farmacias. Si desea obtener
información actualizada sobre las farmacias de la red de
Community HealthFirst™ Medicare Advantage Plans en su área, visite nuestro sitio web en
www.healthfirst.chpw.org o llame a Servicio al cliente.
¿Cómo busco una farmacia de la red de Community HealthFirst Medicare Advantage Plans en
mi área?
Puede visitar nuestro sitio web en www.healthfirst.chpw.org o llamar a Servicio al cliente, en el
horario de 8:00 a. m. a 8:00 p. m., los 7 días de la semana. Los miembros actuales deben llamar
84
al 1-800-942-0247 y los miembros potenciales deben llamar al 1-800-944-1247 (número de
retransmisión para usuarios de
TTY: marque 7-1-1).
¿Cómo surto mis medicamentos recetados en una farmacia de la red?
Para surtir sus medicamentos recetados en una farmacia de la red, debe mostrar su tarjeta de
identificación de miembro de Community HealthFirst™ Medicare Advantage Plans. Si en ese
momento no tiene la tarjeta de identificación de miembro, es posible que tenga que pagar el costo
total del medicamento recetado (en lugar de solo el copago). En dicho caso, puede solicitar que le
reembolsemos la parte del costo que nos corresponde presentando un reclamo. Para saber cómo
presentar un reclamo, revise la Evidencia de cobertura o llame a nuestro Servicio al cliente.
¿Cómo se surten medicamentos recetados mediante el servicio farmacéutico de pedidos por
correo de Community HealthFirst MA Special Needs Plans?
Para obtener los formularios de pedido e información sobre cómo surtir sus medicamentos
recetados por correo, llame al 1-888-823-1968. Recuerde que debe utilizar nuestro servicio de
pedido por correo. Los medicamentos recetados que obtenga a través de cualquier otro servicio de
pedido por correo no están cubiertos.
Puede usar el servicio de pedido por correo del plan para surtir cualquier medicamento recetado
que aparezca en la lista del formulario. El servicio de pedido por correo de nuestro plan exige que
ordene un suministro del medicamento para 30 días como mínimo y 90 días como máximo.
Para obtener un suministro extendido de medicamentos de mantenimiento, no necesita usar
nuestro servicio de pedido por correo. En cambio, tiene la opción de acudir a una farmacia
minorista de la red para obtener un suministro de medicamentos de mantenimiento. Algunas
farmacias minoristas posiblemente acepten la tasa de reembolso del pedido por correo para un
suministro extendido de medicamentos de hasta 90 días por receta; en tal caso, no deberá pagar
ningún gasto directo de su bolsillo. Otras farmacias tal vez no acepten la tasa de reembolso del
pedido por correo para un suministro extendido del medicamento. En este caso, usted deberá
pagar la diferencia. Busque en el directorio a continuación las farmacias de nuestra red donde
podría obtener un suministro extendido de medicamentos de mantenimiento o llame a Servicio al
cliente para obtener más información.
Luego de enviar su pedido, recibirá los medicamentos recetados en un plazo de 14 días. Si por
alguna razón su pedido no fuese entregado en un plazo de 14 días, un representante del servicio de
pedidos por correo se comunicará con usted. Si desea más información sobre los pedidos por
correo, visite el sitio web de Community HealthFirst en www.healthfirst.chpw.org o llame a Servicio
al cliente, en el horario de 8:00 a. m. a 8:00 p. m., los 7 días de la semana. Los miembros actuales
deben llamar al 1-800-942-0247 y los miembros potenciales deben llamar al 1-800-944-1247
(número de retransmisión para usuarios de TTY: marque 7-1-1).
Cómo surtir medicamentos recetados fuera de la red
Generalmente, solo cubrimos los medicamentos que se surten en farmacias fuera de la red en
circunstancias limitadas que no son de rutina, cuando no hay una farmacia de la red disponible. A
continuación, se detallan algunas circunstancias en las que cubriríamos medicamentos recetados
surtidos en una farmacia fuera de la red. Antes de surtir sus medicamentos recetados en estas
situaciones, llame a Servicio al cliente para consultar si hay alguna farmacia de la red en su
área donde pueda surtir los medicamentos. Si debe utilizar una farmacia fuera de la red, por lo
general deberá pagar el costo total del medicamento recetado cuando lo surta (en lugar de pagar la
parte del costo que habitualmente le corresponde). Puede presentar un formulario de reclamo para
85
solicitar que le reembolsemos la parte del costo que nos corresponde. Si surte un medicamento
recetado en una farmacia fuera de la red, deberá presentar un reclamo, ya que cualquier monto
que pague le ayudará a calificar para la cobertura en situaciones catastróficas. Para saber cómo
presentar un reclamo por escrito, consulte el proceso que se describe más adelante.
Podrá obtener un total de tres surtidos en farmacias fuera de la red en un año del plan. Si surte un
medicamento recetado fuera de la red, recibirá un mensaje en la Explicación de beneficios
(Explanation of benefits, EOB) mensual que dirá: “Farmacia fuera de la red”. Si solicita un cuarto
surtido en una farmacia fuera de la red, se le denegará la solicitud de cobertura. Si considera que el
pedido fuera de la red debería haber sido cubierto, comuníquese con el Servicio al cliente, en el
horario de 8:00 a. m. a 8:00 p. m., los 7 días de la semana. Los miembros actuales deben llamar al
1-800-942-0247 y los miembros potenciales deben llamar al 1-800-944-1247
(número de retransmisión para usuarios de TTY: marque 7-1-1).
¿Cómo presento un reclamo por escrito?
Cuando acude a una farmacia de la red, esta nos envía su reclamo de manera automática. No
obstante, si acude a una farmacia fuera de la red, es posible que esta no pueda presentarnos el
reclamo directamente. Cuando esto suceda, usted deberá pagar el costo total de sus
medicamentos recetados.
Para enviar un reclamo por escrito, envíe una copia del recibo de los medicamentos recetados de la
farmacia donde los compró y un formulario de reclamo para medicamentos recetados completo.
Envíe el formulario de reclamo para medicamentos recetados completo y los recibos a la siguiente
dirección:
Express Scripts
Attn: Med D Accts.
PO Box 2858
Clinton, IA 52733-2858
Si no tiene un formulario de reclamo para medicamentos recetados, visite nuestro sitio web en
www.healthfirst.chpw.org o llame a Servicio al cliente.
Farmacias minoristas de Community HealthFirst Medicare Advantage Plans que ofrecen
suministros extendidos de medicamentos
Para obtener un suministro extendido de medicamentos de mantenimiento, no necesita usar
nuestro servicio de pedido por correo. En cambio, tiene la opción de acudir a una farmacia
minorista de la red para obtener un suministro extendido de medicamentos de mantenimiento.
Algunas farmacias minoristas posiblemente acepten la tasa de reembolso del pedido por
correo para un suministro extendido de medicamentos de hasta 90 días por receta; en tal caso,
no deberá pagar ningún gasto directo de su bolsillo. Otras farmacias tal vez no acepten la tasa
de reembolso del pedido por correo para un suministro extendido del medicamento. En este
caso, usted deberá pagar la diferencia. En el directorio de farmacias a continuación encontrará
identificadas las farmacias minoristas en nuestra red que ofrecen suministros extendidos de
medicamentos de mantenimiento.
Si desea más información
Si desea obtener información más detallada sobre la cobertura de medicamentos recetados de
Community HealthFirst Medicare Advantage Plans, consulte la Evidencia de cobertura y el
formulario de Community HealthFirst Medicare Advantage Plans.
86
Si tiene preguntas sobre Community HealthFirst Medicare Advantage Plans, visite nuestro sitio
web en www.healthfirst.chpw.org o llame a Servicio al cliente en el horario de 8:00 a. m. a
8:00 p. m., los 7 días de las semana. Los miembros actuales deben llamar al 1-800-942-0247 y
los miembros potenciales deben llamar al 1-800-944-1247 (número de retransmisión para
usuarios de TTY: marque 7-1-1).
Farmacias de pedidos por correo
Puede pedir por correo los medicamentos recetados a través de nuestro programa de pedidos por
correo de la red. Por lo general, recibirá los medicamentos recetados en un plazo de 14 días desde
el momento en que la farmacia de pedidos por correo reciba el pedido. Si no recibe sus
medicamentos recetados en este plazo, comuníquese con nosotros al 1-800-942-0247 (número de
retransmisión para usuarios de TTY: marque
7-1-1) de 8:00 a. m. a 8:00 p. m., los 7 días de la semana.
Si desea obtener más información acerca de la farmacia de pedidos por correo, llame al
Departamento de Servicio al Cliente al 1-800-942-0247 (número de retransmisión para usuarios de
TTY: marque 7-1-1) de 8:00 a. m. a 8:00 p. m., los 7 días de la semana.
Farmacias con servicio de aplicación de infusiones a domicilio
Si desea obtener más información acerca de las farmacias con servicio de
aplicación de infusiones a domicilio, llame al Departamento de Servicio al Cliente al
1-800-942-0247 (número de retransmisión para usuarios de TTY: marque 7-1-1)
de 8:00 a. m. a 8:00 p. m., los 7 días de la semana.
Farmacias de atención a largo plazo
Los residentes de un centro de atención a largo plazo pueden obtener sus medicamentos recetados
cubiertos por Community HealthFirst a través de la farmacia de atención a largo plazo del centro o de
otra farmacia de atención a largo plazo
de la red.
Si desea obtener más información acerca de las farmacias de atención a largo plazo, llame al
Departamento de Servicio al Cliente al 1-800-942-0247 (número de retransmisión para usuarios de
TTY: marque 7-1-1) de 8:00 a. m. a 8:00 p. m., los 7 días de la semana.
Farmacias (I/T/U) para el Programa de salud para la población indígena
estadounidense urbana o tribal del Servicio de Salud para la Población Indígena
Estadounidense/
Solo los nativos de Estados Unidos y Alaska tienen acceso a Farmacias (I/T/U) para el Programa de
salud para la población indígena estadounidense urbana o tribal del Servicio de Salud para la
Población Indígena Estadounidense a través de la red de farmacias de Community HealthFirst.
Quienes no sean nativos de Estados Unidos y Alaska pueden tener acceso a estas farmacias en
circunstancias limitadas (p. ej., en caso de una emergencia).
Si desea obtener más información acerca del Programa de salud para la población indígena
estadounidense I/T/U, llame al Departamento de Servicio al Cliente al 1-800-942-0247 (número de
retransmisión para usuarios de TTY: marque 7-1-1) de 8:00 a. m. a 8:00 p. m., los 7 días de la
semana.
87
ADAMS COUNTY ............................................................................................................92
OTHELLO.........................................................................................................................92
RITZVILLE........................................................................................................................92
ASOTIN COUNTY............................................................................................................92
CLARKSTON ...................................................................................................................92
BENTON COUNTY ..........................................................................................................92
BENTON CITY .................................................................................................................92
KENNEWICK....................................................................................................................92
PROSSER........................................................................................................................93
RICHLAND .......................................................................................................................93
WEST RICHMOND ..........................................................................................................94
CHELAN COUNTY ..........................................................................................................94
CASHMERE .....................................................................................................................94
CHELAN...........................................................................................................................94
LEAVENWORTH..............................................................................................................94
WENATCHEE ..................................................................................................................94
CLALLAM COUNTY ........................................................................................................94
FORKS .............................................................................................................................94
PORT ANGELES .............................................................................................................94
SEQUIM ...........................................................................................................................95
CLARK COUNTY.............................................................................................................95
BATTLE GROUND ...........................................................................................................95
CAMAS.............................................................................................................................95
ORCHARDS.....................................................................................................................96
VANCOUVER...................................................................................................................96
WASHOUGAL ..................................................................................................................98
COLUMBIA COUNTY ......................................................................................................98
DAYTON ..........................................................................................................................98
COWLITZ COUNTY .........................................................................................................98
CASTLE ROCK ................................................................................................................98
KALAMA...........................................................................................................................98
KELSO .............................................................................................................................98
LONGVIEW ......................................................................................................................99
WOODLAND ....................................................................................................................99
DOUGLAS COUNTY .......................................................................................................99
BRIDGEPORT..................................................................................................................99
EAST WENATCHEE ........................................................................................................99
WENATCHEE ..................................................................................................................99
86
88
FERRY COUNTY ...........................................................................................................100
REPUBLIC .....................................................................................................................100
FRANKLIN COUNTY .....................................................................................................100
CONNELL ......................................................................................................................100
PASCO...........................................................................................................................100
GARFIELD COUNTY .....................................................................................................100
POMEROY .....................................................................................................................100
GRANT COUNTY ..........................................................................................................100
EPHRATA ......................................................................................................................100
GRAND COULEE...........................................................................................................101
MATTAWA .....................................................................................................................101
MOSES LAKE ................................................................................................................101
QUINCY .........................................................................................................................101
GRAYS HARBOR COUNTY..........................................................................................101
ABERDEEN....................................................................................................................101
ELMA..............................................................................................................................101
HOQUIAM ......................................................................................................................101
OCEAN SHORES ..........................................................................................................102
WESTPORT ...................................................................................................................102
ISLAND COUNTY ..........................................................................................................102
CAMANO ISLAND..........................................................................................................102
CLINTON........................................................................................................................102
COUPEVILLE.................................................................................................................102
FREELAND ....................................................................................................................102
OAK HARBOR ...............................................................................................................102
JEFFERSON COUNTY..................................................................................................102
PORT HADLOCK ...........................................................................................................102
PORT TOWNSEND........................................................................................................102
KING COUNTY ..............................................................................................................103
AUBURN ........................................................................................................................103
BELLEVUE.....................................................................................................................103
BOTHELL .......................................................................................................................104
BURIEN..........................................................................................................................104
COVINGTON..................................................................................................................105
DES MOINES.................................................................................................................105
DUVALL .........................................................................................................................105
ENUMCLAW ..................................................................................................................105
FEDERAL WAY..............................................................................................................106
ISSAQUAH.....................................................................................................................106
KENMORE .....................................................................................................................107
KENT..............................................................................................................................107
KIRKLAND .....................................................................................................................108
87
89
MAPLE VALLEY.............................................................................................................109
MERCER ISLAND..........................................................................................................109
NEWCASTLE .................................................................................................................109
NORMANDY PARK........................................................................................................109
NORTH BEND................................................................................................................109
REDMOND.....................................................................................................................109
RENTON ........................................................................................................................110
SAMMAMISH .................................................................................................................111
SEATAC .........................................................................................................................111
SEATTLE .......................................................................................................................111
SHORELINE...................................................................................................................117
SNOQUALMIE ...............................................................................................................118
TUKWILA .......................................................................................................................118
VASHON ........................................................................................................................118
WOODINVILLE ..............................................................................................................118
KITSAP COUNTY ..........................................................................................................119
BAINBRIDGE ISLAND ...................................................................................................119
BREMERTON ................................................................................................................119
KINGSTON.....................................................................................................................120
PORT ORCHARD ..........................................................................................................120
POULSBO ......................................................................................................................120
SILVERDALE .................................................................................................................121
KITTITAS COUNTY .......................................................................................................121
CLE ELUM .....................................................................................................................121
ELLENSBURG ...............................................................................................................121
KLICKITAT COUNTY ....................................................................................................121
WHITE SALMON............................................................................................................121
LEWIS ............................................................................................................................121
CENTRALIA ...................................................................................................................121
CHEHALIS .....................................................................................................................122
MORTON .......................................................................................................................122
WINLOCK.......................................................................................................................122
LINCOLN COUNTY .......................................................................................................122
DAVENPORT .................................................................................................................122
BELFAIR ........................................................................................................................122
SHELTON ......................................................................................................................122
OKANOGAN COUNTY ..................................................................................................123
BREWSTER ...................................................................................................................123
OKANOGAN...................................................................................................................123
OMAK.............................................................................................................................123
TONASKET ....................................................................................................................123
TWISP ............................................................................................................................123
88
90
PACIFIC COUNTY .........................................................................................................123
LONG BEACH................................................................................................................123
OCEAN PARK................................................................................................................123
RAYMOND .....................................................................................................................123
SOUTH BEND................................................................................................................123
PEND OREILLE COUNTY.............................................................................................123
NEWPORT .....................................................................................................................123
PIERCE COUNTY ..........................................................................................................123
AUBURN ........................................................................................................................123
BONNEY LAKE ..............................................................................................................124
BUCKLEY.......................................................................................................................124
DUPONT ........................................................................................................................124
EDGEWOOD..................................................................................................................124
FIRCREST .....................................................................................................................124
GIG HARBOR ................................................................................................................124
GRAHAM........................................................................................................................125
LAKEWOOD...................................................................................................................125
MILTON..........................................................................................................................125
ORTING .........................................................................................................................126
PUYALLUP.....................................................................................................................126
SPANAWAY ...................................................................................................................127
SUMNER........................................................................................................................127
TACOMA ........................................................................................................................127
UNIVERSITY PLACE .....................................................................................................129
SAN JUAN COUNTY .....................................................................................................130
EASTSOUND .................................................................................................................130
FRIDAY HARBOR..........................................................................................................130
LOPEZ ISLAND..............................................................................................................130
SKAGIT COUNTY..........................................................................................................130
ANACORTES .................................................................................................................130
BURLINGTON................................................................................................................130
CONCRETE ...................................................................................................................130
LA CONNER ..................................................................................................................131
MOUNT VERNON ..........................................................................................................131
SEDRO WOOLLEY ........................................................................................................131
SKAMANIA COUNTY ....................................................................................................131
STEVENSON .................................................................................................................131
SNOHOMISH COUNTY .................................................................................................131
ARLINGTON ..................................................................................................................131
BOTHELL .......................................................................................................................132
DARRINGTON ...............................................................................................................132
EDMONDS .....................................................................................................................132
EVERETT.......................................................................................................................133
89
91
GRANITE FALLS ...........................................................................................................135
LAKE STEVENS ............................................................................................................135
LYNNWOOD ..................................................................................................................135
MARYSVILLE.................................................................................................................136
MILL CREEK ..................................................................................................................136
MOUNTLAKE TERRACE ...............................................................................................137
MUKILTEO .....................................................................................................................137
SNOHOMISH .................................................................................................................137
STANWOOD ..................................................................................................................138
SULTAN .........................................................................................................................138
TULALIP.........................................................................................................................138
WOODINVILLE ..............................................................................................................138
SPOKANE COUNTY......................................................................................................138
AIRWAY HEIGHTS ........................................................................................................138
CHENEY ........................................................................................................................138
DEER PARK...................................................................................................................138
FAIRFIELD .....................................................................................................................138
LIBERTY LAKE ..............................................................................................................138
MEAD .............................................................................................................................139
MEDICAL LAKE .............................................................................................................139
MILLWOOD....................................................................................................................139
SPOKANE ......................................................................................................................139
SPOKANE VALLEY........................................................................................................142
VERADALE ....................................................................................................................143
STEVENS COUNTY.......................................................................................................143
CHEWELAH ...................................................................................................................143
COLVILLE ......................................................................................................................143
KETTLE FALLS..............................................................................................................143
NINE MILE FALLS .........................................................................................................143
THURSTON COUNTY ...................................................................................................143
LACEY............................................................................................................................143
OLYMPIA .......................................................................................................................144
TENINO..........................................................................................................................144
TUMWATER...................................................................................................................144
YELM..............................................................................................................................145
WAHKIAKUM COUNTY ................................................................................................145
CATHLAMET..................................................................................................................145
WALLA WALLA ..............................................................................................................145
WHATCOM COUNTY ....................................................................................................146
BELLINGHAM ................................................................................................................146
BLAINE...........................................................................................................................147
EVERSON......................................................................................................................147
LYNDEN.........................................................................................................................147
SUMAS...........................................................................................................................147
90
92
WHITMAN COUNTY ......................................................................................................147
COLFAX .........................................................................................................................147
GARFIELD .....................................................................................................................147
PULLMAN ......................................................................................................................147
SAINT JOHN ..................................................................................................................148
TEKOA ...........................................................................................................................148
YAKIMA COUNTY .........................................................................................................148
GRANDVIEW .................................................................................................................148
SELAH............................................................................................................................148
SUNNYSIDE ..................................................................................................................148
TOPPENISH...................................................................................................................148
UNION GAP ...................................................................................................................148
WAPATO........................................................................................................................148
YAKIMA..........................................................................................................................148
91
93
Pharmacies noted with
a * offer a 90 day
supply.
Retail Pharmacies
ADAMS COUNTY
OTHELLO
OTHELLO FAMILY
CLINIC PHARMACY *
140 E MAIN ST
OTHELLO, WA 99344
(509) 488-5256
WAL-MART *
1860 E MAIN ST
OTHELLO, WA 99344
(509) 488-9324
RITZVILLE
RITZVILLE DRUG *
209 W MAIN AVE
RITZVILLE, WA 99169
(509) 659-0250
ASOTIN COUNTY
CLARKSTON
BI-MART PHARMACY *
511 3RD ST
CLARKSTON, WA
99403
(509) 758-8230
CHAS-WASEM *
800 6TH ST
CLARKSTON, WA
99403
(509) 758-2565
CLARKSTON HEIGHTS
PHARMACY *
2119 5TH AVE
CLARKSTON, WA
99403
(509) 758-3376
COSTCO *
301 FIFTH ST
CLARKSTON, WA
99403
(509) 758-8897
BENTON COUNTY
BENTON CITY
LOGAR PHARMACY *
515 9TH ST STE A
BENTON CITY, WA
99320
(509) 588-8600
KENNEWICK
ALBERTSON'S *
5204 W CLEARWATER
KENNEWICK, WA
99336
(509) 735-8311
OWL TRI-STATE
PHARMACY *
1275 HIGHLAND AVE
CLARKSTON, WA
99403
(509) 758-5533
COLUMBIA BASIN
HEMATOLOGY *
7360 W DESCHUTES
AVE
KENNEWICK, WA
99336
(509) 783-0144
SAVON PHARMACY *
400 BRIDGE ST
CLARKSTON, WA
99403
(509) 758-7475
COSTCO *
8505 W GAGE BLVD
KENNEWICK, WA
99336
(509) 737-8877
WAL-MART *
306 5TH ST
CLARKSTON, WA
99403
(509) 758-6660
FRED MEYER
PHARMACY *
2811 W 10TH AVE
KENNEWICK, WA
99336
(509) 735-8733
WASEM'S DRUG *
800 6TH ST
CLARKSTON, WA
99403
(509) 758-2565
92
94
MEDICAL MALL
PHARMACY *
521 N YOUNG ST
KENNEWICK, WA
99336
(509) 585-5250
RITE AID *
1901 N STEPTOE ST
KENNEWICK, WA
99336
(509) 783-3413
YOKES PHARMACY *
1410 W 27TH AVE
KENNEWICK, WA
99337
(509) 585-0846
SAFEWAY
PHARMACY *
W 2825 KENNEWICK
AVE
KENNEWICK, WA
99336
(509) 783-2622
PROSSER
SHOPKO PHARMACY*
867 N COLUMBIA
CENTER BLVD
KENNEWICK, WA
99336
(509) 736-0505
TARGET PHARMACY *
1160 N COLUMBIA
CENTER BLVD
KENNEWICK, WA
99336
(509) 737-1700
WALGREENS *
4000 W 27TH AVE
KENNEWICK, WA
99337
(509) 582-7781
WALGREENS *
2800 W CLEARWATER
AVE
KENNEWICK, WA
99336
(509) 783-5412
WAL-MART *
2720 S QUILLAN ST
KENNEWICK, WA
99337
(509) 586-1574
ELFERS-LYON
PHARMACY *
820 MEMORIAL ST
STE 2
PROSSER, WA 99350
(509) 786-3200
RICHLAND
ALBERTSON'S *
1320 LEE BLVD
RICHLAND, WA 99352
(509) 946-0656
ALBERTSON'S *
690 GAGE BLVD
RICHLAND, WA 99352
(509) 627-5133
DENSOW'S
PHARMACY *
1011 WRIGHT AVE
RICHLAND, WA 99354
(509) 943-1164
FRED MEYER
PHARMACY *
101 WELLSIAN WAY
RICHLAND, WA 99352
(509) 943-8358
MALLEYS
COMPOUNDING
PHARMACY *
1906 GEORGE
WASHINGTON WAY
RICHLAND, WA 99354
(509) 943-9173
93
95
RITE AID *
1268 LEE BLVD
RICHLAND, WA 99352
(509) 946-4684
RITE AID *
1549 GEORGE
WASHINGTON WAY
RICHLAND, WA 99352
(509) 946-5770
SAFEWAY
PHARMACY *
1803 GEORGE
WASHINGTON WAY
RICHLAND, WA 99352
(509) 946-1157
WALGREENS *
1601 GEORGE
WASHINGTON WAY
RICHLAND, WA 99354
(509) 943-2605
WALGREENS *
800 SWIFT BLVD STE
160
RICHLAND, WA 99352
(509) 943-9121
WALGREENS *
585 GAGE BLVD
RICHLAND, WA 99352
(509) 628-3629
WAL-MART *
2801 DUPORTAIL ST
RICHLAND, WA 99352
(509) 628-1370
YOKES *
455 ENGLEWOOD DR
RICHLAND, WA 99352
(509) 491-3339
WEST RICHMOND
LEAVENWORTH
YOKES PHARMACY *
1401 BOMBING
RANGE RD
WEST RICHMOND, WA
99353
(509) 967-8008
SAFEWAY
PHARMACY *
116 RIVERBEND DR
LEAVENWORTH, WA
98826
(509) 548-5811
CHELAN COUNTY
VILLAGE PHARMACY*
815 FRONT ST
LEAVENWORTH, WA
98826
(509) 548-7622
CASHMERE
DOANE'S VALLEY
PHARMACY *
119 COTTAGE AVE
CASHMERE, WA
98815
(509) 782-2717
CHELAN
LAKE CHELAN
PHARMACY *
223 E JOHNSON AVE
CHELAN, WA 98816
(509) 682-2751
SAFEWAY
PHARMACY *
106 W MANSON RD
CHELAN, WA 98816
(509) 682-4087
WAL-MART *
108 APPLE BLOSSOM
DR
CHELAN, WA 98816
(509) 682-4634
WENATCHEE
ALBERTSON'S *
1128 N MILLER ST
WENATCHEE, WA
98801
(509) 662-2942
CENTRAL
WASHINGTON HOSP
PHCY *
933 RED APPLE RD
STE A
WENATCHEE, WA
98801
(509) 667-3333
COLUMBIA VALLEY
COMM H PHCY *
600 ORONDO AVE
STE 1
WENATCHEE, WA
98801
(509) 664-3508
RITE AID *
1380 N MILLER ST
WENATCHEE, WA
98801
(509) 663-7805
94
96
SAFEWAY
PHARMACY *
501 N MILLER ST
WENATCHEE, WA
98801
(509) 663-5575
WALGREENS *
1050 N MILLER ST
WENATCHEE, WA
98801
(509) 665-7539
WAL-MART *
2000 N WENATCHEE
AVE
WENATCHEE, WA
98801
(509) 664-3698
WENATCHEE CLINIC
PHARMACY *
820 N CHELAN AVE
WENATCHEE, WA
98801
(509) 662-5801
CLALLAM COUNTY
FORKS
CHINOOK PHARMACY
11 S FORKS AVE
FORKS, WA 98331
(360) 374-2294
PORT ANGELES
ALBERTSON'S *
114 E LAURIDSEN
BLVD
PORT ANGELES, WA
98362
(360) 452-4410
JIM'S PHARMACY *
424 2ND ST E
PORT ANGELES, WA
98362
(360) 452-4200
RITE AID *
621 S LINCOLN ST
PORT ANGELES, WA
98362
(360) 452-9784
SEQUIM
COSTCO *
955 W WASHINGTON
ST
SEQUIM, WA 98382
(360) 406-2032
FRED MEYER
PHARMACY *
401 NW 12TH AVE
BATTLE GROUND, WA
98604
(360) 666-5133
QFC PHARMACY *
990 E WASHINGTON
ST BLDG B
SEQUIM, WA 98382
(360) 683-1156
SAFEWAY
PHARMACY *
904 W MAIN ST
BATTLE GROUND, WA
98604
(360) 723-9046
RITE AID *
1940 E 1ST ST STE
110
PORT ANGELES, WA
98362
(360) 457-3456
RITE AID *
520 W WASHINGTON
ST
SEQUIM, WA 98382
(360) 681-0129
SAFEWAY
PHARMACY *
110 E 3RD ST
PORT ANGELES, WA
98362
(360) 457-0599
SAFEWAY
PHARMACY *
680 W WASHINGTON
ST BLDG F
SEQUIM, WA 98382
(360) 681-2120
SAFEWAY
PHARMACY *
2709 E HIGHWAY 101
PORT ANGELES, WA
98362
(360) 457-7865
WALGREENS *
490 W WASHINGTON
ST
SEQUIM, WA 98382
(360) 681-2018
WALGREENS *
932 E FRONT ST
PORT ANGELES, WA
98362
(360) 457-4456
CLARK COUNTY
WAL-MART *
3411 E KOLONELS
WAY
PORT ANGELES, WA
98362
(360) 452-3105
BATTLE GROUND
ALBERTSON'S *
2108 W MAIN ST
BATTLE GROUND, WA
98604
(360) 687-4092
95
97
WALGREENS *
808 W MAIN ST STE
101
BATTLE GROUND, WA
98604
(360) 687-5136
WAL-MART *
1201 SW 13TH AVE
BATTLE GROUND, WA
98604
(360) 723-9007
CAMAS
COSTCO *
19610 SE 1ST ST
CAMAS, WA 98607
(360) 258-6230
SAFEWAY
PHARMACY *
800 NE 3RD AVE
CAMAS, WA 98607
(360) 834-6550
WALGREENS *
3328 NE 3RD AVE
CAMAS, WA 98607
(360) 835-3303
ORCHARDS
BI-MART PHARMACY *
11912 4TH PLAIN
BLVD NE
ORCHARDS, WA
98662
(360) 944-8368
VANCOUVER
ALBERTSON'S *
14300 NE 20TH AVE
VANCOUVER, WA
98686
(360) 576-4844
BI-MART PHARMACY *
2601 FALK RD
VANCOUVER, WA
98668
(360) 695-7578
FRED MEYER
PHARMACY *
7411 NE 117TH AVE
VANCOUVER, WA
98662
(360) 896-3533
FRED MEYER
PHARMACY *
16600 SE
MCGILLIVRAY BLVD
VANCOUVER, WA
98683
(360) 260-3333
FRED MEYER
PHARMACY *
7700 NE HIGHWAY 99
VANCOUVER, WA
98665
(360) 699-8133
COSTCO *
6720 NE 84TH ST
VANCOUVER, WA
98665
(360) 828-2289
FRED MEYER
PHARMACY *
800 NE TENNEY RD
VANCOUVER, WA
98685
(360) 571-2573
FAMILY WELLNESS
CENTER PC *
1000 SE TECH CTR DR
STE 120
VANCOUVER, WA
98683
(360) 260-2773
HI-SCHOOL
PHARMACY
6926 NE FOURTH
PLAIN BLVD
VANCOUVER, WA
98661
(360) 693-8374
FRED MEYER
PHARMACY *
11325 SE MILL PLAIN
BLVD
VANCOUVER, WA
98664
(360) 256-4406
LEGACY SALMON
CREEK
APOTHECARY*
2121 NE 139TH ST
STE 310
VANCOUVER, WA
98686
(360) 487-3700
96
98
MILL PLAIN MEDICAL
AND PHCY *
8614 E MILL PLAIN
BLVD
VANCOUVER, WA
98664
(360) 253-8993
OLYMPIC DRUG *
13898 NE 28TH ST
VANCOUVER, WA
98682
(360) 896-8932
PACIFIC NW
SPECIALTY
PHARMACY *
3801 MAIN ST STE A
VANCOUVER, WA
98663
(360) 448-7890
PEACE HEALTH
SOUTHWEST PHCY *
420 MOTHER JOSEPH
PL
VANCOUVER, WA
98664
(360) 514-2294
PHSW PHARMACY AT
MEDICAL CTR *
420 NE MOTHER
JOSEPH PL
VANCOUVER, WA
98664
(360) 514-2294
QFC PHARMACY *
3505 SE 192ND AVE
VANCOUVER, WA
98683
(360) 253-3043
RITE AID *
2800 NE 162ND AVE
VANCOUVER, WA
98682
(360) 253-5613
RITE AID *
13511 SE 3RD WAY
VANCOUVER, WA
98684
(360) 885-0839
SAFEWAY
PHARMACY *
6711 NE 63RD ST
VANCOUVER, WA
98661
(360) 992-5686
SAFEWAY
PHARMACY *
2615 NE 112TH AVE
VANCOUVER, WA
98684
(360) 449-5205
SAFEWAY
PHARMACY *
6701 E MILL PLAIN
BLVD
VANCOUVER, WA
98661
(360) 992-5726
SAFEWAY
PHARMACY *
11696 NE 76TH ST
VANCOUVER, WA
98662
(360) 944-2665
SAFEWAY
PHARMACY *
3707 MAIN ST
VANCOUVER, WA
98663
(360) 993-8604
THE VANCOUVER
CLINIC *
501 SE 172ND AVE
VANCOUVER, WA
98684
(360) 397-3602
SAFEWAY
PHARMACY *
13719 SE MILL PLAIN
BLVD
VANCOUVER, WA
98684
(360) 891-4254
THE VANCOUVER
CLINIC PHCY *
2525 NE 139TH ST
VANCOUVER, WA
98686
(360) 397-3880
SAFEWAY
PHARMACY *
13023 NE HIGHWAY 99
VANCOUVER, WA
98686
(360) 566-7986
SAFEWAY
PHARMACY *
408 NE 81ST ST
VANCOUVER, WA
98665
(360) 574-8824
TARGET PHARMACY *
8801 NE HAZEL DELL
AVE
VANCOUVER, WA
98665
(360) 713-0005
TARGET PHARMACY *
16200 SE MILL PLAIN
BLVD
VANCOUVER, WA
98684
(360) 449-6425
97
99
VANCOUVER CLINIC
PHARMACY *
700 NE 87TH AVE
VANCOUVER, WA
98664
(360) 397-3314
WALGREENS *
8511 NE 162ND AVE
VANCOUVER, WA
98682
(360) 597-0123
WALGREENS *
6105 NE 114TH AVE
VANCOUVER, WA
98662
(360) 254-3848
WALGREENS *
2903 NE ANDERSON
RD
VANCOUVER, WA
98661
(360) 256-1503
WALGREENS *
13503 SE MILL PLAIN
BLVD
VANCOUVER, WA
98684
(360) 256-9875
WALGREENS *
2521 MAIN ST
VANCOUVER, WA
98660
(360) 693-2524
WAL-MART *
2201 GRAND BLVD
VANCOUVER, WA
98661
(360) 258-2017
WALGREENS *
13009 NE HIGHWAY 99
VANCOUVER, WA
98686
(360) 574-0914
WAL-MART *
7809 NE VANCOUVER
PLAZA DR
VANCOUVER, WA
98662
(360) 253-4038
WALGREENS *
9714 E MILL PLAIN
BLVD
VANCOUVER, WA
98664
(360) 253-7254
WALGREENS *
1900 NE 162ND AVE
BLDG C
VANCOUVER, WA
98684
(360) 891-1809
WALGREENS *
6708 NE 63RD ST
VANCOUVER, WA
98661
(360) 696-0759
WALGREENS *
9812 NE HIGHWAY 99
VANCOUVER, WA
98665
(360) 576-4902
WAL-MART *
430 SE 192ND AVE
VANCOUVER, WA
98683
(360) 256-6361
WAL-MART *
221E NE 104TH AVE
VANCOUVER, WA
98664
(360) 885-0126
WAL-MART *
9000 NE HIGHWAY 99
VANCOUVER, WA
98665
(360) 571-2207
WASHOUGAL
BI-MART PHARMACY *
3003 ADDY ST
WASHOUGAL, WA
98671
(360) 835-0681
RITE AID *
3307 EVERGREEN
BLVD STE 4
WASHOUGAL, WA
98671
(360) 335-9255
98
100
SAFEWAY
PHARMACY *
3307 EVERGREEN
WAY STE 5
WASHOUGAL, WA
98671
(360) 335-2006
COLUMBIA
COUNTY
DAYTON
ELK DRUG
176 E MAIN ST
DAYTON, WA 99328
(509) 382-2536
COWLITZ COUNTY
CASTLE ROCK
CASTLE ROCK
PHARMACY *
117 1ST AVE SW
CASTLE ROCK, WA
98611
(360) 274-8211
KALAMA
GODFREYS
PHARMACY *
270 N 1ST ST
KALAMA, WA 98625
(360) 673-2600
KELSO
L J'S FURNESS
DRUG*
114 S PACIFIC AVE
KELSO, WA 98626
(360) 425-3280
RITE AID *
230 KELSO DR
KELSO, WA 98626
(360) 577-2693
SAFEWAY
PHARMACY *
411 THREE RIVERS
DR
KELSO, WA 98626
(360) 636-5430
TARGET PHARMACY *
205 THREE RIVERS
DR
KELSO, WA 98626
(360) 578-7387
LONGVIEW
FRED MEYER
PHARMACY *
3184 OCEAN BEACH
WAY
LONGVIEW, WA 98632
(360) 425-6222
WALGREENS *
2939 OCEAN BEACH
HWY
LONGVIEW, WA 98632
(360) 232-1021
WAL-MART *
3715 OCEAN BEACH
HWY
LONGVIEW, WA 98632
(360) 355-3082
WAL-MART *
540 7TH AVE
LONGVIEW, WA 98632
(360) 414-9602
WOODLAND
HI-SCHOOL
PHARMACY *
1365 LEWIS RIVER RD
WOODLAND, WA
98674
(360) 225-9475
PEACEHEALTH ST
JOHN MED CTR *
1615 DELAWARE ST
LONGVIEW, WA 98632
(360) 414-7451
SAFEWAY
PHARMACY *
1725 PACIFIC AVE
WOODLAND, WA
98674
(360) 225-4375
SAFEWAY
PHARMACY *
2930 OCEAN BEACH
HWY
LONGVIEW, WA 98632
(360) 575-6246
WAL-MART *
1486 DIKE ACCESS
RD
WOODLAND, WA
98674
(360) 841-9138
SAFEWAY
PHARMACY *
1227 15TH AVE
LONGVIEW, WA 98632
(360) 575-6606
99
101
DOUGLAS
COUNTY
BRIDGEPORT
GROSS DRUG *
2520 FOSTER CREEK
AVE
BRIDGEPORT, WA
98813
(509) 686-5191
EAST WENATCHEE
BI-MART PHARMACY *
780 GRANT RD
EAST WENATCHEE,
WA 98802
(509) 884-4022
E WENATCHEE FOOD
PAVILION PHCY *
315 VALLEY MALL
PKWY
EAST WENATCHEE,
WA 98802
(360) 714-9797
SAFEWAY
PHARMACY *
510 GRANT RD
EAST WENATCHEE,
WA 98802
(509) 884-0678
WENATCHEE
WALGREENS *
470 GRANT RD
WENATCHEE, WA
98802
(509) 886-7047
COSTCO *
375 HIGHLINE DR S
WENATCHEE, WA
98802
(509) 886-0754
FRED MEYER
PHARMACY *
11 GRANT BLVD
WENATCHEE, WA
98802
(509) 881-2833
FERRY COUNTY
REPUBLIC
REPUBLIC DRUG
STORE
6 N CLARK AVE
REPUBLIC, WA 99166
(509) 775-3351
FRANKLIN
COUNTY
CONNELL
CONNELL FAMILY
CLINIC PHARMACY *
1051 COLUMBIA AVE
CONNELL, WA 99326
(509) 488-5256
PASCO
FIESTA PHARMACY *
115 S 10TH AVE
PASCO, WA 99301
(509) 545-0596
LOURDES WEST
PASCO PHARMACY *
7425 WRIGLEY DR
STE 104
PASCO, WA 99301
(509) 546-8388
MEDICINE SHOPPE
PHARMACY *
1121 W COURT ST
PASCO, WA 99301
(509) 547-7537
RITE AID *
215 N 4TH AVE
PASCO, WA 99301
(509) 547-2231
RITE AID *
1308 N 20TH AVE
PASCO, WA 99301
(509) 545-9581
TCCH PHARMACY *
515 W COURT ST
PASCO, WA 99301
(509) 547-2204
WALGREENS *
1200 N 14TH AVE STE
100
PASCO, WA 99301
(509) 547-1220
WALGREENS *
2005 W COURT ST
PASCO, WA 99301
(509) 545-4391
WALGREENS *
5506 RD 68
PASCO, WA 99301
(509) 547-1789
100
102
WAL-MART *
4820 N ROAD 68
PASCO, WA 99301
(509) 543-7947
YOKES PHARMACY *
4905 N ROAD 68
PASCO, WA 99301
(509) 545-4884
GARFIELD
COUNTY
POMEROY
POMEROY
PHARMACY *
764 MAIN STREET
POMEROY, WA 99347
(509) 843-1821
GRANT COUNTY
EPHRATA
RITE AID *
250 BASIN ST SW
EPHRATA, WA 98823
(509) 754-3513
SAFEWAY
PHARMACY *
1150 BASIN ST SW
EPHRATA, WA 98823
(509) 754-3567
WAL-MART *
1399 SE BLVD
EPHRATA, WA 98823
(509) 754-8847
GRAND COULEE
SAFEWAY
PHARMACY *
101 GRAND COULEE
HWY
GRAND COULEE, WA
99133
(509) 633-0463
MATTAWA
WFHC PHARMACY
601 GOVERNMENT
WAY
MATTAWA, WA 99349
(509) 488-5256
MOSES LAKE
PIONEER MED
CENTER PHARMACY *
550 S PIONEER WAY
STE 105
MOSES LAKE, WA
98837
(509) 765-8891
RITE AID *
500 S PIONEER WAY
MOSES LAKE, WA
98837
(509) 765-1219
SAFEWAY
PHARMACY *
601 S PIONEER WAY
MOSES LAKE, WA
98837
(509) 764-4721
SOUTHGATE
PHARMACY *
2709 W BROADWAY
AVE
MOSES LAKE, WA
98837
(509) 765-9332
WALGREENS *
200 E BROADWAY
AVE
MOSES LAKE, WA
98837
(509) 765-1217
WAL-MART *
1005 N STRATFORD
RD
MOSES LAKE, WA
98837
(509) 766-0168
RITE AID *
301 E WISHKAH ST
ABERDEEN, WA 98520
(360) 533-6320
SAFEWAY
PHARMACY *
221 W HERON ST
ABERDEEN, WA 98520
(360) 532-8743
SWANSON OWL
PHARMACY *
117 N BOONE ST
ABERDEEN, WA 98520
(360) 533-3294
WAL-MART *
909 E WISHKAH ST
ABERDEEN, WA 98520
(360) 532-7875
QUINCY
ELMA
SHOPKO PHARMACY*
101 F ST
QUINCY, WA 98848
(509) 787-4437
ELMA HEALTH MART
PHARMACY *
221 W MAIN ST
ELMA, WA 98541
(360) 482-2442
GRAYS HARBOR
COUNTY
ABERDEEN
ABERDEEN HEALTH
MART PHARMACY *
1812 SUMNER AVE
STE H
ABERDEEN, WA 98520
(360) 533-1525
CITY CENTER DRUG *
108 E WISHKAH ST
ABERDEEN, WA 98520
(360) 532-5182
101
103
HOQUIAM
CROWN DRUG *
2544 SIMPSON AVE
HOQUIAM, WA 98550
(360) 533-0961
HARBOR DRUG *
316 8TH ST
HOQUIAM, WA 98550
(360) 532-3061
RITE AID *
3130 SIMPSON AVE
HOQUIAM, WA 98550
(360) 533-5531
OCEAN SHORES
FREELAND
OCEAN SHORES
PHARMACY *
172 W CHANCE A LA
MER NW
OCEAN SHORES, WA
98569
(360) 289-4647
LIND'S FREELAND
PHARMACY *
1609 E MAIN ST
FREELAND, WA 98249
(360) 331-4700
WESTPORT
TWIN HARBOR DRUG*
733 N MONTESANO
ST
WESTPORT, WA 98595
(360) 268-0505
ALBERTSON'S *
1450 SW ERIE ST
OAK HARBOR, WA
98277
(360) 279-8829
ISLAND COUNTY
CAMANO ISLAND
MARKS CAMANO
PHARMACY *
370 NE CAMANO DR
STE 6
CAMANO ISLAND, WA
98282
(360) 387-5757
CLINTON
ISLAND DRUG *
11042 STATE ROUTE
525
CLINTON, WA 98236
(360) 341-3885
COUPEVILLE
LINDS COUPVILLE
PHARMACY *
40 N MAIN ST
COUPEVILLE, WA
98239
(360) 678-4010
OAK HARBOR
ISLAND DRUG *
230 SE PIONEER WAY
OAK HARBOR, WA
98277
(360) 675-6688
KMART PHARMACY *
32165 SR 20
OAK HARBOR, WA
98277
(360) 679-5546
RITE AID *
31645 SR 20
OAK HARBOR, WA
98277
(360) 679-3522
SAAR'S
MARKETPLACE
FOOD *
32199 STATE RTE 20
OAK HARBOR, WA
98277
(360) 675-4511
102
104
WALGREENS *
31490 STATE RTE 20
OAK HARBOR, WA
98277
(360) 675-3497
WAL-MART *
1250 SW ERIE ST
OAK HARBOR, WA
98277
(360) 279-0671
JEFFERSON
COUNTY
PORT HADLOCK
QFC PHARMACY *
1890 IRONDALE RD
PORT HADLOCK, WA
98339
(360) 385-1900
TRI-AREA
PHARMACY*
65 OAK BAY RD
PORT HADLOCK, WA
98339
(360) 379-9800
PORT TOWNSEND
DONS PHARMACY *
1151 WATER ST
PORT TOWNSEND,
WA 98368
(360) 385-0969
SAFEWAY
PHARMACY *
442 W SIMS WAY
PORT TOWNSEND,
WA 98368
(360) 385-2860
KING COUNTY
AUBURN
FRANCISCAN
PHARMACY AUBURN*
205 10TH ST NE
AUBURN, WA 98002
(253) 351-5230
FRED MEYER
PHARMACY *
801 AUBURN WAY N
AUBURN, WA 98002
(253) 931-5584
HEALTHPOINT
AUBURN PHARMACY*
126 AUBURN AVE
STE 104
AUBURN, WA 98002
(253) 804-3591
PECKENPAUGH
DRUG *
1123 E MAIN ST
AUBURN, WA 98002
(253) 833-8020
RITE AID *
1231 AUBURN WAY N
AUBURN, WA 98002
(253) 939-5355
RITE AID *
1509 AUBURN WAY S
AUBURN, WA 98002
(253) 939-1939
SAFEWAY
PHARMACY *
101 AUBURN WAY S
AUBURN, WA 98002
(253) 735-4404
SAM'S CLUB *
1101 SUPERMALL
WAY STE 1275
AUBURN, WA 98001
(253) 333-8191
TOP FOOD AND
DRUG*
1702 AUBURN WAY N
AUBURN, WA 98002
(253) 804-9616
WALGREENS *
1400 HARVEY RD
AUBURN, WA 98002
(253) 394-0022
WALGREENS *
1701 AUBURN WAY S
AUBURN, WA 98002
(253) 394-0029
WAL-MART *
762 OUTLET
COLLECTION DR SW
AUBURN, WA 98001
(253) 735-0708
BELLEVUE
BARTELL DRUGS *
3620 FACTORIA BLVD
SE
BELLEVUE, WA 98006
(425) 644-7529
BARTELL DRUGS *
10116 NE 8TH ST
BELLEVUE, WA 98004
(425) 454-2468
BARTELL DRUGS *
11919 NE 8TH ST
BELLEVUE, WA 98005
(425) 454-0146
103
105
BARTELL DRUGS *
653 156TH AVE NE
BELLEVUE, WA 98007
(425) 641-9127
BELLEGROVE
PHARMACY *
1200 112TH AVE NE
STE A100
BELLEVUE, WA 98004
(425) 455-2123
EVERGREEN
INTEGRATIVE
MEDICINE *
11520 NE 20TH ST
BELLEVUE, WA 98004
(425) 646-4747
FRED MEYER
PHARMACY *
2041 148TH NE
BELLEVUE, WA 98007
(425) 865-8593
LAKEMONT
PHARMACY *
4935 LAKEMONT
BLVD SE
BELLEVUE, WA 98006
(425) 644-6080
MEDIART FAMILY
CLINIC *
1530 140TH AVE NE
STE 101
BELLEVUE, WA 98005
(425) 233-8254
MEDICAL ARTS
ASSOCIATES PS *
1380 112TH AVE NE
STE 100
BELLEVUE, WA 98004
(425) 454-8191
MICHAEL K WOO ND *
4205 148TH AVE NE
STE 103
BELLEVUE, WA 98007
(425) 822-0602
RITE AID *
3905 FACTORIA MALL
SE
BELLEVUE, WA 98006
(425) 644-2925
O'HANA WELLNESS
CENTER *
2310 130TH AVE NE
STE 103
BELLEVUE, WA 98005
(425) 881-2310
SAFEWAY
PHARMACY *
1645 140TH AVE NE
BELLEVUE, WA 98005
(425) 643-1778
PHARMACY PLUS *
1299 156TH AVE NE
STE 140
BELLEVUE, WA 98007
(425) 644-8887
QFC PHARMACY *
2636 BELLEVUE WAY
NE
BELLEVUE, WA 98004
(425) 576-9222
QFC PHARMACY *
1510 145TH PL SE
BELLEVUE, WA 98007
(425) 653-2431
QFC PHARMACY *
3550 FACTORIA BLVD
SE
BELLEVUE, WA 98006
(425) 378-0202
RITE AID *
15100 SE 38TH ST
BELLEVUE, WA 98006
(425) 746-4028
RITE AID *
120 106TH AVE NE
BELLEVUE, WA 98004
(425) 454-6513
SAFEWAY
PHARMACY *
300 BELLEVUE WAY
BELLEVUE, WA 98004
(425) 749-3889
SEATTLE CHILDRENS
HOSPITAL *
1500 116TH AVE NE
BELLEVUE, WA 98004
(206) 884-9120
WALGREENS *
647 140TH AVE NE
BELLEVUE, WA 98005
(425) 603-1438
WALGREENS *
1135 116TH AVE NE
STE 105
BELLEVUE, WA 98004
(425) 453-1130
WALGREENS *
15585 NE 24TH ST
BELLEVUE, WA 98007
(425) 643-8281
WAL-MART *
15063 MAIN ST
BELLEVUE, WA 98007
(425) 643-9402
104
106
WAL-MART *
12620 SE 41ST PL
BELLEVUE, WA 98006
(425) 643-9034
WASHINGTON CTR
FOR PAIN MGMT *
1900 116TH AVE NE
STE 201
BELLEVUE, WA 98004
(425) 774-1538
BOTHELL
HEALTHPOINT
BOTHELL
PHARMACY*
10414 BEARDSLEE
BLVD
BOTHELL, WA 98011
(425) 486-0658
QFC PHARMACY *
18921 BOTHELL WAY
NE
BOTHELL, WA 98011
(425) 487-3031
RITE AID *
19107 BOTHELL WAY
NE
BOTHELL, WA 98011
(425) 489-1814
BURIEN
ALBERTSON'S *
12725 1ST AVE S
BURIEN, WA 98168
(206) 242-7942
BARTELL DRUGS *
14901 4TH AVE SW
BURIEN, WA 98166
(206) 242-1202
RITE AID *
110 SW 148TH ST
BURIEN, WA 98166
(206) 835-0166
THREE MOON CLINIC*
1800 SW 152ND ST
STE A
BURIEN, WA 98166
(206) 838-3878
WALGREENS *
14656 AMBAUM BLVD
SW
BURIEN, WA 98166
(206) 901-1816
COVINGTON
COSTCO *
27520 COVINGTON
WAY SE
COVINGTON, WA
98042
(253) 796-1011
COVINGTON
MULTICARE CLINIC *
17700 SE 272ND ST
STE 100
COVINGTON, WA
98042
(253) 372-7220
RITE AID *
17125 SE 272ND ST
COVINGTON, WA
98042
(253) 630-9880
WAL-MART *
17432 SE 270TH PL
COVINGTON, WA
98042
(253) 630-8682
DES MOINES
ENUMCLAW
BARTELL DRUGS *
27055 PACIFIC HWY S
DES MOINES, WA
98198
(253) 839-1693
JIM'S PHARMACY *
2820 GRIFFIN AVE
STE 102
ENUMCLAW, WA
98022
(360) 825-6523
NATUROPATHIC
MEDICINE *
22015 MARINE VIEW
DR S
DES MOINES, WA
98198
(206) 878-2628
SAFEWAY
PHARMACY *
21401 PACIFIC HWY S
DES MOINES, WA
98198
(206) 824-4784
PLATEAU
COMMUNITY
PHARMACY *
3021 GRIFFIN AVE
ENUMCLAW, WA
98022
(360) 825-2442
QFC PHARMACY *
1009 MONROE ST
ENUMCLAW, WA
98022
(360) 825-9360
WALGREENS *
23003 PACIFIC HWY S
DES MOINES, WA
98198
(206) 870-1832
RITE AID *
232 ROOSEVELT AVE
ENUMCLAW, WA
98022
(360) 825-2558
DUVALL
DUVALL FAMILY
DRUGS *
15602 MAIN ST NE
DUVALL, WA 98019
(425) 788-2644
SAFEWAY
PHARMACY *
152 ROOSEVELT AVE
E
ENUMCLAW, WA
98022
(360) 802-1534
SAFEWAY
PHARMACY *
14020 MAIN ST NE
DUVALL, WA 98019
(425) 844-1199
WALGREENS *
1350 2ND ST
ENUMCLAW, WA
98022
(360) 825-5739
105
107
FEDERAL WAY
ALBERTSON'S *
31009 PACIFIC HWY S
FEDERAL WAY, WA
98003
(253) 946-4033
HIGHLAND
PHARMACY *
31260 PACIFIC HWY S
STE 10
FEDERAL WAY, WA
98003
(253) 839-1399
COSTCO *
35100 ENCHANTED
PKWY S
FEDERAL WAY, WA
98003
(253) 874-4431
ONURI PHARMACY *
33507 9TH AVE S STE
B STE 2
FEDERAL WAY, WA
98003
(253) 719-8554
FEDERAL WAY
PHARMACY *
33501 1ST WAY S
FEDERAL WAY, WA
98003
(253) 874-1650
RITE AID *
2131 SW 336TH ST
FEDERAL WAY, WA
98023
(253) 952-2803
FRANCISCAN
PHARMACY FIRST
AVE *
30809 1ST AVE S
FEDERAL WAY, WA
98003
(253) 529-8888
FRED MEYER
PHARMACY *
33702 21ST AVE SW
FEDERAL WAY, WA
98023
(253) 952-0133
HEALTHPOINT
FEDERAL WAY PHCY*
33431 13TH PL S
FEDERAL WAY, WA
98003
(253) 815-8045
RITE AID *
32015 PACIFIC HWY S
FEDERAL WAY, WA
98003
(253) 945-6011
SAFEWAY
PHARMACY *
1207 S 320TH ST
FEDERAL WAY, WA
98003
(253) 946-1505
TARGET PHARMACY *
2201 S COMMONS
FEDERAL WAY, WA
98003
(253) 733-7521
WALGREENS *
28817 MILITARY RD S
FEDERAL WAY, WA
98003
(253) 839-1027
106
108
WALGREENS *
34008 HOYT RD SW
FEDERAL WAY, WA
98023
(253) 838-5963
WAL-MART *
34520 16TH AVE S
FEDERAL WAY, WA
98003
(253) 835-4976
WAL-MART *
1900 S 314TH ST
FEDERAL WAY, WA
98003
(253) 941-3555
ISSAQUAH
BARTELL DRUGS *
5700 E LAKE
SAMMAMISH PKWY
ISSAQUAH, WA 98029
(425) 391-6408
COSTCO *
1801 10TH AVE NW
ISSAQUAH, WA 98027
(425) 313-9200
FRED MEYER
PHARMACY *
6100 E LAKE
SAMMAMISH PKWY
ISSAQUAH, WA 98029
(425) 416-1133
MEDICAL CENTER
PHARMACY *
450 NW GILMAN BLVD
STE 107
ISSAQUAH, WA 98027
(425) 392-8650
QFC PHARMACY *
4560 KLAHANIE DR
SE
ISSAQUAH, WA 98027
(425) 392-8551
RITE AID *
1065 NW GILMAN
BLVD
ISSAQUAH, WA 98027
(425) 392-2865
SAFEWAY
PHARMACY *
1451 HIGHLANDS DR
NE
ISSAQUAH, WA 98029
(425) 392-4181
SAFEWAY
PHARMACY *
735 NW GILMAN BLVD
ISSAQUAH, WA 98027
(425) 507-1042
SWEDISH ISSAQUAH
RETAIL PHCY *
751 NE BLAKELY DR
ISSAQUAH, WA 98029
(425) 313-5200
TARGET PHARMACY *
755 NW GILMAN BLVD
ISSAQUAH, WA 98027
(425) 507-1020
WALGREENS *
6300 E LAKE
SAMMAMISH PKWY
ISSAQUAH, WA 98029
(425) 369-0265
KENMORE
OSTROM DRUG AND
GIFT *
6414 NE BOTHELL
WAY
KENMORE, WA 98028
(425) 486-7711
RITE AID *
18022 NE 68TH AVE
KENMORE, WA 98028
(425) 424-2320
SAFEWAY
PHARMACY *
6850 NE BOTHELL
WAY
KENMORE, WA 98028
(425) 486-1661
KENT
A AND H
PHARMACEUTICAL
SVCS
610 W MEEKER ST
STE 201
KENT, WA 98032
(253) 852-1123
BARTELL DRUGS *
12946 SE KENT
KANGLEY RD
KENT, WA 98030
(253) 631-6874
FRED MEYER
PHARMACY *
25250 PACIFIC HWY S
KENT, WA 98031
(253) 941-2905
107
109
FRED MEYER
PHARMACY *
16735 SE 272ND ST
KENT, WA 98402
(253) 639-7433
FRED MEYER
PHARMACY *
10201 SE 240TH ST
KENT, WA 98031
(253) 859-5533
HEALTHPOINT KENT
PHARMACY *
403 E MEEKER ST
STE 300
KENT, WA 98030
(253) 372-3661
PROPAC PHARMACY*
7102 S 220TH ST
KENT, WA 98032
(855)535-7183
RITE AID *
26200 PACIFIC HWY S
KENT, WA 98032
(253) 941-4660
RITE AID *
10407 SE 256TH ST
KENT, WA 98030
(253) 854-5343
RITE AID *
105 WASHINGTON
AVE N
KENT, WA 98032
(253) 373-0156
SAFEWAY
PHARMACY *
17051 272ND SE
KENT, WA 98042
(253) 631-2450
SAFEWAY
PHARMACY *
20830 108TH AVE SE
KENT, WA 98031
(253) 852-9319
SAFEWAY
PHARMACY *
13101 SE KENT
KANGLEY HWY
KENT, WA 98031
(253) 638-0831
SAFEWAY
PHARMACY *
210 WASHINGTON
AVE S
KENT, WA 98032
(253) 852-5115
TARGET PHARMACY *
26301 104TH AVE SE
KENT, WA 98031
(253) 518-1190
TOP FOOD AND
DRUG*
26015 104TH AVE SE
KENT, WA 98030
(253) 850-6480
UNITED CARE
PHARMACY *
18230 E VALLEY HWY
STE 188
KENT, WA 98032
(206) 371-7697
UNITED CARE
PHARMACY
18230 E VALLEY HWY
KENT, WA 98032
(425) 656-2900
WALGREENS *
25605 104TH AVE SE
KENT, WA 98030
(253) 813-6968
WALGREENS *
27112 132ND AVE SE
KENT, WA 98042
(253) 638-3324
KIRKLAND
ASSURED
PHARMACY*
12071 124TH AVE NE
KIRKLAND, WA 98034
(425) 820-1030
BARTELL DRUGS *
6619 132ND AVE NE
KIRKLAND, WA 98033
(425) 881-5678
BARTELL DRUGS *
14442 124TH AVE NE
KIRKLAND, WA 98034
(425) 821-7899
BARTELL DRUGS *
14130 JUANITA DR NE
KIRKLAND, WA 98034
(425) 821-6275
BARTELL DRUGS *
10625 NE 68TH ST
KIRKLAND, WA 98033
(425) 822-2241
COSTCO *
8629 120TH AVE NE
KIRKLAND, WA 98033
(425) 822-0414
108
110
EVERGREEN
PHARMACY *
12911 120TH AVE NE
KIRKLAND, WA 98034
(425) 821-8888
EVERGREEN PROF
CTR PHARMACY *
12303 NE 130TH LN
STE 210
KIRKLAND, WA 98034
(425) 899-2790
FRED MEYER
PHARMACY *
12221 120TH AVE NE
KIRKLAND, WA 98034
(425) 820-3233
INTEGRATIVE FOOT
AND ANKLE CTR *
13030 121ST WAY NE
STE 204
KIRKLAND, WA 98034
(425) 822-7426
PACMED CLINIC
PHARMACY
12910 TOTEM LAKE
BLVD NE
KIRKLAND, WA 98034
(425) 814-5003
QFC PHARMACY *
211 PARK PL
KIRKLAND, WA 98033
(425) 822-4123
QFC PHARMACY *
11224 NE 124TH ST
KIRKLAND, WA 98034
(425) 820-0440
RITE AID *
9820 NE 132ND ST
KIRKLAND, WA 98034
(425) 823-4466
RITE AID *
12530 TOTEM LAKE
BLVD
KIRKLAND, WA 98034
(425) 821-1500
SAFEWAY
PHARMACY *
14444 124TH AVE NE
KIRKLAND, WA 98033
(425) 821-7455
FRED MEYER
PHARMACY *
26520 MAPLE VALLEY
BLACK
MAPLE VALLEY, WA
98038
(425) 433-2333
WALGREENS *
26705 BLACK
DIAMOND RD SE
MAPLE VALLEY, WA
98038
(425) 578-9413
MERCER ISLAND
SAFEWAY
PHARMACY *
10020 NE 137TH AVE
KIRKLAND, WA 98033
(425) 821-0708
ALBERTSON'S *
2755 77TH AVE SE
MERCER ISLAND, WA
98040
(206) 232-2222
SAFEWAY
PHARMACY *
12519 85TH ST NE
KIRKLAND, WA 98033
(425) 822-9235
RITE AID *
3023 SE 78TH AVE
MERCER ISLAND, WA
98040
(206) 236-0776
WALGREENS *
11607 98TH AVE NE
KIRKLAND, WA 98034
(425) 825-8841
RITE AID *
8441 SE 68TH ST
MERCER ISLAND, WA
98040
(206) 232-3000
WALGREENS *
12405 NE 85TH ST
KIRKLAND, WA 98033
(425) 822-9202
MAPLE VALLEY
BARTELL DRUGS *
22117 SE 237TH ST
MAPLE VALLEY, WA
98038
(425) 432-1234
WALGREENS *
7707 SE 27TH ST STE
100
MERCER ISLAND, WA
98040
(206) 232-1197
NEWCASTLE
BARTELL DRUGS *
6939 COAL CREEK
PKWY SE
NEWCASTLE, WA
98059
(425) 644-4416
NORMANDY PARK
ACCESS PHARMACY *
17833 1ST AVE S
STE C
NORMANDY PARK,
WA 98148
(206) 246-0040
NORTH BEND
BARTELL DRUGS *
248 BENDIGO BLVD S
NORTH BEND, WA
98045
(425) 888-1308
QFC PHARMACY *
460 E NORTHBEND
WAY
NORTH BEND, WA
98045
(425) 888-2357
SAFEWAY
PHARMACY *
460 SW MOUNT BLVD
NORTH BEND, WA
98045
(425) 831-2126
REDMOND
ALBERTSON'S *
3925 236TH AVE NE
REDMOND, WA 98053
(425) 836-8706
109
111
ALPINE INTEGRATED
MEDICINE *
22635 NE
MARKETPLACE DR
REDMOND, WA 98053
(425) 949-5961
BARTELL DRUGS *
8862 161ST AVE NE
REDMOND, WA 98052
(425) 883-9532
BARTELL DRUGS *
7370 170TH AVE NE
REDMOND, WA 98052
(425) 895-8242
FRED MEYER
PHARMACY *
17667 NE 76TH ST
REDMOND, WA 98052
(425) 556-8033
PHARMACA
INTEGRATIVE
PHARMACY *
15840 REDMOND WAY
REDMOND, WA 98052
(425) 885-2323
QFC PHARMACY *
8867 161ST AVE NE
REDMOND, WA 98052
(425) 869-7474
RITE AID *
14880 NE 24TH ST
REDMOND, WA 98052
(425) 883-0900
RITE AID *
17220 REDMOND WAY
REDMOND, WA 98052
(425) 883-1516
SAFEWAY
PHARMACY *
630 228TH AVE NE
REDMOND, WA 98074
(425) 868-6181
HEALTHPOINT
CENTRAL FILL PHCY *
947 POWELL AVE SW
RENTON, WA 98057
(877)233-0246
TARGET PHARMACY *
17700 NE 76TH ST
REDMOND, WA 98052
(425) 202-1000
JOLLY'S PHARMACY
1412 SW 43RD ST STE
120
RENTON, WA 98057
(425) 251-6335
RENTON
ALBERTSON'S *
14215 SE
PETROVITSKY RD
RENTON, WA 98058
(425) 235-7772
BARTELL DRUGS *
4700 NE 4TH ST
RENTON, WA 98059
(425) 793-1015
BARTELL DRUGS *
17254 140TH SE
RENTON, WA 98058
(425) 226-7000
FRED MEYER
PHARMACY *
17801 108TH AVE SE
RENTON, WA 98055
(425) 235-5383
FRED MEYER
PHARMACY *
365 RENTON CENTER
WAY SW
RENTON, WA 98055
(425) 204-5233
110
112
LAURA J HIEB ND *
304 MAIN AVE S STE
201
RENTON, WA 98057
(425) 282-5304
PACMED CLINIC
PHARMACY
601 S CARR RD STE
100
RENTON, WA 98055
(425) 227-3122
PAIN ASSOCIATES OF
WASHINGTON *
4300 TALBOT RD S
STE 200
RENTON, WA 98055
(425) 271-1255
READY MEDS
PHARMACY *
1412 SW 43RD ST
STE 120
RENTON, WA 98057
(425) 251-6335
RITE AID *
3116 NE SUNSET
BLVD
RENTON, WA 98056
(425) 793-0787
RITE AID *
601 S GRADY WAY
STE P
RENTON, WA 98055
(425) 226-4390
THE PRESCRIPTION
PAD PHARMACY *
3915 TALBOT RD S
RENTON, WA 98055
(425) 656-4050
SAFEWAY
PHARMACY *
4300 4TH ST NE
RENTON, WA 98059
(425) 235-6251
THE PRESCRIPTION
PAD PHARMACY *
400 S 43RD ST
RENTON, WA 98055
(425) 917-6226
SAFEWAY
PHARMACY *
200 S 3RD ST
RENTON, WA 98055
(425) 226-0325
WALGREENS *
4105 NE 4TH ST
RENTON, WA 98059
(425) 207-1278
SAFEWAY
PHARMACY *
6911 COAL CREEK
PKWY SE
RENTON, WA 98056
(425) 644-2726
SAM'S CLUB *
901 S GRADY WAY
RENTON, WA 98057
(425) 793-7937
SUNSET PLAZA
PHARMACY *
3188 NE SUNSET
BLVD
RENTON, WA 98056
(425) 271-6066
TARGET PHARMACY *
1215 LANDING WAY
RENTON, WA 98055
(425) 207-0078
RITE AID *
3066 ISSAQUAH PINE
LAKE
SAMMAMISH, WA
98075
(425) 391-1582
SEATAC
SAFEWAY
PHARMACY *
4011 S 164TH ST
SEATAC, WA 98188
(206) 248-0300
SEATTLE
WALGREENS *
275 RAINER AVE S
RENTON, WA 98055
(425) 277-0212
AFH PHARAMCY *
1017 E UNION ST
SEATTLE, WA 98122
(206) 568-2486
WALGREENS *
3011 NE SUNSET
BLVD
RENTON, WA 98056
(425) 207-0053
AHP PHARMACY *
1120 CHERRY ST STE
124
SEATTLE, WA 98104
(206) 624-1391
WAL-MART *
743 RAINIER AVE S
RENTON, WA 98057
(425) 227-9307
BALLARD PLAZA
PHARMACY *
1801 NW MARKET ST
STE 104
SEATTLE, WA 98107
(206) 782-7200
SAMMAMISH
BARTELL DRUGS *
526 228TH AVE NE
SAMMAMISH, WA
98074
(425) 868-1112
111
113
BARTELL DRUGS *
600 1ST AVE N
SEATTLE, WA 98109
(206) 284-1354
BARTELL DRUGS *
120 N 85TH ST
SEATTLE, WA 98103
(206) 784-7600
BARTELL DRUGS *
9600 15TH AVE SW
SEATTLE, WA 98106
(206) 763-2727
BARTELL DRUGS *
1407 BROADWAY AVE
SEATTLE, WA 98122
(206) 726-3495
BARTELL DRUGS *
3018 NE 125TH ST
SEATTLE, WA 98125
(206) 362-7572
BARTELL DRUGS *
5605 22ND AVE NW
SEATTLE, WA 98107
(206) 783-3050
BARTELL DRUGS *
4706 42ND AVE SW
SEATTLE, WA 98116
(206) 932-8045
BARTELL DRUGS *
1101 MADISON ST
SEATTLE, WA 98104
(206) 340-1171
BARTELL DRUGS *
2345 42ND AVE SW
SEATTLE, WA 98116
(206) 932-7437
BARTELL DRUGS *
6401 12TH AVE NE
SEATTLE, WA 98115
(206) 525-3754
BARTELL DRUGS *
21615 PACIFIC HWY S
SEATTLE, WA 98198
(206) 878-4628
BARTELL DRUGS *
1820 N 45TH ST
SEATTLE, WA 98103
(206) 632-3313
BARTELL DRUGS *
4344 UNIVERSITY
WAY NE
SEATTLE, WA 98105
(206) 632-3513
BARTELL DRUGS *
910 4TH AVE
SEATTLE, WA 98134
(206) 624-8394
BARTELL DRUGS *
2222 32ND AVE W
SEATTLE, WA 98199
(206) 282-2880
BARTELL DRUGS *
1929 QUEEN ANNE
AVE N
SEATTLE, WA 98109
(206) 285-1737
BARTELL DRUGS *
1404 3RD AVE
SEATTLE, WA 98101
(206) 624-1401
BARTELL DRUGS *
2345 RAINIER AVE S
SEATTLE, WA 98144
(206) 325-5725
BARTELL DRUGS *
2700 NE UNIVERSITY
VILLAGE ST
SEATTLE, WA 98105
(206) 525-0705
BARTELL DRUGS *
1001 MERCER ST
SEATTLE, WA 98109
(206) 223-1104
112
114
BARTELL DRUGS *
1500 NW MARKET ST
STE 101
SEATTLE, WA 98107
(206) 783-4182
BOB JOHNSONS
PHARMACY *
1407 NW 85TH ST
SEATTLE, WA 98117
(206) 782-5822
BUCK PAVILION
PHARMACY *
MASON CLINIC 1100
9TH AVE
SEATTLE, WA 98101
(206) 223-6877
CABRINI MEDICAL
TOWER PHCY *
901 BOREN AVE
SEATTLE, WA 98104
(206) 682-1011
CHESTERFIELD
PHARMACY *
720 7TH AVE STE 100
SEATTLE, WA 98104
(206) 838-6070
COLUMBIA
PHARMACY *
4741 RAINIER AVE S
SEATTLE, WA 98118
(206) 723-5233
COMMUNITY *
1001 BROADWAY STE
102
SEATTLE, WA 98122
(206) 324-2335
COSTCO *
1175 N 205TH ST
SEATTLE, WA 98133
(206) 542-0497
COSTCO *
4401 4TH AVE S
SEATTLE, WA 98134
(206) 682-6244
COUNTRY DOCTOR
COMMUNITY CLN *
500 19TH AVE E
SEATTLE, WA 98112
(206) 299-1620
DES MOINES DRUG
627 227TH ST S
SEATTLE, WA 98198
(206) 878-2345
DONG NAI
PHARMACY *
620 S JACKSON ST
SEATTLE, WA 98104
(206) 624-4238
DOWNTOWN PUBLIC
HLTH CNTR PHCY
2124 4TH AVE
SEATTLE, WA 98121
(206) 296-4637
FRED MEYER
PHARMACY *
13000 LAKE CITY WAY
NE
SEATTLE, WA 98125
(206) 440-2419
FRED MEYER
PHARMACY *
100 NW 85TH ST
SEATTLE, WA 98117
(206) 783-2272
FRED MEYER
PHARMACY *
18325 AURORA AVE N
SEATTLE, WA 98133
(206) 546-0753
FRED MEYER
PHARMACY *
14300 1ST AVE S
SEATTLE, WA 98168
(206) 433-6446
FRED MEYER
PHARMACY *
915 NW 45TH ST
SEATTLE, WA 98107
(206) 297-4333
HARBORVIEW
MEDICAL CENTER *
325 9TH AVE
SEATTLE, WA 98104
(206) 744-3219
HOLLY PARK
PHARMACY *
3815 S OTHELLOS ST
SEATTLE, WA 98118
(206) 788-3562
INTERNATIONAL
COMM HLTH SVCS *
720 8TH AVE S
STE 100
SEATTLE, WA 98104
(206) 788-3770
KATTERMAN'S SAND
POINT PHCY *
5400 SAND POINT
WAY NE
SEATTLE, WA 98105
(206) 524-2211
113
115
KELLEY ROSS LTC
PHARMACY
2324 EASTLAKE AVE
E
SEATTLE, WA 98102
(206) 838-4590
KELLEY-ROSS
PHARMACY *
904 7TH AVE STE 103
SEATTLE, WA 98104
(206) 324-6990
KING PLAZA
PHARMACY *
7101 MLK JR WAY S
STE 101B
SEATTLE, WA 98118
(206) 721-5009
LAFFERRY'S
PHARMACY *
5312 17TH AVE NW
SEATTLE, WA 98107
(206) 783-5133
LINDEMAN PAVILION
PHARMACY *
1201 TERRY AVE STE
X2-PN
SEATTLE, WA 98101
(206) 625-7202
LOWRY'S
PRESCRIPTIONS *
10330 MERIDIAN AVE
N
SEATTLE, WA 98133
(206) 368-6060
LUKE'S PHARMACY *
611 MAYNARD AVE S
SEATTLE, WA 98104
(206) 621-8883
MAPLE LEAF
PHARMACY *
8830 ROOSEVELT
WAY NE
SEATTLE, WA 98115
(206) 729-7514
NGUYENS
PHARMACY AND
GIFTS *
2120 RAINIER AVE S
SEATTLE, WA 98144
(206) 323-9525
MERIDIAN
PHARMACY*
11011 MERIDIAN AVE
N
SEATTLE, WA 98133
(206) 403-1137
NGUYENS
PHARMACY AND
GIFTS *
1221 S MAIN ST
STE 103
SEATTLE, WA 98144
(206) 323-6003
NATURAL
HEALTHCARE
NORTHWEST *
509 OLIVE WAY
STE 1315
SEATTLE, WA 98101
(206) 382-9977
NAVOS *
2600 SW HOLDEN ST
SEATTLE, WA 98126
(206) 933-7219
NEIGHBORCARE
HEALTH *
4400 37TH AVE S
SEATTLE, WA 98118
(206) 461-6957
NEIGHBORCARE
HEALTH *
1930 POST ALY
SEATTLE, WA 98101
(206) 728-4143
NEIGHBORCARE
HEALTH *
1629 N 45TH ST
SEATTLE, WA 98103
(206) 548-2964
NORTH PUBLIC
HEALTH CTR PHCY
10501 MERIDIAN AVE
N
SEATTLE, WA 98133
(206) 296-4908
NORTHWEST KIDNEY
CENTER PHCY *
700 BROADWAY
SEATTLE, WA 98122
(206) 343-4870
NORTHWEST
PRESCRIPTION *
1536 N 115TH ST
STE 100
SEATTLE, WA 98133
(206) 365-2255
NW NATUROPATHY
AND ACUPUNCTURE *
6300 9TH AVE NE
STE 310
SEATTLE, WA 98115
(206) 524-0863
PACIFIC DRUGS *
822 1ST AVE
SEATTLE, WA 98104
(206) 624-1454
114
116
PACMED CLINIC
PHARMACY
10416 5TH AVE NE
SEATTLE, WA 98125
(206) 517-6635
PACMED CLINIC
PHARMACY
1200 12TH AVE S
SEATTLE, WA 98144
(206) 621-4109
PACMED CLINIC
PHARMACY
1101 MADISON
STE 306
SEATTLE, WA 98104
(206) 505-1397
PARK'S PHARMACY *
401 NE RAVENNA
BLVD STE A
SEATTLE, WA 98115
(206) 527-3010
PHARMACA
INTEGRATIVE
PHARMACY *
4707 CALIFORNIA
AVE SW
SEATTLE, WA 98116
(206) 932-4225
PHARMACA
INTEGRATIVE PHCY *
4130 EAST MADISON
SEATTLE, WA 98112
(206) 324-1188
PHARMACARE
SPECIALTY PHCY *
1001 MADISON ST
SEATTLE, WA 98104
(206) 381-1259
PLANNED
PARENTHOOD OF
GRT NW PHCY *
2001 E MADISON ST
SEATTLE, WA 98122
(206) 963-2686
QFC PHARMACY *
417 BROADWAY E
SEATTLE, WA 98102
(206) 328-6960
QFC PHARMACY *
9999 HOLMAN RD NW
SEATTLE, WA 98117
(206) 782-4100
QFC PHARMACY *
1531 NE 145TH ST
SEATTLE, WA 98155
(206) 366-4672
QFC PHARMACY *
500 MERCER ST
SEATTLE, WA 98109
(260)352-4030
QFC PHARMACY *
4550 42ND AVE SW
SEATTLE, WA 98116
(206) 923-6391
QUE ARESTE ND *
1605 12TH AVE STE 16
SEATTLE, WA 98122
(206) 328-2926
RITE AID *
13201 N AURORA AVE
SEATTLE, WA 98133
(206) 364-7676
RITE AID *
2603 THIRD AVE
SEATTLE, WA 98121
(206) 441-8790
RITE AID *
655 NW RICHMOND
BEACH RD
SEATTLE, WA 98177
(206) 542-9688
RITE AID *
17171 BOTHELL WAY
NE STE 15
SEATTLE, WA 98155
(206) 363-6364
RITE AID *
9200 RAINIER AVE S
SEATTLE, WA 98118
(206) 760-1076
RITE AID *
201 BROADWAY E
SEATTLE, WA 98102
(206) 324-7111
RITE AID *
8500 35TH AVE NE
SEATTLE, WA 98115
(206) 527-8373
RITE AID *
802 3RD AVE
SEATTLE, WA 98104
(206) 623-0577
QFC PHARMACY *
2746 NE 45TH ST
SEATTLE, WA 98105
(206) 729-3080
RITE AID *
2600 SW BARTON ST
STE D
SEATTLE, WA 98126
(206) 938-4253
RXTRA CARE PHCY
VIEW RIDGE *
7317 35TH AVE NE
SEATTLE, WA 98115
(206) 417-8066
QFC PHARMACY *
11100 ROOSEVELT
WAY NE
SEATTLE, WA 98125
(206) 361-0188
RITE AID *
5217 CALIFORNIA
AVE SW
SEATTLE, WA 98136
(206) 937-2191
QFC PHARMACY *
600 RICHMOND
BEACH RD
SEATTLE, WA 98177
(206) 542-5469
RITE AID *
1300 MADISON ST
SEATTLE, WA 98104
(206) 322-9316
SAFEWAY
PHARMACY *
2100 QUEEN ANNE
AVE N
SEATTLE, WA 98109
(206) 284-4226
115
117
SAFEWAY
PHARMACY *
516 1ST AVE W
SEATTLE, WA 98119
(206) 494-1700
SAFEWAY
PHARMACY *
7300 NE ROOSEVELT
WAY
SEATTLE, WA 98115
(206) 524-1649
SAFEWAY
PHARMACY *
3820 RAINIER AVE S
SEATTLE, WA 98118
(206) 725-9887
SAFEWAY
PHARMACY *
7340 35TH AVE NE
SEATTLE, WA 98115
(206) 494-1255
SAFEWAY
PHARMACY *
3020 NE 45TH ST
SEATTLE, WA 98105
(206) 524-9931
SAFEWAY
PHARMACY *
9620 28TH AVE SW
SEATTLE, WA 98126
(206) 923-9110
SAFEWAY
PHARMACY *
1423 NW MARKET ST
SEATTLE, WA 98107
(206) 782-8688
SAFEWAY
PHARMACY *
138 SW 148TH ST
SEATTLE, WA 98166
(206) 243-2796
SAFEWAY
PHARMACY *
8704 GREENWOOD
AVE N
SEATTLE, WA 98103
(206) 494-0440
SAM'S CLUB *
13550 AURORA AVE N
SEATTLE, WA 98133
(206) 361-1594
SAFEWAY
PHARMACY *
9262 RAINIER AVE S
SEATTLE, WA 98118
(206) 494-1130
SEA MAR CHC
PHARMACY
8800 14TH AVE S
SEATTLE, WA 98108
(206) 762-3397
SAFEWAY
PHARMACY *
17202 15TH AVE NE
SEATTLE, WA 98155
(206) 364-4618
SEATTLE CANCER
CARE ALLIANCE *
825 EASTLAKE AVE E
SEATTLE, WA 98109
(206) 288-1375
SAFEWAY
PHARMACY *
8340 15TH AVE NW
SEATTLE, WA 98117
(206) 782-7480
SEATTLE CHILDREN'S
PHARMACY *
4800 SAND POINT
WAY NE
SEATTLE, WA 98105
(206) 987-2138
SAFEWAY
PHARMACY *
15332 AURORA AVE N
SEATTLE, WA 98133
(206) 362-4940
SAFEWAY
PHARMACY *
2622 CALIFORNIA
AVE SW
SEATTLE, WA 98116
(206) 937-2221
SAFEWAY
PHARMACY *
1410 E JOHN ST
SEATTLE, WA 98112
(206) 323-4935
SAFEWAY
PHARMACY *
2201 E MADISON ST
SEATTLE, WA 98112
(206) 494-1520
116
118
SEATTLEMEDS
PHARMACY *
1305 MADISON ST
SEATTLE, WA 98104
(206) 382-2087
SIMON WELLNESS *
6300 9TH AVE NE STE
310
SEATTLE, WA 98115
(206) 524-0863
SWEDISH FIRST HILL
PHARMACY *
747 BROADWAY
SEATTLE, WA 98122
(206) 386-3784
SWEDISH
ORTHOPEDIC INST
PHCY *
601 BROADWAY
SEATTLE, WA 98122
(206) 215-9110
SWEDISH PHARMACY
CHERRY HILL *
SEATTLE, WA 98122
(206) 320-2699
TARGET PHARMACY *
302 NE NORTHGATE
WAY
SEATTLE, WA 98125
(206) 494-0898
UNION CENTER
PHARMACY *
2324 EASTLAKE AVE
E STE 405
SEATTLE, WA 98102
(206) 441-9174
UWMC AMBULATORY
PHARMACY *
1959 NE PACIFIC ST
SEATTLE, WA 98195
(206) 598-4363
VITAL
THERAPEUTICS*
1836 WESTLAKE AVE
N STE 201
SEATTLE, WA 98109
(206) 729-6100
WALGREENS *
222 PIKE ST
SEATTLE, WA 98101
(206) 903-8392
WALGREENS *
6330 35TH AVE SW
SEATTLE, WA 98126
(206) 938-2759
WALGREENS *
14352 LAKE CITY WAY
NE
SEATTLE, WA 98125
(206) 361-9753
WALGREENS *
5409 15TH AVE NW
SEATTLE, WA 98107
(206) 781-0056
WALGREENS *
9456 16TH AVE SW
SEATTLE, WA 98106
(206) 767-2294
WALGREENS *
4412 RAINIER AVE S
SEATTLE, WA 98118
(206) 760-7880
WALGREENS *
859 NE NORTHGATE
WAY
SEATTLE, WA 98125
(206) 417-0520
WALGREENS *
8701 GREENWOOD
AVE N
SEATTLE, WA 98103
(206) 706-9140
WALGREENS *
8500 15TH AVE NW
STE A
SEATTLE, WA 98117
(206) 706-5210
WALGREENS *
2400 S JACKSON ST
SEATTLE, WA 98144
(206) 329-6850
117
119
WALGREENS *
566 DENNY WAY
SEATTLE, WA 98109
(206) 204-1982
WALGREENS *
4468 STONE WAY N
SEATTLE, WA 98103
(206) 547-1226
WALGREENS *
1205 NE 50TH ST
SEATTLE, WA 98105
(206) 204-0145
WALGREENS *
1531 BROADWAY
BLVD
SEATTLE, WA 98122
(206) 204-0599
WHITE CENTER
PHARMACY *
9601 16TH AVE SW
SEATTLE, WA 98106
(206) 763-2500
SHORELINE
BARTELL DRUGS *
18420 AURORA AVE N
SHORELINE, WA
98133
(206) 542-2948
RITE AID *
20330 BALLINGER
WAY NE
SHORELINE, WA
98155
(206) 368-0034
SHORELINE NATURAL
MEDICINE *
646 NW RICHMOND
BEACH RD
SHORELINE, WA
98177
(206) 542-8687
TOP FOOD AND
DRUG*
1201 N 175TH ST
SHORELINE, WA
98133
(206) 533-2861
WALGREENS *
14510 AURORA AVE N
SHORELINE, WA
98133
(206) 361-8826
WALGREENS *
17524 AURORA AVE N
SHORELINE, WA
98133
(206) 542-4964
WALGREENS *
17518 15TH AVE NE
SHORELINE, WA
98155
(206) 361-7474
SNOQUALMIE
VASHON
SNOQUALMIE
VILLAGE PHARMACY*
7730 CENTER BLVD
SE
SNOQUALMIE, WA
98065
(425) 396-7474
VASHON PHARMACY
17617 VASHON HWY
SW
VASHON, WA 98070
(206) 463-9118
THE FALLS PHCY
UNITED DRUGS *
8112 RAILROAD AVE
SE
SNOQUALMIE, WA
98065
(425) 888-6858
RITE AID *
14035 NE
WOODINVILLE
DUVALL
WOODINVILLE, WA
98072
(425) 485-6468
TUKWILA
SAFEWAY
PHARMACY *
19150 WOODINVILLE
DUVALL RD
WOODINVILLE, WA
98077
(425) 788-6658
BARTELL DRUGS *
14277 PACIFIC HWY S
TUKWILA, WA 98168
(206) 431-9652
COSTCO *
400 COSTCO DR
TUKWILA, WA 98188
(206) 575-8147
PARAMOUNT
PHARMACY *
7200 S 180TH ST
STE 104
TUKWILA, WA 98188
(425) 251-1660
TARGET PHARMACY *
301 STRANDER BLVD
TUKWILA, WA 98188
(206) 575-0682
WALGREENS *
3716 S 144TH ST
TUKWILA, WA 98168
(206) 204-1284
118
120
WOODINVILLE
TARGET PHARMACY *
13950 NE 178TH PL
WOODINVILLE, WA
98072
(425) 492-1820
THE NATURAL PATH
TO HEALING *
15610 NE
WOODINVILLE
DUVALL
WOODINVILLE, WA
98072
(425) 489-5900
TOP FOOD AND
DRUG*
17641 GARDEN WAY
NE
WOODINVILLE, WA
98072
(425) 398-6710
SAFEWAY
PHARMACY *
253 HIGH SCHOOL RD
NE
BAINBRIDGE ISLAND,
WA 98110
(206) 842-0127
PENINSULA
COMMUNITY HLTH
SRVS *
616 6TH ST
BREMERTON, WA
98337
(360) 475-3731
TREE OF HEALTH
INTEGRATIVE *
17311 135TH AVE NE
STE A250
WOODINVILLE, WA
98072
(425) 408-0040
WINSLOW DRUG *
290 WINSLOW WAY E
BAINBRIDGE ISLAND,
WA 98110
(206) 842-2652
RITE AID *
4220 WHEATON WAY
BREMERTON, WA
98310
(360) 479-3450
BREMERTON
WALGREENS *
17520 AVONDALE RD
NE
WOODINVILLE, WA
98077
(425) 844-0302
ALBERTSON'S *
2900 WHEATON WAY
BREMERTON, WA
98310
(360) 377-0933
SAFEWAY
PHARMACY *
900 CALLOW AVE
BREMERTON, WA
98312
(360) 792-9262
WOODINVILLE MED
CTR PHCY *
1700 140TH AVE NE
UNIT E101
WOODINVILLE, WA
98072
(425) 485-2900
KITSAP COUNTY
BAINBRIDGE ISLAND
RITE AID *
301 HIGH SCHOOL RD
NE
BAINBRIDGE ISLAND,
WA 98110
(206) 842-4065
APOTHECARY
SHOPPE *
2500 CHERRY AVE
STE 101
BREMERTON, WA
98310
(360) 479-4900
FRED MEYER
PHARMACY *
5050 STATE HIGHWAY
303 NE
BREMERTON, WA
98311
(360) 792-2833
PENINSULA
COMMUNITY HEALTH
SVS *
2508 WHEATON WAY
BREMERTON, WA
98310
(360) 616-3131
119
121
SAFEWAY
PHARMACY *
1401 NE MCWILLIAMS
RD
BREMERTON, WA
98311
(360) 373-7226
WALGREENS *
3929 KITSAP WAY
BREMERTON, WA
98312
(360) 917-1041
WALGREENS *
6432 STATE HWY 303
NE
BREMERTON, WA
98311
(360) 307-8741
WALGREENS *
3333 WHEATON WAY
BREMERTON, WA
98310
(360) 782-0907
WAL-MART *
6797 STATE HWY 303
NE
BREMERTON, WA
98311
(360) 698-3446
KINGSTON
ALBERTSON'S *
8196 NE STATE
HIGHWAY 104
KINGSTON, WA 98346
(360) 297-1811
RITE AID *
27000 MILLER BAY RD
NE
KINGSTON, WA 98346
(360) 297-5200
PORT ORCHARD
ALBERTSON'S *
390 SW SEDGEWICK
RD
PORT ORCHARD, WA
98367
(360) 876-2698
ALBERTSON'S *
1434 OLNEY ST SE
PORT ORCHARD, WA
98366
(360) 895-0613
FRED MEYER
PHARMACY *
1900 SE SEDGWICK
RD
PORT ORCHARD, WA
98366
(360) 874-7173
WAL-MART *
3497 BETHEL RD SE
PORT ORCHARD, WA
98366
(360) 874-9063
PENINSULA
COMMUNITY HLTH
SVCS *
320 S KITSAP BLVD
PORT ORCHARD, WA
98366
(360) 874-5583
KITSAP PHARMACY *
20148 10TH AVE NE
POULSBO, WA 98370
(360) 779-5335
RITE AID *
3282 BETHEL RD SE
PORT ORCHARD, WA
98366
(360) 876-0969
SAFEWAY
PHARMACY *
3355 BETHEL RD SE
PORT ORCHARD, WA
98366
(360) 876-6064
SOUTH PARK
PHARMACY *
1743 VILLAGE LN SE
PORT ORCHARD, WA
98366
(360) 871-1020
WALGREENS *
3099 BETHEL RD SE
PORT ORCHARD, WA
98366
(360) 876-5212
120
122
POULSBO
PENINSULA COMM
HTLH SVCS PHCY *
19917 7TH AVE NE
POULSBO, WA 98370
(360) 697-7636
POULSBO
COMPOUNDING
PHARMACY *
325 NE HOSTMARK ST
POULSBO, WA 98370
(360) 779-2737
RITE AID *
19475 NE 17TH AVE
POULSBO, WA 98370
(360) 697-2209
SAFEWAY
PHARMACY *
19245 10TH AVE NE
POULSBO, WA 98370
(360) 394-1589
WAL-MART *
21200 OLHAVA WAY
NW
POULSBO, WA 98370
(360) 697-2091
SILVERDALE
KITTITAS COUNTY
ALBERTSON'S *
2222 NW BUCKLIN
HILL RD
SILVERDALE, WA
98383
(360) 692-8596
CLE ELUM
COSTCO *
10000 MICKELBERRY
RD NW
SILVERDALE, WA
98383
(360) 308-2116
NATURAL OPTIONS
HEALTH CLINIC *
9481 BAYSHORE DR
NW
SILVERDALE, WA
98383
(360) 698-4141
RITE AID *
2860 NW BUCKLIN
HILL RD
SILVERDALE, WA
98383
(360) 692-3410
TARGET PHARMACY *
3201 NW RANDALL
WAY
SILVERDALE, WA
98383
(360) 536-6010
WALGREENS *
9709 SILVERDALE
WAY NW
SILVERDALE, WA
98383
(360) 692-7536
CAVALLINI'S
PHARMACY *
106 E 1ST ST
CLE ELUM, WA 98922
(509) 674-2571
CLE ELUM DRUG *
219 E 1ST ST
CLE ELUM, WA 98922
(509) 674-2155
ELLENSBURG
BI-MART PHARMACY *
608 E MOUNTAIN
VIEW AVE
ELLENSBURG, WA
98926
(509) 925-6996
ELLENSBURG
DOWNTOWN HM
PHCY *
414 N PEARL ST
ELLENSBURG, WA
98926
(509) 925-1514
ELLENSBURG
PHARMACY *
521 E MOUNTAIN
VIEW AVE
ELLENSBURG, WA
98926
(509) 962-1430
RITE AID *
700 S MAIN ST
ELLENSBURG, WA
98926
(509) 925-4232
121
123
SAFEWAY
PHARMACY *
400 NORTH RUBY ST
ELLENSBURG, WA
98926
(509) 962-5096
SUPER ONE
PHARMACY *
200 E MOUNTAIN
VIEW AVE
ELLENSBURG, WA
98926
(509) 962-7777
KLICKITAT
COUNTY
WHITE SALMON
HI-SCHOOL
PHARMACY *
250 E JEWETT BLVD
WHITE SALMON, WA
98672
(509) 493-4842
LEWIS
CENTRALIA
HALLS DRUG
CENTER*
505 S TOWER AVE
STE 2
CENTRALIA, WA
98531
(360) 736-5000
PROVIDENCE
CENTRALIA
HOSPITAL
914 S SCHEUBER RD
CENTRALIA, WA
98531
(360) 807-7997
RITE AID *
1200 HARRISON AVE
CENTRALIA, WA
98531
(360) 807-2014
SAFEWAY
PHARMACY *
1129 HARRISON AVE
CENTRALIA, WA
98531
(360) 330-5229
CHEHALIS
KMART PHARMACY *
1201 NW LOUISIANA
AVE
CHEHALIS, WA 98532
(360) 748-9681
RITE AID *
551 S MARKET BLVD
CHEHALIS, WA 98532
(360) 748-8801
SAFEWAY
PHARMACY *
1100 S MARKET BLVD
CHEHALIS, WA 98532
(360) 740-6750
WALGREENS *
1610 NW LOUISIANA
AVE
CHEHALIS, WA 98532
(360) 740-1876
WAL-MART *
1601 NW LOUISIANA
AVE
CHEHALIS, WA 98532
(360) 748-0858
MORTON
COLTON PHARMACY *
377 S 2ND ST
MORTON, WA 98356
(360) 496-5902
WINLOCK
CEDAR VILLAGE
PHARMACY *
206 E WALNUT ST
WINLOCK, WA 98596
(360) 785-4711
LINCOLN COUNTY
DAVENPORT
DAVENPORT GOOD
NEIGHBOR PHCY *
525 MORGAN ST
DAVENPORT, WA
99122
(509) 725-1151
LINCOLN COUNTY
HLTH MRT PHCY *
621 MORGAN ST
DAVENPORT, WA
99122
(509) 725-3310
MASON COUNTY
BELFAIR
QFC PHARMACY *
201 NE STATE ROUTE
300
BELFAIR, WA 98528
(360) 275-9671
122
124
RITE AID *
23940 NE STATE
ROUTE 3
BELFAIR, WA 98528
(360) 275-8964
SAFEWAY
PHARMACY *
23961 NE STATE
ROUTE 3
BELFAIR, WA 98528
(360) 275-0953
SHELTON
FRED MEYER
PHARMACY *
301 E WALLACE
KNEELAND BLVD
SHELTON, WA 98584
(360) 432-5373
MEDICINE SHOPPE
PHARMACY *
207 PROFESSIONAL
WAY
SHELTON, WA 98584
(360) 426-4272
NEIL'S PHARMACY *
512 W FRANKLIN ST
SHELTON, WA 98584
(360) 426-3328
SAFEWAY
PHARMACY *
600 FRANKLIN ST
SHELTON, WA 98584
(360) 426-0718
WAL-MART *
100 E WALLACE
KNEELAND BLVD
SHELTON, WA 98584
(360) 427-0171
OKANOGAN
COUNTY
BREWSTER
BREWSTER HEALTH
MART DRUG *
811 STATE HWY 97
NINTH
BREWSTER, WA
98812
(509) 689-2421
FAMILY HEALTH
CENTERS *
525 W JAY ST
BREWSTER, WA
98812
(509) 689-4406
OKANOGAN
DOUGLAS HOSPITAL
PHCY *
507 HOSPITAL WAY
BREWSTER, WA
98812
(509) 689-2517
OKANOGAN
OKANOGAN VALLEY
PHARMACY *
236 2ND AVE N
OKANOGAN, WA
98840
(509) 422-9958
OMAK
OMAK PHARMACY *
903 ENGH RD STE A
OMAK, WA 98841
(509) 422-1500
RITE AID *
609 OMACHE DR
OMAK, WA 98841
(509) 826-2806
WAL-MART *
902 ENGH RD
OMAK, WA 98841
(509) 826-6146
TONASKET
ROY'S HEALTH MART
PHARMACY *
318 S WHITCOMB AVE
TONASKET, WA 98855
(509) 486-2149
TWISP
ULRICH VALLEY
HEALTH MART PHCY
423 E METHOW
VALLEY HWY
TWISP, WA 98856
(509) 997-2191
PACIFIC COUNTY
LONG BEACH
LONG BEACH
PHARMACY *
101 BOLSTAD AVE E
LONG BEACH, WA
98631
(360) 642-3200
OCEAN PARK
OCEAN PARK
PHARMACY *
1501 BAY AVE
OCEAN PARK, WA
98640
(360) 665-5181
123
125
RAYMOND
SAGENS PHARMACY *
515 COMMERCIAL ST
RAYMOND, WA 98577
(360) 942-2634
SOUTH BEND
SOUTH BEND
PHARMACY *
101 WILLAPA AVE
SOUTH BEND, WA
98586
(360) 875-5757
PEND OREILLE
COUNTY
NEWPORT
SAFEWAY
PHARMACY *
121 W WALNUT ST
NEWPORT, WA 99156
(509) 447-3972
SEEBER'S HEALTH
MART *
336 S WASHINGTON
AVE
NEWPORT, WA 99156
(509) 447-2484
PIERCE COUNTY
AUBURN
HAGGEN FOOD AND
PHARMACY *
1406 LAKE TAPPS
PKWY E
AUBURN, WA 98092
(253) 876-1761
WALGREENS *
1502 LAKE TAPPS
PKWY SE
AUBURN, WA 98092
(253) 394-0019
TARGET PHARMACY *
9400 192ND AVE E
BONNEY LAKE, WA
98391
(253) 862-6401
BONNEY LAKE
WAL-MART *
19205 SR 410 E
BONNEY LAKE, WA
98391
(253) 826-9151
FRANCISCAN PHCY
BONNEY LAKE *
9230 SKY ISLAND DR
E
BONNEY LAKE, WA
98391
(253) 426-6209
FRED MEYER
PHARMACY *
20901 STATE ROUTE
410 E
BONNEY LAKE, WA
98391
(253) 891-7333
MULTICARE BONNEY
LAKE PHARMACY *
10004 204TH AVE E
STE 1200
BONNEY LAKE, WA
98391
(253) 447-3355
RITE AID *
21302 STATE RTE 410
E
BONNEY LAKE, WA
98391
(253) 862-2822
RXPRESS
PHARMACY*
21509 SR 410 E STE 4
BONNEY LAKE, WA
98391
(253) 862-5000
BUCKLEY
CHUCK'S DRUGS *
787 MAIN ST
BUCKLEY, WA 98321
(360) 829-0451
DUPONT
DUPONT PHARMACY *
1545 WILMINGTON DR
STE 160
DUPONT, WA 98327
(253) 964-3400
EDGEWOOD
WALGREENS *
729 MERIDIAN AVE E
EDGEWOOD, WA
98371
(253) 927-3380
FIRCREST
FIRCREST
PHARMACY *
1107 REGENTS BLVD
FIRECREST, WA 98466
(253) 830-5242
124
126
GIG HARBOR
ALBERTSON'S *
11330 51ST AVE NW
GIG HARBOR, WA
98332
(253) 853-4755
BARTELL DRUGS *
5500 OLYMPIC DR NW
GIG HARBOR, WA
98335
(253) 858-7455
COSTCO *
10990 HARBOR HILL
DR
GIG HARBOR, WA
98335
(253) 853-8609
COSTLESS SENIOR
SERVICES *
14216 92ND AVE NW
STE B
GIG HARBOR, WA
98329
(253) 857-7677
FRANCISCAN PHCY
ST ANTHONY *
11511 CANTERWOOD
BLVD NW
GIG HARBOR, WA
98332
(253) 530-2653
MT RAINIER CLINIC
WHOLISTIC *
6712 KIMBALL DR STE
100
GIG HARBOR, WA
98335
(253) 853-8853
MULTICARE GIG
HARBOR PHARMACY*
4545 POINT FOSDICK
DR NW
GIG HARBOR, WA
98335
(253) 530-8030
WALGREENS *
4840 BORGEN BLVD
GIG HARBOR, WA
98332
(253) 853-9340
OLYMPIC PHCY AND
HEALTH CARE *
4700 PT FOSDICK DR
NW
GIG HARBOR, WA
98335
(253) 858-9941
RITE AID *
22201 MERIDIAN AVE
E
GRAHAM, WA 98338
(253) 846-9455
PURDY COST LESS
PRESCRIPTIONS *
14218 92ND AVE NW
GIG HARBOR, WA
98329
(253) 857-7797
RITE AID *
4818 POINT FOSDICK
DR NW
GIG HARBOR, WA
98335
(253) 851-6939
SAFEWAY
PHARMACY *
4831 POINT FOSDICK
DR NW
GIG HARBOR, WA
98335
(253) 851-6870
TARGET PHARMACY *
11400 51ST AVE NW
GIG HARBOR, WA
98335
(253) 858-7799
GRAHAM
SAFEWAY
PHARMACY *
10105 224TH ST E
GRAHAM, WA 98338
(253) 847-7634
LAKEWOOD
LAKEWOOD
PHARMACY *
8720 S TACOMA WAY
STE 103
LAKEWOOD, WA
98499
(253) 581-3426
RITE AID *
5700 100TH ST SW
STE 100
LAKEWOOD, WA
98499
(253) 588-3666
WALGREENS *
8224 STEILACOOM
BLVD SW
LAKEWOOD, WA
98498
(253) 581-0494
FRANCISCAN
PHARMACY ST
CLARE *
11315 BRIDGEPORT
WAY SW
LAKEWOOD, WA
98499
(253) 985-6290
WAL-MART *
7001 BRIDGEPORT
WAY W
LAKEWOOD, WA
98499
(253) 512-0960
GOOD PHARMACY *
8741 S TACOMA WAY
LAKEWOOD, WA
98499
(253) 584-9164
ALBERTSON'S *
2800 MILTON WAY
STE 10
MILTON, WA 98354
(253) 952-8436
INTERNATIONAL
PHARMACY *
11228 BRIDGEPORT
SW
LAKEWOOD, WA
98499
(253) 302-4553
RITE AID *
900 MERIDIAN E
MILTON, WA 98354
(253) 952-2680
125
127
MILTON
SAFEWAY
PHARMACY *
900 MERIDIAN E
MILTON, WA 98354
(253) 952-0390
ORTING
COPE'S PHARMACY *
134 WASHINGTON
AVE S
ORTING, WA 98360
(360) 893-2117
SAFEWAY
PHARMACY *
215 WHITESELL ST
NW
ORTING, WA 98360
(360) 893-0843
PUYALLUP
ALBERTSON'S *
11012 CANYON RD E
PUYALLUP, WA 98373
(253) 537-3808
BEALL'S PHARMACY *
110 W MEEKER
PUYALLUP, WA 98371
(253) 845-8444
COSTCO *
1201 39TH AVE SW
PUYALLUP, WA 98373
(253) 445-7542
FRANCISCAN
PHARMACY *
15214 CANYON RD E
STE 110
PUYALLUP, WA 98375
(253) 539-6030
FRED MEYER
PHARMACY *
1100 N MERIDIAN STE
12
PUYALLUP, WA 98371
(253) 840-8183
GOOD SAMARITAN
BEHAVIORAL HLTH *
325 E PIONEER AVE
PUYALLUP, WA 98372
(253) 697-8333
KIRK'S PHARMACY *
3909 10TH ST SE
STE 2
PUYALLUP, WA 98374
(253) 848-2011
KIRK'S PHARMACY *
11212 SUNRISE BLVD
E
PUYALLUP, WA 98374
(253) 770-3408
MULTICARE GOOD
SAMARITAN PHCY *
1450 5TH ST SE STE
1200
PUYALLUP, WA 98372
(253) 697-3494
PARTNER
ONCOLOGY*
1519 3RD ST SE STE
260
PUYALLUP, WA 98372
(253) 770-1700
RITE AID *
9502 176TH ST E
PUYALLUP, WA 98375
(253) 846-5386
126
128
RITE AID *
11220 E CANYON RD
PUYALLUP, WA 98373
(253) 537-3071
RITE AID *
1323 E MAIN AVE
PUYALLUP, WA 98372
(253) 848-3564
RITE AID *
12811 MERIDIAN ST E
PUYALLUP, WA 98373
(253) 770-4700
SAFEWAY
PHARMACY *
13308 MERIDAN ST E
PUYALLUP, WA 98373
(253) 435-1742
SAFEWAY
PHARMACY *
11501 CANYON RD E
PUYALLUP, WA 98373
(253) 536-5296
SAFEWAY
PHARMACY *
5616 176TH ST E
PUYALLUP, WA 98375
(253) 414-1741
SAFEWAY
PHARMACY *
611 S MERIDIAN
PUYALLUP, WA 98371
(253) 841-1534
TARGET PHARMACY *
3310 S MERIDIAN
PUYALLUP, WA 98373
(253) 864-4617
TARGET PHARMACY *
10302 156TH ST E
PUYALLUP, WA 98374
(253) 604-1067
TOP FOOD & DRUG *
201 37TH AVE SE
PUYALLUP, WA 98374
(253) 770-7720
WALGREENS *
11718 MERIDIAN E
PUYALLUP, WA 98373
(253) 770-6484
WALGREENS *
14308 MERIDIAN E
PUYALLUP, WA 98375
(253) 604-1051
WALGREENS *
11509 CANYON RD E
PUYALLUP, WA 98373
(253) 539-4165
WAL-MART *
16502 MERIDIAN E
PUYALLUP, WA 98375
(253) 446-1754
WAL-MART *
310 31ST AVE SE
PUYALLUP, WA 98374
(253) 770-9889
SPANAWAY
FRED MEYER
PHARMACY *
22303 MOUNTAIN
HWY E
SPANAWAY, WA
98387
(253) 875-4033
RITE AID *
22311 E MOUNTAIN
HWY
SPANAWAY, WA
98387
(253) 846-0542
WAL-MART *
20307 MOUNTAIN
HWY E
SPANAWAY, WA
98387
(253) 846-6260
SUMNER
FRED MEYER
PHARMACY *
1201 VALLEY AVE
SUMNER, WA 98390
(253) 826-8433
NICHOLSON'S
SUMNER
PHARMACY *
910 ALDER AVE
SUMNER, WA 98390
(253) 863-8141
SAFEWAY
PHARMACY *
21301 HIGHWAY 410
SUMNER, WA 98390
(253) 862-2533
TACOMA
ALBERTSON'S *
104 MILITARY RD S
TACOMA, WA 98444
(253) 538-2611
ALLENMORE
OUTPATIENT
PHARMACY *
1901 S UNION AVE
TACOMA, WA 98405
(253) 459-6746
127
129
BARTELL DRUGS *
3601 6TH AVE
TACOMA, WA 98406
(253) 761-1248
CHUNG PHARMACY *
9122 SOUTH TACOMA
WAY
TACOMA, WA 98499
(253) 584-2484
COMM HEALTH CARE
HILLTOP PHCY *
1202 MARTIN LUTHER
KING JR
TACOMA, WA 98405
(253) 441-4779
COMMUNITY
HEALTHCARE
PHARMACY *
11225 PACIFIC AVE S
TACOMA, WA 98444
(253) 536-6257
COMMUNITY
HEALTHCARE
PHARMACY *
1708 E 44TH ST
TACOMA, WA 98404
(253) 284-2226
COST LESS
PRESCRIPTIONS *
5431 PACIFIC AVE
TACOMA, WA 98408
(253) 474-9493
COST PHARMACYFIRCREST *
1109 REGENTS BLVD
TACOMA, WA 98466
(253) 564-5200
COSTCO *
2219 S 37TH ST
TACOMA, WA 98409
(253) 671-6002
MAI LINH PHARMACY*
1211 S 11TH ST
TACOMA, WA 98405
(253) 383-2576
FRANCISCAN
PHARMACY ST
JOSEPH *
1708 YAKIMA AVE
STE 201
TACOMA, WA 98405
(253) 426-6920
MARY BRIDGE RETAIL
CLINIC PHCY *
311 S L ST
TACOMA, WA 98405
(253) 403-1411
FRANCISCAN
PHARMACY TACOMA*
1608 S J ST
TACOMA, WA 98405
(253) 274-7650
FRED MEYER
PHARMACY *
6901 S 19TH ST
TACOMA, WA 98466
(253) 534-3033
FRED MEYER
PHARMACY *
7250 PACIFIC AVE
TACOMA, WA 98408
(253) 475-1994
FRED MEYER
PHARMACY *
4505 S 19TH ST
TACOMA, WA 98405
(253) 756-9322
KMART PHARMACY *
1414 E 72ND ST
TACOMA, WA 98404
(253) 537-6668
MEGA PHARMACY *
1902 96TH ST S STE A
TACOMA, WA 98444
(253) 302-4178
MULTICARE CLINIC
PHARMACY *
521 MLK JR WAY
TACOMA, WA 98405
(253) 403-4920
MULTICARE MEDICAL
CENTER PHCY *
315 MLK JR WAY
TACOMA, WA 98405
(253) 403-2403
MULTICARE
WESTGATE
PHARMACY *
2209 N PEARL ST STE
100
TACOMA, WA 98406
(253) 459-7144
NATURAL HEALTH
AND EDU SVCS *
201 N I ST STE C
TACOMA, WA 98403
(253) 503-8792
LINCOLN PHARMACY*
821 S 38TH ST
TACOMA, WA 98418
(253) 473-1155
128
130
PARKLAND
MARKETPLACE
PHARMACY *
13322 PACIFIC AVE S
TACOMA, WA 98444
(253) 531-3711
PUGET SOUND
PHARMACY *
TACOMA, WA 98405
(253) 572-0180
RANKOS STADIUM
PHARMACY *
101 N TACOMA AVE
TACOMA, WA 98403
(253) 383-2411
RITE AID *
1850 S MILDRED ST
TACOMA, WA 98465
(253) 460-9599
RITE AID *
1912 N PEARL ST
TACOMA, WA 98406
(253) 879-0140
RITE AID *
15801 PACIFIC AVE S
TACOMA, WA 98444
(253) 531-7427
RITE AID *
3840 W BRIDGEPORT
WAY
TACOMA, WA 98466
(253) 564-2255
RITE AID *
7041 PACIFIC AVE
TACOMA, WA 98408
(253) 474-0115
RUMED
3602 CENTER ST # 4
TACOMA, WA 98409
(253) 627-2212
SAFEWAY
PHARMACY *
2637 N PEARL ST
TACOMA, WA 98407
(253) 759-9271
SAFEWAY
PHARMACY *
1112 S M ST
TACOMA, WA 98405
(253) 572-7753
SAFEWAY
PHARMACY *
1302 38TH ST S
TACOMA, WA 98418
(253) 471-5511
SAFEWAY
PHARMACY *
1624 72ND ST E
TACOMA, WA 98404
(253) 537-2435
SAFEWAY
PHARMACY *
2411 N PROCTOR ST
TACOMA, WA 98406
(253) 759-9889
SAFEWAY
PHARMACY *
707 S 56TH ST
TACOMA, WA 98408
(253) 471-1730
SAFEWAY
PHARMACY *
6201 6TH AVE
TACOMA, WA 98406
(253) 566-9217
SAFEWAY
PHARMACY *
10223 GRAVELLY
LAKE DR SW
TACOMA, WA 98499
(253) 581-7181
TACOMA MEDICAL
CENTER PHARMACY *
1206 S 11TH ST STE 1
TACOMA, WA 98405
(253) 383-5359
TARGET PHARMACY *
10509 GRAVELLY
LAKE DR SW
TACOMA, WA 98499
(253) 414-1232
TARGET PHARMACY *
3320 S 23RD ST
TACOMA, WA 98405
(253) 414-0303
TOP FOOD AND
DRUG*
3130 S 23RD ST
TACOMA, WA 98405
(253) 591-3110
WALGREENS *
15225 PACIFIC AVE S
TACOMA, WA 98444
(253) 538-6916
WALGREENS *
5602 PACIFIC AVE
TACOMA, WA 98408
(253) 203-0074
WALGREENS *
3737 PACIFIC AVE
TACOMA, WA 98418
(253) 473-5215
129
131
WALGREENS *
9505 BRIDGEPORT
WAY SW
TACOMA, WA 98499
(253) 582-2230
WALGREENS *
4315 6TH AVE
TACOMA, WA 98406
(253) 756-5159
WALGREENS *
12105 PACIFIC AVE S
TACOMA, WA 98444
(253) 535-9302
WALGREENS *
8405 PACIFIC AVE
TACOMA, WA 98444
(253) 536-3778
WALGREENS *
3540 N PEARL ST
TACOMA, WA 98407
(253) 759-2378
WALGREENS *
2024 6TH AVE
TACOMA, WA 98403
(253) 272-2311
WAL-MART *
1965 S UNION AVE
TACOMA, WA 98405
(253) 627-4094
UNIVERSITY PLACE
BARTELL DRUGS *
2700 BRIDGEPORT
WAY
STE D
UNIVERSITY PLACE,
WA 98466
(253) 460-1879
FRANCISCAN
HOSPICE LTC PHCY *
2901 BRIDGEPORT
WAY W
UNIVERSITY PLACE,
WA 98466
(253) 534-7033
FRED MEYER
PHARMACY *
6305 BRIDGEPORT
WAY W
UNIVERSITY PLACE,
WA 98467
(253) 460-4033
FRIDAY HARBOR
FRIDAY HARBOR
DRUG *
210 SPRING ST W
FRIDAY HARBOR, WA
98250
(360) 378-4421
LOPEZ ISLAND
LOPEZ ISLAND
PHARMACY
352 LOPEZ RD
LOPEZ ISLAND, WA
98261
(360) 468-2616
WALGREENS *
7451 CIRQUE DR W
UNIVERSITY PLACE,
WA 98467
(253) 564-7569
SKAGIT COUNTY
WALGREENS *
2650 BRIDGEPORT
WAY W
UNIVERSITY PLACE,
WA 98466
(253) 564-0351
FAMILY PHARMACY *
1213 24TH ST STE 400
ANACORTES, WA
98221
(360) 293-2124
SAN JUAN
COUNTY
EASTSOUND
RAYS PHARMACY *
5 TEMPLIN CTR
EASTSOUND, WA
98245
(360) 376-2230
ANACORTES
RITE AID *
1517 COMMERCIAL
AVE
ANACORTES, WA
98221
(360) 293-2119
SAFEWAY
PHARMACY *
911 11TH ST
ANACORTES, WA
98221
(360) 293-4148
130
132
WALGREENS *
909 17TH ST
ANACORTES, WA
98221
(360) 299-2816
BURLINGTON
COSTCO *
1725 S BURLINGTON
BLVD
BURLINGTON, WA
98233
(360) 757-5702
FRED MEYER
PHARMACY *
920 S BURLINGTON
BLVD
BURLINGTON, WA
98233
(360) 757-9133
HAGGEN FOOD AND
DRUG *
757 HAGGEN DR
BURLINGTON, WA
98233
(360) 814-1561
WALGREENS *
623 S BURLINGTON
BLVD
BURLINGTON, WA
98233
(360) 707-2741
CONCRETE
EAST VALLEY
PHARMACY *
7438 S D AVE STE C
CONCRETE, WA 98237
(360) 853-8109
LA CONNER
LA CONNER DRUG *
708 E MORRIS ST
LA CONNER, WA
98257
(360) 466-3124
MOUNT VERNON
HAGGEN FOOD AND
PHARMACY *
2601 E DIVISION ST
MOUNT VERNON, WA
98274
(360) 848-6930
HILLTOP PHARMACY *
1223 E DIVISION ST
MOUNT VERNON, WA
98274
(360) 428-1710
SAFEWAY
PHARMACY *
315 E COLLEGE WAY
MOUNT VERNON, WA
98273
(360) 424-0467
SEA MAR CHC
PHARMACY *
1400 N LAVENTURE
MOUNT VERNON, WA
98273
(360) 542-8800
SKAGIT REGIONAL
CLINICS PHCY *
1410 E KINCAID ST
MOUNT VERNON, WA
98274
(360) 428-6465
SKAGIT VALLEY
HOSP PHARMACY *
1415 E KINCAID ST
MOUNT VERNON, WA
98274
(360) 428-2425
SKAGIT VALLEY
HOSPITAL OP PHCY *
1415 E KINCAID ST
MOUNT VERNON, WA
98274
(360) 428-8238
SRC RIVERBEND
PHARMACY *
2320 FREEWAY DR
MOUNT VERNON, WA
98273
(360) 814-6840
WAL-MART *
2301 FREEWAY DR
MOUNT VERNON, WA
98273
(360) 428-3911
SEDRO WOOLLEY
RITE AID *
851 MOORE ST
SEDRO WOOLLEY,
WA 98284
(360) 856-2153
SKAGIT REGIONAL
CLINICS PHCY *
1990 HOSPITAL DR
STE 120
SEDRO WOOLLEY,
WA 98284
(360) 854-2760
131
133
WALGREENS *
320 HARRISON ST
SEDRO WOOLLEY,
WA 98284
(360) 855-0735
HOAGLAND
PHARMACY SOUTH *
640 SR HWY 20
SERDO WOOLLEY,
WA 98284
(360) 503-1676
SKAMANIA
COUNTY
STEVENSON
WIND RIVER
PHARMACY *
280 SW 2ND ST
STEVENSON, WA
98648
(509) 427-5480
SNOHOMISH
COUNTY
ARLINGTON
ARLINGTON CHC
PHARMACY *
326 S
STILLAGUAMISH AVE
ARLINGTON, WA
98223
(360) 572-5454
ARLINGTON
PHARMACY *
540 N WEST AVE
ARLINGTON, WA
98223
(360) 435-5771
HAGGEN FOOD &
PHARMACY *
20115 74TH AVE NE
ARLINGTON, WA
98223
(360) 403-3861
FRED MEYER
PHARMACY *
21045 BOTHELL
EVERETT HWY
BOTHELL, WA 98021
(425) 398-7033
RITE AID *
17226 SMOKEY POINT
BLVD
ARLINGTON, WA
98223
(360) 657-4410
PACIFIC MEDICAL
CENTER PHCY
1909 214TH ST SE STE
300
BOTHELL, WA 98021
(425) 412-6350
SAFEWAY
PHARMACY *
3532 172ND ST NE
ARLINGTON, WA
98223
(360) 651-6194
RITE AID *
22631 SE BOTHELL
WAY
BOTHELL, WA 98021
(425) 481-8667
SMOKEY POINT
PHARMACY *
3823 172ND ST NE
ARLINGTON, WA
98223
(360) 653-2500
WAL-MART *
4010 172ND ST NE
ARLINGTON, WA
98223
(360) 386-4539
BOTHELL
BARTELL DRUGS *
22833 BOTHELL HWY
BOTHELL, WA 98021
(425) 481-7810
SAFEWAY
PHARMACY *
24040 BOTHELL
EVERETT HWY
BOTHELL, WA 98021
(425) 482-2829
SAFEWAY
PHARMACY *
20711 BOTHELL
EVERETT HWY
BOTHELL, WA 98012
(425) 486-4473
WALGREENS *
20812 BOTHELL
EVERETT HWY
BOTHELL, WA 98021
(425) 398-0204
BARTELL DRUGS *
18001 BOTHELL
EVERETT HWY
BOTHELL, WA 98012
(425) 402-6485
132
134
DARRINGTON
DARRINGTON
PHARMACY *
1200 SEEMANN ST
DARRINGTON, WA
98241
(360) 436-1200
EDMONDS
BARTELL DRUGS *
23028 100TH AVE W
EDMONDS, WA 98020
(425) 670-2860
EDMONDS
PHARMACY *
21701 76TH AVE W
STE 104A
EDMONDS, WA 98026
(425) 563-6381
EDMONDS
PHARMACY *
7631 212TH ST SW
STE 100
EDMONDS, WA 98026
(425) 977-4880
EDMONDS WELLNESS
CLINIC *
7935 216TH ST SW
STE E
EDMONDS, WA 98026
(425) 672-2113
FAMILY PHARMACY *
7315 212TH ST SW
STE 100
EDMONDS, WA 98026
(425) 778-7778
HIGHLAND
PHARMACY *
22618 HIGHWAY 99
STE 109
EDMONDS, WA 98026
(425) 673-8533
WALGREENS *
9797 EDMONDS WAY
EDMONDS, WA 98020
(425) 672-0017
PAVILION
PHARMACY*
7320 216TH ST SW
STE 100
EDMONDS, WA 98026
(425) 673-3700
112TH STREET CHC
PHARMACY *
1019 112TH ST SW
EVERETT, WA 98204
(425) 551-6521
QFC PHARMACY *
22828 100TH AVE W
EDMONDS, WA 98020
(425) 778-2144
RITE AID *
22515 HIGHWAY 99
EDMONDS, WA 98026
(425) 670-2667
SAFEWAY
PHARMACY *
23632 HIGHWAY 99
EDMONDS, WA 98026
(425) 775-1030
THE COMPOUNDING
APOTHECARY *
300 ADMIRAL WAY
STE 107
EDMONDS, WA 98020
(425) 672-9888
TOP FOOD AND
DRUG*
21900 HIGHWAY 99
EDMONDS, WA 98026
(425) 672-1520
EVERETT
ALBERTSON'S *
520 128TH ST SW
EVERETT, WA 98204
(425) 347-1007
ALBERTSON'S *
6727 EVERGREEN
WAY
EVERETT, WA 98203
(425) 353-7539
BARTELL DRUGS *
11020 19TH AVE SE
EVERETT, WA 98208
(425) 337-7197
BARTELL DRUGS *
1825 BROADWAY
EVERETT, WA 98201
(425) 303-2584
BARTELL DRUGS *
5006 132ND ST SE
STE A
EVERETT, WA 98208
(425) 357-6162
BARTELL DRUGS *
3909 HOYT AVE
EVERETT, WA 98201
(425) 317-3620
133
135
BROADWAY CHC
PHARMACY *
1410 BROADWAY
EVERETT, WA 98201
(425) 789-2050
COSTCO *
10200 19TH AVE SE
EVERETT, WA 98208
(425) 379-7487
EVERETT FOOT
CLINIC *
3401 RUCKER AVE
EVERETT, WA 98201
(425) 259-3757
FRED MEYER
PHARMACY *
12906 BOTHWELL
EVERETT, WA 98208
(425) 357-2033
HAGGEN FOOD AND
PHARMACY *
8915 MARKET PLACE
DR
EVERETT, WA 98205
(425) 377-7110
JODI BERGS
INTGRTVE FMLY
HLTH*
3903 COLBY AVE
EVERETT, WA 98201
(425) 258-2325
MCQUINN
NATUROPATHIC *
2808 HOYT AVE
STE 201
EVERETT, WA 98201
(425) 293-0107
MEDICAL CENTER
PHARMACY *
1321 COLBY C WING
1ST FL
EVERETT, WA 98201
(425) 261-3559
MOLINA
HEALTHCARE *
15 SW EVERETT MALL
WAY
EVERETT, WA 98204
(952)653-2568
PHYSICAL
REHABILITATION *
919 128TH ST SW
EVERETT, WA 98204
(425) 347-8614
PROVIDENCE MILL
CREEK PHCY *
12800 BOTHELL
EVERETT HWY
EVERETT, WA 98208
(425) 316-5454
QFC PHARMACY *
4919 EVERGREEN
WAY
EVERETT, WA 98203
(425) 259-3444
QFC PHARMACY *
2615 BROADWAY
EVERETT, WA 98201
(425) 259-6262
RITE AID *
4920A EVERGREEN
WAY
EVERETT, WA 98203
(425) 252-4109
RITE AID *
10103 EVERGREEN
WAY
EVERETT, WA 98204
(425) 347-2180
SAFEWAY
PHARMACY *
5802 134TH PL SE
EVERETT, WA 98208
(425) 332-6179
SAFEWAY
PHARMACY *
7601 EVERGREEN
WAY
EVERETT, WA 98203
(425) 355-9303
SAFEWAY
PHARMACY *
4128 RUCKER AVE
EVERETT, WA 98201
(425) 252-1911
SAFEWAY
PHARMACY *
11031 19TH AVE SE
EVERETT, WA 98204
(425) 337-0684
SAFEWAY
PHARMACY *
1715 BROADWAY AVE
EVERETT, WA 98201
(425) 339-9448
SEVAN PHARMACY *
620 SE EVERETT
MALL WAY
EVERETT, WA 98208
(425) 348-5353
134
136
SHIRAZ SPECIALTY
PHARMACY *
205 E CASINO RD STE
B16
EVERETT, WA 98208
(425) 356-3276
SOUND HOLISTIC
HEALTH *
2804 GRAND AVE STE
300
EVERETT, WA 98201
(425) 258-4633
TARGET PHARMACY *
405 SE EVERETT
MALL WAY
EVERETT, WA 98208
(425) 353-7967
WALGREENS *
6807 EVERGREEN
WAY
EVERETT, WA 98203
(425) 438-9380
WALGREENS *
13110 BOTHELL
EVERETT HWY
EVERETT, WA 98208
(425) 379-7274
WALGREENS *
11216 4TH AVE W
EVERETT, WA 98204
(425) 355-9940
WALGREENS *
2205 BROADWAY
EVERETT, WA 98201
(425) 252-5213
WAL-MART *
11400 HIGHWAY 99
EVERETT, WA 98204
(425) 923-1751
GRANITE FALLS
LYNNWOOD
PHARM-A-SAVE
207 E STANLEY ST
GRANITE FALLS, WA
98252
(360) 691-7778
ALBERTSON'S *
19500 HIGHWAY 99
LYNNWOOD, WA
98036
(425) 670-9723
RITE AID *
608 W STANLEY ST
GRANITE FALLS, WA
98252
(360) 691-4659
ALBERTSON'S *
12811 BEVERLY PARK
RD
LYNNWOOD, WA
98087
(425) 347-3145
LAKE STEVENS
BARTELL DRUGS *
621 HIGHWAY 9
LAKE STEVENS, WA
98258
(425) 334-4028
RITE AID *
303 91ST AVE NE
LAKE STEVENS, WA
98258
(425) 335-4513
TARGET PHARMACY *
9601 MARKET PL
LAKE STEVENS, WA
98258
(425) 397-8944
WALGREENS *
718 91ST AVE NE
LAKE STEVENS, WA
98258
(425) 334-1523
BARTELL DRUGS *
3625 148TH ST SW
STE B
LYNNWOOD, WA
98087
(425) 742-1120
BETHEL PHARMACY *
17414 HIGHWAY 99
STE 100
LYNNWOOD, WA
98037
(425) 741-0075
FRED MEYER
PHARMACY *
2902 164TH ST SW
LYNNWOOD, WA
98037
(425) 787-4933
FRED MEYER
PHARMACY *
4615 196TH ST SW
LYNNWOOD, WA
98036
(425) 670-0233
135
137
LYNNWOOD CHC
PHARMACY *
4111 194TH ST SW
LYNNWOOD, WA
98036
(425) 835-5202
PHARMACY CARE *
4629 168TH ST SW
STE A
LYNNWOOD, WA
98037
(425) 743-2211
RITE AID *
7500 196TH ST SW
STE A
LYNNWOOD, WA
98036
(425) 774-6669
RITE AID *
18600B 33RD AVE W
LYNNWOOD, WA
98037
(425) 771-9427
SAFEWAY
PHARMACY *
14826 HIGHWAY 99
LYNNWOOD, WA
98087
(425) 743-6808
SAFEWAY
PHARMACY *
19715 HIGHWAY 99
LYNNWOOD, WA
98036
(425) 778-4862
TARGET PHARMACY *
18305 ALDERWOOD
MALL PKWY
LYNNWOOD, WA
98037
(425) 673-1395
WALGREENS *
20725 HIGHWAY 99
LYNNWOOD, WA
98036
(425) 712-0512
WALGREENS *
16423 LARCH WAY
LYNNWOOD, WA
98037
(425) 741-8283
WALGREENS *
16824 HWY 99
LYNNWOOD, WA
98037
(425) 741-4302
WAL-MART *
1400 164TH ST SW
LYNNWOOD, WA
98087
(425) 741-3646
WAL-MART *
17222 HIGHWAY 99
LYNNWOOD, WA
98037
(425) 741-1284
MARYSVILLE
ALBERTSON'S *
301 MARYSVILLE
MALL # 60
MARYSVILLE, WA
98270
(360) 659-8952
BARTELL DRUGS *
4420 76TH ST NE
MARYSVILLE, WA
98270
(360) 651-7410
COSTCO *
16616 TWIN LAKES
AVE
MARYSVILLE, WA
98271
(360) 652-4539
FRED MEYER
PHARMACY *
9925 STATE AVE
MARYSVILLE, WA
98270
(360) 653-0733
HAGGEN FOOD &
PHARMACY *
3711 88TH ST NE
MARYSVILLE, WA
98270
(360) 530-7761
HILTON PHARMACY *
220 STATE AVE
MARYSVILLE, WA
98270
(360) 659-3222
RITE AID *
251 MARYSVILLE
MALL
MARYSVILLE, WA
98270
(360) 659-0492
SAFEWAY
PHARMACY *
1258 STATE AVE
MARYSVILLE, WA
98270
(360) 659-2882
136
138
TARGET PHARMACY *
16818 TWIN LAKES
AVE
MARYSVILLE, WA
98271
(360) 386-4021
WALGREENS *
404 STATE AVE
MARYSVILLE, WA
98270
(360) 658-5375
WAL-MART *
8713 64TH ST NE
MARYSVILLE, WA
98270
(360) 386-3011
MILL CREEK
ALBERTSON'S *
3322 132ND ST SE
MILL CREEK, WA
98012
(425) 338-1891
MILL CREEK
PHARMACY *
1025 153RD ST SE
STE 104
MILL CREEK, WA
98012
(425) 481-7575
PURITY INTEGRATIVE
HEALTH CTR *
15118 MAIN ST STE
500
MILL CREEK, WA
98012
(425) 337-7029
QFC PHARMACY *
926 164TH ST SE
MILL CREEK, WA
98012
(425) 743-4806
RITE AID *
16222 BOTHELL
EVERETT HWY
MILL CREEK, WA
98012
(425) 741-8649
RITE AID *
3202 132ND ST SE
MILL CREEK, WA
98012
(425) 379-7105
SAFEWAY
PHARMACY *
13314 BOTHELL
EVERETT HWY
MILL CREEK, WA
98012
(425) 337-4805
FRED MEYER
PHARMACY *
18805 STATE ROUTE 2
MONROE, WA 98272
(360) 805-8133
PHARM A SAVE
MONROE *
17788 147TH ST SE
MONROE, WA 98272
(360) 794-4641
PROVIDENCE
PHARMACY MONROE*
19200 N KELSEY ST
MONROE, WA 98272
(360) 794-5555
RITE AID *
18906 STATE ROUTE 2
MONROE, WA 98272
(360) 794-0943
SAFEWAY
PHARMACY *
19651 HIGHWAY 2
MONROE, WA 98272
(360) 794-9644
MOUNTLAKE
TERRACE
ALBERTSON'S *
4301 212TH ST SW
MOUNTLAKE
TERRACE, WA 98043
(425) 775-5011
BARTELL DRUGS *
22803 44TH AVE W
MOUNTLAKE
TERRACE, WA 98043
(425) 771-3738
MUKILTEO
RITE AID *
11700 MUKILTEO
SPEEDWAY
MUKILTEO, WA 98275
(425) 514-0620
WALGREENS *
10200 MUKILTEO
SPEEDWAY
MUKILTEO, WA 98275
(425) 315-9213
137
139
SNOHOMISH
ALBERTSON'S *
17520 STATE ROUTE 9
SE
SNOHOMISH, WA
98296
(360) 668-1407
BARTELL DRUGS *
1115 13TH ST
SNOHOMISH, WA
98290
(360) 568-0548
FRED MEYER
PHARMACY *
2801 BICKFORD AVE
SNOHOMISH, WA
98290
(360) 563-3733
KUSLER'S
PHARMACY *
700 AVENUE D
SNOHOMISH, WA
98290
(360) 568-7787
RITE AID *
205 PINE ST
SNOHOMISH, WA
98290
(360) 563-0223
TOP FOOD AND
DRUG*
1301 AVENUE D
SNOHOMISH, WA
98290
(360) 568-5154
STANWOOD
WOODINVILLE
BARTELL DRUGS *
7205 267TH ST NW
STANWOOD, WA
98292
(360) 939-0572
COSTCO *
24008 SNO WOOD RD
WOODINVILLE, WA
98072
(425) 806-7728
HAGGEN FOOD &
PHARMACY *
26603 72ND AVE NW
STANWOOD, WA
98292
(360) 629-5520
SPOKANE
COUNTY
RITE AID *
26817 88TH DR NW
STANWOOD, WA
98292
(360) 629-9519
SULTAN
SULTAN PHARMACY
AND NAT CARE *
505 W STEVENS AVE
SULTAN, WA 98294
(360) 793-8813
TULALIP
RITE AID *
3733 116TH ST NE
TULALIP, WA 98271
(360) 653-5178
WAL-MART *
8924 QUILCEDA BLVD
TULALIP, WA 98271
(360) 657-1223
CHAS
401 S MAIN ST
DEER PARK, WA
99006
(509) 434-0293
AIRWAY HEIGHTS
MEDICINE SHOPPE
PHARMACY *
11 E H ST STE A
DEER PARK, WA
99006
(509) 276-5081
YOKES PHARMACY *
12825 W SUNSET HWY
AIRWAY HEIGHTS, WA
99001
(509) 244-5822
YOKES PHARMACY *
810 S MAIN ST
DEER PARK, WA
99006
(509) 276-2939
CHENEY
FAIRFIELD
BI-MART PHARMACY *
2221 1ST ST
CHENEY, WA 99004
(509) 235-4705
FAIRFIELD OWL
PHARMACY *
208 MAIN ST
FAIRFIELD, WA 99012
(509) 283-4299
CHENEY OWL
HEALTH MART PHCY *
120 F ST
CHENEY, WA 99004
(509) 235-8441
SAFEWAY
PHARMACY *
2710 1ST ST
CHENEY, WA 99004
(509) 235-6030
DEER PARK
BI-MART PHARMACY *
412 S MAIN AVE
DEER PARK, WA
99006
(509) 276-9016
138
140
LIBERTY LAKE
ALBERTSON'S *
1304 N LIBERTY LAKE
RD
LIBERTY LAKE, WA
99019
(509) 891-6967
MEDICINE MAN
LIBERTY LAKE *
23801 E APPLEWAY
AVE
LIBERTY LAKE, WA
99019
(509) 255-7611
SAFEWAY
PHARMACY *
1233 N LIBERTY LAKE
RD
LIBERTY LAKE, WA
99019
(509) 893-1202
WELL LIFE LIBERTY
LAKE *
23801 E APPLEWAY
AVE
LIBERTY LAKE, WA
99019
(509) 755-3333
MEAD
YOKES PHARMACY *
14202 N MARKET ST
MEAD, WA 99021
(509) 242-0201
MEDICAL LAKE
MEDICAL LAKE OWL
PHARMACY *
123 E LAKE ST
MEDICAL LAKE, WA
99022
(509) 299-5113
MILLWOOD
WALGREENS *
2702 N ARGONNE RD
MILLWOOD, WA 99212
(509) 892-1637
SPOKANE
1ST AVENUE
PHARMACY *
6 E 1ST AVE
SPOKANE, WA 99202
(509) 624-3017
ALBERTSON'S *
6520 N NEVADA ST
SPOKANE, WA 99208
(509) 489-5287
ALBERTSON'S *
9001 N INDIAN TRAIL
RD
SPOKANE, WA 99208
(509) 465-8590
ALBERTSON'S *
3010 E 57TH AVE
SPOKANE, WA 99223
(509) 443-6502
ALBERTSON'S *
12312 N DIVISION ST
SPOKANE, WA 99218
(509) 466-0357
ALBERTSON'S *
510 W 37TH AVE
SPOKANE, WA 99203
(509) 455-4437
BATES
PHARMACEUTICAL
SVCS *
3704 N NEVADA STE B
SPOKANE, WA 99207
(509) 489-4500
BATES PHARMACY *
3704 N NEVADA ST
SPOKANE, WA 99207
(509) 489-4500
CHAS *
3919 N MAPLE ST
SPOKANE, WA 99205
(509) 343-1116
139
141
CHAS DENNY
MURPHY
1001 W 2ND AVE
SPOKANE, WA 99201
(509) 835-1205
CHAS PHARMACY *
5921 N MARKET ST
SPOKANE, WA 99208
(509) 343-1116
CHAS-NHOS *
1803 W MAXWELL
AVE
SPOKANE, WA 99201
(509) 444-8888
COSTCO *
7619 N DIVISION ST
SPOKANE, WA 99208
(509) 466-3315
DEACONESS
OUTPATIENT
PHARMACY *
800 W 5TH AVE
SPOKANE, WA 99204
(509) 473-3784
EVERGREEN
NATUROPATHIC *
315 W 9TH AVE STE
105
SPOKANE, WA 99204
(509) 755-5100
FIFTH AND BROWNE
PHARMACY *
104 W 5TH AVE STE
180E
SPOKANE, WA 99204
(509) 838-4117
FRED MEYER
PHARMACY *
400 SO THOR ST
SPOKANE, WA 99202
(509) 532-4033
FRED MEYER
PHARMACY *
12120 N DIVISION ST
SPOKANE, WA 99208
(509) 465-4433
HART AND DILATUSH
PHARMACY *
601 W RIVERSIDE STE
140
SPOKANE, WA 99201
(509) 624-2111
NORTHWEST HEALTH
SYSTEMS *
2818 N SULLIVAN RD
BLDG 2E
SPOKANE, WA 99216
(509) 744-9891
PAYLESS DRUG LTC
PHARMACY
1224 E WESTVIEW CT
SPOKANE, WA 99218
(800)330-3665
PROVIDENCO
SACRED PHARMACY *
101 W 8TH AVE
SPOKANE, WA 99204
(509) 474-3088
KMART PHARMACY *
4110 E SPRAGUE AVE
SPOKANE, WA 99202
(509) 534-7367
RITE AID *
1443 N ARGONNE RD
SPOKANE, WA 99212
(509) 928-9121
LIDGERWOOD OWL
HM PHARMACY *
5901 N LIDGERWOOD
ST
SPOKANE, WA 99208
(509) 483-3566
RITE AID *
9120 N DIVISION ST
SPOKANE, WA 99218
(509) 464-4480
MEDICAL ONCOLOGY
ASSOCIATES PS *
6001 N MAYFAIR ST
SPOKANE, WA 99208
(509) 462-2273
MEDICINE SHOPPE
PHARMACY *
1327 W NORTHWEST
BLVD
SPOKANE, WA 99205
(509) 327-1504
RITE AID *
4514 REGAL ST S
SPOKANE, WA 99223
(509) 448-9063
RITE AID *
2929 E 29TH AVE
SPOKANE, WA 99223
(509) 535-9056
RITE AID *
12420 N DIVISION ST
SPOKANE, WA 99218
(509) 466-1946
RITE AID *
9007 N INDIAN TRAIL
RD
SPOKANE, WA 99208
(509) 464-2791
RIVERPOINT
PHARMACY *
528 E SPOKANE
FALLS BLVD
SPOKANE, WA 99202
(509) 343-6252
RITE AID *
5520 N DIVISION ST
SPOKANE, WA 99208
(509) 489-6010
RIVERSTONE FAMILY
HEALTH PHCY *
4001 N COOK ST
SPOKANE, WA 99207
(866)983-9279
RITE AID *
2215 A WEST
WELLESLEY AVE
SPOKANE, WA 99205
(509) 328-7887
ROSAUERS
PHARMACY *
907 W 14TH
SPOKANE, WA 99204
(509) 624-2371
RITE AID *
810 E 29TH AVE
SPOKANE, WA 99203
(509) 838-3508
ROSAUERS
PHARMACY *
1724 W FRANCIS
SPOKANE, WA 99205
(509) 325-3431
140
142
ROSAUERS
PHARMACY *
2610 E 29TH AVE
SPOKANE, WA 99223
(509) 535-3623
ROSAUERS
PHARMACY *
10618 E SPRAGUE
AVE
SPOKANE, WA 99206
(509) 924-5560
ROSAUERS
PHARMACY *
1808 W 3RD AVE
SPOKANE, WA 99204
(509) 624-0126
ROSAUERS
PHARMACY *
9414 N DIVISION
SPOKANE, WA 99218
(509) 467-6806
SAFEWAY
PHARMACY *
2509 29TH AVE E
SPOKANE, WA 99223
(509) 532-9182
SAFEWAY
PHARMACY *
3919 N MARKET ST
SPOKANE, WA 99207
(509) 482-3480
SAFEWAY
PHARMACY *
902 W FRANCIS AVE
SPOKANE, WA 99205
(509) 327-6114
SAFEWAY
PHARMACY *
W 1616 NORTHWEST
BLVD
SPOKANE, WA 99205
(509) 327-5010
SAFEWAY
PHARMACY *
1441 N ARGONNE RD
SPOKANE, WA 99212
(509) 921-8032
SAFEWAY
PHARMACY *
10100 N NEWPORT
HWY
SPOKANE, WA 99218
(509) 465-3676
SAFEWAY
PHARMACY *
E 933 MISSION AVE
SPOKANE, WA 99202
(509) 482-2089
SHOPKO PHARMACY*
N 9520 NEWPORT
HWY
SPOKANE, WA 99218
(509) 466-7414
SHOPKO PHARMACY*
E 13414 SPRAGUE
AVE
SPOKANE, WA 99216
(509) 924-1744
SHOPKO PHARMACY*
4515 S REGAL ST
SPOKANE, WA 99223
(509) 448-9585
141
143
SIXTH AVE MEDICAL
PHARMACY *
508 W 6TH AVE
SPOKANE, WA 99204
(509) 455-9345
SPOKANE FALLS
FAMILY CLIN PHCY *
120 W MISSION AVE
SPOKANE, WA 99201
(866)983-9279
TARGET PHARMACY *
9770 N NEWPORT
HWY
SPOKANE, WA 99218
(509) 466-7226
WALGREENS *
910 W 5TH AVE
STE 270
SPOKANE, WA 99204
(509) 624-3350
WALGREENS *
12315 HIGHWAY 395
SPOKANE, WA 99218
(509) 466-7461
WALGREENS *
2830 S GRAND BLVD
SPOKANE, WA 99203
(509) 455-3736
WALGREENS *
12 E EMPIRE AVE
SPOKANE, WA 99207
(509) 325-0781
WALGREENS *
400 E 5TH AVE
STE 102
SPOKANE, WA 99202
(509) 838-0175
WALGREENS *
7905 N DIVISION ST
SPOKANE, WA 99208
(509) 467-8361
WALGREENS *
2105 E WELLESLEY
AVE
SPOKANE, WA 99207
(509) 483-0342
WALGREENS *
1708 W NORTHWEST
BLVD
SPOKANE, WA 99205
(509) 323-0309
WAL-MART *
9212 N COLTON ST
SPOKANE, WA 99218
(509) 464-2736
WAL-MART *
2301 WEST
WELLESLEY AVE
SPOKANE, WA 99205
(509) 327-2015
WELL LIFE LATAH
PHARMACY *
4235 S CHENEY
SPOKANE RD
SPOKANE, WA 99224
(509) 838-0896
YOKES PHARMACY *
210 E NORTH
FOOTHILLS DR
SPOKANE, WA 99207
(509) 325-6933
YOKES PHARMACY *
3321 W INDIAN TRAIL
RD
SPOKANE, WA 99208
(509) 325-8720
SPOKANE VALLEY
ALBERTSON'S *
8851 E TRENT AVE
SPOKANE VALLEY,
WA 99212
(509) 924-9052
ALBERTSON'S *
13606 E 32ND AVE
SPOKANE VALLEY,
WA 99216
(509) 892-3659
CHAS
924 S PINES RD
SPOKANE VALLEY,
WA 99206
(509) 343-1116
FRED MEYER
PHARMACY *
15609 E SPRAGUE
AVE
SPOKANE VALLEY,
WA 99037
(509) 921-5383
MEDICINE SHOPPE
PHARMACY *
12414 E SPRAGUE
AVE
SPOKANE VALLEY,
WA 99216
(509) 924-1222
RITE AID *
12115 E SPRAGUE
AVE
SPOKANE VALLEY,
WA 99206
(509) 924-4922
142
144
RITE AID PHARMACY*
16528 DESMET CT
SPOKANE VALLEY,
WA 99215
(509) 926-6400
SAFEWAY
PHARMACY *
14020 E SPRAGUE
AVE
SPOKANE VALLEY,
WA 99216
(509) 891-6319
TRADING COMPANY
PHARMACY *
13014 E SPRAGUE
AVE
SPOKANE VALLEY,
WA 99216
(509) 926-2200
VALLEY MISSION
HOMECARE PHCY *
12509 E MISSION AVE
STE 103
SPOKANE VALLEY,
WA 99216
(509) 928-6400
WALGREENS *
12312 E SPRAGUE
AVE
SPOKANE VALLEY,
WA 99216
(509) 921-0659
WAL-MART *
5025 E SPRAGUE AVE
SPOKANE VALLEY,
WA 99212
(509) 534-1037
YOKES PHARMACY *
9329 E MONTGOMERY
AVE
SPOKANE VALLEY,
WA 99206
(509) 343-3379
SUPER ONE
PHARMACY *
1250 NORTH
HIGHWAY
COLVILLE, WA 99114
(509) 684-3151
FRED MEYER
PHARMACY *
700 SLEATER-KINNEY
RD SE
LACEY, WA 98503
(360) 438-6483
VERADALE
WAL-MART *
810 N HIGHWAY ST
COLVILLE, WA 99114
(509) 684-2973
HAWKS PRAIRIE
HEALTH MART PHCY *
2539 MARVIN RD NE
LACEY, WA 98516
(360) 438-3072
WALGREENS *
15510 E SPRAGUE
AVE
VERADALE, WA 99037
(509) 891-0735
STEVENS COUNTY
CHEWELAH
AKERS UNITED
DRUG*
406 PARK ST N
CHEWELAH, WA
99109
(509) 935-8441
VALLEY HEALTH
MART DRUG *
102 E MAIN AVE
CHEWELAH, WA
99109
(509) 935-8611
COLVILLE
PROVIDENCE HEALTH
SERVICES WA *
1200 E COLUMBIA
AVE
COLVILLE, WA 99114
(509) 684-7727
KETTLE FALLS
KETTLE FALLS
HEALTH MART PHCY *
280 E 3RD AVE
KETTLE FALLS, WA
99141
(509) 738-2223
NINE MILE FALLS
LAKE SPOKANE
PHARMACY *
5919 HIGHWAY 291
STE 5
NINE MILE FALLS, WA
99026
(509) 443-4178
THURSTON
COUNTY
LACEY
COSTCO *
1470 MARVIN RD NE
LACEY, WA 98516
(360) 412-3488
METMEDS
PHARMACY *
5707 LACEY BLVD SE
LACEY, WA 98503
(360) 459-5401
QFC PHARMACY *
4775 WHITMAN LN SE
LACEY, WA 98509
(360) 438-6314
RITE AID *
691 SLEATER KINNEY
RD SE
LACEY, WA 98503
(360) 491-4111
RITE AID *
4776 WHITMAN LN SE
LACEY, WA 98513
(360) 412-5962
SAFEWAY
PHARMACY *
1243 MARVIN RD NE
LACEY, WA 98516
(360) 252-2235
SAFEWAY
PHARMACY *
6200 PACIFIC AVE SE
LACEY, WA 98503
(360) 486-3401
SAFEWAY
PHARMACY *
391 N MAIN ST
COLVILLE, WA 99114
(509) 684-8481
143
145
SHOPKO PHARMACY*
5500 MARTIN
WAY
SHOPKO
PHARMACY*
LACEY,
WA 98506
5500
MARTIN
WAY
(425)
456-4057
LACEY, WA 98506
(425) 456-4057
TARGET PHARMACY *
665 SLEATER
KINNEY*
TARGET
PHARMACY
RD
SE
665 SLEATER KINNEY
LACEY,
RD
SE WA 98503
(360) 486-8927
LACEY,
WA 98503
(360) 486-8927
WALGREENS *
4540 LACEY BLVD
SE
WALGREENS
*
LACEY,
WA 98503
4540
LACEY
BLVD SE
(360)
438-2353
LACEY, WA 98503
(360) 438-2353
WALGREENS *
8333 MARTIN WAY
E
WALGREENS
*
LACEY,
WA 98516
8333
MARTIN
WAY E
(360) 455-0029
LACEY,
WA 98516
(360) 455-0029
WAL-MART *
1401 GALAXY
WAL-MART
* DR NE
LACEY,
WA
98503
1401 GALAXY
DR NE
(360) 456-7862
LACEY,
WA 98503
(360) 456-7862
OLYMPIA
OLYMPIA
ALBERTSON'S *
3520 PACIFIC AVE
ALBERTSON'S
* SE
OLYMPIA,
WA
98501
3520 PACIFIC AVE SE
(360) 491-0330
OLYMPIA,
WA 98501
(360) 491-0330
MEDICAL CENTER
PHARMACY
*
MEDICAL
CENTER
3525 ENSIGN* RD NE
PHARMACY
OLYMPIA,
WARD
98506
3525
ENSIGN
NE
(360) 491-7521
OLYMPIA,
WA 98506
(360) 491-7521
PROVIDENCE
MOTHER JOSEPH
PROVIDENCE
CTR *
MOTHER
JOSEPH
3333 *ENSIGN RD NE
CTR
OLYMPIA,
WARD
98506
3333
ENSIGN
NE
(360) 493-4572
OLYMPIA,
WA 98506
(360) 493-4572
RALPH'S THRIFTWAY
PHARMACY
*
RALPH'S
THRIFTWAY
1908
4TH
AVE
PHARMACY * E
OLYMPIA,
WA E
98506
1908
4TH AVE
(360)
352-4426
OLYMPIA, WA 98506
(360) 352-4426
RITE AID *
8230 MARTIN
WAY E
RITE
AID *
OLYMPIA,
WA
98516
8230 MARTIN WAY
E
(360) 456-0444
OLYMPIA,
WA 98516
(360) 456-0444
RITE AID *
305 COOPER
POINT
RITE
AID *
RD
NW
305 COOPER POINT
OLYMPIA,
WA 98502
RD
NW
(360)
754-8014
OLYMPIA, WA 98502
(360) 754-8014
SAFEWAY
PHARMACY *
SAFEWAY
4280 MARTIN* WAY E
PHARMACY
OLYMPIA,
WAWAY
98516
4280
MARTIN
E
(360) 456-0709
OLYMPIA,
WA 98516
(360) 456-0709
SAFEWAY
PHARMACY *
SAFEWAY
3215 HARRISON
AVE
PHARMACY
*
NW
3215 HARRISON AVE
OLYMPIA, WA 98502
NW
(360) 956-3827
OLYMPIA,
WA 98502
(360) 956-3827
SAFEWAY
PHARMACY *
SAFEWAY
520 CLEVELAND
AVE
PHARMACY
*
OLYMPIA,
WA
98501
520 CLEVELAND AVE
(360) 943-7600
OLYMPIA,
WA 98501
(360) 943-7600
SEA MAR
COMMUNITY
HEALTH
SEA
MAR
CTRS *
COMMUNITY
HEALTH
3030 LIMITED
LN NW
CTRS
*
OLYMPIA,
WA
98502
3030 LIMITED LN
NW
(360) 704-7575
OLYMPIA,
WA 98502
(360) 704-7575
144
144
146
TOP FOOD AND
DRUG*
TOP
FOOD AND
1313
COOPER POINT
DRUG*
RD SW
1313
COOPER POINT
OLYMPIA,
WA 98502
RD SW
(360) 754-1504
OLYMPIA,
WA 98502
(360) 754-1504
VISTA ONCOLOGY *
420 MCPHEE
RD SW
VISTA
ONCOLOGY
*
OLYMPIA,
WARD
98502
420
MCPHEE
SW
(360) 352-2900
OLYMPIA,
WA 98502
(360) 352-2900
VISTA ONCOLOGY *
141 LILLY
RD NE *
VISTA
ONCOLOGY
OLYMPIA,
WANE
98506
141
LILLY RD
(360)
413-8880
OLYMPIA, WA 98506
(360) 413-8880
WALGREENS *
1510 COOPER*POINT
WALGREENS
RD SW
1510
COOPER POINT
OLYMPIA,
WA 98502
RD SW
(360) 570-8008
OLYMPIA,
WA 98502
(360) 570-8008
YAUGER PARK
PHARMACY
*
YAUGER
PARK
400 YAUGER* WAY SW
PHARMACY
STEYAUGER
B
400
WAY SW
OLYMPIA,
WA 98502
STE
B
(360) 357-3371
OLYMPIA,
WA 98502
(360) 357-3371
TENINO
TENINO
HEDDEN'S
PHARMACY *
HEDDEN'S
196 W SUSSEX
PHARMACY
* AVE
TENINO,
WA
98589
196 W SUSSEX
AVE
(360) 264-2575
TENINO,
WA 98589
(360) 264-2575
TUMWATER
TUMWATER
ALBERTSON'S *
705 TROSPER RD
ALBERTSON'S
* SW
TUMWATER,
WA
705 TROSPER RD SW
98512
TUMWATER,
WA
(360)
705-3679
98512
(360) 705-3679
COSTCO *
5500 LITTLEROCK RD
SW
TUMWATER, WA
98512
(360) 357-7290
FRED MEYER
PHARMACY *
555 TROSPER RD SW
TUMWATER, WA
98501
(360) 753-7933
MARTIN'S
SOUTHGATE DRUG *
5201 CAPITOL BLVD S
TUMWATER, WA
98501
(360) 943-4043
WALGREENS *
702 TROSPER RD SW
TUMWATER, WA
98512
(360) 943-5178
WAL-MART *
5600 LITTLEROCK RD
SW
TUMWATER, WA
98512
(360) 350-6030
YELM
RITE AID *
909 E YELM AVE
YELM, WA 98597
(360) 458-9011
SAFEWAY
PHARMACY *
1109 YELM AVE E
YELM, WA 98597
(360) 458-8835
TIM'S PHARMACY *
106 1ST ST S
YELM, WA 98597
(360) 458-8467
WAL-MART *
17100 STATE ROUTE
507 SE
YELM, WA 98597
(360) 400-8062
WAHKIAKUM
COUNTY
CATHLAMET
CATHLAMET
PHARMACY *
74 MAIN ST
CATHLAMET, WA
98612
(360) 795-3691
WALLA WALLA
COUNTY
WALLA WALLA
ADVENTIST HEALTH
COMMUNITY *
1111 S 2ND AVE
WALLA WALLA, WA
99362
(509) 527-8333
ALBERTSON'S *
450 N WILBUR AVE
WALLA WALLA, WA
99362
(509) 529-3706
BI-MART PHARMACY *
1649 PLAZA WAY
WALLA WALLA, WA
99362
(509) 529-9350
145
147
FAMILY MED CTR
PHARMACY *
1120 W ROSE ST
WALLA WALLA, WA
99362
(866)983-9279
PROVIDENCE ST
MARY PHARMACY *
401 W POPLAR ST
WALLA WALLA, WA
99362
(509) 529-8941
RITE AID *
2028 E ISAACS AVE
WALLA WALLA, WA
99362
(509) 529-1917
SAFEWAY
PHARMACY *
1600 PLAZA WAY
WALLA WALLA, WA
99362
(509) 522-4672
SAFEWAY
PHARMACY *
215 E ROSE ST
WALLA WALLA, WA
99362
(509) 522-0227
SHOPKO PHARMACY*
1651 W ROSE ST
WALLA WALLA, WA
99362
(509) 525-9207
TALLMANS
PHARMACY *
4 W MAIN ST
WALLA WALLA, WA
99362
(509) 525-1010
FRED MEYER
PHARMACY *
800 LAKEWAY DR
BELLINGHAM, WA
98226
(360) 676-1105
INTERFAITH
PHARMACY *
218 UNITY ST
BELLINGHAM, WA
98225
(360) 752-7406
HAGGEN FOOD AND
PHARMACY *
2814 MERIDIAN ST
BELLINGHAM, WA
98225
(360) 671-3305
RITE AID *
3227 NORTHWEST
AVE
BELLINGHAM, WA
98225
(360) 647-2175
HAGGEN FOOD AND
PHARMACY *
2900 WOBURN ST
BELLINGHAM, WA
98226
(360) 715-5320
RITE AID *
1225 E SUNSET DR
STE 110
BELLINGHAM, WA
98226
(360) 671-5041
HAGGEN PHARMACY*
4545 CORDATA PKWY
BELLINGHAM, WA
98226
(360) 676-7373
RITE AID *
220 36TH ST
BELLINGHAM, WA
98225
(360) 734-8254
FAIRHAVEN
PHARMACY *
1115 HARRIS AVE
BELLINGHAM, WA
98225
(360) 734-3340
HOAGLAND
PHARMACY LTC
1414 MEADOR AVE
STE H102
BELLINGHAM, WA
98229
(360) 734-5413
RITE AID *
1400 CORNWALL AVE
BELLINGHAM, WA
98225
(360) 733-1980
FRED MEYER
PHARMACY *
1225 W BAKERVIEW
RD
BELLINGHAM, WA
98226
(360) 788-2933
HOAGLAND'S
PHARMACY*
2330 YEW ST
BELLINGHAM, WA
98229
(360) 734-5413
WALGREENS *
633 W TIETAN ST
WALLA WALLA, WA
99362
(509) 529-1570
WHATCOM
COUNTY
BELLINGHAM
COSTCO *
4299 GUIDE MERIDIAN
ST
BELLINGHAM, WA
98226
(360) 738-7851
CUSTOM
PRESCRIPTION
SHOPPE *
1313 E MAPLE ST
STE 101
BELLINGHAM, WA
98225
(360) 685-4242
146
148
RITE AID *
222 TELEGRAPH RD
BELLINGHAM, WA
98226
(360) 676-8570
SAFEWAY
PHARMACY *
1225 E SUNSET DR
STE 155
BELLINGHAM, WA
98226
(360) 650-1537
TARGET PHARMACY *
30 BELLIS FAIR PKWY
BELLINGHAM, WA
98226
(360) 734-0220
WALGREENS *
4090 GUIDE MERIDIAN
BELLINGHAM, WA
98226
(360) 734-0229
WALGREENS *
1070 E SUNSET DR
BELLINGHAM, WA
98226
(360) 647-2713
WAL-MART *
4420 MERIDIAN ST
BELLINGHAM, WA
98226
(360) 647-1611
BLAINE
THRIFTY PAYLESS
INC *
1195 BOBLETT ST
BLAINE, WA 98230
(360) 332-1616
EVERSON
VALLEY DRUG *
208 E MAIN ST
EVERSON, WA 98247
(360) 966-3481
RITE AID *
5715 4TH AVE
FERNDALE, WA 98248
(360) 384-1551
WALGREENS *
1901 MAIN ST
FERNDALE, WA 98248
(360) 384-7658
LYNDEN
FAIRWAY DRUG *
1758 FRONT ST STE
106
LYNDEN, WA 98264
(360) 354-1226
RITE AID *
8090 GUIDE MERIDIAN
RD
LYNDEN, WA 98264
(360) 354-4284
SAFEWAY
PHARMACY *
8071 GUIDE MERIDAN
RD
LYNDEN, WA 98264
(360) 318-0698
SUMAS
SUMAS DRUG *
315 CHERRY ST
SUMAS, WA 98295
(360) 988-2681
WHITMAN COUNTY
COLFAX
TICK KLOCK DRUGS *
109 S MAIN ST
COLFAX, WA 99111
(509) 397-2111
147
149
GARFIELD
GARFIELD
PHARMACY
207 N 3RD STE 2
GARFIELD, WA 99130
(509) 635-0100
PULLMAN
RITE AID *
1630 GRAND AVE S
PULLMAN, WA 99163
(509) 334-7222
SAFEWAY
PHARMACY *
430 SE BISHOP BLVD
PULLMAN, WA 99163
(509) 334-0819
SHOPKO PHARMACY*
S 1450 GRAND AVE
PULLMAN, WA 99163
(509) 332-0503
SID'S PHARMACY *
825 SE BISHOP BLVD
STE 301
PULLMAN, WA 99163
(509) 332-4608
SIDS PROFESSIONAL
PHARMACY *
825 S E BISHOP
STE 301 B
PULLMAN, WA 99163
(509) 334-6506
WAL-MART *
695 SE BISHOP BLVD
PULLMAN, WA 99163
(509) 334-2981
WSU HEALTH AND
WELLNESS SVC *
1125 SE
WASHINGTON ST
PULLMAN, WA 99163
(509) 335-5742
SAINT JOHN
ST JOHN PHARMACY*
18 E FRONT ST
SAINT JOHN, WA
99171
(509) 648-3430
TEKOA
TEKOA PHARMACY *
124 N CROSBY
TEKOA, WA 99033
(509) 284-4205
YAKIMA COUNTY
GRANDVIEW
YAKIMA VALLY FARM
WORKERS *
1000 WALLACE WAY
GRANDVIEW, WA
98930
(866)983-9279
SELAH
HOWARD'S DRUG *
119 E 3RD AVE
SELAH, WA 98942
(509) 697-6125
SELAH SAVE ON
FOODS PHARMACY *
800 N PARK CTR
SELAH, WA 98942
(360) 714-9797
SUNNYSIDE
BI-MART PHARMACY *
110 W SOUTH HILL RD
SUNNYSIDE, WA
98944
(509) 839-0766
RITE AID *
2010 YAKIMA VALLEY
HWY STE C
SUNNYSIDE, WA
98944
(509) 839-2711
SAFEWAY
PHARMACY *
613 N 6TH ST
SUNNYSIDE, WA
98944
(509) 839-2103
WAL-MART *
2675 E LINCOLN AVE
SUNNYSIDE, WA
98944
(509) 839-7030
YAKIMA
NEIGHBORHOOD
HEALTH *
617 SCOON RD
SUNNYSIDE, WA
98944
(509) 837-8989
TOPPENISH
GIBBONS
PHARMACY*
117 S TOPPENISH
AVE
TOPPENISH, WA
98948
(509) 865-2722
148
150
SAFEWAY
PHARMACY *
711 W FIRST ST
TOPPENISH, WA
98948
(509) 865-4700
YAKIMA VLY FARM
WRKRS CLINIC *
518 W 1ST AVE
TOPPENISH, WA
98948
(509) 865-3355
UNION GAP
COSTCO *
2310 LONGFIBRE RD
UNION GAP, WA 98903
(509) 454-5249
RITE AID *
2519 MAIN ST
UNION GAP, WA 98903
(509) 453-3603
SHOPKO PHARMACY*
2530 RUDKIN RD
UNION GAP, WA 98903
(509) 248-9567
WAPATO
HORIZON
PHARMACY*
633 W 1ST ST
WAPATO, WA 98951
(509) 584-0300
YAKIMA
ALBERTSON'S *
1610 W LINCOLN AVE
YAKIMA, WA 98902
(509) 452-6567
ALBERTSON'S *
401 S 40TH ST
YAKIMA, WA 98908
(509) 965-2336
BI-MART PHARMACY *
1207 N 40TH AVE
YAKIMA, WA 98908
(509) 457-1628
BI-MART PHARMACY *
309 S 5TH AVE
YAKIMA, WA 98902
(509) 452-6648
CENTRAL WA FAMILY
MEDICINE *
1806 W LINCOLN AVE
YAKIMA, WA 98902
(509) 494-6702
FRED MEYER
PHARMACY *
1206 N 40TH AVE
YAKIMA, WA 98908
(509) 576-6833
KMART PHARMACY *
2304 E NOB HILL
BLVD
YAKIMA, WA 98901
(509) 575-7552
MEMORIAL
PHARMACY *
402 S 12TH AVE
YAKIMA, WA 98902
(509) 573-3808
NORTH STAR LODGE
PHARMACY *
808 N 39TH AVE
YAKIMA, WA 98902
(509) 574-3404
RITE AID *
5606 SUMMITVIEW
AVE
YAKIMA, WA 98908
(509) 965-2037
SHOPKO PHARMACY*
5801 SUMMITVIEW
AVE
YAKIMA, WA 98908
(509) 965-6393
RITE AID *
2204 W NOB HILL
BLVD STE B
YAKIMA, WA 98902
(509) 453-4414
TERRACE VILLAGE
HM PHARMACY *
4040 TERRACE
HEIGHTS DR
YAKIMA, WA 98901
(509) 248-3311
RITE AID *
12 N 9TH AVE
YAKIMA, WA 98902
(509) 452-2600
ROSAUERS
PHARMACY *
410 S 72 AVE
YAKIMA, WA 98908
(509) 972-0284
SAFEWAY
PHARMACY *
205 N 5TH AVE
YAKIMA, WA 98902
(509) 457-8869
SAFEWAY
PHARMACY *
905 E MEAD AVE
YAKIMA, WA 98903
(509) 248-8782
SAFEWAY
PHARMACY *
5702 SUMMITVIEW
AVE
YAKIMA, WA 98908
(509) 965-3870
149
151
TIETON VILLAGE
DRUG *
3708 TIETON DR
YAKIMA, WA 98902
(509) 966-6850
WALGREENS *
610 W YAKIMA AVE
YAKIMA, WA 98902
(509) 469-0246
WALGREENS *
4001 SUMMITVIEW
AVE STE 1
YAKIMA, WA 98908
(509) 972-2986
WAL-MART *
1600 E CHESTNUT
AVE
YAKIMA, WA 98901
(509) 248-3855
WAL-MART *
6600 W NOB HILL
BLVD
YAKIMA, WA 98908
(509) 966-3814
WASHINGTON
HEMATOLOGY
ONCOLOGY *
3911 CASTLEVALE RD
STE 201
YAKIMA, WA 98902
(509) 454-9499
WRAY'S CHALET
THRIFTWAY *
5605 SUMMITVIEW
AVE
YAKIMA, WA 98908
(509) 966-0530
WRAY'S THRIFTWAY *
7200 W NOB HILL
BLVD
YAKIMA, WA 98908
(509) 965-0202
YAKIMA
NEIGHBORHOOD
PHARMACY *
12 S 8TH ST
YAKIMA, WA 98901
(509) 853-2354
YAKIMA VALLEY
FARM WKRS CLINIC *
602 E NOB HILL BLVD
YAKIMA, WA 98901
(866)983-9279
150
152
Mail Order Pharmacies
You can get prescription drugs shipped to your home through our network mail order delivery
program. Typically you should expect to receive your prescription drugs within 14 days from
the time that the mail order pharmacy receives the order. If you do not receive your
prescription drug(s) within this time, please contact us at 1-800-942-0247 (TTY Relay: Dial 7-11) from 8:00 a.m. to 8:00 p.m., 7 days a week.
To get more information about the mail order pharmacy, please call our Customer Service
department at 1-800-942-0247 (TTY Relay: Dial 7-1-1) from 8:00 a.m. to 8:00 p.m.,
7 days a week.
Mail Order Pharmacies:
Express Scripts
PO Box 66566
St. Louis, MO 63166-6566
151
153
Home Infusion Pharmacies
To get more information about the home infusion pharmacies, please call our Customer
Service department at 1-800-942-0247 (TTY Relay: Dial 7-1-1) from 8:00 a.m. to 8:00
152
154
Home Infusion
Pharmacies
SNOHOMISH
COUNTY
WHATCOM
COUNTY
BENTON COUNTY
EVERETT
BELLINGHAM
Kennewick
OPTION CARE
8120 EVERGREEN
WAY
EVERETT, WA 98203
(800)737-0613
INFUSION SOLUTIONS
134 PRINCE AVE
STE B
BELLINGHAM, WA
98226
(360) 933-4892
SPOKANE
COUNTY
OPTION CARE
477 W HORTON RD
BELLINGHAM, WA
98226
(800)755-0484
OPTION CARE
7325 DESCHUTES
AVE STE C
KENNEWICK, WA
99336
(509) 783-2273
KING COUNTY
KENT
ACCREDO HEALTH
GROUP
22408 68TH AVE S
KENT, WA 98032
(253) 872-2121
REDMOND
CORAM SPECIALTY
INFUSION SVCS
14935 NE 87TH ST STE
101
REDMOND, WA 98052
(425) 883-3525
SEATTLE
OPTION CARE
13035 GATEWAY DR
STE 131
SEATTLE, WA 98168
(800)277-5805
SPOKANE
CORAM SPECIALTY
INFUSION SVCS
520 E NORTH
FOOTHILLS DR
SPOKANE, WA 99207
(509) 482-4266
WALGREENS
INFUSION SERVICES
1328 N ASH ST
SPOKANE, WA 99201
(509) 326-0306
LIFECARE
SOLUTIONS
11703 E SPRAGUE
AVE STE 3
SPOKANE VALLEY,
WA 99206
(509) 921-6560
153
155
Long Term Care Pharmacies
Residents of a long-term care facility may access their prescription drugs covered under
Community HealthFirst through the facility’s long-term care pharmacy or another
network long-term care pharmacy.
To get more information about the long term care pharmacies, please call our Customer
Service department at 1-800-942-0247 (TTY Relay: Dial 7-1-1) from 8:00 a.m. to 8:00
154
156
Long Term Care
Pharmacies
COLUMBIA
COUNTY
ASOTIN COUNTY
DAYTON
CLARKSTON
ELK DRUG
176 E MAIN ST
DAYTON, WA 99328
(509) 382-2536
WASEM'S DRUG *
800 6TH ST
CLARKSTON, WA
99403
(509) 758-2565
CLARK COUNTY
CAMAS
SURECARE RX
3400 SE 196TH AVE
STE 100
CAMAS, WA 98607
(800)330-9617
VANCOUVER
CHS PHARMACY
6600 NE 112TH CT
STE 103
VANCOUVER, WA
98662
(360) 694-7377
HI-SCHOOL
PHARMACY
6926 NE FOURTH
PLAIN BLVD
VANCOUVER, WA
98661
(360) 693-8374
PROPAC PHARMACY
12606 NE 95TH ST
VANCOUVER, WA
98682
(360) 260-7156
COWLITZ COUNTY
CASTLE ROCK
CASTLE ROCK
PHARMACY *
117 1ST AVE SW
CASTLE ROCK, WA
98611
(360) 274-8211
ISLAND COUNTY
CLINTON
ISLAND DRUG *
11042 STATE ROUTE
525
CLINTON, WA 98236
(360) 341-3885
OAK HARBOR
ISLAND DRUG *
230 SE PIONEER WAY
OAK HARBOR, WA
98277
(360) 675-6688
GARFIELD
COUNTY
ISLAND DRUG LTC
32170 STATE ROUTE
20 STE B
OAK HARBOR, WA
98277
(360) 675-6688
POMEROY
KING COUNTY
POMEROY
PHARMACY *
764 MAIN STREET
POMEROY, WA 99347
(509) 843-1821
AUBURN
GENOA HEALTHCARE
4508 AUBURN WAY N
STE A104
AUBURN, WA 98002
(253) 373-9944
GRAYS HARBOR
COUNTY
MONTESANO
VALU DRUG *
201 E PIONEER AVE
MONTESANO, WA
98563
(360) 249-4444
155
157
QOL MEDS
2704 I ST NE
AUBURN, WA 98002
(253) 288-2111
BELLEVUE
REDMOND
BELLEGROVE
PHARMACY *
1200 112TH AVE NE
STE A100
BELLEVUE, WA 98004
(425) 455-2123
CONSONUS
PHARMACY
SERVICES
14729 NE 87TH ST
REDMOND, WA 98052
(866)698-5120
BURIEN
RENTON
GENOA HEALTHCARE
1210 SW 136TH ST RM
101
BURIEN, WA 98166
(206) 242-4446
JOLLY'S PHARMACY
1412 SW 43RD ST STE
120
RENTON, WA 98057
(425) 251-6335
KENT
PROVIDENCE
INFUSION PHCY SVS
2201 LIND AVE SW
STE 130
RENTON, WA 98057
(425) 687-4429
A AND H
PHARMACEUTICAL
SVCS
610 W MEEKER ST
STE 201
KENT, WA 98032
(253) 852-1123
SEATTLE
PROPAC PHARMACY*
7102 S 220TH ST
KENT, WA 98032
(855)535-7183
BOB JOHNSONS
PHARMACY *
1407 NW 85TH ST
SEATTLE, WA 98117
(206) 782-5822
UNITED CARE
PHARMACY
18230 E VALLEY HWY
KENT, WA 98032
(425) 656-2900
GENOA HEALTHCARE
1600 E OLIVE ST
BLDG D
SEATTLE, WA 98122
(425) 835-7110
KIRKLAND
KELLEY ROSS LTC
PHARMACY
2324 EASTLAKE AVE
E
SEATTLE, WA 98102
(206) 838-4590
EVERGREEN
PHARMACEUTICAL
12220 113TH AVE NE
KIRKLAND, WA 98034
(425) 814-1925
156
158
LOWRY'S
PRESCRIPTIONS *
10330 MERIDIAN AVE
N
SEATTLE, WA 98133
(206) 368-6060
NORTHWEST
MEDICATION MGMT
4120 STONE WAY N
SEATTLE, WA 98103
(206) 547-1765
OTTERSENS
PHARMACEUTICAL
13023 GREENWOOD
AVE N
SEATTLE, WA 98133
(206) 365-4048
PREMIER LTC
PHARMACY
1618 S LANE ST
STE 204
SEATTLE, WA 98144
(206) 323-0868
SURECARE RX
1605 S 93RD ST STE B
SEATTLE, WA 98108
(206) 767-0411
FIRCREST SCHOOL
PHARMACY
15230 15TH AVE NE
SHORELINE, WA
98155
(206) 361-3568
KITSAP COUNTY
GIG HARBOR
BREMERTON
COSTLESS SENIOR
SERVICES *
14216 92ND AVE NW
STE B
GIG HARBOR, WA
98329
(253) 857-7677
GENOA HEALTHCARE
5455 ALMIRA DR NE
STE 329
BREMERTON, WA
98311
(360) 415-6700
PORT ORCHARD
STATE OF WA
VETERANS HOME
1141 BEACH DR E
PORT ORCHARD, WA
98366
(360) 895-4700
LEWIS COUNTY
CENTRALIA
HALLS LONG TERM
CARE PHCY
505 S TOWER AVE
STE 2B
CENTRALIA, WA
98531
(360) 736-5000
PIERCE COUNTY
BUCKLEY
RAINIER SCHOOL
2120 RYAN RD
BUCKLEY, WA 98321
(360) 829-3004
LAKEWOOD
BRIDGEPORT
PHARMACY
SERVICES
7424 BRIDGEPORT
WAY W
LAKEWOOD, WA
98499
(253) 582-2282
GENOA HEALTHCARE
9330 59TH AVE SW
STE 179
LAKEWOOD, WA
98499
(253) 620-5132
INTERNATIONAL
PHARMACY LTC
11228 BRIDGEPORT
WAY SW
LAKEWOOD, WA
98499
(253) 302-4559
MEGA PHARMACY *
1902 96TH ST S STE A
TACOMA, WA 98444
(253) 302-4178
WESTERN STATE
HOSP PHARMACY
9601 STEILACOOM
BLVD SW
TACOMA, WA 98498
(253) 756-2521
UNIVERSITY PLACE
FRANCISCAN
HOSPICE LTC PHCY *
2901 BRIDGEPORT
WAY W
UNIVERSITY PLACE,
WA 98466
(253) 534-7033
SKAGIT COUNTY
LA CONNER
LA CONNER DRUG *
708 E MORRIS ST
LA CONNER, WA
98257
(360) 466-3124
SNOHOMISH
COUNTY
EDMONDS
TACOMA
LINCOLN PHARMACY
821B S 38TH ST
TACOMA, WA 98418
(253) 473-1155
157
159
EDMONDS PHCY
STEVENS HLTH CTR
21701 76TH AVE W
STE 104B
EDMONDS, WA 98026
(425) 563-6381
PAVILION HOMECARE
PHARMACY
7320 216TH ST SW
STE 100B
EDMONDS, WA 98026
(425) 673-3700
EVERETT
GENOA HEALTHCARE
3322 BROADWAY STE
230
EVERETT, WA 98201
(425) 789-3050
PAYLESS DRUG LTC
PHARMACY
111 SE EVERETT
MALL WAY
EVERETT, WA 98203
(425) 257-9645
SHIRAZ SPECIALTY
PHARMACY
205 E CASINO RD STE
B16
EVERETT, WA 98208
(425) 356-3276
MOUNTLAKE
TERRACE
MERCURY
PHARMACY
SERVICES
21718 66TH AVE W
MOUNTLAKE
TERRACE, WA 98043
(425) 673-5200
SPOKANE
COUNTY
MEDICAL LAKE
EASTERN STATE
HOSPITAL
800 MAPLE
MEDICAL LAKE, WA
99022
(509) 565-4598
LAKELAND VILLAGE
SOUTH 2320
SALNAVE RD
MEDICAL LAKE, WA
99022
(509) 299-1930
SPOKANE
1ST AVENUE
PHARMACY *
6 E 1ST AVE
SPOKANE, WA 99202
(509) 624-3017
BATES
PHARMACEUTICAL
SVCS *
3704 N NEVADA STE B
SPOKANE, WA 99207
(509) 489-4500
EVERGREEN
PHARMACEUTICAL
350 E 3RD AVE
SPOKANE, WA 99202
(509) 838-4826
158
160
NORTHWEST HEALTH
SYSTEMS
107 S DIVISION ST
STE 209
SPOKANE, WA 99202
(508)744-9891
NORTHWEST HEALTH
SYSTEMS *
2818 N SULLIVAN RD
BLDG 2E
SPOKANE, WA 99216
(509) 744-9891
PROVIDENCO
SACRED PHARMACY *
101 W 8TH AVE
SPOKANE, WA 99204
(509) 474-3088
RELIANT RX
120 N PINE ST STE
156
SPOKANE, WA 99202
(509) 343-3400
SPOKANE VALLEY
PHARMERICA
2114 N PINES RD
STE 4
SPOKANE VALLEY,
WA 99206
(509) 893-1011
STEVENS COUNTY
COLVILLE
PROVIDENCE HEALTH
SERVICES WA *
1200 E COLUMBIA
AVE
COLVILLE, WA 99114
(509) 684-7727
THURSTON
COUNTY
LACEY
KIRK'S CHS
PHARMACY
6149 MARTIN WAY E
LACEY, WA 98516
(360) 493-8614
PUGET PHARMACY
SERVICES
1751 CIRCLE LN SE
LACEY, WA 98503
(360) 456-5389
OLYMPIA
NORTHWEST
SPECIALTY
PHARMACY
1908 4TH AVE E STE B
OLYMPIA, WA 98506
(360) 596-0108
PROVIDENCE
MOTHER JOSEPH
CTR *
3333 ENSIGN RD NE
OLYMPIA, WA 98506
(360) 493-4572
WHATCOM
COUNTY
BELLINGHAM
(360) 685-4242
YAKIMA
HOAGLAND
PHARMACY LTC
1414 MEADOR AVE
STE H102
BELLINGHAM, WA
98229
(360) 734-5413
CONSULTING AND
PHARMACY SVCS
1221 S 40TH AVE
YAKIMA, WA 98908
(509) 575-0272
WHITMAN COUNTY
PULLMAN
SID'S LTC PHARMACY
825 SE BISHOP BLVD
STE 301 B
PULLMAN, WA 99163
(509) 334-6506
YAKIMA COUNTY
SELAH
YAKIMA VALLEY
SCHOOL
609 SPEYERS RD
SELAH, WA 98942
(509) 698-1345
TOPPENISH
GIBBONS
PHARMACY*
117 S TOPPENISH
AVE
TOPPENISH, WA
98948
(509) 865-2722
CUSTOM
PRESCRIPTION
SHOPPE *
1313 E MAPLE ST
STE 101
BELLINGHAM, WA
98225
159
161
GENOA HEALTHCARE
402 S 4TH AVE
YAKIMA, WA 98902
(509) 248-5153
RIVER VILLAGE
PHARMACY
3708 TIETON DR
YAKIMA, WA 98902
(509) 469-3198
YAKIMA VLY
MEMORIAL HOSP
PHCY
2811 TIETON DR
YAKIMA, WA 98902
(509) 575-8036
Indian Health Service / Tribal / Urban Indian Health Program (I/T/U)
Pharmacies/
Only Native Americans and Alaska Natives have access to Indian Health Service /
Tribal / Urban Indian Health Program (I/T/U) Pharmacies through Community
HealthFirst’s pharmacy network. Those other than Native Americans and Alaska
Natives may be able to access these pharmacies under limited circumstances (i.e.,
emergencies).
To get more information about the I/T/U Indian Health Program, please call our
Customer Service department at 1-800-942-0247 (TTY Relay: Dial 7-1-1) from 8:00
a.m. to 8:00 p.m., 7 days a week.
160
162
I/T/U Pharmacies
MASON COUNTY
CLALLAM COUNTY
SHELTON
NEAH BAY
KAMILCHE
PHARMACY
90 SE KLAH CHE MIN
DR
SHELTON, WA 98584
(360) 432-3990
SOPHIA TRETTEVICK
INDIAN HLTH
HIGHWAY 112 CLINIC
RD
NEAH BAY, WA 98357
(360) 645-2431
FERRY COUNTY
INCHELIUM
INCHELIUM
COMMUNITY CLINIC
INCHELIUM-KETTLE
FALLS HWY
INCHELIUM, WA 99138
(509) 722-3331
GRAYS HARBOR
COUNTY
TAHOLAH
ROGER SAUX
HEALTH CENTER
407 CONNUX ST
TAHOLAH, WA 98587
(360) 276-4405
KING COUNTY
SEATTLE
SEATTLE INDIAN
HEALTH BOARD
611 12TH AVE S
SEATTLE, WA 98114
(206) 324-9360
OKANOGAN
COUNTY
NESPELEM
COLVILLE INDIAN
HEALTH CTR
AGENCY CAMPUS
HWY 155
NESPELEM, WA 99155
(509) 634-2914
OMAK
OMAK HEALTH
STATION PHARMACY
617 BENTON ST
OMAK, WA 98841
(509) 422-7454
PIERCE COUNTY
TACOMA
PUYALLUP TRIBAL
HEALTH
2209 E 32ND ST
BLDG 15
TACOMA, WA 98404
(253) 593-0232
161
163
SNOHOMISH
COUNTY
TULALIP
TULALIP PHARMACY
8825 34TH AVE NE
STE A
TULALIP, WA 98271
(360) 651-4619
STEVENS COUNTY
WELLPINIT
DAVID C WYNECOOP
MEM CLNC
6203 AGENCY LOOP
RD
WELLPINIT, WA 99040
(509) 258-4517
THURSTON
COUNTY
OLYMPIA
NISQUALLY TRIBAL
PHARMACY
4816 SHE NAH NUM
DR SE
OLYMPIA, WA 98513
(360) 459-5312
WHATCOM
COUNTY
BELLINGHAM
LUMMI TRIBAL
HEALTH CENTER
2592 KWINA RD
BELLINGHAM, WA
98226
(360) 384-0464
YAKIMA COUNTY
TOPPENISH
YAKAMA INDIAN
HLTH CTR PHCY
401 BUSTER RD
TOPPENISH, WA
98948
(509) 865-1703
162
164
112TH STREET CHC
PHARMACY * ......... 133
1ST AVENUE
PHARMACY * .. 139,158
A AND H
PHARMACEUTICAL
SVCS ............... 107,156
ABERDEEN HEALTH
MART PHARMACY *
................................ 101
ACCESS PHARMACY *
................................ 109
ACCREDO HEALTH
GROUP ................... 153
ADVENTIST HEALTH
COMMUNITY *........ 145
AFH PHARAMCY * . 111
AKERS UNITED
DRUG* .................... 143
ALBERTSON'S * ...... 9296,102,104,106,109,
110,119-121,124127,133,135-139,142,
144, 145, 148,149
ALLENMORE
OUTPATIENT
PHARMACY * ......... 127
ALPINE INTEGRATED
MEDICINE * ............ 110
APOTHECARY
SHOPPE *............... 119
ARLINGTON CHC
PHARMACY * ......... 131
ARLINGTON
PHARMACY * ......... 131
ASSURED
PHARMACY* .......... 108
BALLARD PLAZA
PHARMACY * ......... 111
BARTELL DRUGS *
............................... 103112, 117,118,124,
127,129,132,133,135138
BATES
PHARMACEUTICAL
SVCS * ............. 139,158
BATES PHARMACY *
................................ 139
BEALL'S PHARMACY *
................................ 126
BELLEGROVE
PHARMACY * .. 103,156
BETHEL PHARMACY *
................................ 135
BI-MART PHARMACY *
.... 92,96,98,99,121,138,
145,148,149
BOB JOHNSONS
PHARMACY * .. 112,156
BREWSTER HEALTH
MART DRUG * ........ 123
BRIDGEPORT
PHARMACY
SERVICES .............. 157
BROADWAY CHC
PHARMACY * ......... 133
BUCK PAVILION
PHARMACY * ......... 112
CABRINI MEDICAL
TOWER PHCY * ..... 112
CASTLE ROCK
PHARMACY * .... 98,155
CATHLAMET
PHARMACY * ......... 145
CAVALLINI'S
PHARMACY * ......... 121
CEDAR VILLAGE
PHARMACY * ......... 122
CENTRAL WA FAMILY
MEDICINE * ............ 149
CENTRAL
WASHINGTON HOSP
PHCY *...................... 94
CHAS ........ 138,139,142
CHAS DENNY
MURPHY................. 139
CHAS PHARMACY *
................................ 139
CHAS-NHOS * ........ 139
163
165
CHAS-WASEM * ....... 92
CHENEY OWL HEALTH
MART PHCY *......... 138
CHESTERFIELD
PHARMACY * ......... 112
CHINOOK PHARMACY
.................................. 94
CHS PHARMACY ... 155
CHUCK'S DRUGS * 124
CHUNG PHARMACY *
................................ 127
CITY CENTER DRUG *
................................ 101
CLARKSTON HEIGHTS
PHARMACY * ........... 92
CLE ELUM DRUG * 121
COLTON PHARMACY *
................................ 122
COLUMBIA BASIN
HEMATOLOGY *....... 92
COLUMBIA
PHARMACY * ......... 112
COLUMBIA VALLEY
COMM H PHCY * ...... 94
COLVILLE INDIAN
HEALTH CTR.......... 161
COMM HEALTH CARE
HILLTOP PHCY * .... 127
COMMUNITY
HEALTHCARE
PHARMACY * ......... 127
CONNELL FAMILY
CLINIC PHARMACY *
................................ 100
CONSONUS
PHARMACY
SERVICES .............. 156
CONSULTING AND
PHARMACY SVCS . 159
COPE'S PHARMACY *
................................ 126
CORAM SPECIALTY
INFUSION SVCS .... 153
COST LESS
PRESCRIPTIONS *. 127
COST PHARMACYFIRCREST *............ 127
COSTCO *
.. 92,95,96,100,105,106,
108,113,118,121,124,
126,128,130,133,136,
138,139,143,145,146,
148
COSTLESS SENIOR
SERVICES *..... 124,157
COUNTRY DOCTOR
COMMUNITY CLN * 113
COVINGTON
MULTICARE CLINIC *
................................ 105
CROWN DRUG * .... 101
CUSTOM
PRESCRIPTION
SHOPPE *........ 146,159
DARRINGTON
PHARMACY * ......... 132
DAVENPORT GOOD
NEIGHBOR PHCY * 122
DAVID C WYNECOOP
MEM CLNC ............. 161
DEACONESS
OUTPATIENT
PHARMACY * ......... 139
DENSOW'S
PHARMACY * ........... 93
DES MOINES DRUG
................................ 113
DOANE'S VALLEY
PHARMACY * ........... 94
DONG NAI
PHARMACY, * ........ 113
DONS PHARMACY *
................................ 102
DOWNTOWN PUBLIC
HLTH CNTR PHCY . 113
DUPONT PHARMACY *
................................ 124
DUVALL FAMILY
DRUGS *................. 105
E WENATCHEE FOOD
PAVILION PHCY * .... 99
EAST VALLEY
PHARMACY * ......... 130
EASTERN STATE
HOSPITAL .............. 158
EDMONDS
PHARMACY * ......... 132
EDMONDS PHCY
STEVENS HLTH CTR
................................ 157
EDMONDS WELLNESS
CLINIC * .................. 132
ELFERS-LYON
PHARMACY * ........... 93
ELK DRUG......... 98,155
ELLENSBURG
DOWNTOWN HM
PHCY *.................... 121
ELLENSBURG
PHARMACY * ......... 121
ELMA HEALTH MART
PHARMACY * ......... 101
EVERETT FOOT
CLINIC * .................. 133
EVERGREEN
INTEGRATIVE
MEDICINE * ............ 103
EVERGREEN
NATUROPATHIC *.. 139
EVERGREEN
PHARMACEUTICAL
......................... 156,158
EVERGREEN
PHARMACY * ......... 108
EVERGREEN PROF
CTR PHARMACY * . 108
FAIRFIELD OWL
PHARMACY * ......... 138
FAIRHAVEN
PHARMACY * ......... 146
FAIRWAY DRUG * .. 147
FAMILY HEALTH
CENTERS *............. 123
FAMILY MED CTR
PHARMACY * ......... 145
FAMILY PHARMACY *
......................... 130,132
164
166
FAMILY WELLNESS
CENTER PC * ........... 96
FEDERAL WAY
PHARMACY * ......... 106
FIESTA PHARMACY *
................................ 100
FIFTH AND BROWNE
PHARMACY * ......... 139
FIRCREST
PHARMACY* .......... 124
FIRCREST SCHOOL
PHARMACY............ 156
FRANCISCAN
HOSPICE LTC PHCY *
......................... 130,157
FRANCISCAN
PHARMACY * ......... 126
FRANCISCAN
PHARMACY AUBURN*
................................ 103
FRANCISCAN
PHARMACY FIRST
AVE *....................... 106
FRANCISCAN
PHARMACY ST
CLARE, *................. 125
FRANCISCAN
PHARMACY ST
JOSEPH * ............... 128
FRANCISCAN
PHARMACY TACOMA*
................................ 128
FRANCISCAN PHCY
BONNEY LAKE * .... 124
FRANCISCAN PHCY
ST ANTHONY *....... 124
FRED MEYER
PHARMACY *
92,93,95,96,99,100,103,
106110,113,119,120,122,12
4,126128,130,132,133,135137,140,142,143,145,14
6,149
FRIDAY HARBOR
DRUG * ................... 130
GARFIELD PHARMACY
................................ 147
GENOA HEALTHCARE
......................... 155-159
GIBBONS PHARMACY*
................................ 148
GIBBONS PHARMACY*
................................ 159
GODFREYS
PHARMACY * ........... 98
GOOD PHARMACY *
................................ 125
GOOD SAMARITAN
BEHAVIORAL HLTH *
................................ 126
GROSS DRUG * ....... 99
HAGGEN FOOD &
PHARMACY *
... 123,131,132,133,136,
138,146
HAGGEN FOOD AND
DRUG * ................... 130
HALLS DRUG
CENTER* ................ 121
HALLS LONG TERM
CARE PHCY ........... 157
HARBOR DRUG * ... 101
HARBORVIEW
MEDICAL CENTER *
................................ 113
HART AND DILATUSH
PHARMACY * ......... 140
HAWKS PRAIRIE
HEALTH MART PHCY *
................................ 143
HEALTHPOINT
AUBURN PHARMACY*
................................ 103
HEALTHPOINT
BOTHELL PHARMACY*
................................ 104
HEALTHPOINT
CENTRAL FILL PHCY *
................................ 110
HEALTHPOINT
FEDERAL WAY PHCY*
................................ 106
HEALTHPOINT KENT
PHARMACY * ......... 107
HEDDEN'S
PHARMACY * ......... 144
HIGHLAND
PHARMACY * ......... 106
HIGHLAND
PHARMACY * ......... 133
HILLTOP PHARMACY *
................................ 131
HILTON PHARMACY *
................................ 136
HI-SCHOOL
PHARMACY*
............... 96,99,121,155
HOAGLAND
PHARMACY LTC .... 146
HOAGLAND
PHARMACY SOUTH *
................................ 131
HOAGLAND'S
PHARMACY* .......... 146
HOLLY PARK
PHARMACY * ......... 113
HORIZON PHARMACY*
................................ 148
HOWARD'S DRUG *148
INCHELIUM
COMMUNITY CLINIC
................................ 161
INFUSION SOLUTIONS
................................ 153
INTEGRATIVE FOOT
AND ANKLE CTR * . 108
INTERFAITH
PHARMACY * ......... 146
INTERNATIONAL
COMM HLTH SVCS *
................................ 113
INTERNATIONAL
PHARMACY * ......... 125
INTERNATIONAL
PHARMACY LTC .... 157
165
167
ISLAND DRUG *
......................... 102,155
JIM'S PHARMACY *
........................... 95,105
JODI BERGS
INTGRTVE FMLY
HLTH* ..................... 133
JOLLY'S PHARMACY
......................... 110,156
KAMILCHE
PHARMACY............ 161
KATTERMAN'S SAND
POINT PHCY * ........ 113
KELLEY ROSS LTC
PHARMACY* ... 113,156
KETTLE FALLS
HEALTH MART PHCY *
................................ 143
KING PLAZA
PHARMACY * ......... 113
KIRK'S CHS
PHARMACY............ 159
KIRK'S PHARMACY *
................................ 126
KITSAP PHARMACY *
................................ 120
KMART PHARMACY *
.... 102,122,128,140,149
KUSLER'S
PHARMACY* .......... 137
L J'S FURNESS DRUG*
.................................. 98
LA CONNER DRUG *
......................... 131,157
LAFFERRY'S
PHARMACY * ......... 113
LAKE CHELAN
PHARMACY * ........... 94
LAKE SPOKANE
PHARMACY * ......... 143
LAKELAND VILLAGE
................................ 158
LAKEMONT
PHARMACY * ......... 103
LAKEWOOD
PHARMACY * ......... 125
LAURA J HIEB ND * 110
LEGACY SALMON
CREEK
APOTHECARY* ........ 96
LIDGERWOOD OWL
HM PHARMACY * ... 140
LINCOLN COUNTY
HLTH MRT PHCY *. 122
LINCOLN PHARMACY*
......................... 128,157
LINDEMAN PAVILION
PHARMACY * ......... 113
LINDS COUPVILLE
PHARMACY * ......... 102
LIND'S FREELAND
PHARMACY * ......... 102
LOGAR PHARMACY *
.................................. 92
LONG BEACH
PHARMACY * ......... 123
LOPEZ ISLAND
PHARMACY............ 130
LOURDES WEST
PASCO PHARMACY *
................................ 100
LOWRY'S
PRESCRIPTIONS *
......................... 113,156
LUKE'S PHARMACY *
................................ 113
LUMMI TRIBAL
HEALTH CENTER .. 161
LYNNWOOD CHC
PHARMACY * ......... 135
MAI LINH PHARMACY*
................................ 128
MALLEYS
COMPOUNDING
PHARMACY * ........... 93
MAPLE LEAF
PHARMACY * ......... 114
MARKS CAMANO
PHARMACY * ......... 102
MARTIN'S
SOUTHGATE DRUG *
................................ 145
MARY BRIDGE RETAIL
CLINIC PHCY * ....... 128
MCQUINN
NATUROPATHIC *.. 133
MEDIART FAMILY
CLINIC * .................. 103
MEDICAL ARTS
ASSOCIATES PS * . 103
MEDICAL CENTER
PHARMACY *
.................. 106,134,144
MEDICAL LAKE OWL
PHARMACY * ......... 139
MEDICAL MALL
PHARMACY * ........... 92
MEDICAL ONCOLOGY
ASSOCIATES PS * . 140
MEDICINE MAN
LIBERTY LAKE *..... 138
MEDICINE SHOPPE
PHARMACY *
.... 100,122,138,140,142
MEGA PHARMACY *
......................... 128,157
MEMORIAL
PHARMACY * ......... 149
MERCURY
PHARMACY
SERVICES .............. 158
MERIDIAN
PHARMACY* .......... 114
METMEDS
PHARMACY* .......... 143
MICHAEL K WOO ND *
................................ 104
MILL CREEK
PHARMACY * ......... 136
MILL PLAIN MEDICAL
AND PHCY * ............. 96
MOLINA
HEALTHCARE*....... 134
MT RAINIER CLINIC
WHOLISTIC *.......... 124
MULTICARE BONNEY
LAKE PHARMACY * 124
166
168
MULTICARE CLINIC
PHARMACY * ......... 128
MULTICARE GIG
HARBOR PHARMACY*
................................ 125
MULTICARE GOOD
SAMARITAN PHCY *
................................ 126
MULTICARE MEDICAL
CENTER PHCY * .... 128
MULTICARE
WESTGATE
PHARMACY * ......... 128
NATURAL HEALTH
AND EDU SVCS * ... 128
NATURAL
HEALTHCARE
NORTHWEST *....... 114
NATURAL OPTIONS
HEALTH CLINIC * ... 121
NATUROPATHIC
MEDICINE * ............ 105
NAVOS * ................. 114
NEIGHBORCARE
HEALTH *................ 114
NEIL'S PHARMACY *
................................ 122
NGUYENS PHARMACY
AND GIFTS *........... 114
NICHOLSON'S
SUMNER................. 127
NISQUALLY TRIBAL
PHARMACY............ 161
NORTH PUBLIC
HEALTH CTR PHCY
................................ 114
NORTH STAR LODGE
PHARMACY * ......... 149
NORTHWEST HEALTH
SYSTEMS *...... 140,158
NORTHWEST KIDNEY
CENTER PHCY * .... 114
NORTHWEST
MEDICATION MGMT
................................ 156
NORTHWEST
PRESCRIPTION * ... 114
NORTHWEST
SPECIALTY
PHARMACY............ 159
NW NATUROPATHY
AND ACUPUNCTURE *
................................ 114
OCEAN PARK
PHARMACY * ......... 123
OCEAN SHORES
PHARMACY * ......... 102
O'HANA WELLNESS
CENTER * ............... 104
OKANOGAN DOUGLAS
HOSPITAL PHCY * . 123
OKANOGAN VALLEY
PHARMACY * ......... 123
OLYMPIC DRUG * .... 96
OLYMPIC PHCY AND
HEALTH CARE *..... 125
OMAK HEALTH
STATION PHARMACY
................................ 161
OMAK PHARMACY *
................................ 123
ONURI PHARMACY *
................................ 106
OPTION CARE ....... 153
OSTROM DRUG AND
GIFT *...................... 107
OTHELLO FAMILY
CLINIC PHARMACY *
.................................. 92
OTTERSENS
PHARMACEUTICAL156
OWL TRI-STATE
PHARMACY * ........... 92
PACIFIC DRUGS *.. 114
PACIFIC MEDICAL
CENTER PHCY ...... 132
PACIFIC NW
SPECIALTY
PHARMACY * ........... 96
PACMED CLINIC
PHARMACY
.................. 108,110,114
PAIN ASSOCIATES OF
WASHINGTON * ..... 110
PARAMOUNT
PHARMACY * ......... 118
PARKLAND
MARKETPLACE
PHARMACY * ......... 128
PARK'S PHARMACY *
................................ 114
PARTNER
ONCOLOGY* .......... 126
PAVILION HOMECARE
PHARMACY............ 158
PAVILION PHARMACY*
................................ 133
PAYLESS DRUG LTC
PHARMACY..... 140,158
PEACE HEALTH
SOUTHWEST PHCY *
.................................. 96
PEACEHEALTH ST
JOHN MED CTR *..... 99
PECKENPAUGH
DRUG* .................... 103
PENINSULA COMM
HTLH SVCS PHCY *
................................ 120
PENINSULA
COMMUNITY HEALTH
SVS *................ 119,120
PHARM A SAVE
MONROE *.............. 137
PHARMACA
INTEGRATIVE
PHARMACY * .. 110,114
PHARMACARE
SPECIALTY PHCY *114
PHARMACY * ......... 127
PHARMACY CARE *
................................ 135
PHARMACY PLUS *104
PHARM-A-SAVE ..... 135
PHARMERICA ........ 158
167
169
PHSW PHARMACY AT
MEDICAL CTR * ....... 96
PHYSICAL
REHABILITATION * 134
PIONEER MED
CENTER PHARMACY *
................................ 101
PLANNED
PARENTHOOD OF
GRT NW PHCY * .... 115
PLATEAU
COMMUNITY
PHARMACY * ......... 105
POMEROY
PHARMACY * .. 100,155
POULSBO
COMPOUNDING
PHARMACY * ......... 120
PREMIER LTC
PHARMACY............ 156
PROPAC PHARMACY*
.................. 107,155,156
PROVIDENCE
CENTRALIA HOSPITAL
................................ 121
PROVIDENCE HEALTH
SERVICES WA * ..... 143
PROVIDENCE HEALTH
SERVICES WA * ..... 158
PROVIDENCE
INFUSION PHCY SVS
................................ 156
PROVIDENCE MILL
CREEK PHCY * ...... 134
PROVIDENCE
MOTHER JOSEPH
CTR, * .............. 144,159
PROVIDENCE
PHARMACY MONROE*
................................ 137
PROVIDENCE ST
MARY PHARMACY *
................................ 145
PROVIDENCO
SACRED PHARMACY *
................................ 140
PROVIDENCO
SACRED PHARMACY *
................................ 158
PUGET PHARMACY
SERVICES .............. 159
PUGET SOUND
PHARMACY * ......... 128
PURDY COST LESS
PRESCRIPTIONS *. 125
PURITY INTEGRATIVE
HEALTH CTR * ....... 136
PUYALLUP TRIBAL
HEALTH .................. 161
QFC PHARMACY *
95,96,102,104,105,107110,115,122,133,134,
137,143
QOL MEDS ............. 155
QUE ARESTE ND *. 115
RAINIER SCHOOL.. 157
RALPH'S THRIFTWAY
PHARMACY * ......... 144
RANKOS STADIUM
PHARMACY * ......... 128
RAYS PHARMACY *
................................ 130
READY MEDS
PHARMACY * ......... 110
RELIANT RX ........... 158
REPUBLIC DRUG
STORE.................... 100
RITE AID *......93-95,97107,109111,115,118-128,130138,140,142-149
RITZVILLE DRUG *... 92
RIVER VILLAGE
PHARMACY............ 159
RIVERPOINT
PHARMACY * ......... 140
RIVERSTONE FAMILY
HEALTH PHCY *..... 140
ROGER SAUX HEALTH
CENTER ................. 161
ROSAUERS
PHARMACY *
.................. 140,141,149
ROY'S HEALTH MART
PHARMACY * ......... 123
RUMED ................... 129
RXPRESS
PHARMACY* .......... 124
RXTRA CARE PHCY
VIEW RIDGE * ........ 115
SAAR'S
MARKETPLACE ..... 102
SAFEWAY
PHARMACY, *93-95,97111,115,116,118123,125-127,129139,141-149
SAGENS PHARMACY *
................................ 123
SAM'S CLUB *
.................. 103,111,116
SAVON PHARMACY *
.................................. 92
SEA MAR CHC
PHARMACY..... 116,131
SEA MAR COMMUNITY
HEALTH CTRS * ..... 144
SEATTLE CANCER
CARE ALLIANCE *.. 116
SEATTLE CHILDRENS
HOSPITAL * ............ 104
SEATTLE CHILDREN'S
PHARMACY * ......... 116
SEATTLE INDIAN
HEALTH BOARD .... 161
SEATTLEMEDS
PHARMACY * ......... 116
SEEBER'S HEALTH
MART *.................... 123
SELAH SAVE ON
FOODS PHARMACY *
................................ 148
SEVAN PHARMACY *
................................ 134
SHIRAZ SPECIALTY
PHARMACY............ 158
168
170
SHIRAZ SPECIALTY
PHARMACY * ......... 134
SHOPKO PHARMACY*
93,101,141,144,145,147
-149
SHORELINE NATURAL
MEDICINE * ............ 118
SID'S LTC PHARMACY
................................ 159
SID'S PHARMACY * 147
SIMON WELLNESS *
................................ 116
SIXTH AVE MEDICAL
PHARMACY * ......... 141
SKAGIT REGIONAL
CLINICS PHCY *..... 131
SKAGIT VALLEY HOSP
PHARMACY * ......... 131
SKAGIT VALLEY
HOSPITAL OP PHCY *
................................ 131
SMOKEY POINT
PHARMACY * ......... 132
SNOQUALMIE
VILLAGE PHARMACY*
................................ 118
SOPHIA TRETTEVICK
INDIAN HLTH.......... 161
SOUND HOLISTIC
HEALTH *................ 134
SOUTH BEND
PHARMACY * ......... 123
SOUTH PARK
PHARMACY * ......... 120
SOUTHGATE
PHARMACY * ......... 101
SPOKANE FALLS
FAMILY CLIN PHCY *
................................ 141
SRC RIVERBEND
PHARMACY * ......... 131
ST JOHN PHARMACY*
................................ 148
STATE OF WA
VETERANS HOME . 157
SULTAN PHARMACY
AND NAT CARE * ... 138
SUMAS DRUG * ..... 147
SUNSET PLAZA
PHARMACY * ......... 111
SUPER ONE
PHARMACY * .. 121,143
SURECARE RX 155,156
SWANSON OWL
PHARMACY * ......... 101
SWEDISH FIRST HILL
PHARMACY * ......... 117
SWEDISH ISSAQUAH
RETAIL PHCY * ...... 107
SWEDISH
ORTHOPEDIC INST
PHCY *.................... 117
SWEDISH PHARMACY
CHERRY HILL * ...... 117
TACOMA MEDICAL
CENTER PHARMACY *
................................ 129
TALLMANS
PHARMACY * ......... 145
TARGET PHARMACY *
................ 93,97,99,106108,110,111,117,118,
121,124-127,129,134136,141,144,147
TCCH PHARMACY *
................................ 100
TEKOA PHARMACY *
................................ 148
TERRACE VILLAGE
HM PHARMACY * ... 149
THE COMPOUNDING
APOTHECARY * ..... 133
THE FALLS PHCY
UNITED DRUGS *... 118
THE NATURAL PATH
TO HEALING * ........ 118
THE PRESCRIPTION
PAD PHARMACY * . 111
THE VANCOUVER
CLINIC PHCY * ......... 97
THREE MOON CLINIC*
................................ 105
THRIFTY PAYLESS
INC *........................ 147
TICK KLOCK DRUGS *
................................ 147
TIETON VILLAGE
DRUG * ................... 149
TIM'S PHARMACY * 145
TOP FOOD & DRUG *
................................ 127
TOP FOOD AND
DRUG*
... 103,108,118,119,129,
133,137,144
TRADING COMPANY
PHARMACY * ......... 142
TREE OF HEALTH
INTEGRATIVE *...... 119
TRI-AREA
PHARMACY* .......... 102
TULALIP PHARMACY
................................ 161
TWIN HARBOR DRUG*
................................ 102
ULRICH VALLEY
HEALTH MART PHCY
................................ 123
UNION CENTER
PHARMACY * ......... 117
UNITED CARE
PHARMACY* ... 108,156
UWMC AMBULATORY
PHARMACY * ......... 117
VALLEY DRUG *..... 147
VALLEY HEALTH
MART DRUG * ........ 143
VALLEY MISSION
HOMECARE PHCY *
................................ 142
VALU DRUG *......... 155
VANCOUVER CLINIC
PHARMACY * ........... 97
VASHON PHARMACY
................................ 118
169
171
VILLAGE PHARMACY*
.................................. 94
VISTA ONCOLOGY *
................................ 144
VITAL
THERAPEUTICS* ... 117
WALGREENS *........ 9395,97-109,111,117122,124,125,127,129137,139,141-149
WAL-MART *..92-95,98106,111,120,122125,127,129,131,132,
134,136,138,142145,147-149
WASEM'S DRUG *
........................... 92,155
WASHINGTON CTR
FOR PAIN MGMT * . 104
WASHINGTON
HEMATOLOGY
ONCOLOGY * ......... 150
WELL LIFE LATAH
PHARMACY * ......... 142
WELL LIFE LIBERTY
LAKE *..................... 139
WENATCHEE CLINIC
PHARMACY * ........... 94
WESTERN STATE
HOSP PHARMACY. 157
WFHC PHARMACY 101
WHITE CENTER
PHARMACY * ......... 117
WIND RIVER
PHARMACY * ......... 131
WINSLOW DRUG *. 119
WOODINVILLE MED
CTR PHCY * ........... 119
WRAY'S CHALET
THRIFTWAY *......... 150
WSU HEALTH AND
WELLNESS SVC * .. 148
YAKAMA INDIAN HLTH
CTR PHCY.............. 162
YAKIMA
NEIGHBORHOOD
HEALTH *................ 148
YAKIMA
NEIGHBORHOOD
PHARMACY * ......... 150
YAKIMA VALLEY FARM
WKRS CLINIC * ...... 150
YAKIMA VALLEY
SCHOOL ................. 159
YAKIMA VALLY FARM
WORKERS * ........... 148
YAKIMA VLY FARM
WRKRS CLINIC *.... 148
YAKIMA VLY
MEMORIAL HOSP
PHCY ...................... 159
YAUGER PARK
PHARMACY * ......... 144
YOKES * ................... 93
YOKES PHARMACY *
93,94,100,138,139,142,
143
170
172
Community Health Plan of Washington is a Coordinated Care Plan with a Medicare
Advantage contract. Enrollment in Community Health Plan of Washington depends
on contract renewal.
173
Offered by
Prospective Members: 1-800-944-1247 • Current Members: 1-800-942-0247
(TTY Relay: Dial 7-1-1) • 8:00 a.m. to 8:00 p.m., 7 days a week
720 Olive Way, Suite 300 • Seattle, WA 98101-1830
www.healthfirst.chpw.org

2015 Prescription Drug Formular and Network Pharmacies

Transcription

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