lamotrigine LaMICtal Starter KIT 25 (42)-100 (7) 1 NF Formulary Update starter kit 100 MG Oral mg / 25 mg, 1 lamotrigine LaMICtal Starter KIT 25 (84)-100(14) 1 NF Formulary Update starter kit 100 MG Oral mg / 25 mg, 1 Methotrexate Sodium (PF) SOLUTION 1 + BD NF CMS Required Deletion N/A 1 GM/40ML Injection Mili Tablet 0.25-35 MG-MCG Oral NF 1 Formulary Enhancement N/A Norvir Packet 100 MG Oral NF 1 Formulary Enhancement N/A ritonavir 100 Norvir Tablet 100 MG Oral 1 NF Formulary Update mg, 1 Ozempic Solution Pen-injector 0.25 or NF 1 Formulary Enhancement N/A 0.5 MG/DOSE Subcutaneous Ozempic Solution Pen-injector 1 NF 1 Formulary Enhancement N/A MG/DOSE Subcutaneous Symfi Tablet 600-300-300 MG Oral NF 1 + QL 30 Formulary Enhancement N/A Synjardy XR Tablet Extended Release NF 1 Formulary Enhancement N/A 24 Hour 10-1000 MG Oral Synjardy XR Tablet Extended Release NF 1 Formulary Enhancement N/A 24 Hour 12.5-1000 MG Oral Synjardy XR Tablet Extended Release NF 1 Formulary Enhancement N/A 24 Hour 25-1000 MG Oral Synjardy XR Tablet Extended Release NF 1 Formulary Enhancement N/A 24 Hour 5-1000 MG Oral Triamterene-HCTZ CAPSULE 50-25 1 NF CMS Required Deletion N/A MG Oral Tri-Mili Tablet 0.18/0.215/0.25 MG-35 NF 1 Formulary Enhancement N/A MCG Oral
LaMICtal Starter KIT 25 (42)-100 (7) MG Oral 1 NF Formulary Update lamotrigine starter kit 100 mg / 25 mg, 1 LaMICtal Starter KIT 25 (84)-100(14) MG Oral 1 NF Formulary Update lamotrigine starter kit 100 mg / 25 mg, 1 Methotrexate Sodium (PF) SOLUTION 1 GM/40ML Injection 1 + BD NF CMS Required Deletion N/A Mili Tablet 0.25-35 MG-MCG Oral NF 1 Formulary Enhancement N/A Norvir Packet 100 MG Oral NF 1 Formulary Enhancement N/A Norvir Tablet 100 MG Oral 1 NF Formulary Update ritonavir 100 mg, 1 Ozempic Solution Pen-injector 0.25 or 0.5 MG/DOSE Subcutaneous NF 1 Formulary Enhancement N/A Ozempic Solution Pen-injector 1 MG/DOSE Subcutaneous NF 1 Formulary Enhancement N/A Symfi Tablet 600-300-300 MG Oral NF 1 + QL 30 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 10-1000 MG Oral NF 1 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 12.5-1000 MG Oral NF 1 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 25-1000 MG Oral NF 1 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 5-1000 MG Oral NF 1 Formulary Enhancement N/A Triamterene-HCTZ CAPSULE 50-25 MG Oral 1 NF CMS Required Deletion N/A Tri-Mili Tablet 0.18/0.215/0.25 MG-35 MCG Oral NF 1 Formulary Enhancement N/A
AgeWell_1-Tier_2018_Addendum_Eff_090120181.docx