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REFILL BY MAIL – RETAIL EXCEPTION DRUG LIST
The medications listed below are exempt from the Refill By Mail
restriction that requires members to receive refills from the mail
service pharmacy after a limited number of fills at a retail location.
Members may participate in low-cost generic and other retail
programs for the drugs included on this list.

GENERIC MEDICATIONS
camila tab 0.35mg
eltroxin tab 0.125mg
junel 1/20 tab
accupril tab 10mg
cardura tab 4mg
eltroxin tab 0.137mg
k-dur tab 10meq CR
accupril tab 20mg
carozide tab 50mg
eltroxin tab 0.15mg
k-dur tab 20meq CR
accupril tab 40mg
carvedilol tab 12.5mg
eltroxin tab 0.175mg
labetalol tab 200mg
achromycin V cap 500mg
carvedilol tab 25mg
eltroxin tab 0.1mg
lamisil tab 250mg
acid control tab 150mg
carvedilol tab 3.125mg
eltroxin tab 0.2mg
levlen tab
acyclovir tab 400mg
carvedilol tab 6.25mg
enalapril tab 10mg
lisinop/HCTZ tab 10-12.5
airet NEB 0.083%
catapres tab 0.1mg
enalapril tab 20mg
lisinop/HCTZ tab 20-12.5
aldactone tab 100mg
catapres tab 0.2mg
enalapril tab 5mg
lisinop/HCTZ tab 20-25mg
aldactone tab 25mg
celexa tab 10mg
enpresse-28 tab
lisinopril tab 10mg
aldactone tab 50mg
celexa tab 20mg
esidrix tab 25mg
lisinopril tab 2.5mg
alendronate tab 70mg
celexa tab 40mg
eskalith cap 300mg
lisinopril tab 20mg
alesse tab -21
chlorhex glu sol 0.12%
estrace tab 0.5mg
lisinopril tab 30mg
allantex tab
cobal-1000 inj 1000mcg
estrace tab 1mg
lisinopril tab 40mg
allopurinol tab 100mg
colchicine tab 0.6mg
estrace tab 2mg
lisinopril tab 5mg
allopurinol tab 300mg
compazine tab 10mg
feldene cap 20mg
lovastatin tab 20mg
amaryl tab 2mg
corgard tab 40mg
fluoxetine cap 10mg
lovastatin tab 40mg
amaryl tab 4mg
coumadin tab 1mg
fluoxetine cap 20mg
meloxicam tab 15mg
ambien tab 10mg
coumadin tab 2.5mg
fluoxetine cap 40mg
meloxicam tab 7.5mg
ambien tab 5mg
coumadin tab 2mg
fluoxetine tab 10mg
methocarbam tab 750mg
amen tab 10mg
coumadin tab 4mg
folic acid tab 1000mcg
meticorten tab 1mg
amiodarone tab 200mg
coumadin tab 5mg
furosemide tab 20mg
metoclopram tab 10mg
amitriptylin tab 10mg
covaryx HS tab
furosemide tab 40mg
metoclopram tab 5mg
amitriptylin tab 25mg
cryselle-28 tab 28 tabs
furosemide tab 80mg
mirtazapine tab 15mg
amitriptylin tab 50mg
cyclobenzapr tab 10mg
gabapentin cap 100mg
mononessa tab
amlodipine tab 10mg
daypro tab 600mg
genora tab 1/35-21
m-vit tab 27-1mg
amlodipine tab 2.5mg
deltasone tab 10mg
gildess FE tab 1.5/30
naprosyn tab 375mg
amlodipine tab 5mg
deltasone tab 20mg
gildess FE tab 1/20
naprosyn tab 500mg
anaprox ds tab 550mg
deltasone tab 5mg
glipizide tab 10mg
necon 7/7/7 tab 28 day
demulen tab 1/35-21
glipizide tab 5mg
nitroglycer sub 0.4mg
aricin CRE 0.1%
depo-provera inj
glipizide ER tab 10mg
nolvadex tab 20mg
atenol/chlor tab 50-25mg
150mg/ml
glipizide ER tab 5mg
ortho tri- tab cyclen
atenolol tab 100mg
desyrel tab 100mg
glucophage tab 1000mg
paroxetine tab 10mg
atenolol tab 25mg
desyrel tab 150mg
glucophage tab 500mg
paroxetine tab 20mg
atenolol tab 50mg
desyrel tab 50mg
glucophage tab 850mg
paroxetine tab 30mg
atretol tab 200mg
diabeta tab 2.5mg
glucophage tab XR 500mg
paroxetine tab 40mg
aventyl cap 25mg
diabeta tab 5mg
glucophage tab XR 750mg
pravachol tab 20mg
baclofen tab 10mg
diclofenac tab 75mg DR
glucovance tab 2.5-500
pravachol tab 40mg
bactrim DS tab 800-160
digitek tab 0.125mg
glucovance tab 5-500mg
pravachol tab 80mg
benazep/HCTZ tab 20-12.5
digitek tab 0.25mg
HCTZ/triamt tab 25-37.5
ranitidine tab 300mg
benazepril tab 10mg
ditropan tab 5mg
HCTZ/triamt tab 50-75mg
sertraline tab 100mg
benazepril tab 20mg
doxy cap 100mg
hydrochlorot cap 12.5mg
sertraline tab 25mg
benazepril tab 40mg
doxy tab 100mg
hytrin cap 5mg
sertraline tab 50mg
bentyl cap 10mg
doxycycline tab 20mg
ib pro tab 600mg
simvastatin tab 10mg
bentyl tab 20mg
dyazide cap 37.5-25
ib pro tab 800mg
simvastatin tab 20mg
bisoprl/HCTZ tab 10/6.25
ed k+10 tab 10meq CR
imdur tab 30mg ER
simvastatin tab 40mg
bisoprl/HCTZ tab 5/6.25mg
eltroxin tab 0.025mg
imdur tab 60mg ER
simvastatin tab 80mg
buspar tab 10mg
eltroxin tab 0.05mg
inderal tab 10mg
tizanidine tab 4mg
buspar tab 15mg
eltroxin tab 0.075mg
inderal tab 20mg
tramadol HCL tab 50mg
calan SR tab 180mg
eltroxin tab 0.088mg
indocin cap 25mg
calan SR tab 240mg
eltroxin tab 0.112mg
indocin cap 50mg
CLINICAL EXCLUSION
Chlordiazepoxide-Amitriptyline
Ephedrine Pow HCL
Invega Tab 9mg
DRUG LIST
Cap 5-12.5 mg
Ephedrine Pow Sulfate
Ipratropium/ Sol Albuter
Abilify INJ 9.75mg
Chlordiazepoxide-Amitriptyline
Ephedrine Tab 25mg
Isoproteren Pow Sulfate
Abilify SOL 1mg/ml
Tab 10-25 mg
Ephedrine SU Cap 25mg
Isuprel Inj 0.2mg/ml
Abilify Tab 10mg
Chlordiazepoxide-Amitriptyline
Epinephrine Inj 0.1mg/ml
Jantoven Tab 10mg
Abilify Tab 15mg
Tab 5-12.5 mg
Equetro Cap 100mg
Lexapro SOL 5mg/5ml
Abilify Tab 20mg
Chlordiazepoxide-Desipramine
Equetro Cap 200mg
Lexapro Tab 10mg
Abilify Tab 2mg
Tab 10-40 mg
Equetro Cap 300mg
Lexapro Tab 20mg
Abilify Tab 30mg
Chlorpromaz INJ 25mg/ml
Eskalith CR Tab 450mg
Lexapro Tab 5mg
Abilify Tab 5mg
Chlorpromaz POW
Exjade Tab 125mg
Lithium Carb Cap 150mg
Abilify Disc Tab 10mg
Chlorpromaz Tab 100mg
Exjade Tab 250mg
Lithium Carb Cap 300mg
Abilify Disc Tab 15mg
Chlorpromaz Tab 10mg
Exjade Tab 500mg
Lithium Carb Cap 600mg
Accuneb Neb 0.63mg/3
Chlorpromaz Tab 200mg
Fazaclo Tab 100mg
Lithium Carb POW
Adrenalin INJ 1mg/ml
Chlorpromaz Tab 25mg
Fazaclo Tab 12.5mg
Lithium Carb Tab 300mg
Advair Disku MIS 100/50
Chlorpromaz Tab 50mg
Fazaclo Tab 25mg
Lithium Carb Tab 300mg ER
Advair Disku MIS 250/50
Clenbuterol Pow HCL
Fluoxetine Cap 10mg
Lithium Citr Sol 8MEQ/5ml
Advair Disku MIS 500/50
Clomipramine Cap 50mg
Fluoxetine Cap 20mg
Lithium Citr SYP 8MEQ/5ml
Advair HFA AER 115/21
Clozapine Tab 100mg
Fluoxetine Liq 20mg/5ml
Loxapine Cap 10mg
Advair HFA AER 230/21
Clozapine Tab 12.5
Fluoxetine Tab 10mg
Loxapine Cap 10mg
Advair HFA AER 45/21
Clozapine Tab 200mg
Fluoxetine Tab 20mg
Loxapine Cap 25mg
Airet Neb 0.083%
Clozapine Tab 50mg
Fluoxetine HCl (PMDD) Cap 10 mg
Loxapine Cap 25mg
Albuterol Aer 90MCG
Clozaril Tab 25mg
Fluoxetine HCl (PMDD) Cap 20 mg
Loxapine Cap 50mg
Albuterol Neb 1.25mg/3
Combivent Aer
Fluoxetine HCl (PMDD) Tab 10 mg
Loxapine Cap 50mg
Albuterol Pow
Compro Sup 25mg
Fluoxetine HCl (PMDD) Tab 15 mg
Loxapine Cap 5mg
Albuterol Pow Sulfate
Coumadin Inj 5 mg
Fluoxetine HCl (PMDD) Tab 20 mg
Loxapine Cap 5mg
Albuterol Syp 2mg/5ml
Coumadin Tab 1mg
Fluphenazine Con 5mg/ml
Ludiomil Tab 25mg
Albuterol Tab 2mg
Coumadin Tab 2.5mg
Fluphenazine Elx 2.5/5ml
Luvox CR Cap 100mg
Albuterol Tab 4mg
Coumadin Tab 3mg
Fluphenazine Inj 2.5mg/ml
Luvox CR Cap 150mg
Albuterol Tab 8mg ER
Coumadin Tab 5mg
Fluphenazine Tab 10mg
Maprotiline Tab 50mg
Alupent Tab 10mg
Coumadin Tab 7.5mg
Fluphenazine Tab 1mg
Maprotiline Tab 75mg
Alupent Tab 20mg
Cymbalta Cap 20mg
Fluphenazine Tab 2.5mg
Marplan Tab 10mg
Alupent Inh Aer .65/Act
Cymbalta Cap 30mg
Fluphenazine Tab 5mg
Maxair Autoh Aer 200MCG
Amitriptylin Pow
Cymbalta Cap 60mg
Fluphenazine-Nortriptyline
Mellaril-S Sus 25mg/5ml
Amitriptylin Tab 100mg
Desipramine Pow
Tab 0.5-10 mg
Metaproteren Neb 0.4%
Amitriptylin Tab 10mg
Desipramine Tab 100mg
Fluphenazine-Nortriptyline
Metaproteren Neb 0.6%
Amitriptylin Tab 150mg
Desipramine Tab 10mg
Tab 1.5-30 mg
Metaproteren Pow Sulfate
Amitriptylin Tab 50mg
Desipramine Tab 150mg
Fluvoxamine Tab 100mg
Metaproteren SYP 10mg/5ml
Amitriptylin Tab 75mg
Desipramine Tab 25mg
Fluvoxamine Tab 25mg
Micronefrin NEB 2.25%
Amoxapine Tab 100mg
Desipramine Tab 50mg
Fluvoxamine Tab 50mg
Mirtazapine Tab 15mg
Amoxapine Tab 150mg
Desipramine Tab 75mg
Foradil Cap AEROLIZE
Mirtazapine Tab 15mg ODT
Amoxapine Tab 25mg
Desyrel Tab 100mg
Geodon Cap 40mg
Mirtazapine Tab 30mg
Amoxapine Tab 50mg
Desyrel Tab 150mg
Geodon Cap 60mg
Mirtazapine Tab 30mg ODT
Anafranil Cap 75mg
Desyrel Tab 300mg
Geodon Cap 80mg
Mirtazapine Tab 7.5mg
Aplenzin Tab 522mg
Desyrel Tab 50mg
Geodon Inj 20mg
Moban Tab 10mg
Aventyl Cap 10mg
Doxepin HCL Cap 100mg
Haldol Con 2mg/ml
Moban Tab 25mg
Brethine Tab 2.5mg
Doxepin HCL Cap 10mg
Haldol Tab 0.5mg
Moban Tab 50mg
Brethine Tab 5mg
Doxepin HCL Cap 150mg
Haldol Tab 10mg
Moban Tab 5mg
Bronchial Aer 0.22mg/A
Doxepin HCL Cap 25mg
Haldol Tab 1mg
Navane Cap 10mg
Bronkometer Aer 0.61%
Doxepin HCL Cap 50mg
Haldol Tab 20mg
Navane Cap 20mg
Bronkosol Neb 1%
Doxepin HCL Cap 75mg
Haldol Tab 5mg
Navane Cap 2mg
Budeprion Tab 100mg SR
Doxepin HCL CON 10mg/ml
Haldol Decan Inj 100mg/ml
Navane Cap 5mg
Budeprion Tab 150mg SR
Doxepin HCL POW
Haldol Decan Inj 50mg/ml
Nefazodone Tab 100mg
Budeprion XL Tab 150mg
Duo-Medihal Aer Kit Inh
Haloperidol Pow
Nefazodone Tab 150mg
Budeprion XL Tab 300mg
Effexor Tab 100mg
Haloperidol Tab 0.5mg
Nefazodone Tab 200mg
Bupropion Tab 100mg
Effexor Tab 25mg
Haloperidol Tab 2mg
Nefazodone Tab 250mg
Bupropion Tab 200mg SR
Effexor Tab 37.5mg
Imipram HCL Tab 10mg
Nefazodone Tab 50mg
Bupropion Tab 75mg
Effexor Tab 50mg
Imipram HCL Tab 25mg
Nortriptylin Cap 50mg
CA-DTPA Sol 1000mg
Effexor Tab 75mg
Imipram HCL Tab 50mg
Nortriptylin Pow HCL
Celexa Sol 10mg/5ml
Effexor XR Cap 150mg
Imipram Pam Cap 100mg
Nortriptylin Sol 10mg/5ml
Celexa Tab 10mg
Effexor XR Cap 37.5mg
Imipram Pam Cap 125mg
Olanzapine-Fluoxetine HCl
Celexa Tab 20mg
Effexor XR Cap 75mg
Imipram Pam Cap 150mg
Cap 12-25 mg
Celexa Tab 40mg
Elavil Tab 25mg
Imipram Pam Cap 75mg
Olanzapine-Fluoxetine HCl
Chemet Cap 100mg
Emsam Dis 12mg/24H
Imipramine POW
Cap 12-50 mg
Chlordiazepoxide-Amitriptyline
Emsam Dis 6mg/24HR
Invega Tab 3mg
Olanzapine-Fluoxetine HCl
Cap 10-25 mg
Emsam Dis 9mg/24HR
Invega Tab 6mg
Cap 3-25 mg
Olanzapine-Fluoxetine HCl
Risperdal Tab 0.5mg
Warfarin Tab 4mg
Chlordiazepoxide-Amitriptyline
Cap 6-25 mg
Risperdal Tab 1mg
Warfarin Tab 6mg
Tab 10-25 mg
Olanzapine-Fluoxetine HCl
Risperdal Tab 2mg
Xopenex Neb 0.31mg
Chlordiazepoxide-Amitriptyline
Cap 6-50 mg
Risperdal Tab 3mg
Xopenex Neb 0.63mg
Tab 5-12.5 mg
Pamelor Cap 25mg
Risperdal Tab 4mg
Xopenex Neb 1.25/3ml
Clonazepam Orally
Pamelor Cap 75mg
Risperdal M Tab 0.5mg
Xopenex Conc Neb 1.25/0.5
Disintegrating Tab 0.125 mg
Parnate Tab 10mg
Risperdal M Tab 1mg
Xopenex HFA Aer
Clonazepam Orally
Paroxetin ER Tab 37.5mg
Risperdal M Tab 2mg
Zyprexa Inj 10mg
Disintegrating Tab 0.25 mg
Paroxetine SUS 10mg/5ml
Risperdal M Tab 3mg
Zyprexa Tab 10mg
Clonazepam Orally
Paroxetine Tab 10mg
Risperdal M Tab 4mg
Zyprexa Tab 15mg
Disintegrating Tab 0.5 mg
Paroxetine Tab 20mg
Serevent DIS Aer 50MCG
Zyprexa Tab 2.5mg
Clonazepam Orally
Paroxetine Tab 25mg ER
Seroquel Tab 100mg
Zyprexa Tab 20mg
Disintegrating Tab 1 mg
Paxil Tab 30mg
Seroquel Tab 200mg
Zyprexa Tab 5mg
Clonazepam Orally
Paxil Tab 40mg
Seroquel Tab 25mg
Zyprexa Tab 7.5mg
Disintegrating Tab 2 mg
Paxil CR Tab 12.5mg
Seroquel Tab 300mg
Zyprexa ZYDI Tab 10mg
Clonazepam Tab 0.5 mg
Perforomist Neb 20MCG
Seroquel Tab 400mg
Zyprexa ZYDI Tab 15mg
Clonazepam Tab 1 mg
Perphenazine Con 16mg/5ml
Seroquel Tab 50mg
Zyprexa ZYDI Tab 20mg
Clonazepam Tab 2 mg
Perphenazine Tab 16mg
Seroquel XR Tab 150mg
Zyprexa ZYDI Tab 5mg
Dexmethylphenidate HCL Cap
Perphenazine Tab 2mg
Seroquel XR Tab 200mg
SR 24 HR 10 mg
Perphenazine Tab 4mg
Seroquel XR Tab 300mg
CONTROLLED SUBSTANCES
Dexmethylphenidate HCL Cap
Perphenazine Tab 8mg
Seroquel XR Tab 400mg
Modafinil Tab 100 mg &
SR 24 HR 15 mg
Perphenazine-Amitriptyline
Seroquel XR Tab 50mg
Dietary Management Cap
Dexmethylphenidate HCL Cap
Tab 2-10 mg
Sertraline Tab 100mg
Pack Modafinil Tab 100 mg
SR 24 HR 20 mg
Perphenazine-Amitriptyline
Sertraline Tab 25mg
Amphetamine-
Dexmethylphenidate HCL Cap
Tab 2-25 mg
Sertraline Tab 50mg
Dextroamphetamine Cap SR
SR 24 HR 5 mg
Perphenazine-Amitriptyline
Sparine Tab 25mg
24HR 10 mg
Dexmethylphenidate HCL
Tab 3-15 mg
Sparine Tab 50mg
Amphetamine-
Perphenazine-Amitriptyline
Surmontil Cap 100mg
Dextroamphetamine Cap SR
Dexmethylphenidate HCL
Tab 4-10 mg
Surmontil Cap 25mg
24HR 15 mg
Tab 2.5 mg
Perphenazine-Amitriptyline
Sus-Phrine Inj 5mg/ml
Amphetamine-
Dexmethylphenidate HCL
Tab 4-25 mg
Symbicort Aer 160-4.5
Dextroamphetamine Cap SR
Perphenazine-Amitriptyline
Symbicort Aer 80-4.5
24HR 20 mg
Dextroamphetamine Sulfate
Tab 4-50 mg
Terbutaline Inj 1mg/ml
Amphetamine-
Cap SR 24HR 10 mg
Perphenazine-Nortriptyline
Terbutaline Pow Sulfate
Dextroamphetamine Cap SR
Dextroamphetamine Sulfate
Tab 2-10 mg
Thioridazine Tab 100mg
24HR 25 mg
Cap SR 24HR 15 mg
Perphenazine-Nortriptyline
Thioridazine Tab 10mg
Amphetamine-
Dextroamphetamine Sulfate
Tab 2-20 mg
Thioridazine Tab 150mg
Dextroamphetamine Cap SR
Cap SR 24HR 5 mg
Perphenazine-Nortriptyline
Thioridazine Tab 15mg
24HR 30 mg
Dextroamphetamine Sulfate
Tab 2-40 mg
Thioridazine Tab 200mg
Amphetamine-
Oral Solution 5 mg/5ml
Pexeva Tab 10mg
Thioridazine Tab 25mg
Dextroamphetamine Cap SR
Dextroamphetamine Sulfate
Pexeva Tab 20mg
Thioridazine Tab 50mg
Pexeva Tab 30mg
Thiothixene Cap 1mg
Amphetamine-
Dextroamphetamine Sulfate
Pexeva Tab 40mg
Thorazine Con 100mg/ml
Dextroamphetamine
Pristiq Tab 100mg
Thorazine Con 30mg/ml
Fluoxymesterone Tab 10 mg
Pristiq Tab 50mg
Thorazine Sup 100mg
Amphetamine-
Lacosamide Tab 100 mg
Proair HFA Aer
Tofranil Inj 25mg/2ml
Dextroamphetamine
Lacosamide Tab 150 mg
Prochlorper Inj 5mg/ml
Tofranil-PM Cap 125mg
Tab 12.5 mg
Lacosamide Tab 200 mg
Prochlorper Pow Maleate
Trazodone Pow
Amphetamine-
Lacosamide Tab 50 mg
Prochlorper SUP 2.5mg
Trifluoperaz Pow
Dextroamphetamine
Lisdexamfetamine Dimesylate
Prochlorper SUP 5mg
Trifluoperaz Tab 10mg
Prochlorper Tab 10mg
Trifluoperaz Tab 1mg
Amphetamine-
Lisdexamfetamine Dimesylate
Prochlorper Tab 5mg
Trifluoperaz Tab 2mg
Dextroamphetamine
Protriptylin Tab 5mg
Trifluoperaz Tab 5mg
Lisdexamfetamine Dimesylate
Proventil NEB 0.5%
Trimipramine Cap 50mg
Amphetamine-
Proventil RE Tab 4mg ER
Trimipramine Pow Maleate
Dextroamphetamine
Lisdexamfetamine Dimesylate
Prozac Cap 40mg
Venlafaxine Tab 100mg
Prozac WeekL Cap 90mg
Venlafaxine Tab 150mg ER
Amphetamine-
Lisdexamfetamine Dimesylate
Remeron Tab 45mg
Venlafaxine Tab 225mg ER
Dextroamphetamine
Remeron Sltb Tab 45mg
Venlafaxine Tab 37.5 ER
Lisdexamfetamine Dimesylate
Risperdal Inj 12.5mg
Venlafaxine Tab 50mg
Amphetamine-
Risperdal Inj 25mg
Venlafaxine Tab 75mg
Dextroamphetamine
Medroxprogestrone Acetate
Risperdal Inj 37.5mg
Venlafaxine Tab 75mg ER
Tab 7.5 mg
Risperdal Inj 50mg
Vivactil Tab 10mg
Armodafinil Tab 150 mg
Mephobarbital Tab 100 mg
Risperdal Sol 1mg/ml
Warfarin Pow Sodium
Armodafinil Tab 250 mg
Mephobarbital Tab 32 mg
Risperdal Tab 0.25mg
Warfarin Tab 2mg
Armodafinil Tab 50 mg
Mephobarbital Tab 50 mg
Methamphetamine HCL
Methylphenidate HCL
LIMITED DISTRIBUTION
Tab SA OSM 54 mg
DRUG LIST
Methylphenidate HCL
Methylphenidate TD Patch
Actimmune INJ 2MU/0.5
Cap CR 10 mg
10 mg/9HR
Exjade Tab 125mg
Methylphenidate HCL
Methylphenidate TD Patch
Exjade Tab 250mg
Cap CR 20 mg
15 mg/9HR
Exjade Tab 500mg
Methylphenidate HCL
Methylphenidate TD Patch
Orfadin Cap 10mg
Cap CR 30 mg
20 mg/9HR
Orfadin Cap 2mg
Methylphenidate HCL
Methylphenidate TD Patch
Orfadin Cap 5mg
Cap CR 40 mg
30 mg/9HR
Tracleer Tab 125mg
Methylphenidate HCL
Methyltestosterone Cap 10 mg
Tracleer Tab 62.5mg
Cap CR 50 mg
Methyltestosterone Oral
Ventavis SOL 10MCG/ml
Methylphenidate HCL
Zavesca Cap 100mg
Cap CR 60 mg
Modafinil Tab 100 mg
Methylphenidate HCL
Modafinil Tab 200 mg
Cap SR 24HR 10 mg
Pemoline Tab 18.75 mg
Methylphenidate HCL
Pemoline Tab 37.5 mg
Cap SR 24HR 20 mg
Pemoline Tab 75 mg
Methylphenidate HCL
Phenobarbital Elixir
Cap SR 24HR 30 mg
20 mg/5ml
Methylphenidate HCL
Phenobarbital Tab 100 mg
Cap SR 24HR 40 mg
Phenobarbital Tab 15 mg
Methylphenidate HCL Chew
Phenobarbital Tab 16.2 mg
Phenobarbital Tab 30 mg
Methylphenidate HCL Chew
Phenobarbital Tab 32.4 mg
Tab 2.5 mg
Phenobarbital Tab 60 mg
Methylphenidate HCL Chew
Phenobarbital Tab 64.8 mg
Phenobarbital Tab 97.2 mg
Methylphenidate HCL Soln
Pregabalin Cap 100 mg
10 mg/5ml
Pregabalin Cap 150 mg
Methylphenidate HCL Soln
Pregabalin Cap 200 mg
Pregabalin Cap 225 mg
Methylphenidate HCL Tab
Pregabalin Cap 25 mg
PREGABALIN Cap 300 mg
Methylphenidate HCL
Pregabalin Cap 50 mg
Pregabalin Cap 75 mg
Methylphenidate HCL
Testosterone Buccal
Mucoadhesive System 30 mg
Methylphenidate HCL
Testosterone Propionate TD
Tab CR 10 mg
Methylphenidate HCL
Testosterone Propionate TD
Tab CR 20 mg
Ointment 2%
Methylphenidate HCL
Testosterone TD Gel 1%
Tab SA OSM 18 mg
Testosterone TD Patch 24HR
Methylphenidate HCL
2.5 mg/24HR
Tab SA OSM 27 mg
Testosterone TD Patch 24HR
Methylphenidate HCL
5 mg/24HR
Tab SA OSM 36 mg
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a
registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.

12422CAMEN | 012010

Source: http://cpi.pswbenefits.net/Portals/10/Anthem-HMO/Anthem%20Refill%20by%20Mail%20Retail%20Exception%20List.pdf

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