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抗糖尿病层1- acarbose tab（previv）β阻滞剂1- acebutolol cap（Acebutolol Cap（e e e epiv）镇痛药 - 阿片类药物2 QL乙酰氨基酚/咖啡因/咖啡因/咖啡因/二氢可源性drocoseine tabs/for for 20或for for 20或for for 20或for for 20或for 20年龄; 90 days) ANALGESICS - OPIOID Tier 1 QL acetaminophen/codeine tab (TYLENOL/CODEINE equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days) MIGRAINE PRODUCTS Tier 1 - acetaminophen/isometheptene/dichloral cap (MIDRIN equiv) MIGRAINE PRODUCTS Tier 2 - ACETAMINOPHEN/ISOMETHEPTENE/DICHLORAL CAP DIURETICS Tier 1 - acetazolamide ER cap (DIAMOX SEQUEL equiv) DIURETICS Tier 1 - acetazolamide tab OTIC AGENTS Tier 1 - acetic acid otic soln (VOSOL equiv) OTIC AGENTS Tier 1 - ACETIC ACID/ALUMINUM ACETATE OTIC SOLN COUGH/COLD/ALLERGY第1层 - 乙酰半胱氨酸溶液（Mucomyst Equiv）皮肤病学层2型抗凝集素帽（Soriatane Equiv）（阶梯疗法）需要对Adapalene，Adapalene/Adapalene/Adapalene/Benzoyl过氧化物或维美替诺蛋白）进行试验。Tier 2专业LD-PA ACTHAR HP凝胶ING（仅通过Accredo 800-803-2523或Walgreens 888-347-3416）内分泌和代谢剂 - Misc。Tier 2专业LD-PA Acthar Inj 80unit（仅通过认证800-803-2523或Walgreens 888-347-3416）咳嗽/冷/冷/过敏2 Ql actier 2 ql actier液体液体（Ql = 1200ml/30天） Acuvail Ophth Soln抗病毒药层1-阿塞克洛维尔帽（Zovirax equiv）皮肤病学系列2- acyclovir Cream（Zovirax equiv）
ump（arrayrx）首选药物清单（PDL）2025
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