MAP / MAP Basic Formulary

NON-COMMUNITYCARE PROVIDERS: Medications restricted to CUC Prescribers and/or CUC in-house pharmacies are considered non-formulary outside of CUC. These medications may be obtained via Prescription Assistance Programs (PAP). If the patient does not qualify for PAP, the provider may submit a NON-FORMULARY DRUG REQUEST (NFDR) FORM. Documentation of PAP ineligibility or rejection should be submitted with the NDFR form.

More information on pharmacy benefits can be found in the MAP and MAP Basic Provider Handbook.

NON-FORMULARY DRUG REQUEST (NFDR) FORM

Request an addition to the MAP/MAP Basic formulary

Request an addition to the Central Health floor stock formulary

MAP / MAP Basic Formulary (August 2024)

wdt_ID	Generic Code	Generic Sequence Number	Therapeutic Class	Brand Name	Generic Name	Formulation	Strength	Coverage	Location	Comments
1	49.291	17.037	040800-SECOND GENERATION ANTIHISTAMINES	Zyrtec	CETIRIZINE HCL	TABLET	10 MG	COVERED	FORMULARY
2	60.563	18.698	040800-SECOND GENERATION ANTIHISTAMINES	Claritin	LORATADINE	TABLET	10 MG	COVERED	FORMULARY
3	17.853	50.714	120808-ANTIMUSCARINICS/ANTISPASMODICS	Spiriva Handihaler	TIOTROPIUM BROMIDE	CAP W/DEV	18 MCG	COVERED	FORMULARY	CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies
4	3.421	16.425	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	PATCH TD24	7 MG/24HR	COVERED	FORMULARY
5	3.422	16.426	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	PATCH TD24	14 MG/24HR	COVERED	FORMULARY
6	3.423	16.427	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	PATCH TD24	21 MG/24HR	COVERED	FORMULARY
7	27.047	60.897	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Chantix	VARENICLINE TARTRATE	TABLET	1 MG	COVERED	FORMULARY	only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment
8	27.046	60.896	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Chantix	VARENICLINE TARTRATE	TABLET	0.5 MG	COVERED	FORMULARY	only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment
9	18.387	51.214	240605-CHOLESTEROL ABSORPTION INHIBITORS	Zetia	EZETIMIBE	TABLET	10 MG	COVERED	FORMULARY
10	42.001	41.285	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	100 MG	COVERED	FORMULARY
11	42.002	41.286	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	200 MG	COVERED	FORMULARY
12	97.785	62.001	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	50 MG	COVERED	FORMULARY
13	18.127	50.832	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	400 MG	COVERED	FORMULARY
14	23.046	57.800	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	50 MG	COVERED	FORMULARY
15	23.047	57.801	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	75 MG	COVERED	FORMULARY
16	23.048	57.802	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	100 MG	COVERED	FORMULARY
17	23.049	57.803	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	150 MG	COVERED	FORMULARY
18	23.051	57.804	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	200 MG	COVERED	FORMULARY
19	23.052	57.805	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	300 MG	COVERED	FORMULARY
20	23.039	57.799	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	25 MG	COVERED	FORMULARY
21	25.019	59.401	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	225 MG	COVERED	FORMULARY
22	32.359	69.339	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	Solution	20 mg/ml	COVERED	FORMULARY
23	18.537	51.333	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	10 MG	COVERED	FORMULARY
24	18.538	51.334	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	15 MG	COVERED	FORMULARY
25	18.539	51.335	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	20 MG	COVERED	FORMULARY
	Generic Code	Generic Sequence Number	Therapeutic Class	Brand Name	Generic Name	Formulation	Strength	Coverage	Location	Comments

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MAP / MAP Basic Formulary (August 2024)