Online Formulary

Main Content

InterCommunity Health Network CCO

For questions please call:

Members: 1-800-832-4580, TTY 1-800-735-2900

Providers: 1-888-435-2396

Vaccines: For members up to age 18 years old vaccines must be administered in a providers office.

Note: This plan has limits on Opioid Medications. See page footer for details.

Drug Search Main Content

Alphabetical Search Skip to Brand & Generic Search

Brand & Generic Name Search

Therapeutic Class Search Skip to Footer

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*
*Allergenic Extracts/Biologicals Misc*
*Alternative Medicines*
*Aminoglycosides*
*Analgesics - Anti-Inflammatory*
*Analgesics - Nonnarcotic*
*Analgesics - Opioid*
*Androgens-Anabolic*
*Anorectal Agents*
*Anorectal And Related Products*
*Antacids*
*Anthelmintics*
*Antianginal Agents*
*Antianxiety Agents*
*Antiarrhythmics*
*Antiasthmatic And Bronchodilator Agents*
*Anticoagulants*
*Anticonvulsants*
*Antidepressants*
*Antidiabetics*
*Antidiarrheal/Probiotic Agents*
*Antidiarrheals*
*Antidotes And Specific Antagonists*
*Antidotes*
*Antiemetics*
*Antifungals*
*Antihistamines*
*Antihyperlipidemics*
*Antihypertensives*
*Anti-Infective Agents - Misc.*
*Antimalarials*
*Antimyasthenic/Cholinergic Agents*
*Antimycobacterial Agents*
*Antineoplastics And Adjunctive Therapies*
*Antiparkinson Agents*
*Antiparkinson And Related Therapy Agents*
*Antipsychotics/Antimanic Agents*
*Antivirals*
*Assorted Classes*
*Beta Blockers*
*Biologicals Misc*
*Calcium Channel Blockers*
*Cardiotonics*
*Cardiovascular Agents - Misc.*
*Cephalosporins*
*Chemicals*
*Contraceptives*
*Corticosteroids*
*Cough/Cold/Allergy*
*Dermatologicals*
*Diagnostic Products*
*Digestive Aids*
*Diuretics*
*Endocrine And Metabolic Agents - Misc.*
*Estrogens*
*Fluoroquinolones*
*Gastrointestinal Agents - Misc.*
*Genitourinary Agents - Miscellaneous*
*Gout Agents*
*Hematological Agents - Misc.*
*Hematopoietic Agents*
*Hemostatics*
*Hypnotics*
*Hypnotics/Sedatives/Sleep Disorder Agents*
*Laxatives*
*Macrolides*
*Medical Devices And Supplies*
*Medical Devices*
*Migraine Products*
*Minerals & Electrolytes*
*Miscellaneous Therapeutic Classes*
*Mouth/Throat/Dental Agents*
*Multivitamins*
*Musculoskeletal Therapy Agents*
*Nasal Agents - Systemic And Topical*
*Neuromuscular Agents*
*Nutrients*
*Ophthalmic Agents*
*Otic Agents*
*Oxytocics*
*Penicillins*
*Progestins*
*Psychotherapeutic And Neurological Agents - Misc.*
*Respiratory Agents - Misc.*
*Tetracyclines*
*Thyroid Agents*
*Toxoids*
*Ulcer Drugs*
*Ulcer Drugs/Antispasmodics/Anticholinergics*
*Urinary Anti-Infectives*
*Urinary Antispasmodics*
*Vaccines*
*Vaginal And Related Products*
*Vaginal Products*
*Vasopressors*
*Vitamins*

Opioid anti-tussive limits:

Liquids: Maximum of 240ML per fill.
Tablets/Capsules: Maximum 7-day supply per fill.

Short-acting Opioid (SAO) Limits:

New to therapy: Maximum of 49 MED and Maximum 7-day supply per fill.
Experience with therapy: Maximum of 90 MED.

Long-acting Opioid (LOA) Limits: PA required and Maximum of 90 MED.

You can get this document in another language, format, large print or ask for an interpreter at no cost to you. Please call us at 800-832-4580 (TTY 800-735-2900) to request a copy of this document or an interpreter.

Puede obtener este documento en otro idioma, otro formato o en letra grande o pedir un intérprete sin costo alguno para usted. Llámenos al 800-832-4580 (TTY 800-735-2900) para pedir una copia de este documento o un intérprete.

Formulary Effective Date: 11/01/2024

Updated:

11/2024