Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Helidac metronid-tetracyc-bis subsal 250-500-262.4 mg Combo Pack     Not Applicable Omeclamox-Pak omeprazole-clarith-amoxicillin 20 mg (20)- 500 mg (20) Combo Pack     $$$$ Prevpac amoxicil-clarithromy-lansopraz 500-500-30 mg Combo Pack     Not Applicable Pylera bismuth subcit k-metronidz-tcn capsule     Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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