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Tufts Health RITogether
Pharmacy program and Preferred Drug List
December 1, 2018
Introduction
Pharmacy program
We aim to provide high-quality, cost-effective options for drug therapy. We work with your health care providers and pharmacists to make sure we cover the most important
and useful drugs for a variety of conditions and diseases. We cover both first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your provider writes a prescription and it is filled at a pharmacy.
Our pharmacy program does not cover all drugs and prescriptions. Some drugs must
meet certain clinical guidelines before we can cover them. Your provider must ask us for prior approval before we will cover these drugs.
Preferred Drug List (PDL)
We list all drugs according to their therapeutic category and drug class, followed by generic or brand drug name. Use the index to find a drug according to its generic or
brand name. In general, we cover brand-name medications only when a generic medication is not available or if we give prior approval for the brand-name drug.
Co-payments
Outpatient drugs that are medically necessary are covered when they are prescribed by
a provider who is licensed to prescribe drugs. Some drugs on the
Tufts Health RITogether formulary are only covered when your provider submits a prior approval request. Eligibility for outpatient prescription drug benefits and co-payment amounts are based on your individual benefit plan.
The PDL applies only to drugs you get at retail and specialty pharmacies. The PDL does not apply to drugs you get if you are in the hospital. Drugs you get while in the hospital are covered as part of your stay.
For the most current PDL coverage information, please visit tuftshealthplan.com or call us at 866.738.4116 (TTY: 711).
Prior approval
Some drugs always require prior approval, which means your provider must ask us for
approval before we will cover the drug. One of our clinicians will review this request. We will cover the drug according to our clinical guidelines if:
There is a medical reason you need the particular drug
Depending on the drug, other drugs on the PDL have not worked
If we do not approve the request for prior approval, you or your authorized
representative, if you identify one, can appeal the decision. See your Member Handbook for our member grievances and appeals information.
Step therapy program
We cover some types of drugs only through our step therapy program. Our step
therapy program requires you to try first-level drugs before we will cover another drug of that type. If you and your provider feel a certain drug is not appropriate for treating your health condition, your provider can ask us for prior approval for the other drug.
One of our clinicians will review the request. We will cover the drug according to our clinical guidelines. If we do not approve the request for prior approval, you or your authorized representative, if you identify one, can appeal the decision. See your
Member Handbook for our grievances and appeals information.
Quantity limit
To make sure the drugs you take are safe and that you are getting the right amount,
we may limit how much you can get at one time. Your provider can ask us for prior
approval if you need more than we cover. One of our clinicians will review the request. We will cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we do not approve the request for prior approval,
you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.
Generic drugs
Generic drugs have the same active ingredients and work the same as brand-name
drugs. Rhode Island has a Generic First Program and requires that all members use generic drugs first. When generic drugs are available, we will not cover the brand-name drug without giving prior approval. If you and your provider feel a generic drug is not
right for treating your health condition and that the brand-name drug is medically necessary, your provider can ask for prior approval. One of our clinicians will review the request. If we do not approve the request for prior approval, you or your authorized
representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.
New-to-market drugs
We review new drugs for safety and effectiveness before we add them to our PDL.
Coverage limits
The Requirements/Limits column in the PDL shows when a drug has a certain
requirement or limit for coverage. Coverage limits include:
AGE — Age restriction may apply
This medication requires prior approval if the drug is not covered based on your age. Your provider should send us a prior approval request if the drug is
medically necessary.
PA — Prior approval
This medication requires prior approval. Your provider may prescribe a different
medication on the PDL or send us a prior approval request.
QL — Quantity limit
This medication is limited to a specific amount. If a larger amount is medically necessary, your provider should send us a prior approval request.
ST — Step therapy
This medication requires prior approval if you have not already used a first-line medication on the PDL. Your provider may prescribe another medication on the
PDL or send us a prior approval request.
Specialty pharmacy program
A specialty pharmacy may supply you with some drugs often used to treat chronic
conditions like hepatitis C or multiple sclerosis. These types of drugs need additional expertise and support. Specialty pharmacies have knowledge in these areas. These
pharmacies can give extra support to members and providers.
CVS Specialty is our specialty pharmacy and can provide you with these drugs. In
addition to providing specific specialty drugs, CVS Specialty will:
Deliver drugs to your home, provider’s office or any delivery address you choose (except for a P.O. box)
Answer your questions and offer help with your drugs
Give you information, materials and ongoing support to help you manage your
health condition and make sure you take your drugs the right way
Have staff pharmacists available who can help you at 800.237.2767.
THP-OCR-NOTICE-0716
DISCRIMINATION IS AGAINST THE LAW
Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not
exclude people or treat them differently because of race, color, national origin, age, disability,
or sex.
Tufts Health Plan:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
— Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
— Qualified interpreters
— Information written in other languages
If you need these services, contact Tufts Health Plan at 888.257.1985.
If you believe that Tufts Health Plan has failed to provide these services or discriminated in another way
on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Tufts Health Plan
Attention: Civil Rights Coordinator, Legal Dept.
705 Mount Auburn St.
Watertown, MA 02472
Phone: 888.880.8699 ext. 48000, [TTY number— 711 or 800.439.2370]
Fax: 617.972.9048
Email: OCRCoordinator@tufts-health.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a
grievance, the Tufts Health Plan Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Phone: 800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
tuftshealthplan.com | 888.257.1985
THP-OCR-NOTICE-0716
LA DISCRIMINACIÓN ES
CONTRA LA LEY
Tufts Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina
por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Tufts Health Plan no
excluye a las personas ni las trata de forma diferente debido a su raza, color, nacionalidad,
edad, discapacidad o sexo.
Tufts Health Plan:
Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera
eficaz con nosotros, como los siguientes:
— Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)
Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:
— Intérpretes capacitados
— Información escrita en otros idiomas
Si necesita recibir estos servicios, comuníquese con Servicios para Miembros de Tufts Health Plan a 888.257.1985.
Si considera que Tufts Health Plan no le proporcionó estos servicios o lo discriminó de otra manera por motivos de
raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:
Tufts Health Plan
Attention: Civil Rights Coordinator, Legal Dept.
705 Mount Auburn St.
Watertown, MA 02472
Phone: 888.880.8699 ext. 48000, [TTY number— 866-930-9252]
Fax: 617.972.9048
Email: OCRCoordinator@tufts-health.com
Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el
coordinador de derechos civiles con Tufts Health Plan está a su disposición para brindársela.
También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles)
del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera
electrónica a través de Office for Civil Rights Complaint Portal, disponible en
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los
números que figuran a continuación:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Phone: 800.368.1019, 800.537.7697 (TDD)
Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.
tuftshealthplan.com | 888.257.1985
For no-cost translation in English, call 866.738.4116.
Arabic 866.738.4116 الرقم على الاتصال یرجى العربیة، باللغة المجانیة الترجمة خدمة على للحصول
Chinese 若需免費的中文版本,請撥打 866.738.4116。
French Pour demander une traduction gratuite en français, composez le 866.738.4116.
German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die folgende Telefonnummer
an: 866.738.4116.
Greek Για δωρεάν μετάφραση στα ελληνικά, καλέστε στο 866.738.4116.
Haitian Creole Pou tradiksyon gratis nan Kreyòl Ayisyen, rele 866.738.4116.
Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero 866.738.4116.
Japanese 日本語の無料翻訳については 866.738.4116 に電話してください。
Khmer (Cambodian) សមរាបស់សវាបកបបរបសោយឥតគតិថ្ ៃ លជា ភាោ ប ្ប មរ សមូទរូសព័្ទសៅកានស់សម 866.738.4116 ។
Korean 한국어로 무료 통역을 원하시면, 866.738.4116 로 전화하십시오.
Laotian ໍ ສາໍ ລບການແປພາສາເໍ ປນພາສາລາ ວທໍ ໍ
ບໄ ໍ ດເສຍ ຄາໃ ໍ ຊຈາຍ , ໃໍ ຫໂທຫາເ ບ 866.738.4116.
Navajo Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 866.738.4116.
naisreP تلفن شماره بھ فارسی بھ رایگان ترجمھ برای .866.738.4116.بزنید زنگ
Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer 866.738.4116.
Portuguese Para tradução grátis para português, ligue para o número 866.738.4116.
Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру 866.738.4116.
Spanish Para servicio de traducción gratuito en español, llame al 866.738.4116.
Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 866.738.4116.
Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số 866.738.4116.
List-Languages-THP-Number-07/16
Table of Contents
BLOOD DISORDER................................................................................................................................................. 3CALORIC UNDERNUTRITION..............................................................................................................................7CHRONIC LUNG OR BREATHING PASSAGE PROBLEM................................................................................ 8COLD SYMPTOMS................................................................................................................................................12COLLAGEN VASCULAR DISEASE.................................................................................................................... 14CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM...........................................................17DISEASE AFFECTING THE BODY'S METABOLISM.......................................................................................25DISEASE OF THE HEART AND BLOOD VESSELS..........................................................................................34DISEASE OF THE URINARY TRACT................................................................................................................. 43DISORDER OF NERVE......................................................................................................................................... 47DISORDER OF NERVOUS SYSTEM................................................................................................................... 58DISORDER OF REPRODUCTIVE SYSTEM....................................................................................................... 68DISORDER OF RESPIRATORY SYSTEM...........................................................................................................76DISORDER OF THE DIGESTIVE SYSTEM........................................................................................................ 82DISORDER OF THE ENDOCRINE GLANDS......................................................................................................90EAR PROBLEM......................................................................................................................................................95EYE DISORDER..................................................................................................................................................... 96FEVER..................................................................................................................................................................... 98INFECTION.............................................................................................................................................................98INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY.............................................................107INFLAMMATORY DISORDER.......................................................................................................................... 107INJURY TO A MUCOUS MEMBRANE............................................................................................................. 124LUNG DISEASE................................................................................................................................................... 125MAJOR TRAUMATIC INJURY.......................................................................................................................... 130MARGINAL ZONE LYMPHOMA...................................................................................................................... 131MUSCLE OR BONE DISORDER........................................................................................................................ 131NEUROPSYCHIATRIC DISORDER...................................................................................................................141NOT FEELING WELL..........................................................................................................................................151NUTRITIONAL DISORDER................................................................................................................................151OTHER OVER-THE-COUNTER DRUGS...........................................................................................................152OTHER PRESCRIPTION DRUGS.......................................................................................................................157OVERDOSE...........................................................................................................................................................178PAIN.......................................................................................................................................................................179PATIENT DEMOGRAPHICS...............................................................................................................................187PREGNANCY....................................................................................................................................................... 188PROCEDURE........................................................................................................................................................ 189REACTION DUE TO AN ALLERGEN............................................................................................................... 192RECENT OPERATION.........................................................................................................................................194SKIN CONDITION............................................................................................................................................... 197SLOW DRUG ELIMINATION BY KIDNEY......................................................................................................207TACHYARRHYTHMIA.......................................................................................................................................207TUMOR................................................................................................................................................................. 207
1
2
Drug Status NotesBLOOD DISORDER
ACTIMMUNE SUBCUTANEOUS SOLUTION Brand PA; SP
ADEMPAS ORAL TABLET Brand PA; SP
Advate Intravenous Solution Reconstituted MB/RX PA; SP
Adynovate Intravenous Solution Reconstituted MB/RX PA; SP
Afstyla Intravenous Kit MB/RX PA; SP
Alphanate/VWF Complex/Human Intravenous Solution Reconstituted
MB/RX PA; SP
AlphaNine SD Intravenous Solution Reconstituted
MB/RX PA; SP
Alprolix Intravenous Solution Reconstituted MB/RX PA; SP
ANADROL-50 ORAL TABLET Brand PA
anagrelide hcl oral capsule Generic
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
Brand SP; QL (4 ML per 30 days)
ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML
Brand SP; QL (4 ML per 30 days)
aspirin-dipyridamole er oral capsule extended release 12 hour
Generic PA; QL (60 EA per 30 days)
AURYXIA ORAL TABLET Brand PA
Bebulin Intravenous Solution Reconstituted MB/RX PA; SP
BeneFIX Intravenous Kit MB/RX PA; SP
BeneFIX Intravenous Solution Reconstituted 1000 UNIT, 2000 UNIT, 500 UNIT
MB/RX PA; SP
BEVYXXA ORAL CAPSULE Brand PA
BRILINTA ORAL TABLET Brand PA; QL (60 EA per 30 days)
CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM
Medical Benefit PA; SP
Coagadex Intravenous Solution Reconstituted MB/RX PA; SP
Corifact Intravenous Kit MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
3
Drug Status Notesdipyridamole oral tablet Generic
DOPTELET ORAL TABLET 20 MG Brand PA
DROXIA ORAL CAPSULE Brand
ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)
Eloctate Intravenous Solution Reconstituted MB/RX PA; SP
ENDARI ORAL PACKET Brand PA
enoxaparin sodium injection solution Generic
enoxaparin sodium subcutaneous solution Generic
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Brand SP
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Brand SP; QL (10 ML per 14 days)
FARYDAK ORAL CAPSULE Brand PA; SP
Feiba Intravenous Solution Reconstituted MB/RX PA; SP
folic acid oral tablet 1 mg Generic
fondaparinux sodium subcutaneous solution Generic
FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand QL (0.6 ML per 14 days)
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA
GAMMAPLEX INTRAVENOUS SOLUTION5 GM/50ML Medical Benefit PA
GAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP
GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
Helixate FS Intravenous Kit MB/RX PA; SP
HEMLIBRA SUBCUTANEOUS SOLUTION Brand PA
Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 500 UNIT, 801-1500 UNIT
MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
4
Drug Status Notesheparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml
Generic
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
MB/RX PA; SP
Idelvion Intravenous Solution Reconstituted MB/RX PA; SP
IMBRUVICA ORAL CAPSULE 70 MG Brand PA
IMBRUVICA ORAL TABLET Brand PA
IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED Brand QL (24 vials per 12 days)
Ixinity Intravenous Solution Reconstituted MB/RX PA; SP
JADENU ORAL TABLET Brand PA; SP
JADENU SPRINKLE ORAL PACKET Brand PA
JAKAFI ORAL TABLET Brand PA; SP
Koate Intravenous Solution Reconstituted MB/RX PA; SP
Koate-DVI Intravenous Solution Reconstituted MB/RX PA; SP
Kogenate FS Bio-Set Intravenous Kit MB/RX PA; SP
Kogenate FS Intravenous Kit MB/RX PA; SP
Kovaltry Intravenous Solution Reconstituted MB/RX PA; SP
leucovorin calcium oral tablet Generic
LEUKERAN ORAL TABLET Brand
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG Medical Benefit PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG Medical Benefit PA
Monoclate-P Intravenous Kit 1000 UNIT, 1500 UNIT
MB/RX PA; SP
Mononine Intravenous Solution Reconstituted 1000 UNIT
MB/RX PA; SP
NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP; QL (0.6 ML per 14 days)
NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP; QL (0.6 ML per 14 days)
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Brand
PA; SP; QL (10 Syringes per 14 days)
NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
5
Drug Status NotesNINLARO ORAL CAPSULE Brand PA; SP
Novoeight Intravenous Solution Reconstituted MB/RX PA; SP
NovoSeven RT Intravenous Solution Reconstituted
MB/RX PA; SP
Nuwiq Intravenous Kit MB/RX PA; SP
Nuwiq Intravenous Solution Reconstituted MB/RX PA; SP
Obizur Intravenous Solution Reconstituted MB/RX PA; SP
OCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA; SP
phytonadione oral tablet Generic
PRADAXA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
prasugrel hcl oral tablet Generic PA
PRIVIGEN INTRAVENOUS SOLUTION Medical Benefit PA
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Brand SP
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Brand SP; QL (10 ML per 14 days)
Profilnine Intravenous Solution Reconstituted MB/RX PA; SP
Profilnine SD Intravenous Solution Reconstituted MB/RX PA; SP
PROMACTA ORAL TABLET Brand SP
Rebinyn Intravenous Solution Reconstituted MB/RX PA; SP
Recombinate Intravenous Solution Reconstituted MB/RX PA; SP
Rixubis Intravenous Solution Reconstituted MB/RX PA; SP
SAVAYSA ORAL TABLET Brand PA
SIKLOS ORAL TABLET 100 MG Brand PA
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
TAVALISSE ORAL TABLET Brand QL (60 EA per 30 days)
THALOMID ORAL CAPSULE Brand SP
Tretten Intravenous Solution Reconstituted MB/RX PA; SP
Vonvendi Intravenous Solution Reconstituted MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
6
Drug Status Noteswarfarin sodium oral tablet Generic
Wilate Intravenous Kit MB/RX PA; SP
Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT
MB/RX PA; SP
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)
XARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand
PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)
XATMEP ORAL SOLUTION Brand PA
Xyntha Intravenous Kit MB/RX PA; SP
Xyntha Solofuse Intravenous Kit MB/RX PA; SP
ZARXIO INJECTION SOLUTION PREFILLED SYRINGE Brand SP; QL (10 Syringes per 14 days)
ZONTIVITY ORAL TABLET Brand PA
CALORIC UNDERNUTRITION
AURYXIA ORAL TABLET Brand PA
calcium acetate (phos binder) oral capsule Generic
calcium acetate (phos binder) oral tablet Generic
CRYSVITA SUBCUTANEOUS SOLUTION Medical Benefit PA
cyanocobalamin injection solution Generic
ergocalciferol oral capsule Generic
folbee oral tablet Generic
folic acid oral tablet 1 mg Generic
leucovorin calcium oral tablet Generic
levocarnitine oral solution Generic
levocarnitine oral tablet Generic
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml
Generic
multi vitamin/fluoride oral tablet chewable Brand
multi vitamin/minerals oral tablet Generic
multi-vit/fluoride oral solution Generic
multi-vit/fluoride/iron oral solution Generic
multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
7
Drug Status Notesmulti-vitamin/fluoride oral tablet chewable 0.5 mg
Brand
mynephrocaps oral capsule Generic
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP
RENAL ORAL CAPSULE Generic
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP
tri-vit/fluoride/iron oral solution Brand
tri-vitamin/fluoride oral solution Generic
vitamin d (ergocalciferol) oral capsule 50000 unit Generic
ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
CHRONIC LUNG OR BREATHING PASSAGE PROBLEM
ADEMPAS ORAL TABLET Brand PA; SP
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE
BrandPA; Age Limit (Min 4 Years and Max 11 Years)
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE
Brand PA
ADVAIR HFA INHALATION AEROSOL Brand PA
albuterol sulfate er oral tablet extended release 12 hour
Generic
albuterol sulfate inhalation nebulization solution Generic
albuterol sulfate oral syrup Generic
albuterol sulfate oral tablet Generic
ALVESCO INHALATION AEROSOL SOLUTION Brand
ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
ARCAPTA NEOHALER INHALATION CAPSULE Brand QL (1 EA per 30 days)
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
8
Drug Status NotesASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX HFA INHALATION AEROSOL Brand
ATROVENT HFA INHALATION AEROSOL SOLUTION Brand
azelastine hcl nasal solution 0.1 % Brand
BECONASE AQ NASAL SUSPENSION Brand PA
BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED Brand PA; QL (1 EA per 30 days)
budesonide inhalation suspension Generic
CAYSTON INHALATION SOLUTION RECONSTITUTED Brand
CINQAIR INTRAVENOUS SOLUTION Medical Benefit PA
CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Brand
cromolyn sodium inhalation nebulization solution Generic
DALIRESP ORAL TABLET Brand PA; STPA
DULERA INHALATION AEROSOL Brand PA
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML Brand PA; SP; QL (2 ML per 28 days)
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Brand PA; QL (4 ML per 28 days)
epoprostenol sodium intravenous solution reconstituted 0.5 mg
Medical Benefit PA; QL (4 EA per 30 days)
epoprostenol sodium intravenous solution reconstituted 1.5 mg
Medical Benefit PA; QL (2 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
9
Drug Status NotesESBRIET ORAL CAPSULE Brand SP; QL (270 EA per 30 days)
ESBRIET ORAL TABLET Brand SP; QL (270 EA per 30 days)
FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA
FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
FLOVENT HFA INHALATION AEROSOL Brand
fluticasone propionate nasal suspension Generic
fluticasone-salmeterol inhalation aerosol powder breath activated
Generic
FORADIL AEROLIZER INHALATION CAPSULE Brand
INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ipratropium bromide inhalation solution Generic
ipratropium bromide nasal solution Generic
ipratropium-albuterol inhalation solution Generic
KALYDECO ORAL PACKET Brand PA; SP; QL (60 EA per 30 days)
KALYDECO ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
LETAIRIS ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml
Generic
levalbuterol tartrate inhalation aerosol Generic PA
metaproterenol sulfate oral syrup Generic
metaproterenol sulfate oral tablet Generic
montelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA
OFEV ORAL CAPSULE Brand QL (60 EA per 30 days)
OMNARIS NASAL SUSPENSION Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
10
Drug Status NotesOPSUMIT ORAL TABLET Brand PA; SP
ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG Brand PA
ORKAMBI ORAL PACKET Brand PA; QL (56 EA per 28 days)
ORKAMBI ORAL TABLET Brand PA; QL (120 EA per 30 days)
PERFOROMIST INHALATION NEBULIZATION SOLUTION Brand
PROAIR HFA INHALATION AEROSOL SOLUTION Brand PA
PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
PROVENTIL HFA INHALATION AEROSOL SOLUTION Brand PA
PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
PULMOZYME INHALATION SOLUTION Brand SP
QVAR INHALATION AEROSOL SOLUTION Brand
QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED Brand QL (10.6 GM per 30 days)
REMODULIN INJECTION SOLUTION Medical Benefit PA; SP
REVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP
SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
sildenafil citrate oral tablet 20 mg Generic PA; QL (90 EA per 30 days)
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
Brand
STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
11
Drug Status NotesSYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT Brand PA
SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT Brand
PA; ¥ (PA applies to members 0-5 years of age and members 12 years of age and older (no PA required for members 6 through 11 years of age))
SYMDEKO ORAL TABLET THERAPY PACK Brand PA; QL (56 EA per 28 days)
tadalafil (pah) oral tablet Generic PA; SP; QL (60 EA per 30 days)
terbutaline sulfate oral tablet Generic
theophylline er oral tablet extended release 12 hour
Generic
theophylline er oral tablet extended release 24 hour
Generic
theophylline oral solution Generic
TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)
tobramycin inhalation nebulization solution Generic
TRACLEER ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
TRACLEER ORAL TABLET SOLUBLE Brand PA; SP; QL (120 EA per 30 days)
Tyvaso Inhalation Solution MB/RX PA; SP
Tyvaso Refill Inhalation Solution MB/RX PA; SP
Tyvaso Starter Inhalation Solution MB/RX PA; SP
UPTRAVI ORAL TABLET Brand PA; SP
UPTRAVI ORAL TABLET THERAPY PACK Brand PA; SP
VELETRI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
Ventavis Inhalation Solution MB/RX PA; SP; QL (9 Vials per 1 day)
VENTOLIN HFA INHALATION AEROSOL SOLUTION Brand
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
zafirlukast oral tablet Brand
ZETONNA NASAL AEROSOL SOLUTION Brand PA
COLD SYMPTOMS
azelastine hcl nasal solution 0.1 % Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
12
Drug Status NotesBECONASE AQ NASAL SUSPENSION Brand PA
benzonatate oral capsule 100 mg, 200 mg Generic
budesonide nasal suspension Generic PA
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
CLARINEX ORAL SYRUP Brand PA
CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
clemastine fumarate oral tablet 2.68 mg Generic
cyproheptadine hcl oral syrup Generic
cyproheptadine hcl oral tablet Generic
desloratadine oral tablet Generic PA
flunisolide nasal solution 25 mcg/act (0.025%) Generic
fluticasone propionate nasal suspension Generic
guaifenesin er oral tablet extended release 12 hour 600 mg
Generic
hydrocod polst-cpm polst er oral suspension extended release
Generic
hydrocodone-homatropine oral syrup Generic
hydrocodone-homatropine oral tablet Generic
hydromet oral syrup Generic
ipratropium bromide nasal solution Generic
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
mometasone furoate nasal suspension Generic PA
montelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
ODACTRA SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
OMNARIS NASAL SUSPENSION Brand PA
ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
phenyleph-promethazine-cod oral syrup Generic
promethazine vc plain oral syrup Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
13
Drug Status Notespromethazine vc/codeine oral syrup Generic
promethazine-codeine oral syrup Generic
promethazine-dm oral syrup Generic
promethazine-phenylephrine oral syrup Generic
pseudoephedrine hcl oral tablet 60 mg Generic
QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA
QNASL NASAL AEROSOL SOLUTION Brand PA
SEMPREX-D ORAL CAPSULE Brand PA
triamcinolone acetonide nasal aerosol Generic
TUSSIGON ORAL TABLET Generic
VERAMYST NASAL SUSPENSION Brand PA
ZETONNA NASAL AEROSOL SOLUTION Brand PA
COLLAGEN VASCULAR DISEASE
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 400 MG/20ML Medical Benefit PA; SP; QL (2 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 80 MG/4ML Medical Benefit PA; SP; QL (10 vials per 28 days)
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (4 syringes per 28 days)
azathioprine oral tablet Generic
BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA
BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA
celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)
cevimeline hcl oral capsule Generic
CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)
CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand
PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
14
Drug Status NotesCOSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
BrandPA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
BrandPA; SP; QL (1 Syringe per 28 days)
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 28 days)
diclofenac sodium er oral tablet extended release 24 hour
Generic
EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE Brand PA; SP; QL (4 each per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (4 syringes per 28 days)
etodolac er oral tablet extended release 24 hour Generic
flurbiprofen oral tablet Generic
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
15
Drug Status NotesHUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)
hydroxychloroquine sulfate oral tablet Generic
INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
ketoprofen er oral capsule extended release 24 hour
Generic
KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (2.28 ML per 30 days)
KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (2.28 ML per 30 days)
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)
leflunomide oral tablet Generic
meloxicam oral suspension Generic
meloxicam oral tablet Generic
methotrexate oral tablet Generic
MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; QL (30 Vials per 30 days)
nabumetone oral tablet Generic
OLUMIANT ORAL TABLET Brand PA
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)
ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit
PA; SP; QL (4 VIALS per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML
Brand PA; QL (1.6 ML per 28 days)
oxaprozin oral tablet Generic
PANRETIN EXTERNAL GEL Brand PA
pilocarpine hcl oral tablet Generic
piroxicam oral capsule Generic
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
16
Drug Status NotesRENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP
salsalate oral tablet Generic
SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (1 syringe per 28 days)
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 syringe per 28 days)
sulfasalazine oral tablet delayed release Generic
tolmetin sodium oral capsule Generic
tolmetin sodium oral tablet Generic
TREXALL ORAL TABLET Brand
XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)
CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM
abacavir sulfate oral solution Generic
abacavir sulfate oral tablet Generic
abacavir sulfate-lamivudine oral tablet Brand
abacavir-lamivudine-zidovudine oral tablet Brand
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 400 MG/20ML Medical Benefit PA; SP; QL (2 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 80 MG/4ML Medical Benefit PA; SP; QL (10 vials per 28 days)
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (4 syringes per 28 days)
ACTIMMUNE SUBCUTANEOUS SOLUTION Brand PA; SP
Alphanate/VWF Complex/Human Intravenous Solution Reconstituted
MB/RX PA; SP
ANADROL-50 ORAL TABLET Brand PA
APTIVUS ORAL CAPSULE Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
17
Drug Status NotesAPTIVUS ORAL SOLUTION Brand
ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)
atazanavir sulfate oral capsule Generic
ATRIPLA ORAL TABLET Brand
azathioprine oral tablet Generic
BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA
BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA
Berinert Intravenous Kit MB/RX SP
BIKTARVY ORAL TABLET Brand
BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML Medical Benefit PA
CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM
Medical Benefit PA; SP
celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)
cevimeline hcl oral capsule Generic
CIMDUO ORAL TABLET Brand
CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)
CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand
PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)
COMPLERA ORAL TABLET Brand
cortisone acetate oral tablet Generic
COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
BrandPA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
BrandPA; SP; QL (1 Syringe per 28 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
18
Drug Status NotesCOSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 28 days)
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand
cromolyn sodium oral concentrate Generic
Cuvitru Subcutaneous Solution MB/RX PA
cyclosporine modified oral capsule Generic
cyclosporine modified oral solution Generic
cyclosporine oral capsule Generic
DESCOVY ORAL TABLET Brand
diclofenac sodium er oral tablet extended release 24 hour
Generic
didanosine oral capsule delayed release Generic
dronabinol oral capsule Generic
EDURANT ORAL TABLET Brand
efavirenz oral capsule Generic
efavirenz oral tablet Generic
EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
EMTRIVA ORAL CAPSULE Brand
EMTRIVA ORAL SOLUTION Brand
ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE Brand PA; SP; QL (4 each per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (4 syringes per 28 days)
etodolac er oral tablet extended release 24 hour Generic
EVOTAZ ORAL TABLET Brand
FIRAZYR SUBCUTANEOUS SOLUTION Brand PA; SP; QL (3 ML per 1 Fill)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
19
Drug Status NotesFLEBOGAMMA DIF INTRAVENOUS SOLUTION Medical Benefit PA
flurbiprofen oral tablet Generic
fosamprenavir calcium oral tablet Generic
FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand QL (0.6 ML per 14 days)
FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP
Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML
MB/RX PA
Gammagard Injection Solution 20 GM/200ML MB/RX PA; SP
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA
GAMMAPLEX INTRAVENOUS SOLUTION5 GM/50ML Medical Benefit PA
GAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP
GENGRAF ORAL CAPSULE Generic
GENGRAF ORAL SOLUTION Generic
GENVOYA ORAL TABLET Brand
GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
guanidine hcl oral tablet Brand PA
Hizentra Subcutaneous Solution 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML
MB/RX PA; SP
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
MB/RX PA; SP
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
20
Drug Status NotesHUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)
hydrocortisone oral tablet Generic
hydroxychloroquine sulfate oral tablet Generic
Hyqvia Subcutaneous Kit MB/RX PA; SP
ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP
INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
INTELENCE ORAL TABLET Brand
INVIRASE ORAL CAPSULE Brand
INVIRASE ORAL TABLET Brand
ISENTRESS HD ORAL TABLET Brand QL (60 EA per 30 days)
ISENTRESS ORAL PACKET Brand QL (60 EA per 30 days)
ISENTRESS ORAL TABLET Brand
ISENTRESS ORAL TABLET CHEWABLE Brand
JULUCA ORAL TABLET Brand
KALETRA ORAL SOLUTION Brand
KALETRA ORAL TABLET Brand
ketoprofen er oral capsule extended release 24 hour
Generic
KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (2.28 ML per 30 days)
KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (2.28 ML per 30 days)
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)
lamivudine oral solution Brand
lamivudine oral tablet 150 mg, 300 mg Brand
lamivudine-zidovudine oral tablet Brand
leflunomide oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
21
Drug Status NotesLEXIVA ORAL SUSPENSION Brand
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml
Generic
meloxicam oral suspension Generic
meloxicam oral tablet Generic
methotrexate oral tablet Generic
methylprednisolone oral tablet Generic
methylprednisolone oral tablet therapy pack Generic
methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg
Generic
MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; QL (30 Vials per 30 days)
mycophenolate mofetil oral capsule Generic
mycophenolate mofetil oral suspension reconstituted
Generic
mycophenolate mofetil oral tablet Generic
mycophenolic acid oral tablet delayed release Generic
nabumetone oral tablet Generic
NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP; QL (0.6 ML per 14 days)
NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP; QL (0.6 ML per 14 days)
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Brand
PA; SP; QL (10 Syringes per 14 days)
NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
nevirapine er oral tablet extended release 24 hour Generic
nevirapine oral suspension Generic
nevirapine oral tablet Generic
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP
NORVIR ORAL CAPSULE Brand
NORVIR ORAL PACKET Brand
NORVIR ORAL SOLUTION Brand
NOXAFIL ORAL SUSPENSION Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
22
Drug Status NotesNOXAFIL ORAL TABLET DELAYED RELEASE Brand PA
Obizur Intravenous Solution Reconstituted MB/RX PA; SP
OCTAGAM INTRAVENOUS SOLUTION Medical Benefit PA; SP
ODEFSEY ORAL TABLET Brand
OLUMIANT ORAL TABLET Brand PA
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)
ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit
PA; SP; QL (4 VIALS per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML
Brand PA; QL (1.6 ML per 28 days)
oxaprozin oral tablet Generic
PANRETIN EXTERNAL GEL Brand PA
pilocarpine hcl oral tablet Generic
piroxicam oral capsule Generic
prednisolone oral solution Generic
prednisolone oral syrup 15 mg/5ml Generic
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
Generic
prednisolone sodium phosphate oral tablet dispersible
Generic
PREVYMIS INTRAVENOUS SOLUTION Medical Benefit PA
PREVYMIS ORAL TABLET Brand PA
PREZCOBIX ORAL TABLET Brand
PREZISTA ORAL SUSPENSION Brand
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG Brand
PRIVIGEN INTRAVENOUS SOLUTION Medical Benefit PA
PROMACTA ORAL TABLET Brand SP
pyridostigmine bromide er oral tablet extended release
Generic
pyridostigmine bromide oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
23
Drug Status NotesRAPAMUNE ORAL SOLUTION Brand
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RESCRIPTOR ORAL TABLET Brand
REYATAZ ORAL PACKET Brand
ritonavir oral tablet Generic
RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP
Ruconest Intravenous Solution Reconstituted MB/RX SP
salsalate oral tablet Generic
SELZENTRY ORAL SOLUTION Brand QL (1800 ML per 30 days)
SELZENTRY ORAL TABLET Brand
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP
SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (1 syringe per 28 days)
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 syringe per 28 days)
sirolimus oral tablet Generic
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
stavudine oral capsule Brand
stavudine oral solution reconstituted Brand
STRIBILD ORAL TABLET Brand
sulfasalazine oral tablet delayed release Generic
SYMFI LO ORAL TABLET Brand
SYMFI ORAL TABLET Brand
SYMTUZA ORAL TABLET Brand
SYNDROS ORAL SOLUTION Brand PA
tacrolimus oral capsule Generic
TAVALISSE ORAL TABLET Brand QL (60 EA per 30 days)
tenofovir disoproxil fumarate oral tablet Generic
TIVICAY ORAL TABLET Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
24
Drug Status Notestolmetin sodium oral capsule Generic
tolmetin sodium oral tablet Generic
TREXALL ORAL TABLET Brand
TRIUMEQ ORAL TABLET Brand
TRUVADA ORAL TABLET 200-300 MG Brand
TYBOST ORAL TABLET Brand
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Brand
VIRACEPT ORAL TABLET Brand
VIREAD ORAL POWDER Brand
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Brand
Wilate Intravenous Kit MB/RX PA; SP
Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT
MB/RX PA; SP
XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)
ZARXIO INJECTION SOLUTION PREFILLED SYRINGE Brand SP; QL (10 Syringes per 14 days)
zidovudine oral capsule Brand
zidovudine oral syrup Brand
zidovudine oral tablet Brand
ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
ZORTRESS ORAL TABLET Brand SP
DISEASE AFFECTING THE BODY'S METABOLISM
acarbose oral tablet Generic
acetazolamide oral tablet Generic
ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT Brand PA
ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
25
Drug Status Notesalendronate sodium oral tablet 40 mg Generic QL (1 EA per 6 Months)
ALLI ORAL CAPSULE Brand PA
allopurinol oral tablet Generic
alogliptin benzoate oral tablet Generic PA; QL (30 EA per 30 days)
alogliptin-metformin hcl oral tablet Generic PA; QL (60 EA per 30 days)
alogliptin-pioglitazone oral tablet Generic PA; QL (30 EA per 30 days)
amiloride hcl oral tablet Generic
amlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)
ANTARA ORAL CAPSULE 30 MG, 90 MG Brand PA; QL (30 EA per 30 days)
ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)
atorvastatin calcium oral tablet Generic
AURYXIA ORAL TABLET Brand PA
AVANDAMET ORAL TABLET 2-1000 MG Brand PA
AVANDIA ORAL TABLET Brand PA
BELVIQ ORAL TABLET Brand PA
BELVIQ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
benzphetamine hcl oral tablet Generic PA
Berinert Intravenous Kit MB/RX SP
BRINEURA SOLUTION Medical Benefit PA
bumetanide oral tablet Generic
BYDUREON SUBCUTANEOUS PEN-INJECTOR Brand PA
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER Brand PA
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION Brand PA
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION Brand PA
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
calcitriol oral capsule Generic
calcitriol oral solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
26
Drug Status Notescalcium acetate (phos binder) oral capsule Generic
calcium acetate (phos binder) oral tablet Generic
captopril oral tablet Generic
CARBAGLU ORAL TABLET Brand PA
CAYSTON INHALATION SOLUTION RECONSTITUTED Brand
CERDELGA ORAL CAPSULE Brand PA; SP
CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT Medical Benefit PA; SP
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
chlorothiazide oral tablet Generic
chlorpropamide oral tablet Generic
chlorthalidone oral tablet 25 mg, 50 mg Generic
CHOLBAM ORAL CAPSULE Brand PA
cholestyramine light oral packet Generic
cholestyramine light oral powder Generic
cholestyramine oral packet Generic
cholestyramine oral powder Generic
Cinryze Intravenous Solution Reconstituted MB/RX PA
colchicine oral tablet Generic
colchicine-probenecid oral tablet Generic
colesevelam hcl oral tablet Generic PA
colestipol hcl oral packet Generic
colestipol hcl oral tablet Generic
constulose oral solution Generic
CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
CRYSVITA SUBCUTANEOUS SOLUTION Medical Benefit PA
CYSTAGON ORAL CAPSULE Brand PA; SP
danazol oral capsule Generic
desmopressin ace rhinal tube nasal solution Generic
desmopressin ace spray refrig nasal solution Generic
desmopressin acetate oral tablet Generic
desmopressin acetate spray nasal solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
27
Drug Status Notesdiethylpropion hcl er oral tablet extended release 24 hour
Generic PA
diethylpropion hcl oral tablet Generic PA
dronabinol oral capsule Generic
DUZALLO ORAL TABLET Brand PA
EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
enulose oral solution Generic
ethacrynic acid oral tablet Generic PA
etidronate disodium oral tablet Generic
ezetimibe oral tablet Generic PA; QL (30 EA per 30 days)
ezetimibe-simvastatin oral tablet Generic PA; QL (30 EA per 30 days)
FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
FARXIGA ORAL TABLET Brand PA; QL (30 EA per 30 days)
fenofibrate micronized oral capsule 130 mg, 43 mg
Generic PA; QL (30 EA per 30 days)
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Generic QL (30 EA per 30 days)
fenofibrate oral capsule 150 mg, 50 mg Generic PA; QL (30 EA per 30 days)
fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg
Generic PA; QL (30 EA per 30 days)
fenofibrate oral tablet 160 mg, 54 mg Generic QL (30 EA per 30 days)
fenofibric acid oral capsule delayed release Generic PA; QL (30 EA per 30 days)
fenofibric acid oral tablet Generic PA; QL (30 EA per 30 days)
FIRAZYR SUBCUTANEOUS SOLUTION Brand PA; SP; QL (3 ML per 1 Fill)
flolipid oral suspension Brand PA
fluvastatin sodium er oral tablet extended release 24 hour
Generic PA; QL (30 EA per 30 days)
fluvastatin sodium oral capsule Generic PA; QL (30 EA per 30 days)
furosemide injection solution 10 mg/ml Generic
furosemide oral solution 10 mg/ml, 8 mg/ml Generic
furosemide oral tablet Generic
gemfibrozil oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
28
Drug Status Notesgenerlac oral solution Generic
glimepiride oral tablet Generic
glipizide er oral tablet extended release 24 hour Generic
glipizide oral tablet Generic
glipizide xl oral tablet extended release 24 hour Generic
glipizide-metformin hcl oral tablet Generic
GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED Brand
GLUCAGON EMERGENCY INJECTION KIT Brand
glyburide micronized oral tablet Generic
glyburide oral tablet Generic
glyburide-metformin oral tablet Generic
HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Brand
HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
Brand
ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP
indapamide oral tablet Generic
indomethacin er oral capsule extended release Generic
indomethacin oral capsule Generic
INVOKAMET ORAL TABLET BrandPA; STPA; QL (60 EA per 30 days)
INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand
PA; STPA; QL (60 Tablets per 30 days)
INVOKANA ORAL TABLET 100 MG Brand STPA; QL (60 EA per 30 days)
INVOKANA ORAL TABLET 300 MG Brand STPA; QL (30 EA per 30 days)
JUXTAPID ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
KALYDECO ORAL PACKET Brand PA; SP; QL (60 EA per 30 days)
KALYDECO ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
KANUMA INTRAVENOUS SOLUTION Medical Benefit PA
KEVEYIS ORAL TABLET Brand PA
KIONEX ORAL POWDER Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
29
Drug Status NotesKIONEX ORAL SUSPENSION Generic
KORLYM ORAL TABLET Brand PA
KRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP
KUVAN ORAL PACKET Brand PA; SP
KUVAN ORAL TABLET SOLUBLE Brand PA; SP
KYNAMRO SUBCUTANEOUS SOLUTION Brand PA; SP; QL (4 EA per 28 days)
KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (4 EA per 28 days)
lactulose encephalopathy oral solution Generic
lactulose oral solution Generic
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
LIVALO ORAL TABLET Brand PA; QL (30 EA per 30 days)
lovastatin oral tablet Generic
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
LYRICA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
LYRICA ORAL SOLUTION Brand PA; QL (900 ML per 30 days)
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml
Generic
metformin hcl er (mod) oral tablet extended release 24 hour
Generic PA
metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg
Generic PA
metformin hcl er oral tablet extended release 24 hour
Generic
metformin hcl oral tablet Generic
methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)
methyclothiazide oral tablet Generic
metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml
Generic
metoclopramide hcl oral tablet Generic
metolazone oral tablet Generic
micronized colestipol hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
30
Drug Status Notesmiglitol oral tablet Generic
MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; QL (30 Vials per 30 days)
nateglinide oral tablet Generic
NATPARA SUBCUTANEOUS CARTRIDGE BrandPA; SP; QL (2 Cartridges per 21 days)
niacin er (antihyperlipidemic) oral tablet extended release
Generic
niacin er oral capsule extended release Generic
NIACOR ORAL TABLET Generic
NITYR ORAL TABLET Brand PA
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
ORFADIN ORAL CAPSULE Brand PA
ORFADIN ORAL SUSPENSION Brand PA
ORKAMBI ORAL PACKET Brand PA; QL (56 EA per 28 days)
ORKAMBI ORAL TABLET Brand PA; QL (120 EA per 30 days)
oxandrolone oral tablet 10 mg Generic PA; QL (60 EA per 30 days)
oxandrolone oral tablet 2.5 mg Generic PA; QL (240 EA per 30 days)
PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML
Brand PA
PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML Brand PA; QL (1 Unit per 1 day)
phendimetrazine tartrate er oral capsule extended release 24 hour
Generic PA
phendimetrazine tartrate oral tablet Generic PA
phentermine hcl oral capsule Generic PA
phentermine hcl oral tablet Generic PA
PHOSPHA 250 NEUTRAL ORAL TABLET Generic
pioglitazone hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
31
Drug Status Notespioglitazone hcl-glimepiride oral tablet Generic
pioglitazone hcl-metformin hcl oral tablet Generic
pot bicarb-pot chloride oral tablet effervescent Generic
potassium bicarbonate oral tablet effervescent Generic
potassium chloride crys er oral tablet extended release
Generic
potassium chloride er oral capsule extended release
Generic
potassium chloride er oral tablet extended release Generic
potassium chloride oral packet Generic
potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)
Generic
PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; SP; QL (2 ML per 28 days)
pravastatin sodium oral tablet Generic
probenecid oral tablet Generic
PULMOZYME INHALATION SOLUTION Brand SP
QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA
RAVICTI ORAL LIQUID Brand PA; SP
repaglinide oral tablet Generic
repaglinide-metformin hcl oral tablet Generic
REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE Brand
PA; SP; # (Preferred product); QL (1 ML per 28 days)
REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; # (Preferred product); QL (2 ML per 28 days)
REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; # (Preferred product); QL (2 ML per 28 days)
risedronate sodium oral tablet 30 mg Generic PA; QL (30 EA per 30 days)
rosuvastatin calcium oral tablet Generic PA; QL (30 EA per 30 days)
Ruconest Intravenous Solution Reconstituted MB/RX SP
SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
32
Drug Status NotesSIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG
Medical Benefit PA
simvastatin oral tablet Generic
sodium polystyrene sulfonate oral powder Generic
sodium polystyrene sulfonate oral suspension Generic
sodium polystyrene sulfonate rectal suspension Generic
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)
spironolactone oral tablet Generic
spironolactone-hctz oral tablet Generic
SPS ORAL SUSPENSION Generic
STRENSIQ SUBCUTANEOUS SOLUTION Brand PA; QL (24 Vials per 28 days)
SUPRENZA ORAL TABLET DISPERSIBLE Brand PA
SYMDEKO ORAL TABLET THERAPY PACK Brand PA; QL (56 EA per 28 days)
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
SYNDROS ORAL SOLUTION Brand PA
TANZEUM SUBCUTANEOUS PEN-INJECTOR Brand PA
TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)
tobramycin inhalation nebulization solution Generic
tolazamide oral tablet Generic
tolbutamide oral tablet Generic
torsemide oral tablet Generic
triamterene-hctz oral capsule Generic
triamterene-hctz oral tablet Generic
trientine hcl oral capsule Generic PA
TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
VELTASSA ORAL PACKET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
33
Drug Status NotesVICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
VPRIV INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
XENICAL ORAL CAPSULE Brand PA
XGEVA SUBCUTANEOUS SOLUTION Medical Benefit PA; SP; QL (1 vial per 30 days)
XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG Brand PA; QL (6 EA per 30 days)
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
XURIDEN ORAL PACKET Brand PA; QL (120 Packets per 30 days)
ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
ZURAMPIC ORAL TABLET Brand PA
ZYPITAMAG ORAL TABLET Brand PA
DISEASE OF THE HEART AND BLOOD VESSELS
acebutolol hcl oral capsule Generic
ADEMPAS ORAL TABLET Brand PA; SP
almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)
Alphanate/VWF Complex/Human Intravenous Solution Reconstituted
MB/RX PA; SP
amiloride hcl oral tablet Generic
amiloride-hydrochlorothiazide oral tablet Generic
aminocaproic acid oral tablet Generic
amiodarone hcl oral tablet Generic
amlodipine besy-benazepril hcl oral capsule Generic QL (30 EA per 30 days)
amlodipine besylate oral tablet Generic
amlodipine besylate-valsartan oral tablet Generic PA; QL (30 EA per 30 days)
amlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)
amlodipine-olmesartan oral tablet Generic PA
amlodipine-valsartan-hctz oral tablet Generic PA; QL (30 EA per 30 days)
anagrelide hcl oral capsule Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
34
Drug Status Notesaspirin-dipyridamole er oral capsule extended release 12 hour
Generic PA; QL (60 EA per 30 days)
atenolol oral tablet Generic
atenolol-chlorthalidone oral tablet Generic
benazepril hcl oral tablet Generic
benazepril-hydrochlorothiazide oral tablet Generic
betaxolol hcl oral tablet Generic
BEVYXXA ORAL CAPSULE Brand PA
BIDIL ORAL TABLET Brand PA
bisoprolol fumarate oral tablet Generic
bisoprolol-hydrochlorothiazide oral tablet Generic
BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP
BRILINTA ORAL TABLET Brand PA; QL (60 EA per 30 days)
bumetanide oral tablet Generic
BYSTOLIC ORAL TABLET BrandPA; STPA; QL (30 EA per 30 days)
candesartan cilexetil oral tablet Generic PA
captopril oral tablet Generic
captopril-hydrochlorothiazide oral tablet Generic
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG Brand PA
CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM
Medical Benefit PA; SP
carvedilol oral tablet Generic
carvedilol phosphate er oral capsule extended release 24 hour
GenericPA; STPA; QL (30 EA per 30 days)
cilostazol oral tablet Generic
clonidine hcl oral tablet Generic
clonidine hcl transdermal patch weekly Generic
clopidogrel bisulfate oral tablet Generic
CLORPRES ORAL TABLET Generic
CORLANOR ORAL TABLET Brand PA
DEMSER ORAL CAPSULE Brand
DIGITEK ORAL TABLET Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
35
Drug Status NotesDIGOX ORAL TABLET Generic
digoxin oral solution Generic
digoxin oral tablet Generic
dihydroergotamine mesylate nasal solution Generic
diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
Generic
diltiazem hcl er beads oral capsule extended release 24 hour
Generic
diltiazem hcl er coated beads oral capsule extended release 24 hour
Generic
diltiazem hcl er coated beads oral tablet extended release 24 hour
Generic PA
diltiazem hcl er oral capsule extended release 12 hour
Generic
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
Generic
diltiazem hcl oral tablet Generic
disopyramide phosphate oral capsule Generic
divalproex sodium er oral tablet extended release 24 hour
Generic
divalproex sodium oral capsule delayed release sprinkle
Generic
divalproex sodium oral tablet delayed release Generic
dofetilide oral capsule Generic
doxazosin mesylate oral tablet Generic
EDARBI ORAL TABLET Brand PA
eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)
ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)
enalapril maleate oral tablet Generic
enalapril-hydrochlorothiazide oral tablet Generic
enoxaparin sodium injection solution Generic
enoxaparin sodium subcutaneous solution Generic
ENTRESTO ORAL TABLET Brand PA
epinephrine hcl injection solution 1 mg/ml Generic
eplerenone oral tablet Generic PA; QL (60 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
36
Drug Status Notesepoprostenol sodium intravenous solution reconstituted 0.5 mg
Medical Benefit PA; QL (4 EA per 30 days)
epoprostenol sodium intravenous solution reconstituted 1.5 mg
Medical Benefit PA; QL (2 EA per 30 days)
eprosartan mesylate oral tablet Generic PA
ethacrynic acid oral tablet Generic PA
Feiba Intravenous Solution Reconstituted MB/RX PA; SP
felodipine er oral tablet extended release 24 hour Generic
flecainide acetate oral tablet Generic
FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
fondaparinux sodium subcutaneous solution Generic
fosinopril sodium oral tablet Generic
fosinopril sodium-hctz oral tablet Generic
frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)
furosemide oral solution 10 mg/ml, 8 mg/ml Generic
furosemide oral tablet Generic
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA
GAMMAPLEX INTRAVENOUS SOLUTION5 GM/50ML Medical Benefit PA
GAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP
guanfacine hcl oral tablet Generic
HEMLIBRA SUBCUTANEOUS SOLUTION Brand PA
HEMMOREX-HC RECTAL SUPPOSITORY Generic
heparin (porcine) in nacl intravenous solution5000-0.9 ut/500ml-%
Brand
heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml
Generic
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
MB/RX PA; SP
hydralazine hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
37
Drug Status Noteshydrochlorothiazide oral capsule Generic
hydrochlorothiazide oral tablet Generic
hydrocortisone ace-pramoxine external cream2.5-1 %
Generic
hydrocortisone ace-pramoxine rectal cream Generic
hydrocortisone acetate rectal suppository Generic
HYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
indapamide oral tablet Generic
IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED Brand QL (24 vials per 12 days)
irbesartan oral tablet Generic STPA
irbesartan-hydrochlorothiazide oral tablet Generic STPA
isosorbide dinitrate er oral tablet extended release
Generic
isosorbide dinitrate oral tablet Generic
isosorbide mononitrate er oral tablet extended release 24 hour
Generic
isosorbide mononitrate oral tablet Generic
isradipine oral capsule Generic PA
JAKAFI ORAL TABLET Brand PA; SP
labetalol hcl oral tablet Generic
LETAIRIS ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
lisinopril oral tablet Generic
lisinopril-hydrochlorothiazide oral tablet Generic
losartan potassium oral tablet Generic
losartan potassium-hctz oral tablet Generic
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG Medical Benefit PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG Medical Benefit PA
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR Generic PA
meclizine hcl oral tablet Generic
medroxyprogesterone acetate oral tablet Generic
MESNEX ORAL TABLET Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
38
Drug Status Notesmethyldopa oral tablet Generic
methyldopa-hydrochlorothiazide oral tablet Generic
methylergonovine maleate oral tablet Generic
metoprolol succinate er oral tablet extended release 24 hour
Generic
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
Generic
metoprolol tartrate oral tablet 37.5 mg, 75 mg Brand PA
metoprolol-hydrochlorothiazide oral tablet Generic
mexiletine hcl oral capsule Generic
midodrine hcl oral tablet Generic
MIGERGOT RECTAL SUPPOSITORY Generic
minoxidil oral tablet Generic
moexipril hcl oral tablet Generic
moexipril-hydrochlorothiazide oral tablet Generic
nadolol oral tablet 20 mg, 40 mg, 80 mg Generic
nadolol-bendroflumethiazide oral tablet Generic
naratriptan hcl oral tablet Generic STPA; QL (9 EA per 30 days)
NATAZIA ORAL TABLET Generic
nicardipine hcl oral capsule Generic
nifedipine er oral tablet extended release 24 hour Generic
nifedipine er osmotic release oral tablet extended release 24 hour
Generic
nifedipine oral capsule Generic
nimodipine oral capsule Generic PA
nisoldipine er oral tablet extended release 24 hour
Generic
nitroglycerin sublingual tablet sublingual Generic
nitroglycerin transdermal patch 24 hour Generic
nitroglycerin translingual aerosol solution Generic
nitroglycerin translingual solution Generic
norethindrone acetate oral tablet Generic
NORTHERA ORAL CAPSULE Brand PA
NovoSeven RT Intravenous Solution Reconstituted
MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
39
Drug Status NotesNUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA
Obizur Intravenous Solution Reconstituted MB/RX PA; SP
OCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA; SP
olmesartan medoxomil oral tablet Generic STPA
olmesartan medoxomil-hctz oral tablet Generic STPA
omeprazole-sodium bicarbonate oral packet Generic PA
OPSUMIT ORAL TABLET Brand PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG Brand PA
pentoxifylline er oral tablet extended release Generic
perindopril erbumine oral tablet Generic
phenoxybenzamine hcl oral capsule Generic
pindolol oral tablet Generic
PRADAXA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; SP; QL (2 ML per 28 days)
pramcort rectal cream Generic
prasugrel hcl oral tablet Generic PA
prazosin hcl oral capsule Generic
PRIVIGEN INTRAVENOUS SOLUTION Medical Benefit PA
progesterone intramuscular oil Generic PA
PROMACTA ORAL TABLET Brand SP
propafenone hcl er oral capsule extended release 12 hour
Generic
propafenone hcl oral tablet Generic
propranolol hcl er oral capsule extended release 24 hour
Generic
propranolol hcl oral solution 40 mg/5ml Generic
propranolol hcl oral tablet Generic
propranolol-hctz oral tablet Generic
quinapril hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
40
Drug Status Notesquinapril-hydrochlorothiazide oral tablet Generic
quinidine gluconate er oral tablet extended release
Generic
quinidine sulfate er oral tablet extended release Generic
quinidine sulfate oral tablet Generic
ramipril oral capsule Generic
RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA; QL (60 EA per 30 days)
ranitidine hcl oral capsule Generic
ranitidine hcl oral syrup Generic
ranitidine hcl oral tablet 150 mg, 300 mg Generic
REMODULIN INJECTION SOLUTION Medical Benefit PA; SP
REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE Brand
PA; SP; # (Preferred product); QL (1 ML per 28 days)
REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; # (Preferred product); QL (2 ML per 28 days)
REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; # (Preferred product); QL (2 ML per 28 days)
reserpine oral tablet Generic
REVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP
rizatriptan benzoate oral tablet Generic STPA; QL (9 EA per 30 days)
rizatriptan benzoate oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
SAVAYSA ORAL TABLET Brand PA
sildenafil citrate oral tablet 20 mg Generic PA; QL (90 EA per 30 days)
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
sotalol hcl (af) oral tablet 120 mg, 80 mg Generic
sotalol hcl oral tablet Generic
spironolactone oral tablet Generic
spironolactone-hctz oral tablet Generic
sumatriptan nasal solution Generic QL (6 Units per 30 days)
sumatriptan succinate oral tablet Generic QL (9 EA per 30 days)
sumatriptan succinate refill subcutaneous solution cartridge
Generic QL (4 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
41
Drug Status Notessumatriptan succinate subcutaneous solution 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml
Generic QL (4 EA per 30 days)
tadalafil (pah) oral tablet Generic PA; SP; QL (60 EA per 30 days)
TAVALISSE ORAL TABLET Brand QL (60 EA per 30 days)
TEKTURNA HCT ORAL TABLET Brand PA; QL (30 EA per 30 days)
TEKTURNA ORAL TABLET Brand PA; QL (30 EA per 30 days)
telmisartan oral tablet Generic PA
telmisartan-hctz oral tablet Generic PA
terazosin hcl oral capsule Generic
timolol maleate oral tablet Generic
topiramate er oral capsule er 24 hour sprinkle100 mg, 25 mg, 50 mg
Generic PA; QL (30 EA per 30 days)
topiramate er oral capsule er 24 hour sprinkle150 mg, 200 mg
Generic PA; QL (60 EA per 30 days)
topiramate oral capsule sprinkle 15 mg Generic
topiramate oral capsule sprinkle 25 mg Generic QL (180 EA per 30 days)
topiramate oral tablet 100 mg, 50 mg Generic QL (90 EA per 30 days)
topiramate oral tablet 200 mg Generic
topiramate oral tablet 25 mg Generic QL (180 EA per 30 days)
torsemide oral tablet Generic
TRACLEER ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
TRACLEER ORAL TABLET SOLUBLE Brand PA; SP; QL (120 EA per 30 days)
trandolapril oral tablet Generic
trandolapril-verapamil hcl er oral tablet extended release
Generic
tranexamic acid oral tablet Generic PA
triamterene-hctz oral capsule Generic
triamterene-hctz oral tablet Generic
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG
Brand PA; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
42
Drug Status NotesTROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)
Tyvaso Inhalation Solution MB/RX PA; SP
Tyvaso Refill Inhalation Solution MB/RX PA; SP
Tyvaso Starter Inhalation Solution MB/RX PA; SP
UPTRAVI ORAL TABLET Brand PA; SP
UPTRAVI ORAL TABLET THERAPY PACK Brand PA; SP
valsartan oral tablet Generic STPA
valsartan-hydrochlorothiazide oral tablet Generic STPA
VELETRI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
Ventavis Inhalation Solution MB/RX PA; SP; QL (9 Vials per 1 day)
verapamil hcl er oral capsule extended release 24 hour
Generic
verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg
Generic
verapamil hcl oral tablet Generic
Vonvendi Intravenous Solution Reconstituted MB/RX PA; SP
warfarin sodium oral tablet Generic
Wilate Intravenous Kit MB/RX PA; SP
Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT
MB/RX PA; SP
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)
XARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand
PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)
zolmitriptan oral tablet Generic STPA; QL (9 EA per 30 days)
zolmitriptan oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
ZOMIG NASAL SOLUTION BrandPA; STPA; QL (6 Units per 30 days)
ZONTIVITY ORAL TABLET Brand PA
DISEASE OF THE URINARY TRACT
AFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
43
Drug Status Notesalfuzosin hcl er oral tablet extended release 24 hour
Generic
allopurinol oral tablet Generic
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
Brand SP; QL (4 ML per 30 days)
ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML
Brand SP; QL (4 ML per 30 days)
AURYXIA ORAL TABLET Brand PA
azathioprine oral tablet Generic
bethanechol chloride oral tablet Generic
calcium acetate (phos binder) oral capsule Generic
calcium acetate (phos binder) oral tablet Generic
captopril oral tablet Generic
clindamycin phosphate vaginal cream Generic
cyclosporine modified oral capsule Generic
cyclosporine modified oral solution Generic
cyclosporine oral capsule Generic
darifenacin hydrobromide er oral tablet extended release 24 hour
Generic PA
desmopressin acetate oral tablet Generic
doxazosin mesylate oral tablet Generic
doxercalciferol oral capsule Generic
dutasteride oral capsule Generic PA; QL (30 EA per 30 days)
dutasteride-tamsulosin hcl oral capsule Generic PA; QL (30 EA per 30 days)
ELIGARD SUBCUTANEOUS KIT Medical Benefit PA; SP
EMCYT ORAL CAPSULE Brand
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Brand SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
44
Drug Status NotesEPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Brand SP; QL (10 ML per 14 days)
FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
finasteride oral tablet 5 mg Generic
flavoxate hcl oral tablet Generic
GELNIQUE TRANSDERMAL GEL Brand PA
GENGRAF ORAL CAPSULE Generic
GENGRAF ORAL SOLUTION Generic
GLYDO EXTERNAL GEL Generic
HYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
imipramine hcl oral tablet Generic
INTRAROSA VAGINAL INSERT Brand PA; QL (28 EA per 28 days)
JYNARQUE ORAL TABLET THERAPY PACK Brand
leuprolide acetate injection kit Medical Benefit PA; SP
lidocaine hcl external gel 2 % Generic
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG Medical Benefit PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG Medical Benefit PA
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
medroxyprogesterone acetate oral tablet Generic
MESNEX ORAL TABLET Brand
methenamine hippurate oral tablet Generic
methenamine mandelate oral tablet Generic
metolazone oral tablet Generic
metronidazole vaginal gel Generic
miconazole 3 vaginal suppository Generic
mycophenolate mofetil oral capsule Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
45
Drug Status Notesmycophenolate mofetil oral suspension reconstituted
Generic
mycophenolate mofetil oral tablet Generic
mycophenolic acid oral tablet delayed release Generic
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
NATAZIA ORAL TABLET Generic
norethindrone acetate oral tablet Generic
OSPHENA ORAL TABLET Brand PA
oxybutynin chloride er oral tablet extended release 24 hour
Generic
oxybutynin chloride oral syrup Generic
oxybutynin chloride oral tablet Generic
OXYTROL TRANSDERMAL PATCH TWICE WEEKLY Brand PA
paricalcitol oral capsule Generic PA
phenazopyridine hcl oral tablet 100 mg, 200 mg Generic
PREMARIN VAGINAL CREAM Brand
PREMPHASE ORAL TABLET Brand
PREMPRO ORAL TABLET Brand
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Brand SP
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Brand SP; QL (10 ML per 14 days)
progesterone intramuscular oil Generic PA
RAPAFLO ORAL CAPSULE Brand PA
RAPAMUNE ORAL SOLUTION Brand
SENSIPAR ORAL TABLET Brand PA
sirolimus oral tablet Generic
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
SOLOSEC ORAL PACKET Brand PA
tacrolimus oral capsule Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
46
Drug Status Notestamsulosin hcl oral capsule Generic
terazosin hcl oral capsule Generic
terconazole vaginal cream Generic
terconazole vaginal suppository Generic
tinidazole oral tablet Generic
tolterodine tartrate er oral capsule extended release 24 hour
Generic
tolterodine tartrate oral tablet Generic
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
tranexamic acid oral tablet Generic PA
trospium chloride er oral capsule extended release 24 hour
Generic
trospium chloride oral tablet Generic
VANDAZOLE VAGINAL GEL Generic
VESICARE ORAL TABLET 10 MG Generic PA
VESICARE ORAL TABLET 5 MG Brand PA
ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG Medical Benefit PA; QL (1 EA per 84 days)
ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Medical Benefit PA; QL (1 EA per 28 days)
ZORTRESS ORAL TABLET Brand SP
DISORDER OF NERVE
AFINITOR DISPERZ ORAL TABLET SOLUBLE Brand PA; SP; QL (60 EA per 30 days)
almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)
amantadine hcl oral capsule Generic
amantadine hcl oral syrup Generic
amantadine hcl oral tablet Generic
amlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)
amphetamine-dextroamphet er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
amphetamine-dextroamphetamine oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
47
Drug Status NotesAPTIOM ORAL TABLET Brand PA
armodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)
armodafinil oral tablet 50 mg Generic PA; QL (60 Tablets per 30 days)
aspirin-dipyridamole er oral capsule extended release 12 hour
Generic PA; QL (60 EA per 30 days)
atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)
atropine sulfate ophthalmic solution Generic
AUBAGIO ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
AUSTEDO ORAL TABLET Brand PA; QL (60 EA per 30 days)
AVONEX INTRAMUSCULAR KIT Brand SP
AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT Brand SP
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT Brand SP
baclofen oral tablet Generic
BELSOMRA ORAL TABLET Brand PA
benztropine mesylate oral tablet Generic
BETASERON SUBCUTANEOUS KIT Brand SP
BETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP
BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP
BRIVIACT ORAL SOLUTION Brand PA
BRIVIACT ORAL TABLET Brand PA
bromocriptine mesylate oral capsule Generic
bromocriptine mesylate oral tablet Generic
caffeine citrate oral solution Generic
carbamazepine er oral capsule extended release 12 hour
Generic
carbamazepine er oral tablet extended release 12 hour
Generic
carbamazepine oral suspension Generic
carbamazepine oral tablet Generic
carbamazepine oral tablet chewable Generic
carbidopa oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
48
Drug Status Notescarbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
Generic
carbidopa-levodopa oral tablet Generic
carbidopa-levodopa oral tablet dispersible Generic
carbidopa-levodopa-entacapone oral tablet Generic
chlordiazepoxide hcl oral capsule Generic
clonazepam oral tablet Generic
clonidine hcl er oral tablet extended release 12 hour
Generic PA; QL (60 EA per 30 days)
clorazepate dipotassium oral tablet Generic
constulose oral solution Generic
dalfampridine er oral tablet extended release 12 hour
Generic PA; SP; QL (60 EA per 30 days)
dantrolene sodium oral capsule Generic
DAYTRANA TRANSDERMAL PATCH Brand PA; QL (30 patches per 30 days)
DEXEDRINE ORAL TABLET BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg
Generic PA; QL (30 EA per 30 days)
dexmethylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
dextroamphetamine sulfate er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dextroamphetamine sulfate oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (1200 mL per 30 days)
dextroamphetamine sulfate oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
DIAZEPAM INTENSOL ORAL CONCENTRATE Generic
diazepam oral concentrate Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
49
Drug Status Notesdiazepam oral solution Generic
diazepam oral tablet Generic
diazepam rectal gel Generic QL (1 System per 1 Rx)
dihydroergotamine mesylate nasal solution Generic
DILANTIN ORAL CAPSULE 30 MG BrandPA; ¥ (PA applies to members 6 years and under)
diphenhydramine hcl oral capsule 25 mg Brand
diphenhydramine hcl oral capsule 50 mg Generic
diphenhydramine hcl oral elixir Brand
divalproex sodium er oral tablet extended release 24 hour
Generic
divalproex sodium oral capsule delayed release sprinkle
Generic
divalproex sodium oral tablet delayed release Generic
donepezil hcl oral tablet 10 mg, 5 mg Generic
donepezil hcl oral tablet dispersible Generic
DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE Brand PA; QL (240 ML per 30 days)
DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
EDLUAR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)
EMFLAZA ORAL SUSPENSION Brand PA; QL (26 ML per 30 days)
EMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)
entacapone oral tablet Generic
enulose oral solution Generic
EPITOL ORAL TABLET Generic
ergoloid mesylates oral tablet Generic
estazolam oral tablet 1 mg Generic
eszopiclone oral tablet Generic PA; QL (30 EA per 30 days)
ethosuximide oral capsule Generic
ethosuximide oral solution Generic
EXONDYS 51 INTRAVENOUS SOLUTION Medical Benefit PA
EXTAVIA SUBCUTANEOUS KIT Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
50
Drug Status Notesflurazepam hcl oral capsule Generic
frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)
FYCOMPA ORAL SUSPENSION Brand PA
FYCOMPA ORAL TABLET Brand PA
gabapentin oral capsule Generic
gabapentin oral solution 250 mg/5ml Generic
gabapentin oral tablet Generic
galantamine hydrobromide er oral capsule extended release 24 hour
Generic
galantamine hydrobromide oral solution Generic
galantamine hydrobromide oral tablet Generic
Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML
MB/RX PA
Gammagard Injection Solution 20 GM/200ML MB/RX PA; SP
generlac oral solution Generic
GILENYA ORAL CAPSULE 0.5 MG Brand PA
glatiramer acetate subcutaneous solution prefilled syringe
Generic SP
GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML Generic
GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA
GRALISE ORAL TABLET Brand PA; QL (90 EA per 30 days)
GRALISE STARTER ORAL Brand PA
guanfacine hcl er oral tablet extended release 24 hour
Generic PA
guanidine hcl oral tablet Brand PA
HETLIOZ ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
HORIZANT ORAL TABLET EXTENDED RELEASE Brand PA; QL (60 EA per 30 days)
hydroxyzine hcl oral syrup Generic
hydroxyzine hcl oral tablet Generic
hydroxyzine pamoate oral capsule Generic
INCRELEX SUBCUTANEOUS SOLUTION Brand PA; SP
INGREZZA ORAL CAPSULE Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
51
Drug Status NotesKEVEYIS ORAL TABLET Brand PA
lactulose encephalopathy oral solution Generic
lactulose oral solution Generic
lamotrigine er oral tablet extended release 24 hour
Generic PA; QL (90 EA per 30 days)
lamotrigine odt oral tablet dispersible Generic
lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg
Generic
lamotrigine oral tablet 100 mg, 150 mg Generic QL (90 EA per 30 days)
lamotrigine oral tablet 200 mg Generic
lamotrigine oral tablet 25 mg Generic QL (180 EA per 30 days)
lamotrigine oral tablet chewable Generic QL (180 EA per 30 days)
lamotrigine oral tablet dispersible Generic
lamotrigine starter kit-blue oral kit Generic
lamotrigine starter kit-green oral kit Generic
lamotrigine starter kit-orange oral kit Generic
lamotrigine titration oral kit Generic
LEMTRADA INTRAVENOUS SOLUTION Medical Benefit PA
levetiracetam er oral tablet extended release 24 hour 500 mg
Generic PA; QL (180 EA per 30 days)
levetiracetam er oral tablet extended release 24 hour 750 mg
Generic PA; QL (120 EA per 30 days)
levetiracetam oral solution Generic
levetiracetam oral tablet Generic
lidocaine external patch 5 % Generic
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
LYRICA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
LYRICA ORAL SOLUTION Brand PA; QL (900 ML per 30 days)
meclizine hcl oral tablet Generic
memantine hcl oral solution Generic
memantine hcl oral tablet Generic
methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
52
Drug Status Notes
methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (cd) oral capsule extended release 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 60 mg
Generic PA; QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er oral tablet extended release 10 mg, 20 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 36 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (900 mL per 30 days)
methylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
MIGERGOT RECTAL SUPPOSITORY Generic
modafinil oral tablet Generic PA; QL (30 EA per 30 days)
MYOBLOC INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
naratriptan hcl oral tablet Generic STPA; QL (9 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
53
Drug Status NotesNEUPRO TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)
nimodipine oral capsule Generic PA
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
NUPLAZID ORAL CAPSULE Brand PA; SP; QL (30 EA per 30 days)
NUPLAZID ORAL TABLET BrandPA; SP; QL (60 Tablets per 30 days)
OCREVUS INTRAVENOUS SOLUTION Medical Benefit PA
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
ONFI ORAL SUSPENSION Brand PA
ONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)
oxazepam oral capsule Generic
oxcarbazepine oral suspension Generic
oxcarbazepine oral tablet Generic
OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG
Brand PA; QL (30 EA per 30 days)
OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG Brand PA; QL (120 EA per 30 days)
PEGANONE ORAL TABLET Brand PA
PHENYTOIN INFATABS ORAL TABLET CHEWABLE Generic
phenytoin oral suspension 125 mg/5ml Generic
phenytoin oral tablet chewable Generic
phenytoin sodium extended oral capsule Generic
pimozide oral tablet Generic PA
pramipexole dihydrochloride er oral tablet extended release 24 hour
Generic
pramipexole dihydrochloride oral tablet Generic
propranolol hcl er oral capsule extended release 24 hour
Generic
propranolol hcl oral solution Generic
propranolol hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
54
Drug Status Notespyridostigmine bromide er oral tablet extended release
Generic
pyridostigmine bromide oral tablet Generic
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED Brand PA; QL (360 mL per 30 days)
RADICAVA INTRAVENOUS SOLUTION Medical Benefit PA
rasagiline mesylate oral tablet Generic
REBIF REBIDOSE SUBCUTANEOUS SOLUTION Brand SP
REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand SP
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Brand SP
REBIF SUBCUTANEOUS SOLUTION Brand SP
REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Brand SP
riluzole oral tablet Generic
rivastigmine tartrate oral capsule Generic
rivastigmine transdermal patch 24 hour Generic
rizatriptan benzoate oral tablet Generic STPA; QL (9 EA per 30 days)
rizatriptan benzoate oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
ropinirole hcl er oral tablet extended release 24 hour
Generic
ropinirole hcl oral tablet Generic
ROZEREM ORAL TABLET Brand PA; QL (30 EA per 30 days)
SABRIL ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)
selegiline hcl oral capsule Generic
selegiline hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
55
Drug Status NotesSIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG
Medical Benefit PA
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)
SPINRAZA INTRATHECAL SOLUTION Medical Benefit PA
SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)
sumatriptan nasal solution Generic QL (6 Units per 30 days)
sumatriptan succinate oral tablet Generic QL (9 EA per 30 days)
sumatriptan succinate refill subcutaneous solution cartridge
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml
Generic QL (4 EA per 30 days)
TECFIDERA ORAL Brand PA; SP; QL (60 EA per 30 days)
TECFIDERA ORAL CAPSULE DELAYED RELEASE Brand PA; SP; QL (60 EA per 30 days)
temazepam oral capsule Generic
tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)
tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)
tiagabine hcl oral tablet 2 mg, 4 mg Generic
tolcapone oral tablet Generic PA; QL (180 EA per 30 days)
topiramate er oral capsule er 24 hour sprinkle100 mg, 25 mg, 50 mg
Generic PA; QL (30 EA per 30 days)
topiramate er oral capsule er 24 hour sprinkle150 mg, 200 mg
Generic PA; QL (60 EA per 30 days)
topiramate oral capsule sprinkle 15 mg Generic
topiramate oral capsule sprinkle 25 mg Generic QL (180 EA per 30 days)
topiramate oral tablet 100 mg, 50 mg Generic QL (90 EA per 30 days)
topiramate oral tablet 200 mg Generic
topiramate oral tablet 25 mg Generic QL (180 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
56
Drug Status Notestrientine hcl oral capsule Generic PA
trihexyphenidyl hcl oral elixir Generic
trihexyphenidyl hcl oral tablet Generic
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG
Brand PA; QL (30 EA per 30 days)
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)
TYSABRI INTRAVENOUS CONCENTRATE Medical Benefit PA; SP; QL (1 vial per 28 days)
valproic acid oral capsule Generic
valproic acid oral solution Generic
valproic acid oral syrup Generic
vigabatrin oral packet Generic PA; QL (180 EA per 30 days)
VIMPAT ORAL SOLUTION Brand PA; QL (1200 ML per 30 days)
VIMPAT ORAL TABLET Brand PA; QL (60 EA per 30 days)
VYVANSE ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
XADAGO ORAL TABLET Brand PA
XARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG Brand PA; QL (6 EA per 30 days)
XYREM ORAL SOLUTION Brand PA
zaleplon oral capsule Generic QL (30 EA per 30 days)
ZELAPAR ORAL TABLET DISPERSIBLE Brand PA; QL (60 EA per 30 days)
ZENZEDI ORAL TABLET 10 MG, 5 MG BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Injection per 30 days)
zolmitriptan oral tablet Generic STPA; QL (9 EA per 30 days)
zolmitriptan oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
zolpidem tartrate er oral tablet extended release Generic PA; QL (30 EA per 30 days)
zolpidem tartrate oral tablet Generic QL (30 EA per 30 days)
zolpidem tartrate sublingual tablet sublingual Generic PA; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
57
Drug Status Notes
ZOMIG NASAL SOLUTION BrandPA; STPA; QL (6 Units per 30 days)
zonisamide oral capsule Generic
ZONTIVITY ORAL TABLET Brand PA
DISORDER OF NERVOUS SYSTEM
AFINITOR DISPERZ ORAL TABLET SOLUBLE Brand PA; SP; QL (60 EA per 30 days)
almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)
amantadine hcl oral capsule Generic
amantadine hcl oral syrup Generic
amantadine hcl oral tablet Generic
amlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)
amphetamine-dextroamphet er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
amphetamine-dextroamphetamine oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
APTIOM ORAL TABLET Brand PA
armodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)
armodafinil oral tablet 50 mg Generic PA; QL (60 Tablets per 30 days)
aspirin-dipyridamole er oral capsule extended release 12 hour
Generic PA; QL (60 EA per 30 days)
atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)
atropine sulfate ophthalmic solution Generic
AUBAGIO ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
AUSTEDO ORAL TABLET Brand PA; QL (60 EA per 30 days)
AVONEX INTRAMUSCULAR KIT Brand SP
AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT Brand SP
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT Brand SP
baclofen oral tablet Generic
BELSOMRA ORAL TABLET Brand PA
benztropine mesylate oral tablet Generic
BETASERON SUBCUTANEOUS KIT Brand SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
58
Drug Status NotesBETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP
BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP
BRIVIACT ORAL SOLUTION Brand PA
BRIVIACT ORAL TABLET Brand PA
bromocriptine mesylate oral capsule Generic
bromocriptine mesylate oral tablet Generic
caffeine citrate oral solution Generic
carbamazepine er oral capsule extended release 12 hour
Generic
carbamazepine er oral tablet extended release 12 hour
Generic
carbamazepine oral suspension Generic
carbamazepine oral tablet Generic
carbamazepine oral tablet chewable Generic
carbidopa oral tablet Generic
carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
Generic
carbidopa-levodopa oral tablet Generic
carbidopa-levodopa oral tablet dispersible Generic
carbidopa-levodopa-entacapone oral tablet Generic
chlordiazepoxide hcl oral capsule Generic
clonazepam oral tablet Generic
clonidine hcl er oral tablet extended release 12 hour
Generic PA; QL (60 EA per 30 days)
clorazepate dipotassium oral tablet Generic
constulose oral solution Generic
dalfampridine er oral tablet extended release 12 hour
Generic PA; SP; QL (60 EA per 30 days)
dantrolene sodium oral capsule Generic
DAYTRANA TRANSDERMAL PATCH Brand PA; QL (30 patches per 30 days)
DEXEDRINE ORAL TABLET BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
59
Drug Status Notesdexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg
Generic PA; QL (30 EA per 30 days)
dexmethylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
dextroamphetamine sulfate er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dextroamphetamine sulfate oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (1200 mL per 30 days)
dextroamphetamine sulfate oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
DIAZEPAM INTENSOL ORAL CONCENTRATE Generic
diazepam oral concentrate Generic
diazepam oral solution Generic
diazepam oral tablet Generic
diazepam rectal gel Generic QL (1 System per 1 Rx)
dihydroergotamine mesylate nasal solution Generic
DILANTIN ORAL CAPSULE 30 MG BrandPA; ¥ (PA applies to members 6 years and under)
diphenhydramine hcl oral capsule 25 mg Brand
diphenhydramine hcl oral capsule 50 mg Generic
diphenhydramine hcl oral elixir Brand
divalproex sodium er oral tablet extended release 24 hour
Generic
divalproex sodium oral capsule delayed release sprinkle
Generic
divalproex sodium oral tablet delayed release Generic
donepezil hcl oral tablet 10 mg, 5 mg Generic
donepezil hcl oral tablet dispersible Generic
DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE Brand PA; QL (240 ML per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
60
Drug Status NotesDYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
EDLUAR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)
EMFLAZA ORAL SUSPENSION Brand PA; QL (26 ML per 30 days)
EMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)
entacapone oral tablet Generic
enulose oral solution Generic
EPITOL ORAL TABLET Generic
ergoloid mesylates oral tablet Generic
estazolam oral tablet 1 mg Generic
eszopiclone oral tablet Generic PA; QL (30 EA per 30 days)
ethosuximide oral capsule Generic
ethosuximide oral solution Generic
EXONDYS 51 INTRAVENOUS SOLUTION Medical Benefit PA
EXTAVIA SUBCUTANEOUS KIT Brand
flurazepam hcl oral capsule Generic
frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)
FYCOMPA ORAL SUSPENSION Brand PA
FYCOMPA ORAL TABLET Brand PA
gabapentin oral capsule Generic
gabapentin oral solution 250 mg/5ml Generic
gabapentin oral tablet Generic
galantamine hydrobromide er oral capsule extended release 24 hour
Generic
galantamine hydrobromide oral solution Generic
galantamine hydrobromide oral tablet Generic
Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML
MB/RX PA
Gammagard Injection Solution 20 GM/200ML MB/RX PA; SP
generlac oral solution Generic
GILENYA ORAL CAPSULE 0.5 MG Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
61
Drug Status Notesglatiramer acetate subcutaneous solution prefilled syringe
Generic SP
GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML Generic
GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA
GRALISE ORAL TABLET Brand PA; QL (90 EA per 30 days)
GRALISE STARTER ORAL Brand PA
guanfacine hcl er oral tablet extended release 24 hour
Generic PA
guanidine hcl oral tablet Brand PA
HETLIOZ ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
HORIZANT ORAL TABLET EXTENDED RELEASE Brand PA; QL (60 EA per 30 days)
hydroxyzine hcl oral syrup Generic
hydroxyzine hcl oral tablet Generic
hydroxyzine pamoate oral capsule Generic
INCRELEX SUBCUTANEOUS SOLUTION Brand PA; SP
INGREZZA ORAL CAPSULE Brand PA
KEVEYIS ORAL TABLET Brand PA
lactulose encephalopathy oral solution Generic
lactulose oral solution Generic
lamotrigine er oral tablet extended release 24 hour
Generic PA; QL (90 EA per 30 days)
lamotrigine odt oral tablet dispersible Generic
lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg
Generic
lamotrigine oral tablet 100 mg, 150 mg Generic QL (90 EA per 30 days)
lamotrigine oral tablet 200 mg Generic
lamotrigine oral tablet 25 mg Generic QL (180 EA per 30 days)
lamotrigine oral tablet chewable Generic QL (180 EA per 30 days)
lamotrigine oral tablet dispersible Generic
lamotrigine starter kit-blue oral kit Generic
lamotrigine starter kit-green oral kit Generic
lamotrigine starter kit-orange oral kit Generic
lamotrigine titration oral kit Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
62
Drug Status NotesLEMTRADA INTRAVENOUS SOLUTION Medical Benefit PA
levetiracetam er oral tablet extended release 24 hour 500 mg
Generic PA; QL (180 EA per 30 days)
levetiracetam er oral tablet extended release 24 hour 750 mg
Generic PA; QL (120 EA per 30 days)
levetiracetam oral solution Generic
levetiracetam oral tablet Generic
lidocaine external patch 5 % Generic
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
LYRICA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
LYRICA ORAL SOLUTION Brand PA; QL (900 ML per 30 days)
meclizine hcl oral tablet Generic
memantine hcl oral solution Generic
memantine hcl oral tablet Generic
methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)
methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (cd) oral capsule extended release 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 60 mg
Generic PA; QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er oral tablet extended release 10 mg, 20 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
63
Drug Status Notes
methylphenidate hcl er oral tablet extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 36 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (900 mL per 30 days)
methylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
MIGERGOT RECTAL SUPPOSITORY Generic
modafinil oral tablet Generic PA; QL (30 EA per 30 days)
MYOBLOC INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
naratriptan hcl oral tablet Generic STPA; QL (9 EA per 30 days)
NEUPRO TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)
nimodipine oral capsule Generic PA
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
NUPLAZID ORAL CAPSULE Brand PA; SP; QL (30 EA per 30 days)
NUPLAZID ORAL TABLET BrandPA; SP; QL (60 Tablets per 30 days)
OCREVUS INTRAVENOUS SOLUTION Medical Benefit PA
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
ONFI ORAL SUSPENSION Brand PA
ONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)
oxazepam oral capsule Generic
oxcarbazepine oral suspension Generic
oxcarbazepine oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
64
Drug Status NotesOXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG
Brand PA; QL (30 EA per 30 days)
OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG Brand PA; QL (120 EA per 30 days)
PEGANONE ORAL TABLET Brand PA
PHENYTOIN INFATABS ORAL TABLET CHEWABLE Generic
phenytoin oral suspension 125 mg/5ml Generic
phenytoin oral tablet chewable Generic
phenytoin sodium extended oral capsule Generic
pimozide oral tablet Generic PA
pramipexole dihydrochloride er oral tablet extended release 24 hour
Generic
pramipexole dihydrochloride oral tablet Generic
propranolol hcl er oral capsule extended release 24 hour
Generic
propranolol hcl oral solution Generic
propranolol hcl oral tablet Generic
pyridostigmine bromide er oral tablet extended release
Generic
pyridostigmine bromide oral tablet Generic
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED Brand PA; QL (360 mL per 30 days)
RADICAVA INTRAVENOUS SOLUTION Medical Benefit PA
rasagiline mesylate oral tablet Generic
REBIF REBIDOSE SUBCUTANEOUS SOLUTION Brand SP
REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand SP
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
Brand SP
REBIF SUBCUTANEOUS SOLUTION Brand SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
65
Drug Status NotesREBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Brand SP
riluzole oral tablet Generic
rivastigmine tartrate oral capsule Generic
rivastigmine transdermal patch 24 hour Generic
rizatriptan benzoate oral tablet Generic STPA; QL (9 EA per 30 days)
rizatriptan benzoate oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
ropinirole hcl er oral tablet extended release 24 hour
Generic
ropinirole hcl oral tablet Generic
ROZEREM ORAL TABLET Brand PA; QL (30 EA per 30 days)
SABRIL ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)
selegiline hcl oral capsule Generic
selegiline hcl oral tablet Generic
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG
Medical Benefit PA
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)
SPINRAZA INTRATHECAL SOLUTION Medical Benefit PA
SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)
sumatriptan nasal solution Generic QL (6 Units per 30 days)
sumatriptan succinate oral tablet Generic QL (9 EA per 30 days)
sumatriptan succinate refill subcutaneous solution cartridge
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
Generic QL (4 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
66
Drug Status Notessumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml
Generic QL (4 EA per 30 days)
TECFIDERA ORAL Brand PA; SP; QL (60 EA per 30 days)
TECFIDERA ORAL CAPSULE DELAYED RELEASE Brand PA; SP; QL (60 EA per 30 days)
temazepam oral capsule Generic
tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)
tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)
tiagabine hcl oral tablet 2 mg, 4 mg Generic
tolcapone oral tablet Generic PA; QL (180 EA per 30 days)
topiramate er oral capsule er 24 hour sprinkle100 mg, 25 mg, 50 mg
Generic PA; QL (30 EA per 30 days)
topiramate er oral capsule er 24 hour sprinkle150 mg, 200 mg
Generic PA; QL (60 EA per 30 days)
topiramate oral capsule sprinkle 15 mg Generic
topiramate oral capsule sprinkle 25 mg Generic QL (180 EA per 30 days)
topiramate oral tablet 100 mg, 50 mg Generic QL (90 EA per 30 days)
topiramate oral tablet 200 mg Generic
topiramate oral tablet 25 mg Generic QL (180 EA per 30 days)
trientine hcl oral capsule Generic PA
trihexyphenidyl hcl oral elixir Generic
trihexyphenidyl hcl oral tablet Generic
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG
Brand PA; QL (30 EA per 30 days)
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)
TYSABRI INTRAVENOUS CONCENTRATE Medical Benefit PA; SP; QL (1 vial per 28 days)
valproic acid oral capsule Generic
valproic acid oral solution Generic
valproic acid oral syrup Generic
vigabatrin oral packet Generic PA; QL (180 EA per 30 days)
VIMPAT ORAL SOLUTION Brand PA; QL (1200 ML per 30 days)
VIMPAT ORAL TABLET Brand PA; QL (60 EA per 30 days)
VYVANSE ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
XADAGO ORAL TABLET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
67
Drug Status NotesXARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG Brand PA; QL (6 EA per 30 days)
XYREM ORAL SOLUTION Brand PA
zaleplon oral capsule Generic QL (30 EA per 30 days)
ZELAPAR ORAL TABLET DISPERSIBLE Brand PA; QL (60 EA per 30 days)
ZENZEDI ORAL TABLET 10 MG, 5 MG BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Injection per 30 days)
zolmitriptan oral tablet Generic STPA; QL (9 EA per 30 days)
zolmitriptan oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
zolpidem tartrate er oral tablet extended release Generic PA; QL (30 EA per 30 days)
zolpidem tartrate oral tablet Generic QL (30 EA per 30 days)
zolpidem tartrate sublingual tablet sublingual Generic PA; QL (30 EA per 30 days)
ZOMIG NASAL SOLUTION BrandPA; STPA; QL (6 Units per 30 days)
zonisamide oral capsule Generic
ZONTIVITY ORAL TABLET Brand PA
DISORDER OF REPRODUCTIVE SYSTEM
AFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
alendronate sodium oral tablet 10 mg, 5 mg Generic QL (30 EA per 30 days)
alendronate sodium oral tablet 35 mg, 70 mg Generic QL (4 EA per 28 days)
ALTAVERA ORAL TABLET Generic
alyacen 1/35 oral tablet Generic
alyacen 7/7/7 oral tablet Generic
AMETHIA LO ORAL TABLET Generic
AMETHIA ORAL TABLET Generic
AMETHYST ORAL TABLET Generic
ANDRODERM TRANSDERMAL PATCH 24 HOUR Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
68
Drug Status NotesANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
Brand PA
ANDROXY ORAL TABLET Brand PA
APRI ORAL TABLET Generic
ARANELLE ORAL TABLET Generic
ASHLYNA ORAL TABLET Generic
AUBRA ORAL TABLET Generic
AVIANE ORAL TABLET Generic
AZURETTE ORAL TABLET Generic
BALZIVA ORAL TABLET Generic
BEKYREE ORAL TABLET Generic
BLISOVI 24 FE ORAL TABLET Generic
BLISOVI FE 1.5/30 ORAL TABLET Generic
BLISOVI FE 1/20 ORAL TABLET Generic
briellyn oral tablet Generic
calcitonin (salmon) nasal solution Generic
CAMILA ORAL TABLET Generic
CAMRESE LO ORAL TABLET Generic
CAMRESE ORAL TABLET Generic
CAZIANT ORAL TABLET Generic
CHATEAL ORAL TABLET Generic
clindamycin phosphate vaginal cream Generic
clomiphene citrate oral tablet Generic PA
CRINONE VAGINAL GEL 8 % Brand PA
CRYSELLE-28 ORAL TABLET Generic
CYCLAFEM 1/35 ORAL TABLET Generic
CYCLAFEM 7/7/7 ORAL TABLET Generic
CYRED ORAL TABLET Generic
danazol oral capsule Generic
DASETTA 1/35 ORAL TABLET Generic
DASETTA 7/7/7 ORAL TABLET Generic
DAYSEE ORAL TABLET Generic
DEBLITANE ORAL TABLET Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
69
Drug Status Notesdesogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)
$0
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
Generic
drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg
Generic
drospirenone-ethinyl estradiol oral tablet Generic
DUAVEE ORAL TABLET Brand PA
ELINEST ORAL TABLET Generic
ELLA ORAL TABLET Brand
EMOQUETTE ORAL TABLET Generic
ENPRESSE-28 ORAL TABLET Generic
ENSKYCE ORAL TABLET 0.15-30 MG-MCG Generic
ERRIN ORAL TABLET Generic
ESTARYLLA ORAL TABLET Generic
estradiol oral tablet Generic
estradiol transdermal patch twice weekly Generic
estradiol transdermal patch weekly Generic
estropipate oral tablet Generic
exemestane oral tablet Generic
FALMINA ORAL TABLET Generic
FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML Brand PA; SP; QL (1 vial per 30 days)
FOSAMAX PLUS D ORAL TABLET Brand PA; QL (4 EA per 28 days)
GIANVI ORAL TABLET Generic
GILDAGIA ORAL TABLET Generic
GILDESS 1.5/30 ORAL TABLET Generic
GILDESS 1/20 ORAL TABLET Generic
GILDESS 24 FE ORAL TABLET Generic
GILDESS FE 1.5/30 ORAL TABLET Generic
GILDESS FE 1/20 ORAL TABLET Generic
HEATHER ORAL TABLET Generic
HYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
70
Drug Status Notesibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)
INTRAROSA VAGINAL INSERT Brand PA; QL (28 EA per 28 days)
INTROVALE ORAL TABLET Generic
JENCYCLA ORAL TABLET Generic
JOLESSA ORAL TABLET Generic
JOLIVETTE ORAL TABLET Generic
JULEBER ORAL TABLET Generic
JUNEL 1.5/30 ORAL TABLET Generic
JUNEL 1/20 ORAL TABLET Generic
JUNEL FE 1.5/30 ORAL TABLET Generic
JUNEL FE 1/20 ORAL TABLET Generic
JUNEL FE 24 ORAL TABLET Generic
KAITLIB FE ORAL TABLET CHEWABLE Generic
KARIVA ORAL TABLET Generic
KELNOR 1/35 ORAL TABLET Generic
KIMIDESS ORAL TABLET Generic
KURVELO ORAL TABLET Generic
LARIN 1.5/30 ORAL TABLET Generic
LARIN 1/20 ORAL TABLET Generic
LARIN 24 FE ORAL TABLET Generic
LARIN FE 1.5/30 ORAL TABLET Generic
LARIN FE 1/20 ORAL TABLET Generic
LAYOLIS FE ORAL TABLET CHEWABLE Generic
LEENA ORAL TABLET Generic
LESSINA ORAL TABLET Generic
letrozole oral tablet Generic
LEVONEST ORAL TABLET Generic
levonorgest-eth estrad 91-day oral tablet Generic
levonorgestrel oral tablet 1.5 mg Generic
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg
Generic
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
$0
levonorg-eth estrad triphasic oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
71
Drug Status NotesLEVORA 0.15/30 (28) ORAL TABLET Generic
LO LOESTRIN FE ORAL TABLET Generic
LOMEDIA 24 FE ORAL TABLET Generic
LORYNA ORAL TABLET Generic
LOW-OGESTREL ORAL TABLET Generic
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG Medical Benefit PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG Medical Benefit PA
LUTERA ORAL TABLET Generic
LYZA ORAL TABLET Generic
marlissa oral tablet Generic
medroxyprogesterone acetate oral tablet Generic
mefenamic acid oral capsule Generic PA
MESNEX ORAL TABLET Brand
methitest oral tablet Brand PA
methyltestosterone oral capsule Generic
metronidazole vaginal gel Generic
MIACALCIN INJECTION SOLUTION Brand
miconazole 3 vaginal suppository Generic
MICROGESTIN 1.5/30 ORAL TABLET Generic
MICROGESTIN 1/20 ORAL TABLET Generic
MICROGESTIN 24 FE ORAL TABLET Generic
MICROGESTIN FE 1.5/30 ORAL TABLET Generic
MICROGESTIN FE 1/20 ORAL TABLET Generic
MONO-LINYAH ORAL TABLET Generic
MONONESSA ORAL TABLET Generic
MY WAY ORAL TABLET Generic
MYZILRA ORAL TABLET Generic
NATAZIA ORAL TABLET Generic
NECON 0.5/35 (28) ORAL TABLET Generic
NECON 1/35 (28) ORAL TABLET Generic
NECON 1/50 (28) ORAL TABLET Generic
NECON 10/11 (28) ORAL TABLET Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
72
Drug Status NotesNECON 7/7/7 ORAL TABLET Generic
NEXT CHOICE ONE DOSE ORAL TABLET Generic
NIKKI ORAL TABLET Generic
NORA-BE ORAL TABLET Generic
norethin ace-eth estrad-fe oral tablet Generic
norethin ace-eth estrad-fe oral tablet chewable Generic
norethindrone acetate oral tablet Generic
norethindrone acet-ethinyl est oral tablet Generic
norethindrone oral tablet Generic
norethindrone-eth estradiol oral tablet Generic
norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg
Generic
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
Generic
norgestim-eth estrad triphasic oral tablet Generic
NORTREL 0.5/35 (28) ORAL TABLET Generic
NORTREL 1/35 (21) ORAL TABLET Generic
NORTREL 1/35 (28) ORAL TABLET Generic
NORTREL 7/7/7 ORAL TABLET Generic
NUVARING VAGINAL RING Brand
OCELLA ORAL TABLET Generic
OGESTREL ORAL TABLET Generic
ORSYTHIA ORAL TABLET Generic
OSPHENA ORAL TABLET Brand PA
PHILITH ORAL TABLET Generic
PIMTREA ORAL TABLET Generic
PIRMELLA 1/35 ORAL TABLET Generic
PIRMELLA 7/7/7 ORAL TABLET Generic
PORTIA-28 ORAL TABLET Generic
PREMARIN ORAL TABLET Brand
PREMARIN VAGINAL CREAM Brand
PREMPHASE ORAL TABLET Brand
PREMPRO ORAL TABLET Brand
PREVIFEM ORAL TABLET Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
73
Drug Status Notesprogesterone intramuscular oil Generic PA
progesterone micronized oral capsule Generic
PROLIA SUBCUTANEOUS SOLUTION Medical BenefitPA; SP; QL (1 syringe per 180 days)
QUASENSE ORAL TABLET Generic
raloxifene hcl oral tablet Generic
RECLIPSEN ORAL TABLET Generic
risedronate sodium oral tablet 150 mg Generic PA; QL (1 EA per 30 days)
risedronate sodium oral tablet 35 mg Generic PA; QL (4 EA per 28 days)
risedronate sodium oral tablet 5 mg Generic PA; QL (30 EA per 30 days)
risedronate sodium oral tablet delayed release Generic PA; QL (4 EA per 28 days)
SETLAKIN ORAL TABLET Generic
SHAROBEL ORAL TABLET Generic
SOLOSEC ORAL PACKET Brand PA
SOLTAMOX ORAL SOLUTION Brand
SPRINTEC 28 ORAL TABLET Generic
SRONYX ORAL TABLET Generic
STRIANT BUCCAL Brand PA
SYEDA ORAL TABLET Generic
SYNAREL NASAL SOLUTION Brand PA
tadalafil oral tablet 5 mg Generic PA; QL (30 EA per 30 days)
tamoxifen citrate oral tablet Generic
TARINA FE 1/20 ORAL TABLET Generic
terconazole vaginal cream Generic
terconazole vaginal suppository Generic
TESTOPEL IMPLANT PELLET Brand PA
testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml
Generic PA
testosterone enanthate intramuscular solution Generic PA
testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
Generic PA
testosterone transdermal solution Generic PA
TILIA FE ORAL TABLET Generic
tinidazole oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
74
Drug Status Notestranexamic acid oral tablet Generic PA
TRI-ESTARYLLA ORAL TABLET Generic
TRI-LEGEST FE ORAL TABLET Generic
TRI-LINYAH ORAL TABLET Generic
TRI-LO-ESTARYLLA ORAL TABLET Generic
TRI-LO-MARZIA ORAL TABLET Generic
TRI-LO-SPRINTEC ORAL TABLET Generic
TRINESSA (28) ORAL TABLET Generic
TRINESSA LO ORAL TABLET Generic
TRI-PREVIFEM ORAL TABLET Generic
TRI-SPRINTEC ORAL TABLET Generic
TRIVORA (28) ORAL TABLET Generic
TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; QL (2 ML per 30 days)
VANDAZOLE VAGINAL GEL Generic
VELIVET ORAL TABLET Generic
VESTURA ORAL TABLET Generic
VIENVA ORAL TABLET Generic
viorele oral tablet Generic
VYFEMLA ORAL TABLET Generic
WERA ORAL TABLET Generic
WYMZYA FE ORAL TABLET CHEWABLE Generic
XIAFLEX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA
XULANE TRANSDERMAL PATCH WEEKLY Generic
ZARAH ORAL TABLET Generic
ZENCHENT FE ORAL TABLET CHEWABLE Generic
ZENCHENT ORAL TABLET Generic
ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Medical Benefit PA; QL (1 EA per 28 days)
ZOVIA 1/35E (28) ORAL TABLET Generic
ZOVIA 1/50E (28) ORAL TABLET Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
75
Drug Status NotesDISORDER OF RESPIRATORY SYSTEM
acetazolamide oral tablet Generic
acetylcysteine inhalation solution Generic
ADEMPAS ORAL TABLET Brand PA; SP
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE
BrandPA; Age Limit (Min 4 Years and Max 11 Years)
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE
Brand PA
ADVAIR HFA INHALATION AEROSOL Brand PA
albuterol sulfate er oral tablet extended release 12 hour
Generic
albuterol sulfate inhalation nebulization solution Generic
albuterol sulfate oral syrup Generic
albuterol sulfate oral tablet Generic
ALVESCO INHALATION AEROSOL SOLUTION Brand
ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
ARCAPTA NEOHALER INHALATION CAPSULE Brand QL (1 EA per 30 days)
armodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)
armodafinil oral tablet 50 mg Generic PA; QL (60 Tablets per 30 days)
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
76
Drug Status NotesASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX HFA INHALATION AEROSOL Brand
ATROVENT HFA INHALATION AEROSOL SOLUTION Brand
azelastine hcl nasal solution 0.1 % Brand
BECONASE AQ NASAL SUSPENSION Brand PA
benzonatate oral capsule 100 mg, 200 mg Generic
BEVYXXA ORAL CAPSULE Brand PA
BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED Brand PA; QL (1 EA per 30 days)
budesonide inhalation suspension Generic
budesonide nasal suspension Generic PA
caffeine citrate oral solution Generic
CAYSTON INHALATION SOLUTION RECONSTITUTED Brand
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
chlorpromazine hcl oral tablet Generic
CINQAIR INTRAVENOUS SOLUTION Medical Benefit PA
CLARINEX ORAL SYRUP Brand PA
CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
clemastine fumarate oral tablet 2.68 mg Generic
clotrimazole mouth/throat lozenge Generic
clotrimazole mouth/throat troche Generic
COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Brand
cromolyn sodium inhalation nebulization solution Generic
cyproheptadine hcl oral syrup Generic
cyproheptadine hcl oral tablet Generic
DALIRESP ORAL TABLET Brand PA; STPA
desloratadine oral tablet Generic PA
DULERA INHALATION AEROSOL Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
77
Drug Status NotesDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML Brand PA; SP; QL (2 ML per 28 days)
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Brand PA; QL (4 ML per 28 days)
ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)
epoprostenol sodium intravenous solution reconstituted 0.5 mg
Medical Benefit PA; QL (4 EA per 30 days)
epoprostenol sodium intravenous solution reconstituted 1.5 mg
Medical Benefit PA; QL (2 EA per 30 days)
ESBRIET ORAL CAPSULE Brand SP; QL (270 EA per 30 days)
ESBRIET ORAL TABLET Brand SP; QL (270 EA per 30 days)
ethacrynic acid oral tablet Generic PA
FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA
FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
FLOVENT HFA INHALATION AEROSOL Brand
flunisolide nasal solution 25 mcg/act (0.025%) Generic
fluticasone propionate nasal suspension Generic
fluticasone-salmeterol inhalation aerosol powder breath activated
Generic
FORADIL AEROLIZER INHALATION CAPSULE Brand
furosemide injection solution 10 mg/ml Generic
GLYDO EXTERNAL GEL Generic
guaifenesin er oral tablet extended release 12 hour 600 mg
Generic
hydrocod polst-cpm polst er oral suspension extended release
Generic
hydrocodone-homatropine oral syrup Generic
hydrocodone-homatropine oral tablet Generic
hydromet oral syrup Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
78
Drug Status NotesINCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ipratropium bromide inhalation solution Generic
ipratropium bromide nasal solution Generic
ipratropium-albuterol inhalation solution Generic
KALYDECO ORAL PACKET Brand PA; SP; QL (60 EA per 30 days)
KALYDECO ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
LETAIRIS ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml
Generic
levalbuterol tartrate inhalation aerosol Generic PA
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
lidocaine external ointment Generic QL (50 GM per 30 days)
lidocaine hcl external gel 2 % Generic
metaproterenol sulfate oral syrup Generic
metaproterenol sulfate oral tablet Generic
modafinil oral tablet Generic PA; QL (30 EA per 30 days)
mometasone furoate nasal suspension Generic PA
montelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
NOXAFIL ORAL SUSPENSION Brand PA
NOXAFIL ORAL TABLET DELAYED RELEASE Brand PA
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA
ODACTRA SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
OFEV ORAL CAPSULE Brand QL (60 EA per 30 days)
OMNARIS NASAL SUSPENSION Brand PA
OPSUMIT ORAL TABLET Brand PA; SP
ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
79
Drug Status NotesORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG Brand PA
ORKAMBI ORAL PACKET Brand PA; QL (56 EA per 28 days)
ORKAMBI ORAL TABLET Brand PA; QL (120 EA per 30 days)
PASER ORAL PACKET Brand PA
PERFOROMIST INHALATION NEBULIZATION SOLUTION Brand
phenyleph-promethazine-cod oral syrup Generic
PRIFTIN ORAL TABLET Brand PA
PROAIR HFA INHALATION AEROSOL SOLUTION Brand PA
PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
promethazine vc plain oral syrup Generic
promethazine vc/codeine oral syrup Generic
promethazine-codeine oral syrup Generic
promethazine-dm oral syrup Generic
promethazine-phenylephrine oral syrup Generic
PROVENTIL HFA INHALATION AEROSOL SOLUTION Brand PA
pseudoephedrine hcl oral tablet 60 mg Generic
PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
PULMOZYME INHALATION SOLUTION Brand SP
QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA
QNASL NASAL AEROSOL SOLUTION Brand PA
QVAR INHALATION AEROSOL SOLUTION Brand
QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED Brand QL (10.6 GM per 30 days)
RAPAMUNE ORAL SOLUTION Brand
REMODULIN INJECTION SOLUTION Medical Benefit PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
80
Drug Status NotesREVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP
SAVAYSA ORAL TABLET Brand PA
SEMPREX-D ORAL CAPSULE Brand PA
SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
sildenafil citrate oral tablet 20 mg Generic PA; QL (90 EA per 30 days)
sirolimus oral tablet Generic
SIRTURO ORAL TABLET Brand PA
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
Brand
STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION Brand
SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT Brand PA
SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT Brand
PA; ¥ (PA applies to members 0-5 years of age and members 12 years of age and older (no PA required for members 6 through 11 years of age))
SYMDEKO ORAL TABLET THERAPY PACK Brand PA; QL (56 EA per 28 days)
SYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
tadalafil (pah) oral tablet Generic PA; SP; QL (60 EA per 30 days)
terbutaline sulfate oral tablet Generic
theophylline er oral tablet extended release 12 hour
Generic
theophylline er oral tablet extended release 24 hour
Generic
theophylline oral solution Generic
TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)
tobramycin inhalation nebulization solution Generic
TRACLEER ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
TRACLEER ORAL TABLET SOLUBLE Brand PA; SP; QL (120 EA per 30 days)
triamcinolone acetonide nasal aerosol Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
81
Drug Status NotesTUSSIGON ORAL TABLET Generic
Tyvaso Inhalation Solution MB/RX PA; SP
Tyvaso Refill Inhalation Solution MB/RX PA; SP
Tyvaso Starter Inhalation Solution MB/RX PA; SP
UPTRAVI ORAL TABLET Brand PA; SP
UPTRAVI ORAL TABLET THERAPY PACK Brand PA; SP
VELETRI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
Ventavis Inhalation Solution MB/RX PA; SP; QL (9 Vials per 1 day)
VENTOLIN HFA INHALATION AEROSOL SOLUTION Brand
VERAMYST NASAL SUSPENSION Brand PA
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand
PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
zafirlukast oral tablet Brand
ZETONNA NASAL AEROSOL SOLUTION Brand PA
DISORDER OF THE DIGESTIVE SYSTEM
ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE Brand PA
adefovir dipivoxil oral tablet Generic
AFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
AKYNZEO ORAL CAPSULE Brand PA; QL (1 EA per 1 Fill)
alosetron hcl oral tablet Generic
AMITIZA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
amoxicill-clarithro-lansopraz oral Generic
ANZEMET ORAL TABLET 100 MG Brand PA; QL (10 EA per 1 fill)
ANZEMET ORAL TABLET 50 MG Brand PA; QL (5 EA per 1 fill)
APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand
balsalazide disodium oral capsule Generic
BARACLUDE ORAL SOLUTION Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
82
Drug Status NotesBONJESTA ORAL TABLET EXTENDED RELEASE Brand PA
budesonide er oral tablet extended release 24 hour
Generic PA
budesonide oral capsule delayed release particles Generic
CANTIL ORAL TABLET Brand PA
CARAFATE ORAL SUSPENSION BrandPA; ¥ (PA applies to members 12 years and older)
CESAMET ORAL CAPSULE Brand PA
cevimeline hcl oral capsule Generic
chlordiazepoxide-clidinium oral capsule Generic
chlorhexidine gluconate mouth/throat solution Generic
CHOLBAM ORAL CAPSULE Brand PA
cimetidine hcl oral solution Generic
cimetidine oral tablet Generic
CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)
CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand
PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)
CLINPRO 5000 DENTAL PASTE Generic
COLOCORT RECTAL ENEMA Generic
COMPRO RECTAL SUPPOSITORY Generic
constulose oral solution Generic
CREON ORAL CAPSULE DELAYED RELEASE PARTICLES Brand
cyclosporine modified oral capsule Generic
cyclosporine modified oral solution Generic
cyclosporine oral capsule Generic
DAKLINZA ORAL TABLET Brand PA; SP
DENAVIR EXTERNAL CREAM Brand PA; QL (5 GM per 1 Fill)
DENTA 5000 PLUS DENTAL CREAM Generic
DENTAGEL DENTAL GEL Generic
DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
83
Drug Status NotesDICLEGIS ORAL TABLET DELAYED RELEASE Brand PA
dicyclomine hcl oral capsule Generic
dicyclomine hcl oral solution Generic
dicyclomine hcl oral tablet Generic
DIFICID ORAL TABLET Brand PA; QL (20 EA per 1 Fill)
dimenhydrinate oral tablet Generic
DIPENTUM ORAL CAPSULE Brand
diphenoxylate-atropine oral liquid Generic
diphenoxylate-atropine oral tablet Generic
dronabinol oral capsule Generic
EMEND ORAL CAPSULE Brand PA; QL (6 EA per 1 Rx)
EMEND ORAL SUSPENSION RECONSTITUTED Brand PA; QL (3 Units per 7 days)
entecavir oral tablet Generic
ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
enulose oral solution Generic
EPCLUSA ORAL TABLET Brand PA; SP; # (Genotypes 2-6)
famotidine oral suspension reconstituted Generic
famotidine oral tablet 20 mg, 40 mg Generic
FLUOR-A-DAY ORAL SOLUTION Generic
FLUORIDEX DAILY DEFENSE DENTAL GEL Generic
FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE Generic
FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP Generic
GAMASTAN S/D INTRAMUSCULAR INJECTABLE Medical Benefit PA; SP
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
GATTEX SUBCUTANEOUS KIT Brand SP; QL (1 Kit per 1 day)
GAVILYTE-C ORAL SOLUTION RECONSTITUTED Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
84
Drug Status NotesGAVILYTE-G ORAL SOLUTION RECONSTITUTED Generic
GAVILYTE-H ORAL KIT Generic
generlac oral solution Generic
GENGRAF ORAL CAPSULE Generic
GENGRAF ORAL SOLUTION Generic
GIAZO ORAL TABLET Brand PA
granisetron hcl oral tablet Generic QL (14 EA per 1 Fill)
HARVONI ORAL TABLET Brand PA; SP
HEMMOREX-HC RECTAL SUPPOSITORY Generic
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)
hydrocortisone ace-pramoxine external cream2.5-1 %
Generic
hydrocortisone ace-pramoxine rectal cream Generic
hydrocortisone acetate rectal suppository Generic
hydrocortisone rectal enema Generic
INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
ivermectin oral tablet Generic
lactulose encephalopathy oral solution Generic
lactulose oral solution Generic
lamivudine oral tablet 100 mg Generic
lansoprazole oral capsule delayed release Generic PA
lansoprazole oral tablet dispersible Generic PA; ¥ (Age Limit: Max 2 years)
LINZESS ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
85
Drug Status NotesLONSURF ORAL TABLET Brand PA; SP
loperamide hcl oral capsule Generic
MAVYRET ORAL TABLET Brand PA; SP
mesalamine oral tablet delayed release 1.2 gm GenericPA; STPA; QL (120 EA per 30 days)
mesalamine oral tablet delayed release 800 mg Generic
mesalamine rectal enema Generic
methscopolamine bromide oral tablet Generic PA
metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml
Generic
metoclopramide hcl oral tablet Generic
misoprostol oral tablet Generic
MOVANTIK ORAL TABLET Brand PA
multi vitamin/fluoride oral tablet chewable Brand
multi-vit/fluoride oral solution Generic
multi-vit/fluoride/iron oral solution Generic
multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg
Generic
multi-vitamin/fluoride oral tablet chewable 0.5 mg
Brand
mycophenolate mofetil oral capsule Generic
mycophenolate mofetil oral suspension reconstituted
Generic
mycophenolate mofetil oral tablet Generic
neomycin sulfate oral tablet Generic
NEXIUM ORAL PACKET Brand PA
nizatidine oral capsule Generic
nizatidine oral solution Generic
NUTRESTORE ORAL PACKET Brand PA
OCALIVA ORAL TABLET BrandPA; SP; QL (30 TABS per 30 days)
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
OLYSIO ORAL CAPSULE Brand PA; SP
omeprazole oral capsule delayed release Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
86
Drug Status Notesomeprazole-sodium bicarbonate oral packet Generic PA
ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml
Generic
ondansetron hcl oral solution Generic QL (105 ML per 1 Fill)
ondansetron hcl oral tablet Generic QL (21 EA per 1 Fill)
ondansetron oral tablet dispersible Generic QL (21 EA per 1 Fill)
PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT
Brand
paregoric oral tincture Generic
PAROEX MOUTH/THROAT SOLUTION Generic
paromomycin sulfate oral capsule Generic
peg 3350/electrolytes oral solution reconstituted Generic
peg 3350-kcl-na bicarb-nacl oral solution reconstituted
Generic
peg-3350/electrolytes oral solution reconstituted Generic
PENTASA ORAL CAPSULE EXTENDED RELEASE Brand
PERIOGARD MOUTH/THROAT SOLUTION Generic
PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES Brand
PHENERGAN RECTAL SUPPOSITORY12.5 MG Generic
pilocarpine hcl oral tablet Generic
polyethylene glycol 3350 oral powder Generic
pramcort rectal cream Generic
praziquantel oral tablet Generic
PRILOSEC ORAL PACKET Brand PA
prochlorperazine edisylate injection solution Generic
prochlorperazine maleate oral tablet Generic
prochlorperazine rectal suppository Generic
PROMACTA ORAL TABLET Brand SP
promethazine hcl oral solution Generic
promethazine hcl oral syrup Generic
promethazine hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
87
Drug Status Notespromethazine hcl rectal suppository Generic
rabeprazole sodium oral tablet delayed release Generic PA
ranitidine hcl oral capsule Generic
ranitidine hcl oral syrup Generic
ranitidine hcl oral tablet 150 mg, 300 mg Generic
RELISTOR ORAL TABLET Brand PA; QL (90 Tablets per 30 days)
RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML Brand PA
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RIBASPHERE ORAL CAPSULE Generic QL (210 EA per 30 days)
RIBASPHERE ORAL TABLET 200 MG Generic QL (210 EA per 30 days)
ribavirin oral capsule Generic
ribavirin oral tablet 200 mg Generic
SANCUSO TRANSDERMAL PATCH Brand PA
sf 5000 plus dental cream Generic
sf dental gel Generic
sodium fluoride oral solution Generic
sodium fluoride oral tablet chewable Generic
SOVALDI ORAL TABLET Brand PA; SP
spironolactone oral tablet Generic
STELARA INTRAVENOUS SOLUTION Medical BenefitPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 84 days)
sucralfate oral tablet Generic
sulfasalazine oral tablet Generic
sulfasalazine oral tablet delayed release Generic
SYMPROIC ORAL TABLET Brand PA
SYNDROS ORAL SOLUTION Brand PA
tacrolimus oral capsule Generic
TECHNIVIE ORAL TABLET Brand PA; SP
tenofovir disoproxil fumarate oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
88
Drug Status Notestinidazole oral tablet Generic
trientine hcl oral capsule Generic PA
TRILYTE ORAL SOLUTION RECONSTITUTED Generic
trimethobenzamide hcl oral capsule Generic
tri-vit/fluoride/iron oral solution Brand
tri-vitamin/fluoride oral solution Generic
TYSABRI INTRAVENOUS CONCENTRATE Medical Benefit PA; SP; QL (1 vial per 28 days)
UCERIS RECTAL FOAM Brand PA
ursodiol oral capsule Generic
ursodiol oral tablet Generic
VARUBI ORAL TABLET BrandPA; ¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)
VIBERZI ORAL TABLET Brand PA
VIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; SP
VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP
VIREAD ORAL POWDER Brand
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Brand
VOSEVI ORAL TABLET Brand PA; SP
XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)
XERMELO ORAL TABLET Brand PA
XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG Brand PA; QL (6 EA per 30 days)
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000-24000 UNIT
Brand
ZEPATIER ORAL TABLET Brand PA; SP
ZINPLAVA INTRAVENOUS SOLUTION Medical Benefit PA
ZORTRESS ORAL TABLET Brand SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
89
Drug Status NotesDISORDER OF THE ENDOCRINE GLANDS
acarbose oral tablet Generic
ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT Brand PA
ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
alendronate sodium oral tablet 10 mg, 5 mg Generic QL (30 EA per 30 days)
alendronate sodium oral tablet 35 mg, 70 mg Generic QL (4 EA per 28 days)
alogliptin benzoate oral tablet Generic PA; QL (30 EA per 30 days)
alogliptin-metformin hcl oral tablet Generic PA; QL (60 EA per 30 days)
alogliptin-pioglitazone oral tablet Generic PA; QL (30 EA per 30 days)
ANDRODERM TRANSDERMAL PATCH 24 HOUR Brand PA
ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
Brand PA
ANDROXY ORAL TABLET Brand PA
AURYXIA ORAL TABLET Brand PA
AVANDAMET ORAL TABLET 2-1000 MG Brand PA
AVANDIA ORAL TABLET Brand PA
bromocriptine mesylate oral capsule Generic
bromocriptine mesylate oral tablet Generic
BYDUREON SUBCUTANEOUS PEN-INJECTOR Brand PA
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER Brand PA
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION Brand PA
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION Brand PA
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
cabergoline oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
90
Drug Status Notescalcitonin (salmon) nasal solution Generic
calcium acetate (phos binder) oral capsule Generic
calcium acetate (phos binder) oral tablet Generic
captopril oral tablet Generic
chlorpropamide oral tablet Generic
cortisone acetate oral tablet Generic
CRINONE VAGINAL GEL 8 % Brand PA
desmopressin ace rhinal tube nasal solution Generic
desmopressin ace spray refrig nasal solution Generic
desmopressin acetate oral tablet Generic
desmopressin acetate spray nasal solution Generic
dexamethasone oral elixir Generic
dexamethasone oral solution Generic
dexamethasone oral tablet Generic
doxercalciferol oral capsule Generic
DUAVEE ORAL TABLET Brand PA
estradiol transdermal patch twice weekly Generic
estradiol transdermal patch weekly Generic
estropipate oral tablet Generic
FARXIGA ORAL TABLET Brand PA; QL (30 EA per 30 days)
fludrocortisone acetate oral tablet Generic
FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML Brand PA; SP; QL (1 vial per 30 days)
FOSAMAX PLUS D ORAL TABLET Brand PA; QL (4 EA per 28 days)
glimepiride oral tablet Generic
glipizide er oral tablet extended release 24 hour Generic
glipizide oral tablet Generic
glipizide xl oral tablet extended release 24 hour Generic
glipizide-metformin hcl oral tablet Generic
GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED Brand
GLUCAGON EMERGENCY INJECTION KIT Brand
glyburide micronized oral tablet Generic
glyburide oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
91
Drug Status Notesglyburide-metformin oral tablet Generic
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Brand
HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
Brand
hydrocortisone oral tablet Generic
HYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
ibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)
INCRELEX SUBCUTANEOUS SOLUTION Brand PA; SP
INTRAROSA VAGINAL INSERT Brand PA; QL (28 EA per 28 days)
INVOKAMET ORAL TABLET BrandPA; STPA; QL (60 EA per 30 days)
INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand
PA; STPA; QL (60 Tablets per 30 days)
INVOKANA ORAL TABLET 100 MG Brand STPA; QL (60 EA per 30 days)
INVOKANA ORAL TABLET 300 MG Brand STPA; QL (30 EA per 30 days)
KORLYM ORAL TABLET Brand PA
leuprolide acetate injection kit Medical Benefit PA; SP
LEVO-T ORAL TABLET Generic
levothyroxine sodium oral tablet Generic
liothyronine sodium oral tablet Generic
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
LYRICA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
LYRICA ORAL SOLUTION Brand PA; QL (900 ML per 30 days)
medroxyprogesterone acetate oral tablet Generic
metformin hcl er (mod) oral tablet extended release 24 hour
Generic PA
metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg
Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
92
Drug Status Notesmetformin hcl er oral tablet extended release 24 hour
Generic
metformin hcl oral tablet Generic
methimazole oral tablet Generic
methitest oral tablet Brand PA
methylprednisolone oral tablet Generic
methylprednisolone oral tablet therapy pack Generic
methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg
Generic
methyltestosterone oral capsule Generic
metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml
Generic
metoclopramide hcl oral tablet Generic
MIACALCIN INJECTION SOLUTION Brand
miglitol oral tablet Generic
nateglinide oral tablet Generic
NATPARA SUBCUTANEOUS CARTRIDGE BrandPA; SP; QL (2 Cartridges per 21 days)
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP
norethindrone acetate oral tablet Generic
norethindrone-eth estradiol oral tablet Generic
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
OSPHENA ORAL TABLET Brand PA
paricalcitol oral capsule Generic PA
pioglitazone hcl oral tablet Generic
pioglitazone hcl-glimepiride oral tablet Generic
pioglitazone hcl-metformin hcl oral tablet Generic
prednisolone oral solution Generic
prednisolone oral syrup 15 mg/5ml Generic
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
93
Drug Status Notesprednisolone sodium phosphate oral tablet dispersible
Generic
PREMARIN ORAL TABLET Brand
PREMARIN VAGINAL CREAM Brand
PREMPHASE ORAL TABLET Brand
PREMPRO ORAL TABLET Brand
progesterone intramuscular oil Generic PA
PROLIA SUBCUTANEOUS SOLUTION Medical BenefitPA; SP; QL (1 syringe per 180 days)
propylthiouracil oral tablet Generic
raloxifene hcl oral tablet Generic
repaglinide oral tablet Generic
repaglinide-metformin hcl oral tablet Generic
risedronate sodium oral tablet 150 mg Generic PA; QL (1 EA per 30 days)
risedronate sodium oral tablet 35 mg Generic PA; QL (4 EA per 28 days)
risedronate sodium oral tablet 5 mg Generic PA; QL (30 EA per 30 days)
risedronate sodium oral tablet delayed release Generic PA; QL (4 EA per 28 days)
SENSIPAR ORAL TABLET Brand PA
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG
Medical Benefit PA
SIGNIFOR SUBCUTANEOUS SOLUTION Brand PA; QL (60 ML per 30 days)
SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)
STRIANT BUCCAL Brand PA
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
SYNAREL NASAL SOLUTION Brand PA
TANZEUM SUBCUTANEOUS PEN-INJECTOR Brand PA
TESTOPEL IMPLANT PELLET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
94
Drug Status Notestestosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml
Generic PA
testosterone enanthate intramuscular solution Generic PA
testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
Generic PA
testosterone transdermal solution Generic PA
tolazamide oral tablet Generic
tolbutamide oral tablet Generic
TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; QL (2 ML per 30 days)
UNITHROID ORAL TABLET 137 MCG Generic
UNITHROID ORAL TABLET 50 MCG, 75 MCG, 88 MCG Brand
VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
EAR PROBLEM
ACETASOL HC OTIC SOLUTION Generic
acetic acid otic solution Generic
acetic acid-aluminum acetate otic solution Generic
ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)
CIPRO HC OTIC SUSPENSION Brand PA
CIPRODEX OTIC SUSPENSION Brand PA
dexamethasone sodium phosphate ophthalmic solution
Generic
fluocinolone acetonide otic oil Generic
hydrocortisone-acetic acid otic solution Generic
ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP
neomycin-polymyxin-hc otic solution Generic
neomycin-polymyxin-hc otic suspension Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
95
Drug Status Notesofloxacin otic solution Generic
EYE DISORDER
acetazolamide oral tablet Generic
ALOCRIL OPHTHALMIC SOLUTION Brand PA
ALPHAGAN P OPHTHALMIC SOLUTION0.1 % Brand PA
atropine sulfate ophthalmic solution Generic
azelastine hcl ophthalmic solution Generic PA
AZOPT OPHTHALMIC SUSPENSION Brand PA
bacitracin ophthalmic ointment Generic
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm
Generic
BEPREVE OPHTHALMIC SOLUTION Brand PA
betaxolol hcl ophthalmic solution Generic
bimatoprost ophthalmic solution Generic PA
brimonidine tartrate ophthalmic solution 0.15 % Generic PA
bromfenac sodium (once-daily) ophthalmic solution
Generic
bromfenac sodium ophthalmic solution Generic
carteolol hcl ophthalmic solution Generic
cevimeline hcl oral capsule Generic
COMBIGAN OPHTHALMIC SOLUTION Brand PA
cromolyn sodium ophthalmic solution Generic
cyclopentolate hcl ophthalmic solution 0.5 % Generic QL (15 ML per 30 days)
cyclopentolate hcl ophthalmic solution 1 %, 2 % Generic QL (2 ML per 30 days)
dexamethasone sodium phosphate ophthalmic solution
Generic
diclofenac sodium ophthalmic solution Generic
dorzolamide hcl ophthalmic solution Generic
dorzolamide hcl-timolol mal ophthalmic solution Generic
EMADINE OPHTHALMIC SOLUTION Brand PA
epinastine hcl ophthalmic solution Generic PA
erythromycin ophthalmic ointment Generic
fluorometholone ophthalmic suspension Generic
flurbiprofen sodium ophthalmic solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
96
Drug Status NotesGAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
HOMATROPAIRE OPHTHALMIC SOLUTION Generic
homatropine hbr ophthalmic solution Generic
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
ketorolac tromethamine ophthalmic solution Generic
ketotifen fumarate ophthalmic solution Generic
LASTACAFT OPHTHALMIC SOLUTION Brand PA
latanoprost ophthalmic solution Generic
levobunolol hcl ophthalmic solution 0.5 % Generic
LUMIGAN OPHTHALMIC SOLUTION 0.01 % Brand PA
methazolamide oral tablet Generic
metipranolol ophthalmic solution Generic
naphazoline hcl ophthalmic solution Generic
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025
Generic
neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1
Generic
NEO-POLYCIN OPHTHALMIC OINTMENT Generic
olopatadine hcl ophthalmic solution Generic PA
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
Generic
pilocarpine hcl oral tablet Generic
polymyxin b-trimethoprim ophthalmic solution Generic
polyvinyl alcohol ophthalmic solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
97
Drug Status Notesprednisolone acetate ophthalmic suspension Generic
proparacaine hcl ophthalmic solution Generic
RESCULA OPHTHALMIC SOLUTION Brand PA
RESTASIS OPHTHALMIC EMULSION Brand PA; QL (60 EA per 30 days)
RHOPRESSA OPHTHALMIC SOLUTION Brand PA
SIMBRINZA OPHTHALMIC SUSPENSION Brand PA
sulfacetamide sodium ophthalmic ointment Generic
sulfacetamide sodium ophthalmic solution Generic
sulfacetamide-prednisolone ophthalmic solution Generic
timolol maleate ophthalmic gel forming solution Generic
timolol maleate ophthalmic solution 0.25 %, 0.5 %
Generic
tobramycin-dexamethasone ophthalmic suspension
Generic
TRAVATAN Z OPHTHALMIC SOLUTION Brand PA
trifluridine ophthalmic solution Generic
tropicamide ophthalmic solution Generic
VYZULTA OPHTHALMIC SOLUTION Brand PA
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
ZIOPTAN OPHTHALMIC SOLUTION Brand PA
ZIRGAN OPHTHALMIC GEL Brand PA
FEVER
dantrolene sodium oral capsule Generic
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
INFECTION
abacavir sulfate oral solution Generic
abacavir sulfate oral tablet Generic
abacavir sulfate-lamivudine oral tablet Brand
abacavir-lamivudine-zidovudine oral tablet Brand
acyclovir external ointment Generic
adefovir dipivoxil oral tablet Generic
ALFERON N INJECTION SOLUTION Medical Benefit PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
98
Drug Status Notesamantadine hcl oral capsule Generic
amantadine hcl oral syrup Generic
amantadine hcl oral tablet Generic
amoxicill-clarithro-lansopraz oral Generic
APTIVUS ORAL CAPSULE Brand
APTIVUS ORAL SOLUTION Brand
atazanavir sulfate oral capsule Generic
atovaquone-proguanil hcl oral tablet Generic
ATRIPLA ORAL TABLET Brand
azelastine hcl nasal solution 0.1 % Brand
bacitracin ophthalmic ointment Generic
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm
Generic
BARACLUDE ORAL SOLUTION Brand
BECONASE AQ NASAL SUSPENSION Brand PA
benznidazole oral tablet Brand
benzonatate oral capsule 100 mg, 200 mg Generic
BIKTARVY ORAL TABLET Brand
budesonide nasal suspension Generic PA
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
chlorhexidine gluconate mouth/throat solution Generic
chloroquine phosphate oral tablet Generic
CICLODAN EXTERNAL CREAM Generic
CICLODAN EXTERNAL SOLUTION Generic
ciclopirox external gel Generic
ciclopirox external solution Brand
ciclopirox olamine external cream Generic
ciclopirox olamine external suspension Generic PA
CIMDUO ORAL TABLET Brand
CIPRODEX OTIC SUSPENSION Brand PA
CLARINEX ORAL SYRUP Brand PA
CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
99
Drug Status Notesclemastine fumarate oral tablet 2.68 mg Generic
clindamycin phosphate vaginal cream Generic
clotrimazole anti-fungal external cream Generic
clotrimazole external cream Generic
clotrimazole external solution Generic
clotrimazole mouth/throat lozenge Generic
clotrimazole mouth/throat troche Generic
clotrimazole-betamethasone external cream Generic
clotrimazole-betamethasone external lotion Generic
COARTEM ORAL TABLET Brand QL (24 EA per 30 days)
COMPLERA ORAL TABLET Brand
CRESEMBA ORAL CAPSULE Brand PA
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand
cyproheptadine hcl oral syrup Generic
cyproheptadine hcl oral tablet Generic
DAKLINZA ORAL TABLET Brand PA; SP
dapsone oral tablet Brand
DENAVIR EXTERNAL CREAM Brand PA; QL (5 GM per 1 Fill)
DESCOVY ORAL TABLET Brand
desloratadine oral tablet Generic PA
didanosine oral capsule delayed release Generic
DIFICID ORAL TABLET Brand PA; QL (20 EA per 1 Fill)
dronabinol oral capsule Generic
econazole nitrate external cream Generic
ECOZA EXTERNAL FOAM Brand PA
EDURANT ORAL TABLET Brand
efavirenz oral capsule Generic
efavirenz oral tablet Generic
EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
EMTRIVA ORAL CAPSULE Brand
EMTRIVA ORAL SOLUTION Brand
entecavir oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
100
Drug Status NotesEPCLUSA ORAL TABLET Brand PA; SP; # (Genotypes 2-6)
epinephrine hcl injection solution 1 mg/ml Generic
erythromycin ophthalmic ointment Generic
EVOTAZ ORAL TABLET Brand
EXELDERM EXTERNAL CREAM Brand PA
EXELDERM EXTERNAL SOLUTION Brand PA
flunisolide nasal solution 25 mcg/act (0.025%) Generic
fluticasone propionate nasal suspension Generic
fosamprenavir calcium oral tablet Generic
FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP
gabapentin oral capsule Generic
gabapentin oral solution 250 mg/5ml Generic
gabapentin oral tablet Generic
GAMASTAN S/D INTRAMUSCULAR INJECTABLE Medical Benefit PA; SP
gentamicin sulfate external cream Generic
gentamicin sulfate external ointment Generic
GENVOYA ORAL TABLET Brand
GRALISE ORAL TABLET Brand PA; QL (90 EA per 30 days)
GRALISE STARTER ORAL Brand PA
griseofulvin microsize oral suspension Generic
griseofulvin microsize oral tablet Generic
griseofulvin ultramicrosize oral tablet Generic
guaifenesin er oral tablet extended release 12 hour 600 mg
Generic
HARVONI ORAL TABLET Brand PA; SP
hydrocod polst-cpm polst er oral suspension extended release
Generic
hydrocodone-homatropine oral syrup Generic
hydrocodone-homatropine oral tablet Generic
hydromet oral syrup Generic
imiquimod external cream Generic
IMPAVIDO ORAL CAPSULE Brand
INTELENCE ORAL TABLET Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
101
Drug Status NotesINVIRASE ORAL CAPSULE Brand
INVIRASE ORAL TABLET Brand
ipratropium bromide nasal solution Generic
ISENTRESS HD ORAL TABLET Brand QL (60 EA per 30 days)
ISENTRESS ORAL PACKET Brand QL (60 EA per 30 days)
ISENTRESS ORAL TABLET Brand
ISENTRESS ORAL TABLET CHEWABLE Brand
isoniazid oral syrup Generic
isoniazid oral tablet Generic
ivermectin oral tablet Generic
JUBLIA EXTERNAL SOLUTION Brand PA
JULUCA ORAL TABLET Brand
KALETRA ORAL SOLUTION Brand
KALETRA ORAL TABLET Brand
ketoconazole external cream Generic
ketoconazole external shampoo Generic
LAMISIL ORAL PACKET BrandPA; ¥ (Max of 6 weeks); QL (2 Packets per 1 day)
lamivudine oral solution Brand
lamivudine oral tablet 100 mg Generic
lamivudine oral tablet 150 mg, 300 mg Brand
lamivudine-zidovudine oral tablet Brand
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
LEXIVA ORAL SUSPENSION Brand
lidocaine external patch 5 % Generic
lindane external lotion Generic
lindane external shampoo Generic
luliconazole external cream Generic PA
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
malathion external lotion Generic
MAVYRET ORAL TABLET Brand PA; SP
mefloquine hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
102
Drug Status Notesmegestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml
Generic
methenamine hippurate oral tablet Generic
methenamine mandelate oral tablet Generic
metronidazole vaginal gel Generic
miconazole 3 vaginal suppository Generic
mometasone furoate nasal suspension Generic PA
montelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
mupirocin calcium external cream Generic PA
mupirocin external ointment Generic
naftifine hcl external cream Generic PA
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025
Generic
neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1
Generic
NEO-POLYCIN OPHTHALMIC OINTMENT Generic
nevirapine er oral tablet extended release 24 hour Generic
nevirapine oral suspension Generic
nevirapine oral tablet Generic
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP
NORVIR ORAL CAPSULE Brand
NORVIR ORAL PACKET Brand
NORVIR ORAL SOLUTION Brand
NOXAFIL ORAL SUSPENSION Brand PA
NOXAFIL ORAL TABLET DELAYED RELEASE Brand PA
NYAMYC EXTERNAL POWDER Generic
nystatin external cream Generic
nystatin external ointment Generic
nystatin external powder Generic
nystatin mouth/throat suspension Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
103
Drug Status Notesnystatin oral powder Generic
nystatin oral tablet Generic
nystatin-triamcinolone external cream Generic
nystatin-triamcinolone external ointment Generic
NYSTOP EXTERNAL POWDER Generic
ODACTRA SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
ODEFSEY ORAL TABLET Brand
OLYSIO ORAL CAPSULE Brand PA; SP
OMNARIS NASAL SUSPENSION Brand PA
ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
oseltamivir phosphate oral capsule 30 mg Generic¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)
oseltamivir phosphate oral capsule 45 mg, 75 mg Generic¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)
oseltamivir phosphate oral suspension reconstituted
Generic¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)
oxiconazole nitrate external cream Generic PA
OXISTAT EXTERNAL LOTION Brand PA
PAROEX MOUTH/THROAT SOLUTION Generic
paromomycin sulfate oral capsule Generic
PASER ORAL PACKET Brand PA
PERIOGARD MOUTH/THROAT SOLUTION Generic
permethrin external cream Generic
phenyleph-promethazine-cod oral syrup Generic
podofilox external solution Generic
polymyxin b-trimethoprim ophthalmic solution Generic
praziquantel oral tablet Generic
PREVYMIS INTRAVENOUS SOLUTION Medical Benefit PA
PREVYMIS ORAL TABLET Brand PA
PREZCOBIX ORAL TABLET Brand
PREZISTA ORAL SUSPENSION Brand
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
104
Drug Status NotesPRIFTIN ORAL TABLET Brand PA
PROMACTA ORAL TABLET Brand SP
promethazine vc plain oral syrup Generic
promethazine vc/codeine oral syrup Generic
promethazine-codeine oral syrup Generic
promethazine-dm oral syrup Generic
promethazine-phenylephrine oral syrup Generic
pseudoephedrine hcl oral tablet 60 mg Generic
QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA
QNASL NASAL AEROSOL SOLUTION Brand PA
RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand¥ (Max of 2 fills per year); QL (20 Blisters per 1 Rx)
RESCRIPTOR ORAL TABLET Brand
REYATAZ ORAL PACKET Brand
RIBASPHERE ORAL CAPSULE Generic QL (210 EA per 30 days)
RIBASPHERE ORAL TABLET 200 MG Generic QL (210 EA per 30 days)
ribavirin oral capsule Generic
ribavirin oral tablet 200 mg Generic
rimantadine hcl oral tablet Generic
ritonavir oral tablet Generic
SELZENTRY ORAL SOLUTION Brand QL (1800 ML per 30 days)
SELZENTRY ORAL TABLET Brand
SEMPREX-D ORAL CAPSULE Brand PA
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP
silver sulfadiazine external cream Generic
SIRTURO ORAL TABLET Brand PA
SKLICE EXTERNAL LOTION BrandPA; STPA; QL (117 GM per 1 day)
SOLOSEC ORAL PACKET Brand PA
SOVALDI ORAL TABLET Brand PA; SP
spinosad external suspension BrandPA; STPA; QL (120 ML per 1 Fill)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
105
Drug Status NotesSSD EXTERNAL CREAM Generic
stavudine oral capsule Brand
stavudine oral solution reconstituted Brand
STRIBILD ORAL TABLET Brand
sulfacetamide sodium ophthalmic ointment Generic
sulfacetamide sodium ophthalmic solution Generic
SYMFI LO ORAL TABLET Brand
SYMFI ORAL TABLET Brand
SYMTUZA ORAL TABLET Brand
SYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
SYNDROS ORAL SOLUTION Brand PA
TECHNIVIE ORAL TABLET Brand PA; SP
tenofovir disoproxil fumarate oral tablet Generic
terconazole vaginal cream Generic
terconazole vaginal suppository Generic
tinidazole oral tablet Generic
TIVICAY ORAL TABLET Brand
TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)
tobramycin inhalation nebulization solution Generic
tobramycin-dexamethasone ophthalmic suspension
Generic
TRECATOR ORAL TABLET Brand PA
triamcinolone acetonide nasal aerosol Generic
trifluridine ophthalmic solution Generic
TRIUMEQ ORAL TABLET Brand
TRUVADA ORAL TABLET 200-300 MG Brand
TUSSIGON ORAL TABLET Generic
TYBOST ORAL TABLET Brand
ULESFIA EXTERNAL LOTION Brand PA; QL (12 Bottles per 1 Rx)
VANDAZOLE VAGINAL GEL Generic
VERAMYST NASAL SUSPENSION Brand PA
VEREGEN EXTERNAL OINTMENT Brand PA
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
106
Drug Status NotesVIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; SP
VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP
VIRACEPT ORAL TABLET Brand
VIREAD ORAL POWDER Brand
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Brand
VOSEVI ORAL TABLET Brand PA; SP
XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG Brand PA; QL (6 EA per 30 days)
ZEPATIER ORAL TABLET Brand PA; SP
ZETONNA NASAL AEROSOL SOLUTION Brand PA
zidovudine oral capsule Brand
zidovudine oral syrup Brand
zidovudine oral tablet Brand
ZINPLAVA INTRAVENOUS SOLUTION Medical Benefit PA
ZIRGAN OPHTHALMIC GEL Brand PA
ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY
spironolactone oral tablet Generic
INFLAMMATORY DISORDER
ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE Brand PA
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 400 MG/20ML Medical Benefit PA; SP; QL (2 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 80 MG/4ML Medical Benefit PA; SP; QL (10 vials per 28 days)
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (4 syringes per 28 days)
adefovir dipivoxil oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
107
Drug Status NotesADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE
BrandPA; Age Limit (Min 4 Years and Max 11 Years)
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE
Brand PA
ADVAIR HFA INHALATION AEROSOL Brand PA
alclometasone dipropionate external cream Generic
alclometasone dipropionate external ointment Generic
ALFERON N INJECTION SOLUTION Medical Benefit PA
ALOCRIL OPHTHALMIC SOLUTION Brand PA
Alphanate/VWF Complex/Human Intravenous Solution Reconstituted
MB/RX PA; SP
ALVESCO INHALATION AEROSOL SOLUTION Brand
amcinonide external cream Generic PA
amcinonide external lotion Generic PA
amcinonide external ointment Generic PA
amoxicill-clarithro-lansopraz oral Generic
ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
APEXICON E EXTERNAL CREAM Brand PA
APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand
ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)
ARCAPTA NEOHALER INHALATION CAPSULE Brand QL (1 EA per 30 days)
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
108
Drug Status NotesASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX HFA INHALATION AEROSOL Brand
azathioprine oral tablet Generic
azelastine hcl nasal solution 0.1 % Brand
azelastine hcl ophthalmic solution Generic PA
balsalazide disodium oral capsule Generic
BARACLUDE ORAL SOLUTION Brand
BECONASE AQ NASAL SUSPENSION Brand PA
BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA
BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA
benzonatate oral capsule 100 mg, 200 mg Generic
BEPREVE OPHTHALMIC SOLUTION Brand PA
betamethasone dipropionate aug external cream Generic
betamethasone dipropionate aug external gel Generic
betamethasone dipropionate aug external lotion Generic
betamethasone dipropionate aug external ointment
Generic
betamethasone dipropionate external cream Generic
betamethasone dipropionate external lotion Generic
betamethasone dipropionate external ointment Generic
betamethasone valerate external cream Generic
betamethasone valerate external lotion Generic
betamethasone valerate external ointment Generic
BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED Brand PA; QL (1 EA per 30 days)
bromfenac sodium (once-daily) ophthalmic solution
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
109
Drug Status Notesbromfenac sodium ophthalmic solution Generic
budesonide er oral tablet extended release 24 hour
Generic PA
budesonide inhalation suspension Generic
budesonide nasal suspension Generic PA
budesonide oral capsule delayed release particles Generic
CAPEX EXTERNAL SHAMPOO Brand PA
CARAFATE ORAL SUSPENSION BrandPA; ¥ (PA applies to members 12 years and older)
CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM
Medical Benefit PA; SP
celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
cevimeline hcl oral capsule Generic
chlordiazepoxide-clidinium oral capsule Generic
choline-mag trisalicylate oral liquid Generic
CICLODAN EXTERNAL CREAM Generic
ciclopirox external gel Generic
ciclopirox external shampoo Brand PA
ciclopirox olamine external cream Generic
ciclopirox olamine external suspension Generic PA
cimetidine hcl oral solution Generic
cimetidine oral tablet 300 mg, 400 mg, 800 mg Generic
CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)
CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand
PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)
CINQAIR INTRAVENOUS SOLUTION Medical Benefit PA
CLARINEX ORAL SYRUP Brand PA
CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
clemastine fumarate oral tablet 2.68 mg Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
110
Drug Status Notesclobetasol propionate e external cream Generic
clobetasol propionate external cream Generic PA
clobetasol propionate external foam Generic
clobetasol propionate external gel Generic PA
clobetasol propionate external lotion Generic
clobetasol propionate external ointment Generic PA
clocortolone pivalate external cream Generic PA
clocortolone pivalate pump external cream Generic PA
clotrimazole anti-fungal external cream Generic
clotrimazole external cream Generic
clotrimazole external solution Generic
clotrimazole mouth/throat lozenge Generic
clotrimazole mouth/throat troche Generic
clotrimazole-betamethasone external cream Generic
clotrimazole-betamethasone external lotion Generic
colchicine oral tablet Generic
colchicine-probenecid oral tablet Generic
COLOCORT RECTAL ENEMA Generic
CORDRAN EXTERNAL TAPE Brand PA
cortisone acetate oral tablet Generic
COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
BrandPA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
BrandPA; SP; QL (1 Syringe per 28 days)
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 28 days)
cromolyn sodium inhalation nebulization solution Generic
cromolyn sodium ophthalmic solution Generic
cyproheptadine hcl oral syrup Generic
cyproheptadine hcl oral tablet Generic
DAKLINZA ORAL TABLET Brand PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
111
Drug Status NotesDALIRESP ORAL TABLET Brand PA; STPA
desloratadine oral tablet Generic PA
desonide external cream Generic PA
desonide external lotion Generic PA
desonide external ointment Generic PA
desoximetasone external cream 0.05 % Generic PA
desoximetasone external cream 0.25 % Generic
desoximetasone external gel Generic
desoximetasone external ointment 0.05 % Generic PA
desoximetasone external ointment 0.25 % Generic
dexamethasone sodium phosphate ophthalmic solution
Generic
diclofenac potassium oral tablet Generic
diclofenac sodium er oral tablet extended release 24 hour
Generic
diclofenac sodium ophthalmic solution Generic
diclofenac sodium transdermal gel 1 % Generic STPA
diclofenac sodium transdermal solution Generic PA
DIFICID ORAL TABLET Brand PA; QL (20 EA per 1 Fill)
diflorasone diacetate external cream Generic PA
diflorasone diacetate external ointment Generic PA
DIPENTUM ORAL CAPSULE Brand
DULERA INHALATION AEROSOL Brand PA
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML Brand PA; SP; QL (2 ML per 28 days)
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Brand PA; QL (4 ML per 28 days)
DUZALLO ORAL TABLET Brand PA
econazole nitrate external cream Generic
ECOZA EXTERNAL FOAM Brand PA
EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
ELIDEL EXTERNAL CREAM Brand PA
EMADINE OPHTHALMIC SOLUTION Brand PA
EMFLAZA ORAL SUSPENSION Brand PA; QL (26 ML per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
112
Drug Status NotesEMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)
ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE Brand PA; SP; QL (4 each per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (4 syringes per 28 days)
entecavir oral tablet Generic
ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
EPCLUSA ORAL TABLET Brand PA; SP; # (Genotypes 2-6)
epinastine hcl ophthalmic solution Generic PA
etodolac er oral tablet extended release 24 hour Generic
etodolac oral capsule Generic
etodolac oral tablet Generic
EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP
EXELDERM EXTERNAL CREAM Brand PA
EXELDERM EXTERNAL SOLUTION Brand PA
EXONDYS 51 INTRAVENOUS SOLUTION Medical Benefit PA
FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA
FINACEA EXTERNAL FOAM Brand PA; QL (50 GM per 1 Rx)
FINACEA EXTERNAL GEL Brand PA; QL (50 GM per 1 Rx)
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
FLOVENT HFA INHALATION AEROSOL Brand
flunisolide nasal solution 25 mcg/act (0.025%) Generic
fluocinolone acetonide body external oil Generic
fluocinolone acetonide external cream Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
113
Drug Status Notesfluocinolone acetonide external ointment Generic
fluocinolone acetonide external solution Generic
fluocinolone acetonide otic oil Generic
fluocinolone acetonide scalp external oil Generic
fluocinonide external cream 0.05 % Generic QL (60 GM per 30 days)
fluocinonide external cream 0.1 % Generic PA; QL (120 GM per 30 days)
fluocinonide external gel Generic QL (60 GM per 30 days)
fluocinonide external ointment Generic QL (60 GM per 30 days)
fluocinonide external solution Generic QL (60 ML per 30 days)
fluorometholone ophthalmic suspension Generic
flurandrenolide external cream Generic PA
flurandrenolide external lotion Generic PA
flurandrenolide external ointment Generic PA
flurbiprofen oral tablet Generic
fluticasone propionate external cream Generic
fluticasone propionate external lotion Generic
fluticasone propionate external ointment Generic
fluticasone propionate nasal suspension Generic
fluticasone-salmeterol inhalation aerosol powder breath activated
Generic
FORADIL AEROLIZER INHALATION CAPSULE Brand
GAMASTAN S/D INTRAMUSCULAR INJECTABLE Medical Benefit PA; SP
Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML
MB/RX PA
Gammagard Injection Solution 20 GM/200ML MB/RX PA; SP
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA
GAMMAPLEX INTRAVENOUS SOLUTION5 GM/50ML Medical Benefit PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
114
Drug Status NotesGAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP
GIAZO ORAL TABLET Brand PA
guaifenesin er oral tablet extended release 12 hour 600 mg
Generic
guanidine hcl oral tablet Brand PA
halobetasol propionate external cream Generic PA
halobetasol propionate external ointment Generic PA
HALOG EXTERNAL CREAM Brand PA
HALOG EXTERNAL OINTMENT Brand PA
HARVONI ORAL TABLET Brand PA; SP
HEMMOREX-HC RECTAL SUPPOSITORY Generic
HOMATROPAIRE OPHTHALMIC SOLUTION Generic
homatropine hbr ophthalmic solution Generic
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
MB/RX PA; SP
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)
hydrocod polst-cpm polst er oral suspension extended release
Generic
hydrocodone-homatropine oral syrup Generic
hydrocodone-homatropine oral tablet Generic
hydrocortisone ace-pramoxine external cream2.5-1 %
Generic
hydrocortisone acetate rectal suppository Generic
hydrocortisone butyrate external cream Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
115
Drug Status Noteshydrocortisone butyrate external ointment Generic PA
hydrocortisone butyrate external solution Generic PA
hydrocortisone external cream 1 %, 2.5 % Generic
hydrocortisone external lotion Generic
hydrocortisone external ointment 1 %, 2.5 % Generic
hydrocortisone oral tablet Generic
hydrocortisone rectal cream Generic
hydrocortisone rectal enema Generic
hydrocortisone valerate external cream Generic
hydrocortisone valerate external ointment Generic
hydromet oral syrup Generic
hydroxychloroquine sulfate oral tablet Generic
ibuprofen oral suspension Generic
ibuprofen oral tablet 400 mg, 600 mg, 800 mg Generic
ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP
imiquimod external cream Generic
INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
indomethacin er oral capsule extended release Generic
indomethacin oral capsule Generic
INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
ipratropium bromide nasal solution Generic
JUBLIA EXTERNAL SOLUTION Brand PA
ketoconazole external cream Generic
ketoconazole external foam Generic
ketoconazole external shampoo Generic
KETODAN EXTERNAL FOAM Generic
ketoprofen er oral capsule extended release 24 hour
Generic
ketoprofen oral capsule Generic
ketorolac tromethamine ophthalmic solution Generic
ketotifen fumarate ophthalmic solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
116
Drug Status NotesKEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (2.28 ML per 30 days)
KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (2.28 ML per 30 days)
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)
KRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP
LAMISIL ORAL PACKET BrandPA; ¥ (Max of 6 weeks); QL (2 Packets per 1 day)
lamivudine oral tablet 100 mg Generic
lansoprazole oral capsule delayed release Generic PA
lansoprazole oral tablet dispersible Generic PA; ¥ (Age Limit: Max 2 years)
LASTACAFT OPHTHALMIC SOLUTION Brand PA
leflunomide oral tablet Generic
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
luliconazole external cream Generic PA
MAVYRET ORAL TABLET Brand PA; SP
meclofenamate sodium oral capsule Generic
meloxicam oral suspension Generic
meloxicam oral tablet Generic
mesalamine oral tablet delayed release 1.2 gm GenericPA; STPA; QL (120 EA per 30 days)
mesalamine oral tablet delayed release 800 mg Generic
mesalamine rectal enema Generic
methotrexate oral tablet Generic
methylprednisolone oral tablet Generic
methylprednisolone oral tablet therapy pack Generic
methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg
Generic
metronidazole external cream Generic
metronidazole external gel 0.75 % Generic
metronidazole external gel 1 % Generic PA
metronidazole external lotion Generic
MIRVASO EXTERNAL GEL Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
117
Drug Status Notesmometasone furoate external cream Generic
mometasone furoate external ointment Generic
mometasone furoate external solution Generic
mometasone furoate nasal suspension Generic PA
montelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
mupirocin calcium external cream Generic PA
mupirocin external ointment Generic
MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; QL (30 Vials per 30 days)
nabumetone oral tablet Generic
naftifine hcl external cream Generic PA
naproxen dr oral tablet delayed release Generic
naproxen oral suspension Generic
naproxen oral tablet Generic
naproxen sodium oral tablet Generic
nizatidine oral capsule Generic
nizatidine oral solution Generic
NORITATE EXTERNAL CREAM Brand PA
NOXAFIL ORAL SUSPENSION Brand PA
NOXAFIL ORAL TABLET DELAYED RELEASE Brand PA
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA
NYAMYC EXTERNAL POWDER Generic
nystatin external cream Generic
nystatin external ointment Generic
nystatin external powder Generic
nystatin-triamcinolone external cream Generic
nystatin-triamcinolone external ointment Generic
NYSTOP EXTERNAL POWDER Generic
Obizur Intravenous Solution Reconstituted MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
118
Drug Status NotesOCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML
Medical Benefit PA; SP
ODACTRA SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
olopatadine hcl ophthalmic solution Generic PA
OLUMIANT ORAL TABLET Brand PA
OLYSIO ORAL CAPSULE Brand PA; SP
omeprazole oral capsule delayed release Generic
omeprazole-sodium bicarbonate oral packet Generic PA
OMNARIS NASAL SUSPENSION Brand PA
ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)
ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit
PA; SP; QL (4 VIALS per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML
Brand PA; QL (1.6 ML per 28 days)
OTEZLA ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
OTEZLA ORAL TABLET THERAPY PACK Brand PA; SP; QL (60 EA per 30 days)
oxaprozin oral tablet Generic
oxiconazole nitrate external cream Generic PA
OXISTAT EXTERNAL LOTION Brand PA
PANRETIN EXTERNAL GEL Brand PA
PASER ORAL PACKET Brand PA
PENNSAID TRANSDERMAL SOLUTION 2 % Brand PA
PENTASA ORAL CAPSULE EXTENDED RELEASE Brand
PERFOROMIST INHALATION NEBULIZATION SOLUTION Brand
phenyleph-promethazine-cod oral syrup Generic
pilocarpine hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
119
Drug Status Notespiroxicam oral capsule Generic
podofilox external solution Generic
polymyxin b-trimethoprim ophthalmic solution Generic
prednicarbate external cream Generic
prednisolone acetate ophthalmic suspension Generic
prednisolone oral solution Generic
prednisolone oral syrup 15 mg/5ml Generic
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
Generic
prednisolone sodium phosphate oral tablet dispersible
Generic
PRIFTIN ORAL TABLET Brand PA
PRILOSEC ORAL PACKET Brand PA
PRIVIGEN INTRAVENOUS SOLUTION Medical Benefit PA
probenecid oral tablet Generic
PROCTO-PAK RECTAL CREAM Generic
PROCTOSOL HC RECTAL CREAM Generic
PROCTOZONE-HC RECTAL CREAM Generic
PROMACTA ORAL TABLET Brand SP
promethazine vc plain oral syrup Generic
promethazine vc/codeine oral syrup Generic
promethazine-codeine oral syrup Generic
promethazine-dm oral syrup Generic
promethazine-phenylephrine oral syrup Generic
pseudoephedrine hcl oral tablet 60 mg Generic
PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
pyridostigmine bromide er oral tablet extended release
Generic
pyridostigmine bromide oral tablet Generic
QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA
QNASL NASAL AEROSOL SOLUTION Brand PA
QVAR INHALATION AEROSOL SOLUTION Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
120
Drug Status NotesQVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED Brand QL (10.6 GM per 30 days)
rabeprazole sodium oral tablet delayed release Generic PA
ranitidine hcl oral capsule Generic
ranitidine hcl oral syrup Generic
ranitidine hcl oral tablet 150 mg, 300 mg Generic
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RESTASIS OPHTHALMIC EMULSION Brand PA; QL (60 EA per 30 days)
RIBASPHERE ORAL CAPSULE Generic QL (210 EA per 30 days)
RIBASPHERE ORAL TABLET 200 MG Generic QL (210 EA per 30 days)
ribavirin oral capsule Generic
ribavirin oral tablet 200 mg Generic
RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP
salsalate oral tablet Generic
SAVELLA ORAL TABLET Brand STPA; QL (60 EA per 30 days)
SAVELLA TITRATION PACK ORAL Brand STPA; QL (60 EA per 30 days)
selenium sulfide external lotion Generic
selenium sulfide external shampoo 2.25 % Generic
selenium sulf-pyrithione-urea external shampoo Generic
SEMPREX-D ORAL CAPSULE Brand PA
SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (1 syringe per 28 days)
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 syringe per 28 days)
SIRTURO ORAL TABLET Brand PA
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
SOOLANTRA EXTERNAL CREAM Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
121
Drug Status NotesSOVALDI ORAL TABLET Brand PA; SP
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
Brand
STELARA INTRAVENOUS SOLUTION Medical BenefitPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 84 days)
STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION Brand
sucralfate oral tablet Generic
sulfacetamide sodium ophthalmic ointment Generic
sulfacetamide sodium ophthalmic solution Generic
sulfacetamide-prednisolone ophthalmic solution Generic
sulfasalazine oral tablet Generic
sulfasalazine oral tablet delayed release Generic
sulindac oral tablet Generic
SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT Brand PA
SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT Brand
PA; ¥ (PA applies to members 0-5 years of age and members 12 years of age and older (no PA required for members 6 through 11 years of age))
SYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
SYNALAR (CREAM) EXTERNAL KIT Brand PA
SYNALAR (OINTMENT) EXTERNAL KIT Brand PA
tacrolimus external ointment Generic PA
TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)
TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)
TAVALISSE ORAL TABLET Brand QL (60 EA per 30 days)
TECHNIVIE ORAL TABLET Brand PA; SP
tenofovir disoproxil fumarate oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
122
Drug Status Notestheophylline er oral tablet extended release 12 hour
Generic
theophylline er oral tablet extended release 24 hour
Generic
theophylline oral solution Generic
TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)
tobramycin inhalation nebulization solution Generic
tobramycin-dexamethasone ophthalmic suspension
Generic
tolmetin sodium oral capsule Generic
tolmetin sodium oral tablet Generic
TREXALL ORAL TABLET Brand
triamcinolone acetonide external aerosol solution Generic PA
triamcinolone acetonide external cream Generic
triamcinolone acetonide external lotion Generic
triamcinolone acetonide external ointment Generic
triamcinolone acetonide nasal aerosol Generic
trifluridine ophthalmic solution Generic
TUSSIGON ORAL TABLET Generic
TYSABRI INTRAVENOUS CONCENTRATE Medical Benefit PA; SP; QL (1 vial per 28 days)
UCERIS RECTAL FOAM Brand PA
VERAMYST NASAL SUSPENSION Brand PA
VEREGEN EXTERNAL OINTMENT Brand PA
VIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; SP
VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP
VIREAD ORAL POWDER Brand
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Brand
VOSEVI ORAL TABLET Brand PA; SP
Wilate Intravenous Kit MB/RX PA; SP
Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT
MB/RX PA; SP
XATMEP ORAL SOLUTION Brand PA
XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
123
Drug Status NotesXELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
zafirlukast oral tablet Brand
ZEPATIER ORAL TABLET Brand PA; SP
ZETONNA NASAL AEROSOL SOLUTION Brand PA
ZINPLAVA INTRAVENOUS SOLUTION Medical Benefit PA
ZIRGAN OPHTHALMIC GEL Brand PA
ZURAMPIC ORAL TABLET Brand PA
INJURY TO A MUCOUS MEMBRANE
ALOCRIL OPHTHALMIC SOLUTION Brand PA
azelastine hcl ophthalmic solution Generic PA
BECONASE AQ NASAL SUSPENSION Brand PA
BEPREVE OPHTHALMIC SOLUTION Brand PA
chlorhexidine gluconate mouth/throat solution Generic
clotrimazole mouth/throat lozenge Generic
clotrimazole mouth/throat troche Generic
cromolyn sodium ophthalmic solution Generic
doxycycline hyclate oral tablet 20 mg Generic
EMADINE OPHTHALMIC SOLUTION Brand PA
epinastine hcl ophthalmic solution Generic PA
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
INTRAROSA VAGINAL INSERT Brand PA; QL (28 EA per 28 days)
ketotifen fumarate ophthalmic solution Generic
LASTACAFT OPHTHALMIC SOLUTION Brand PA
NOXAFIL ORAL SUSPENSION Brand PA
nystatin mouth/throat suspension Generic
nystatin oral powder Generic
nystatin oral tablet Generic
olopatadine hcl ophthalmic solution Generic PA
OSPHENA ORAL TABLET Brand PA
PAROEX MOUTH/THROAT SOLUTION Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
124
Drug Status NotesPERIOGARD MOUTH/THROAT SOLUTION Generic
polymyxin b-trimethoprim ophthalmic solution Generic
PREMARIN VAGINAL CREAM Brand
PREMPHASE ORAL TABLET Brand
PREMPRO ORAL TABLET Brand
RESTASIS OPHTHALMIC EMULSION Brand PA; QL (60 EA per 30 days)
sulfacetamide sodium ophthalmic ointment Generic
sulfacetamide sodium ophthalmic solution Generic
triamcinolone acetonide mouth/throat paste Generic
trifluridine ophthalmic solution Generic
LUNG DISEASE
acetazolamide oral tablet Generic
acetylcysteine inhalation solution Generic
ADEMPAS ORAL TABLET Brand PA; SP
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE
BrandPA; Age Limit (Min 4 Years and Max 11 Years)
ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE
Brand PA
ADVAIR HFA INHALATION AEROSOL Brand PA
albuterol sulfate er oral tablet extended release 12 hour
Generic
albuterol sulfate inhalation nebulization solution Generic
albuterol sulfate oral syrup Generic
albuterol sulfate oral tablet Generic
ALVESCO INHALATION AEROSOL SOLUTION Brand
ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
ARCAPTA NEOHALER INHALATION CAPSULE Brand QL (1 EA per 30 days)
armodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)
armodafinil oral tablet 50 mg Generic PA; QL (60 Tablets per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
125
Drug Status NotesASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ASMANEX HFA INHALATION AEROSOL Brand
ATROVENT HFA INHALATION AEROSOL SOLUTION Brand
benzonatate oral capsule 100 mg, 200 mg Generic
BEVYXXA ORAL CAPSULE Brand PA
BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED Brand PA; QL (1 EA per 30 days)
budesonide inhalation suspension Generic
caffeine citrate oral solution Generic
CAYSTON INHALATION SOLUTION RECONSTITUTED Brand
chlorpromazine hcl oral tablet Generic
CINQAIR INTRAVENOUS SOLUTION Medical Benefit PA
COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Brand
cromolyn sodium inhalation nebulization solution Generic
DALIRESP ORAL TABLET Brand PA; STPA
DULERA INHALATION AEROSOL Brand PA
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML Brand PA; SP; QL (2 ML per 28 days)
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Brand PA; QL (4 ML per 28 days)
ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
126
Drug Status Notesepoprostenol sodium intravenous solution reconstituted 0.5 mg
Medical Benefit PA; QL (4 EA per 30 days)
epoprostenol sodium intravenous solution reconstituted 1.5 mg
Medical Benefit PA; QL (2 EA per 30 days)
ESBRIET ORAL CAPSULE Brand SP; QL (270 EA per 30 days)
ESBRIET ORAL TABLET Brand SP; QL (270 EA per 30 days)
ethacrynic acid oral tablet Generic PA
FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA
FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
FLOVENT HFA INHALATION AEROSOL Brand
fluticasone-salmeterol inhalation aerosol powder breath activated
Generic
FORADIL AEROLIZER INHALATION CAPSULE Brand
furosemide injection solution 10 mg/ml Generic
GLYDO EXTERNAL GEL Generic
guaifenesin er oral tablet extended release 12 hour 600 mg
Generic
hydrocod polst-cpm polst er oral suspension extended release
Generic
hydrocodone-homatropine oral syrup Generic
hydrocodone-homatropine oral tablet Generic
hydromet oral syrup Generic
INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
ipratropium bromide inhalation solution Generic
ipratropium-albuterol inhalation solution Generic
KALYDECO ORAL PACKET Brand PA; SP; QL (60 EA per 30 days)
KALYDECO ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
LETAIRIS ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
127
Drug Status Noteslevalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml
Generic
levalbuterol tartrate inhalation aerosol Generic PA
lidocaine external ointment Generic QL (50 GM per 30 days)
lidocaine hcl external gel 2 % Generic
metaproterenol sulfate oral syrup Generic
metaproterenol sulfate oral tablet Generic
modafinil oral tablet Generic PA; QL (30 EA per 30 days)
montelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
NOXAFIL ORAL SUSPENSION Brand PA
NOXAFIL ORAL TABLET DELAYED RELEASE Brand PA
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA
OFEV ORAL CAPSULE Brand QL (60 EA per 30 days)
OPSUMIT ORAL TABLET Brand PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG Brand PA
ORKAMBI ORAL PACKET Brand PA; QL (56 EA per 28 days)
ORKAMBI ORAL TABLET Brand PA; QL (120 EA per 30 days)
PASER ORAL PACKET Brand PA
PERFOROMIST INHALATION NEBULIZATION SOLUTION Brand
phenyleph-promethazine-cod oral syrup Generic
PRIFTIN ORAL TABLET Brand PA
PROAIR HFA INHALATION AEROSOL SOLUTION Brand PA
PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
promethazine vc/codeine oral syrup Generic
promethazine-codeine oral syrup Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
128
Drug Status Notespromethazine-dm oral syrup Generic
PROVENTIL HFA INHALATION AEROSOL SOLUTION Brand PA
PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
PULMOZYME INHALATION SOLUTION Brand SP
QVAR INHALATION AEROSOL SOLUTION Brand
QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED Brand QL (10.6 GM per 30 days)
RAPAMUNE ORAL SOLUTION Brand
REMODULIN INJECTION SOLUTION Medical Benefit PA; SP
REVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP
SAVAYSA ORAL TABLET Brand PA
SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand
sildenafil citrate oral tablet 20 mg Generic PA; QL (90 EA per 30 days)
sirolimus oral tablet Generic
SIRTURO ORAL TABLET Brand PA
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
Brand
STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION Brand
SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT Brand PA
SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT Brand
PA; ¥ (PA applies to members 0-5 years of age and members 12 years of age and older (no PA required for members 6 through 11 years of age))
SYMDEKO ORAL TABLET THERAPY PACK Brand PA; QL (56 EA per 28 days)
SYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
tadalafil (pah) oral tablet Generic PA; SP; QL (60 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
129
Drug Status Notesterbutaline sulfate oral tablet Generic
theophylline er oral tablet extended release 12 hour
Generic
theophylline er oral tablet extended release 24 hour
Generic
theophylline oral solution Generic
TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)
tobramycin inhalation nebulization solution Generic
TRACLEER ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
TRACLEER ORAL TABLET SOLUBLE Brand PA; SP; QL (120 EA per 30 days)
TUSSIGON ORAL TABLET Generic
Tyvaso Inhalation Solution MB/RX PA; SP
Tyvaso Refill Inhalation Solution MB/RX PA; SP
Tyvaso Starter Inhalation Solution MB/RX PA; SP
UPTRAVI ORAL TABLET Brand PA; SP
UPTRAVI ORAL TABLET THERAPY PACK Brand PA; SP
VELETRI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
Ventavis Inhalation Solution MB/RX PA; SP; QL (9 Vials per 1 day)
VENTOLIN HFA INHALATION AEROSOL SOLUTION Brand
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand
PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
zafirlukast oral tablet Brand
MAJOR TRAUMATIC INJURY
CIDALEAZE EXTERNAL CREAM Generic
FLECTOR TRANSDERMAL PATCH BrandPA; ¥ (Max of 3 months); QL (60 Patches per 30 days)
lidocaine hcl external cream 3 % Generic
lidocaine hcl external lotion Generic
nimodipine oral capsule Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
130
Drug Status Notessilver sulfadiazine external cream Generic
SSD EXTERNAL CREAM Generic
MARGINAL ZONE LYMPHOMA
IMBRUVICA ORAL CAPSULE 70 MG Brand PA
IMBRUVICA ORAL TABLET Brand PA
MUSCLE OR BONE DISORDER
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 400 MG/20ML Medical Benefit PA; SP; QL (2 vials per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 80 MG/4ML Medical Benefit PA; SP; QL (10 vials per 28 days)
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (4 syringes per 28 days)
ACTIMMUNE SUBCUTANEOUS SOLUTION Brand PA; SP
alendronate sodium oral tablet 10 mg, 5 mg Generic QL (30 EA per 30 days)
alendronate sodium oral tablet 35 mg, 70 mg Generic QL (4 EA per 28 days)
alendronate sodium oral tablet 40 mg Generic QL (1 EA per 6 Months)
amphetamine-dextroamphet er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
amphetamine-dextroamphetamine oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)
atropine sulfate ophthalmic solution Generic
AURYXIA ORAL TABLET Brand PA
AUSTEDO ORAL TABLET Brand PA; QL (60 EA per 30 days)
azathioprine oral tablet Generic
baclofen oral tablet Generic
BRINEURA SOLUTION Medical Benefit PA
calcitonin (salmon) nasal solution Generic
calcium acetate (phos binder) oral capsule Generic
calcium acetate (phos binder) oral tablet Generic
carbamazepine oral suspension Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
131
Drug Status Notescarbamazepine oral tablet Generic
carbamazepine oral tablet chewable Generic
carisoprodol oral tablet 350 mg Generic
carisoprodol-aspirin oral tablet Generic
celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)
chlorzoxazone oral tablet 500 mg Generic
choline-mag trisalicylate oral liquid Generic
cilostazol oral tablet Generic
CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)
CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand
PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)
clonazepam oral tablet Generic
clonidine hcl er oral tablet extended release 12 hour
Generic PA; QL (60 EA per 30 days)
colchicine oral tablet Generic
colchicine-probenecid oral tablet Generic
COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
BrandPA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
BrandPA; SP; QL (1 Syringe per 28 days)
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 28 days)
CRYSVITA SUBCUTANEOUS SOLUTION Medical Benefit PA
cyclobenzaprine hcl oral tablet 10 mg, 5 mg Generic
dalfampridine er oral tablet extended release 12 hour
Generic PA; SP; QL (60 EA per 30 days)
dantrolene sodium oral capsule Generic
darifenacin hydrobromide er oral tablet extended release 24 hour
Generic PA
DAYTRANA TRANSDERMAL PATCH Brand PA; QL (30 patches per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
132
Drug Status Notes
DEXEDRINE ORAL TABLET BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg
Generic PA; QL (30 EA per 30 days)
dexmethylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
dextroamphetamine sulfate er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dextroamphetamine sulfate oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (1200 mL per 30 days)
dextroamphetamine sulfate oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
DIAZEPAM INTENSOL ORAL CONCENTRATE Generic
diazepam oral concentrate Generic
diazepam oral solution Generic
diazepam oral tablet Generic
diclofenac potassium oral tablet Generic
diclofenac sodium er oral tablet extended release 24 hour
Generic
diclofenac sodium transdermal gel 1 % Generic STPA
diclofenac sodium transdermal solution Generic PA
DUAVEE ORAL TABLET Brand PA
duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg
Generic STPA; QL (60 EA per 30 days)
duloxetine hcl oral capsule delayed release particles 30 mg
Generic STPA; QL (30 EA per 30 days)
DUZALLO ORAL TABLET Brand PA
DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE Brand PA; QL (240 ML per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
133
Drug Status NotesDYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
EMFLAZA ORAL SUSPENSION Brand PA; QL (26 ML per 30 days)
EMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)
ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE Brand PA; SP; QL (4 each per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (4 syringes per 28 days)
EPITOL ORAL TABLET Generic
etidronate disodium oral tablet Generic
etodolac er oral tablet extended release 24 hour Generic
etodolac oral capsule Generic
etodolac oral tablet Generic
EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP
EXONDYS 51 INTRAVENOUS SOLUTION Medical Benefit PA
FLECTOR TRANSDERMAL PATCH BrandPA; ¥ (Max of 3 months); QL (60 Patches per 30 days)
flurbiprofen oral tablet Generic
FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML Brand PA; SP; QL (1 vial per 30 days)
FOSAMAX PLUS D ORAL TABLET Brand PA; QL (4 EA per 28 days)
FYCOMPA ORAL SUSPENSION Brand PA
FYCOMPA ORAL TABLET Brand PA
Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML
MB/RX PA
Gammagard Injection Solution 20 GM/200ML MB/RX PA; SP
GELNIQUE TRANSDERMAL GEL Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
134
Drug Status NotesGLYDO EXTERNAL GEL Generic
guanfacine hcl er oral tablet extended release 24 hour
Generic PA
guanidine hcl oral tablet Brand PA
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)
hydroxychloroquine sulfate oral tablet Generic
ibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)
ibuprofen oral suspension Generic
ibuprofen oral tablet 400 mg, 600 mg, 800 mg Generic
ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP
indomethacin er oral capsule extended release Generic
indomethacin oral capsule Generic
INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
INGREZZA ORAL CAPSULE Brand PA
ketoprofen er oral capsule extended release 24 hour
Generic
ketoprofen oral capsule Generic
KEVEYIS ORAL TABLET Brand PA
KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (2.28 ML per 30 days)
KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (2.28 ML per 30 days)
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)
KRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
135
Drug Status Noteslamotrigine odt oral tablet dispersible Generic
lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg
Generic
lamotrigine oral tablet 100 mg, 150 mg Generic QL (90 EA per 30 days)
lamotrigine oral tablet 200 mg Generic
lamotrigine oral tablet 25 mg Generic QL (180 EA per 30 days)
lamotrigine oral tablet chewable Generic QL (180 EA per 30 days)
lamotrigine oral tablet dispersible Generic
lamotrigine starter kit-blue oral kit Generic
lamotrigine starter kit-green oral kit Generic
lamotrigine starter kit-orange oral kit Generic
lamotrigine titration oral kit Generic
leflunomide oral tablet Generic
levetiracetam oral solution Generic
levetiracetam oral tablet Generic
lidocaine hcl external gel 2 % Generic
meclofenamate sodium oral capsule Generic
meloxicam oral suspension Generic
meloxicam oral tablet Generic
metaxalone oral tablet 800 mg Generic STPA; QL (120 EA per 30 days)
methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)
methocarbamol oral tablet Generic
methotrexate oral tablet Generic
methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (cd) oral capsule extended release 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 60 mg
Generic PA; QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
136
Drug Status Notes
methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er oral tablet extended release 10 mg, 20 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 36 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (900 mL per 30 days)
methylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
MIACALCIN INJECTION SOLUTION Brand
MYOBLOC INTRAMUSCULAR SOLUTION Medical Benefit PA; SP
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
nabumetone oral tablet Generic
naproxen dr oral tablet delayed release Generic
naproxen oral suspension Generic
naproxen oral tablet Generic
naproxen sodium oral tablet Generic
norethindrone-eth estradiol oral tablet Generic
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
OLUMIANT ORAL TABLET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
137
Drug Status NotesORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)
ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit
PA; SP; QL (4 VIALS per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML
Brand PA; QL (1.6 ML per 28 days)
orphenadrine citrate er oral tablet extended release 12 hour
Generic
OTEZLA ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
OTEZLA ORAL TABLET THERAPY PACK Brand PA; SP; QL (60 EA per 30 days)
oxaprozin oral tablet Generic
oxybutynin chloride er oral tablet extended release 24 hour
Generic
oxybutynin chloride oral syrup Generic
oxybutynin chloride oral tablet Generic
OXYTROL TRANSDERMAL PATCH TWICE WEEKLY Brand PA
PEGANONE ORAL TABLET Brand PA
PENNSAID TRANSDERMAL SOLUTION 2 % Brand PA
pentoxifylline er oral tablet extended release Generic
pimozide oral tablet Generic PA
piroxicam oral capsule Generic
probenecid oral tablet Generic
PROLIA SUBCUTANEOUS SOLUTION Medical BenefitPA; SP; QL (1 syringe per 180 days)
propranolol hcl oral solution Generic
propranolol hcl oral tablet Generic
pyridostigmine bromide er oral tablet extended release
Generic
pyridostigmine bromide oral tablet Generic
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED Brand PA; QL (360 mL per 30 days)
RADICAVA INTRAVENOUS SOLUTION Medical Benefit PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
138
Drug Status Notesraloxifene hcl oral tablet Generic
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
riluzole oral tablet Generic
risedronate sodium oral tablet 150 mg Generic PA; QL (1 EA per 30 days)
risedronate sodium oral tablet 30 mg, 5 mg Generic PA; QL (30 EA per 30 days)
risedronate sodium oral tablet 35 mg Generic PA; QL (4 EA per 28 days)
risedronate sodium oral tablet delayed release Generic PA; QL (4 EA per 28 days)
RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP
SABRIL ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)
salsalate oral tablet Generic
SAVELLA ORAL TABLET Brand STPA; QL (60 EA per 30 days)
SAVELLA TITRATION PACK ORAL Brand STPA; QL (60 EA per 30 days)
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG
Medical Benefit PA
SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (1 syringe per 28 days)
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 syringe per 28 days)
SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP
SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)
SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)
STELARA INTRAVENOUS SOLUTION Medical BenefitPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 84 days)
sulfasalazine oral tablet delayed release Generic
sulindac oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
139
Drug Status Notes
TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)
TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)
tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)
tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)
tizanidine hcl oral tablet Generic
tolmetin sodium oral capsule Generic
tolmetin sodium oral tablet Generic
tolterodine tartrate er oral capsule extended release 24 hour
Generic
tolterodine tartrate oral tablet Generic
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA
TREXALL ORAL TABLET Brand
trientine hcl oral capsule Generic PA
trospium chloride er oral capsule extended release 24 hour
Generic
trospium chloride oral tablet Generic
TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; QL (2 ML per 30 days)
VESICARE ORAL TABLET 10 MG Generic PA
VESICARE ORAL TABLET 5 MG Brand PA
vigabatrin oral packet Generic PA; QL (180 EA per 30 days)
VYVANSE ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
XATMEP ORAL SOLUTION Brand PA
XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
XGEVA SUBCUTANEOUS SOLUTION Medical Benefit PA; SP; QL (1 vial per 30 days)
XIAFLEX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA
XYREM ORAL SOLUTION Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
140
Drug Status Notes
ZENZEDI ORAL TABLET 10 MG, 5 MG BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
ZURAMPIC ORAL TABLET Brand PA
NEUROPSYCHIATRIC DISORDER
Abilify Maintena Intramuscular Prefilled Syringe MB/RX PA
Abilify Maintena Intramuscular Suspension Reconstituted ER
MB/RX PA
acamprosate calcium oral tablet delayed release Generic QL (180 EA per 30 days)
alprazolam er oral tablet extended release 24 hour
Generic
alprazolam oral tablet Generic
alprazolam oral tablet dispersible Generic
alprazolam xr oral tablet extended release 24 hour
Generic
amoxapine oral tablet Generic
amphetamine-dextroamphet er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
amphetamine-dextroamphetamine oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
aripiprazole oral solution Generic PA; QL (750 ML per 30 days)
aripiprazole oral tablet Generic PA; QL (30 EA per 30 days)
aripiprazole oral tablet dispersible Generic PA; QL (30 EA per 30 days)
Aristada Initio Intramuscular Prefilled Syringe MB/RX PA
Aristada Intramuscular Prefilled Syringe MB/RX PA
ASCOMP-CODEINE ORAL CAPSULE Generic QL (180 EA per 30 days)
atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)
AUSTEDO ORAL TABLET Brand PA; QL (60 EA per 30 days)
BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 6.3-1 MG Brand
PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)
BUNAVAIL BUCCAL FILM 4.2-0.7 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)
buprenorphine hcl sublingual tablet sublingual Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
141
Drug Status Notes
buprenorphine hcl-naloxone hcl sublingual film GenericPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg
Generic¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg
Generic¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)
bupropion hcl er (smoking det) oral tablet extended release 12 hour
Generic
bupropion hcl er (sr) oral tablet extended release 12 hour
Generic
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
Generic
bupropion hcl oral tablet Generic
buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg
Generic
buspirone hcl oral tablet 30 mg Generic PA
butalbital-acetaminophen oral tablet 50-325 mg Generic QL (180 EA per 30 days)
butalbital-apap-caffeine oral capsule 50-325-40 mg
Generic QL (180 EA per 30 days)
butalbital-apap-caffeine oral tablet 50-325-40 mg Generic QL (180 EA per 30 days)
butalbital-asa-caff-codeine oral capsule Generic QL (180 EA per 30 days)
butalbital-aspirin-caffeine oral capsule Generic QL (180 EA per 30 days)
carbamazepine er oral capsule extended release 12 hour
Generic
carbamazepine er oral tablet extended release 12 hour
Generic
carbamazepine oral tablet Generic
CHANTIX CONTINUING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)
CHANTIX ORAL TABLET Brand PA; QL (60 EA per 30 days)
CHANTIX STARTING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)
chlordiazepoxide hcl oral capsule Generic
chlorpromazine hcl oral tablet Generic
citalopram hydrobromide oral solution Generic
citalopram hydrobromide oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
142
Drug Status Notesclomipramine hcl oral capsule Generic
clonazepam oral tablet Generic
clonidine hcl er oral tablet extended release 12 hour
Generic PA; QL (60 EA per 30 days)
clorazepate dipotassium oral tablet Generic
clozapine oral tablet Generic
clozapine oral tablet dispersible Generic QL (60 EA per 30 days)
DAYTRANA TRANSDERMAL PATCH Brand PA; QL (30 patches per 30 days)
desipramine hcl oral tablet Generic
desvenlafaxine er oral tablet extended release 24 hour
Generic PA; STPA
desvenlafaxine fumarate er oral tablet extended release 24 hour
Brand PA; STPA
DEXEDRINE ORAL TABLET BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg
Generic PA; QL (30 EA per 30 days)
dexmethylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
dextroamphetamine sulfate er oral capsule extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
dextroamphetamine sulfate oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (1200 mL per 30 days)
dextroamphetamine sulfate oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
DIAZEPAM INTENSOL ORAL CONCENTRATE Generic
diazepam oral concentrate Generic
diazepam oral solution Generic
diazepam oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
143
Drug Status Notesdisulfiram oral tablet Generic
divalproex sodium er oral tablet extended release 24 hour
Generic
divalproex sodium oral capsule delayed release sprinkle
Generic
divalproex sodium oral tablet delayed release Generic
donepezil hcl oral tablet 10 mg, 5 mg Generic
donepezil hcl oral tablet dispersible Generic
doxepin hcl oral capsule Generic
doxepin hcl oral concentrate Generic
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg
Generic
duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg
Generic STPA; QL (60 EA per 30 days)
duloxetine hcl oral capsule delayed release particles 30 mg
Generic STPA; QL (30 EA per 30 days)
DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE Brand PA; QL (240 ML per 30 days)
EMSAM TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)
eq nicotine mouth/throat lozenge Generic
eq nicotine polacrilex mouth/throat gum Generic
eq nicotine polacrilex mouth/throat lozenge Generic
eq nicotine step 3 transdermal patch 24 hour Generic
eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr
Generic
eql nicotine polacrilex mouth/throat gum Generic
eql nicotine polacrilex mouth/throat lozenge Generic
eql nicotine transdermal patch 24 hour Generic
ergoloid mesylates oral tablet Generic
escitalopram oxalate oral solution Generic
escitalopram oxalate oral tablet Generic
FANAPT ORAL TABLET Brand PA; QL (60 EA per 30 days)
FANAPT TITRATION PACK ORAL TABLET Brand PA
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
144
Drug Status NotesFETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK Brand PA; QL (28 EA per 28 days)
fluoxetine hcl (pmdd) oral capsule Generic PA
fluoxetine hcl (pmdd) oral tablet Generic PA
fluoxetine hcl oral capsule Generic
fluoxetine hcl oral solution Generic
fluoxetine hcl oral tablet 10 mg, 20 mg Generic PA
fluphenazine decanoate injection solution Generic
fluphenazine hcl oral concentrate Generic
fluphenazine hcl oral elixir Generic
fluphenazine hcl oral tablet Generic
fluvoxamine maleate er oral capsule extended release 24 hour
Generic PA; QL (30 EA per 30 days)
fluvoxamine maleate oral tablet Generic
galantamine hydrobromide er oral capsule extended release 24 hour
Generic
galantamine hydrobromide oral solution Generic
galantamine hydrobromide oral tablet Generic
GIANVI ORAL TABLET Generic
gnp nicotine mini mouth/throat lozenge Generic
gnp nicotine polacrilex mouth/throat gum Generic
gnp nicotine polacrilex mouth/throat lozenge Generic
guanfacine hcl er oral tablet extended release 24 hour
Generic PA
haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml
Generic
haloperidol lactate injection solution 5 mg/ml Generic
haloperidol lactate oral concentrate Generic
haloperidol oral tablet Generic
hm nicotine polacrilex mouth/throat gum Generic
hm nicotine polacrilex mouth/throat lozenge Generic
hm nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr
Generic
hydroxyzine hcl oral syrup Generic
hydroxyzine hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
145
Drug Status Noteshydroxyzine pamoate oral capsule Generic
imipramine hcl oral tablet Generic
imipramine pamoate oral capsule Generic PA
Invega Sustenna Intramuscular Suspension MB/RXPA; ¥ (2 vials for first month); QL (1 vial per 30 days)
Invega Trinza Intramuscular Suspension MB/RX PA
lamotrigine odt oral tablet dispersible Generic
lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg
Generic
lamotrigine oral tablet 100 mg, 150 mg Generic QL (90 EA per 30 days)
lamotrigine oral tablet 200 mg Generic
lamotrigine oral tablet 25 mg Generic QL (180 EA per 30 days)
lamotrigine oral tablet chewable Generic QL (180 EA per 30 days)
lamotrigine oral tablet dispersible Generic
lamotrigine starter kit-blue oral kit Generic
lamotrigine starter kit-green oral kit Generic
lamotrigine starter kit-orange oral kit Generic
lamotrigine titration oral kit Generic
LATUDA ORAL TABLET Brand PA; QL (30 EA per 30 days)
lithium carbonate er oral tablet extended release Generic
lithium carbonate oral capsule Generic
lithium carbonate oral tablet Generic
lithium oral solution Generic
LORAZEPAM INTENSOL ORAL CONCENTRATE Generic
lorazepam oral concentrate Generic
lorazepam oral tablet Generic
LORYNA ORAL TABLET Generic
loxapine succinate oral capsule Generic
maprotiline hcl oral tablet Generic
memantine hcl oral solution Generic
memantine hcl oral tablet Generic
meprobamate oral tablet Generic PA
METHADONE HCL INTENSOL ORAL CONCENTRATE Generic QL (6 ML per 1 day)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
146
Drug Status Notesmethadone hcl oral concentrate Generic QL (6 ML per 1 day)
methadone hcl oral solution 10 mg/5ml Generic QL (30 ML per 1 day)
methadone hcl oral solution 5 mg/5ml Generic QL (60 ML per 1 day)
methadone hcl oral tablet 10 mg Generic QL (6 EA per 1 day)
methadone hcl oral tablet 5 mg Generic QL (12 EA per 1 day)
methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)
methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (cd) oral capsule extended release 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 60 mg
Generic PA; QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl er oral tablet extended release 10 mg, 20 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 24 hour
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
methylphenidate hcl er oral tablet extended release 36 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)
methylphenidate hcl oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (900 mL per 30 days)
methylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
147
Drug Status Notes
methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
mirtazapine oral tablet Generic
mirtazapine oral tablet dispersible Generic
naltrexone hcl oral tablet Generic
nefazodone hcl oral tablet Generic
NICORELIEF MOUTH/THROAT GUM Generic
nicotine mini mouth/throat lozenge Generic
nicotine polacrilex mouth/throat gum Generic
nicotine polacrilex mouth/throat lozenge Generic
nicotine step 1 transdermal patch 24 hour Generic
nicotine step 2 transdermal patch 24 hour Generic
nicotine step 3 transdermal patch 24 hour Generic
nicotine transdermal patch 24 hour Generic
NICOTROL INHALATION INHALER Brand PA
NICOTROL NS NASAL SOLUTION Brand PA
NIKKI ORAL TABLET Generic
nortriptyline hcl oral capsule Generic
nortriptyline hcl oral solution Generic
NUEDEXTA ORAL CAPSULE Brand PA
NUPLAZID ORAL CAPSULE Brand PA; SP; QL (30 EA per 30 days)
NUPLAZID ORAL TABLET BrandPA; SP; QL (60 Tablets per 30 days)
olanzapine oral tablet Generic QL (30 EA per 30 days)
olanzapine oral tablet dispersible Generic QL (30 EA per 30 days)
olanzapine-fluoxetine hcl oral capsule Generic PA; QL (30 EA per 30 days)
OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; STPA
oxazepam oral capsule Generic
paliperidone er oral tablet extended release 24 hour
Generic PA; QL (30 EA per 30 days)
paroxetine hcl er oral tablet extended release 24 hour
Generic PA; QL (30 EA per 30 days)
paroxetine hcl oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
148
Drug Status Notesperphenazine oral tablet Generic
phenelzine sulfate oral tablet Generic
pimozide oral tablet Generic PA
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG Brand STPA
PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT Medical Benefit PA
protriptyline hcl oral tablet Generic PA
quetiapine fumarate er oral tablet extended release 24 hour
Generic PA
quetiapine fumarate oral tablet Generic QL (90 EA per 30 days)
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED Brand PA; QL (360 mL per 30 days)
ra mini nicotine mouth/throat lozenge Generic
ra nicotine mouth/throat gum Generic
ra nicotine polacrilex mouth/throat gum Generic
ra nicotine polacrilex mouth/throat lozenge Generic
ra nicotine transdermal patch 24 hour Generic
REXULTI ORAL TABLET Brand PA; QL (30 EA per 30 days)
RisperDAL Consta Intramuscular Suspension Reconstituted
MB/RX PA; QL (2 injections per 28 days)
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE Generic
risperidone oral solution Generic
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg
Generic QL (60 EA per 30 days)
risperidone oral tablet 4 mg Generic
risperidone oral tablet dispersible Generic
rivastigmine tartrate oral capsule Generic
rivastigmine transdermal patch 24 hour Generic
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (60 EA per 30 days)
sertraline hcl oral concentrate Generic
sertraline hcl oral tablet Generic
SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
149
Drug Status Notes
SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG Brand
PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)
tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)
tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)
tgt nicotine mouth/throat gum 4 mg Generic
tgt nicotine polacrilex mouth/throat gum Generic
tgt nicotine polacrilex mouth/throat lozenge Generic
tgt nicotine step one transdermal patch 24 hour Generic
tgt nicotine step three transdermal patch 24 hour Generic
tgt nicotine step two transdermal patch 24 hour Generic
thioridazine hcl oral tablet Generic
thiothixene oral capsule Generic
tranylcypromine sulfate oral tablet Generic
trazodone hcl oral tablet Generic
trifluoperazine hcl oral tablet Generic
trimipramine maleate oral capsule Generic PA
TRINTELLIX ORAL TABLET Brand PA; QL (30 EA per 30 days)
venlafaxine hcl er oral capsule extended release 24 hour
Generic
venlafaxine hcl er oral tablet extended release 24 hour
Generic STPA
venlafaxine hcl oral tablet Generic
VESTURA ORAL TABLET Generic
VIIBRYD ORAL TABLET Brand PA; QL (30 EA per 30 days)
VIIBRYD STARTER PACK ORAL KIT Brand PA
VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit PA
VRAYLAR ORAL CAPSULE Brand PA
VRAYLAR ORAL CAPSULE THERAPY PACK Brand PA
VYVANSE ORAL CAPSULE Brand PA; QL (30 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
150
Drug Status Notes
ZENZEDI ORAL TABLET 10 MG, 5 MG BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
ziprasidone hcl oral capsule Generic QL (60 EA per 30 days)
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG
BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG Brand
PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)
ZyPREXA Relprevv Intramuscular Suspension Reconstituted 210 MG, 300 MG
MB/RX PA; QL (2 vials per 28 days)
ZyPREXA Relprevv Intramuscular Suspension Reconstituted 405 MG
MB/RX PA; QL (1 vial per 28 days)
NOT FEELING WELL
caffeine citrate oral solution Generic
NUTRITIONAL DISORDER
AURYXIA ORAL TABLET Brand PA
calcium acetate (phos binder) oral capsule Generic
calcium acetate (phos binder) oral tablet Generic
CRYSVITA SUBCUTANEOUS SOLUTION Medical Benefit PA
cyanocobalamin injection solution Generic
ergocalciferol oral capsule Generic
folbee oral tablet Generic
folic acid oral tablet 1 mg Generic
leucovorin calcium oral tablet Generic
levocarnitine oral solution Generic
levocarnitine oral tablet Generic
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml
Generic
multi vitamin/fluoride oral tablet chewable Brand
multi vitamin/minerals oral tablet Generic
multi-vit/fluoride oral solution Generic
multi-vit/fluoride/iron oral solution Generic
multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
151
Drug Status Notesmulti-vitamin/fluoride oral tablet chewable 0.5 mg
Brand
mynephrocaps oral capsule Generic
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP
RENAL ORAL CAPSULE Generic
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP
tri-vit/fluoride/iron oral solution Brand
tri-vitamin/fluoride oral solution Generic
vitamin d (ergocalciferol) oral capsule 50000 unit Generic
ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP
OTHER OVER-THE-COUNTER DRUGS
ACCU-CHEK SAFE-T PRO LANCETS Brand
ACCU-CHEK SOFT TOUCH LANCETS Brand
ACCU-CHEK SOFTCLIX LANCETS Brand
AT LAST LANCETS Brand
BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 29G X 1/2" 2 ML, U-100 1 ML
Brand
BD INSULIN SYRINGE MICROFINE Brand
BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML Brand
BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML
Brand
BD LANCET ULTRAFINE 33G Brand
BD SAFETY-LOK INSULIN SYRINGE Brand
BD SYRINGE SLIP TIP 3 ML Brand
CLEANLET LANCETS 28G Brand
clotrimazole anti-fungal external cream Generic
comfort lancets Brand
cytra-2 oral solution Generic
daily multi oral tablet Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
152
Drug Status Notesdiphenhydramine hcl oral capsule 25 mg Brand
eq nicotine mouth/throat gum 4 mg Generic
eq nicotine polacrilex mouth/throat lozenge Generic
eq nicotine step 3 transdermal patch 24 hour Generic
eq nicotine transdermal patch 24 hour 7 mg/24hr Generic
EZ-LETS LANCETS 26G Brand
FINGERSTIX LANCETS Brand
FREESTYLE INSULINX TEST IN VITRO STRIP $0 QL (150 strips per 30 days)
FREESTYLE LANCETS Brand
FREESTYLE LITE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)
FREESTYLE PRECISION NEO TEST IN VITRO STRIP $0 QL (150 strips per 30 days)
FREESTYLE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)
GENTLE-LET GP LANCETS Brand
GENTLE-LET LANCETS Brand
GLUCOSOURCE LANCETS Brand
gnp lancets Brand
gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml
Brand
HAEMOLANCE LOW FLOW LANCETS Brand
hm nicotine transdermal patch 24 hour 7 mg/24hr Generic
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
Brand
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION Brand
HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR Brand
HUMULIN N SUBCUTANEOUS SUSPENSION Brand
HUMULIN R INJECTION SOLUTION Brand
HY-VEE LANCETS Brand
hy-vee thin lancets Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
153
Drug Status Notesinsulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
Brand
insulin syringe 29g x 1/2" 1 ml, 30g x 5/16" 1 ml Brand
insulin syringe/needle Brand
kinney lancets Brand
kinney thin lancets Brand
kinray insulin syringe 29g x 1/2" 0.5 ml Brand
lancets Brand
lancets thin Brand
levocarnitine oral solution Generic
LIFESCAN UNISTIK II LANCETS Brand
lite touch lancets Brand
longs lancets thin Brand
MEDISENSE THIN LANCETS Brand
MEIJER LANCETS Brand
MICROTAINER SAFETY FLOW LANCET Brand
MONOJECT FILTER ASPIRATOR Brand
MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 1 ML, U-100 1 ML
Brand
MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML Brand
MONOJECT PHARMACY TRAY 20 ML , 3 ML , 35 ML , 6 ML , 60 ML Brand
MONOJECT PISTON SYRINGE Brand
MONOJECT SAFETY SYRINGE/SHIELD 12 ML , 20G X 1-1/2" 12 ML, 21G X 1" 3 ML, 21G X 1-1/2" 3 ML, 3 ML
Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
154
Drug Status NotesMONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML
Brand
MONOJECT SYRINGE CATH TIP Brand
MONOJECT SYRINGE ECC LUER 35 ML Brand
MONOJECT SYRINGE LUER LOCK Brand
MONOJECT SYRINGE REG LUER 12 ML , 20 ML , 3 ML , 35 ML , 6 ML Brand
MONOJECT TB SAFETY SYRINGE 28G X 1/2" 1 ML Brand
MONOJECT TB SYRINGE 25G X 5/8" 1 ML, 26G X 3/8" 1 ML, 28G X 1/2" 1 ML Brand
MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML Brand
MONOLET LANCETS Brand
MULTI COMPLETE ORAL CAPSULE Generic
n-acetyl-l-cysteine oral capsule Generic
NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION Brand
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION Brand
NOVOLIN N RELION SUBCUTANEOUS SUSPENSION Brand
NOVOLIN N SUBCUTANEOUS SUSPENSION Brand
NOVOLIN R INJECTION SOLUTION Brand
NOVOLIN R RELION INJECTION SOLUTION Brand
ONETOUCH CLUB LANCETS FINE PT Brand
ONETOUCH FINEPOINT LANCETS Brand
ONETOUCH LANCETS Brand
ONETOUCH ULTRASOFT LANCETS Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
155
Drug Status NotesPRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML
Brand
PRECISION THIN LANCETS Brand
PRECISION THINS GP LANCETS Brand
PRECISION ULTRA LANCET Brand
PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP $0 QL (150 strips per 30 days)
preferred plus lancets colored Brand
preferred plus lancets thin Brand
prenatal 19 oral tablet Generic
prenatal 19 oral tablet chewable Generic
PSS SELECT GP LANCETS Brand
PSS SELECT SAFETY LANCETS Brand
qc nicotine polacrilex mouth/throat gum Generic
reality lancets Brand
reality trigger lancets Brand
sb lancets thin Brand
sb lancets ultra thin Brand
sr nicotine mouth/throat gum Generic
super thin lancets Brand
sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml
Brand
SURELITE LANCETS Brand
tb syringe 1 ml Brand
TECHLITE LANCETS Brand
tgt nicotine mouth/throat gum Generic
THINLETS GP LANCETS Brand
THINLETS LANCET Brand
topco insulin syringe Brand
ULTILET CLASSIC LANCETS Brand
ULTILET LANCETS Brand
ULTRA-THIN II AUTO LANCET Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
156
Drug Status NotesULTRA-THIN II LANCETS Brand
UNILET COMFORTOUCH LANCET Brand
UNILET G.P. LANCET Brand
UNILET G.P. SUPERLITE LANCET Brand
UNILET LANCET Brand
UNILET SUPERLITE LANCET Brand
UNISTIK 1 Brand
VITALET PRO LANCETS Brand
VITALET PRO PLUS LANCETS Brand
W&F LANCETS 26G Brand
W&F LANCETS COLORED 21G Brand
weight loss daily multi oral tablet Generic
OTHER PRESCRIPTION DRUGS
abacavir sulfate oral solution Generic
abacavir sulfate-lamivudine oral tablet Brand
abacavir-lamivudine-zidovudine oral tablet Brand
acamprosate calcium oral tablet delayed release Generic QL (180 EA per 30 days)
acetaminophen-codeine oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)
acetazolamide er oral capsule extended release 12 hour
Generic
ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE Brand PA
acitretin oral capsule Generic QL (60 EA per 30 days)
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (4 syringes per 28 days)
acyclovir oral capsule Generic
acyclovir oral suspension Generic
acyclovir oral tablet Generic
adefovir dipivoxil oral tablet Generic
ADEMPAS ORAL TABLET Brand PA; SP
ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
ADMELOG SUBCUTANEOUS SOLUTION Brand
ALBENZA ORAL TABLET Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
157
Drug Status NotesALECENSA ORAL CAPSULE Brand PA; SP
ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)
alogliptin benzoate oral tablet Generic PA; QL (30 EA per 30 days)
alogliptin-metformin hcl oral tablet Generic PA; QL (60 EA per 30 days)
alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 25-30 mg, 25-45 mg
Generic PA; QL (30 EA per 30 days)
ALOMIDE OPHTHALMIC SOLUTION Brand PA
alosetron hcl oral tablet 0.5 mg Generic
Alphanate Intravenous Solution Reconstituted MB/RX PA; SP
ALUNBRIG ORAL TABLET Brand PA; SP
ALUNBRIG ORAL TABLET THERAPY PACK Brand PA; SP
amiodarone hcl oral tablet 100 mg Generic
amitriptyline hcl oral tablet Generic
amlodipine besylate-valsartan oral tablet Generic PA; QL (30 EA per 30 days)
amlodipine-olmesartan oral tablet Generic PA
amlodipine-valsartan-hctz oral tablet Generic PA; QL (30 EA per 30 days)
amoxicill-clarithro-lansopraz oral Generic
amoxicillin oral capsule Generic
amoxicillin oral suspension reconstituted Generic
amoxicillin oral tablet Generic
amoxicillin oral tablet chewable 125 mg, 250 mg Generic
amoxicillin-pot clavulanate er oral tablet extended release 12 hour
Generic
amoxicillin-pot clavulanate oral suspension reconstituted
Generic
amoxicillin-pot clavulanate oral tablet Generic
amoxicillin-pot clavulanate oral tablet chewable Generic
amphetamine-dextroamphetamine oral tablet 12.5 mg, 15 mg, 7.5 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
ampicillin oral capsule Generic
ampicillin oral suspension reconstituted Generic
anastrozole oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
158
Drug Status NotesANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED
Brand PA
ANTARA ORAL CAPSULE 30 MG, 90 MG Brand PA; QL (30 EA per 30 days)
antipyrine-benzocaine otic solution 5.4-1.4 %, 54-14 mg/ml
Generic
APIDRA INJECTION SOLUTION Brand
APIDRA OPTICLIK SUBCUTANEOUS SOLUTION Brand
APIDRA OPTICLIK SUBCUTANEOUS SOLUTION CARTRIDGE Brand
APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
APTIOM ORAL TABLET Brand PA
aripiprazole oral tablet 2 mg Generic PA; QL (30 EA per 30 days)
aripiprazole oral tablet dispersible Generic PA; QL (30 EA per 30 days)
aspirin-dipyridamole er oral capsule extended release 12 hour
Generic PA; QL (60 EA per 30 days)
atazanavir sulfate oral capsule Generic
atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)
atovaquone oral suspension Generic
AUBRA ORAL TABLET Generic
AURYXIA ORAL TABLET Brand PA
AVAR CLEANSER EXTERNAL EMULSION Generic
azithromycin oral packet Generic
azithromycin oral suspension reconstituted Generic
azithromycin oral tablet 250 mg, 500 mg, 600 mg Generic
bacitra-neomycin-polymyxin-hc ophthalmic ointment
Generic
BANZEL ORAL SUSPENSION Brand PA
BANZEL ORAL TABLET Brand PA
BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
BAXDELA ORAL TABLET Brand PA
benzphetamine hcl oral tablet 25 mg Generic PA
bexarotene oral capsule Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
159
Drug Status Notesbicalutamide oral tablet Generic
bimatoprost ophthalmic solution Generic PA
BOSULIF ORAL TABLET 100 MG Brand PA; SP; QL (120 EA per 30 days)
BOSULIF ORAL TABLET 500 MG Brand PA; SP; QL (30 EA per 30 days)
bp multinatal plus oral tablet chewable Generic
BRAFTOVI ORAL CAPSULE Brand PA
BRINTELLIX ORAL TABLET Brand PA; QL (30 EA per 30 days)
bromfenac sodium (once-daily) ophthalmic solution
Generic
budesonide inhalation suspension 1 mg/2ml Generic
buprenorphine hcl-naloxone hcl sublingual film GenericPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)
buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr
Generic PA; QL (4 EA per 28 days)
butalbital-aspirin-caffeine oral capsule Generic QL (180 EA per 30 days)
CABOMETYX ORAL TABLET Brand PA; SP
calcipotriene-betameth diprop external ointment Generic PA
CALQUENCE ORAL CAPSULE Brand PA
capecitabine oral tablet Generic
CAPRELSA ORAL TABLET 100 MG Brand PA; QL (60 EA per 30 days)
CAPRELSA ORAL TABLET 300 MG Brand PA; QL (30 EA per 30 days)
carbamazepine er oral tablet extended release 12 hour 100 mg
Generic
carbidopa oral tablet Generic
carvedilol phosphate er oral capsule extended release 24 hour
GenericPA; STPA; QL (30 EA per 30 days)
cefaclor oral capsule Generic
cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
Generic
cefadroxil oral capsule Generic
cefadroxil oral suspension reconstituted Generic
cefadroxil oral tablet Generic
cefdinir oral capsule Generic
cefdinir oral suspension reconstituted Generic
cefditoren pivoxil oral tablet 200 mg Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
160
Drug Status Notescefixime oral suspension reconstituted Generic
cefpodoxime proxetil oral suspension reconstituted
Generic
cefpodoxime proxetil oral tablet Generic
cefprozil oral suspension reconstituted Generic
cefprozil oral tablet Generic
ceftibuten oral capsule Generic
CEFTIN ORAL SUSPENSION RECONSTITUTED Brand PA
cefuroxime axetil oral tablet Generic
celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)
cephalexin oral capsule Generic
cephalexin oral suspension reconstituted Generic
cephalexin oral tablet Generic
CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT Medical Benefit PA
CEROVEL EXTERNAL LOTION Generic
chlorthalidone oral tablet 100 mg Generic
choline & mag trisalicylate oral tablet 1000 mg Generic
ciprofloxacin hcl ophthalmic solution Generic
ciprofloxacin hcl oral tablet Generic
ciprofloxacin oral suspension reconstituted Generic
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour
Generic
clarithromycin er oral tablet extended release 24 hour
Generic
clarithromycin oral suspension reconstituted Generic
clarithromycin oral tablet Generic
clindamycin hcl oral capsule Generic
clindamycin palmitate hcl oral solution reconstituted
Generic
clobetasol propionate external liquid Generic PA
clocortolone pivalate external cream Generic PA
clocortolone pivalate pump external cream Generic PA
clonidine hcl er oral tablet extended release 12 hour
Generic PA; QL (60 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
161
Drug Status Notesclozapine oral tablet dispersible 150 mg, 200 mg Generic QL (60 EA per 30 days)
colesevelam hcl oral tablet Generic PA
COMETRIQ (100 MG DAILY DOSE) ORAL KIT Brand PA
COMETRIQ (140 MG DAILY DOSE) ORAL KIT Brand PA
COMETRIQ (60 MG DAILY DOSE) ORAL KIT Brand PA
CORTISPORIN-TC OTIC SUSPENSION Brand PA
COTELLIC ORAL TABLET Brand PA; SP
cyclopentolate hcl ophthalmic solution 0.5 % Generic QL (15 ML per 30 days)
cyclophosphamide oral capsule Generic
cycloserine oral capsule Generic
dalfampridine er oral tablet extended release 12 hour
Generic PA; SP; QL (60 EA per 30 days)
darifenacin hydrobromide er oral tablet extended release 24 hour
Generic PA
demeclocycline hcl oral tablet Generic PA
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)
$0
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
Generic
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg
GenericPA; ¥ (PA applies to members 25 and older); QL (30 EA per 30 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg
Generic PA; QL (30 EA per 30 days)
diazepam oral concentrate Generic
diazepam oral solution 5 mg/5ml Generic
diclofenac sodium oral tablet delayed release Generic
diclofenac sodium transdermal gel 1 % Generic STPA
diclofenac sodium transdermal gel 3 % Generic¥ (Max of 90 days per year); QL (200 GM per 30 days)
diclofenac sodium transdermal solution Generic PA
dicloxacillin sodium oral capsule Generic
dicyclomine hcl oral solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
162
Drug Status Notesdiltiazem hcl er coated beads oral tablet extended release 24 hour
Generic PA
dofetilide oral capsule Generic
dorzolamide hcl ophthalmic solution Generic
dorzolamide hcl-timolol mal ophthalmic solution Generic
doxepin hcl external cream Generic QL (45 grams per 1 Fill)
doxercalciferol oral capsule Generic
doxycycline hyclate oral capsule Generic
doxycycline hyclate oral tablet 100 mg Generic
doxycycline monohydrate oral capsule 100 mg, 50 mg
Generic
doxycycline monohydrate oral suspension reconstituted
Generic
doxycycline monohydrate oral tablet 100 mg, 50 mg
Generic
drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg
Generic
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg
Generic
DUAVEE ORAL TABLET Brand PA
duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg
Generic STPA; QL (60 EA per 30 days)
duloxetine hcl oral capsule delayed release particles 30 mg
Generic STPA; QL (30 EA per 30 days)
dutasteride oral capsule Generic PA; QL (30 EA per 30 days)
dutasteride-tamsulosin hcl oral capsule Generic PA; QL (30 EA per 30 days)
DYSPORT (GLABELLAR LINES) INTRAMUSCULAR SOLUTION RECONSTITUTED
Medical Benefit PA; SP
E.E.S. 400 ORAL TABLET Generic
ECOZA EXTERNAL FOAM Brand PA
efavirenz oral capsule Generic
efavirenz oral tablet Generic
eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)
entecavir oral tablet Generic
ERLEADA ORAL TABLET Brand PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
163
Drug Status NotesERYPED 400 ORAL SUSPENSION RECONSTITUTED Generic
ERY-TAB ORAL TABLET DELAYED RELEASE Generic
ERYTHROCIN STEARATE ORAL TABLET250 MG Generic
erythromycin base oral capsule delayed release particles
Generic
erythromycin base oral tablet Generic
erythromycin ethylsuccinate oral suspension reconstituted
Generic
erythromycin ethylsuccinate oral tablet Generic
est estrogens-methyltest hs oral tablet Generic
est estrogens-methyltest oral tablet Generic
estradiol transdermal patch twice weekly Generic
estradiol-norethindrone acet oral tablet Generic
ethacrynic acid oral tablet Generic PA
ethambutol hcl oral tablet Generic
etoposide oral capsule Generic
ezetimibe oral tablet Generic PA; QL (30 EA per 30 days)
ezetimibe-simvastatin oral tablet Generic PA; QL (30 EA per 30 days)
FABIOR EXTERNAL FOAM Brand PA
famciclovir oral tablet Generic
FARESTON ORAL TABLET Brand
FARXIGA ORAL TABLET Brand PA; QL (30 EA per 30 days)
felbamate oral suspension Generic PA
felbamate oral tablet Generic PA
fenofibrate oral capsule 150 mg, 50 mg Generic PA; QL (30 EA per 30 days)
fenofibrate oral tablet 120 mg, 40 mg Generic PA; QL (30 EA per 30 days)
fenofibric acid oral capsule delayed release Generic PA; QL (30 EA per 30 days)
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK Brand PA; QL (28 EA per 28 days)
FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
164
Drug Status NotesFIASP SUBCUTANEOUS SOLUTION Brand
FIRST-LANSOPRAZOLE ORAL SUSPENSION Brand
PA; ¥ (PA applies to members 14 and older (No PA required for members 0-13 years of age))
FIRST-OMEPRAZOLE ORAL SUSPENSION Brand
PA; ¥ (PA applies to members 14 and older (No PA required for members 0-13 years of age))
FIRVANQ ORAL SOLUTION RECONSTITUTED Brand PA; QL (2 Bottles per 10 days)
fluconazole oral suspension reconstituted Generic
fluconazole oral tablet Generic
flucytosine oral capsule Generic PA
fluocinonide external cream 0.1 % Generic PA; QL (120 GM per 30 days)
FLUORIDEX ENHANCED WHITENING DENTAL GEL Generic
fluoxetine hcl (pmdd) oral tablet Generic PA
flurandrenolide external cream Generic PA
flurandrenolide external lotion Generic PA
flutamide oral capsule Generic
fluvastatin sodium er oral tablet extended release 24 hour
Generic PA; QL (30 EA per 30 days)
fosamprenavir calcium oral tablet Generic
frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)
FYCOMPA ORAL TABLET Brand PA
gatifloxacin ophthalmic solution Generic
gentamicin sulfate ophthalmic ointment Generic
gentamicin sulfate ophthalmic solution Generic
GILOTRIF ORAL TABLET Brand PA
GLEOSTINE ORAL CAPSULE 5 MG Brand
glycopyrrolate oral tablet 1 mg, 2 mg Generic
GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 1701-2000 UNIT, 250 UNIT, 500 UNIT, 801-1700 UNIT
MB/RX PA; SP
heparin sodium (porcine) injection solution 2500 unit/ml
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
165
Drug Status NotesHEXALEN ORAL CAPSULE Brand
Hizentra Subcutaneous Solution 10 GM/50ML MB/RX PA; SP
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML
Brand
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
Brand
HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION Brand
HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
Brand
HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION Brand
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
Brand
HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION Brand
HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
Brand
HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION Brand
HUMALOG PEN SUBCUTANEOUS SOLUTION Brand
HUMALOG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
HUMALOG SUBCUTANEOUS SOLUTION Brand
Humate-P Intravenous Solution Reconstituted 1000-2000 UNIT, 250-500 UNIT, 500-1000 UNIT
MB/RX PA; SP
HYCAMTIN ORAL CAPSULE 0.25 MG Brand PA; SP; QL (15 EA per 21 days)
HYCAMTIN ORAL CAPSULE 1 MG Brand PA; SP; QL (25 EA per 21 days)
hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml
Generic QL (480 ML per 1 day)
hydrocortisone rectal cream Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
166
Drug Status NotesHYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
HYOPHEN ORAL TABLET Generic
hyoscyamine sulfate er oral tablet extended release 12 hour
Generic
hyoscyamine sulfate oral elixir Generic
hyoscyamine sulfate oral solution Generic
hyoscyamine sulfate oral tablet Generic
hyoscyamine sulfate oral tablet dispersible Generic
hyoscyamine sulfate sublingual tablet sublingual Generic
hyosyne oral elixir Generic
hyosyne oral solution Generic
IBRANCE ORAL CAPSULE Brand PA; SP
ICLUSIG ORAL TABLET Brand PA
IDHIFA ORAL TABLET Brand PA; QL (30 EA per 30 days)
ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
imatinib mesylate oral tablet 100 mg Generic
imatinib mesylate oral tablet 400 mg Brand
IMBRUVICA ORAL TABLET 140 MG Brand PA
INLYTA ORAL TABLET Brand PA; SP
IRESSA ORAL TABLET Brand PA
isometheptene-dichloral-apap oral capsule Generic QL (300 EA per 30 days)
isotretinoin oral capsule Generic PA
itraconazole oral capsule Generic
ivermectin oral tablet Generic
ketoconazole oral tablet Generic
KISQALI 200 DOSE ORAL TABLET Brand PA
KISQALI 400 DOSE ORAL TABLET Brand PA
KISQALI 600 DOSE ORAL TABLET Brand PA
Kogenate FS Intravenous Kit MB/RX PA; SP
KUVAN ORAL PACKET 100 MG Brand PA; SP
lamivudine oral solution Brand
lamivudine oral tablet 100 mg Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
167
Drug Status NotesLARIN FE 1.5/30 ORAL TABLET Generic
LARIN FE 1/20 ORAL TABLET Generic
latanoprost ophthalmic solution Generic
LATRIX EXTERNAL SUSPENSION Generic
LATUDA ORAL TABLET 60 MG Brand PA; QL (30 EA per 30 days)
LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA
LENVIMA 12 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA
LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA
LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA
LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA
LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA
levalbuterol tartrate inhalation aerosol Generic PA
levofloxacin ophthalmic solution Generic
levofloxacin oral solution Generic
levofloxacin oral tablet Generic
levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg
Generic
levonorgestrel oral tablet 1.5 mg Generic
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
$0
levonorg-eth estrad triphasic oral tablet Generic
lidocaine external patch 5 % Generic
linezolid oral suspension reconstituted Generic QL (840 ML per 14 days)
linezolid oral tablet Generic QL (28 EA per 14 days)
LOMEDIA 24 FE ORAL TABLET Generic
lomustine oral capsule Generic
LUPRON INJECTION KIT Medical Benefit PA
LUPRON SUBCUTANEOUS SOLUTION Medical Benefit PA
LYNPARZA ORAL CAPSULE Brand PA
LYNPARZA ORAL TABLET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
168
Drug Status NotesLYSODREN ORAL TABLET Brand
LYZA ORAL TABLET Generic
MATULANE ORAL CAPSULE Brand
me/naphos/mb/hyo1 oral tablet Generic
megestrol acetate oral suspension 625 mg/5ml Generic
megestrol acetate oral tablet Generic
MEKINIST ORAL TABLET Brand PA; SP
MEKTOVI ORAL TABLET Brand PA
melphalan oral tablet Generic
memantine hcl oral solution Generic
memantine hcl oral tablet Generic
meperidine hcl oral tablet 100 mg Generic QL (12 EA per 1 day)
mercaptopurine oral tablet Generic
mesalamine oral tablet delayed release 1.2 gm GenericPA; STPA; QL (120 EA per 30 days)
mesalamine oral tablet delayed release 800 mg Generic
metformin hcl er (mod) oral tablet extended release 24 hour
Generic PA
methoxsalen rapid oral capsule Generic
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg
Generic PA; QL (30 EA per 30 days)
methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)
methyltestosterone oral capsule Generic
metronidazole oral capsule Generic
metronidazole oral tablet Generic
miglitol oral tablet Generic
minocycline hcl oral capsule Generic
MIRVASO EXTERNAL GEL Brand PA
mometasone furoate nasal suspension Generic PA
Monoclate-P Intravenous Kit 1500 UNIT, 250 UNIT, 500 UNIT
MB/RX PA; SP
MONOJECT CONTROL SYRINGE Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
169
Drug Status NotesMONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML
Brand
MONOJECT SAFETY SYRINGE/SHIELD21G X 1-1/2" 12 ML, 22G X 1-1/2" 3 ML Brand
MONOJECT SYRINGE 22G X 1-1/2" 12 ML, 22G X 1-1/2" 6 ML, 3 ML , 6 ML Brand
MONOJECT SYRINGE LUER LOCK 6 ML , 60 ML Brand
MONOJECT SYRINGE REG LUER 12 ML Brand
Mononine Intravenous Solution Reconstituted MB/RX PA; SP
morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg
Generic PA; QL (2 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 30 mg
Generic PA; QL (8 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 45 mg
Generic PA; QL (5 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 60 mg
Generic PA; QL (4 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 75 mg
Generic PA; QL (3 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 10 mg
Generic PA; QL (24 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 40 mg
Generic PA; QL (6 EA per 1 day)
moxifloxacin hcl oral tablet Generic
multi-vit/fluoride oral solution Generic
multi-vit/fluoride/iron oral solution Generic
multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 mg, 1-0.3 mg
Generic
mycophenolate mofetil oral suspension reconstituted
Generic
mycophenolic acid oral tablet delayed release Generic
MYLERAN ORAL TABLET Brand
naftifine hcl external cream Generic PA
neomycin-polymyxin-dexameth ophthalmic ointment
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
170
Drug Status Notesneomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
Generic
neomycin-polymyxin-hc otic solution 1 % Generic
NEO-POLYCIN HC OPHTHALMIC OINTMENT Generic
NERLYNX ORAL TABLET Brand PA
nevirapine er oral tablet extended release 24 hour400 mg
Generic
NEXAVAR ORAL TABLET Brand PA; SP; QL (120 EA per 30 days)
niacin er (antihyperlipidemic) oral tablet extended release
Generic
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG Generic
nilutamide oral tablet Generic
nitrofurantoin macrocrystal oral capsule Generic
nitrofurantoin monohyd macro oral capsule Generic
nitrofurantoin oral suspension Generic
NODOLOR ORAL CAPSULE Generic QL (300 EA per 30 days)
norethin ace-eth estrad-fe oral tablet Generic
norethin ace-eth estrad-fe oral tablet chewable Generic
norethindrone acet-ethinyl est oral tablet Generic
norethindrone-eth estradiol oral tablet Generic
norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg
Generic
norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg
Generic
norgestrel-ethinyl estradiol oral tablet Generic
NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
Brand
NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION Brand
NOVOLOG SUBCUTANEOUS SOLUTION Brand
NovoSeven Intravenous Solution Reconstituted MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
171
Drug Status NotesNOXAFIL ORAL TABLET DELAYED RELEASE Brand PA
np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg
Generic
ofloxacin ophthalmic solution Generic
ofloxacin oral tablet 400 mg Generic
olmesartan medoxomil oral tablet Generic STPA
olmesartan medoxomil-hctz oral tablet Generic STPA
olopatadine hcl ophthalmic solution Generic PA
OLYSIO ORAL CAPSULE Brand PA; SP
OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION Brand PA
omeprazole-sodium bicarbonate oral packet Generic PA
ONFI ORAL SUSPENSION Brand PA
ONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)
opium oral tincture Generic
OPSUMIT ORAL TABLET Brand PA; SP
oseltamivir phosphate oral capsule 30 mg Generic¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)
oseltamivir phosphate oral capsule 45 mg, 75 mg Generic¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)
oseltamivir phosphate oral suspension reconstituted
Generic¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)
otic care otic solution Generic
oxiconazole nitrate external cream Generic PA
oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 40 mg, 80 mg
Generic QL (90 EA per 30 days)
oxycodone-acetaminophen oral solution Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG Brand PA; QL (90 EA per 30 days)
paliperidone er oral tablet extended release 24 hour
Generic PA; QL (30 EA per 30 days)
PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT
Brand
pantoprazole sodium oral tablet delayed release Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
172
Drug Status Notesparicalcitol oral capsule Generic PA
PEGANONE ORAL TABLET Brand PA
penicillin g procaine intramuscular suspension Generic
penicillin v potassium oral solution reconstituted Generic
penicillin v potassium oral tablet Generic
PENNSAID TRANSDERMAL SOLUTION 2 % Brand PA
phenobarbital oral elixir Generic
phenobarbital oral solution Generic
phenobarbital oral tablet Generic
PHENOHYTRO ORAL TABLET Generic
phenoxybenzamine hcl oral capsule Generic
phenyleph-promethazine-cod oral syrup Generic
phenylephrine-guaifenesin oral liquid Generic
PHOS-FLUR DENTAL GEL Generic
PHOSPHASAL ORAL TABLET Generic
phytonadione oral tablet Generic
pimozide oral tablet 2 mg Generic PA
PIMTREA ORAL TABLET Generic
PIRMELLA 7/7/7 ORAL TABLET Generic
POMALYST ORAL CAPSULE Brand PA; SP
potassium chloride er oral tablet extended release20 meq
Generic
potassium chloride oral packet Generic
potassium citrate er oral tablet extended release Generic
pramipexole dihydrochloride er oral tablet extended release 24 hour
Generic
prasugrel hcl oral tablet Generic PA
praziquantel oral tablet Generic
prednisolone sodium phosphate oral tablet dispersible
Generic
prednisone oral solution Generic
prednisone oral tablet Generic
prednisone oral tablet therapy pack Generic
premium lidocaine external ointment Generic QL (50 GM per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
173
Drug Status Notesprimidone oral tablet Generic
PROCTOSOL HC RECTAL CREAM Generic
PROCTOZONE-HC RECTAL CREAM Generic
progesterone micronized transdermal cream Generic
promethazine hcl rectal suppository 50 mg Generic
promethazine-phenylephrine oral syrup Generic
PROTONIX ORAL PACKET Brand PA
PURIXAN ORAL SUSPENSION Brand
pyrazinamide oral tablet Generic
pyridostigmine bromide er oral tablet extended release
Generic
quetiapine fumarate er oral tablet extended release 24 hour
Generic PA
quinine sulfate oral capsule Generic PA
rabeprazole sodium oral tablet delayed release Generic PA
raloxifene hcl oral tablet Generic
rasagiline mesylate oral tablet Generic
REA LO 40 EXTERNAL CREAM Generic
REA LO 40 EXTERNAL LOTION Generic
REMEVEN EXTERNAL CREAM Generic
repaglinide oral tablet Generic
repaglinide-metformin hcl oral tablet Generic
REVLIMID ORAL CAPSULE Brand PA; SP
rifabutin oral capsule Generic
rifampin oral capsule Generic
risedronate sodium oral tablet 150 mg Generic PA; QL (1 EA per 30 days)
risedronate sodium oral tablet 30 mg, 5 mg Generic PA; QL (30 EA per 30 days)
risedronate sodium oral tablet 35 mg Generic PA; QL (4 EA per 28 days)
risedronate sodium oral tablet delayed release Generic PA; QL (4 EA per 28 days)
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE Generic
ritonavir oral tablet Generic
rivastigmine transdermal patch 24 hour 4.6 mg/24hr, 9.5 mg/24hr
Generic
Rixubis Intravenous Solution Reconstituted MB/RX PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
174
Drug Status NotesROSANIL CLEANSER EXTERNAL EMULSION Generic
rosuvastatin calcium oral tablet Generic PA; QL (30 EA per 30 days)
RUBRACA ORAL TABLET 200 MG, 300 MG Brand PA; SP; QL (120 EA per 30 days)
RUBRACA ORAL TABLET 250 MG Brand PA; QL (120 EA per 30 days)
RYDAPT ORAL CAPSULE Brand PA
selenium sulfide external lotion Generic
SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)
sirolimus oral tablet Generic
SIVEXTRO ORAL TABLET Brand PA; QL (6 EA per 365 days)
sodium fluoride oral tablet 2.2 (1 f) mg Generic
sodium polystyrene sulfonate oral powder Generic
SOVALDI ORAL TABLET Brand PA; SP
SPRYCEL ORAL TABLET 100 MG, 140 MG Brand PA; SP; QL (30 EA per 30 days)
SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG Brand PA; SP; QL (60 EA per 30 days)
STIVARGA ORAL TABLET Brand PA; SP; QL (84 EA per 28 days)
sulfacetamide sodium-sulfur external emulsion Generic
sulfacetamide sodium-sulfur external lotion 10-5 %
Generic
sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml
Generic
sulfamethoxazole-trimethoprim oral tablet Generic
sulfasalazine oral tablet delayed release Generic
SUPRAX ORAL CAPSULE Brand PA
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML Brand PA
SUPRAX ORAL TABLET CHEWABLE Brand PA
SUTENT ORAL CAPSULE Brand PA; SP
TABLOID ORAL TABLET Brand
tacrolimus external ointment Generic PA
tadalafil (pah) oral tablet Generic PA; SP; QL (60 EA per 30 days)
tadalafil oral tablet 5 mg Generic PA; QL (30 EA per 30 days)
TAFINLAR ORAL CAPSULE Brand PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
175
Drug Status NotesTAGRISSO ORAL TABLET 40 MG Brand PA; QL (30 Tablets per 30 days)
TAGRISSO ORAL TABLET 80 MG Brand PA
TARCEVA ORAL TABLET 100 MG, 150 MG Brand SP; QL (30 EA per 30 days)
TARCEVA ORAL TABLET 25 MG Brand SP; QL (90 EA per 30 days)
TASIGNA ORAL CAPSULE Brand PA; SP
telmisartan oral tablet Generic PA
telmisartan-hctz oral tablet Generic PA
temozolomide oral capsule Generic
tenofovir disoproxil fumarate oral tablet Generic
terbinafine hcl oral tablet Generic¥ (Max of 90 tablets per 365 days); QL (30 EA per 30 days)
testosterone transdermal gel 10 mg/act (2%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
Generic PA
testosterone transdermal solution Generic PA
tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)
tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)
tetracycline hcl oral capsule Generic
TIBSOVO ORAL TABLET Brand PA
TIVICAY ORAL TABLET 50 MG Brand
tobramycin inhalation nebulization solution Generic
tobramycin ophthalmic solution Generic
tolcapone oral tablet Generic PA; QL (180 EA per 30 days)
tolterodine tartrate er oral capsule extended release 24 hour
Generic
TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand
tretinoin external gel 0.05 % Generic PA; Age Limit (Max 26 Years)
tretinoin oral capsule Generic
triamcinolone acetonide external aerosol solution Generic PA
trientine hcl oral capsule Generic PA
TRI-LO-SPRINTEC ORAL TABLET Generic
TRILYTE ORAL SOLUTION RECONSTITUTED Generic
trimethoprim oral tablet Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
176
Drug Status NotesTROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG
Brand PA; QL (30 EA per 30 days)
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)
TYKERB ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)
UNITHROID DIRECT ORAL TABLET Generic
UNITHROID ORAL TABLET 137 MCG Generic
urea external cream 40 %, 50 % Generic
urea external lotion 40 % Generic
urea external suspension Generic
urea nail film external suspension Generic
urea-c40 external lotion Generic
ure-k external cream Generic
URIMAR-T ORAL TABLET Generic
UROLET MB ORAL TABLET Generic
UROPHEN MB ORAL TABLET Generic
URYL ORAL TABLET Generic
valacyclovir hcl oral tablet Generic
valganciclovir hcl oral solution reconstituted Generic
valganciclovir hcl oral tablet Generic
valsartan oral tablet Generic STPA
vancomycin hcl oral capsule Generic QL (40 EA per 10 days)
VENCLEXTA ORAL TABLET Brand PA
VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK Brand PA
VERZENIO ORAL TABLET Brand PA; SP
vigabatrin oral packet Generic PA; QL (180 EA per 30 days)
voriconazole oral suspension reconstituted Generic PA
voriconazole oral tablet Generic PA; QL (180 EA per 30 days)
VOTRIENT ORAL TABLET Brand PA; SP; QL (120 EA per 30 days)
VYFEMLA ORAL TABLET Generic
Wilate Intravenous Solution Reconstituted MB/RX PA; SP
XALKORI ORAL CAPSULE Brand PA; SP
XTANDI ORAL CAPSULE Brand PA; SP; QL (120 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
177
Drug Status NotesYONSA ORAL TABLET Brand PA
ZEJULA ORAL CAPSULE Brand PA
ZELBORAF ORAL TABLET Brand PA; SP
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 5000 UNIT
Brand
ZOMIG NASAL SOLUTION 2.5 MG BrandPA; STPA; QL (6 Units per 30 days)
ZOVIRAX EXTERNAL CREAM Brand PA; QL (5 GM per 1 Rx)
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG Brand
PA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)
ZYDELIG ORAL TABLET Brand PA
ZYKADIA ORAL CAPSULE Brand PA; SP
ZYTIGA ORAL TABLET 250 MG Brand PA; SP; QL (120 EA per 30 days)
OVERDOSE
acetylcysteine inhalation solution Generic
AMITIZA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
EVZIO INJECTION SOLUTION AUTO-INJECTOR Brand
PA; ¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)
FERRIPROX ORAL SOLUTION Brand PA
FERRIPROX ORAL TABLET Brand PA
JADENU ORAL TABLET Brand PA; SP
JADENU SPRINKLE ORAL PACKET Brand PA
leucovorin calcium oral tablet Generic
MOVANTIK ORAL TABLET Brand PA
naloxone hcl injection solution 0.4 mg/ml Generic
NARCAN NASAL LIQUID Brand¥ (1 kit(box) per RX, 2 kits(boxes) per 30 days); QL (1 Kit per 1 RX)
RELISTOR ORAL TABLET Brand PA; QL (90 Tablets per 30 days)
RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML Brand PA
SYMPROIC ORAL TABLET Brand PA
trientine hcl oral capsule Generic PA
VISTOGARD ORAL PACKET Brand QL (20 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
178
Drug Status NotesPAIN
ABSTRAL SUBLINGUAL TABLET SUBLINGUAL Brand PA
acetaminophen-codeine #2 oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)
acetaminophen-codeine #3 oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)
acetaminophen-codeine #4 oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)
acetaminophen-codeine oral solution Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)
acetaminophen-codeine oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)
almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)
amlodipine besylate oral tablet Generic
ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT Brand PA
ASCOMP-CODEINE ORAL CAPSULE Generic QL (180 EA per 30 days)
atenolol oral tablet Generic
BELBUCA BUCCAL FILM Brand PA; QL (60 Films per 30 days)
BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP
BRILINTA ORAL TABLET Brand PA; QL (60 EA per 30 days)
bromfenac sodium (once-daily) ophthalmic solution
Generic
bromfenac sodium ophthalmic solution Generic
buprenorphine transdermal patch weekly Generic PA; QL (4 EA per 28 days)
butalbital-acetaminophen oral tablet 50-325 mg Generic QL (180 EA per 30 days)
butalbital-apap-caffeine oral capsule 50-325-40 mg
Generic QL (180 EA per 30 days)
butalbital-apap-caffeine oral tablet 50-325-40 mg Generic QL (180 EA per 30 days)
butalbital-asa-caff-codeine oral capsule Generic QL (180 EA per 30 days)
butalbital-aspirin-caffeine oral capsule Generic QL (180 EA per 30 days)
butorphanol tartrate injection solution Generic
butorphanol tartrate nasal solution Generic
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
179
Drug Status NotesCIDALEAZE EXTERNAL CREAM Generic
cilostazol oral tablet Generic
cimetidine oral tablet 200 mg Generic
clopidogrel bisulfate oral tablet Generic
codeine sulfate oral tablet Generic QL (360 mg per 1 day)
diclofenac potassium oral tablet Generic
diclofenac sodium ophthalmic solution Generic
diflunisal oral tablet Generic
dihydroergotamine mesylate nasal solution Generic
diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
Generic
diltiazem hcl er beads oral capsule extended release 24 hour
Generic
diltiazem hcl er coated beads oral capsule extended release 24 hour
Generic
diltiazem hcl er coated beads oral tablet extended release 24 hour
Generic PA
diltiazem hcl er oral capsule extended release 12 hour
Generic
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
Generic
diltiazem hcl oral tablet Generic
divalproex sodium er oral tablet extended release 24 hour
Generic
divalproex sodium oral capsule delayed release sprinkle
Generic
divalproex sodium oral tablet delayed release Generic
duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg
Generic STPA; QL (60 EA per 30 days)
duloxetine hcl oral capsule delayed release particles 30 mg
Generic STPA; QL (30 EA per 30 days)
eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)
EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG Brand PA; QL (2 EA per 1 day)
EMBEDA ORAL CAPSULE EXTENDED RELEASE 20-0.8 MG Brand PA; QL (12 EA per 1 day)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
180
Drug Status NotesEMBEDA ORAL CAPSULE EXTENDED RELEASE 30-1.2 MG Brand PA; QL (8 EA per 1 day)
EMBEDA ORAL CAPSULE EXTENDED RELEASE 50-2 MG, 60-2.4 MG Brand PA; QL (4 EA per 1 day)
EMBEDA ORAL CAPSULE EXTENDED RELEASE 80-3.2 MG Brand PA; QL (3 EA per 1 day)
enoxaparin sodium injection solution Generic
enoxaparin sodium subcutaneous solution Generic
eplerenone oral tablet Generic PA; QL (60 EA per 30 days)
etodolac oral capsule Generic
etodolac oral tablet Generic
famotidine oral suspension reconstituted Generic
famotidine oral tablet 20 mg, 40 mg Generic
fenoprofen calcium oral tablet Generic
fentanyl citrate buccal lozenge on a handle Generic PA; QL (120 EA per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Generic QL (10 EA per 30 days)
fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
Generic PA; QL (10 EA per 30 days)
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Brand PA; QL (4 EA per 1 day)
flavoxate hcl oral tablet Generic
frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)
gabapentin oral capsule Generic
gabapentin oral solution 250 mg/5ml Generic
gabapentin oral tablet Generic
GLYDO EXTERNAL GEL Generic
GRALISE ORAL TABLET Brand PA; QL (90 EA per 30 days)
GRALISE STARTER ORAL Brand PA
hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
Generic QL (480 ML per 1 day)
hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Generic QL (12 EA per 1 day)
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
Generic QL (5 EA per 1 day)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
181
Drug Status Noteshydromorphone hcl er oral tablet er 24 hour abuse-deterrent
Generic PA; QL (64 mg per 1 day)
hydromorphone hcl oral liquid Generic QL (120 mg per 1 day)
hydromorphone hcl oral tablet Generic QL (120 mg per 1 day)
hydromorphone hcl rectal suppository Generic
IBUDONE ORAL TABLET Generic QL (5 EA per 1 day)
ibuprofen oral suspension Generic
ibuprofen oral tablet 400 mg, 600 mg, 800 mg Generic
INTRAROSA VAGINAL INSERT Brand PA; QL (28 EA per 28 days)
isosorbide dinitrate er oral tablet extended release
Generic
isosorbide dinitrate oral tablet Generic
isosorbide mononitrate er oral tablet extended release 24 hour
Generic
isosorbide mononitrate oral tablet Generic
KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (1 EA per 1 day)
ketoprofen oral capsule Generic
ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml
Generic¥ (Max of 5 days per Rx); QL (120 MG per 1 day)
ketorolac tromethamine intramuscular solution60 mg/2ml
Generic¥ (Max of 5 days per Rx); QL (120 mg per 1 day)
ketorolac tromethamine ophthalmic solution Generic
ketorolac tromethamine oral tablet Generic QL (20 EA per 30 days)
lidocaine external patch 5 % Generic
lidocaine hcl external cream 3 % Generic
lidocaine hcl external gel 2 % Generic
lidocaine hcl external lotion Generic
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR Generic PA
meclofenamate sodium oral capsule Generic
mefenamic acid oral capsule Generic PA
meperidine hcl oral solution Generic QL (120 ML per 1 day)
meperidine hcl oral tablet 100 mg Generic QL (12 EA per 1 day)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
182
Drug Status Notesmeperidine hcl oral tablet 50 mg Generic QL (24 EA per 1 day)
METHADONE HCL INTENSOL ORAL CONCENTRATE Generic QL (6 ML per 1 day)
methadone hcl oral concentrate Generic QL (6 ML per 1 day)
methadone hcl oral solution 10 mg/5ml Generic QL (30 ML per 1 day)
methadone hcl oral solution 5 mg/5ml Generic QL (60 ML per 1 day)
methadone hcl oral tablet 10 mg Generic QL (6 EA per 1 day)
methadone hcl oral tablet 5 mg Generic QL (12 EA per 1 day)
metoprolol succinate er oral tablet extended release 24 hour
Generic
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
Generic
metoprolol tartrate oral tablet 37.5 mg, 75 mg Brand PA
MIGERGOT RECTAL SUPPOSITORY Generic
MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (60 EA per 30 days)
morphine sulfate (concentrate) oral solution 100 mg/5ml
Generic QL (12 ML per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg
Generic PA; QL (2 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 30 mg
Generic PA; QL (8 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 45 mg
Generic PA; QL (5 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 60 mg
Generic PA; QL (4 EA per 1 day)
morphine sulfate er beads oral capsule extended release 24 hour 75 mg
Generic PA; QL (3 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 10 mg
Generic PA; QL (24 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 100 mg
Generic PA; QL (2 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 20 mg
Generic PA; QL (12 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 30 mg
Generic PA; QL (8 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 40 mg
Generic PA; QL (6 EA per 1 day)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
183
Drug Status Notesmorphine sulfate er oral capsule extended release 24 hour 50 mg, 60 mg
Generic PA; QL (4 EA per 1 day)
morphine sulfate er oral capsule extended release 24 hour 80 mg
Generic PA; QL (3 EA per 1 day)
morphine sulfate er oral tablet extended release100 mg
Generic QL (2 EA per 1 day)
morphine sulfate er oral tablet extended release15 mg
Generic QL (16 EA per 1 day)
morphine sulfate er oral tablet extended release200 mg
Generic QL (1 EA per 1 day)
morphine sulfate er oral tablet extended release30 mg
Generic QL (8 EA per 1 day)
morphine sulfate er oral tablet extended release60 mg
Generic QL (4 EA per 1 day)
morphine sulfate oral solution 10 mg/5ml Generic QL (120 ML per 1 day)
morphine sulfate oral solution 20 mg/5ml Generic QL (60 ML per 1 day)
morphine sulfate oral tablet 15 mg Generic QL (16 EA per 1 day)
morphine sulfate oral tablet 30 mg Generic QL (8 EA per 1 day)
nadolol oral tablet 20 mg, 40 mg, 80 mg Generic
naproxen oral suspension Generic
naproxen oral tablet Generic
naproxen sodium oral tablet Generic
naratriptan hcl oral tablet Generic STPA; QL (9 EA per 30 days)
nicardipine hcl oral capsule Generic
nifedipine er oral tablet extended release 24 hour Generic
nifedipine er osmotic release oral tablet extended release 24 hour
Generic
nifedipine oral capsule Generic
nitroglycerin sublingual tablet sublingual Generic
nitroglycerin transdermal patch 24 hour Generic
nitroglycerin translingual aerosol solution Generic
nitroglycerin translingual solution Generic
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
NUCYNTA ORAL TABLET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
184
Drug Status NotesOPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (80 mg per 1 day)
OSPHENA ORAL TABLET Brand PA
oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
Generic QL (90 EA per 30 days)
oxycodone hcl er oral tablet er 12 hour abuse-deterrent 15 mg
Brand QL (90 EA per 30 days)
oxycodone hcl oral capsule Generic QL (160 mg per 1 day)
oxycodone hcl oral concentrate 100 mg/5ml Generic QL (160 mg per 1 day)
oxycodone hcl oral solution Generic
oxycodone hcl oral tablet Generic QL (160 mg per 1 day)
oxycodone-acetaminophen oral solution Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )
oxycodone-aspirin oral tablet 4.8355-325 mg Generic
oxycodone-ibuprofen oral tablet Generic PA
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG Brand PA; QL (90 EA per 30 days)
oxymorphone hcl er oral tablet extended release 12 hour
Generic PA; QL (80 mg per 1 day)
oxymorphone hcl oral tablet Generic PA; QL (80 mg per 1 day)
pentoxifylline er oral tablet extended release Generic
perindopril erbumine oral tablet Generic
phenazopyridine hcl oral tablet 100 mg, 200 mg Generic
PHENERGAN RECTAL SUPPOSITORY12.5 MG Generic
prasugrel hcl oral tablet Generic PA
PREMARIN VAGINAL CREAM Brand
promethazine hcl oral solution Generic
promethazine hcl oral syrup Generic
promethazine hcl oral tablet Generic
promethazine hcl rectal suppository Generic
propranolol hcl er oral capsule extended release 24 hour
Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
185
Drug Status Notespropranolol hcl oral solution 40 mg/5ml Generic
propranolol hcl oral tablet Generic
RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA; QL (60 EA per 30 days)
rizatriptan benzoate oral tablet Generic STPA; QL (9 EA per 30 days)
rizatriptan benzoate oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
SAVELLA ORAL TABLET Brand STPA; QL (60 EA per 30 days)
SAVELLA TITRATION PACK ORAL Brand STPA; QL (60 EA per 30 days)
SPRIX NASAL SOLUTION BrandPA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)
sumatriptan nasal solution Generic QL (6 Units per 30 days)
sumatriptan succinate oral tablet Generic QL (9 EA per 30 days)
sumatriptan succinate refill subcutaneous solution cartridge
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
Generic QL (4 EA per 30 days)
sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml
Generic QL (4 EA per 30 days)
telmisartan oral tablet Generic PA
timolol maleate oral tablet Generic
topiramate er oral capsule er 24 hour sprinkle100 mg, 25 mg, 50 mg
Generic PA; QL (30 EA per 30 days)
topiramate er oral capsule er 24 hour sprinkle150 mg, 200 mg
Generic PA; QL (60 EA per 30 days)
topiramate oral capsule sprinkle 15 mg Generic
topiramate oral capsule sprinkle 25 mg Generic QL (180 EA per 30 days)
topiramate oral tablet 100 mg, 50 mg Generic QL (90 EA per 30 days)
topiramate oral tablet 200 mg Generic
topiramate oral tablet 25 mg Generic QL (180 EA per 30 days)
tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 300 mg
Generic PA
tramadol hcl er oral tablet extended release 24 hour
Generic PA; QL (30 EA per 30 days)
tramadol hcl oral tablet Generic QL (240 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
186
Drug Status Notestramadol-acetaminophen oral tablet Generic QL (240 EA per 30 days)
trandolapril oral tablet Generic
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG
Brand PA; QL (30 EA per 30 days)
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)
verapamil hcl oral tablet Generic
XARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)
ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (120 mg per 1 day)
zolmitriptan oral tablet Generic STPA; QL (9 EA per 30 days)
zolmitriptan oral tablet dispersible Generic STPA; QL (9 EA per 30 days)
ZOMIG NASAL SOLUTION BrandPA; STPA; QL (6 Units per 30 days)
ZONTIVITY ORAL TABLET Brand PA
PATIENT DEMOGRAPHICS
bupropion hcl er (smoking det) oral tablet extended release 12 hour
Generic
CHANTIX CONTINUING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)
CHANTIX ORAL TABLET Brand PA; QL (60 EA per 30 days)
CHANTIX STARTING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)
eq nicotine mouth/throat lozenge Generic
eq nicotine polacrilex mouth/throat gum Generic
eq nicotine polacrilex mouth/throat lozenge Generic
eq nicotine step 3 transdermal patch 24 hour Generic
eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr
Generic
eql nicotine polacrilex mouth/throat gum Generic
eql nicotine polacrilex mouth/throat lozenge Generic
eql nicotine transdermal patch 24 hour Generic
gnp nicotine mini mouth/throat lozenge Generic
gnp nicotine polacrilex mouth/throat gum Generic
gnp nicotine polacrilex mouth/throat lozenge Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
187
Drug Status Noteshm nicotine polacrilex mouth/throat gum Generic
hm nicotine polacrilex mouth/throat lozenge Generic
hm nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr
Generic
NICORELIEF MOUTH/THROAT GUM Generic
nicotine mini mouth/throat lozenge Generic
nicotine polacrilex mouth/throat gum Generic
nicotine polacrilex mouth/throat lozenge Generic
nicotine step 1 transdermal patch 24 hour Generic
nicotine step 2 transdermal patch 24 hour Generic
nicotine step 3 transdermal patch 24 hour Generic
nicotine transdermal patch 24 hour Generic
NICOTROL INHALATION INHALER Brand PA
NICOTROL NS NASAL SOLUTION Brand PA
ra mini nicotine mouth/throat lozenge Generic
ra nicotine mouth/throat gum Generic
ra nicotine polacrilex mouth/throat gum Generic
ra nicotine polacrilex mouth/throat lozenge Generic
ra nicotine transdermal patch 24 hour Generic
tgt nicotine mouth/throat gum 4 mg Generic
tgt nicotine polacrilex mouth/throat gum Generic
tgt nicotine polacrilex mouth/throat lozenge Generic
tgt nicotine step one transdermal patch 24 hour Generic
tgt nicotine step three transdermal patch 24 hour Generic
tgt nicotine step two transdermal patch 24 hour Generic
PREGNANCY
BONJESTA ORAL TABLET EXTENDED RELEASE Brand PA
caffeine citrate oral solution Generic
DICLEGIS ORAL TABLET DELAYED RELEASE Brand PA
ELITE-OB ORAL TABLET Generic
HYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
INATAL ADVANCE ORAL TABLET Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
188
Drug Status Notes
Makena Intramuscular Oil MB/RXSingle Dose Vial Only; QL (1 ML per 7 days)
Makena Subcutaneous Solution Auto-Injector MB/RX QL (2 ML per 7 days)
methylergonovine maleate oral tablet Generic
prenatabs fa oral tablet Generic
prenatal 19 oral tablet Generic
prenatal 19 oral tablet chewable Generic
prenatal oral tablet 27-0.8 mg Generic
TRINATE ORAL TABLET Generic
PROCEDURE
Alphanate/VWF Complex/Human Intravenous Solution Reconstituted
MB/RX PA; SP
aminocaproic acid oral tablet Generic
aspirin-dipyridamole er oral capsule extended release 12 hour
Generic PA; QL (60 EA per 30 days)
azathioprine oral tablet Generic
BEVYXXA ORAL CAPSULE Brand PA
BRILINTA ORAL TABLET Brand PA; QL (60 EA per 30 days)
bromfenac sodium (once-daily) ophthalmic solution
Generic
bromfenac sodium ophthalmic solution Generic
CIDALEAZE EXTERNAL CREAM Generic
cyclosporine modified oral capsule Generic
cyclosporine modified oral solution Generic
cyclosporine oral capsule Generic
dexamethasone sodium phosphate ophthalmic solution
Generic
diclofenac sodium ophthalmic solution Generic
dofetilide oral capsule Generic
doxercalciferol oral capsule Generic
ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)
EMEND ORAL CAPSULE Brand PA; QL (6 EA per 1 Rx)
enoxaparin sodium injection solution Generic
enoxaparin sodium subcutaneous solution Generic
FERRIPROX ORAL SOLUTION Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
189
Drug Status NotesFERRIPROX ORAL TABLET Brand PA
flurbiprofen sodium ophthalmic solution Generic
fondaparinux sodium subcutaneous solution Generic
GATTEX SUBCUTANEOUS KIT Brand SP; QL (1 Kit per 1 day)
GAVILYTE-C ORAL SOLUTION RECONSTITUTED Generic
GAVILYTE-G ORAL SOLUTION RECONSTITUTED Generic
GENGRAF ORAL CAPSULE Generic
GENGRAF ORAL SOLUTION Generic
GLYDO EXTERNAL GEL Generic
heparin (porcine) in nacl intravenous solution5000-0.9 ut/500ml-%
Brand
heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml
Generic
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
MB/RX PA; SP
hydroxyzine hcl oral syrup Generic
hydroxyzine hcl oral tablet Generic
hydroxyzine pamoate oral capsule Generic
IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED Brand QL (24 vials per 12 days)
JADENU ORAL TABLET Brand PA; SP
JADENU SPRINKLE ORAL PACKET Brand PA
ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml
Generic¥ (Max of 5 days per Rx); QL (120 MG per 1 day)
ketorolac tromethamine intramuscular solution60 mg/2ml
Generic¥ (Max of 5 days per Rx); QL (120 mg per 1 day)
ketorolac tromethamine ophthalmic solution Generic
ketorolac tromethamine oral tablet Generic QL (20 EA per 30 days)
lidocaine external ointment Generic QL (50 GM per 30 days)
lidocaine hcl external cream 3 % Generic
lidocaine hcl external gel 2 % Generic
lidocaine hcl external lotion Generic
lidocaine hcl external solution Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
190
Drug Status Noteslidocaine viscous mouth/throat solution Generic
lidocaine-prilocaine external cream Generic
lidocaine-prilocaine external kit Generic
liothyronine sodium oral tablet Generic
mycophenolate mofetil oral capsule Generic
mycophenolate mofetil oral suspension reconstituted
Generic
mycophenolate mofetil oral tablet Generic
mycophenolic acid oral tablet delayed release Generic
neomycin sulfate oral tablet Generic
NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP; QL (0.6 ML per 14 days)
NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP; QL (0.6 ML per 14 days)
NUTRESTORE ORAL PACKET Brand PA
ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml
Generic
oxycodone-ibuprofen oral tablet Generic PA
peg 3350/electrolytes oral solution reconstituted Generic
peg 3350-kcl-na bicarb-nacl oral solution reconstituted
Generic
peg-3350/electrolytes oral solution reconstituted Generic
PHENERGAN RECTAL SUPPOSITORY12.5 MG Generic
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
Generic
pilocarpine hcl oral tablet Generic
PRADAXA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
prasugrel hcl oral tablet Generic PA
PREVYMIS INTRAVENOUS SOLUTION Medical Benefit PA
PREVYMIS ORAL TABLET Brand PA
probenecid oral tablet Generic
promethazine hcl oral solution Generic
promethazine hcl oral syrup Generic
promethazine hcl oral tablet Generic
promethazine hcl rectal suppository Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
191
Drug Status Notesproparacaine hcl ophthalmic solution Generic
quinidine gluconate er oral tablet extended release
Generic
quinidine sulfate er oral tablet extended release Generic
quinidine sulfate oral tablet Generic
RAPAMUNE ORAL SOLUTION Brand
SENSIPAR ORAL TABLET Brand PA
silver sulfadiazine external cream Generic
sirolimus oral tablet Generic
SPRIX NASAL SOLUTION BrandPA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)
SSD EXTERNAL CREAM Generic
tacrolimus oral capsule Generic
TRILYTE ORAL SOLUTION RECONSTITUTED Generic
trimethobenzamide hcl oral capsule Generic
Vonvendi Intravenous Solution Reconstituted MB/RX PA; SP
Wilate Intravenous Kit MB/RX PA; SP
Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT
MB/RX PA; SP
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)
XARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand
PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)
ZONTIVITY ORAL TABLET Brand PA
ZORTRESS ORAL TABLET Brand SP
REACTION DUE TO AN ALLERGEN
ADRENACLICK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)
ALOCRIL OPHTHALMIC SOLUTION Brand PA
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML Brand PA; QL (2 EA per 1 Fill)
azelastine hcl nasal solution 0.1 % Brand
azelastine hcl ophthalmic solution Generic PA
BECONASE AQ NASAL SUSPENSION Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
192
Drug Status NotesBEPREVE OPHTHALMIC SOLUTION Brand PA
Berinert Intravenous Kit MB/RX SP
budesonide nasal suspension Generic PA
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
CLARINEX ORAL SYRUP Brand PA
CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA
clemastine fumarate oral tablet 2.68 mg Generic
cromolyn sodium ophthalmic solution Generic
cyproheptadine hcl oral syrup Generic
cyproheptadine hcl oral tablet Generic
desloratadine oral tablet Generic PA
diphenhydramine hcl oral capsule 25 mg Brand
diphenhydramine hcl oral capsule 50 mg Generic
diphenhydramine hcl oral elixir Brand
EMADINE OPHTHALMIC SOLUTION Brand PA
epinastine hcl ophthalmic solution Generic PA
epinephrine hcl injection solution 1 mg/ml Generic
epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml
Generic QL (2 EA per 1 Fill)
EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)
EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)
FIRAZYR SUBCUTANEOUS SOLUTION Brand PA; SP; QL (3 ML per 1 Fill)
flunisolide nasal solution 25 mcg/act (0.025%) Generic
hydrocod polst-cpm polst er oral suspension extended release
Generic
ipratropium bromide nasal solution Generic
ketotifen fumarate ophthalmic solution Generic
LASTACAFT OPHTHALMIC SOLUTION Brand PA
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
mometasone furoate nasal suspension Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
193
Drug Status Notesmontelukast sodium oral packet Generic
montelukast sodium oral tablet Generic
montelukast sodium oral tablet chewable Generic
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA
ODACTRA SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
olopatadine hcl ophthalmic solution Generic PA
OMNARIS NASAL SUSPENSION Brand PA
ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)
promethazine vc plain oral syrup Generic
promethazine-codeine oral syrup Generic
promethazine-dm oral syrup Generic
promethazine-phenylephrine oral syrup Generic
QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA
QNASL NASAL AEROSOL SOLUTION Brand PA
Ruconest Intravenous Solution Reconstituted MB/RX SP
SEMPREX-D ORAL CAPSULE Brand PA
triamcinolone acetonide nasal aerosol Generic
VERAMYST NASAL SUSPENSION Brand PA
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
ZETONNA NASAL AEROSOL SOLUTION Brand PA
RECENT OPERATION
Alphanate/VWF Complex/Human Intravenous Solution Reconstituted
MB/RX PA; SP
aminocaproic acid oral tablet Generic
azathioprine oral tablet Generic
BRILINTA ORAL TABLET Brand PA; QL (60 EA per 30 days)
bromfenac sodium (once-daily) ophthalmic solution
Generic
bromfenac sodium ophthalmic solution Generic
CIDALEAZE EXTERNAL CREAM Generic
cyclosporine modified oral capsule Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
194
Drug Status Notescyclosporine modified oral solution Generic
cyclosporine oral capsule Generic
dexamethasone sodium phosphate ophthalmic solution
Generic
diclofenac sodium ophthalmic solution Generic
EMEND ORAL CAPSULE Brand PA; QL (6 EA per 1 Rx)
flurbiprofen sodium ophthalmic solution Generic
fondaparinux sodium subcutaneous solution Generic
GATTEX SUBCUTANEOUS KIT Brand SP; QL (1 Kit per 1 day)
GENGRAF ORAL CAPSULE Generic
GENGRAF ORAL SOLUTION Generic
GLYDO EXTERNAL GEL Generic
heparin (porcine) in nacl intravenous solution5000-0.9 ut/500ml-%
Brand
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
MB/RX PA; SP
hydroxyzine hcl oral syrup Generic
hydroxyzine hcl oral tablet Generic
hydroxyzine pamoate oral capsule Generic
IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED Brand QL (24 vials per 12 days)
ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml
Generic¥ (Max of 5 days per Rx); QL (120 MG per 1 day)
ketorolac tromethamine intramuscular solution60 mg/2ml
Generic¥ (Max of 5 days per Rx); QL (120 mg per 1 day)
ketorolac tromethamine ophthalmic solution Generic
ketorolac tromethamine oral tablet Generic QL (20 EA per 30 days)
lidocaine external ointment Generic QL (50 GM per 30 days)
lidocaine hcl external cream 3 % Generic
lidocaine hcl external gel 2 % Generic
lidocaine hcl external lotion Generic
lidocaine hcl external solution Generic
lidocaine viscous mouth/throat solution Generic
lidocaine-prilocaine external cream Generic
lidocaine-prilocaine external kit Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
195
Drug Status Notesmycophenolate mofetil oral capsule Generic
mycophenolate mofetil oral suspension reconstituted
Generic
mycophenolate mofetil oral tablet Generic
mycophenolic acid oral tablet delayed release Generic
neomycin sulfate oral tablet Generic
NUTRESTORE ORAL PACKET Brand PA
ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml
Generic
oxycodone-ibuprofen oral tablet Generic PA
PHENERGAN RECTAL SUPPOSITORY12.5 MG Generic
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
Generic
prasugrel hcl oral tablet Generic PA
PREVYMIS INTRAVENOUS SOLUTION Medical Benefit PA
PREVYMIS ORAL TABLET Brand PA
promethazine hcl oral solution Generic
promethazine hcl oral syrup Generic
promethazine hcl oral tablet Generic
promethazine hcl rectal suppository Generic
proparacaine hcl ophthalmic solution Generic
RAPAMUNE ORAL SOLUTION Brand
silver sulfadiazine external cream Generic
sirolimus oral tablet Generic
SPRIX NASAL SOLUTION BrandPA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)
SSD EXTERNAL CREAM Generic
tacrolimus oral capsule Generic
trimethobenzamide hcl oral capsule Generic
Vonvendi Intravenous Solution Reconstituted MB/RX PA; SP
Wilate Intravenous Kit MB/RX PA; SP
Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT
MB/RX PA; SP
ZONTIVITY ORAL TABLET Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
196
Drug Status NotesZORTRESS ORAL TABLET Brand SP
SKIN CONDITION
ABSORICA ORAL CAPSULE Brand PA
acitretin oral capsule Generic QL (60 EA per 30 days)
acne medication 5 external gel Generic
acyclovir external ointment Generic
ACZONE EXTERNAL GEL 7.5 % Brand PA; QL (60 GM per 30 days)
adapalene external cream Generic STPA
adapalene external gel Generic STPA
adapalene external lotion Generic STPA
alclometasone dipropionate external cream Generic
alclometasone dipropionate external ointment Generic
ALFERON N INJECTION SOLUTION Medical Benefit PA
ALTRENO EXTERNAL LOTION Brand PA
amcinonide external cream Generic PA
amcinonide external lotion Generic PA
amcinonide external ointment Generic PA
ammonium lactate external cream Generic
ammonium lactate external lotion Generic
AMNESTEEM ORAL CAPSULE Generic PA
APEXICON E EXTERNAL CREAM Brand PA
AVITA EXTERNAL CREAM Generic PA; Age Limit (Max 26 Years)
AVITA EXTERNAL GEL Generic PA; Age Limit (Max 26 Years)
AZELEX EXTERNAL CREAM Brand PA; QL (30 grams per 1 fill)
BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP
BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA
BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA
benzoyl peroxide external gel 10 %, 2.5 %, 5 % Generic
benzoyl peroxide wash external liquid Generic
benzoyl peroxide-erythromycin external gel Generic QL (23 GM per 30 days)
Berinert Intravenous Kit MB/RX SP
betamethasone dipropionate aug external cream Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
197
Drug Status Notesbetamethasone dipropionate aug external gel Generic
betamethasone dipropionate aug external lotion Generic
betamethasone dipropionate aug external ointment
Generic
betamethasone dipropionate external cream Generic
betamethasone dipropionate external lotion Generic
betamethasone dipropionate external ointment Generic
betamethasone valerate external cream Generic
betamethasone valerate external foam Generic
betamethasone valerate external lotion Generic
betamethasone valerate external ointment Generic
bexarotene oral capsule Generic
BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP
bp foaming wash external liquid Generic
bp wash external liquid 10 %, 2.5 %, 5 % Generic
bpo external gel Brand PA
calcipotriene external cream Generic
calcipotriene external ointment Generic
calcipotriene external solution Generic
calcipotriene-betameth diprop external ointment Generic PA
CALCITRENE EXTERNAL OINTMENT Generic
calcitriol external ointment Generic
CAPEX EXTERNAL SHAMPOO Brand PA
cetirizine hcl oral solution 1 mg/ml Generic PA
cetirizine hcl oral syrup 1 mg/ml Generic PA
CICLODAN EXTERNAL CREAM Generic
CICLODAN EXTERNAL SOLUTION Generic
ciclopirox external gel Generic
ciclopirox external shampoo Brand PA
ciclopirox external solution Brand
ciclopirox olamine external cream Generic
ciclopirox olamine external suspension Generic PA
CIDALEAZE EXTERNAL CREAM Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
198
Drug Status NotesCIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)
CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand
PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)
CLARAVIS ORAL CAPSULE GenericPA; ¥ (Max of 5 months); QL (60 EA per 30 days)
clemastine fumarate oral tablet 2.68 mg Generic
clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %
Generic PA; QL (50 GM per 30 days)
clindamycin phosphate external foam Generic PA
clindamycin phosphate external gel Generic
clindamycin phosphate external lotion Generic
clindamycin phosphate external solution Generic
clobetasol propionate e external cream Generic
clobetasol propionate external cream Generic PA
clobetasol propionate external foam Generic
clobetasol propionate external gel Generic PA
clobetasol propionate external liquid Generic PA
clobetasol propionate external lotion Generic
clobetasol propionate external ointment Generic PA
clobetasol propionate external shampoo Generic
clobetasol propionate external solution Generic PA
clocortolone pivalate external cream Generic PA
clocortolone pivalate pump external cream Generic PA
clotrimazole anti-fungal external cream Generic
clotrimazole external cream Generic
clotrimazole external solution Generic
clotrimazole-betamethasone external cream Generic
clotrimazole-betamethasone external lotion Generic
CORDRAN EXTERNAL TAPE Brand PA
COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (2 Syringes per 28 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
199
Drug Status NotesCOSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
BrandPA; SP; QL (2 Syringes per 28 days)
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
BrandPA; SP; QL (1 Syringe per 28 days)
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 28 days)
cyproheptadine hcl oral syrup Generic
cyproheptadine hcl oral tablet Generic
dapsone external gel Generic PA; QL (60 GM per 30 days)
dapsone oral tablet Brand
DENAVIR EXTERNAL CREAM Brand PA; QL (5 GM per 1 Fill)
desonide external cream Generic PA
desonide external lotion Generic PA
desonide external ointment Generic PA
desoximetasone external cream 0.05 % Generic PA
desoximetasone external cream 0.25 % Generic
desoximetasone external gel Generic
desoximetasone external ointment 0.05 % Generic PA
desoximetasone external ointment 0.25 % Generic
diclofenac sodium transdermal gel 3 % Generic¥ (Max of 90 days per year); QL (200 GM per 30 days)
diflorasone diacetate external cream Generic PA
diflorasone diacetate external ointment Generic PA
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg
Generic
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Brand PA; QL (4 ML per 28 days)
DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
econazole nitrate external cream Generic
ECOZA EXTERNAL FOAM Brand PA
ELIDEL EXTERNAL CREAM Brand PA
ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE Brand PA; SP; QL (4 each per 28 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
200
Drug Status NotesENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand
PA; SP; QL (8 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand
PA; SP; QL (4 syringes per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; QL (4 syringes per 28 days)
ERIVEDGE ORAL CAPSULE Brand PA; SP
erythromycin external gel Generic
erythromycin external solution Generic
EXELDERM EXTERNAL CREAM Brand PA
EXELDERM EXTERNAL SOLUTION Brand PA
FABIOR EXTERNAL FOAM Brand PA
FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
FINACEA EXTERNAL FOAM Brand PA; QL (50 GM per 1 Rx)
FINACEA EXTERNAL GEL Brand PA; QL (50 GM per 1 Rx)
FIRAZYR SUBCUTANEOUS SOLUTION Brand PA; SP; QL (3 ML per 1 Fill)
fluocinolone acetonide body external oil Generic
fluocinolone acetonide external cream Generic
fluocinolone acetonide external ointment Generic
fluocinolone acetonide external solution Generic
fluocinolone acetonide otic oil Generic
fluocinolone acetonide scalp external oil Generic
fluocinonide external cream 0.05 % Generic QL (60 GM per 30 days)
fluocinonide external cream 0.1 % Generic PA; QL (120 GM per 30 days)
fluocinonide external gel Generic QL (60 GM per 30 days)
fluocinonide external ointment Generic QL (60 GM per 30 days)
fluocinonide external solution Generic QL (60 ML per 30 days)
fluorouracil external cream Generic
fluorouracil external solution Generic
flurandrenolide external cream Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
201
Drug Status Notesflurandrenolide external lotion Generic PA
flurandrenolide external ointment Generic PA
fluticasone propionate external cream Generic
fluticasone propionate external lotion Generic
fluticasone propionate external ointment Generic
GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED
Medical Benefit PA; SP
gentamicin sulfate external cream Generic
gentamicin sulfate external ointment Generic
GIANVI ORAL TABLET Generic
griseofulvin microsize oral suspension Generic
griseofulvin microsize oral tablet Generic
griseofulvin ultramicrosize oral tablet Generic
halobetasol propionate external cream Generic PA
halobetasol propionate external ointment Generic PA
HALOG EXTERNAL CREAM Brand PA
HALOG EXTERNAL OINTMENT Brand PA
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)
hydrocortisone ace-pramoxine external cream2.5-1 %
Generic
hydrocortisone butyrate external cream Generic PA
hydrocortisone butyrate external ointment Generic PA
hydrocortisone butyrate external solution Generic PA
hydrocortisone external cream 1 %, 2.5 % Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
202
Drug Status Noteshydrocortisone external lotion Generic
hydrocortisone external ointment 1 %, 2.5 % Generic
hydrocortisone rectal cream Generic
hydrocortisone valerate external cream Generic
hydrocortisone valerate external ointment Generic
hydroxychloroquine sulfate oral tablet Generic
hydroxyurea oral capsule Generic
imiquimod external cream Generic
imiquimod pump external cream Generic PA; QL (7.5 GM per 14 days)
IMPAVIDO ORAL CAPSULE Brand
INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
isotretinoin oral capsule Generic PA
JUBLIA EXTERNAL SOLUTION Brand PA
ketoconazole external cream Generic
ketoconazole external foam Generic
ketoconazole external shampoo Generic
KETODAN EXTERNAL FOAM Generic
LAMISIL ORAL PACKET BrandPA; ¥ (Max of 6 weeks); QL (2 Packets per 1 day)
levocetirizine dihydrochloride oral solution Generic PA
levocetirizine dihydrochloride oral tablet Generic PA
lidocaine external ointment Generic QL (50 GM per 30 days)
lidocaine hcl external cream 3 % Generic
lidocaine hcl external lotion Generic
lindane external lotion Generic
lindane external shampoo Generic
LORYNA ORAL TABLET Generic
luliconazole external cream Generic PA
malathion external lotion Generic
methotrexate oral tablet Generic
methoxsalen rapid oral capsule Generic
metronidazole external cream Generic
metronidazole external gel 0.75 % Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
203
Drug Status Notesmetronidazole external gel 1 % Generic PA
metronidazole external lotion Generic
MIRVASO EXTERNAL GEL Brand PA
mometasone furoate external cream Generic
mometasone furoate external ointment Generic
mometasone furoate external solution Generic
mupirocin calcium external cream Generic PA
mupirocin external ointment Generic
MYORISAN ORAL CAPSULE Generic PA
naftifine hcl external cream Generic PA
NEUAC EXTERNAL GEL Brand PA
NIKKI ORAL TABLET Generic
NORITATE EXTERNAL CREAM Brand PA
NYAMYC EXTERNAL POWDER Generic
nystatin external cream Generic
nystatin external ointment Generic
nystatin external powder Generic
nystatin-triamcinolone external cream Generic
nystatin-triamcinolone external ointment Generic
NYSTOP EXTERNAL POWDER Generic
ODOMZO ORAL CAPSULE Brand PA
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)
ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit
PA; SP; QL (4 VIALS per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML
Brand PA; QL (1.6 ML per 28 days)
OTEZLA ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
OTEZLA ORAL TABLET THERAPY PACK Brand PA; SP; QL (60 EA per 30 days)
oxiconazole nitrate external cream Generic PA
OXISTAT EXTERNAL LOTION Brand PA
PANRETIN EXTERNAL GEL Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
204
Drug Status Notespermethrin external cream Generic
PICATO EXTERNAL GEL Brand PA; QL (1 Box per 1 Rx)
podofilox external solution Generic
prednicarbate external cream Generic
PROCTO-PAK RECTAL CREAM Generic
PROCTOSOL HC RECTAL CREAM Generic
PROCTOZONE-HC RECTAL CREAM Generic
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
RETIN-A MICRO PUMP EXTERNAL GEL0.08 % Brand PA; Age Limit (Max 26 Years)
Ruconest Intravenous Solution Reconstituted MB/RX SP
selenium sulfide external lotion Generic
selenium sulfide external shampoo 2.25 % Generic
selenium sulf-pyrithione-urea external shampoo Generic
SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (3 ML per 28 days)
SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)
SOOLANTRA EXTERNAL CREAM Brand PA
spinosad external suspension BrandPA; STPA; QL (120 ML per 1 Fill)
STELARA INTRAVENOUS SOLUTION Medical BenefitPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (1 Syringe per 84 days)
sulfacetamide sodium (acne) external lotion Generic
sulfacetamide sodium external suspension Generic
SYNALAR (CREAM) EXTERNAL KIT Brand PA
SYNALAR (OINTMENT) EXTERNAL KIT Brand PA
TACLONEX EXTERNAL SUSPENSION Brand PA
tacrolimus external ointment Generic PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
205
Drug Status Notes
TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand
PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)
TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)
TAZORAC EXTERNAL CREAM Brand PA; STPA
TAZORAC EXTERNAL GEL Brand PA; STPA
TILIA FE ORAL TABLET Generic
TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (1 ML per 54 days)
tretinoin external cream GenericPA; ^ (Preferred Product); Age Limit (Max 26 Years)
tretinoin external gel 0.01 %, 0.025 % GenericPA; ^ (Preferred Product); Age Limit (Max 26 Years)
tretinoin external gel 0.05 % Generic PA; Age Limit (Max 26 Years)
tretinoin microsphere external gel Generic PA; Age Limit (Max 26 Years)
tretinoin microsphere pump external gel Generic PA; Age Limit (Max 26 Years)
TREXALL ORAL TABLET Brand
triamcinolone acetonide external aerosol solution Generic PA
triamcinolone acetonide external cream Generic
triamcinolone acetonide external lotion Generic
triamcinolone acetonide external ointment Generic
TRI-LEGEST FE ORAL TABLET Generic
ULESFIA EXTERNAL LOTION Brand PA; QL (12 Bottles per 1 Rx)
VEREGEN EXTERNAL OINTMENT Brand PA
VESTURA ORAL TABLET Generic
XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)
ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG Generic PA
ZENATANE ORAL CAPSULE 40 MG Brand PA
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
206
Drug Status NotesZOLINZA ORAL CAPSULE Brand PA; SP
ZYCLARA EXTERNAL CREAM Brand PA; QL (28 EA per 14 days)
ZYCLARA PUMP EXTERNAL CREAM 2.5 % Brand PA; QL (7.5 GM per 14 days)
SLOW DRUG ELIMINATION BY KIDNEY
probenecid oral tablet Generic
TACHYARRHYTHMIA
amiodarone hcl oral tablet Generic
DIGITEK ORAL TABLET Generic
DIGOX ORAL TABLET Generic
digoxin oral solution Generic
digoxin oral tablet Generic
dofetilide oral capsule Generic
ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)
flecainide acetate oral tablet Generic
PRADAXA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)
propafenone hcl er oral capsule extended release 12 hour
Generic
propafenone hcl oral tablet Generic
quinidine gluconate er oral tablet extended release
Generic
quinidine sulfate er oral tablet extended release Generic
quinidine sulfate oral tablet Generic
SAVAYSA ORAL TABLET Brand PA
sotalol hcl (af) oral tablet 120 mg, 80 mg Generic
sotalol hcl oral tablet Generic
verapamil hcl oral tablet Generic
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand
PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)
TUMOR
ABSTRAL SUBLINGUAL TABLET SUBLINGUAL Brand PA
AFINITOR DISPERZ ORAL TABLET SOLUBLE Brand PA; SP; QL (60 EA per 30 days)
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
207
Drug Status NotesAFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)
AKYNZEO ORAL CAPSULE Brand PA; QL (1 EA per 1 Fill)
alfuzosin hcl er oral tablet extended release 24 hour
Generic
allopurinol oral tablet Generic
anagrelide hcl oral capsule Generic
ANZEMET ORAL TABLET 100 MG Brand PA; QL (10 EA per 1 fill)
ANZEMET ORAL TABLET 50 MG Brand PA; QL (5 EA per 1 fill)
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
Brand SP; QL (4 ML per 30 days)
ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML
Brand SP; QL (4 ML per 30 days)
bexarotene oral capsule Generic
CESAMET ORAL CAPSULE Brand PA
DEMSER ORAL CAPSULE Brand
doxazosin mesylate oral tablet Generic
dronabinol oral capsule Generic
dutasteride oral capsule Generic PA; QL (30 EA per 30 days)
dutasteride-tamsulosin hcl oral capsule Generic PA; QL (30 EA per 30 days)
ELIGARD SUBCUTANEOUS KIT Medical Benefit PA; SP
EMCYT ORAL CAPSULE Brand
EMEND ORAL CAPSULE Brand PA; QL (6 EA per 1 Rx)
EMEND ORAL SUSPENSION RECONSTITUTED Brand PA; QL (3 Units per 7 days)
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Brand SP
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Brand SP; QL (10 ML per 14 days)
ERIVEDGE ORAL CAPSULE Brand PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
208
Drug Status Notesexemestane oral tablet Generic
FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA
FARYDAK ORAL CAPSULE Brand PA; SP
fentanyl citrate buccal lozenge on a handle Generic PA; QL (120 EA per 30 days)
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Brand PA; QL (4 EA per 1 day)
finasteride oral tablet 5 mg Generic
fluorouracil external cream 5 % Generic
fluorouracil external solution 5 % Generic
FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand QL (0.6 ML per 14 days)
granisetron hcl oral tablet Generic QL (14 EA per 1 Fill)
GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
HYDROXYprogesterone Caproate Intramuscular Oil
MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)
hydroxyurea oral capsule Generic
IMBRUVICA ORAL CAPSULE 70 MG Brand PA
IMBRUVICA ORAL TABLET Brand PA
imiquimod external cream Generic
JAKAFI ORAL TABLET Brand PA; SP
letrozole oral tablet Generic
LEUKERAN ORAL TABLET Brand
leuprolide acetate injection kit Medical Benefit PA; SP
LONSURF ORAL TABLET Brand PA; SP
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT Medical Benefit PA
MESNEX ORAL TABLET Brand
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
209
Drug Status NotesNEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP; QL (0.6 ML per 14 days)
NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP; QL (0.6 ML per 14 days)
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Brand
PA; SP; QL (10 Syringes per 14 days)
NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE Brand
PA; SP; QL (10 Syringes per 14 days)
NINLARO ORAL CAPSULE Brand PA; SP
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml
Generic PA; SP; QL (30 ML per 30 days)
octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)
ODOMZO ORAL CAPSULE Brand PA
ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml
Generic
ondansetron hcl oral solution Generic QL (105 ML per 1 Fill)
ondansetron hcl oral tablet Generic QL (21 EA per 1 Fill)
ondansetron oral tablet dispersible Generic QL (21 EA per 1 Fill)
PANRETIN EXTERNAL GEL Brand PA
phenoxybenzamine hcl oral capsule Generic
pilocarpine hcl oral tablet Generic
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Brand SP
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Brand SP; QL (10 ML per 14 days)
raloxifene hcl oral tablet Generic
RAPAFLO ORAL CAPSULE Brand PA
RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP
SANCUSO TRANSDERMAL PATCH Brand PA
SOLTAMOX ORAL SOLUTION Brand
SYNDROS ORAL SOLUTION Brand PA
tamoxifen citrate oral tablet Generic
tamsulosin hcl oral capsule Generic
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
210
Drug Status Notesterazosin hcl oral capsule Generic
THALOMID ORAL CAPSULE Brand SP
VARUBI ORAL TABLET BrandPA; ¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)
XATMEP ORAL SOLUTION Brand PA
XERMELO ORAL TABLET Brand PA
XGEVA SUBCUTANEOUS SOLUTION Medical Benefit PA; SP; QL (1 vial per 30 days)
ZARXIO INJECTION SOLUTION PREFILLED SYRINGE Brand SP; QL (10 Syringes per 14 days)
ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG Medical Benefit PA; QL (1 EA per 84 days)
ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Medical Benefit PA; QL (1 EA per 28 days)
ZOLINZA ORAL CAPSULE Brand PA; SP
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
211
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
212
Indexabacavir sulfate ............ 17, 98, 157abacavir sulfate-lamivudine.......................................17, 98, 157abacavir-lamivudine-zidovudine.......................................17, 98, 157Abilify Maintena.......................141ABSORICA ............................. 197ABSTRAL ....................... 179, 207acamprosate calcium ........ 141, 157acarbose ................................25, 90ACCU-CHEK SAFE-T PRO LANCETS ............................... 152ACCU-CHEK SOFT TOUCH LANCETS ............................... 152ACCU-CHEK SOFTCLIX LANCETS ............................... 152acebutolol hcl ..............................34acetaminophen-codeine .... 157, 179acetaminophen-codeine #2 ....... 179acetaminophen-codeine #3 ....... 179acetaminophen-codeine #4 ....... 179ACETASOL HC ....................... 95acetazolamide ......... 25, 76, 96, 125acetazolamide er .......................157acetic acid ...................................95acetic acid-aluminum acetate ..... 95acetylcysteine .............. 76, 125, 178ACIPHEX SPRINKLE.....................................82, 107, 157acitretin .............................157, 197acne medication 5 ..................... 197ACTEMRA ..14, 17, 107, 131, 157ACTIMMUNE .............. 3, 17, 131ACTOPLUS MET XR ........25, 90acyclovir ......................98, 157, 197ACZONE ................................. 197adapalene ..................................197adefovir dipivoxil .. 82, 98, 107, 157ADEMPAS ...3, 8, 34, 76, 125, 157ADLYXIN ............................25, 90ADLYXIN STARTER PACK...............................................25, 90ADMELOG ............................. 157ADMELOG SOLOSTAR ...... 157ADRENACLICK .................... 192ADVAIR DISKUS 8, 76, 108, 125
ADVAIR HFA .......8, 76, 108, 125Advate...........................................3Adynovate.....................................3AFINITOR ............ 43, 68, 82, 208AFINITOR DISPERZ 47, 58, 207Afstyla...........................................3AKYNZEO ........................ 82, 208ALBENZA ............................... 157albuterol sulfate .............. 8, 76, 125albuterol sulfate er ..........8, 76, 125alclometasone dipropionate...........................................108, 197ALECENSA .............................158alendronate sodium 26, 68, 90, 131ALFERON N .............98, 108, 197alfuzosin hcl er ....................44, 208ALIQOPA ................................158ALLI ...........................................26allopurinol .................... 26, 44, 208almotriptan malate.........................34, 47, 58, 158, 179ALOCRIL ..........96, 108, 124, 192alogliptin benzoate ........26, 90, 158alogliptin-metformin hcl.......................................26, 90, 158alogliptin-pioglitazone ..26, 90, 158ALOMIDE ...............................158alosetron hcl ....................... 82, 158ALPHAGAN P .......................... 96Alphanate..................................158Alphanate/VWF Complex/Human...................3, 17, 34, 108, 189, 194AlphaNine SD...............................3alprazolam ................................ 141alprazolam er ............................141alprazolam xr ............................141Alprolix.........................................3ALTAVERA ..............................68ALTRENO ...............................197ALUNBRIG .............................158ALVESCO ............. 8, 76, 108, 125alyacen 1/35 ................................68alyacen 7/7/7 ...............................68amantadine hcl ................47, 58, 99amcinonide ........................108, 197
AMETHIA .................................68AMETHIA LO .......................... 68AMETHYST ............................. 68amiloride hcl .........................26, 34amiloride-hydrochlorothiazide ... 34aminocaproic acid ...... 34, 189, 194amiodarone hcl ........... 34, 158, 207AMITIZA .......................... 82, 178amitriptyline hcl ........................158amlodipine besy-benazepril hcl .. 34amlodipine besylate ............ 34, 179amlodipine besylate-valsartan.............................................34, 158amlodipine-atorvastatin...................................26, 34, 47, 58amlodipine-olmesartan ....... 34, 158amlodipine-valsartan-hctz .. 34, 158ammonium lactate .....................197AMNESTEEM ........................ 197amoxapine .................................141amoxicill-clarithro-lansopraz...............................82, 99, 108, 158amoxicillin ................................ 158amoxicillin-pot clavulanate ...... 158amoxicillin-pot clavulanate er ..158amphetamine-dextroamphet er...............................47, 58, 131, 141amphetamine-dextroamphetamine.......................47, 58, 131, 141, 158ampicillin .................................. 158ANADROL-50 .......................3, 17anagrelide hcl ................. 3, 34, 208anastrozole ................................158ANDRODERM ....................68, 90ANDROGEL ....................... 69, 90ANDROXY ..........................69, 90ANORO ELLIPTA.........................8, 76, 108, 125, 159ANTARA ........................... 26, 159antipyrine-benzocaine ...............159ANZEMET ........................ 82, 208APEXICON E ................. 108, 197APIDRA ...................................159APIDRA OPTICLIK ..............159APIDRA SOLOSTAR ............ 159
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
213
APRI ...........................................69APRISO ............................. 82, 108APTIOM ......................48, 58, 159APTIVUS .......................17, 18, 99ARANELLE .............................. 69ARANESP (ALBUMIN FREE) ............................ 3, 44, 208ARCALYST .......... 18, 26, 95, 108ARCAPTA NEOHALER.................................8, 76, 108, 125aripiprazole .......................141, 159Aristada.....................................141Aristada Initio........................... 141armodafinil ............. 48, 58, 76, 125ARYMO ER ............................ 179ASCOMP-CODEINE ..... 141, 179ASHLYNA .................................69ASMANEX 120 METERED DOSES ................... 8, 76, 108, 126ASMANEX 14 METERED DOSES ................... 9, 76, 108, 126ASMANEX 30 METERED DOSES ................... 9, 76, 108, 126ASMANEX 60 METERED DOSES ................... 9, 76, 109, 126ASMANEX 7 METERED DOSES ................... 9, 77, 109, 126ASMANEX HFA ...9, 77, 109, 126aspirin-dipyridamole er.....................3, 35, 48, 58, 159, 189AT LAST LANCETS ............. 152atazanavir sulfate ..........18, 99, 159atenolol ............................... 35, 179atenolol-chlorthalidone .............. 35atomoxetine hcl.......................48, 58, 131, 141, 159atorvastatin calcium ................... 26atovaquone ................................159atovaquone-proguanil hcl ...........99ATRIPLA ............................ 18, 99atropine sulfate ....... 48, 58, 96, 131ATROVENT HFA ........ 9, 77, 126AUBAGIO ........................... 48, 58AUBRA .............................. 69, 159AURYXIA.........3, 7, 26, 44, 90, 131, 151, 159AUSTEDO ........... 48, 58, 131, 141
AUVI-Q ....................................192AVANDAMET ....................26, 90AVANDIA ............................26, 90AVAR CLEANSER ................ 159AVIANE .....................................69AVITA ..................................... 197AVONEX ............................. 48, 58AVONEX PEN .................... 48, 58AVONEX PREFILLED ..... 48, 58azathioprine.........14, 18, 44, 109, 131, 189, 194azelastine hcl.......9, 12, 77, 96, 99, 109, 124, 192AZELEX ..................................197azithromycin ............................. 159AZOPT .......................................96AZURETTE .............................. 69bacitracin ..............................96, 99bacitracin-polymyxin b ......... 96, 99bacitra-neomycin-polymyxin-hc159baclofen .........................48, 58, 131balsalazide disodium .......... 82, 109BALZIVA .................................. 69BANZEL ..................................159BARACLUDE ............. 82, 99, 109BASAGLAR KWIKPEN ....... 159BAXDELA ...............................159BD INSULIN SYRINGE ........152BD INSULIN SYRINGE MICROFINE ...........................152BD INSULIN SYRINGE U/F 152BD INSULIN SYRINGE ULTRAFINE ...........................152BD LANCET ULTRAFINE 33G ........................................... 152BD SAFETY-LOK INSULIN SYRINGE ................................ 152BD SYRINGE SLIP TIP ........ 152Bebulin..........................................3BECONASE AQ.............9, 13, 77, 99, 109, 124, 192BEKYREE .................................69BELBUCA ............................... 179BELSOMRA ....................... 48, 58BELVIQ .....................................26BELVIQ XR .............................. 26benazepril hcl ..............................35
benazepril-hydrochlorothiazide ..35BeneFIX........................................3BENLYSTA .........14, 18, 109, 197benznidazole ............................... 99benzonatate ..... 13, 77, 99, 109, 126benzoyl peroxide ....................... 197benzoyl peroxide wash ..............197benzoyl peroxide-erythromycin .197benzphetamine hcl ...............26, 159benztropine mesylate .............48, 58BEPREVE ......... 96, 109, 124, 193Berinert................. 18, 26, 193, 197betamethasone dipropionate...........................................109, 198betamethasone dipropionate aug ............................ 109, 197, 198betamethasone valerate .... 109, 198BETASERON ................48, 58, 59betaxolol hcl ..........................35, 96bethanechol chloride ...................44BEVYXXA .......3, 35, 77, 126, 189bexarotene .................159, 198, 208bicalutamide ............................. 160BIDIL ......................................... 35BIKTARVY .........................18, 99bimatoprost ......................... 96, 160bisoprolol fumarate .................... 35bisoprolol-hydrochlorothiazide .. 35BIVIGAM ..................................18BLISOVI 24 FE .........................69BLISOVI FE 1.5/30 .................. 69BLISOVI FE 1/20 ..................... 69BONJESTA ....................... 83, 188BOSULIF .................................160BOTOX ..........35, 48, 59, 179, 198bp foaming wash ....................... 198bp multinatal plus ..................... 160bp wash ..................................... 198bpo ............................................ 198BRAFTOVI ............................. 160BREO ELLIPTA .. 9, 77, 109, 126briellyn ........................................69BRILINTA .....3, 35, 179, 189, 194brimonidine tartrate ....................96BRINEURA ....................... 26, 131BRINTELLIX ......................... 160BRIVIACT .......................... 48, 59
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
214
bromfenac sodium.....................96, 110, 179, 189, 194bromfenac sodium (once-daily).............96, 109, 160, 179, 189, 194bromocriptine mesylate ...48, 59, 90budesonide9, 13, 77, 83, 99, 110, 126, 160, 193budesonide er ......................83, 110bumetanide ............................26, 35BUNAVAIL ............................. 141buprenorphine ...................160, 179buprenorphine hcl .....................141buprenorphine hcl-naloxone hcl...........................................142, 160bupropion hcl ............................142bupropion hcl er (smoking det)...........................................142, 187bupropion hcl er (sr) .................142bupropion hcl er (xl) .................142buspirone hcl ............................ 142butalbital-acetaminophen . 142, 179butalbital-apap-caffeine ... 142, 179butalbital-asa-caff-codeine...........................................142, 179butalbital-aspirin-caffeine...................................142, 160, 179butorphanol tartrate ................. 179BYDUREON ....................... 26, 90BYETTA 10 MCG PEN ..... 26, 90BYETTA 5 MCG PEN ....... 26, 90BYSTOLIC ................................35cabergoline ................................. 90CABOMETYX ........................160caffeine citrate.................48, 59, 77, 126, 151, 188calcipotriene ............................. 198calcipotriene-betameth diprop...........................................160, 198calcitonin (salmon) ....... 69, 91, 131CALCITRENE ........................198calcitriol ..............................26, 198calcium acetate (phos binder).....................7, 27, 44, 91, 131, 151CALQUENCE .........................160CAMILA ....................................69CAMRESE ................................ 69CAMRESE LO ..........................69
candesartan cilexetil ...................35CANTIL .....................................83capecitabine ..............................160CAPEX .............................110, 198CAPRELSA .............................160captopril ....................27, 35, 44, 91captopril-hydrochlorothiazide ....35CARAFATE ...................... 83, 110CARBAGLU ............................. 27carbamazepine.......................48, 59, 131, 132, 142carbamazepine er ..48, 59, 142, 160carbidopa ......................48, 59, 160carbidopa-levodopa ..............49, 59carbidopa-levodopa er ..........49, 59carbidopa-levodopa-entacapone...............................................49, 59CARDIZEM LA ................35, 179CARIMUNE NF ......3, 18, 35, 110carisoprodol ..............................132carisoprodol-aspirin ................. 132carteolol hcl ................................ 96carvedilol .................................... 35carvedilol phosphate er ...... 35, 160CAYSTON ...............9, 27, 77, 126CAZIANT ..................................69cefaclor ..................................... 160cefadroxil .................................. 160cefdinir ......................................160cefditoren pivoxil ...................... 160cefixime ..................................... 161cefpodoxime proxetil .................161cefprozil .................................... 161ceftibuten ...................................161CEFTIN ................................... 161cefuroxime axetil .......................161celecoxib ....... 14, 18, 110, 132, 161cephalexin ................................. 161CERDELGA ..............................27CEREZYME ..................... 27, 161CEROVEL ...............................161CESAMET .........................83, 208cetirizine hcl...........13, 27, 77, 99, 110, 193, 198cevimeline hcl ... 14, 18, 83, 96, 110CHANTIX ....................... 142, 187
CHANTIX CONTINUING MONTH PAK ................. 142, 187CHANTIX STARTING MONTH PAK ................. 142, 187CHATEAL .................................69chlordiazepoxide hcl .....49, 59, 142chlordiazepoxide-clidinium 83, 110chlorhexidine gluconate83, 99, 124chloroquine phosphate ................99chlorothiazide ............................. 27chlorpromazine hcl ..... 77, 126, 142chlorpropamide .....................27, 91chlorthalidone .....................27, 161chlorzoxazone ........................... 132CHOLBAM ......................... 27, 83cholestyramine ............................27cholestyramine light ....................27choline & mag trisalicylate ...... 161choline-mag trisalicylate .. 110, 132CICLODAN ...............99, 110, 198ciclopirox .................... 99, 110, 198ciclopirox olamine ...... 99, 110, 198CIDALEAZE...................130, 180, 189, 194, 198cilostazol ..................... 35, 132, 180CIMDUO ............................. 18, 99cimetidine ....................83, 110, 180cimetidine hcl ......................83, 110CIMZIA . 14, 18, 83, 110, 132, 199CIMZIA PREFILLED.................14, 18, 83, 110, 132, 199CIMZIA STARTER KIT.................14, 18, 83, 110, 132, 199CINQAIR ...............9, 77, 110, 126Cinryze........................................27CIPRO HC ................................ 95CIPRODEX ......................... 95, 99ciprofloxacin ............................. 161ciprofloxacin hcl ....................... 161ciprofloxacin-ciproflox hcl er ... 161citalopram hydrobromide ......... 142CLARAVIS ............................. 199CLARINEX ... 13, 77, 99, 110, 193CLARINEX-D 12 HOUR.....................9, 13, 77, 99, 110, 193clarithromycin ...........................161clarithromycin er ...................... 161
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
215
CLEANLET LANCETS 28G 152clemastine fumarate...............13, 77, 100, 110, 193, 199clindamycin hcl .........................161clindamycin palmitate hcl .........161clindamycin phos-benzoyl perox...................................................199clindamycin phosphate...............................44, 69, 100, 199CLINPRO 5000 .........................83clobetasol propionate111, 161, 199clobetasol propionate e .....111, 199clocortolone pivalate 111, 161, 199clocortolone pivalate pump...................................111, 161, 199clomiphene citrate .......................69clomipramine hcl ...................... 143clonazepam ........... 49, 59, 132, 143clonidine hcl ................................35clonidine hcl er.......................49, 59, 132, 143, 161clopidogrel bisulfate ........... 35, 180clorazepate dipotassium49, 59, 143CLORPRES ...............................35clotrimazole 77, 100, 111, 124, 199clotrimazole anti-fungal...........................100, 111, 152, 199clotrimazole-betamethasone...................................100, 111, 199clozapine ........................... 143, 162Coagadex...................................... 3COARTEM ............................. 100codeine sulfate .......................... 180colchicine ....................27, 111, 132colchicine-probenecid .27, 111, 132colesevelam hcl ................... 27, 162colestipol hcl ...............................27COLOCORT ..................... 83, 111COMBIGAN ............................. 96COMBIVENT RESPIMAT.........................................9, 77, 126COMETRIQ (100 MG DAILY DOSE) ........................ 162COMETRIQ (140 MG DAILY DOSE) ........................ 162COMETRIQ (60 MG DAILY DOSE) ...................................... 162
comfort lancets ..........................152COMPLERA ..................... 18, 100COMPRO .................................. 83constulose ................. 27, 49, 59, 83CONTRAVE ............................. 27CORDRAN ......................111, 199Corifact......................................... 3CORLANOR ............................. 35cortisone acetate ...........18, 91, 111CORTISPORIN-TC ............... 162COSENTYX 15, 19, 111, 132, 200COSENTYX 300 DOSE.......................15, 18, 111, 132, 199COSENTYX SENSOREADY 300 DOSE .... 15, 18, 111, 132, 200COSENTYX SENSOREADY PEN .............. 15, 18, 111, 132, 200COTELLIC ............................. 162CREON ......................................83CRESEMBA ............................100CRINONE ........................... 69, 91CRIXIVAN ........................19, 100cromolyn sodium.....9, 19, 77, 96, 111, 124, 126, 193CRYSELLE-28 ......................... 69CRYSVITA ........... 7, 27, 132, 151Cuvitru........................................ 19cyanocobalamin ....................7, 151CYCLAFEM 1/35 ..................... 69CYCLAFEM 7/7/7 .................... 69cyclobenzaprine hcl .................. 132cyclopentolate hcl ............... 96, 162cyclophosphamide .....................162cycloserine ................................ 162cyclosporine ....19, 44, 83, 189, 195cyclosporine modified.................19, 44, 83, 189, 194, 195cyproheptadine hcl...............13, 77, 100, 111, 193, 200CYRED ...................................... 69CYSTAGON ..............................27cytra-2 .......................................152daily multi ................................. 152DAKLINZA ...............83, 100, 111dalfampridine er ... 49, 59, 132, 162DALIRESP ............ 9, 77, 112, 126danazol ..................................27, 69
dantrolene sodium .. 49, 59, 98, 132dapsone ............................. 100, 200darifenacin hydrobromide er.....................................44, 132, 162DASETTA 1/35 ......................... 69DASETTA 7/7/7 ........................ 69DAYSEE .................................... 69DAYTRANA ........49, 59, 132, 143DEBLITANE .............................69demeclocycline hcl ....................162DEMSER ........................... 35, 208DENAVIR ..................83, 100, 200DENTA 5000 PLUS .................. 83DENTAGEL ..............................83DESCOVY .........................19, 100desipramine hcl .........................143desloratadine 13, 77, 100, 112, 193desmopressin ace rhinal tube27, 91desmopressin ace spray refrig...............................................27, 91desmopressin acetate ...... 27, 44, 91desmopressin acetate spray .. 27, 91desogestrel-ethinyl estradiol.............................................70, 162desonide ............................ 112, 200desoximetasone ................. 112, 200desvenlafaxine er ...................... 143desvenlafaxine fumarate er .......143dexamethasone ............................91dexamethasone sodium phosphate ......95, 96, 112, 189, 195DEXEDRINE ...... 49, 59, 133, 143DEXILANT ............................... 83dexmethylphenidate hcl...............................49, 60, 133, 143dexmethylphenidate hcl er.......................49, 60, 133, 143, 162dextroamphetamine sulfate...............................49, 60, 133, 143dextroamphetamine sulfate er...............................49, 60, 133, 143diazepam . 49, 50, 60, 133, 143, 162DIAZEPAM INTENSOL...............................49, 60, 133, 143DICLEGIS .........................84, 188diclofenac potassium 112, 133, 180
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
216
diclofenac sodium96, 112, 133, 162, 180, 189, 195, 200diclofenac sodium er...............................15, 19, 112, 133dicloxacillin sodium ..................162dicyclomine hcl ................... 84, 162didanosine ...........................19, 100diethylpropion hcl .......................28diethylpropion hcl er ...................28DIFICID .....................84, 100, 112diflorasone diacetate ........ 112, 200diflunisal ................................... 180DIGITEK ...........................35, 207DIGOX ...............................36, 207digoxin ................................ 36, 207dihydroergotamine mesylate.................................36, 50, 60, 180DILANTIN .......................... 50, 60diltiazem cd .........................36, 180diltiazem hcl ........................36, 180diltiazem hcl er ................... 36, 180diltiazem hcl er beads ......... 36, 180diltiazem hcl er coated beads.....................................36, 163, 180dimenhydrinate ........................... 84DIPENTUM .......................84, 112diphenhydramine hcl...............................50, 60, 153, 193diphenoxylate-atropine ............... 84dipyridamole ................................. 4disopyramide phosphate ............. 36disulfiram ..................................144divalproex sodium.........................36, 50, 60, 144, 180divalproex sodium er.........................36, 50, 60, 144, 180dofetilide ............. 36, 163, 189, 207donepezil hcl ................. 50, 60, 144DOPTELET .................................4dorzolamide hcl .................. 96, 163dorzolamide hcl-timolol mal.............................................96, 163doxazosin mesylate ....... 36, 44, 208doxepin hcl ........................144, 163doxercalciferol ......44, 91, 163, 189doxycycline hyclate ........... 124, 163
doxycycline monohydrate ......... 163dronabinol .......19, 28, 84, 100, 208drospiren-eth estrad-levomefol.............................................70, 163drospirenone-ethinyl estradiol.............................70, 144, 163, 200DROXIA ...................................... 4DUAVEE ............. 70, 91, 133, 163DULERA ............... 9, 77, 112, 126duloxetine hcl ....133, 144, 163, 180DUPIXENT ... 9, 78, 112, 126, 200dutasteride .................. 44, 163, 208dutasteride-tamsulosin hcl.....................................44, 163, 208DUZALLO .................28, 112, 133DYANAVEL XR .50, 60, 133, 144DYSPORT ........... 50, 61, 134, 200DYSPORT (GLABELLAR LINES) ..................................... 163E.E.S. 400 .................................163econazole nitrate .......100, 112, 200ECOZA ............ 100, 112, 163, 200EDARBI .....................................36EDLUAR ............................. 50, 61EDURANT .........................19, 100efavirenz ......................19, 100, 163EGRIFTA ...... 15, 19, 28, 100, 112ELELYSO ................................. 28eletriptan hydrobromide.........................36, 50, 61, 163, 180ELIDEL ........................... 112, 200ELIGARD ..........................44, 208ELINEST ................................... 70ELIQUIS ..4, 36, 78, 126, 189, 207ELITE-OB ............................... 188ELLA ......................................... 70Eloctate......................................... 4EMADINE ......... 96, 112, 124, 193EMBEDA .........................180, 181EMCYT ............................. 44, 208EMEND ............. 84, 189, 195, 208EMFLAZA .. 50, 61, 112, 113, 134EMOQUETTE .......................... 70EMSAM ................................... 144EMTRIVA ......................... 19, 100enalapril maleate ........................ 36enalapril-hydrochlorothiazide ....36
ENBREL ......15, 19, 113, 134, 201ENBREL MINI.......................15, 19, 113, 134, 200ENBREL SURECLICK.......................15, 19, 113, 134, 201ENDARI .......................................4enoxaparin sodium ..4, 36, 181, 189ENPRESSE-28 .......................... 70ENSKYCE ................................. 70entacapone ............................50, 61entecavir ..............84, 100, 113, 163ENTRESTO ...............................36ENTYVIO ..........................84, 113enulose ...................... 28, 50, 61, 84EPCLUSA ..................84, 101, 113epinastine hcl ...... 96, 113, 124, 193epinephrine ............................... 193epinephrine hcl ........... 36, 101, 193EPIPEN 2-PAK .......................193EPIPEN JR 2-PAK ................. 193EPITOL ....................... 50, 61, 134eplerenone ...........................36, 181EPOGEN ................. 4, 44, 45, 208epoprostenol sodium .9, 37, 78, 127eprosartan mesylate ....................37eq nicotine .................144, 153, 187eq nicotine polacrilex144, 153, 187eq nicotine step 3 ...... 144, 153, 187eql nicotine ........................144, 187eql nicotine polacrilex ...... 144, 187ergocalciferol ........................7, 151ergoloid mesylates ........ 50, 61, 144ERIVEDGE ..................... 201, 208ERLEADA ...............................163ERRIN ....................................... 70ERYPED 400 ...........................164ERY-TAB ................................ 164ERYTHROCIN STEARATE 164erythromycin ............... 96, 101, 201erythromycin base .....................164erythromycin ethylsuccinate ..... 164ESBRIET ..................... 10, 78, 127escitalopram oxalate .................144est estrogens-methyltest ............ 164est estrogens-methyltest hs ........164ESTARYLLA ............................70estazolam .............................. 50, 61
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
217
estradiol ........................ 70, 91, 164estradiol-norethindrone acet .... 164estropipate ............................ 70, 91eszopiclone ............................50, 61ethacrynic acid28, 37, 78, 127, 164ethambutol hcl .......................... 164ethosuximide ......................... 50, 61etidronate disodium ............ 28, 134etodolac .....................113, 134, 181etodolac er ............ 15, 19, 113, 134etoposide ................................... 164EUFLEXXA .................... 113, 134EVOTAZ ........................... 19, 101EVZIO ..................................... 178EXELDERM ........... 101, 113, 201exemestane .......................... 70, 209EXONDYS 51 ......50, 61, 113, 134EXTAVIA ............................50, 61ezetimibe ............................. 28, 164ezetimibe-simvastatin ..........28, 164EZ-LETS LANCETS 26G ..... 153FABIOR ...........................164, 201FABRAZYME .....28, 45, 201, 209FALMINA ................................. 70famciclovir ................................ 164famotidine ........................... 84, 181FANAPT .................................. 144FANAPT TITRATION PACK ....................................... 144FARESTON .............................164FARXIGA ....................28, 91, 164FARYDAK .......................... 4, 209FASENRA ........... 10, 78, 113, 127Feiba....................................... 4, 37felbamate ...................................164felodipine er ................................ 37fenofibrate ...........................28, 164fenofibrate micronized ................ 28fenofibric acid .....................28, 164fenoprofen calcium ................... 181fentanyl ..................................... 181fentanyl citrate .................. 181, 209FENTORA .......................181, 209FERRIPROX ...........178, 189, 190FETZIMA ........................144, 164FETZIMA TITRATION 145, 164FIASP .......................................165
FIASP FLEXTOUCH ............ 164FINACEA ........................ 113, 201finasteride ........................... 45, 209FINGERSTIX LANCETS ......153FIRAZYR ............ 19, 28, 193, 201FIRST-LANSOPRAZOLE .... 165FIRST-OMEPRAZOLE ........ 165FIRVANQ ................................165flavoxate hcl ........................45, 181FLEBOGAMMA DIF .............. 20flecainide acetate ................ 37, 207FLECTOR ....................... 130, 134FLOLAN ................10, 37, 78, 127flolipid .........................................28FLOVENT DISKUS...............................10, 78, 113, 127FLOVENT HFA ..10, 78, 113, 127fluconazole ................................165flucytosine ................................. 165fludrocortisone acetate ............... 91flunisolide ..... 13, 78, 101, 113, 193fluocinolone acetonide.............................95, 113, 114, 201fluocinolone acetonide body...........................................113, 201fluocinolone acetonide scalp...........................................114, 201fluocinonide .............. 114, 165, 201FLUOR-A-DAY ........................ 84FLUORIDEX DAILY DEFENSE ..................................84FLUORIDEX ENHANCED WHITENING ..........................165FLUORIDEX SENSITIVITY RELIEF ..................................... 84fluorometholone ..................96, 114fluorouracil ....................... 201, 209fluoxetine hcl .............................145fluoxetine hcl (pmdd) ........ 145, 165fluphenazine decanoate .............145fluphenazine hcl ........................ 145FLURA-DROPS ........................84flurandrenolide . 114, 165, 201, 202flurazepam hcl ...................... 51, 61flurbiprofen ........... 15, 20, 114, 134flurbiprofen sodium .... 96, 190, 195flutamide ................................... 165
fluticasone propionate.................10, 13, 78, 101, 114, 202fluticasone-salmeterol...............................10, 78, 114, 127fluvastatin sodium .......................28fluvastatin sodium er ...........28, 165fluvoxamine maleate ................. 145fluvoxamine maleate er .............145folbee .....................................7, 151folic acid ........................... 4, 7, 151fondaparinux sodium.................................4, 37, 190, 195FORADIL AEROLIZER...............................10, 78, 114, 127FORTEO ..................... 70, 91, 134FOSAMAX PLUS D ... 70, 91, 134fosamprenavir calcium20, 101, 165fosinopril sodium ........................ 37fosinopril sodium-hctz ................ 37FREESTYLE INSULINX TEST ........................................ 153FREESTYLE LANCETS .......153FREESTYLE LITE TEST .....153FREESTYLE PRECISION NEO TEST .............................. 153FREESTYLE TEST ............... 153frovatriptan succinate.........................37, 51, 61, 165, 181FULPHILA ....................4, 20, 209furosemide ...............28, 37, 78, 127FUZEON ............................20, 101FYCOMPA ..........51, 61, 134, 165gabapentin ............ 51, 61, 101, 181galantamine hydrobromide.......................................51, 61, 145galantamine hydrobromide er.......................................51, 61, 145GAMASTAN S/D ......84, 101, 114Gammagard.....20, 51, 61, 114, 134GAMMAGARD S/D LESS IGA.4, 20, 37, 84, 97, 98, 114, 124, 202GAMMAKED ......... 4, 20, 37, 114GAMMAPLEX ....... 4, 20, 37, 114GAMUNEX-C ......... 4, 20, 37, 115gatifloxacin ............................... 165GATTEX ................... 84, 190, 195
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
218
GAVILYTE-C ...................84, 190GAVILYTE-G ...................85, 190GAVILYTE-H ...........................85GELNIQUE .......................45, 134gemfibrozil .................................. 28generlac .................... 29, 51, 61, 85GENGRAF .... 20, 45, 85, 190, 195gentamicin sulfate .....101, 165, 202GENTLE-LET GP LANCETS ............................... 153GENTLE-LET LANCETS .... 153GENVOYA ........................20, 101GIANVI ..................... 70, 145, 202GIAZO ............................... 85, 115GILDAGIA ................................70GILDESS 1.5/30 ........................70GILDESS 1/20 ...........................70GILDESS 24 FE ........................70GILDESS FE 1.5/30 ..................70GILDESS FE 1/20 .....................70GILENYA ............................51, 61GILOTRIF .............................. 165glatiramer acetate .................51, 62GLATOPA ...........................51, 62GLEOSTINE ...........................165glimepiride ............................29, 91glipizide .................................29, 91glipizide er ............................ 29, 91glipizide xl .............................29, 91glipizide-metformin hcl .........29, 91GLUCAGEN HYPOKIT ... 29, 91GLUCAGON EMERGENCY...............................................29, 91GLUCOSOURCE LANCETS...................................................153glyburide ............................... 29, 91glyburide micronized ............ 29, 91glyburide-metformin ............. 29, 92glycopyrrolate ...........................165GLYDO.......45, 78, 127, 135, 181, 190, 195gnp lancets ................................ 153gnp nicotine mini .............. 145, 187gnp nicotine polacrilex ..... 145, 187gnp ultra com insulin syringe ... 153GOCOVRI ...........................51, 62GRALISE ............ 51, 62, 101, 181
GRALISE STARTER...............................51, 62, 101, 181granisetron hcl ....................85, 209GRANIX ................ 4, 20, 165, 209griseofulvin microsize .......101, 202griseofulvin ultramicrosize...........................................101, 202guaifenesin er13, 78, 101, 115, 127guanfacine hcl .............................37guanfacine hcl er .. 51, 62, 135, 145guanidine hcl .. 20, 51, 62, 115, 135HAEGARDA ............................. 29HAEMOLANCE LOW FLOW LANCETS .................. 153halobetasol propionate ..... 115, 202HALOG ........................... 115, 202haloperidol ................................145haloperidol decanoate .............. 145haloperidol lactate ....................145HARVONI ................. 85, 101, 115HEATHER ................................ 70Helixate FS................................... 4HEMLIBRA .......................... 4, 37HEMMOREX-HC ...... 37, 85, 115Hemofil M............................ 4, 165heparin (porcine) in nacl.....................................37, 190, 195heparin sodium (porcine).................................5, 37, 165, 190HETLIOZ ............................51, 62HEXALEN ...............................166Hizentra...............................20, 166hm nicotine ................145, 153, 188hm nicotine polacrilex ...... 145, 188HOMATROPAIRE .......... 97, 115homatropine hbr ................. 97, 115HORIZANT .........................51, 62HUMALOG .............................166HUMALOG KWIKPEN ........ 166HUMALOG MIX 50/50 ......... 166HUMALOG MIX 50/50 KWIKPEN ...............................166HUMALOG MIX 50/50 PEN 166HUMALOG MIX 75/25 ......... 166HUMALOG MIX 75/25 KWIKPEN ...............................166HUMALOG MIX 75/25 PEN 166
HUMALOG PEN ....................166Humate-P...........5, 20, 37, 115, 166, 190, 195HUMIRA16, 21, 85, 115, 135, 202HUMIRA PEDIATRIC CROHNS START...........15, 20, 85, 97, 115, 135, 202HUMIRA PEN.................15, 21, 85, 115, 135, 202HUMIRA PEN-CD/UC/HS STARTER...........15, 21, 85, 97, 115, 135, 202HUMIRA PEN-PS/UV/ADOL HS START...........15, 21, 85, 97, 115, 135, 202HUMULIN 70/30 .................... 153HUMULIN 70/30 KWIKPEN 153HUMULIN N ...........................153HUMULIN N KWIKPEN ......153HUMULIN R ...........................153HUMULIN R U-500 (CONCENTRATED) ..........29, 92HUMULIN R U-500 KWIKPEN ...........................29, 92HYCAMTIN ............................166hydralazine hcl ............................37hydrochlorothiazide ....................38hydrocod polst-cpm polst er...............13, 78, 101, 115, 127, 193hydrocodone-acetaminophen...........................................166, 181hydrocodone-homatropine.......................13, 78, 101, 115, 127hydrocodone-ibuprofen .............181hydrocortisone.........21, 85, 92, 116, 166, 202, 203hydrocortisone ace-pramoxine...............................38, 85, 115, 202hydrocortisone acetate ..38, 85, 115hydrocortisone butyrate...................................115, 116, 202hydrocortisone valerate .... 116, 203hydrocortisone-acetic acid ......... 95hydromet ....... 13, 78, 101, 116, 127hydromorphone hcl ...................182hydromorphone hcl er ...............182
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
219
hydroxychloroquine sulfate.......................16, 21, 116, 135, 203HYDROXYprogesterone Caproate...........38, 45, 70, 92, 167, 188, 209hydroxyurea ...................... 203, 209hydroxyzine hcl.......................51, 62, 145, 190, 195hydroxyzine pamoate.......................51, 62, 146, 190, 195HYOPHEN .............................. 167hyoscyamine sulfate .................. 167hyoscyamine sulfate er ..............167hyosyne ......................................167Hyqvia.........................................21HY-VEE LANCETS ...............153hy-vee thin lancets .................... 153ibandronate sodium ...... 71, 92, 135IBRANCE ................................167IBUDONE ................................182ibuprofen ...................116, 135, 182ICLUSIG ................................. 167Idelvion......................................... 5IDHIFA ....................................167ILARIS ...........21, 29, 95, 116, 135ILARIS (150MG DELIVERED) ......................... 167imatinib mesylate ...................... 167IMBRUVICA ...... 5, 131, 167, 209imipramine hcl .................... 45, 146imipramine pamoate ................. 146imiquimod ......... 101, 116, 203, 209imiquimod pump ....................... 203IMPAVIDO ..................... 101, 203INATAL ADVANCE ..............188INCRELEX ................... 51, 62, 92INCRUSE ELLIPTA...............................10, 79, 116, 127indapamide ........................... 29, 38indomethacin ...............29, 116, 135indomethacin er .......... 29, 116, 135INFLECTRA.................16, 21, 85, 116, 135, 203INGREZZA ................. 51, 62, 135INLYTA ...................................167insulin syringe ...........................154insulin syringe/needle ............... 154
INTELENCE .....................21, 101INTRAROSA 45, 71, 92, 124, 182INTROVALE ............................ 71Invega Sustenna........................ 146Invega Trinza............................ 146INVIRASE .........................21, 102INVOKAMET .....................29, 92INVOKAMET XR .............. 29, 92INVOKANA ........................ 29, 92ipratropium bromide.........10, 13, 79, 102, 116, 127, 193ipratropium-albuterol ... 10, 79, 127IPRIVASK .............5, 38, 190, 195irbesartan ....................................38irbesartan-hydrochlorothiazide ..38IRESSA ....................................167ISENTRESS ...................... 21, 102ISENTRESS HD ............... 21, 102isometheptene-dichloral-apap .. 167isoniazid ....................................102isosorbide dinitrate .............38, 182isosorbide dinitrate er .........38, 182isosorbide mononitrate ....... 38, 182isosorbide mononitrate er ...38, 182isotretinoin ........................167, 203isradipine .................................... 38itraconazole .............................. 167ivermectin ....................85, 102, 167Ixinity............................................5JADENU ...................... 5, 178, 190JADENU SPRINKLE .5, 178, 190JAKAFI ......................... 5, 38, 209JENCYCLA ...............................71JOLESSA ...................................71JOLIVETTE ............................. 71JUBLIA ....................102, 116, 203JULEBER ..................................71JULUCA ............................ 21, 102JUNEL 1.5/30 ............................ 71JUNEL 1/20 ............................... 71JUNEL FE 1.5/30 ...................... 71JUNEL FE 1/20 ......................... 71JUNEL FE 24 ............................ 71JUXTAPID ................................ 29JYNARQUE .............................. 45KADIAN .................................. 182KAITLIB FE ............................. 71
KALETRA .........................21, 102KALYDECO ......... 10, 29, 79, 127KANUMA ..................................29KARIVA .................................... 71KELNOR 1/35 ...........................71ketoconazole ......102, 116, 167, 203KETODAN ...................... 116, 203ketoprofen ................. 116, 135, 182ketoprofen er .........16, 21, 116, 135ketorolac tromethamine.....................97, 116, 182, 190, 195ketotifen fumarate97, 116, 124, 193KEVEYIS .............. 29, 52, 62, 135KEVZARA .......... 16, 21, 117, 135KIMIDESS ................................ 71KINERET ............16, 21, 117, 135kinney lancets ............................154kinney thin lancets .................... 154kinray insulin syringe ............... 154KIONEX .............................. 29, 30KISQALI 200 DOSE .............. 167KISQALI 400 DOSE .............. 167KISQALI 600 DOSE .............. 167Koate.............................................5Koate-DVI.................................... 5Kogenate FS..........................5, 167Kogenate FS Bio-Set.................... 5KORLYM ............................30, 92Kovaltry........................................ 5KRYSTEXXA ........... 30, 117, 135KURVELO ................................ 71KUVAN ..............................30, 167KYNAMRO ...............................30labetalol hcl ................................ 38lactulose ....................30, 52, 62, 85lactulose encephalopathy...................................30, 52, 62, 85LAMISIL ................. 102, 117, 203lamivudine .....21, 85, 102, 117, 167lamivudine-zidovudine ........21, 102lamotrigine ............52, 62, 136, 146lamotrigine er ....................... 52, 62lamotrigine odt ......52, 62, 136, 146lamotrigine starter kit-blue...............................52, 62, 136, 146
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
220
lamotrigine starter kit-green...............................52, 62, 136, 146lamotrigine starter kit-orange...............................52, 62, 136, 146lamotrigine titration...............................52, 62, 136, 146lancets ....................................... 154lancets thin ................................154lansoprazole ........................85, 117LARIN 1.5/30 ............................ 71LARIN 1/20 ............................... 71LARIN 24 FE ............................ 71LARIN FE 1.5/30 .............. 71, 168LARIN FE 1/20 ................. 71, 168LASTACAFT .... 97, 117, 124, 193latanoprost ..........................97, 168LATRIX ...................................168LATUDA ......................... 146, 168LAYOLIS FE ............................ 71LEENA .......................................71leflunomide ........... 16, 21, 117, 136LEMTRADA ....................... 52, 63LENVIMA 10 MG DAILY DOSE ....................................... 168LENVIMA 12 MG DAILY DOSE ....................................... 168LENVIMA 14 MG DAILY DOSE ....................................... 168LENVIMA 20 MG DAILY DOSE ....................................... 168LENVIMA 24 MG DAILY DOSE ....................................... 168LENVIMA 4 MG DAILY DOSE ....................................... 168LESSINA ................................... 71LETAIRIS ............. 10, 38, 79, 127letrozole .............................. 71, 209leucovorin calcium ....5, 7, 151, 178LEUKERAN ........................5, 209leuprolide acetate ......... 45, 92, 209levalbuterol hcl ............. 10, 79, 128levalbuterol tartrate...............................10, 79, 128, 168levetiracetam .................52, 63, 136levetiracetam er .................... 52, 63levobunolol hcl ............................97levocarnitine ................. 7, 151, 154
levocetirizine dihydrochloride.........13, 30, 79, 102, 117, 193, 203levofloxacin ...............................168LEVONEST ...............................71levonorgest-eth estrad 91-day.............................................71, 168levonorgestrel ..................... 71, 168levonorgestrel-ethinyl estrad.............................................71, 168levonorg-eth estrad triphasic.............................................71, 168LEVORA 0.15/30 (28) .............. 72LEVO-T ..................................... 92levothyroxine sodium .................. 92LEXIVA .............................22, 102lidocaine52, 63, 79, 102, 128, 168, 182, 190, 195, 203lidocaine hcl45, 79, 128, 130, 136, 182, 190, 195, 203lidocaine viscous ...............191, 195lidocaine-prilocaine ..........191, 195LIFESCAN UNISTIK II LANCETS ............................... 154lindane .............................. 102, 203linezolid .....................................168LINZESS ................................... 85liothyronine sodium ............ 92, 191lisinopril ......................................38lisinopril-hydrochlorothiazide ....38lite touch lancets ....................... 154lithium ....................................... 146lithium carbonate ......................146lithium carbonate er ................. 146LIVALO .....................................30LO LOESTRIN FE ...................72LOMEDIA 24 FE ..............72, 168lomustine ...................................168longs lancets thin ...................... 154LONSURF ......................... 86, 209loperamide hcl ............................ 86lorazepam ................................. 146LORAZEPAM INTENSOL ...146LORYNA ................... 72, 146, 203losartan potassium ......................38losartan potassium-hctz .............. 38
lovastatin .....................................30LOW-OGESTREL ................... 72loxapine succinate .....................146luliconazole ...............102, 117, 203LUMIGAN .................................97LUPRON ................................. 168LUPRON DEPOT (1-MONTH) ........... 5, 38, 45, 72, 209LUPRON DEPOT (3-MONTH) ........... 5, 38, 45, 72, 209LUPRON DEPOT (4-MONTH) ........................... 45, 209LUPRON DEPOT (6-MONTH) ........................... 45, 209LUPRON DEPOT-PED (1-MONTH) ................................... 92LUPRON DEPOT-PED (3-MONTH) ................................... 92LUTERA ....................................72LYNPARZA ............................ 168LYRICA ...................30, 52, 63, 92LYRICA CR...................30, 52, 63, 92, 102, 182LYSODREN ............................ 169LYZA ................................. 72, 169Makena......................................189malathion .......................... 102, 203maprotiline hcl ..........................146marlissa .......................................72MATULANE ........................... 169MATZIM LA .................... 38, 182MAVYRET ................86, 102, 117me/naphos/mb/hyo1 .................. 169meclizine hcl ................... 38, 52, 63meclofenamate sodium...................................117, 136, 182MEDISENSE THIN LANCETS ............................... 154medroxyprogesterone acetate...................................38, 45, 72, 92mefenamic acid ................... 72, 182mefloquine hcl ...........................102megestrol acetate...................7, 22, 30, 103, 151, 169MEIJER LANCETS ...............154MEKINIST ..............................169MEKTOVI ...............................169
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
221
meloxicam ............. 16, 22, 117, 136melphalan ................................. 169memantine hcl .......52, 63, 146, 169meperidine hcl ...........169, 182, 183meprobamate ............................ 146mercaptopurine .........................169mesalamine ................. 86, 117, 169MESNEX ............... 38, 45, 72, 209metaproterenol sulfate .. 10, 79, 128metaxalone ................................136metformin hcl ........................ 30, 93metformin hcl er ....................30, 93metformin hcl er (mod) . 30, 92, 169metformin hcl er (osm) ..........30, 92methadone hcl ...................147, 183METHADONE HCL INTENSOL ......................146, 183methamphetamine hcl.........................30, 52, 63, 136, 147methazolamide ............................ 97methenamine hippurate .......45, 103methenamine mandelate ..... 45, 103methimazole ................................ 93methitest ................................72, 93methocarbamol ......................... 136methotrexate ..16, 22, 117, 136, 203methoxsalen rapid .............169, 203methscopolamine bromide .......... 86methyclothiazide ......................... 30methyldopa ..................................39methyldopa-hydrochlorothiazide ....................39methylergonovine maleate .. 39, 189methylphenidate hcl...............53, 64, 137, 147, 148, 169methylphenidate hcl er.........................53, 63, 64, 137, 147methylphenidate hcl er (cd)...............................53, 63, 136, 147methylphenidate hcl er (la)...............53, 63, 136, 137, 147, 169methylprednisolone .......22, 93, 117methylprednisolone sodium succ.......................................22, 93, 117methyltestosterone ........ 72, 93, 169metipranolol ................................97metoclopramide hcl .........30, 86, 93
metolazone ............................ 30, 45metoprolol succinate er ...... 39, 183metoprolol tartrate ..............39, 183metoprolol-hydrochlorothiazide . 39metronidazole.......45, 72, 103, 117, 169, 203, 204mexiletine hcl .............................. 39MIACALCIN .............. 72, 93, 137miconazole 3 ................. 45, 72, 103MICROGESTIN 1.5/30 ............72MICROGESTIN 1/20 ...............72MICROGESTIN 24 FE ............72MICROGESTIN FE 1.5/30 ......72MICROGESTIN FE 1/20 .........72micronized colestipol hcl ............ 30MICROTAINER SAFETY FLOW LANCET .................... 154midodrine hcl .............................. 39MIGERGOT ......... 39, 53, 64, 183miglitol ..........................31, 93, 169minocycline hcl ......................... 169minoxidil ..................................... 39mirtazapine ............................... 148MIRVASO ............... 117, 169, 204misoprostol ................................. 86modafinil ................. 53, 64, 79, 128moexipril hcl ............................... 39moexipril-hydrochlorothiazide ... 39mometasone furoate.......13, 79, 103, 118, 169, 193, 204Monoclate-P..........................5, 169MONOJECT CONTROL SYRINGE ................................ 169MONOJECT FILTER ASPIRATOR ...........................154MONOJECT INSULIN SYRINGE ........................ 154, 170MONOJECT PHARMACY TRAY ....................................... 154MONOJECT PISTON SYRINGE ................................ 154MONOJECT SAFETY SYRINGE/SHIELD ........154, 170MONOJECT SYRINGE 155, 170MONOJECT SYRINGE CATH TIP ............................... 155
MONOJECT SYRINGE ECC LUER ....................................... 155MONOJECT SYRINGE LUER LOCK .................. 155, 170MONOJECT SYRINGE REG LUER ............................... 155, 170MONOJECT TB SAFETY SYRINGE ................................ 155MONOJECT TB SYRINGE ..155MONOJECT ULTRA COMFORT SYRINGE .......... 155MONOLET LANCETS ..........155MONO-LINYAH ...................... 72MONONESSA ...........................72Mononine..............................5, 170montelukast sodium.........10, 13, 79, 103, 118, 128, 194MORPHABOND ER .............. 183morphine sulfate ....................... 184morphine sulfate (concentrate) .183morphine sulfate er ... 170, 183, 184morphine sulfate er beads .170, 183MOVANTIK ..................... 86, 178moxifloxacin hcl ........................170MULTI COMPLETE .............155multi vitamin/fluoride ..... 7, 86, 151multi vitamin/minerals .......... 7, 151multi-vit/fluoride ..... 7, 86, 151, 170multi-vit/fluoride/iron.................................7, 86, 151, 170multivitamin/fluoride.................................7, 86, 151, 170multi-vitamin/fluoride ..... 8, 86, 152mupirocin ..................103, 118, 204mupirocin calcium .... 103, 118, 204MY WAY ...................................72MYALEPT ............ 16, 22, 31, 118mycophenolate mofetil...........22, 45, 46, 86, 170, 191, 196mycophenolic acid.......................22, 46, 170, 191, 196MYLERAN ..............................170mynephrocaps ....................... 8, 152MYOBLOC ................. 53, 64, 137MYORISAN ............................ 204MYRBETRIQ ................... 46, 137MYZILRA ................................. 72
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
222
nabumetone ...........16, 22, 118, 137n-acetyl-l-cysteine .....................155nadolol ................................ 39, 184nadolol-bendroflumethiazide ......39naftifine hcl ....... 103, 118, 170, 204naloxone hcl ..............................178naltrexone hcl ........................... 148naphazoline hcl ...........................97naproxen ................... 118, 137, 184naproxen dr .......................118, 137naproxen sodium .......118, 137, 184naratriptan hcl ........ 39, 53, 64, 184NARCAN ................................. 178NATAZIA ......................39, 46, 72nateglinide ............................ 31, 93NATPARA ...........................31, 93NECON 0.5/35 (28) ................... 72NECON 1/35 (28) ...................... 72NECON 1/50 (28) ...................... 72NECON 10/11 (28) .................... 72NECON 7/7/7 .............................73nefazodone hcl .......................... 148neomycin sulfate ......... 86, 191, 196neomycin-polymyxin-dexameth...........................................170, 171neomycin-polymyxin-gramicidin.............................................97, 103neomycin-polymyxin-hc...............................95, 97, 103, 171NEO-POLYCIN ................97, 103NEO-POLYCIN HC ...............171NERLYNX ...............................171NEUAC .................................... 204NEULASTA ...........5, 22, 191, 210NEULASTA ONPRO.................................5, 22, 191, 210NEUPOGEN ..................5, 22, 210NEUPRO ............................. 54, 64nevirapine ........................... 22, 103nevirapine er ...............22, 103, 171NEXAVAR .............................. 171NEXIUM ....................................86NEXT CHOICE ONE DOSE .. 73niacin er ...................................... 31niacin er (antihyperlipidemic).............................................31, 171NIACOR .................................... 31
nicardipine hcl .................... 39, 184NICORELIEF ................. 148, 188nicotine ............................. 148, 188nicotine mini ..................... 148, 188nicotine polacrilex ............ 148, 188nicotine step 1 ................... 148, 188nicotine step 2 ................... 148, 188nicotine step 3 ................... 148, 188NICOTROL .....................148, 188NICOTROL NS .............. 148, 188NIFEDIAC CC ........................171nifedipine ............................ 39, 184nifedipine er ........................ 39, 184nifedipine er osmotic release.............................................39, 184NIKKI ........................ 73, 148, 204nilutamide ................................. 171nimodipine .............. 39, 54, 64, 130NINLARO ........................... 6, 210nisoldipine er .............................. 39nitrofurantoin ............................171nitrofurantoin macrocrystal ......171nitrofurantoin monohyd macro .171nitroglycerin ....................... 39, 184NITYR ....................................... 31nizatidine .............................86, 118NODOLOR ..............................171NORA-BE ..................................73NORDITROPIN FLEXPRO.....................8, 22, 31, 93, 103, 152norethin ace-eth estrad-fe ...73, 171norethindrone ............................. 73norethindrone acetate...................................39, 46, 73, 93norethindrone acet-ethinyl est.............................................73, 171norethindrone-eth estradiol...............................73, 93, 137, 171norethin-eth estradiol-fe ..... 73, 171norgestimate-eth estradiol .......... 73norgestim-eth estrad triphasic.............................................73, 171norgestrel-ethinyl estradiol ...... 171NORITATE ..................... 118, 204NORTHERA ............................. 39NORTREL 0.5/35 (28) ..............73NORTREL 1/35 (21) .................73
NORTREL 1/35 (28) .................73NORTREL 7/7/7 ....................... 73nortriptyline hcl ........................ 148NORVIR ............................ 22, 103Novoeight..................................... 6NOVOLIN 70/30 ..................... 155NOVOLIN 70/30 RELION .... 155NOVOLIN N ........................... 155NOVOLIN N RELION ...........155NOVOLIN R ........................... 155NOVOLIN R RELION ...........155NOVOLOG ............................. 171NOVOLOG FLEXPEN ..........171NOVOLOG MIX 70/30 .......... 171NOVOLOG MIX 70/30 FLEXPEN ................................171NovoSeven................................171NovoSeven RT........................6, 39NOXAFIL.22, 23, 79, 103, 118, 124, 128, 172np thyroid ..................................172NUCALA10, 40, 79, 118, 128, 194NUCYNTA .............................. 184NUCYNTA ER 31, 54, 64, 93, 184NUEDEXTA ............................148NUPLAZID ................. 54, 64, 148NUTRESTORE .........86, 191, 196NUVARING .............................. 73Nuwiq........................................... 6NYAMYC ................ 103, 118, 204nystatin ......103, 104, 118, 124, 204nystatin-triamcinolone...................................104, 118, 204NYSTOP .................. 104, 118, 204Obizur....................... 6, 23, 40, 118OCALIVA ................................. 86OCELLA ................................... 73OCREVUS ...........................54, 64OCTAGAM ............. 6, 23, 40, 119octreotide acetate.............31, 54, 64, 86, 93, 137, 210ODACTRA .. 13, 79, 104, 119, 194ODEFSEY ......................... 23, 104ODOMZO ........................204, 210OFEV ........................... 10, 79, 128ofloxacin ............................. 96, 172OGESTREL .............................. 73
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
223
olanzapine .................................148olanzapine-fluoxetine hcl ..........148OLEPTRO ...............................148olmesartan medoxomil ........40, 172olmesartan medoxomil-hctz 40, 172olopatadine hcl.....................97, 119, 124, 172, 194OLUMIANT ........16, 23, 119, 137OLYSIO .............86, 104, 119, 172omeprazole ..........................86, 119OMEPRAZOLE+SYRSPEND SF ALKA ............................. 172omeprazole-sodium bicarbonate...............................40, 87, 119, 172OMNARIS.................10, 13, 79, 104, 119, 194ondansetron ........................ 87, 210ondansetron hcl .. 87, 191, 196, 210ONETOUCH CLUB LANCETS FINE PT ...............155ONETOUCH FINEPOINT LANCETS ............................... 155ONETOUCH LANCETS ....... 155ONETOUCH ULTRASOFT LANCETS ............................... 155ONFI ............................ 54, 64, 172OPANA ER ..............................185opium ........................................ 172OPSUMIT ......11, 40, 79, 128, 172ORALAIR.................11, 13, 79, 104, 119, 194ORENCIA ... 16, 23, 119, 138, 204ORENCIA CLICKJECT.......................16, 23, 119, 138, 204ORENITRAM ....... 11, 40, 80, 128ORFADIN ..................................31ORKAMBI ............ 11, 31, 80, 128orphenadrine citrate er .............138ORSYTHIA ............................... 73oseltamivir phosphate .......104, 172OSPHENA ..... 46, 73, 93, 124, 185OTEZLA ..................119, 138, 204otic care .................................... 172oxandrolone ................................ 31oxaprozin .............. 16, 23, 119, 138oxazepam ...................... 54, 64, 148oxcarbazepine ....................... 54, 64
oxiconazole nitrate...........................104, 119, 172, 204OXISTAT ................ 104, 119, 204OXTELLAR XR ................. 54, 65oxybutynin chloride .............46, 138oxybutynin chloride er ........ 46, 138oxycodone hcl ........................... 185oxycodone hcl er ............... 172, 185oxycodone-acetaminophen172, 185oxycodone-aspirin .....................185oxycodone-ibuprofen 185, 191, 196OXYCONTIN ................. 172, 185oxymorphone hcl .......................185oxymorphone hcl er .................. 185OXYTROL ........................ 46, 138paliperidone er ..................148, 172PALYNZIQ ............................... 31PANCREAZE ................... 87, 172PANRETIN . 16, 23, 119, 204, 210pantoprazole sodium .................172paregoric .....................................87paricalcitol ....................46, 93, 173PAROEX ................... 87, 104, 124paromomycin sulfate ...........87, 104paroxetine hcl ........................... 148paroxetine hcl er ....................... 148PASER ............... 80, 104, 119, 128peg 3350/electrolytes .......... 87, 191peg 3350-kcl-na bicarb-nacl.............................................87, 191peg-3350/electrolytes ..........87, 191PEGANONE ........54, 65, 138, 173penicillin g procaine ................. 173penicillin v potassium ............... 173PENNSAID ..............119, 138, 173PENTASA ..........................87, 119pentoxifylline er .......... 40, 138, 185PERFOROMIST .11, 80, 119, 128perindopril erbumine .......... 40, 185PERIOGARD ............87, 104, 125permethrin .........................104, 205perphenazine .............................149PERTZYE ................................. 87phenazopyridine hcl ............46, 185phendimetrazine tartrate ............ 31phendimetrazine tartrate er ........ 31phenelzine sulfate ......................149
PHENERGAN ...87, 185, 191, 196phenobarbital ............................173PHENOHYTRO ..................... 173phenoxybenzamine hcl 40, 173, 210phentermine hcl ...........................31phenyleph-promethazine-cod...............13, 80, 104, 119, 128, 173phenylephrine-guaifenesin ........173phenytoin ...............................54, 65PHENYTOIN INFATABS .54, 65phenytoin sodium extended ...54, 65PHILITH ................................... 73PHOS-FLUR ........................... 173PHOSPHA 250 NEUTRAL ..... 31PHOSPHASAL ....................... 173phytonadione .........................6, 173PICATO ...................................205pilocarpine hcl...16, 23, 87, 97, 119, 191, 196, 210pimozide ........54, 65, 138, 149, 173PIMTREA ......................... 73, 173pindolol ....................................... 40pioglitazone hcl .....................31, 93pioglitazone hcl-glimepiride .32, 93pioglitazone hcl-metformin hcl...............................................32, 93PIRMELLA 1/35 .......................73PIRMELLA 7/7/7 ..............73, 173piroxicam .............. 16, 23, 120, 138podofilox ................... 104, 120, 205polyethylene glycol 3350 ............ 87polymyxin b-trimethoprim.............................97, 104, 120, 125polyvinyl alcohol .........................97POMALYST ............................173PORTIA-28 ............................... 73pot bicarb-pot chloride ............... 32potassium bicarbonate ................32potassium chloride ..............32, 173potassium chloride crys er ..........32potassium chloride er ......... 32, 173potassium citrate er .................. 173PRADAXA .............6, 40, 191, 207PRALUENT ........................ 32, 40pramcort ............................... 40, 87pramipexole dihydrochloride54, 65
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
224
pramipexole dihydrochloride er.......................................54, 65, 173prasugrel hcl.................6, 40, 173, 185, 191, 196pravastatin sodium ......................32praziquantel ................ 87, 104, 173prazosin hcl .................................40PRECISION SURE-DOSE SYRINGE ................................ 156PRECISION THIN LANCETS ............................... 156PRECISION THINS GP LANCETS ............................... 156PRECISION ULTRA LANCET ..................................156PRECISION XTRA BLOOD GLUCOSE ...............................156prednicarbate ....................120, 205prednisolone ................. 23, 93, 120prednisolone acetate ...........98, 120prednisolone sodium phosphate.........................23, 93, 94, 120, 173prednisone .................................173preferred plus lancets colored .. 156preferred plus lancets thin ........ 156PREMARIN .. 46, 73, 94, 125, 185premium lidocaine .................... 173PREMPHASE ....... 46, 73, 94, 125PREMPRO ............ 46, 73, 94, 125prenatabs fa .............................. 189prenatal .....................................189prenatal 19 ........................156, 189PREVIFEM ............................... 73PREVYMIS ....... 23, 104, 191, 196PREZCOBIX .....................23, 104PREZISTA ........................ 23, 104PRIFTIN ............80, 105, 120, 128PRILOSEC ........................87, 120primidone ..................................174PRISTIQ ..................................149PRIVIGEN .............. 6, 23, 40, 120PROAIR HFA ............. 11, 80, 128PROAIR RESPICLICK.......................................11, 80, 128probenecid .. 32, 120, 138, 191, 207PROBUPHINE IMPLANT KIT ........................................... 149
prochlorperazine .........................87prochlorperazine edisylate ......... 87prochlorperazine maleate ...........87PROCRIT ......................6, 46, 210PROCTO-PAK ............... 120, 205PROCTOSOL HC .. 120, 174, 205PROCTOZONE-HC...................................120, 174, 205Profilnine...................................... 6Profilnine SD................................ 6progesterone ............. 40, 46, 74, 94progesterone micronized .....74, 174PROLIA .......................74, 94, 138PROMACTA.....................6, 23, 40, 87, 105, 120promethazine hcl...............87, 88, 174, 185, 191, 196promethazine vc plain.......................13, 80, 105, 120, 194promethazine vc/codeine.......................14, 80, 105, 120, 128promethazine-codeine...............14, 80, 105, 120, 128, 194promethazine-dm...............14, 80, 105, 120, 129, 194promethazine-phenylephrine...............14, 80, 105, 120, 174, 194propafenone hcl .................. 40, 207propafenone hcl er ..............40, 207proparacaine hcl .........98, 192, 196propranolol hcl.........................40, 54, 65, 138, 186propranolol hcl er ...40, 54, 65, 185propranolol-hctz ......................... 40propylthiouracil .......................... 94PROTONIX .............................174protriptyline hcl ........................ 149PROVENTIL HFA ..... 11, 80, 129pseudoephedrine hcl...............................14, 80, 105, 120PSS SELECT GP LANCETS 156PSS SELECT SAFETY LANCETS ............................... 156PULMICORT FLEXHALER...............................11, 80, 120, 129PULMOZYME ..... 11, 32, 80, 129PURIXAN ................................174
pyrazinamide .............................174pyridostigmine bromide.........................23, 55, 65, 120, 138pyridostigmine bromide er.................23, 55, 65, 120, 138, 174qc nicotine polacrilex ................156QNASL .........14, 80, 105, 120, 194QNASL CHILDRENS.......................14, 80, 105, 120, 194QSYMIA ....................................32QUASENSE ...............................74quetiapine fumarate .................. 149quetiapine fumarate er ......149, 174QUILLIVANT XR...............................55, 65, 138, 149quinapril hcl ................................40quinapril-hydrochlorothiazide ....41quinidine gluconate er 41, 192, 207quinidine sulfate ..........41, 192, 207quinidine sulfate er ..... 41, 192, 207quinine sulfate ...........................174QVAR ...................11, 80, 120, 129QVAR REDIHALER...............................11, 80, 121, 129ra mini nicotine .................149, 188ra nicotine .........................149, 188ra nicotine polacrilex ........149, 188rabeprazole sodium .... 88, 121, 174RADICAVA .................55, 65, 138raloxifene hcl 74, 94, 139, 174, 210ramipril ....................................... 41RANEXA ........................... 41, 186ranitidine hcl .................41, 88, 121RAPAFLO ......................... 46, 210RAPAMUNE.................24, 46, 80, 129, 192, 196rasagiline mesylate ....... 55, 65, 174RAVICTI ................................... 32REA LO 40 .............................. 174reality lancets ............................156reality trigger lancets ............... 156REBIF ............................ 55, 65, 66REBIF REBIDOSE ............ 55, 65REBIF REBIDOSE TITRATION PACK ........... 55, 65
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
225
REBIF TITRATION PACK...............................................55, 66Rebinyn.........................................6RECLIPSEN ............................. 74Recombinate................................. 6RELENZA DISKHALER ...... 105RELISTOR ........................88, 178REMEVEN ..............................174REMICADE.................16, 24, 88, 121, 139, 205REMODULIN ....... 11, 41, 80, 129RENAL ................................ 8, 152RENFLEXIS.................17, 24, 88, 121, 139, 205repaglinide ....................32, 94, 174repaglinide-metformin hcl.......................................32, 94, 174REPATHA ...........................32, 41REPATHA PUSHTRONEX SYSTEM ..............................32, 41REPATHA SURECLICK .. 32, 41RESCRIPTOR .................. 24, 105RESCULA ................................. 98reserpine ..................................... 41RESTASIS ................. 98, 121, 125RETIN-A MICRO PUMP ......205REVATIO ..............11, 41, 81, 129REVLIMID ............................. 174REXULTI ................................ 149REYATAZ .........................24, 105RHOPRESSA ............................98RIBASPHERE .......... 88, 105, 121ribavirin ...................... 88, 105, 121rifabutin .................................... 174rifampin .....................................174riluzole .......................... 55, 66, 139rimantadine hcl .........................105risedronate sodium.........................32, 74, 94, 139, 174RisperDAL Consta....................149risperidone ................................149RISPERIDONE M-TAB 149, 174ritonavir ...................... 24, 105, 174RITUXAN ....17, 24, 121, 139, 210rivastigmine .......... 55, 66, 149, 174rivastigmine tartrate ..... 55, 66, 149Rixubis..................................6, 174
rizatriptan benzoate 41, 55, 66, 186ropinirole hcl ........................ 55, 66ropinirole hcl er ....................55, 66ROSANIL CLEANSER ......... 175rosuvastatin calcium ...........32, 175ROZEREM ..........................55, 66RUBRACA .............................. 175Ruconest............... 24, 32, 194, 205RYDAPT ..................................175SABRIL ....................... 55, 66, 139salsalate ................ 17, 24, 121, 139SANCUSO ......................... 88, 210SAPHRIS ................................. 149SAVAYSA ....... 6, 41, 81, 129, 207SAVELLA ............... 121, 139, 186SAVELLA TITRATION PACK ....................... 121, 139, 186SAXENDA ................................. 32sb lancets thin ........................... 156sb lancets ultra thin .................. 156selegiline hcl ......................... 55, 66selenium sulfide ........ 121, 175, 205selenium sulf-pyrithione-urea...........................................121, 205SELZENTRY .................... 24, 105SEMPREX-D.......................14, 81, 105, 121, 194SENSIPAR ...................46, 94, 192SEREVENT DISKUS...............................11, 81, 121, 129SEROSTIM8, 24, 32, 94, 105, 152sertraline hcl .............................149SETLAKIN ................................74sf ..................................................88sf 5000 plus ................................. 88SHAROBEL .............................. 74SIGNIFOR .................................94SIGNIFOR LAR...........................33, 56, 66, 94, 139SIKLOS ....................................... 6sildenafil citrate ...... 11, 41, 81, 129SILIQ ....................................... 205silver sulfadiazine...........................105, 131, 192, 196SIMBRINZA ............................. 98SIMPONI .............17, 24, 121, 139
SIMPONI ARIA...............17, 24, 121, 139, 175, 205simvastatin .................................. 33sirolimus.........24, 46, 81, 129, 175, 192, 196SIRTURO .......... 81, 105, 121, 129SIVEXTRO ............................. 175SKLICE ................................... 105sodium fluoride ................... 88, 175sodium polystyrene sulfonate.............................................33, 175SOLIRIS...6, 24, 33, 41, 46, 56, 66, 121, 139SOLOSEC ................... 46, 74, 105SOLTAMOX ..................... 74, 210SOMAVERT ... 33, 56, 66, 94, 139SOOLANTRA ................. 121, 205sotalol hcl ............................41, 207sotalol hcl (af) .....................41, 207SOVALDI .......... 88, 105, 122, 175spinosad ............................ 105, 205SPINRAZA ..........................56, 66SPIRIVA RESPIMAT...............................11, 81, 122, 129spironolactone ........ 33, 41, 88, 107spironolactone-hctz ...............33, 41SPRINTEC 28 ........................... 74SPRITAM ....................56, 66, 139SPRIX ...................... 186, 192, 196SPRYCEL ................................175SPS ............................................. 33sr nicotine ................................. 156SRONYX ................................... 74SSD ................... 106, 131, 192, 196stavudine ............................. 24, 106STELARA ......... 88, 122, 139, 205STIVARGA ............................. 175STRENSIQ ................................ 33STRIANT .............................74, 94STRIBILD ......................... 24, 106STRIVERDI RESPIMAT...............................11, 81, 122, 129SUBLOCADE ......................... 149SUBOXONE ............................150sucralfate ............................ 88, 122
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
226
sulfacetamide sodium.....................98, 106, 122, 125, 205sulfacetamide sodium (acne) .... 205sulfacetamide sodium-sulfur .....175sulfacetamide-prednisolone 98, 122sulfamethoxazole-trimethoprim 175sulfasalazine.................17, 24, 88, 122, 139, 175sulindac .............................122, 139sumatriptan ............. 41, 56, 66, 186sumatriptan succinate.....................41, 42, 56, 66, 67, 186sumatriptan succinate refill.................................41, 56, 66, 186super thin lancets ......................156SUPRAX .................................. 175SUPRENZA ...............................33sure comfort insulin syringe ..... 156SURELITE LANCETS .......... 156SUTENT .................................. 175SYEDA .......................................74SYMBICORT ......12, 81, 122, 129SYMDEKO ............12, 33, 81, 129SYMFI ............................... 24, 106SYMFI LO .........................24, 106SYMLINPEN 120 ............... 33, 94SYMLINPEN 60 ................. 33, 94SYMPROIC .......................88, 178SYMTUZA ........................ 24, 106SYNAGIS ...........81, 106, 122, 129SYNALAR (CREAM) .... 122, 205SYNALAR (OINTMENT)...........................................122, 205SYNAREL ........................... 74, 94SYNDROS ..... 24, 33, 88, 106, 210TABLOID ................................175TACLONEX ............................205tacrolimus.24, 46, 88, 122, 175, 192, 196, 205tadalafil ...............................74, 175tadalafil (pah) . 12, 42, 81, 129, 175TAFINLAR ............................. 175TAGRISSO ..............................176TALTZ .....................122, 140, 206tamoxifen citrate ................. 74, 210tamsulosin hcl ..................... 47, 210TANZEUM ..........................33, 94
TARCEVA ...............................176TARINA FE 1/20 ...................... 74TASIGNA ................................ 176TAVALISSE ............6, 24, 42, 122TAZORAC .............................. 206tb syringe 1 ml .......................... 156TECFIDERA .......................56, 67TECHLITE LANCETS ..........156TECHNIVIE ............. 88, 106, 122TEKTURNA ..............................42TEKTURNA HCT .................... 42telmisartan .................. 42, 176, 186telmisartan-hctz .................. 42, 176temazepam ............................ 56, 67temozolomide ............................ 176tenofovir disoproxil fumarate.......................24, 88, 106, 122, 176terazosin hcl ..................42, 47, 211terbinafine hcl ...........................176terbutaline sulfate ......... 12, 81, 130terconazole ....................47, 74, 106TESTOPEL ......................... 74, 94testosterone ................... 74, 95, 176testosterone cypionate ...........74, 95testosterone enanthate .......... 74, 95tetrabenazine .56, 67, 140, 150, 176tetracycline hcl ..........................176tgt nicotine ................ 150, 156, 188tgt nicotine polacrilex ....... 150, 188tgt nicotine step one .......... 150, 188tgt nicotine step three ........150, 188tgt nicotine step two .......... 150, 188THALOMID ........................6, 211theophylline ...........12, 81, 123, 130theophylline er ...... 12, 81, 123, 130THINLETS GP LANCETS ... 156THINLETS LANCET ............ 156thioridazine hcl ......................... 150thiothixene .................................150tiagabine hcl ......................... 56, 67TIBSOVO ................................ 176TILIA FE ...........................74, 206timolol maleate ............. 42, 98, 186tinidazole .................47, 74, 89, 106TIVICAY ................... 24, 106, 176tizanidine hcl .............................140
TOBI PODHALER.................12, 33, 81, 106, 123, 130tobramycin.........12, 33, 81, 106, 123, 130, 176tobramycin-dexamethasone.....................................98, 106, 123tolazamide .............................33, 95tolbutamide ........................... 33, 95tolcapone .......................56, 67, 176tolmetin sodium .....17, 25, 123, 140tolterodine tartrate ..............47, 140tolterodine tartrate er . 47, 140, 176topco insulin syringe .................156topiramate ...............42, 56, 67, 186topiramate er .......... 42, 56, 67, 186torsemide ...............................33, 42TOVIAZ .............................47, 140TRACLEER .......... 12, 42, 81, 130tramadol hcl ..............................186tramadol hcl er ......................... 186tramadol hcl er (biphasic) ........ 186tramadol-acetaminophen ..........187trandolapril .........................42, 187trandolapril-verapamil hcl er ..... 42tranexamic acid ...............42, 47, 75tranylcypromine sulfate ............ 150TRAVATAN Z .......................... 98trazodone hcl ............................ 150TRECATOR ............................106TREMFYA .............................. 206TRESIBA FLEXTOUCH ...... 176tretinoin .............................176, 206tretinoin microsphere ................206tretinoin microsphere pump ......206Tretten...........................................6TREXALL ... 17, 25, 123, 140, 206triamcinolone acetonide14, 81, 106, 123, 125, 176, 194, 206triamterene-hctz ....................33, 42trientine hcl...........33, 57, 67, 89, 140, 176, 178TRI-ESTARYLLA ................... 75trifluoperazine hcl .....................150trifluridine ...........98, 106, 123, 125trihexyphenidyl hcl ................57, 67TRI-LEGEST FE ..............75, 206TRI-LINYAH ............................75
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
227
TRI-LO-ESTARYLLA ............ 75TRI-LO-MARZIA .................... 75TRI-LO-SPRINTEC .........75, 176TRILYTE .................. 89, 176, 192trimethobenzamide hcl 89, 192, 196trimethoprim ............................. 176trimipramine maleate ................150TRINATE ................................ 189TRINESSA (28) .........................75TRINESSA LO ..........................75TRINTELLIX ......................... 150TRI-PREVIFEM .......................75TRI-SPRINTEC ........................75TRIUMEQ .........................25, 106tri-vit/fluoride/iron ..........8, 89, 152tri-vitamin/fluoride ......... 8, 89, 152TRIVORA (28) ..........................75TROKENDI XR...................42, 43, 57, 67, 177, 187tropicamide ................................. 98trospium chloride ................47, 140trospium chloride er ........... 47, 140TRULICITY ........................33, 95TRUVADA ........................ 25, 106TUSSIGON ..14, 82, 106, 123, 130TYBOST ............................ 25, 106TYKERB ................................. 177TYMLOS ..................... 75, 95, 140TYSABRI ...............57, 67, 89, 123Tyvaso.....................12, 43, 82, 130Tyvaso Refill .......... 12, 43, 82, 130Tyvaso Starter.........12, 43, 82, 130UCERIS ............................. 89, 123ULESFIA ......................... 106, 206ULTILET CLASSIC LANCETS ............................... 156ULTILET LANCETS .............156ULTRA-THIN II AUTO LANCET ..................................156ULTRA-THIN II LANCETS .157UNILET COMFORTOUCH LANCET ..................................157UNILET G.P. LANCET .........157UNILET G.P. SUPERLITE LANCET ..................................157UNILET LANCET ................. 157
UNILET SUPERLITE LANCET ..................................157UNISTIK 1 .............................. 157UNITHROID .....................95, 177UNITHROID DIRECT .......... 177UPTRAVI .............. 12, 43, 82, 130urea ........................................... 177urea nail film .............................177urea-c40 ....................................177ure-k ..........................................177URIMAR-T ..............................177UROLET MB .......................... 177UROPHEN MB .......................177ursodiol ....................................... 89URYL ....................................... 177valacyclovir hcl .........................177valganciclovir hcl ..................... 177valproic acid ......................... 57, 67valsartan ............................. 43, 177valsartan-hydrochlorothiazide ... 43vancomycin hcl ......................... 177VANDAZOLE .............47, 75, 106VARUBI .............................89, 211VELETRI .............. 12, 43, 82, 130VELIVET .................................. 75VELTASSA ............................... 33VENCLEXTA ......................... 177VENCLEXTA STARTING PACK ....................................... 177venlafaxine hcl .......................... 150venlafaxine hcl er ......................150Ventavis.................. 12, 43, 82, 130VENTOLIN HFA ........12, 82, 130VERAMYST14, 82, 106, 123, 194verapamil hcl .............. 43, 187, 207verapamil hcl er ..........................43VEREGEN ...............106, 123, 206VERZENIO ............................. 177VESICARE ........................47, 140VESTURA ................. 75, 150, 206VIBERZI ................................... 89VICTOZA ............................34, 95VIDEX ............................... 25, 106VIEKIRA PAK ......... 89, 107, 123VIEKIRA XR ............ 89, 107, 123VIENVA .....................................75vigabatrin ..............57, 67, 140, 177
VIIBRYD ................................. 150VIIBRYD STARTER PACK .150VIMPAT .............................. 57, 67viorele ......................................... 75VIRACEPT ....................... 25, 107VIREAD ...............25, 89, 107, 123VISTOGARD .......................... 178VITALET PRO LANCETS ... 157VITALET PRO PLUS LANCETS ............................... 157vitamin d (ergocalciferol) ..... 8, 152VIVITROL .............................. 150Vonvendi.................6, 43, 192, 196voriconazole ..............................177VOSEVI ..................... 89, 107, 123VOTRIENT ............................. 177VPRIV ........................................34VRAYLAR .............................. 150VYFEMLA ........................ 75, 177VYVANSE ........... 57, 67, 140, 150VYZULTA .................................98W&F LANCETS 26G .............157W&F LANCETS COLORED 21G ........................................... 157warfarin sodium ......................7, 43weight loss daily multi .............. 157WERA ........................................75Wilate 7, 25, 43, 123, 177, 192, 196WYMZYA FE ........................... 75XADAGO .............................57, 67XALKORI ............................... 177XARELTO7, 43, 57, 68, 82, 130, 187, 192, 207XARELTO STARTER PACK...................7, 43, 82, 130, 192, 207XATMEP ............. 7, 123, 140, 211XELJANZ.................17, 25, 89, 123, 140, 206XELJANZ XR.................17, 25, 89, 124, 140, 206XENICAL ..................................34XEOMIN ....... 57, 68, 98, 140, 206XERMELO ........................89, 211XGEVA ......................34, 140, 211XIAFLEX .......................... 75, 140XIFAXAN ........34, 57, 68, 89, 107XIGDUO XR ....................... 34, 95
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
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XOLAIR.........12, 34, 82, 124, 130, 194, 206XTANDI ...................................177XULANE ................................... 75XURIDEN ..................................34Xyntha...........................................7Xyntha Solofuse............................7XYREM ....................... 57, 68, 140YONSA .................................... 178zafirlukast ............. 12, 82, 124, 130zaleplon .................................57, 68ZARAH ......................................75ZARXIO ........................ 7, 25, 211ZEJULA ...................................178ZELAPAR ........................... 57, 68ZELBORAF ............................ 178ZENATANE ............................ 206ZENCHENT ..............................75ZENCHENT FE ........................75ZENPEP .............................89, 178ZENZEDI ............ 57, 68, 141, 151ZEPATIER ................89, 107, 124ZETONNA.................12, 14, 82, 107, 124, 194zidovudine ........................... 25, 107ZINBRYTA ......................... 57, 68ZINPLAVA ............... 89, 107, 124ZIOPTAN .................................. 98ziprasidone hcl ..........................151ZIRGAN .................... 98, 107, 124ZOHYDRO ER ....................... 187ZOLADEX ...................47, 75, 211ZOLINZA ........................207, 211zolmitriptan .............43, 57, 68, 187zolpidem tartrate ...................57, 68zolpidem tartrate er .............. 57, 68ZOMIG .......... 43, 58, 68, 178, 187zonisamide ............................ 58, 68ZONTIVITY.............7, 43, 58, 68, 187, 192, 196ZORBTIVE8, 25, 34, 95, 107, 152ZORTRESS ... 25, 47, 89, 192, 197ZOVIA 1/35E (28) .....................75ZOVIA 1/50E (28) .....................75ZOVIRAX ............................... 178ZUBSOLV ....................... 151, 178ZURAMPIC .............. 34, 124, 141
ZYCLARA ...............................207ZYCLARA PUMP .................. 207ZYDELIG ................................178ZYKADIA ............................... 178ZYPITAMAG ........................... 34ZyPREXA Relprevv................. 151ZYTIGA ...................................178
^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy
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