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OHP Drug List (Formulary)
2018
For members of Yamhill Community Care Organization
If you want a copy of this book, need this book in another language, large print, Braille, CD, or other format, please call Customer Service toll‐free at 1‐855‐722‐8205. TTY/TDD users can call 7‐1‐1. You can always view the most recent version of this drug list on our website at www.yamhillcco.org/druglist
Si desea una copia de este documento, necesita este documento en otro idioma, letra grande, Braille, CD u otro formato, llame gratis al departamento de servicio al cliente al 1‐855‐722‐8205. Los usuarios de TTY/TDD pueden llamar al 7‐1‐1. Puede consultar en cualquier momento la versión más reciente de esta lista de medicamentos en nuestro sitio web: www.yamhillcco.org/druglist
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2018 OHP Drug List (Formulary) Administered by
INTRODUCTION Pharmacy benefit As a member of Yamhill Community Care Organization, you have Medicaid prescription drug
coverage under the Oregon Health Plan (OHP). This booklet is your list of the drugs that are
covered. We call it a drug “formulary.” A group of pharmacists and doctors decide which drugs
should be in the formulary. Their goal is to create a formulary with medications that are safe
and effective. This formulary is administered by CareOregon, a partner in Yamhill Community
Care Organization.
This booklet was last updated on October 1, 2018. Usually, we will update this formulary every
two months. To get up‐to‐date information about drugs covered by us, call our Customer
Service department. We are available Monday‐Friday, from 8 a.m. to 5 p.m.
Yamhill Community Care Organization Customer Service: toll free, 855‐722‐8205
Getting started For some drugs, your provider will need to check with us before we will cover the prescription. This will save you time, help you avoid any hassles and get you started on your medication as soon as possible. Important things for you to know are:
1. Before you leave your provider’s office, ask if Yamhill Community Care Organization covers the drug.
2. If we don’t cover it, ask if there is a covered drug that would work for you. 3. If your provider does not prescribe a different drug for you, ask your provider’s office
staff to mail or fax a Prior Authorization or Formulary Exception Request Form to us. A copy of this form can be found on the Yamhill Community Care Organization website in the “Provider Forms and Policies” section.
Be sure to follow your provider’s and pharmacist’s directions for taking your medication(s).
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How to fill your prescriptions You must fill your prescriptions at a participating network pharmacy. A list of pharmacies can be found using the online Provider Directory on the Yamhill Community Care Organization web site. Yamhill Community Care Organization: yamhillcco.org/providerdirectory
Show your Yamhill Community Care Organization ID card every time you fill a prescription. The drugs listed in the formulary do not have copays. If a pharmacy asks you to pay for a prescription, call Customer Service before you pay. IMPORTANT: As a member, it is your responsibility to contact Customer Service before paying out‐of‐pocket for prescriptions. In situations where contacting us is not possible due to emergency, we may pay you back on prescriptions you paid for on your own. This depends on your benefit coverage and the limitations and exclusions of the plan. A form with instructions for getting paid back can be found in the “Member Forms” section of the Yamhill Community Care Organization website. If your PCP’s clinic is closed and you think you need a prescription filled immediately, call your PCP’s after‐hours telephone number. There will usually be someone there that can answer your questions.
How to search the formulary You can search for a drug in the formulary in two ways: 1. By medical condition The drugs are organized into categories that match the type of medical conditions each drug treats. For example, drugs to treat heart conditions are listed under the category “Cardiovascular Agents.” If you know what a drug is used for, start by looking for its category in the table of contents. Then check the category for the name of your drug. 2. Alphabetically If you’re not sure which category a drug is in, look for the drug in the index that begins on page 95. The number next to the drug shows which page has information on the drug. Turn to that page and find the name of your drug in the first column. Note: If the formulary includes only generic versions of a drug, this means that we do not cover the brand‐name drug.
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Non-covered drugs To help members have the best possible health outcomes, Yamhill Community Care Organization may add or remove drugs from the formulary or change coverage rules on drugs. If we remove a drug from the formulary or change the rules for a drug that you take, we will tell you at least 30 days before we do it. The following items are not covered:
Drugs not listed in the formulary (see section titled “Drugs Not Listed in the Formulary” for more information)
Drugs used to treat conditions that are not covered by the Oregon Health Plan, such as fibromyalgia, allergic rhinitis, acne and chronic back pain
Drugs used for cosmetic purposes
Drugs used for non‐medically accepted indications
Investigational drugs and/or drugs used in an investigational manner Mental health drugs, such as antidepressants, anxiolytics and antipsychotics, are covered through the state’s Medical Assistance Programs (MAP). These drugs are not listed in this formulary. Your pharmacist sends the bill directly to MAP. Yamhill Community Care Organization covers some over‐the‐counter drugs that are listed in the formulary. These drugs are covered if you have a prescription for the drug from your provider.
Non-formulary or restricted drugs for a chronic (constant) medical condition New members or members who move to a different level of care may be using a non‐formulary or restricted drug. If a provider asks for this drug to be covered, we may provide a transition supply. A transition supply gives you time to try a different formulary drug to see if it meets your needs. Meanwhile, your provider may send a Prior Authorization or Formulary Exception Request Form to us, with reasons why this drug should be covered. A copy of this form can be found on the Yamhill Community Care Organization website in the “Provider Forms and Policies” section.
Generic drugs A generic drug is a copy of a brand‐name drug. It has the same active ingredients as the brand‐name drug. Generic drugs are approved by the U.S. Food and Drug Administration after being tested for effectiveness and safety. They usually cost less than brand‐name drugs and become available after the patent for a brand‐ name drug expires. If your PCP decides that you have a medical need for a brand‐name drug that does not have a generic equivalent, they must send a Prior Authorization or Formulary Exception Request Form to us.
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Restrictions on the formulary drugs Some covered drugs may have special rules related to their use. These rules may include:
Prior Authorization (PA): If providers want to prescribe a drug marked “PA” in the formulary, they must send a Prior Authorization or Formulary Exception Request Form to us. We cannot pay for the prescription unless we approve the request in advance. Usually, we only approve prior authorization requests if the drug treats conditions covered by the Oregon Health Plan. Also, the prescription must meet drug use rules set by our Pharmacy & Therapeutics Committee. Each Prior Authorization or Formulary Exception Request Form must have only one medication request. All fields on the form must be complete and legible.
Quantity Limits (QL): For drugs marked “QL,” we limit the amount of the drug we’ll pay for. Your provider must send a Prior Authorization or Formulary Exception Request Form to us if they want to prescribe an amount of the drug that is over our quantity limits. Our decisions for prior authorization and formulary exception requests are based only on appropriate care and coverage. Our staff are not rewarded for denying requests. We do not use financial incentives to reward underutilization.
Step Therapy (ST): Sometimes we ask you to try other drugs before we cover a drug marked “ST.” Suppose Drug A and Drug B both treat your medical condition. We may not cover Drug B before you try Drug A. If Drug A has harmful side effects or doesn’t work for you, we’ll cover Drug B.
Age Restriction (AR): For some drugs, we require you to be younger than or older than a specific age. For example, a drug may be restricted to people under age 6 or over age 16.
Over‐the‐Counter (OTC): Some over‐the‐counter (OTC) drugs are in the formulary. We can cover an OTC drug if you get a prescription from your provider and give it to a network pharmacist.
Exceptions You may get up to a 90‐day supply of the following drugs:
Generic oral contraceptives (birth control pills) Pediatric multivitamins with fluoride, prenatal vitamins, folic acid, sodium fluoride Digoxin, furosemide, hydrochlorothiazide, atenolol, metoprolol, captopril, enalapril,
lisinopril Levothyroxine Albuterol HFA inhalers and nebulizer solutions
Note: Yamhill Community Care Organization may approve an additional refill in the following situations:
Your prescription is lost, stolen, or spilled.
You need extra medication because you will be out of town.
You need extra medication because your dosage was increased.
You need a supply of a certain medication for work or school.
For more information call our Customer Service department.
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Drugs not listed in the formulary Drugs usually are not covered unless they are in the formulary. However, if your provider believes a drug outside of our formulary is the best drug for you, the provider can ask us to cover it. This is called “making a formulary exception request.” Your provider will need to submit a Prior Authorization or Formulary Exception Request Form to us. Usually, we’ll approve formulary exception requests only if other formulary drugs would be less effective in treating your condition, or would cause side effects that could hurt you.
Urgent needs for non-formulary or restricted drugs You, or your provider or a pharmacist may ask for a five‐day emergency supply of a non‐formulary or restricted drug. This gives you, or your provider time to send a Prior Authorization or Formulary Exception Request Form to us. To ask for an emergency supply, call Customer Service.
Formulary updates As mentioned above, the formulary is updated about every two months. Generally, drugs on the formulary will not change during the year unless:
The same medication becomes available in generic form.
The FDA deems a drug to be unsafe.
The drug’s manufacturer removes the drug from the market.
For more information For the most up‐to‐date information about medications covered by your pharmacy benefit, visit the Yamhill Community Care Organization website, or call the Customer Service department. Customer service hours are 8 a.m.‐5 p.m., Monday through Friday.
Yamhill Community Care Organization Customer Service: toll free, 855‐722‐8205
Other prescription drug resources To keep track of your prescription history, search for network pharmacies or check on the status of a prior authorization request, you can create an account with OptumRx. Simply go to the Yamhill Community Care Organization website at the link below and click on the big yellow button at the bottom of the page. Yamhill Community Care Organization: yamhillcco.org/druglist
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TABLE OF CONTENTS
ANTI‐INFECTIVES .......................................................................................................... 1
PENICILLINS ........................................................................................................................................................ 1
CEPHALOSPORINS.............................................................................................................................................. 2
MACROLIDES ...................................................................................................................................................... 3
TETRACYCLINES.................................................................................................................................................. 3
FLUOROQUINOLONES ....................................................................................................................................... 3
AMEBICIDES ....................................................................................................................................................... 4
AMINOGLYCOSIDES ........................................................................................................................................... 4
ANTITUBERCULOSIS AGENTS ............................................................................................................................ 4
ANTIFUNGALS .................................................................................................................................................... 4
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) ............................................................................................................ 5
ANTIVIRALS ........................................................................................................................................................ 6
HEPATITIS AGENTS ............................................................................................................................................. 6
HIV ...................................................................................................................................................................... 7
INFLUENZA AGENTS ........................................................................................................................................... 9
ANTIMALARIALS .............................................................................................................................................. 10
ANTHELMINTICS .............................................................................................................................................. 10
ANTI‐INFECTIVE AGENTS: MISC .............................................................................................................................. 10
HEPATIC ENCEPHALOPATHY ........................................................................................................................... 11
MONOBACTAMS ............................................................................................................................................. 11
BIOLOGICALS (VACCINES) ........................................................................................... 11
VACCINES AGES 18 AND YOUNGER COVERED BY VACCINES FOR CHILDREN .................................................................... 11
ANTI‐NEOPLASTICS ..................................................................................................... 12
ANTIDOTES ....................................................................................................................................................... 12
ANTIMETABOLITES ..................................................................................................... 12
ANTINEOPLASTIC AGENTS ............................................................................................................................... 13
PROGESTINS ..................................................................................................................................................... 17
ENDOCRINE AND METABOLIC DRUGS ......................................................................... 18
ADRENALS ........................................................................................................................................................ 18
ANDROGENS .................................................................................................................................................... 19
ESTROGENS ...................................................................................................................................................... 19
CONTRACEPTIVES ............................................................................................................................................ 20
ALPHA‐GLUCOSIDASE INHIBITORS .................................................................................................................. 24
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS ........................................................................................... 24
BIGUANIDES ..................................................................................................................................................... 25
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COMBO ANTI‐DIABETIC ......................................................................................................................................... 25
GLUCAGON .......................................................................................................................................................... 25
INCRETIN MIMETICS ........................................................................................................................................ 25
INSULINS .......................................................................................................................................................... 25
DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS .............................................................................................................. 26
MEGLITINIDES .................................................................................................................................................. 26
SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB ............................................................................................. 26
SULFONYLUREAS ............................................................................................................................................. 26
THIAZOLIDINEDIONES ..................................................................................................................................... 27
ANTITHYROID AGENTS .................................................................................................................................... 27
THYROID AGENTS ............................................................................................................................................ 27
OXYTOCICS ....................................................................................................................................................... 29
ERGOT‐DERIV. DOPAMINE RECEPTOR AGONISTS .......................................................................................... 29
ESTROGEN AGONIST‐ANTAGONISTS .............................................................................................................. 29
OSTEOPOROSIS ................................................................................................................................................ 29
OTHER MISCELLANEOUS THERAPEUTIC AGENTS ........................................................................................... 29
PITUITARY ........................................................................................................................................................ 30
SOMATOTROPIN AGONISTS ............................................................................................................................ 30
SOMATOTROPIN ANTAGONISTS ..................................................................................................................... 31
VITAMIN D ........................................................................................................................................................ 31
CARDIOVASCULAR AGENTS ........................................................................................ 32
CARDIOTONIC AGENTS .................................................................................................................................... 32
CARDIAC DRUGS, MISCELLANEOUS ................................................................................................................ 32
NITRATES AND NITRITES .................................................................................................................................. 33
BETA‐ADRENERGIC BLOCKING AGENTS .......................................................................................................... 33
CALCIUM‐CHANNEL BLOCKING AGENTS ........................................................................................................ 34
ANTIARRHYTHMICS ................................................................................................................................................ 36
ANGIOTENSIN II RECEPTOR ANTAGONISTS .................................................................................................... 37
ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS ....................................................................................... 37
CENTRAL ALPHA‐AGONISTS ............................................................................................................................ 38
COMBO HYPERTENSION MEDS ....................................................................................................................... 38
DIRECT VASODILATORS ................................................................................................................................... 39
CARBONIC ANHYDRASE INHIBITORS (EENT) ................................................................................................... 39
LOOP DIURETICS .............................................................................................................................................. 40
POTASSIUM‐SPARING DIURETICS ................................................................................................................... 40
THIAZIDE AND THIAZIDE‐LIKE DIURETICS ........................................................................................................ 40
ALPHA‐ADRENERGIC AGONISTS ...................................................................................................................... 40
EPINEPHRINE ................................................................................................................................................... 41
ANTILIPEMIC AGENTS, MISCELLANEOUS ........................................................................................................ 41
BILE ACID SEQUESTRANTS ............................................................................................................................... 41
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CHOLESTEROL ABSORPTION INHIBITORS ....................................................................................................... 41
FIBRIC ACID DERIVATIVES ................................................................................................................................ 41
PCSK9 INHIBITORS ........................................................................................................................................... 41
STATINS ............................................................................................................................................................ 41
PULMONARY HYPERTENSION ......................................................................................................................... 42
RESPIRATORY AGENTS ................................................................................................ 42
ANTI‐HISTAMINES ............................................................................................................................................ 42
NASAL STEROIDS .............................................................................................................................................. 43
COUGH ............................................................................................................................................................. 43
CYSTIC FIBROSIS ............................................................................................................................................... 43
INHALED ANTICHOLINERGICS ......................................................................................................................... 44
INHALED BETA‐AGONISTS ............................................................................................................................... 44
INHALED COMBO ANTICHOLINERGICS/BETA‐AGONISTS .............................................................................. 44
INHALED COMBO BETA‐AGONISTS/ANTICHOLINERGICS .............................................................................. 44
INHALED COMBO STEROID/BETA‐AGONISTS ................................................................................................. 44
INHALED STEROIDS .......................................................................................................................................... 45
LEUKOTRIENE MODIFIERS ............................................................................................................................... 45
MAST‐CELL STABILIZERS .................................................................................................................................. 45
OTHER ASTHMA/COPD .................................................................................................................................... 45
GASTROINTESTINAL AGENTS ...................................................................................... 46
CATHARTICS AND LAXATIVES .......................................................................................................................... 46
ANTACIDS AND ADSORBENTS ......................................................................................................................... 46
ANTIMUSCARINICS/ANTISPASMODICS .......................................................................................................... 47
HISTAMINE H2‐ANTAGONISTS ........................................................................................................................ 48
PROSTAGLANDINS ........................................................................................................................................... 48
PROTECTANTS .................................................................................................................................................. 49
PROTON‐PUMP INHIBITORS ............................................................................................................................ 49
ANTI‐NAUSEA ................................................................................................................................................... 49
DIGESTANTS ..................................................................................................................................................... 50
CHOLELITHOLYTIC AGENTS ............................................................................................................................. 51
INFLAMMATORY BOWEL AGENTS .................................................................................................................. 51
PHOSPHATE‐REMOVING AGENTS ................................................................................................................... 51
PROKINETIC AGENTS ....................................................................................................................................... 52
GENITOURINARY PRODUCTS ...................................................................................... 52
INCONTINENCE/URINARY FREQUENCY .......................................................................................................... 52
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) ...................................................................................... 52
CONTRACEPTIVES (E.G. FOAMS, DEVICES) ..................................................................................................... 52
VAGINAL ANTI‐INFECTIVES .............................................................................................................................. 53
ALKALINIZING AGENTS .................................................................................................................................... 53
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IRRIGATING SOLUTIONS .................................................................................................................................. 54
MISCL URINARY AGENTS ................................................................................................................................. 54
BPH AGENTS ..................................................................................................................................................... 54
CENTRAL NERVOUS SYSTEM DRUGS ........................................................................... 54
ANXIOLYTICS, SEDATIVES & HYPNOTICS, MISC. .............................................................................................. 54
BENZODIAZEPINES ................................................................................................................................................. 55
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) ............................................................................................... 55
ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANT AGENTS ............................... 55
AMPHETAMINES .............................................................................................................................................. 55
METHYLPHENIDATES ....................................................................................................................................... 56
RESPIRATORY AND CNS STIMULANTS ............................................................................................................. 56
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC ...................................... 56
ALCOHOL DETERRENTS ................................................................................................................................... 56
ANTIDEMENTIA AGENTS ................................................................................................................................. 57
MULTIPLE SCLEROSIS ....................................................................................................................................... 57
SMOKING DETERRENTS ................................................................................................................................... 58
ANALGESICS AND ANESTHETICS ................................................................................. 58
ANALGESICS AND ANTIPYRETICS, MISC. ......................................................................................................... 58
SALICYLATES ..................................................................................................................................................... 58
OPIATE PARTIAL AGONISTS ............................................................................................................................. 59
OPIATES ............................................................................................................................................................ 59
ANTI‐TNF INHIBITORS ...................................................................................................................................... 61
DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS ........................................................................................... 62
MISCL BIOLOGIC ............................................................................................................................................... 62
NONSTEROIDAL ANTI‐INFLAMMATORY (NSAID) ........................................................................................... 62
MIGRAINE PRODUCTS ..................................................................................................................................... 63
TRIPTANS .......................................................................................................................................................... 63
ANTIGOUT AGENTS ......................................................................................................................................... 64
URICOSURIC AGENTS ....................................................................................................................................... 64
NEUROMUSCULAR DRUGS ......................................................................................... 66
ANTICHOLINERGIC AGENTS (CNS) ................................................................................................................... 66
ANTIPARKINSON .............................................................................................................................................. 66
DOPAMINERGICS ............................................................................................................................................. 66
CENTRAL NERVOUS SYSTEM AGENTS, MISC. .................................................................................................. 67
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT .......................................................................................... 67
DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS ............................................................................................ 67
NUTRITIONAL PRODUCTS ........................................................................................... 67
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VITAMIN B COMPLEX ....................................................................................................................................... 67
MULTIVITAMIN PREPARATIONS ..................................................................................................................... 68
FLUORIDE ............................................................................................................................................................ 76
REPLACEMENT PREPARATIONS ...................................................................................................................... 77
CALORIC AGENTS ............................................................................................................................................. 80
HEMATOLOGICAL AGENTS .......................................................................................... 80
HEMATOPOIETIC AGENTS ............................................................................................................................... 80
IRON PREPARATIONS ....................................................................................................................................... 81
ANTICOAGULANTS .......................................................................................................................................... 82
HEMOSTATICS .................................................................................................................................................. 84
HEMORRHEOLOGIC AGENTS ........................................................................................................................... 84
PLATELET‐ACTING AGENTS ............................................................................................................................. 84
TOPICAL PRODUCTS .................................................................................................... 84
ALPHA‐ADRENERGIC AGONISTS (EENT) .......................................................................................................... 84
ANTIBACTERIALS (EENT) .................................................................................................................................. 84
ANTIVIRALS (EENT) .......................................................................................................................................... 85
BETA‐ADRENERGIC BLOCKING AGENTS (EENT) .............................................................................................. 85
CORTICOSTEROIDS (EENT) ............................................................................................................................... 85
EENT DRUGS, MISCELLANEOUS ...................................................................................................................... 86
EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS ............................................................................................... 86
MIOTICS ........................................................................................................................................................... 86
MYDRIATICS ..................................................................................................................................................... 86
PROSTAGLANDIN ANALOGS ............................................................................................................................ 86
LOCAL ANESTHETICS (EENT) ............................................................................................................................ 86
EENT ANTI‐INFECTIVES, MISCELLANEOUS ...................................................................................................... 86
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) .......................................................................................... 86
ANTIPRURITICS AND LOCAL ANESTHETICS ..................................................................................................... 87
LOCAL ANTI‐INFECTIVES, MISCELLANEOUS .................................................................................................... 87
SCABICIDES AND PEDICULICIDES ..................................................................................................................... 87
SKIN AND MUCOUS MEMBRANE AGENTS, MISC. .......................................................................................... 87
TOPICAL CORTICOSTEROIDS ............................................................................................................................ 88
MISCELLANEOUS PRODUCTS ...................................................................................... 90
COMPLEMENT INHIBITORS ............................................................................................................................. 90
EMETICS ........................................................................................................................................................... 90
OPIATE ANTAGONISTS ..................................................................................................................................... 90
ADRENOCORTICAL INSUFFICIENCY ................................................................................................................. 90
MISCL OTHER ................................................................................................................................................... 90
DEVICES ............................................................................................................................................................ 91
IMMUNOSUPPRESSIVE AGENTS ..................................................................................................................... 93
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POTASSIUM‐REMOVING AGENTS ................................................................................................................... 94
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
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Drug Name Dosage Form/Strength Drug Type Requirements
ANTI‐INFECTIVES PENICILLINS AMOXICILLIN/CLAVULANATE POTASSIUM TAB 250MG Generic
AMOXICILLIN/CLAVULANATE POTASSIUM TAB 500MG Generic
AMOXICILLIN/CLAVULANATE POTASSIUM TAB 875MG Generic
AMOXICILLIN/CLAVULANATE POTASSIUM CHW 200MG Generic
AMOXICILLIN/CLAVULANATE POTASSIUM CHW 400MG Generic
AMOXICILLIN/CLAVULANATE POTASSIUM SUS 200/5ML Generic
AMOXICILLIN/CLAVULANATE POTASSIUM SUS 250/5ML Generic
AMOXICILLIN/CLAVULANATE POTASSIUM SUS 400/5ML Generic
AMOXICILLIN/CLAVULANATE POTASSIUM SUS 600/5ML Generic
AMOXICILLIN TAB 875MG Generic
AMOXICILLIN CAP 250MG Generic
AMOXICILLIN CAP 500MG Generic
AMOXICILLIN CHW 250MG Generic
AMOXICILLIN SUS 125/5ML Generic
AMOXICILLIN SUS 200/5ML Generic
AMOXICILLIN SUS 250/5ML Generic
AMOXICILLIN SUS 400/5ML Generic
AMOXICILLIN/CLAVULANATE POTASSIUM TAB ER Generic
AMPICILLIN CAP 250MG Generic
AMPICILLIN CAP 500MG Generic
AMP‐SULBACTA INJ 1.5GM Generic
AMP‐SULBACTA INJ 1‐0.5GM Generic
AMP‐SULBACTA INJ 1.5GM Generic
AMP‐SULBACTA INJ 3GM Generic
AMP‐SULBACTA INJ 2‐1GM Generic
AMP‐SULBACTA INJ 10‐5GM Generic
AMP‐SULBACTA INJ 15GM Generic
DICLOXACILLIN SODIUM CAP 250MG Generic
DICLOXACILLIN SODIUM CAP 500MG Generic
PENICILLIN G POTASSIUM INJ 5000000 Generic
PENICILLN VK TAB 250MG Generic
PENICILLN VK TAB 500MG Generic
PENICILLN VK SOL 125/5ML Generic
PENICILLN VK SOL 250/5ML Generic
PIPER/TAZOBA INJ 2‐0.25GM Generic
PIPER/TAZOBA INJ 3‐0.375G Generic
PIPER/TAZOBA INJ 4‐0.5GM Generic
PIPER/TAZOBA INJ 12‐1.5GM Generic
PIPER/TAZOBA INJ 36‐4.5GM Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
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Drug Name Dosage Form/Strength Drug Type Requirements
CEPHALOSPORINS CEFACLOR CAP 250MG Generic
CEFACLOR CAP 500MG Generic
CEFADROXIL CAP 500MG Generic
CEFADROXIL TAB 1GM Generic
CEFADROXIL SUS 250/5ML Generic
CEFADROXIL SUS 500/5ML Generic
CEFAZOLIN INJ 500MG Generic
CEFAZOLIN INJ 1GM Generic
CEFAZOLIN INJ 10GM Generic
CEFAZOLIN INJ 20GM Generic
CEFAZOLIN INJ 100GM Generic
CEFAZOLIN INJ 300GM Generic
CEFAZOLIN INJ 1GM/50ML Generic
CEFAZOLIN/DEXTROSE SOL 1GM Generic
CEFAZOLIN/DEXTROSE SOL 2GM Generic
CEFDINIR CAP 300MG Generic
CEFDINIR SUS 125/5ML Generic
CEFDINIR SUS 250/5ML Generic
CEFIXIME SUS 100/5ML Generic
CEFIXIME SUS 200/5ML Generic
CEFPODOXIME TAB 100MG Generic
CEFPODOXIME TAB 200MG Generic
CEFPROZIL TAB 250MG Generic
CEFPROZIL TAB 500MG Generic
CEFPROZIL SUS 125/5ML Generic
CEFPROZIL SUS 250/5ML Generic
CEFTRIAXONE INJ 250MG Generic
CEFTRIAXONE INJ 500MG Generic
CEFTRIAXONE INJ 1GM Generic
CEFTRIAXONE INJ 2GM Generic
CEFTRIAXONE INJ 10GM Generic
CEFTRIAXONE INJ 100GM Generic
CEFTRIAXONE INJ DEX 1GM Generic
CEFTRIAXONE INJ DEX 2GM Generic
CEFUROXIME TAB 250MG Generic
CEFUROXIME TAB 500MG Generic
CEPHALEXIN CAP 250MG Generic
CEPHALEXIN CAP 500MG Generic
CEPHALEXIN SUS 125/5ML Generic
CEPHALEXIN SUS 250/5ML Generic
SUPRAX SUS 500/5ML Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
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Drug Name Dosage Form/Strength Drug Type Requirements
MACROLIDES AZITHROMYCIN TAB 250MG Generic
AZITHROMYCIN TAB 500MG Generic
AZITHROMYCIN TAB 600MG Generic
AZITHROMYCIN SUS 100/5ML Generic
AZITHROMYCIN SUS 200/5ML Generic
AZITHROMYCIN POW 1GM PAK Generic
CLARITHROMYCIN TAB 250MG Generic
CLARITHROMYCIN TAB 500MG Generic
CLARITHROMYCIN SUS 125/5ML Generic
CLARITHROMYCIN SUS 250/5ML Generic
CLARITHROMYCIN TAB 500MG ER Generic
ZITHROMAX POW 1GM PAK Brand
TETRACYCLINES
DOXYCYCLINE HYCLATE CAP 50MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE HYCLATE CAP 100MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE HYCLATE TAB 50MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE HYCLATE TAB 100MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE MONOHYDRATE CAP 50MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE MONOHYDRATE CAP 100MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE MONOHYDRATE TAB 50MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
DOXYCYCLINE MONOHYDRATE TAB 100MG Generic
QL 14‐day supply per fill; Max 28‐day supply per 90
days
VIBRAMYCIN SYP 50MG/5ML Brand AR PA required > 6
FLUOROQUINOLONES
CIPROFLOXACIN SUS 500MG/5 Generic AR Covered for members
6 and younger
CIPROFLOXACIN TAB 100MG Generic
CIPROFLOXACIN TAB 250MG Generic
CIPROFLOXACIN TAB 500MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
4
Drug Name Dosage Form/Strength Drug Type Requirements
CIPROFLOXACIN TAB 750MG Generic
CIPROFLOXACIN INJ 200MG Generic
CIPROFLOXACIN INJ 400MG Generic
LEVOFLOXACIN TAB 250MG Generic
LEVOFLOXACIN TAB 500MG Generic
LEVOFLOXACIN TAB 750MG Generic
LEVOFLOXACIN SOL 25MG/ML Generic
MOXIFLOXACIN TAB 400MG Generic
AMEBICIDES PAROMOMYCIN CAP 250MG Generic
YODOXIN TAB 210MG Brand
YODOXIN TAB 650MG Brand
AMINOGLYCOSIDES BETHKIS NEB 300/4ML Brand
NEOMYCIN TAB 500MG Generic
TOBRAMYCIN NEB 300/5ML Generic QL 280ml per 60 days
TOBRAMYCIN INJ 80MG/2ML Generic
TOBRAMYCIN INJ 40MG/ML Generic
ANTITUBERCULOSIS AGENTS ETHAMBUTOL TAB 100MG Generic
ETHAMBUTOL TAB 400MG Generic
ISONIAZID TAB 100MG Generic
ISONIAZID TAB 300MG Generic
PYRAZINAMIDE TAB 500MG Generic
RIFABUTIN CAP 150MG Generic
RIFAMPIN CAP 150MG Generic
RIFAMPIN CAP 300MG Generic
ANTIFUNGALS AMPHOTERICIN INJ 50MG Generic PA
BIO‐STATIN POW Generic PA
FLUCONAZOLE TAB 50MG Generic
FLUCONAZOLE TAB 100MG Generic
FLUCONAZOLE TAB 150MG Generic
FLUCONAZOLE TAB 200MG Generic
FLUCONAZOLE SUS 10MG/ML Generic
FLUCONAZOLE SUS 40MG/ML Generic
FLUCYTOSINE CAP 250MG Generic
FLUCYTOSINE CAP 500MG Generic
GRISEOFULVIN SUS 125/5ML Generic PA required > 6
ITRACONAZOLE CAP 100MG Generic PA
KETOCONAZOLE TAB 200MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
5
Drug Name Dosage Form/Strength Drug Type Requirements
NOXAFIL TAB 100 MG DR Brand PA
NOXAFIL SUSP 40MG/ML Brand PA
NYSTATIN TAB 500000 Generic
NYSTATIN POW Generic
NYSTATIN SUS 100000 Generic
NYSTATIN POW 10BU Generic PA
NYSTATIN POW 50MU Generic PA
NYSTATIN POW 150MU Generic PA
NYSTATIN POW 500MU Generic PA
NYSTATIN POW 1BU Generic PA
NYSTATIN POW 2BU Generic PA
NYSTATIN POW 5BU Generic PA
NYSTATIN CRE 100000 Generic
NYSTATIN OIN 100000 Generic
SPORANOX SOL 10MG/ML Brand PA
TERBINAFINE TAB 250MG Generic
VORICONAZOLE TAB 50MG Generic PA
VORICONAZOLE TAB 200MG Generic PA
VORICONAZOLE SUS 40MG/ML Generic PA
VORICONAZOLE INJ 200MG Generic PA
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) 3 DAY VAGINAL CRE 2% Generic
3 DAY VAGINAL CRE 4% Generic
ATHLETE FOOT CRE 1% Generic
CLOTRIMAZOLE CRE 1% Generic
CLOTRIMAZOLE CRE 1% VAG Generic
CLOTRIMAZOLE CRE 2% Generic
CLOTRIMAZOLE CRE 3 DAY Generic
CLOTRIMAZOLE TRO 10MG Generic
CLOTRIMAZOLE LOZ 10MG Generic
CLOTRIMAZOLE CRE GRX 1% Generic
DESENEX CRE 1% Generic
JOCK ITCH CRE 1% Generic
MICADERM CRE 2% Generic
MICONAZOLE 3 KIT COMBO PK Generic
MICONAZOLE SUP 100MG Generic
MICONAZOLE CRE 2% CRE 2% Generic
MICONAZOLE POW POW Generic PA
MICONAZOLE 3 CRE 4% Generic
MICONAZOLE 7 CRE TUBE/KIT Generic
MICONAZOLE 7 CRE 2% Generic
MICONAZOLE 7 SUP 100MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
6
Drug Name Dosage Form/Strength Drug Type Requirements
MICRO GUARD CRE 2% Generic
NEOSPORIN AF CRE 2% JOCK Generic
PODACTIN CRE 2% Generic
RINGWORM CRE 1% Generic
SM ANTIFUNGL CRE 1% Generic
SOOTHE&COOL CRE INZO 2% Generic
TINEACIDE CRE Generic
VAGISTAT‐3 KIT COMBO PK Generic
ANTIVIRALS AMANTADINE TAB 100MG Generic
AMANTADINE CAP 100MG Generic
AMANTADINE SYP 50MG/5ML Generic
RIMANTADINE TAB 100MG Generic
ACYCLOVIR CAP 200MG Generic
ACYCLOVIR TAB 400MG Generic
ACYCLOVIR TAB 800MG Generic
ACYCLOVIR SUS 200/5ML Generic
FAMCICLOVIR TAB 125MG Generic PA
FAMCICLOVIR TAB 250MG Generic PA
FAMCICLOVIR TAB 500MG Generic PA
PREVYMIS TAB 240MG Brand PA QL 1 per day
PREVYMIS TAB 480MG Brand PA QL 1 per day
VALACYCLOVIR TAB 500MG Generic
VALACYCLOVIR TAB 1GM Generic
VALGANCICLOVIR SOL 50MG/ML Generic PA required > 6
VALGANCICLOVIR TAB 450MG Generic
HEPATITIS AGENTS ADEFOVIR DIPIVOXIL TAB 10MG Generic PA QL 1 per day
BARACLUDE SOL .05MG/ML Brand QL 20 per day
CIDOFOVIR INJ 75MG/ML Generic
DAKLINZA TAB 30MG Brand PA QL 1 per day; 84 tabs per life
DAKLINZA TAB 60MG Brand PA QL 1 per day; 84 tabs per life
ENTECAVIR TAB 0.5MG Generic QL 1 per day
ENTECAVIR TAB 1MG Generic QL 1 per day
EPCLUSA TAB 400‐100 Brand PA QL 1 per day; 84 tabs
per life
INFERGEN INJ 9MCG Brand PA
INFERGEN INJ 15MCG Brand PA
MAVYRET TAB 100‐40MG Brand PA QL 3 tabs per day; max 112‐day supply per life
MODERIBA TAB 200MG Generic PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
7
Drug Name Dosage Form/Strength Drug Type Requirements
RIBASPHERE CAP 200MG Generic PA
RIBASPHERE TAB 200MG Generic PA
RIBAVIRIN CAP 200MG Generic PA
RIBAVIRIN TAB 200MG Generic PA
SOVALDI TAB 400MG Brand PA QL 1 per day; 84 tabs per life
TYZEKA TAB 600MG Brand PA QL 1 per day
VOSEVI TAB 400‐100‐100MG Brand PA QL 1 per day; max 84‐day
supply per life
ZEPATIER TAB 50‐100MG Brand PA QL 1 per day; 84 tabs per life
HIV ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE
TAB 300MG‐150MG‐300MG Generic
ABACAVIR/LAMIVUDINE TAB 600MG‐300MG Generic
ABACAVIR TAB 300MG Generic
APTIVUS CAP 250MG Brand
APTIVUS SOL Brand
ATAZANAVIR CAP 150MG Generic
ATAZANAVIR CAP 200MG Generic
ATAZANAVIR CAP 300MG Generic
ATRIPLA TAB Brand
BIKTARVY TAB Brand QL 1 per day
CIMDUO TAB 300MG Brand QL 1 per day
COMPLERA TAB 200MG‐25MG‐
300MG Brand
CRIXIVAN CAP 200MG Brand
CRIXIVAN CAP 400MG Brand
DESCOVY TAB 200/25MG Brand QL 1 per day
DIDANOSINE CAP 125MG Generic
DIDANOSINE CAP 200MG Generic
DIDANOSINE CAP 250MG Generic
DIDANOSINE CAP 400MG Generic
EDURANT TAB 25MG Brand
EFAVIRENZ CAP 50MG Generic
EFAVIRENZ CAP 200MG Generic
EFAVIRENZ TAB 600MG Generic
EMTRIVA CAP 200MG Brand
EMTRIVA SOL 10MG/ML Brand
EPIVIR HBV SOL 5MG/ML Brand
EVOTAZ TAB 300‐150 Brand QL 1 per day
FOSAMPRENAVIR TAB 700MG Generic
FUZEON INJ 90MG Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
8
Drug Name Dosage Form/Strength Drug Type Requirements
GENVOYA TAB 150‐150‐200‐10 MG Brand QL 1 per day
INTELENCE TAB 100MG Brand
INTELENCE TAB 200MG Brand
INTELENCE TAB 25MG Brand
INVIRASE CAP 200MG Brand
INVIRASE TAB 500MG Brand
ISENTRESS CHEW 100MG Brand
ISENTRESS CHEW 25MG Brand
ISENTRESS POW 100MG Brand
ISENTRESS TAB 400MG Brand
ISENTRESS HD TAB 600 MG Brand QL 2 per day
JULUCA TAB 50‐25MG Brand QL 1 per day
KALETRA TAB 100‐25MG Brand
KALETRA TAB 200‐50MG Brand
KALETRA SOL Brand
LAMIVUDINE/ZIDOVUDINE TAB 150‐300 Generic
LAMIVUDINE TAB 150MG Generic
LAMIVUDINE TAB 300MG Generic QL 1 per day
LAMIVUDINE SOL 10MG/ML Generic
LAMIVUDINE TAB 100MG Generic
LEXIVA SUS 50MG/ML Brand
NEVIRAPINE SUS 50MG/5ML Generic
NEVIRAPINE TAB 100MG Generic AR PA required > 18
NEVIRAPINE TAB 200MG Generic
NEVIRAPINE TAB 400MG ER Generic
NORVIR CAP 100MG Brand
NORVIR SOL 80MG/ML Brand
ODEFSY TAB 200‐25‐25MG Brand QL 1 per day
PREZCOBIX TAB 800‐150 Brand QL 1 per day
PREZISTA TAB 75MG Brand
PREZISTA TAB 150MG Brand
PREZISTA TAB 400MG Brand
PREZISTA TAB 600MG Brand
PREZISTA TAB 800MG Brand
PREZISTA SUS 100MG/ML Brand
RESCRIPTOR TAB 100 MG Brand
RESCRIPTOR TAB 200MG Brand
RETROVIR INJ 10MG/ML Brand
REYATAZ POW 50MG Brand
RITONAVIR TAB 100MG Generic
SELZENTRY TAB 25MG Brand QL 4 tabs per day
SELZENTRY TAB 75MG Brand QL 2 tabs per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
9
Drug Name Dosage Form/Strength Drug Type Requirements
SELZENTRY TAB 150MG Brand
SELZENTRY TAB 300MG Brand
SELZENTRY SOLN 20MG/ML Brand AR Covered for patients <6
STAVUDINE CAP 15MG Generic
STAVUDINE CAP 20MG Generic
STAVUDINE CAP 30MG Generic
STAVUDINE CAP 40MG Generic
STAVUDINE SOL 1MG/ML Generic
STRIBILD TAB Brand
SYMFI LO TAB Brand QL 1 tab per day
SYMFI TAB Brand QL 1 tab per day
SYMTUZA TAB 800‐150‐200‐
10MG Brand QL 1 per day
TENOFOVIR TAB 300MG Generic
TIVICAY TAB 10MG Brand QL 1 per day
TIVICAY TAB 25MG Brand QL 1 per day
TIVICAY TAB 50MG Brand
TRIUMEQ TAB Brand QL 1 per day
TRUVADA TAB 100‐150 Brand QL 1 per day
TRUVADA TAB 133‐200 Brand QL 1 per day
TRUVADA TAB 167‐250 Brand QL 1 per day
TRUVADA TAB 200‐300 Brand QL 1 per day
TYBOST TAB 150MG Brand QL 1 per day
VIDEX SOL 2GM Brand
VIDEX SOL 4GM Brand
VIRACEPT TAB 250MG Brand
VIRACEPT TAB 625MG Brand
VIREAD TAB 150MG Brand QL 1 per day
VIREAD TAB 200MG Brand
VIREAD TAB 250MG Brand
VIREAD POW 40MG/GM Brand AR PA required > 6
VITEKTA TAB 150MG Brand QL 1 per day
VITEKTA TAB 85MG Brand QL 1 per day
ZIAGEN SOL 20MG/ML Brand
ZIDOVUDINE CAP 100MG Generic
ZIDOVUDINE TAB 300MG Generic
ZIDOVUDINE SYP 50MG/5ML Generic
INFLUENZA AGENTS OSELTAMIVIR CAP 30MG Generic QL 40 per 365 days
OSELTAMIVIR CAP 45MG Generic QL 20 per 365 days
OSELTAMIVIR CAP 75MG Generic QL 20 per 365 days
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
10
Drug Name Dosage Form/Strength Drug Type Requirements
OSELTAMIVIR SUS 6MG/ML Generic AR PA required > 8; QL 240mls per 365 days
RELENZA MIS DISKHALE Brand QL 20 per 30 days
ANTIMALARIALS CHLOROQUINE TAB 250MG Generic
CHLOROQUINE TAB 500MG Generic
COARTEM TAB 20‐120MG Brand
DARAPRIM TAB 25MG Brand
HYDROXYCHLOR TAB 200MG Generic
MEFLOQUINE TAB 250MG Generic
ANTHELMINTICS ALBENZA TAB 200MG Brand PA
IVERMECTIN TAB 3MG Generic
PINWORM TAB MEDICINE Generic
PIN‐X SUS 50MG/ML Generic
PRAZIQUANTEL TAB 600MG Generic
REESES MED SUS PINWORM Generic
ANTI‐INFECTIVE AGENTS: MISC ATOVAQUONE SUS 750/5ML Generic PA; QL 10mls per day
BENZNIDAZOLE TAB 12.5MG Brand PA
BENZNIDAZOLE TAB 100MG Brand PA
CLINDAMYCIN CAP 75MG Generic
CLINDAMYCIN CAP 150MG Generic
CLINDAMYCIN CAP 300MG Generic
CLINDAMYCIN SOL 75MG/5ML Generic AR PA required > 6
FIRVANQ SOL 25MG/ML Brand
FIRVANQ SOL 50MG/ML Brand
IMPAVIDO CAP 50MG Brand PA; QL 3 per day
LINEZOLID TAB 600MG Generic QL 14‐day supply per fill
LINEZOLID INJ 2MG/ML Generic QL 14‐day supply per fill
METRONIDAZOLE CAP 375MG Generic
METRONIDAZOLE TAB 250MG Generic
METRONIDAZOLE TAB 500MG Generic
NEBUPENT INH 300MG Brand
NEUTREXIN INJ 25MG Brand
NITROFURANTOIN MACROCRYSTALS CAP 25MG Generic AR PA required > 64
NITROFURANTOIN MACROCRYSTALS CAP 50MG Generic AR PA required > 64
NITROFURANTOIN MACROCRYSTALS CAP 100MG Generic AR PA required > 64
NITROFURANTOIN SUS 25MG/5ML Generic
NITROFURANTOIN CAP 100MG Generic AR PA required > 64
PENTAM 300 INJ 300MG Brand
SMZ/TMP DS TAB 800‐160 Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
11
Drug Name Dosage Form/Strength Drug Type Requirements
SMZ‐TMP TAB 400‐80MG Generic
SMZ‐TMP SUS 200‐40/5 Generic
SULFATRIM PD SUS 200‐40/5 Generic
SYNAGIS INJ 50MG Brand PA QL 5 fills per 6 months
SYNAGIS INJ 100MG/ML Brand PA QL 5 fills per 6 months
TRIMETHOPRIM TAB 100MG Generic
VANCOMYCIN CAP 125MG Generic
VANCOMYCIN CAP 250MG Generic
VANCOMYCIN INJ 500MG Generic
VANCOMYCIN INJ 750MG Generic
VANCOMYCIN INJ 1 GM Generic
VANCOMYCIN INJ 1000MG Generic
VANCOMYCIN INJ 5GM Generic
VANCOMYCIN INJ 10GM Generic
VANCOMYCIN (compound kit) SOL 25MG/ML Brand
VANCOMYCIN (compound kit) SOL 50MG/ML Brand
VANCOMYCIN/DEXTROSE INJ 500MG/100ML Generic
VANCOMYCIN/DEXTROSE INJ 750MG/150ML Generic
VANCOMYCIN/DEXTROSE INJ 1GM/200ML Generic
HEPATIC ENCEPHALOPATHY CONSTULOSE SOL 10GM/15 Generic
ENULOSE SOL 10GM/15 Generic
GENERLAC SOL 10GM/15 Generic
LACTULOSE SOL 10GM/15 Generic
LACTULOSE SOL 20GM/30 Generic
XIFAXAN TAB 550MG Brand PA
MONOBACTAMS CAYSTON INH 75MG Brand PA 84mls per 60 days
BIOLOGICALS (VACCINES) VACCINES AGES 18 AND YOUNGER COVERED BY VACCINES FOR CHILDREN ADACEL INJ Brand AR <19 covered by VFC
AFLURIA INJ 2018‐2019 Brand AR <19 covered by VFC
AFLURIA QUAD INJ 2018‐2019 Brand AR <19 covered by VFC
BEXSERO INJ Brand AR covered for ages 19‐25
BOOSTRIX INJ Brand AR <19 covered by VFC
DAPTACEL INJ Brand AR <19 covered by VFC
ENGERIX‐B INJ 10/0.5ML Brand AR <19 covered by VFC
ENGERIX‐B INJ 20MCG/ML Brand AR <19 covered by VFC
FLUAD INJ 2018‐2019 Brand AR covered ages >64
FLUBLOK QUAD INJ 2018‐2019 Brand AR <19 covered by VFC
FLUCELVAX QUAD INJ 2018‐19 Brand AR <19 covered by VFC
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
12
Drug Name Dosage Form/Strength Drug Type Requirements
FLULAVAL QUAD INJ 2018‐2019 Brand AR <19 covered by VFC
FLUMIST QUAD SUSP 2018‐2019 Brand AR Covered for ages 19‐49
FLUVIRIN INJ 2018‐2019 Brand AR <19 covered by VFC
FLUZONE INJ INTRADRM Brand AR <19 covered by VFC
FLUZONE HD INJ PF 2018‐2019 Brand AR < 65 not covered
FLUZONE QUAD INJ 2018‐2019 Brand AR <19 covered by VFC
GARDASIL 9 INJ Brand AR Covered for ages 19‐26
HAVRIX INJ 720UNIT Brand AR <19 covered by VFC
HAVRIX INJ 1440UNIT Brand AR <19 covered by VFC
HEPLISAV‐B INJ 20MCG Brand AR <19 covered by VFC
INFANRIX INJ Brand AR <19 covered by VFC
MENACTRA INJ Brand AR <19 covered by VFC
MENOMUNE INJ A/C/Y/W Brand AR <19 covered by VFC
MENVEO INJ Brand AR Covered for ages 19‐55
M‐M‐R II INJ Brand AR <19 covered by VFC
PNEUMOVAX 23 INJ 25/0.5 Generic AR <19 covered by VFC;
QL 0.5ml per day
PREVNAR 13 INJ Brand AR <19 covered by VFC
RECOMBIVA HB INJ 5MCG/0.5 Brand AR <19 covered by VFC
RECOMBIVA HB INJ 10MCG/ML Brand AR <19 covered by VFC
RECOMBIVA HB INJ 40MCG/ML Brand AR <19 covered by VFC
SHINGRIX INJ 50MCG Brand AR Covered ages > 50; QL
2 inj per lifetime
TRUMENBA INJ Brand AR Covered ages 19‐25
TWINRIX INJ Brand AR <19 Covered by VFC
VAQTA INJ 25/0.5ML Brand AR <19 covered by VFC
VAQTA INJ 50UNT/ML Brand AR <19 covered by VFC
VARIVAX INJ Brand AR <19 covered by VFC
ANTI‐NEOPLASTICS ANTIDOTES LEUCOVOR CA TAB 5MG Generic
LEUCOVOR CA TAB 10MG Generic
LEUCOVOR CA TAB 15MG Generic
LEUCOVOR CA TAB 25MG Generic
ANTIMETABOLITES MERCAPTOPURINE TAB 50MG Generic
METHOTREXATE INJ 100/4ML Generic
METHOTREXATE INJ 1GM Generic
METHOTREXATE INJ 1GM/40ML Generic
METHOTREXATE INJ 200/8ML Generic
METHOTREXATE INJ 250/10ML Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
13
Drug Name Dosage Form/Strength Drug Type Requirements
METHOTREXATE INJ 25MG/ML Generic
METHOTREXATE INJ 50MG/2ML Generic
METHOTREXATE TAB 2.5MG Generic
ANTINEOPLASTIC AGENTS ACTIMMUNE INJ 2MU/0.5 Brand PA
AFINITOR TAB 10MG Brand PA QL 1 per day
AFINITOR TAB 2.5MG Brand PA QL 1 per day
AFINITOR TAB 5MG Brand PA QL 2 per day
AFINITOR TAB 7.5MG Brand PA QL 1 per day
AFINITOR DIS TAB 2MG Brand PA
AFINITOR DIS TAB 2MG Brand PA
AFINITOR DIS TAB 3MG Brand PA
AFINITOR DIS TAB 5MG Brand PA
ALECENSA CAP 150MG Brand PA QL 8 per day
ALFERON N INJ 5MU/ML Brand PA
ALKERAN TAB 2MG Brand
ALUNBRIG STARTER PAK Brand PA QL 30 tabs per 180
days
ALUNBRIG 30MG Brand PA QL 2 per day
ALUNBRIG 90MG Brand PA QL 1 per day
ALUNBRIG 180MG Brand PA QL 1 per day
ANASTROZOLE TAB 1MG Generic
BICALUTAMIDE TAB 50MG Generic
BOSULIF TAB 100MG Brand PA QL 3 per day
BOSULIF TAB 400MG Brand PA QL 1 per day
BOSULIF TAB 500MG Brand PA QL 1 per day
BRAFTOVI TAB 50MG Brand PA QL 1 per day
BRAFTOVI TAB 75MG Brand PA QL 6 per day
CABOMETYX TAB 20MG Brand PA QL 1 per day
CABOMETYX TAB 40MG Brand PA QL 1 per day
CABOMETYX TAB 60MG Brand PA QL 1 per day
CALQUENCE CAP 100MG Brand PA QL 2 per day
CAPECITABINE TAB 150MG Generic
CAPECITABINE TAB 500MG Generic
CAPRELSA TAB 100MG Brand PA QL 2 per day
CAPRELSA TAB 300MG Brand PA QL 1 per day
COMETRIQ KIT 60MG Brand PA QL 3 per day
COMETRIQ KIT 100MG Brand PA QL 2 per day
COMETRIQ KIT 140MG Brand PA QL 4 per day
COTELLIC TAB 20MG Brand PA
CYCLOPHOSPH CAP 25MG Generic
CYCLOPHOSPH CAP 50MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
14
Drug Name Dosage Form/Strength Drug Type Requirements
DROXIA CAP 200MG Brand
DROXIA CAP 300MG Brand
DROXIA CAP 400MG Brand
ELIGARD INJ 22.5MG Brand PA
ELIGARD INJ 7.5MG Brand PA
EMCYT CAP 140MG Brand
ERLEADA TAB 60MG Brand PA QL 4 per day
ERIVEDGE TAB 150MG Brand PA QL 1 per day
ETOPOSIDE CAP 50MG Generic
EXEMESTANE TAB 25MG Generic
FARESTON TAB 60MG Brand
FARYDAK CAP 10MG Brand PA
FARYDAK CAP 15MG Brand PA
FARYDAK CAP 20MG Brand PA
FLUTAMIDE CAP 125MG Generic
GILOTRIF TAB 20MG Brand PA QL 1 per day
GILOTRIF TAB 30MG Brand PA QL 1 per day
GILOTRIF TAB 40mg Brand PA QL 1 per day
GLEOSTINE CAP 5MG Brand PA
GLEOSTINE CAP 10MG Brand PA
GLEOSTINE CAP 40MG Brand PA
GLEOSTINE CAP 100MG Brand PA
HEXALEN CAP 50MG Brand
HYCAMTIN CAP 0.25MG Brand
HYCAMTIN CAP 1MG Brand
HYDROXYUREA CAP 500MG Generic
IBRANCE CAP 100MG Brand PA QL 0.75/day
IBRANCE CAP 125MG Brand PA QL 0.75/day
IBRANCE CAP 75MG Brand PA QL 0.75/day
ICLUSIG TAB 15MG Brand PA
ICLUSIG TAB 45MG Brand PA
IDHIFA TAB 50MG Brand PA QL 1 per day
IDHIFA TAB 100MG Brand PA QL 1 per day
IMATINIB MESYLATE TAB 100MG Generic PA QL 2 per day
IMATINIB MESYLATE TAB 400MG Generic PA QL 1 per day
IMBRUVICA CAP 140MG Brand PA
IMBRUVICA CAP 70MG Brand PA QL 1 per day
INLYTA TAB 1MG Brand PA QL 8 per day
INLYTA TAB 5MG Brand PA QL 4 per day
INTRON A INJ 10MU Brand PA
INTRON A INJ 18MU Brand PA
INTRON A INJ 25MU Brand PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
15
Drug Name Dosage Form/Strength Drug Type Requirements
INTRON A INJ 50MU Brand PA
IRESSA TAB 250MG Brand PA QL 1 per day
JAKAFI TAB 5MG Brand PA QL 2 tabs per day
JAKAFI TAB 10MG Brand PA QL 2 tabs per day
JAKAFI TAB 15MG Brand PA QL 2 tabs per day
JAKAFI TAB 20MG Brand PA QL 2 tabs per day
JAKAFI TAB 25MG Brand PA QL 2 tabs per day
KISQALI TAB 200 DOSE Brand PA QL 2.25 per day
KISQALI TAB 400 DOSE Brand PA QL 2.25 per day
KISQALI TAB 600 DOSE Brand PA QL 2.25 per day
LENVIMA CAP 4MG Brand PA QL 1 per day
LENVIMA CAP 8MG Brand PA QL 2 per day
LENVIMA CAP 10MG Brand PA QL 1 per day
LENVIMA CAP 12MG Brand PA QL 3 per day
LENVIMA CAP 14 MG Brand PA QL 2 per day
LENVIMA CAP 18MG Brand PA QL 3 per day
LENVIMA CAP 20 MG Brand PA QL 2 per day
LENVIMA CAP 24MG Brand PA QL 3 per day
LETROZOLE TAB 2.5MG Generic
LEUKERAN TAB 2MG Brand
LEUPROLIDE INJ 1MG/0.2 Generic PA
LOMUSTINE CAP 100MG Generic
LOMUSTINE CAP 10MG Generic
LOMUSTINE CAP 40MG Generic
LONSURF TAB 15‐6.14MG Brand PA
LONSURF TAB 20‐8.19MG Brand PA
LUPANETA KIT 11.25‐5 Brand PA
LUPANETA KIT 3.75‐5 Brand PA
LUPR DEP‐PED INJ 11.25MG Brand PA
LUPR DEP‐PED INJ 15MG Brand PA
LUPR DEP‐PED INJ 30MG Brand PA QL 1 per day
LUPR DEP‐PED INJ 7.5MG Brand PA
LUPRON DEPOT INJ 11.25MG Brand PA QL 1 per 90 days
LUPRON DEPOT INJ 22.5MG Brand PA QL 1 per 90 days
LUPRON DEPOT INJ 3.75MG Brand PA
LUPRON DEPOT INJ 30MG Brand PA
LUPRON DEPOT INJ 45MG Brand PA
LUPRON DEPOT INJ 7.5MG Brand PA
LYNPARZA CAP 50MG Brand PA QL 8 per day
LYNPARZA TAB 100MG Brand PA QL 4 per day
LYNPARZA TAB 150MG Brand PA QL 4 per day
LYSODREN TAB 500MG Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
16
Drug Name Dosage Form/Strength Drug Type Requirements
MATULANE CAP 50MG Brand PA
MEGESTROL AC SUS 400MG/10 Generic AR PA required >64
MEGESTROL AC SUS 40MG/ML Generic AR PA required >64
MEGESTROL AC TAB 20MG Generic AR PA required >64
MEGESTROL AC TAB 40MG Generic AR PA required >64
MEKINIST TAB 0.5MG Brand PA QL 3 per day
MEKINIST TAB 2MG Brand PA QL 1 per day
MEKTOVI TAB 15MG Brand PA 6 per day
MYLERAN TAB 2MG Brand
NERLYNX TAB 40MG Brand PA QL 6 per day
NEXAVAR TAB 200MG Brand PA QL 4 per day
NINLARO CAP 2.3MG Brand PA QL 1 per day
NINLARO CAP 3MG Brand PA QL 1 per day
NINLARO CAP 4MG Brand PA QL 1 per day
ODOMZO CAP 200MG Brand PA QL 1 per day
POMALYST CAP 1MG Brand PA
POMALYST CAP 2MG Brand PA
POMALYST CAP 3MG Brand PA
POMALYST CAP 4MG Brand PA
REVLIMID CAP 2.5 MG Brand PA QL 1 per day
REVLIMID CAP 5 MG Brand PA QL 1 per day
REVLIMID CAP 10 MG Brand PA QL 1 per day
REVLIMID CAP 20 MG Brand PA QL 1 per day
REVLIMID CAP 25 MG Brand PA QL 1 per day
RUBRACA TAB 200MG Brand PA QL 4 per day
RUBRACA TAB 300MG Brand PA QL 4 per day
RYDAPT CAP 25MG Brand PA QL 8 per day
SPRYCEL TAB 100MG Brand PA
SPRYCEL TAB 140MG Brand PA
SPRYCEL TAB 20MG Brand PA
SPRYCEL TAB 50MG Brand PA
SPRYCEL TAB 70MG Brand PA
SPRYCEL TAB 80MG Brand PA
STIVARGA TAB 40 MG Brand PA QL 4 per day
SUTENT CAP 12.5MG Brand PA QL 1 per day
SUTENT CAP 25MG Brand PA QL 1 per day
SUTENT CAP 37.5MG Brand PA QL 1 per day
SUTENT CAP 50MG Brand PA QL 1 per day
TABLOID TAB 40MG Brand
TAFINLAR CAP 50MG Brand PA QL 4 per day
TAFINLAR CAP 75MG Brand PA QL 4 per day
TAGRISSO TAB 40MG Brand PA QL 1 per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
17
Drug Name Dosage Form/Strength Drug Type Requirements
TAGRISSO TAB 80MG Brand PA QL 1 per day
TAMOXIFEN TAB 10MG Generic
TAMOXIFEN TAB 20MG Generic
TARCEVA TAB 100MG Brand PA QL 1 per day
TARCEVA TAB 150MG Brand PA QL 1 per day
TARCEVA TAB 25MG Brand PA QL 1 per day
TASIGNA CAP 200MG Brand PA
TEMOZOLOMIDE CAP 100MG Generic PA
TEMOZOLOMIDE CAP 140MG Generic PA
TEMOZOLOMIDE CAP 180MG Generic PA
TEMOZOLOMIDE CAP 20MG Generic PA
TEMOZOLOMIDE CAP 250MG Generic PA
TEMOZOLOMIDE CAP 5MG Generic PA
TIBSOVO TAB 250MG Brand PA QL 2 per day
TRETINOIN CAP 10MG Generic
TYKERB TAB 250MG Brand PA QL 5 per day
VENCLEXTA TAB 10MG Brand PA QL 4 per day
VENCLEXTA TAB 50MG Brand PA QL 4 per day
VENCLEXTA TAB 100MG Brand PA QL 4 per day
VENCLEXTA TAB STARTER PACK Brand PA QL 1 fill per 180 days
VERZENIO TAB 50MG Brand PA QL 2 tabs per day
VERZENIO TAB 150MG Brand PA QL 2 tabs per day
VERZENIO TAB 200MG Brand PA QL 2 tabs per day
VOTRIENT TAB 200MG Brand PA QL 4 per day
XALKORI CAP 200MG Brand PA
XTANDI TAB 40MG Brand PA
ZEJULA CAP 100MG Brand PA QL 3 cap per day
ZELBORAF TAB 240MG Brand PA QL 8 per day
ZOLINZA CAP 100MG Brand PA
ZYDELIG TAB 100MG Brand PA QL 2 per day
ZYDELIG TAB 150MG Brand PA QL 2 per day
ZYKADIA CAP 150MG Brand PA QL 5 per day
ZYTIGA TAB 250MG Brand PA QL 4 per day
ZYTIGA TAB 500MG Brand PA QL 2 per day
PROGESTINS DEPO‐PROVERA INJ 400/ML Brand
HYDROXYPROG POW CAPROATE Generic
MEDROXYPR AC INJ 150MG/ML Generic QL 1 injection per 90 days
MEDROXYPR AC TAB 2.5MG Generic
MEDROXYPR AC TAB 5MG Generic
MEDROXYPR AC TAB 10MG Generic
NORETHIN ACE TAB 5MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
18
Drug Name Dosage Form/Strength Drug Type Requirements
PROGESTERONE CAP 100MG Generic
PROGESTERONE CAP 200MG Generic
ENDOCRINE AND METABOLIC DRUGS ADRENALS BAYCADRON ELX 0.5/5ML Generic
DELTASONE TAB 20MG Generic
DEXAMETHASONE ELX 0.5/5ML Generic
DEXAMETHASONE TAB 0.5MG Generic
DEXAMETHASONE TAB 0.75MG Generic
DEXAMETHASONE TAB 1MG Generic
DEXAMETHASONE TAB 1.5MG Generic
DEXAMETHASONE TAB 2MG Generic
DEXAMETHASONE TAB 4MG Generic
DEXAMETHASONE TAB 6MG Generic
DEXAMETHASONE ELX 0.5/5ML Generic
DEXAMETHASONE CON 1MG/ML Brand
DEXAMETHASONE SOL 0.5/5ML Generic
FLUDROCORTISONE TAB 0.1MG Generic
HYDROCORTISONE TAB 10MG Generic
HYDROCORTISONE TAB 5MG Generic
HYDROCORTISONE TAB 20MG Generic
METHYLPREDNISOLONE TAB 4MG Generic
METHYLPREDNISOLONE TAB 8MG Generic
METHYLPREDNISOLONE TAB 16MG Generic
METHYLPREDNISOLONE TAB 32MG Generic
METHYLPREDNISOLONE PAK 4MG Generic
PREDNISOLONE SODIUM PHOSPHATE SOL 5MG/5ML Generic
PREDNISOLONE SODIUM PHOSPHATE SOL 5MG/5ML Generic
PREDNISOLONE SOL 15MG/5ML Generic
PREDNISOLONE SYP 15MG/5ML Generic
PREDNISONE TAB 1MG Generic
PREDNISONE TAB 2.5MG Generic
PREDNISONE TAB 5MG Generic
PREDNISONE TAB 10MG Generic
PREDNISONE TAB 20MG Generic
PREDNISONE TAB 50MG Generic
PREDNISONE SOL 5MG/5ML Generic
PREDNISONE PAK 5MG Generic
PREDNISONE PAK 10MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
19
Drug Name Dosage Form/Strength Drug Type Requirements
ANDROGENS ANDRODERM DIS 4MG/24HR Brand PA
ANDRODERM DIS 2MG/24HR Brand PA
DANAZOL CAP 50MG Generic
DANAZOL CAP 100MG Generic
DANAZOL CAP 200MG Generic
FIRST‐TESTOSTERONE OIN 2% Brand PA
METHITEST TAB 10MG Brand PA
OXANDROLONE TAB 2.5MG Generic PA
TESTIM GEL 1%(50MG) Brand PA
TESTOSTERONE CYPIONATE INJ 100MG/ML Generic QL 91‐day supply available
TESTOSTERONE CYPIONATE INJ 200MG/ML Generic QL 91‐day supply
available
TESTOSTERONE ENATHATE INJ 200MG/ML Generic QL 91‐day supply
available
TESTOSTERONE GEL 1%(25MG) Generic PA
TESTOSTERONE GEL 1%(50MG) Generic PA
TESTOSTERONE GEL PUMP 1% Generic PA
TESTOSTERONE INJ 250MG/ML Generic PA
VOGELXO GEL 1%(50MG) Brand PA
VOGELXO GEL PUMP 1% Brand PA
ESTROGENS COMBIPATCH DIS .05/.14 Brand
COMBIPATCH DIS .05/.25 Brand
ESTRADIOL CRE 0.1MG/GM Generic
ESTRADIOL TAB 0.5MG Generic AR PA required >64
ESTRADIOL TAB 1MG Generic AR PA required >64
ESTRADIOL TAB 2MG Generic AR PA required >64
ESTRADIOL (Generic Climara) PATCH WKLY 0.025MG Generic QL 4 per month AR PA
required >64
ESTRADIOL (Generic Climara) PATCH WKLY 0.0375MG Generic
QL 4 per month AR PA required >64
ESTRADIOL (Generic Climara) PATCH WKLY 0.05MG Generic QL 4 per month AR PA
required >64
ESTRADIOL (Generic Climara) PATCH WKLY 0.06MG Generic QL 4 per month AR PA
required >64
ESTRADIOL (Generic Climara) PATCH WKLY 0.075MG Generic QL 4 per month AR PA
required >64
ESTRADIOL (Generic Climara) PATCH WKLY 0.1MG Generic QL 4 per month AR PA
required >64
ESTRADIOL (Generic Vivelle Dot) PATCH TW 0.025MG Generic QL 8 per month; AR PA
required >64
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
20
Drug Name Dosage Form/Strength Drug Type Requirements
ESTRADIOL (Generic Vivelle Dot) PATCH TW 0.0375MG Generic QL 8 per month; AR PA
required >64
ESTRADIOL (Generic Vivelle Dot) PATCH TW 0.05MG Generic QL 8 per month; AR PA
required >64
ESTRADIOL (Generic Vivelle Dot) PATCH TW 0.075MG Generic QL 8 per month; AR PA
required >64
ESTRADIOL (Generic Vivelle Dot) PATCH TW 0.1MG Generic QL 8 per month; AR PA
required >64
ESTRADIOL VALERATE INJ 10MG/ML Generic AR PA required >64
ESTRADIOL VALERATE INJ 200MG/5 Generic AR PA required >64
ESTRADIOL VALERATE INJ 20MG/ML Generic AR PA required >64
ESTRADIOL VALERATE INJ 40MG/ML Generic AR PA required >64
DEPO‐ESTRADIOL INJ 5MG/ML Brand AR PA required >64
ESTRING MIS 2MG Brand AR PA required >64
ESTROPIPATE TAB 0.75MG Generic AR PA required >64
ESTROPIPATE TAB 1.5MG Generic AR PA required >64
ESTROPIPATE TAB 3MG Generic AR PA required >64
MENEST TAB 0.3MG Brand AR PA required >64
MENEST TAB 0.625MG Brand AR PA required >64
MENEST TAB 1.25MG Brand AR PA required >64
MENEST TAB 2.5MG Brand AR PA required >64
ORTHO‐EST TAB 0.625 Generic AR PA required >64
ORTHO‐EST TAB 1.25 Generic AR PA required >64
PREMARIN VAG CRE 0.625MG Brand QL 1 per day
YUVAFEM TAB 10MCG Generic
CONTRACEPTIVES *unless otherwise stated: generics QL max 91‐day supply first fill;
future fills up to 12‐month supply. Brands QL max 91‐day supply all fills
AFTERA TAB 1.5MG Generic *QL
ALTAVERA TAB Generic *QL
ALYACEN TAB 1/35 Generic *QL
ALYACEN TAB 7/7/7 Generic *QL
AMETHIA TAB Generic *QL
AMETHIA LO TAB Generic *QL
AMETHYST TAB 90‐20MCG Generic *QL
APRI TAB Generic *QL
ARANELLE TAB Generic *QL
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
21
Drug Name Dosage Form/Strength Drug Type Requirements
ASHLYNA TAB Generic *QL
AUBRA TAB 0.1‐0.02 Generic *QL
AVIANE TAB Generic *QL
AZURETTE TAB 28‐DAY Generic *QL
BALZIVA TAB Generic *QL
BRIELLYN TAB Generic *QL
CAMILA TAB 0.35MG Generic *QL
CAMRESE TAB Generic *QL
CAMRESE LO TAB Generic *QL
CAZIANT PAK Generic *QL
CESIA PAK Generic *QL
CHATEAL TAB 0.15/30 Generic *QL
CRYSELLE‐28 TAB 28 TABS Generic *QL
CYCLAFEM TAB 1/35 Generic *QL
CYCLAFEM TAB 7/7/7 Generic *QL
CYRED TAB Generic *QL
DASETTA TAB 1/35 Generic *QL
DASETTA TAB 7/7/7 Generic *QL
DAYSEE TAB Generic *QL
DEBLITANE TAB 0.35MG Generic *QL
DELYLA TAB 0.1‐0.02 Generic *QL
DESO/ETHINYL TAB ESTRADIO Generic *QL
DROSPIR/ETHI TAB 3‐0.03MG Generic *QL
DROSPIRE/ETH TAB ESTR/LEV TAB Generic *QL
DROSPIRENONE TAB ETHY EST Generic *QL
ECONTRA EZ TAB 1.5MG Generic *QL
ELINEST TAB Generic *QL
ELLA TAB 30MG Brand QL 3 tabs per 31 days
EMOQUETTE TAB Generic *QL
ENPRESSE‐28 TAB Generic *QL
ENSKYCE TAB Generic *QL
ERRIN TAB 0.35MG Generic *QL
ESTARYLLA TAB 0.25‐35 Generic *QL
FALLBACK TAB 1.5MG Generic *QL
FALMINA TAB Generic *QL
FAYOSIM TAB Generic *QL
GIANVI TAB 3‐0.02MG Generic *QL
GILDAGIA TAB 0.4‐35 Generic *QL
GILDESS TAB 1/20 Generic *QL
GILDESS TAB 1.5/30 Generic *QL
GILDESS 24 TAB FE 1/20 Generic *QL
GILDESS FE TAB 1/20 Generic *QL
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
22
Drug Name Dosage Form/Strength Drug Type Requirements
GILDESS FE TAB 1.5/30 Generic *QL
HEATHER TAB 0.35MG Generic *QL
IMPLANON IMP 68MG Brand
INTROVALE TAB Generic *QL
JENCYCLA TAB 0.35MG Generic *QL
JOLESSA TAB Generic *QL
JOLIVETTE TAB 0.35MG Generic *QL
JULEBER TAB Generic *QL
JUNEL 1.5/30 TAB Generic *QL
JUNEL 1/20 TAB Generic *QL
JUNEL FE TAB 1/20 Generic *QL
JUNEL FE TAB 1.5/30 Generic *QL
JUNEL FE 24 TAB 1/20 Generic *QL
KARIVA TAB 28‐DAY Generic *QL
KELNOR TAB 1/35 Generic *QL
KIMIDESS TAB Generic *QL
KURVELO TAB 0.15/30 Generic *QL
LARIN TAB 1/20 Generic *QL
LARIN TAB 1.5/30 Generic *QL
LARIN 24 TAB FE 1/20 Generic *QL
LARIN FE TAB 1/20 Generic *QL
LARIN FE TAB 1.5/30 Generic *QL
LAYOLIS FE CHW Generic *QL
LEENA TAB Generic *QL
LESSINA TAB Generic *QL
LEVO‐ETH EST TAB 90‐20MCG Generic *QL
LEVONEST TAB Generic *QL
LEVONOR/ETHI TAB 0.1‐0.02 Generic *QL
LEVONOR/ETHI TAB ESTRADIO Generic *QL
LEVONORGESTR TAB 0.75MG Generic *QL
LEVONORGESTR TAB 1.5MG Generic *QL
LEVORA‐28 TAB 0.15/30 Generic *QL
LO LOESTRIN TAB Brand *QL
LO MINASTRIN PAK FE Brand *QL
LOMEDIA 24 TAB FE Generic *QL
LORYNA TAB 3‐0.02MG Generic *QL
LOW‐OGESTREL TAB Generic *QL
LUTERA TAB Generic *QL
LYZA TAB 0.35MG Generic *QL
MARLISSA TAB 0.15/30 Generic *QL
MIBELAS 24 CHW FE Generic *QL
MICROGESTIN TAB 1/20 Generic *QL
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
23
Drug Name Dosage Form/Strength Drug Type Requirements
MICROGESTIN TAB 1.5/30 Generic *QL
MICROGESTIN TAB FE 1/20 Generic *QL
MICROGESTIN TAB FE1.5/30 Generic *QL
MONO‐LINYAH TAB 0.25‐35 Generic *QL
MONONESSA TAB Generic *QL
MY WAY TAB 1.5MG Generic *QL
MYZILRA TAB Generic *QL
NECON TAB 0.5/35 Generic *QL
NECON TAB 1/35 Generic *QL
NECON TAB 1/50‐28 Generic *QL
NECON TAB 10/11‐28 Generic *QL
NECON TAB 7/7/7 Generic *QL
NEXT CHOICE TAB 1.5MG Generic *QL
NIKKI TAB 3‐0.02MG Generic *QL
NORA‐BE TAB 0.35MG Generic *QL
NORETH/ETHIN TAB 1/20 Generic *QL
NORETH/ETHIN CHW FE Generic *QL
NORETH/ETHIN TAB FE 1/20 Generic *QL
NORETHINDRON TAB 0.35MG Generic *QL
NORGEST/ETHI TAB 0.25/35 Generic *QL
NORGEST/ETHI TAB ESTRADIO Generic *QL
NORINYL TAB 1+50‐28 Generic *QL
NORLYROC TAB 0.35MG Generic *QL
NORTREL TAB 0.5/35 Generic *QL
NORTREL TAB 1/35 Generic *QL
NORTREL TAB 7/7/7 Generic *QL
NUVARING MIS Brand *QL
OCELLA TAB 3‐0.03MG Generic *QL
OGESTREL TAB Generic *QL
OPCICON TAB 1.5MG Generic *QL
ORSYTHIA TAB Generic *QL
ORTHO TRI‐CYCLN LO TAB Generic *QL
PHILITH TAB 0.4‐35 Generic *QL
PIMTREA TAB Generic *QL
PIRMELLA TAB 1/35 Generic *QL
PIRMELLA TAB 7/7/7 Generic *QL
PLAN B TAB 0.75MG Brand QL 6 tabs per 31 days
PLAN B TAB 1.5MG Brand QL 3 tabs per 31 days
PORTIA‐28 TAB Generic *QL
PREVIFEM TAB Generic *QL
QUASENSE TAB Generic *QL
RAJANI TAB Generic *QL
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
24
Drug Name Dosage Form/Strength Drug Type Requirements
RECLIPSEN TAB Generic *QL
RIVELSA TAB Generic *QL
SAFYRAL TAB Brand *QL
SETLAKIN TAB Generic *QL
SHAROBEL TAB 0.35MG Generic *QL
SOLIA TAB Generic *QL
SPRINTEC 28 TAB 28‐DAY Generic *QL
SRONYX TAB Generic *QL
SYEDA TAB 3‐0.03MG Generic *QL
TAKE ACTION TAB 1.5MG Generic *QL
TARINA FE TAB 1/20 Generic *QL
TILIA FE TAB Generic *QL
TRI‐ESTARYLL TAB Generic *QL
TRI‐LEGEST TAB FE Generic *QL
TRI‐LINYAH TAB Generic *QL
TRINESSA TAB Generic *QL
TRI‐PREVIFEM TAB Generic *QL
TRI‐SPRINTEC TAB Generic *QL
TRIVORA‐28 TAB Generic *QL
VELIVET PAK Generic *QL
VESTURA TAB 3‐0.02MG Generic *QL
VIORELE TAB Generic *QL
VYFEMLA TAB 0.4‐35 Generic *QL
WERA TAB 0.5/35 Generic *QL
WYMZYA FE CHW 0.4MG‐35 Generic *QL
XULANE DIS 150‐35 Generic *QL
ZARAH TAB 3‐0.03MG Generic *QL
ZENCHENT TAB Generic *QL
ZENCHENT FE CHW 0.4MG‐35 Generic *QL
ZOVIA TAB 1/35E Generic *QL
ZOVIA TAB 1/50E Generic *QL
ALPHA‐GLUCOSIDASE INHIBITORS ACARBOSE TAB 50MG Generic QL 3 per day
ACARBOSE TAB 100MG Generic QL 3 per day
ACARBOSE TAB 25MG Generic QL 3 per day
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS DEX4 CHW 1GM Brand
DEX4 GLUCOSE CHW QK DISLV Brand
GLUCOSE CHW 4GM various
flavors Generic
GLUCOSE BITS CHW 1GM Brand
GLUTOSE 15 GEL 40% Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
25
Drug Name Dosage Form/Strength Drug Type Requirements
GLUTOSE 45 GEL 40% Generic
INSTA‐GLUCOS GEL 77.4% Brand
PROGLYCEM SUS 50MG/ML Brand
BIGUANIDES METFORMIN TAB 500MG Generic
METFORMIN TAB 850MG Generic
METFORMIN TAB 1000MG Generic
METFORMIN TAB 500MG ER Generic
METFORMIN TAB 750MG ER Generic
COMBO ANTI‐DIABETIC GLIPIZIDE/METFORMIN TAB 2.5‐250M Generic
GLIPIZIDE/METFORMIN TAB 2.5‐500M Generic
GLIPIZIDE/METFORMIN TAB 5‐500MG Generic
GLYBURIDE/METFORMIN TAB 1.25‐250 Generic AR PA required > 64
GLYBURIDE/METFORMIN TAB 2.5‐500 Generic AR PA required > 64
GLYBURIDE/METFORMIN TAB 5‐500MG Generic AR PA required > 64
PIOGLITAZONE/METFORMIN TAB 15‐500MG Generic QL 3 per day
PIOGLITAZONE/METFORMIN TAB 15‐850MG Generic QL 3 per day
GLUCAGON GLUCAGEN INJ HYPOKIT Brand
GLUCAGON KIT 1MG Brand
INCRETIN MIMETICS ADLYXIN INJ 20MCG Brand PA; QL 0.215mls per day
ADLYXIN INJ 10/20MCG Brand PA; QL 6 per 180 days
BYDUREON INJ Brand PA QL 0.143mls per day
BYDUREON INJ BCISE Brand PA QL 0.122mls per day
BYETTA INJ 10MCG Brand PA QL 2.4mls per month
BYETTA INJ 5MCG Brand PA QL 1.2mls per month
TANZEUM INJ 30MG Brand PA QL 0.143mls per day
TANZEUM INJ 50MG Brand PA QL 0.143mls per day
VICTOZA INJ 18MG/3ML Brand PA QL 0.3mls per day
INSULINS ADMELOG INJ 100U/ML Brand
ADMELOG SOLO INJ 100U/ML Brand PA
BASAGLAR INJ 100U Brand
HUMALOG MIX INJ 50/50 Brand
HUMALOG MIX INJ 50/50KWP Brand PA
HUMALOG MIX INJ 75/25KWP Brand PA
HUMALOG MIX SUS 75/25 Brand
HUMULIN INJ 70/30 Brand
HUMULIN INJ 70/30KWP Brand PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
26
Drug Name Dosage Form/Strength Drug Type Requirements
HUMULIN N INJ U‐100 Brand
HUMULIN N INJ U‐100KWP Brand PA
HUMULIN N PN INJ U‐100 Brand PA
HUMULIN PEN INJ 70/30 Brand PA
HUMULIN R INJ U‐100 Brand
HUMULIN R INJ 5‐500 (pens) Brand PA
NOVOLIN INJ 70/30 Brand
NOVOLIN N INJ RELION Brand
NOVOLIN N INJ U‐100 Brand
NOVOLIN R INJ RELION Brand
NOVOLIN R INJ U‐100 Brand
NOVOLIN 70/30 INJ RELION Brand
NOVOLOG MIX INJ 70/30 Brand
NOVOLOG MIX INJ FLEXPEN Brand PA
RELION R INJ 100/ML Brand
SOLIQUA INJ 10/33 Brand PA
TOUJEO SOLO INJ 300IU/ML Brand PA
DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS ALOGLIPTIN TAB 6.25MG Brand PA
ALOGLIPTIN TAB 12.5MG Brand PA
ALOGLIPTIN TAB 25MG Brand PA
MEGLITINIDES NATEGLINIDE TAB 60MG Generic
NATEGLINIDE TAB 120MG Generic
SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB STEGLATRO TAB 5MG Brand PA QL 1 per day
STEGLATRO TAB 15MG Brand PA QL 1 per day
SEGLUROMET TAB 2.5‐500MG Brand PA QL 2 per day
SEGLUROMET TAB 2.5‐1000MG Brand PA QL 2 per day
SEGLUROMET TAB 7.5‐500MG Brand PA QL 2 per day
SEGLUROMET TAB 7.5‐1000MG Brand PA QL 2 per day
SULFONYLUREAS GLIMEPIRIDE TAB 1MG Generic QL 2 per day
GLIMEPIRIDE TAB 2MG Generic QL 2 per day
GLIMEPIRIDE TAB 4MG Generic QL 2 per day
GLIPIZIDE TAB 5MG Generic
GLIPIZIDE TAB 10MG Generic
GLIPIZIDE ER TAB 2.5MG Generic
GLIPIZIDE ER TAB 5MG Generic
GLIPIZIDE ER TAB 10MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
27
Drug Name Dosage Form/Strength Drug Type Requirements
GLIPIZIDE XL TAB 2.5MG Generic
GLIPIZIDE XL TAB 5MG Generic
GLIPIZIDE XL TAB 10MG Generic
GLYBURID MCR TAB 1.5MG Generic AR PA required > 64
GLYBURID MCR TAB 3MG Generic AR PA required > 64
GLYBURID MCR TAB 6MG Generic AR PA required > 64
GLYBURIDE TAB 1.25MG Generic AR PA required > 64
GLYBURIDE TAB 2.5MG Generic AR PA required > 64
GLYBURIDE TAB 5MG Generic AR PA required > 64
TOLAZAMIDE TAB 250MG Generic
THIAZOLIDINEDIONES PIOGLITAZONE TAB 15MG Generic QL 1 per day
PIOGLITAZONE TAB 30MG Generic QL 1 per day
PIOGLITAZONE TAB 45MG Generic QL 1 per day
ANTITHYROID AGENTS METHIMAZOLE TAB 5MG Generic
METHIMAZOLE TAB 10MG Generic
PROPYLTHIOUR TAB 50MG Generic
SSKI SOL 1GM/ML Brand
THYROID AGENTS ARMOUR THYROID TAB 15MG Brand AR PA required > 64
ARMOUR THYROID TAB 30MG Brand AR PA required > 64
ARMOUR THYROID TAB 60MG Brand AR PA required > 64
ARMOUR THYROID TAB 90MG Brand AR PA required > 64
ARMOUR THYROID TAB 120MG Brand AR PA required > 64
ARMOUR THYROID TAB 180MG Brand AR PA required > 64
ARMOUR THYROID TAB 240MG Brand AR PA required > 64
ARMOUR THYROID TAB 300MG Brand AR PA required > 64
LEVOTHYROXINE TAB 25MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 50MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 75MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 88MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 100MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 112MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 125MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 137MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 150MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 175MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 200MCG Generic QL 90‐day fill available
LEVOTHYROXINE TAB 300MCG Generic QL 90‐day fill available
LEVOXYL TAB 25MCG Generic QL 90‐day fill available
LEVOXYL TAB 50MCG Generic QL 90‐day fill available
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
28
Drug Name Dosage Form/Strength Drug Type Requirements
LEVOXYL TAB 75MCG Generic QL 90‐day fill available
LEVOXYL TAB 88MCG Generic QL 90‐day fill available
LEVOXYL TAB 100MCG Generic QL 90‐day fill available
LEVOXYL TAB 112MCG Generic QL 90‐day fill available
LEVOXYL TAB 125MCG Generic QL 90‐day fill available
LEVOXYL TAB 137MCG Generic QL 90‐day fill available
LEVOXYL TAB 150MCG Generic QL 90‐day fill available
LEVOXYL TAB 175MCG Generic QL 90‐day fill available
LEVOXYL TAB 200MCG Generic QL 90‐day fill available
LIOTHYRONINE TAB 5MCG Generic
LIOTHYRONINE TAB 25MCG Generic
LIOTHYRONINE TAB 50MCG Generic
NP THYROID TAB 30MG Generic AR PA required > 64
NP THYROID TAB 60MG Generic AR PA required > 64
NP THYROID TAB 90MG Generic AR PA required > 64
SYNTHROID TAB 25MCG Brand QL 90‐day fill available
SYNTHROID TAB 50MCG Brand QL 90‐day fill available
SYNTHROID TAB 75MCG Brand QL 90‐day fill available
SYNTHROID TAB 88MCG Brand QL 90‐day fill available
SYNTHROID TAB 100MCG Brand QL 90‐day fill available
SYNTHROID TAB 112MCG Brand QL 90‐day fill available
SYNTHROID TAB 125MCG Brand QL 90‐day fill available
SYNTHROID TAB 137MCG Brand QL 90‐day fill available
SYNTHROID TAB 150MCG Brand QL 90‐day fill available
SYNTHROID TAB 175MCG Brand QL 90‐day fill available
SYNTHROID TAB 200MCG Brand QL 90‐day fill available
SYNTHROID TAB 300MCG Brand QL 90‐day fill available
THYROLAR‐1 TAB 60MG Brand
THYROLAR‐1/2 TAB 30MG Brand
THYROLAR‐1/4 TAB 15MG Brand
THYROLAR‐2 TAB 120MG Brand
THYROLAR‐3 TAB 180MG Brand
UNITHROID DIRECT TAB 25MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 50MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 75MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 88MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 100MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 112MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 125MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 150MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 175MCG Generic QL 90‐day fill available
UNITHROID DIRECT TAB 200MCG Generic QL 90‐day fill available
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
29
Drug Name Dosage Form/Strength Drug Type Requirements
UNITHROID DIRECT TAB 300MCG Generic QL 90‐day fill available
UNITHROID TAB 25MCG Generic QL 90‐day fill available
UNITHROID TAB 50MCG Generic QL 90‐day fill available
UNITHROID TAB 75MCG Generic QL 90‐day fill available
UNITHROID TAB 88MCG Generic QL 90‐day fill available
UNITHROID TAB 100MCG Generic QL 90‐day fill available
UNITHROID TAB 112MCG Generic QL 90‐day fill available
UNITHROID TAB 125MCG Generic QL 90‐day fill available
UNITHROID TAB 137MCG Generic QL 90‐day fill available
UNITHROID TAB 150MCG Generic QL 90‐day fill available
UNITHROID TAB 175MCG Generic QL 90‐day fill available
UNITHROID TAB 200MCG Generic QL 90‐day fill available
UNITHROID TAB 300MCG Generic QL 90‐day fill available
OXYTOCICS METHYLERGON TAB 0.2MG Generic
ERGOT‐DERIV. DOPAMINE RECEPTOR AGONISTS CABERGOLINE TAB 0.5MG Generic QL 20 per month
ESTROGEN AGONIST‐ANTAGONISTS RALOXIFENE TAB 60MG Generic
OSTEOPOROSIS ALENDRONATE TAB 5MG Generic QL 1 per day
ALENDRONATE TAB 10MG Generic QL 1 per day
ALENDRONATE TAB 35MG Generic QL 4 per 30 days
ALENDRONATE TAB 40MG Generic QL 1 per day
ALENDRONATE TAB 70MG Generic QL 4 per 30 days
CALCITONIN SPR 200/ACT Generic QL 3.7mls per 30 days
ETIDRONATE DISODIUM TAB 200MG Generic
ETIDRONATE DISODIUM TAB 400MG Generic
IBANDRONATE TAB 150MG Generic QL 1 per 30 days
RISEDRONATE TAB 5MG Generic ST (Alendronate) QL 1 per day
RISEDRONATE TAB 30MG Generic ST (Alendronate) QL 1 per day
RISEDRONATE TAB 35MG Generic ST (Alendronate) QL 4 per 30 days
RISEDRONATE TAB 150MG Generic ST (Alendronate) QL 4 per 30 days
TYMLOS INJ Brand PA QL 0.052ml per day
OTHER MISCELLANEOUS THERAPEUTIC AGENTS FISH OIL CAP 1000MG Generic
FISH OIL CAP 1200MG Generic
FISH OIL CAP 500MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
30
Drug Name Dosage Form/Strength Drug Type Requirements
FISH OIL CAP 300MG Generic
FISH OIL CAP 435MG Generic
FISH OIL CAP 900MG Brand
JYNARQUE PAK 45‐15MG Brand PA QL 2 per day
JYNARQUE PAK 60‐30MG Brand PA QL 2 per day
JYNARQUE PAK 90‐30MG Brand PA QL 2 per day
KUVAN POW 100MG Brand PA
KUVAN POW 500MG Brand PA
KUVAN TAB 100MG Brand PA
LEVOCARNITINE TAB 330MG Generic
LEVOCARNITINE SOL 1GM/10ML Generic
OMEGA III CAP EPA+DHA Generic
SAM‐E.P.A. CAP 500MG Generic
SENSIPAR TAB 30MG Brand
SENSIPAR TAB 60MG Brand
SENSIPAR TAB 90MG Brand
SUPER DHA CAP GEMS Generic
SUPER OMEGA CAP 500MG Generic
SUPER OMEGA CAP ‐3 Generic
SUPER OMEGA CAP‐EPA Generic
PITUITARY DESMOPRESSIN TAB 0.1MG Generic PA
DESMOPRESSIN TAB 0.2MG Generic PA
DESMOPRESSIN INJ 4MCG/ML Generic PA
DESMOPRESSIN SOL 0.01% Generic PA
DESMOPRESSIN SPR 0.01% Generic PA
SOMATOTROPIN AGONISTS GENOTROPIN INJ 5MG Brand PA
GENOTROPIN INJ 12MG Brand PA
GENOTROPIN INJ 0.2MG Brand PA
GENOTROPIN INJ 0.4MG Brand PA
GENOTROPIN INJ 0.6MG Brand PA
GENOTROPIN INJ 0.8MG Brand PA
GENOTROPIN INJ 1MG Brand PA
GENOTROPIN INJ 1.2MG Brand PA
GENOTROPIN INJ 1.4MG Brand PA
GENOTROPIN INJ 1.6MG Brand PA
GENOTROPIN INJ 1.8MG Brand PA
GENOTROPIN INJ 2MG Brand PA
HUMATROPE INJ 5MG Brand PA
HUMATROPE INJ 6MG Brand PA
HUMATROPE INJ 12MG Brand PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
31
Drug Name Dosage Form/Strength Drug Type Requirements
HUMATROPE INJ 24MG Brand PA
INCRELEX INJ 40MG/4ML Brand PA
NORDITROPIN INJ 5/1.5ML Brand PA
NORDITROPIN INJ 10/1.5ML Brand PA
NORDITROPIN INJ 15/1.5ML Brand PA
NORDITROPIN INJ 30/3ML Brand PA
NUTROPIN INJ 10MG Brand PA
NUTROPIN AQ INJ NUSPIN 5 Brand PA
NUTROPIN AQ INJ 10MG/2ML Brand PA
OCTREOTIDE INJ 100MCG Generic PA
OCTREOTIDE INJ 1000MCG Generic PA
OMNITROPE INJ 5/1.5ML Brand PA
OMNITROPE INJ 10/1.5ML Brand PA
OMNITROPE INJ 5.8MG Brand PA
SIGNIFOR INJ 0.3MG/ML Brand PA
SIGNIFOR INJ 0.6MG/ML Brand PA
SIGNIFOR INJ 0.9MG/ML Brand PA
TEV‐TROPIN INJ 5MG Brand PA
ZOMACTON INJ 5MG Brand PA
ZOMACTON INJ 10MG Brand PA
SOMATOTROPIN ANTAGONISTS SOMAVERT INJ 10MG Brand PA
SOMAVERT INJ 15MG Brand PA
SOMAVERT INJ 20MG Brand PA
SOMAVERT INJ 25MG Brand PA
SOMAVERT INJ 30MG Brand PA
VITAMIN D CALCITRIOL CAP 0.25MCG Generic
CALCITRIOL CAP 0.5MCG Generic
CALCITRIOL SOL 1MCG/ML Generic
CHILD VIT D CHW 400UNIT Generic
D 400 CHW 400UNIT Generic
D‐3 GUMMY CHW 400UNIT Generic
D3 KIDS CHW 400UNIT Generic
D‐VI‐SOL LIQ 400UNIT Brand
D‐VITA LIQ 400UNIT Generic
ERGOCALCIFER DRO 8000/ML Generic
ERGOCALCIFER SOL 8000/ML Generic
JUST D LIQ 400UNIT Generic
PARICALCITOL CAP 1 MCG Generic PA QL 15 per 31 days
PARICALCITOL CAP 2 MCG Generic PA QL 15 per 31 days
PARICALCITOL CAP 4 MCG Generic PA QL 15 per 31 days
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
32
Drug Name Dosage Form/Strength Drug Type Requirements
PHYTONADIONE TAB 5MG Generic QL 5 tabs per fill; ST
(warfarin)
THERA‐D TAB 4000UNIT Brand
VITAJOY DALY CHW D 1000IU Generic
VITAMIN D CHW 400UNIT Generic
VITAMIN D TAB 5000IU Generic
VITAMIN D3 TAB 1000UNIT Generic
VITAMIN D3 TAB 2000UNIT Generic
VITAMIN D3 TAB 3000UNIT Generic
VITAMIN D3 TAB 400UNIT Generic
VITAMIN D3 TAB 5000UNIT Generic
VITAMIN D3 TAB 50000UNIT Brand
VITAMIN D3 CAP 400UNIT Generic
VITAMIN D3 CAP 5000UNIT Generic
VITAMIN D3 CAP 10000UNT Generic
VITAMIN D3 CAP 2000UNIT Generic
VITAMIN D3 CHW 1000UNIT Generic
VITAMIN D3 CHW 400UNIT Generic
VITAMIN D3 DRO 400UNIT Generic
VIT D GUMMIE CHW 400UNIT Generic
CARDIOVASCULAR AGENTSCARDIOTONIC AGENTS DIGITEK TAB 0.125MG Generic QL 90‐day fill available
DIGITEK TAB 0.25MG Generic QL 90‐day fill available; PA
required > 64
DIGOX TAB 0.125MG Generic QL 90‐day fill available
DIGOX TAB 0.25MG Generic QL 90‐day fill available; PA
required > 64
DIGOXIN TAB 0.125MG Generic QL 90‐day fill available
DIGOXIN TAB 0.25MG Generic QL 90‐day fill available; PA
required > 64
DIGOXIN SOL 50MCG/ML Generic QL 90‐day fill available
CARDIAC DRUGS, MISCELLANEOUS CORLANOR TAB 5MG Brand QL 2 per day
CORLANOR TAB 7.5MG Brand QL 2 per day
ENTRESTO TAB 24‐26MG Brand PA QL 2 per day
ENTRESTO TAB 49‐51MG Brand PA QL 2 per day
ENTRESTO TAB 97‐103MG Brand PA QL 2 per day
RANEXA TAB 500MG Brand
RANEXA TAB 1000MG Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
33
Drug Name Dosage Form/Strength Drug Type Requirements
NITRATES AND NITRITES DILATRATE SR CAP 40MG Brand
ISORDIL TAB 40MG Brand
ISOSORBIDE DINITRATE TAB 5MG Generic
ISOSORBIDE DINITRATE TAB 10MG Generic
ISOSORBIDE DINITRATE TAB 20MG Generic
ISOSORBIDE DINITRATE TAB 30MG Generic
ISOSORBIDE DINITRATE TAB 40MG ER Generic
ISOSORBIDE MONONITRATE TAB 10MG Generic
ISOSORBIDE MONONITRATE TAB 20MG Generic
ISOSORBIDE MONONITRATE TAB 30MG ER Generic
ISOSORBIDE MONONITRATE TAB 60MG ER Generic
ISOSORBIDE MONONITRATE TAB 120MG ER Generic
MINITRAN DIS 0.1MG/HR Generic
MINITRAN DIS 0.2MG/HR Generic
MINITRAN DIS 0.4MG/HR Generic
MINITRAN DIS 0.6MG/HR Generic
NITRO‐BID OIN 2% Brand
NITRO‐DUR DIS 0.3MG/HR Brand
NITRO‐DUR DIS 0.8MG/HR Brand
NITROGLYCERIN INJ 5MG/ML Generic
NITROGLYCERIN DIS 0.1MG/HR Generic
NITROGLYCERIN DIS 0.2MG/HR Generic
NITROGLYCERIN DIS 0.4MG/HR Generic
NITROGLYCERIN DIS 0.6MG/HR Generic
NITROGLYCERIN SPR 0.4MG Generic
NITROGLYCERIN SPR LINGUAL Generic
NITROGLYCERIN SUB 0.3MG Generic
NITROGLYCERIN SUB 0.4MG Generic
NITROGLYCERIN SUB 0.6MG Generic
BETA‐ADRENERGIC BLOCKING AGENTS ACEBUTOLOL CAP 200MG Generic
ACEBUTOLOL CAP 400MG Generic
ATENOLOL TAB 25MG Generic QL 90‐day supply available
ATENOLOL TAB 50MG Generic QL 90‐day supply available
ATENOLOL TAB 100MG Generic QL 90‐day supply available
CARVEDILOL TAB 3.125MG Generic
CARVEDILOL TAB 6.25MG Generic
CARVEDILOL TAB 12.5MG Generic
CARVEDILOL TAB 25MG Generic
LABETALOL TAB 100MG Generic
LABETALOL TAB 200MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
34
Drug Name Dosage Form/Strength Drug Type Requirements
LABETALOL TAB 300MG Generic
METOPROLOL TARTRATE TAB 25MG Generic QL 90‐day supply available
METOPROLOL TARTRATE TAB 50MG Generic QL 90‐day supply available
METOPROLOL TARTRATE TAB 100MG Generic QL 90‐day supply available
METOPROLOL TAB 25MG ER Generic QL 90‐day supply available
METOPROLOL TAB 50MG ER Generic QL 90‐day supply available
METOPROLOL TAB 100MG ER Generic QL 90‐day supply available
METOPROLOL TAB 200MG ER Generic QL 90‐day supply available
NADOLOL TAB 20MG Generic
NADOLOL TAB 40MG Generic
NADOLOL TAB 80MG Generic
PINDOLOL TAB 10MG Generic
PINDOLOL TAB 5MG Generic
PROPRANOLOL CAP 60MG ER Generic
PROPRANOLOL CAP 80MG ER Generic
PROPRANOLOL CAP 120MG ER Generic
PROPRANOLOL CAP 160MG ER Generic
PROPRANOLOL TAB 10MG Generic
PROPRANOLOL TAB 20MG Generic
PROPRANOLOL TAB 40MG Generic
PROPRANOLOL TAB 60MG Generic
PROPRANOLOL TAB 80MG Generic
PROPRANOLOL SOL 20MG/5ML Generic AR PA required >6
PROPRANOLOL SOL 40MG/5ML Generic AR PA required >6
SORINE TAB 80MG Generic
SORINE TAB 120MG Generic
SORINE TAB 160MG Generic
SORINE TAB 240MG Generic
SOTALOL AF TAB 80MG Generic
SOTALOL AF TAB 120MG Generic
SOTALOL AF TAB 160MG Generic
SOTALOL HCL TAB 80MG Generic
SOTALOL HCL TAB 120MG Generic
SOTALOL HCL TAB 160MG Generic
SOTALOL HCL TAB 240MG Generic
CALCIUM‐CHANNEL BLOCKING AGENTS AFEDITAB TAB 30MG CR Generic
AFEDITAB TAB 60MG CR Generic
AMLODIPINE TAB 2.5MG Generic
AMLODIPINE TAB 5MG Generic
AMLODIPINE TAB 10MG Generic
CARTIA XT CAP 120/24HR Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
35
Drug Name Dosage Form/Strength Drug Type Requirements
CARTIA XT CAP 180/24HR Generic
CARTIA XT CAP 240/24HR Generic
CARTIA XT CAP 300/24HR Generic
DILT‐CD CAP 120MG Generic
DILT‐CD CAP 180MG Generic
DILT‐CD CAP 240MG Generic
DILT‐CD CAP 300MG Generic
DILTIAZEM TAB 30MG Generic
DILTIAZEM TAB 60MG Generic
DILTIAZEM TAB 90MG Generic
DILTIAZEM TAB 120MG Generic
DILTIAZEM CAP 60MG ER Generic
DILTIAZEM CAP 90MG ER Generic
DILTIAZEM CAP 120MG ER Generic
DILTIAZEM CAP 180MG ER Generic
DILTIAZEM CAP 240MG ER Generic
DILTIAZEM CAP 120MG/24 Generic
DILTIAZEM CAP 180MG/24 Generic
DILTIAZEM CAP 240MG/24 Generic
DILTIAZEM CAP 300MG/24 Generic
DILTIAZEM CAP 360MG/24 Generic
DILTIAZEM CAP 360MG ER Generic
DILTIAZEM CAP 420MG/24 Generic
DILTIAZEM CAP 120MG CD Generic
DILTIAZEM CAP 180MG CD Generic
DILTIAZEM CAP 240MG CD Generic
DILTIAZEM CAP 300MG ER Generic
DILTIAZEM CAP 300MG CD Generic
DILTIAZEM CAP 360MG CD Generic
DILT‐XR CAP 120MG Generic
DILT‐XR CAP 180MG Generic
DILT‐XR CAP 240MG Generic
DILTZAC CAP 120MG/24 Generic
DILTZAC CAP 180MG/24 Generic
DILTZAC CAP 240MG/24 Generic
DILTZAC CAP 300MG/24 Generic
DILTZAC CAP 360MG/24 Generic
NIFEDIAC CC TAB 30MG ER Generic
NIFEDIAC CC TAB 60MG ER Generic
NIFEDICAL XL TAB 30MG Generic
NIFEDICAL XL TAB 60MG Generic
NIFEDIPINE CAP 10MG Generic AR PA required > 64
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
36
Drug Name Dosage Form/Strength Drug Type Requirements
NIFEDIPINE CAP 20MG Generic AR PA required > 64
NIFEDIPINE TAB 30MG ER Generic
NIFEDIPINE TAB 60MG ER Generic
NIFEDIPINE TAB 90MG ER Generic
TAZTIA XT CAP 120MG/24 Generic
TAZTIA XT CAP 180MG/24 Generic
TAZTIA XT CAP 240MG/24 Generic
TAZTIA XT CAP 300MG/24 Generic
TAZTIA XT CAP 360MG/24 Generic
VERAPAMIL TAB 40MG Generic
VERAPAMIL TAB 80MG Generic
VERAPAMIL TAB 120MG Generic
VERAPAMIL TAB 120MG ER Generic
VERAPAMIL TAB 180MG ER Generic
VERAPAMIL TAB 240MG ER Generic
VERAPAMIL INJ 2.5MG/ML Generic
VERAPAMIL CAP 100MG ER Generic
VERAPAMIL CAP 120MG ER Generic
VERAPAMIL CAP 120MG SR Generic
VERAPAMIL CAP 180MG ER Generic
VERAPAMIL CAP 180MG SR Generic
VERAPAMIL CAP 200MG ER Generic
VERAPAMIL CAP 240MG ER Generic
VERAPAMIL CAP 240MG SR Generic
VERAPAMIL CAP 300MG ER Generic
VERAPAMIL CAP 360MG SR Generic
ANTIARRHYTHMICS ADENOSINE INJ 6MG/2ML Generic
ADENOSINE INJ 12MG/4ML Generic
AMIODARONE TAB 200MG Generic QL 90‐day fill available
AMIODARONE INJ 50MG/ML Generic
AMIODARONE INJ 150MG/3M Generic
DISOPYRAMIDE CAP 100MG Generic AR PA required > 64
DISOPYRAMIDE CAP 150MG Generic AR PA required > 64
DOFETILIDE CAP 125MCG Generic
DOFETILIDE CAP 250MCG Generic
DOFETILIDE CAP 500MCG Generic
FLECAINIDE TAB 50MG Generic
FLECAINIDE TAB 100MG Generic
FLECAINIDE TAB 150MG Generic
LIDOCAINE INJ 20MG/ML Generic
MEXILETINE CAP 150MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
37
Drug Name Dosage Form/Strength Drug Type Requirements
MEXILETINE CAP 200MG Generic
MEXILETINE CAP 250MG Generic
MULTAQ TAB 400MG Brand PA QL 2 per day
NORPACE CAP 100MG CR Brand
NORPACE CAP 150MG CR Brand
PACERONE TAB 200MG Generic QL 90‐day fill available
PROCAINAMIDE INJ 100MG/ML Generic
PROCAINAMIDE INJ 500MG/ML Generic
PROPAFENONE TAB 150MG Generic
PROPAFENONE TAB 225MG Generic
PROPAFENONE TAB 300MG Generic
QUINIDINE GLUCONATE TAB 324MG CR Generic
QUINIDINE GLUCONATE TAB 324MG ER Generic
QUINIDINE SULFATE TAB 200MG Generic
QUINIDINE SULFATE TAB 300MG Generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN TAB 4MG Generic PA
CANDESARTAN TAB 8MG Generic PA
CANDESARTAN TAB 16MG Generic PA
CANDESARTAN TAB 32MG Generic PA
CANDESARTAN/HCTZ TAB 16‐12.5MG Generic PA
CANDESARTAN/HCTZ TAB 32‐12.5MG Generic PA
CANDESARTAN/HCTZ TAB 32‐25MG Generic PA
IRBESARTAN TAB 75MG Generic
IRBESARTAN TAB 150MG Generic
IRBESARTAN TAB 300MG Generic
LOSARTAN POTASSIUM TAB 25MG Generic
LOSARTAN POTASSIUM TAB 50MG Generic
LOSARTAN POTASSIUM TAB 100MG Generic
VALSARTAN TAB 40MG Generic PA
VALSARTAN TAB 80MG Generic PA
VALSARTAN TAB 160MG Generic PA
VALSARTAN TAB 320MG Generic PA
VALSARTAN/HCTZ TAB 80‐12.5MG Generic PA
VALSARTAN/HCTZ TAB 160‐12.5MG Generic PA
VALSARTAN/HCTZ TAB 160‐25MG Generic PA
VALSARTAN/HCTZ TAB 320‐12.5MG Generic PA
VALSARTAN/HCTZ TAB 320‐25MG Generic PA
ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS BENAZEPRIL TAB 5MG Generic
BENAZEPRIL TAB 10MG Generic
BENAZEPRIL TAB 20MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
38
Drug Name Dosage Form/Strength Drug Type Requirements
BENAZEPRIL TAB 40MG Generic
CAPTOPRIL TAB 12.5MG Generic QL 90‐day supply available
CAPTOPRIL TAB 25MG Generic QL 90‐day supply available
CAPTOPRIL TAB 50MG Generic QL 90‐day supply available
CAPTOPRIL TAB 100MG Generic QL 90‐day supply available
ENALAPRIL TAB 2.5MG Generic QL 90‐day supply available
ENALAPRIL TAB 5MG Generic QL 90‐day supply available
ENALAPRIL TAB 10MG Generic QL 90‐day supply available
ENALAPRIL TAB 20MG Generic QL 90‐day supply available
FOSINOPRIL TAB 10MG Generic
FOSINOPRIL TAB 20MG Generic
FOSINOPRIL TAB 40MG Generic
LISINOPRIL TAB 2.5MG Generic QL 90‐day supply available
LISINOPRIL TAB 5MG Generic QL 90‐day supply available
LISINOPRIL TAB 10MG Generic QL 90‐day supply available
LISINOPRIL TAB 20MG Generic QL 90‐day supply available
LISINOPRIL TAB 30MG Generic QL 90‐day supply available
LISINOPRIL TAB 40MG Generic QL 90‐day supply available
QUINAPRIL TAB 5MG Generic
QUINAPRIL TAB 5MG Generic
QUINAPRIL TAB 10MG Generic
QUINAPRIL TAB 20MG Generic
QUINAPRIL TAB 40MG Generic
RAMIPRIL CAP 10MG Generic
RAMIPRIL CAP 1.25MG Generic
RAMIPRIL CAP 2.5MG Generic
RAMIPRIL CAP 5MG Generic
CENTRAL ALPHA‐AGONISTS CLONIDINE TAB 0.1MG Generic
CLONIDINE TAB 0.2MG Generic
CLONIDINE TAB 0.3MG Generic
GUANFACINE TAB 1MG Generic AR PA required > 64
GUANFACINE TAB 2MG Generic AR PA required > 64
METHYLDOPA TAB 250MG Generic AR PA required > 64
METHYLDOPA TAB 500MG Generic AR PA required > 64
COMBO HYPERTENSION MEDS ATENOLOL/CHLORTHALIDONE TAB 50‐25MG Generic QL 90‐day supply available
ATENOLOL/CHLORTHALIDONE TAB 100‐25MG Generic QL 90‐day supply available
BENAZEPRIL/HYDROCHLOROTHIAZIDE TAB 5‐6.25 Generic
BENAZEPRIL/HYDROCHLOROTHIAZIDE TAB 10‐12.5 Generic
BENAZEPRIL/HYDROCHLOROTHIAZIDE TAB 20‐12.5 Generic
BENAZEPRIL/HYDROCHLOROTHIAZIDE TAB 20‐25MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
39
Drug Name Dosage Form/Strength Drug Type Requirements
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TAB 2.5/6.25 Generic
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TAB 5‐6.25MG Generic
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TAB 10/6.25 Generic
CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB 25‐15MG Generic QL 90‐day supply available
CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB 50‐15MG Generic QL 90‐day supply available
CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB 50‐25MG Generic QL 90‐day supply available
ENALAPRIL/HYDROCHLOROTHIAZIDE TAB 5‐12.5MG Generic QL 90‐day supply available
ENALAPRIL/HYDROCHLOROTHIAZIDE TAB 10‐25MG Generic QL 90‐day supply available
IRBESARTAN/HYDROCHLOROTHIAZIDE TAB 300‐12.5 Generic
IRBESARTAN/HYDROCHLOROTHIAZIDE TAB 150‐12.5 Generic
LISINOPRIL/HYDROCHLOROTHIAZIDE TAB 10‐12.5 Generic QL 90‐day supply available
LISINOPRIL/HYDROCHLOROTHIAZIDE TAB 20‐12.5 Generic QL 90‐day supply available
LISINOPRIL/HYDROCHLOROTHIAZIDE TAB 20‐25MG Generic QL 90‐day supply available
LOSARTAN/HYDROCHLOROTHIAZIDE TAB 50‐12.5 Generic
LOSARTAN/HYDROCHLOROTHIAZIDE TAB 100‐12.5 Generic
LOSARTAN/HYDROCHLOROTHIAZIDE TAB 100‐25 Generic
METOPROLOL/HYDROCHLOROTHIAZIDE TAB 50‐25MG Generic
METOPROLOL/HYDROCHLOROTHIAZIDE TAB 100‐25MG Generic
METOPROLOL/HYDROCHLOROTHIAZIDE TAB 100‐50MG Generic
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TAB 25/25 Generic
TRIAMTERENE/HYDROCHLOROTHIAZIDE CAP 37.5‐25 Generic
TRIAMTERENE/HYDROCHLOROTHIAZIDE TAB 37.5‐25 Generic
TRIAMTERENE/HYDROCHLOROTHIAZIDE TAB 75‐50MG Generic
DIRECT VASODILATORS HYDRALAZINE TAB 10MG Generic
HYDRALAZINE TAB 25MG Generic
HYDRALAZINE TAB 50MG Generic
HYDRALAZINE TAB 100MG Generic
MINOXIDIL TAB 2.5MG Generic
MINOXIDIL TAB 10MG Generic
CARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMIDE TAB 125MG Generic
ACETAZOLAMIDE TAB 250MG Generic
ACETAZOLAMIDE CAP 500MG ER Generic
AZOPT SUS 1% OP Brand
DORZOLAMIDE/TIMOLOL MALEATE SOL 22.3‐6.8 Generic
DORZOLAMIDE SOL 2% OP Generic
METHAZOLAMIDE TAB 25MG Generic
METHAZOLAMIDE TAB 50MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
40
Drug Name Dosage Form/Strength Drug Type Requirements
LOOP DIURETICS BUMETANIDE TAB 0.5MG Generic
BUMETANIDE TAB 1MG Generic
BUMETANIDE TAB 2MG Generic
BUMETANIDE INJ 0.25/ML Generic
FUROSEMIDE TAB 20MG Generic QL 90‐day fill available
FUROSEMIDE TAB 40MG Generic QL 90‐day fill available
FUROSEMIDE TAB 80MG Generic QL 90‐day fill available
FUROSEMIDE INJ 10MG/ML Generic QL 90‐day fill available
FUROSEMIDE INJ 20MG/2ML Generic QL 90‐day fill available
FUROSEMIDE INJ 40MG/4ML Generic QL 90‐day fill available
FUROSEMIDE INJ 100/10ML Generic QL 90‐day fill available
FUROSEMIDE SOL 8MG/ML Generic QL 90‐day fill available
FUROSEMIDE SOL 10MG/ML Generic QL 90‐day fill available
TORSEMIDE TAB 5MG Generic
TORSEMIDE TAB 10MG Generic
TORSEMIDE TAB 20MG Generic
TORSEMIDE TAB 100MG Generic
POTASSIUM‐SPARING DIURETICS AMILORIDE/HYDROCHLOROTHIAZIDE TAB 5‐50 Generic
AMILORIDE TAB 5MG Generic
DYRENIUM CAP 50MG Brand
DYRENIUM CAP 100MG Brand
SPIRONOLACTONE TAB 25MG Generic
SPIRONOLACTONE TAB 50MG Generic
SPIRONOLACTONE TAB 100MG Generic
THIAZIDE AND THIAZIDE‐LIKE DIURETICS CHLORTHALIDONE TAB 25MG Generic
CHLORTHALIDONE TAB 50MG Generic
CHLORTHALIDONE TAB 100MG Generic
HYDROCHLOROTHIAZIDE CAP 12.5MG Generic 90‐day fill available
HYDROCHLOROTHIAZIDE TAB 12.5MG Generic 90‐day fill available
HYDROCHLOROTHIAZIDE TAB 25MG Generic 90‐day fill available
HYDROCHLOROTHIAZIDE TAB 50MG Generic 90‐day fill available
INDAPAMIDE TAB 1.25MG Generic
INDAPAMIDE TAB 2.5MG Generic
METOLAZONE TAB 2.5MG Generic
METOLAZONE TAB 5MG Generic
METOLAZONE TAB 10MG Generic
ALPHA‐ADRENERGIC AGONISTS MIDODRINE TAB 2.5MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
41
Drug Name Dosage Form/Strength Drug Type Requirements
MIDODRINE TAB 5MG Generic
MIDODRINE TAB 10MG Generic
EPINEPHRINE EPINEPHRINE AUTO‐INJECTOR INJ 0.15MG Generic
EPINEPHRINE AUTO‐INJECTOR INJ 0.3MG Generic
ANTILIPEMIC AGENTS, MISCELLANEOUS NIACIN TAB 500MG ER Generic
NIACIN ER TAB 500MG Generic
NIACIN ER TAB 1000MG Generic
NIACIN ER TAB 750MG Generic
BILE ACID SEQUESTRANTS CHOLESTYRAM POW 4GM Generic
CHOLESTYRAM POW 4GM LITE Generic
COLESTIPOL TAB 1GM Generic
COLESTIPOL GRA 5GM Generic
PREVALITE POW 4GM Generic
PREVALITE POW 4GM PK Generic
CHOLESTEROL ABSORPTION INHIBITORS EZETIMIBE TAB 10MG Brand PA
FIBRIC ACID DERIVATIVES FENOFIBRATE TAB 48MG Generic
FENOFIBRATE TAB 54MG Generic
FENOFIBRATE TAB 160MG Generic
FENOFIBRATE CAP 43MG Generic
FENOFIBRATE CAP 67MG Generic
FENOFIBRATE CAP 134MG Generic
FENOFIBRIC CAP 45MG DR Generic
GEMFIBROZIL TAB 600MG Generic
PCSK9 INHIBITORS REPATHA PUSH INJ 420/3.5 Brand PA; QL 1 device per month
REPATHA SURE INJ 140MG/ML Brand PA; QL 2 pens per month
REPATHA INJ 140MG/ML Brand PA; QL 2 pens per month
STATINS ATORVASTATIN TAB 10MG Generic
ATORVASTATIN TAB 20MG Generic
ATORVASTATIN TAB 40MG Generic
ATORVASTATIN TAB 80MG Generic
LOVASTATIN TAB 10MG Generic QL 90‐day supply available
LOVASTATIN TAB 20MG Generic QL 90‐day supply available
LOVASTATIN TAB 40MG Generic QL 90‐day supply available
PRAVASTATIN TAB 10MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
42
Drug Name Dosage Form/Strength Drug Type Requirements
PRAVASTATIN TAB 20MG Generic
PRAVASTATIN TAB 40MG Generic
PRAVASTATIN TAB 80MG Generic
ROSUVASTATIN TAB 5MG Generic
ROSUVASTATIN TAB 10MG Generic
ROSUVASTATIN TAB 20MG Generic
ROSUVASTATIN TAB 40MG Generic
SIMVASTATIN TAB 5MG Generic
SIMVASTATIN TAB 10MG Generic
SIMVASTATIN TAB 20MG Generic
SIMVASTATIN TAB 40MG Generic
SIMVASTATIN TAB 80MG Generic
PULMONARY HYPERTENSION ADEMPAS TAB 0.5MG Brand PA
ADEMPAS TAB 1MG Brand PA
ADEMPAS TAB 1.5MG Brand PA
ADEMPAS TAB 2MG Brand PA
ADEMPAS TAB 2.5MG Brand PA
EPOPROSTENOL INJ 0.5MG Generic PA
EPOPROSTENOL INJ 1.5MG Generic PA
LETAIRIS TAB 5MG Brand PA QL 1 per day
LETAIRIS TAB 10MG Brand PA QL 1 per day
REMODULIN INJ 1MG/ML Brand PA
REMODULIN INJ 2.5MG/ML Brand PA
REMODULIN INJ 5MG/ML Brand PA
REMODULIN INJ 10MG/ML Brand PA
SILDENAFIL TAB 20MG Generic PA QL 3 per day
TADALAFIL TAB 20MG Generic PA QL 2 per day
TRACLEER TAB 32MG Brand PA QL 4 per day
TRACLEER TAB 62.5MG Brand PA
TRACLEER TAB 125MG Brand PA
VELETRI INJ 0.5MG Brand PA
VELETRI INJ 1.5MG Generic PA
VENTAVIS SOL 10MCG/ML Brand PA
VENTAVIS SOL 20MCG/ML Brand PA
RESPIRATORY AGENTS ANTI‐HISTAMINES ALA‐HIST IR TAB 2MG Brand
ALAVERT TAB 10MG Generic QL 1 per day
ALER‐DRYL TAB 50MG Generic AR PA required > 64
CHLORPHENIRAMINE MALEATE TAB 4MG Generic AR PA required > 64
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
43
Drug Name Dosage Form/Strength Drug Type Requirements
DIPHENHYDRAMINE CAP 25MG Generic AR PA required > 64
DIPHENHYDRAMINE TAB 25MG Generic AR PA required > 64
DIPHENHYDRAMINE LIQ 12.5/5ML Generic AR PA required > 64
CHLORPHENIRAMINE MALEATE TAB 12MG CR Generic AR PA required > 64
DIPHENHYDRAMINE TAB DYE‐FREE Generic AR PA required > 64
DIPHENHYDRAMINE LIQ 12.5/5ML Generic AR PA required > 64
DIPHENHYDRAMINE CHW 12.5MG Generic AR PA required > 64
DIPHENHYDRAMINE ELX 12.5/5ML Generic AR PA required > 64
DIPHENHYDRAMINE LIQ 50/20ML Generic AR PA required > 64
CETIRIZINE TAB 5MG Generic QL 1 per day
CETIRIZINE TAB 10MG Generic QL 1 per day
CETIRIZINE SYP 5MG/5ML Generic
CETIRIZINE SYP 1MG/ML Generic
CETIRIZINE SOL 1MG/ML Generic
CETIRIZINE SOL 5MG/5ML Generic
CYPROHEPTADINE TAB 4MG Generic AR PA required > 64
CYPROHEPTADINE SYP 2MG/5ML Generic AR PA required > 64
DIABET TUSS SYP ALLERGY Generic
DIPHENHYDRAMINE INJ 50MG/ML Generic
FEXOFENADINE TAB 60MG Generic ST (loratadine, cetirizine)
FEXOFENADINE TAB 180MG Generic ST (loratadine, cetirizine)
LORATADINE TAB 10MG Generic QL 1 per day
LORATADINE SOL 5MG/5ML Generic
LORATADINE SYP 5MG/5ML Generic
NASAL STEROIDS FLUNISOLIDE SPR 0.025% Generic PA QL 25mls per 30 days
FLUTICASONE SPR 50MCG Generic QL 16mls per 30 days
TRIAMCINOLONE NASAL SPR 55MCG/AC Generic ST (fluticasone)
COUGH BENZONATATE CAP 100MG Generic
BENZONATATE CAP 200MG Generic
CYSTIC FIBROSIS KALYDECO TAB 150MG Brand PA QL 2 per day
KALYDECO PAK 50MG Brand PA QL 2 per day
KALYDECO PAK 75MG Brand PA QL 2 per day
NEBUSAL NEB 3% Generic
ORKAMBI TAB 200‐125 Brand PA QL 4 tabs per day
PULMOSAL NEB 7% Generic
PULMOZYME SOL 1MG/ML Brand QL 150mls per 31 days
SODIUM CHLORIDE NEB 0.9% Generic
SODIUM CHLORIDE NEB 3% Generic
SODIUM CHLORIDE NEB 7% Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
44
Drug Name Dosage Form/Strength Drug Type Requirements
SYMDEKO TAB 100‐150MG Brand PA QL 2 per day
INHALED ANTICHOLINERGICS ATROVENT HFA AER 17MCG Brand
SPIRIVA CAP HANDIHLR Brand QL 1 per day
SPIRIVA SPR RESPIMAT Brand QL 2 puffs per day
INHALED BETA‐AGONISTS ALBUTEROL NEB 0.083% Generic QL 90‐day fill available
ALBUTEROL NEB 0.5% Generic QL 90‐day fill available
ALBUTEROL NEB 0.63MG/3 Generic QL 90‐day fill available
ALBUTEROL NEB 1.25MG/3 Generic QL 90‐day fill available
PROAIR HFA AER Brand QL 90‐day fill available
PROVENTIL AER HFA Brand QL 90‐day fill available
SEREVENT DISKUS AER 50MCG Brand
VENTOLIN HFA AER Brand QL 90‐day fill available
XOPENEX HFA AER Brand QL 60‐day supply per fill
INHALED COMBO ANTICHOLINERGICS/BETA‐AGONISTS ANORO ELLIPTA AER 62.5‐25 Brand QL 2 per day
INCRUSE ELLIPTA INH 62.5MCG Brand QL 1 per day
STIOLTO AER RESPIMAT Brand QL 0.134 per day
INHALED COMBO BETA‐AGONISTS/ANTICHOLINERGICS COMBIVENT AER Brand
COMBIVENT AER RESPIMAT Brand
IPRATROPIUM/ SOL ALBUTER Generic
IPRATROPIUM/ SOL SULFATE Generic
INHALED COMBO STEROID/BETA‐AGONISTS ADVAIR DISKUS AER 100/50 Brand PA Required; QL 2 per day
ADVAIR DISKUS AER 250/50 Brand PA Required; QL 2 per day
ADVAIR DISKUS AER 500/50 Brand PA Required; QL 2 per day
ADVAIR HFA AER 45/21 Brand PA Required
ADVAIR HFA AER 115/21 Brand PA Required
ADVAIR HFA AER 230/21 Brand PA Required
FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) AER 55/14 Generic QL 2 inhalers per month
FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) AER 113‐14 Generic QL 2 inhalers per month
FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) AER 232‐14 Generic QL 2 inhalers per month
SYMBICORT AER 80‐4.5 Brand PA Required
SYMBICORT AER 160‐4.5 Brand PA Required
TRELEGY AER ELLIPTA Brand PA QL 2 blister strips per
day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
45
Drug Name Dosage Form/Strength Drug Type Requirements
INHALED STEROIDS ARMONAIR AER 55/ACT Brand QL 1 inhaler per month
ARMONAIR AER 113/ACT Brand QL 1 inhaler per month
ARMONAIR AER 232/ACT Brand QL 1 inhaler per month
BUDESONIDE SUS 0.25MG/2 Generic AR PA > 6 years of age
BUDESONIDE SUS 0.5MG/2 Generic AR PA > 6 years of age
BUDESONIDE SUS 1MG/2ML Generic AR PA > 6 years of age
FLOVENT HFA AER 110MCG Brand QL 60 days per fill
FLOVENT HFA AER 220MCG Brand QL 60 days per fill
FLOVENT HFA AER 44MCG Brand QL 60 days per fill
FLOVENT DISK AER 100MCG Brand QL 60 days per fill
FLOVENT DISK AER 50MCG Brand
FLOVENT DISK AER 250MCG Brand QL 60 days per fill
QVAR AER 40MCG Brand QL 50 days per fill
QVAR AER 80MCG Brand QL 50 days per fill
QVAR REDIHALER AER 40MCG Brand QL 2 puffs per day; 60‐day
supply per fill
QVAR REDIHALER AER 80MCG Brand QL up to 60‐day supply
per fill
LEUKOTRIENE MODIFIERS MONTELUKAST TAB 10MG Generic
MONTELUKAST CHW 4MG Generic
MONTELUKAST CHW 5MG Generic
MONTELUKAST GRA 4MG Generic
ZAFIRLUKAST TAB 10MG Generic
ZAFIRLUKAST TAB 20MG Generic
MAST‐CELL STABILIZERS CROMOLYN SOD NEB 20MG/2ML Generic
OTHER ASTHMA/COPD ALBUTEROL TAB 4MG ER Generic
ALBUTEROL TAB 2MG Generic
ALBUTEROL TAB 4MG Generic
ALBUTEROL SYP 2MG/5ML Generic
ARALAST NP INJ 400MG Brand PA
ARALAST NP INJ 500MG Brand PA
ARALAST NP INJ 800MG Brand PA
ARALAST NP INJ 1000MG Brand PA
ELIXOPHYLLIN ELX 80/15ML Brand
METAPROTEREN SYP 10MG/5ML Generic
TERBUTALINE TAB 2.5MG Generic
TERBUTALINE TAB 5MG Generic
THEO‐24 CAP 200MG CR Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
46
Drug Name Dosage Form/Strength Drug Type Requirements
THEOCHRON TAB 100MG CR Generic
THEOCHRON TAB 200MG CR Generic
THEOCHRON TAB 300MG CR Generic
THEOPHYLLINE TAB 100MG ER Generic
THEOPHYLLINE TAB 100MG CR Generic
THEOPHYLLINE TAB 200MG ER Generic
THEOPHYLLINE TAB 200MG CR Generic
THEOPHYLLINE TAB 300MG ER Generic
THEOPHYLLINE TAB 450MG ER Generic
THEOPHYLLINE TAB 400MG ER Generic
THEOPHYLLINE TAB 600MG ER Generic
ZEMAIRA INJ 1000MG Brand PA
GASTROINTESTINAL AGENTSCATHARTICS AND LAXATIVES (List not all encompassing. Representative products listed only)
BISACODYL SUPP, TAB, TAB EC, Generic
CASCARA SAGRADA CAP 450MG Generic
DOCUSATE SODIUM CAP, SOFTGEL, SOL,
SYRUP, TAB Generic
ENEMA Generic
GLYCERIN SUPP Generic
KONSYL CAP Generic
MAGNESIUM CITRATE SOLN Generic
METAMUCIL PACKET, WAFER Generic
MILK OF MAGNESIUM SUSP Generic
MINERAL OIL ENEMA, LAXATIVE Generic
SALINE LAXATIVE Generic
POLYETHYLENE GLYCOL POWDER, PACKET Generic
PSYLLIUM FIBER TAB, POWDER Generic
SENNA TAB, LAXATIVE Generic
SENNA‐DOCUSATE SODIUM TAB Generic
GAVILYTE‐C SOLN Generic
GAVILYTE‐G SOLN Generic
GAVILYTE‐N SOLN Generic
PEDIA‐LAX LIQ 50MG Brand
TRILYTE SOL Generic
ANTACIDS AND ADSORBENTS (List not all encompassing. Representative products listed only)
ALCALAK CHW 420MG Generic
ALMACONE SUS CHW 1000MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
47
Drug Name Dosage Form/Strength Drug Type Requirements
ANTACID TAB, GELCAP, CHEW
TAB, SUSP Generic
CALC ANTACID CHW 1000MG Generic
CALC ANTACID CHW 500MG Generic
CALC ANTACID CHW 750MG Generic
CALCIUM CARB CHW 500MG Generic
CALCIUM CARB TAB 648MG Generic
CHILD SOOTHE CHW 400MG Generic
CHILDRENS CHW PEPTO Generic
COMFORT GEL SUS Generic
MAALOX LIQ, CHEW Generic
MAG OXIDE TAB 400MG Generic
SODIUM BICAR TAB 10GR Generic
SODIUM BICAR TAB 650MG Generic
STOMACH RLF CHW 400MG Generic
ANTIMUSCARINICS/ANTISPASMODICS BELLA/OPIUM SUP 16.2‐30 Generic QL 1 per 180 days
BELLA/OPIUM SUP 16.2‐60 Generic QL 1 per 180 days
DAPSONE TAB 100MG Generic
DAPSONE TAB 25MG Generic
DICYCLOMINE CAP 10MG Generic AR PA required > 64
DICYCLOMINE SOL 10MG/5ML Generic AR PA required > 64
DICYCLOMINE TAB 20MG Generic AR PA required > 64
ED‐SPAZ TAB 0.125MG Generic AR PA required > 64
HYOMAX‐SL SUB 0.125MG Generic AR PA required > 64
HYOSCYAMINE DRO 0.125/ML Generic AR PA required > 64
HYOSCYAMINE ELX 0.125/5 Generic AR PA required > 64
HYOSCYAMINE SUB 0.125MG Generic AR PA required > 64
HYOSCYAMINE TAB 0.375 ER Generic AR PA required > 64
HYOSCYAMINE TAB 0.375 SR Generic AR PA required > 64
HYOSYNE DRO 0.125/ML Generic AR PA required > 64
HYOSYNE ELX 0.125/5 Generic AR PA required > 64
IPRATROPIUM SOL 0.02%INH Generic
NULEV TAB 0.125MG Generic AR PA required > 64
OSCIMIN TAB 0.125MG Generic AR PA required > 64
OSCIMIN SUB 0.125MG Generic AR PA required > 64
OSCIMIN SR TAB 0.375MG Generic AR PA required > 64
PROPANTHELIN TAB 15MG Generic AR PA required > 64
SYMAX FASTAB TAB 0.125MG Generic AR PA required > 64
SYMAX‐SL SUB 0.125MG Generic AR PA required > 64
SYMAX‐SR TAB 0.375MG Generic AR PA required > 64
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
48
Drug Name Dosage Form/Strength Drug Type Requirements
HISTAMINE H2‐ANTAGONISTS ACID CONTROL TAB 10MG Generic
ACID CONTROL TAB 150MG Generic
ACID CONTROL TAB 20MG Generic
ACID CONTROL TAB 75MG Generic
ACID REDUCER TAB 10MG Generic
ACID REDUCER TAB 150MG Generic
ACID REDUCER TAB 200MG Generic
ACID REDUCER TAB 20MG Generic
ACID REDUCER TAB 75MG Generic
ACID RELIEF TAB 200MG Generic
CIMETIDINE SOL 300/5ML Generic
CIMETIDINE TAB 200MG Generic
CIMETIDINE TAB 300MG Generic
CIMETIDINE TAB 400MG Generic
CIMETIDINE TAB 800MG Generic
EQL HEARTBRN TAB 10MG Generic
FAMOTIDINE TAB 10MG Generic
FAMOTIDINE TAB 20MG Generic
FAMOTIDINE TAB 40MG Generic
HEARTBRN REL TAB 200MG Generic
HEARTBRN REL TAB 75MG Generic
HEARTBURN TAB 150MG Generic
HEARTBURN TAB 20MG Generic
NIZATIDINE SOL 15MG/ML Generic AR PA required > 6
PEPCID AC TAB 20MG Generic
RANITIDINE CAP 150MG Generic
RANITIDINE CAP 300MG Generic
RANITIDINE SYP 150/10ML Generic
RANITIDINE SYP 15MG/ML Generic
RANITIDINE SYP 75MG/5ML Generic
RANITIDINE TAB 150MG Generic
RANITIDINE TAB 300MG Generic
RANITIDINE TAB 75MG Generic
SM ACID REDU TAB 200MG Generic
WAL‐ZAN TAB 150MG Generic
WAL‐ZAN TAB 75MG Generic
WAL‐ZAN 75 TAB Generic
PROSTAGLANDINS MISOPROSTOL TAB 100MCG Generic
MISOPROSTOL TAB 200MCG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
49
Drug Name Dosage Form/Strength Drug Type Requirements
PROTECTANTS CARAFATE SUS 1GM/10ML Brand
SUCRALFATE TAB 1GM Generic
PROTON‐PUMP INHIBITORS FIRST‐OMEPRA SUS 2MG/ML Brand AR PA > 6
LANSOPRAZOLE SUS 3MG/ML Brand PA
LANSOPRAZOLE CAP 15MG DR Generic PA QL 1 per day
LANSOPRAZOLE CAP 30MG DR Generic PA QL 1 per day
OMEPRAZOLE CAP 10MG Generic
OMEPRAZOLE CAP 20MG Generic
OMEPRAZOLE CAP 40MG Generic
OMEPRAZOLE + SUS SYRSPEND Brand AR PA Required > 6
PANTOPRAZOLE TAB 20MG Generic QL 1 per day
PANTOPRAZOLE TAB 40MG Generic
RABEPRAZOLE TAB 20MG Generic PA
ANTI‐NAUSEA AMBIZINE TAB 25MG Generic
COMPAZINE SUP 25MG Generic
APREPITANT CAP 40MG Generic PA
APREPITANT CAP 80MG Generic PA
APREPITANT CAP 125MG Generic PA
APREPITANT PAK 80 & 125 Generic PA
COMPRO SUP 25MG Generic
DIMENHYDRIN TAB 50MG Generic
DRAMAMINE TAB 25MG Generic
DRIMINATE TAB 50MG Generic
DRONABINOL CAP 2.5MG Generic PA QL 4 per day
DRONABINOL CAP 5MG Generic PA QL 4 per day
DRONABINOL CAP 10MG Generic PA QL 4 per day
EMEND SUSP 125 MG Brand PA
GRANISETRON INJ 0.1MG/ML Generic PA
GRANISETRON INJ 4MG/4ML Generic PA
GRANISETRON INJ 1MG/ML Generic PA
GRANISOL SOL 2MG/10ML Brand PA
MECLIZINE CHW 25MG Generic
MECLIZINE TAB 12.5MG Generic
MECLIZINE TAB 25MG Generic
MEDI‐MECLIZI TAB 25MG Generic
MOTION RELF CHW 25MG Generic
MOTION SICK TAB 50MG Generic
MOTION‐TIME CHW 25MG Generic
ONDANSETRON SOL 4MG/5ML Generic QL 6 per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
50
Drug Name Dosage Form/Strength Drug Type Requirements
ONDANSETRON TAB 4MG ODT Generic QL 3 per day
ONDANSETRON TAB 8MG ODT Generic QL 3 per day
ONDANSETRON TAB 4MG Generic QL 3 per day
ONDANSETRON TAB 8MG Generic QL 3 per day
ONDANSETRON TAB 24MG Generic QL 1 per day
PHENADOZ SUP 12.5MG Generic AR PA required < 2
PHENADOZ SUP 25MG Generic AR PA required < 2
PHENERGAN SUP 12.5MG Generic AR PA required < 2
PHENERGAN SUP 25MG Generic AR PA required < 2
PHENERGAN SUP 50MG Generic AR PA required < 2
PROCHLORPER SUP 25MG Generic
PROCHLORPER TAB 5MG Generic
PROCHLORPER TAB 10MG Generic
PROMETHAZINE TAB 12.5MG Generic AR PA required < 2 or > 64
PROMETHAZINE TAB 25MG Generic AR PA required < 2 or > 64
PROMETHAZINE TAB 50MG Generic AR PA required < 2 or > 64
PROMETHAZINE SYP 6.25/5ML Generic AR PA required < 2 or > 64
PROMETHAZINE SOL 6.25/5ML Generic AR PA required < 2 or > 64
PROMETHAZINE INJ 25MG/ML Generic AR PA required < 2
PROMETHAZINE INJ 50MG/ML Generic AR PA required < 2
PROMETHAZINE SUP 12.5MG Generic AR PA required < 2
PROMETHAZINE SUP 25MG Generic AR PA required < 2
PROMETHAZINE SUP 50MG Generic AR PA required < 2
PROMETHEGAN SUP 12.5MG Generic AR PA required < 2
PROMETHEGAN SUP 25MG Generic AR PA required < 2
PROMETHEGAN SUP 50MG Generic AR PA required < 2
TRAVEL SICK CHW 25MG Generic
TRAVEL SICK TAB 50MG Generic
TRAV‐TABS TAB 50MG Generic
TRIPTONE TAB 50MG Generic
WAL‐DRAM TAB 50MG Generic
WAL‐DRAM II TAB 25MG Generic
DIGESTANTS CREON CAP 3000UNIT Brand PA
CREON CAP 6000UNIT Brand PA
CREON CAP 12000UNT Brand PA
CREON CAP 24000UNT Brand PA
CREON CAP 36000UNT Brand PA
PANCREAZE CAP 4200UNIT Brand PA
PANCREAZE CAP 10500UNT Brand PA
PANCREAZE CAP 16800UNT Brand PA
PANCREAZE CAP 21000UNT Brand PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
51
Drug Name Dosage Form/Strength Drug Type Requirements
ZENPEP CAP 3000UNIT Brand PA
ZENPEP CAP 5000UNIT Brand PA
ZENPEP CAP 10000UNT Brand PA
ZENPEP CAP 15000UNT Brand PA
ZENPEP CAP 20000UNT Brand PA
ZENPEP CAP 25000UNT Brand PA
ZENPEP CAP 40000UNT Brand PA
CHOLELITHOLYTIC AGENTS URSODIOL CAP 300MG Generic
URSODIOL TAB 250MG Generic
URSODIOL TAB 500MG Generic
INFLAMMATORY BOWEL AGENTS
APRISO CAP 0.375GM Brand ST (sulfasalazine,
balsalazide)
BALSALAZIDE CAP 750MG Generic
CANASA SUP 1000MG Brand QL 42 per fill
DELZICOL CAP 400MG Brand ST (sulfasalazine,
balsalazide)
MESALAMINE ENE 4GM Generic
MESALAMINE (generic Asacol HD) TAB 800MG DR Generic ST (sulfasalazine,
balsalazide); QL 6 per day
MESALAMINE (generic Lialda) TAB 1.2GM Generic ST (sulfasalazine,
balsalazide)
PENTASA CAP 250MG CR Brand ST (sulfasalazine,
balsalazide)
PENTASA CAP 500MG CR Brand ST (sulfasalazine,
balsalazide)
SULFADIAZINE TAB 500MG Generic
SULFASALAZIN TAB 500MG Generic
SULFASALAZIN TAB 500MG DR Generic
SULFAZINE TAB 500MG Generic
SULFAZINE EC TAB 500MG Generic
PHOSPHATE‐REMOVING AGENTS CALCIUM ACETATE CAP 667MG Generic
CALCIUM ACETATE TAB 667MG Generic
FOSRENOL POW 750MG Brand
FOSRENOL POW 1000MG Brand
LANTHANUM CHW 500MG Generic
LANTHANUM CHW 750MG Generic
LANTHANUM CHW 1000MG Generic
RENAGEL TAB 400MG Brand
RENAGEL TAB 800MG Brand
SEVELAMER TAB 800MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
52
Drug Name Dosage Form/Strength Drug Type Requirements
SEVELAMER PAK 2.4 GM Generic
SEVELAMER PAK 0.8GM Generic
PROKINETIC AGENTS METOCLOPRAMIDE TAB 5MG Generic
METOCLOPRAMIDE TAB 10MG Generic
METOCLOPRAMIDE INJ 5MG/ML Generic
METOCLOPRAMIDE INJ 10MG/2ML Generic
METOCLOPRAMIDE SOL 5MG/5ML Generic
METOCLOPRAMIDE SOL 10/10ML Generic
GENITOURINARY PRODUCTSINCONTINENCE/URINARY FREQUENCY OXYBUTYNIN TAB 5MG Generic
OXYBUTYNIN SYP 5MG/5ML Generic
OXYBUTYNIN TAB 5MG ER Generic
OXYBUTYNIN TAB 10MG ER Generic
OXYBUTYNIN TAB 15MG ER Generic
OXYTROL/WOMN DIS 3.9MG/24 Brand ST
TOLTERODINE TAB 1MG Generic PA
TOLTERODINE TAB 2MG Generic PA
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) BETHANECHOL TAB 5MG Generic
BETHANECHOL TAB 10MG Generic
BETHANECHOL TAB 25MG Generic
BETHANECHOL TAB 50MG Generic
PILOCARPINE TAB 5MG Generic
PILOCARPINE TAB 7.5MG Generic
PYRIDOSTIGMINE BROMIDE TAB 60MG Generic
PYRIDOSTIGMINE BROMIDE TAB 180MG Generic
REGONOL INJ 5MG/ML Brand
CONTRACEPTIVES (E.G. FOAMS, DEVICES) CERVICAL CAP Various Brand QL 1 per 180 days
FEMALE CONDOMS Various Various
MALE CONDOMS Various Various
ORTHO COIL DPR KIT 50 Brand QL 1 per 180 days
ORTHO COIL DPR KIT 100 Brand QL 1 per 180 days
ORTHO COIL DPR KIT 105 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 55 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 60 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 65 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 70 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 75 Brand QL 1 per 180 days
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
53
Drug Name Dosage Form/Strength Drug Type Requirements
ORTHO FLAT DPR KIT 80 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 85 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 90 Brand QL 1 per 180 days
ORTHO FLAT DPR KIT 95 Brand QL 1 per 180 days
ORTHO FLEX DPR 65MM Brand QL 1 per 180 days
ORTHO FLEX DPR 70MM Brand QL 1 per 180 days
ORTHO FLEX DPR 75MM Brand QL 1 per 180 days
ORTHO FLEX DPR 80MM Brand QL 1 per 180 days
SPONGE VAGINAL SPONGE Brand
VCF VAGINAL AER CONTRACP Generic
WIDE‐SEAL DPR KIT 60 Brand QL 1 per 180 days
WIDE‐SEAL DPR KIT 65 Brand QL 1 per 180 days
WIDE‐SEAL DPR KIT 70 Brand QL 1 per 180 days
WIDE‐SEAL DPR KIT 75 Brand QL 1 per 180 days
WIDE‐SEAL DPR KIT 80 Brand QL 1 per 180 days
WIDE‐SEAL DPR KIT 85 Brand QL 1 per 180 days
WIDE‐SEAL DPR KIT 95 Brand QL 1 per 180 days
VAGINAL ANTI‐INFECTIVES CLEOCIN SUP 100MG Generic
CLINDAMYCIN CRE 2% VAG Generic
METRONIDAZOLE GEL 0.75%VAG Generic
VANDAZOLE GEL 0.75% Generic
ALKALINIZING AGENTS CITRIC ACID/SODIUM CITRATE SOL Generic
CYTRA K CRYSTALS PACK Generic
CYTRA‐2 SOL Generic
CYTRA‐3 SYP Generic
CYTRA‐K SOL Generic
POTASSIUM CITRATE/CITRIC ACID SOL Generic
NEUT INJ 4% Brand
POTASSIUM CITRATE TAB 540MG ER Generic
POTASSIUM CITRATE TAB 1080MG Generic
POTASSIUM CITRATE TAB 1620MG Generic
POTASSIUM CITRATE/CITRIC ACID PACK Generic
SOD BICARB INJ 8.4% Generic
SOD BICARB INJ 4.2% Generic
SOD BICARB INJ 7.5% Generic
VIRTRATE‐2 SOL 500‐334 Generic
VIRTRATE‐2 SOL Generic
VIRTRATE‐K SOL 1100‐334 Generic
VIRTRATE‐K SOL Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
54
Drug Name Dosage Form/Strength Drug Type Requirements
IRRIGATING SOLUTIONS ARGYL SALINE SOL 0.9% Generic
ARGYL SALINE SOL 100ML Generic
CURITY SALIN SOL 0.9% IRR Generic
SODIUM CHLOR SOL 0.9% IRR Generic
STERIL WATER SOL IRRIG Generic
MISCL URINARY AGENTS ELMIRON CAP 100MG Brand PA
PHENAZO TAB 200MG Generic
PHENAZOPYRID TAB 100MG Generic
PHENAZOPYRID TAB 200MG Generic
BPH AGENTS DOXAZOSIN TAB 1MG Generic
DOXAZOSIN TAB 2MG Generic
DOXAZOSIN TAB 4MG Generic
DOXAZOSIN TAB 8MG Generic
FINASTERIDE TAB 5MG Generic
PRAZOSIN HCL CAP 1MG Generic
PRAZOSIN HCL CAP 2MG Generic
PRAZOSIN HCL CAP 5MG Generic
TAMSULOSIN CAP 0.4MG Generic
TERAZOSIN CAP 1MG Generic
TERAZOSIN CAP 2MG Generic
TERAZOSIN CAP 5MG Generic
TERAZOSIN CAP 10MG Generic
CENTRAL NERVOUS SYSTEM DRUGS ANXIOLYTICS, SEDATIVES & HYPNOTICS, MISC. COMPOZ TAB 50MG Generic AR PA required > 64
DIPHENHYDRAM TAB 50MG Generic AR PA required > 64
HYDROXYZINE HCL TAB 10MG Generic AR PA required > 64
HYDROXYZINE HCL TAB 25MG Generic AR PA required > 64
HYDROXYZINE HCL TAB 50MG Generic AR PA required > 64
HYDROXYZINE HCL SYP 10MG/5ML Generic AR PA required > 64
HYDROXYZINE HCL SOL 10MG/5ML Generic AR PA required > 64
HYDROXYZINE PAMOATE CAP 25MG Generic AR PA required > 64
HYDROXYZINE PAMOATE CAP 50MG Generic AR PA required > 64
HYDROXYZINE PAMOATE CAP 100MG Generic AR PA required > 64
IBUPROFEN PM TAB 200‐38MG Generic AR PA required > 64
MOTRIN PM TAB 200‐38MG Generic AR PA required > 64
SLEEP AID CAP 50MG Generic AR PA required > 64
SLEEP AID TAB 25MG Generic AR PA required > 64
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
55
Drug Name Dosage Form/Strength Drug Type Requirements
ZOLPIDEM TAB 5MG Generic PA required > 64 QL 15
per 30 days
ZOLPIDEM TAB 10MG Generic PA required > 64 QL 15
per 30 days
BENZODIAZEPINES CLONAZEPAM TAB 0.5MG Generic
CLONAZEPAM TAB 1MG Generic
CLONAZEPAM TAB 2MG Generic
DIAZEPAM GEL 2.5MG Generic
DIAZEPAM GEL 10MG Generic
DIAZEPAM GEL 20MG Generic
LORAZEPAM INJ 2MG/ML Generic
LORAZEPAM INJ 4MG/ML Generic
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PHENOBARB TAB 15MG Generic AR PA required > 64
PHENOBARB TAB 16.2MG Generic AR PA required > 64
PHENOBARB TAB 30MG Generic AR PA required > 64
PHENOBARB TAB 32.4MG Generic AR PA required > 64
PHENOBARB TAB 60MG Generic AR PA required > 64
PHENOBARB TAB 64.8MG Generic AR PA required > 64
PHENOBARB TAB 97.2MG Generic AR PA required > 64
PHENOBARB TAB 100MG Generic AR PA required > 64
PHENOBARB ELX 20MG/5ML Generic AR PA required > 64
PHENOBARB SOL 20MG/5ML Generic AR PA required > 64
ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANT AGENTSAMPHETAMINES AMPHETAMINE (Generic Adderall IR) TAB 30MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall XR) CAP 15MG ER Generic Age > 18 not covered QL
1 per day
AMPHETAMINE (Generic Adderall XR) CAP 20MG ER Generic Age > 18 not covered QL
1 per day
AMPHETAMINE (Generic Adderall IR) TAB 5MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall IR) TAB 7.5MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall IR) TAB 10MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall IR) TAB 12.5MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall IR) TAB 15MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall IR) TAB 20MG Generic QL 3 per day
AMPHETAMINE (Generic Adderall XR) CAP 5MG ER Generic Age > 18 not covered QL
1 per day
AMPHETAMINE (Generic Adderall XR) CAP 10MG ER Generic Age > 18 not covered QL
1 per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
56
Drug Name Dosage Form/Strength Drug Type Requirements
AMPHETAMINE (Generic Adderall XR) CAP 20MG ER Generic Age > 18 not covered QL
1 per day
AMPHETAMINE (Generic Adderall XR) CAP 25MG ER Generic Age > 18 not covered QL
1 per day
AMPHETAMINE (Generic Adderall XR) CAP 30MG ER Generic Age > 18 not covered QL
1 per day
DEXTROAMPHETAMINE (Dexedrine IR) TAB 5MG Generic
DEXTROAMPHETAMINE (Dexedrine IR) TAB 10MG Generic
METHYLPHENIDATES DEXMETHYLPHENIDATE TAB 2.5MG Generic
DEXMETHYLPHENIDATE TAB 5MG Generic
DEXMETHYLPHENIDATE TAB 10MG Generic
METHYLPHENIDATE (generic Metadate CD) CAP 10MG Generic AR PA >18
METHYLPHENIDATE (generic Metadate CD) CAP 20MG Generic AR PA >18
METHYLPHENIDATE (generic Metadate CD) CAP 30MG Generic AR PA >18
METHYLPHENIDATE (generic Metadate CD) CAP 40MG Generic AR PA >18
METHYLPHENIDATE (generic Metadate CD) CAP 50MG Generic AR PA >18
METHYLPHENIDATE (generic Metadate CD) CAP 60MG Generic AR PA >18
METHYLPHENIDATE TAB 5MG Generic AR PA>64
METHYLPHENIDATE TAB 10MG Generic AR PA>64
METHYLPHENIDATE TAB 20MG Generic AR PA>64
METHYLPHENIDATE (generic Concerta) TAB 18MG ER Generic AR PA >18; QL 1 per day
METHYLPHENIDATE (generic Concerta) TAB 27MG ER Generic AR PA >18; QL 1 per day
METHYLPHENIDATE (generic Concerta) TAB 36MG ER Generic AR PA >18; QL 1 per day
METHYLPHENIDATE (generic Concerta) TAB 54MG ER Generic AR PA >18; QL 1 per day
METHYLPHENIDATE SOL 5MG/5ML Generic AR PA>6
METHYLPHENIDATE SOL 10MG/5ML Generic AR PA>6
METHLPHENIDATE (generic Ritalin LA) CAP 10MG ER Generic AR PA >18; QL 1 per day
METHYLPHENIDATE (generic Ritalin LA) CAP 20MG ER Generic AR PA > 18; QL 1 per day
METHYLPHENIDATE (generic Ritalin LA) CAP 30MG ER Generic AR PA > 18; QL 1 per day
METHYLPHENIDATE (generic Ritalin LA) CAP 40MG ER Generic AR PA > 18; QL 1 per day
RESPIRATORY AND CNS STIMULANTS CAFFEINE CIT INJ 60MG/3ML Generic AR PA >1
CAFFEINE CIT SOL 20MG/ML Generic AR PA >1
CAFFEINE CIT SOL 60MG/3ML Generic AR PA >1
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC ALCOHOL DETERRENTS ACAMPRO CAL TAB 333MG Generic PA QL 6 per day
DISULFIRAM TAB 250MG Generic
DISULFIRAM TAB 500MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
57
Drug Name Dosage Form/Strength Drug Type Requirements
ANTIDEMENTIA AGENTS DONEPEZIL TAB 5MG Generic QL 1 per day
DONEPEZIL TAB 10MG Generic QL 1 per day
DONEPEZIL TAB 5MG ODT Generic QL 1 per day
DONEPEZIL TAB 10MG ODT Generic QL 1 per day
GALANTAMINE TAB 4MG Generic
GALANTAMINE TAB 8MG Generic
GALANTAMINE TAB 12MG Generic
GALANTAMINE CAP 8MG ER Generic
GALANTAMINE CAP 16MG ER Generic
GALANTAMINE CAP 24MG ER Generic
MEMANTINE TAB HCL 5MG Generic
MEMANTINE TAB HCL 10MG Generic
MEMANTINE HC SOL 2MG/ML Generic
RIVASTIGMINE CAP 1.5MG Generic
RIVASTIGMINE CAP 3MG Generic
RIVASTIGMINE CAP 4.5MG Generic
RIVASTIGMINE CAP 6MG Generic
MULTIPLE SCLEROSIS AUBAGIO TAB 7MG Brand PA
AUBAGIO TAB 14MG Brand PA
AVONEX KIT 30MCG Brand QL 4 per month
AVONEX PEN KIT 30MCG Brand QL 1 per 30 days
AVONEX PREFL KIT 30MCG Brand QL 1 per 30 days
EXTAVIA INJ 0.3MG Brand QL 14 per month
GLATOPA (Generic Copaxone 20 mg) INJ 20MG/ML Generic QL 30 syringes per 30 days
GLATIRAMER (Generic Copaxone 40mg) INJ 40MG/ML Generic QL 12 syringes per 28 days
PLEGRIDY INJ PEN Brand QL 0.036mls per day
PLEGRIDY INJ Brand QL 0.036mls per day
PLEGRIDY INJ STARTER Brand QL 1 per 180 days
PLEGRIDY PEN INJ STARTER Brand QL 1 per 180 days
REBIF INJ 22/0.5 Brand QL 6ml per 30 days
REBIF INJ 44/0.5 Brand QL 6ml per 30 days
REBIF REBIDO INJ 22/0.5 Brand QL 6ml per 30 days
REBIF REBIDO INJ 44/0.5 Brand QL 6ml per 30 days
REBIF REBIDO INJ TITRATN Brand
REBIF TITRTN INJ PACK Brand
TECFIDERA MIS STARTER Brand PA
TECFIDERA CAP 120MG Brand PA
TECFIDERA CAP 240MG Brand PA
ZINBRYTA INJ 150MG/ML Brand PA QL 0.034mls per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
58
Drug Name Dosage Form/Strength Drug Type Requirements
SMOKING DETERRENTS
BUPROBAN TAB 150MG Generic QL 2 per day;180 days per
365 days
CHANTIX PAK 1MG Brand QL 2 per day; max benefit 90 days per 365 days
CHANTIX PAK 0.5& 1MG Brand QL 2 per day; max benefit 90 days per 365 days
CHANTIX TAB 0.5MG Brand QL 2 per day; max benefit 90 days per 365 days
CHANTIX TAB 1MG Brand QL 2 per day; max benefit 90 days per 365 days
NICOTINE GUM 2MG Generic QL 24 pieces per day max 180 days per 365 days
NICOTINE GUM 4MG Generic QL 24 pieces per day; 180
days per 365 days
NICOTINE PATCH 7MG/24HR Generic QL 1 patch per day; 180
days per 365 days
NICOTINE LOZENGE 2MG Generic QL 20 lozenges per day; 180 days per 365 days
NICOTINE LOZENGE 4MG Generic QL 20 lozenges per day; 180 days per 365 days
NICOTINE PATCH 21MG/24H Generic QL 1 patch per day;
180 days per 365 days
NICOTINE PATCH 14MG/24H Generic QL 1 patch per day;
180 days per 365 days
NICOTINE SYS KIT TRANSDER Generic
QL 1 patch per day; 180 days per 365 days; 56‐
day supply per fill
NICOTROL NASAL SPRAY 10MG/ML Brand
PA QL 4mls per day (80 sprays) 180‐day supply per
365 days
NICOTROL INHALER 10MG Brand PA QL
16 cartridges per day
ANALGESICS AND ANESTHETICSANALGESICS AND ANTIPYRETICS, MISC. (List not all encompassing. Representative products listed only)
ACETAMINOPHEN
CAP, CHEW, DROPS, ELIX, GELCAP, SOLN, SUPP, SUSP, TAB Generic
ACETAMINOPHEN/CAFF/PYRILAMINE TAB Generic
SALICYLATES (List not all encompassing. Representative products listed only)
ASPIRIN TAB, CHEW, TAB EC,
SUP Generic
CHILD ASPIRIN CHW 81MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
59
Drug Name Dosage Form/Strength Drug Type Requirements
CHOLINE MAG TRISALICYLATE TAB, LIQ Generic
SALSALATE TAB 500MG Generic
SALSALATE TAB 750MG Generic
OPIATE PARTIAL AGONISTS BUPRENORPHINE/NALOXONE SUB 2‐0.5MG Generic QL 3 per day
BUPRENORPHINE/NALOXONE SUB 8‐2MG Generic QL 3 per day
BUPRENORPHINE SUB 2MG Generic QL 3 per day
BUPRENORPHINE SUB 8MG Generic QL 3 per day
OPIATES APAP/CODEINE TAB 300‐15MG Generic QL 13 per day
APAP/CODEINE TAB 300‐30MG Generic QL 13 per day
APAP/CODEINE TAB 300‐60MG Generic QL 13 per day
APAP/CODEINE SOL 120‐12/5 Generic QL 166mls per day
CODEINE SULF TAB 30MG Generic QL 26 tabs per day
CODEINE SULF TAB 60MG Generic QL 13 tabs per day
DILAUDID‐HP INJ 250MG Brand
ENDOCET TAB 5‐325MG Generic QL 12 per day
ENDOCET TAB 7.5‐325 Generic QL 12 per day
ENDOCET TAB 7.5‐500M Generic QL 8 per day
ENDOCET TAB 10‐325MG Generic QL 12 per day
ENDOCET TAB 10‐650MG Generic QL 6 per day
ENDODAN TAB 4.8355‐325MG Generic QL 12 per day
FENTANYL DIS 12MCG/HR Generic PA QL 11 per month
FENTANYL DIS 25MCG/HR Generic PA QL 11 per month
FENTANYL DIS 37.5MCG Generic PA QL 11 per month
FENTANYL DIS 50MCG/HR Generic PA QL 11 per month
FENTANYL DIS 62.5MCG Generic PA QL 11 per month
FENTANYL DIS 75MCG/HR Generic PA QL 11 per month
FENTANYL DIS 87.5MCG Generic PA QL 11 per month
FENTANYL DIS 100MCG/H Generic PA QL 11 per month
HYDROCODONE/APAP TAB 10‐325MG Generic QL 12 per day
HYDROCODONE/APAP TAB 2.5‐500 Generic QL 8 per day
HYDROCODONE/APAP TAB 5‐500MG Generic QL 8 per day
HYDROCODONE/APAP TAB 7.5‐500 Generic QL 8 per day
HYDROCODONE/APAP TAB 7.5‐650 Generic QL 6 per day
HYDROCODONE/APAP TAB 10‐650MG Generic QL 6 per day
HYDROCODONE/APAP TAB 10‐660MG Generic QL 6 per day
HYDROCODONE/APAP TAB 7.5‐750 Generic QL 5 per day
HYDROCODONE/APAP TAB 5‐325MG Generic QL 12 per day
HYDROCODONE/APAP TAB 7.5‐325 Generic QL 12 per day
HYDROCODONE/APAP SOL 7.5‐325 Generic QL 184mls per day
HYDROCODONE/APAP SOL 5‐217/10 Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
60
Drug Name Dosage Form/Strength Drug Type Requirements
HYDROCODONE/IBUPROFEN TAB 7.5‐200 Generic QL 16 tabs per day
HYDROMORPHONE INJ 1MG/ML Generic QL 30mls per day
HYDROMORPHONE INJ 2MG/ML Generic QL 15mls per day
HYDROMORPHONE INJ 4MG/ML Generic QL 7mls per day
HYDROMORPHONE INJ 10MG/ML Generic QL 3mls per day
HYDROMORPHONE INJ 50MG/5ML Generic QL 3mls per day
HYDROMORPHONE INJ 500/50ML Generic QL 3mls per day
LORCET TAB 5‐325MG Generic QL 12 per day
LORCET HD TAB 10‐325MG Generic QL 12 per day
LORCET PLUS TAB 7.5‐325 Generic QL 12 per day
LORTAB TAB 10‐325MG Generic QL 12 per day
LORTAB TAB 5‐325MG Generic QL 12 per day
LORTAB TAB 7.5‐325 Generic QL 12 per day
MORPHINE SULFATE TAB 15MG Generic QL 8 tabs per day
MORPHINE SULFATE TAB 30MG Generic QL 4 tabs per day
MORPHINE SULFATE TAB 15MG ER Generic PA QL 3 per day
MORPHINE SULFATE TAB 30MG ER Generic PA QL 3 per day
MORPHINE SULFATE TAB 60MG ER Generic PA QL 3 per day
MORPHINE SULFATE TAB 100MG ER Generic PA QL 3 per day
MORPHINE SULFATE TAB 200MG ER Generic PA QL 3 per day
MORPHINE SULFATE INJ 1MG/ML Generic QL 120mls per day
MORPHINE SULFATE INJ 2MG/ML Generic QL 60mls per day
MORPHINE SULFATE INJ 4MG/ML Generic QL 30mls per day
MORPHINE SULFATE INJ 5MG/ML Generic QL 24mls per day
MORPHINE SULFATE INJ 150/30ML Generic QL 24mls per day
MORPHINE SULFATE INJ 25MG/ML Generic QL 4mls per day
MORPHINE SULFATE INJ 50MG/ML Generic QL 2mls per day
MORPHINE SULFATE SOL 10MG/5ML Generic QL 60mls per day
MORPHINE SULFATE SOL 20MG/5ML Generic QL 30mls per day
MORPHINE SULFATE SOL 100/5ML Generic QL 6mls per day
MORPHINE SULFATE SUP 5MG Generic 24 per day
MORPHINE SULFATE SUP 10MG Generic 12 per day
MORPHINE SULFATE SUP 20MG Generic 6 per day
MORPHINE SULFATE SUP 30MG Generic 4 per day
OXYCODONE/APAP CAP 5‐500MG Generic QL 8 per day
OXYCODONE/APAP TAB 5‐325MG Generic QL 12 per day
OXYCODONE/APAP SOLN 5‐325MG/5ML Generic QL 61mls per day
OXYCODONE/APAP TAB 7.5‐325 Generic QL 10 per day
OXYCODONE/APAP TAB 7.5‐500 Generic QL 8 per day
OXYCODONE/APAP TAB 10‐325MG Generic QL 8 per day
OXYCODONE/APAP TAB 10‐650MG Generic QL 6 per day
OXYCODONE/ASA TAB Generic QL 12 per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
61
Drug Name Dosage Form/Strength Drug Type Requirements
OXYCODONE TAB 5MG Generic QL 16 per day
OXYCODONE TAB 10MG Generic QL 8 per day
OXYCODONE TAB 15MG Generic QL 5 per day
OXYCODONE TAB 20MG Generic QL 4 per day
OXYCODONE TAB 30MG Generic QL 2 per day
OXYCODONE CON 100/5ML Generic QL 4mls per day
OXYCODONE CON 20MG/ML Generic QL 4mls per day
OXYCODONE SOL 5MG/5ML Generic QL 80mls per day
OXYCODONE TAB 10MG ER Generic PA QL 3 per day
OXYCODONE TAB 20MG ER Generic PA QL 3 per day
OXYCODONE TAB 40MG ER Generic PA QL 3 per day
OXYCODONE TAB 80MG ER Generic PA QL 3 per day
OXYCONTIN TAB 10MG CR Brand PA QL 3 per day
OXYCONTIN TAB 15MG CR Brand PA QL 3 per day
OXYCONTIN TAB 20MG CR Brand PA QL 3 per day
OXYCONTIN TAB 30MG CR Brand PA QL 3 per day
OXYCONTIN TAB 40MG CR Brand PA QL 3 per day
OXYCONTIN TAB 60MG CR Brand PA QL 3 per day
OXYCONTIN TAB 80MG CR Brand PA QL 3 per day
ROXICET TAB 5‐325MG Generic QL 12 per day
TRAMADL/APAP TAB 37.5‐325 Generic QL 10 per day
TRAMADOL HCL TAB 50MG Generic QL 8 per day
ANTI‐TNF INHIBITORS ENBREL INJ 25MG Brand PA QL 8mls per month
ENBREL INJ 25/0.5ML Brand PA QL 2mls per 28 days
ENBREL INJ 50MG/ML Brand PA QL 4mls per 28 days
ENBREL SRCLK INJ 50MG/ML Brand PA QL 4mls per 28 days
HUMIRA INJ 10MG/0.1 Brand PA QL 2 per 28 days
HUMIRA INJ 10MG/0.2 Brand PA QL 2 per 28 days
HUMIRA INJ 20/0.2ML Brand PA QL 2 per 28 days
HUMIRA KIT 20MG/0.4 Brand PA QL 2.4 per 28 days
HUMIRA INJ 40MG/0.4 Brand PA QL 2 per 28 days
HUMIRA KIT 40MG/0.8 Brand PA QL 2 per 28 days
HUMIRA PEDIA INJ CROHNS STARTER PACK 40MG/0.8ML Brand PA QL 3 per 180 days
HUMIRA PEDIA INJ CROHNS STARTER PACK 80MG/0.8ML Brand PA QL 3 per 180 days
HUMIRA PEDIA
INJ CROHNS STARTER PACK 80MG/0.8ML &
40MG/0.4ML Brand PA QL 2 per 180 days
HUMIRA PEN INJ 40MG/0.8 Brand PA QL 2 syringes per
month
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
62
Drug Name Dosage Form/Strength Drug Type Requirements
HUMIRA PEN INJ CROHNS Brand PA QL 6 syringes per 180
days
HUMIRA PEN INJ PSORIASI Brand PA QL 4 syringes per 180
days
DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS LEFLUNOMIDE TAB 10MG Generic
LEFLUNOMIDE TAB 20MG Generic
OTEZLA TAB 30MG Brand PA QL 2 tabs per day
OTEZLA TAB 10/20/30 Brand PA QL 1 per 180 days
MISCL BIOLOGIC ACTEMRA INJ 162/0.9 Brand PA QL 3.6mls per 31 days
COSENTYX INJ 150MG/ML Brand PA QL 1 per month
COSENTYX PEN INJ 150MG/ML Brand PA QL 1 per month
TALTZ INJ 80MG/ML Brand PA QL 0.036mls per day
NONSTEROIDAL ANTI‐INFLAMMATORY (NSAID) (List not all encompassing. Representative products listed only)
CELECOXIB CAP 100MG Generic PA QL 1 per day
CELECOXIB CAP 200MG Generic PA QL 2 per day
DICLOFEN POTASSIUM TAB 50MG Generic
DICLOFENAC TAB 25MG DR Generic
DICLOFENAC TAB 50MG DR Generic
DICLOFENAC TAB 75MG DR Generic
DICLOFENAC TAB 100MG ER Generic
FLURBIPROFEN TAB 50MG Generic
ETODOLAC CAP 200MG Generic ST (meloxicam)
ETODOLAC CAP 300MG Generic ST (meloxicam)
ETODOLAC TAB 400MG Generic ST (meloxicam)
ETODOLAC TAB 500MG Generic ST (meloxicam)
FLURBIPROFEN TAB 100MG Generic
GENPRIL TAB 200MG Generic
IBU‐DROPS DRO 40MG/ML Generic
IBUPROFEN CAP 200MG Generic
IBUPROFEN TAB 200MG Generic
IBUPROFEN TAB 400MG Generic
IBUPROFEN TAB 600MG Generic
IBUPROFEN TAB 800MG Generic
IBUPROFEN DRO 50/1.25 Generic
IBUPROFEN SUS 100/5ML Generic
IBUPROFEN IB TAB 200MG Generic
IBUPROFEN JR CHW 100MG Generic
INDOCIN SUS 25MG/5ML Brand
INDOMETHACIN CAP 25MG Generic AR PA required > 64
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
63
Drug Name Dosage Form/Strength Drug Type Requirements
INDOMETHACIN CAP 50MG Generic AR PA required > 64
INDOMETHACIN CAP 75MG ER Generic AR PA required > 64
KETOPROFEN CAP 50MG Generic
KETOPROFEN CAP 75MG Generic
MEDI‐PROFEN CAP 200MG Generic
MEDI‐PROFEN TAB 200MG Generic
MEDI‐PROFEN SUS 40MG/ML Generic
MEDI‐PROFEN SUS 100/5ML Generic
MELOXICAM TAB 7.5MG Generic QL 2 per day
MELOXICAM TAB 15MG Generic
MIDOL CAP 200MG Generic
NABUMETONE TAB 500MG Generic
NABUMETONE TAB 750MG Generic
NAPROXEN TAB 250MG Generic
NAPROXEN TAB 375MG Generic
NAPROXEN TAB 500MG Generic
NAPROXEN SUS 125/5ML Generic
PROVIL TAB 200MG Generic
SULINDAC TAB 150MG Generic
SULINDAC TAB 200MG Generic
MIGRAINE PRODUCTS AIMOVIG INJ 70MG/ML Brand PA QL 2 per 56 days
DIHYDROERGOT INJ 1MG/ML Generic
DIHYDROERGOT SPR 4MG/ML Generic QL 24mls per 30 days
ERGOMAR SUB 2MG Brand
TRIPTANS NARATRIPTAN TAB 1MG Generic QL 9 per 30 days
NARATRIPTAN TAB 2.5MG Generic QL 9 per 30 days
RIZATRIPTAN TAB 5MG Generic QL 12 per 30 days
RIZATRIPTAN TAB 5MG ODT Generic QL 12 per 30 days
RIZATRIPTAN TAB 10MG Generic QL 12 per 30 days
RIZATRIPTAN TAB 10MG ODT Generic QL 12 per 30 days
SUMATRIPTAN SPR 5MG/ACT Generic QL 6 per 30 days
SUMATRIPTAN SPR 20MG/ACT Generic QL 6 per 30 days
SUMATRIPTAN TAB 25MG Generic QL 9 per 30 days
SUMATRIPTAN TAB 50MG Generic QL 9 per 30 days
SUMATRIPTAN TAB 100MG Generic QL 9 per 30 days
SUMATRIPTAN INJ 4MG/0.5 Generic
SUMATRIPTAN INJ 6MG/0.5 Generic QL 3mls per 30 days
ZOLMITRIPTAN TAB 2.5MG Generic QL 12 per 30 days
ZOLMITRIPTAN TAB 5MG Generic QL 12 per 30 days
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
64
Drug Name Dosage Form/Strength Drug Type Requirements
ANTIGOUT AGENTS ALLOPURINOL TAB 100MG Generic
ALLOPURINOL TAB 300MG Generic
COLCHICINE TAB 0.6MG Generic
COLCRYS TAB 0.6MG Brand
URICOSURIC AGENTS PROBEN/COLCH TAB 500‐0.5 Generic
PROBENECID TAB 500MG Generic
CARBAMAZEPINE TAB 200MG Generic
CARBAMAZEPINE CHW 100MG Generic
CARBAMAZEPINE SUS 100/5ML Generic
CARBAMAZEPINE CAP 100MG ER Generic
CARBAMAZEPINE CAP 200MG ER Generic
CARBAMAZEPINE CAP 300MG ER Generic
CARBAMAZEPINE TAB 100MG ER Generic
CARBAMAZEPINE TAB 200MG ER Generic
CARBAMAZEPINE TAB 400MG ER Generic
CELONTIN CAP 300MG Brand
DILANTIN CHW 50MG Brand
DILANTIN CAP 30MG Brand
DILANTIN CAP 100MG Brand
DILANTIN‐125 SUS 125/5ML Brand
EPITOL TAB 200MG Generic
ETHOSUXIMIDE CAP 250MG Generic
ETHOSUXIMIDE SOL 250/5ML Generic
FELBAMATE TAB 400MG Generic
FELBAMATE TAB 600MG Generic
FELBAMATE SUS 600/5ML Generic
FOSPHENYTOIN INJ 100/2ML Generic
FOSPHENYTOIN INJ 500/10ML Generic
GABAPENTIN CAP 100MG Generic
GABAPENTIN CAP 300MG Generic
GABAPENTIN CAP 400MG Generic
GABAPENTIN TAB 600MG Generic
GABAPENTIN TAB 800MG Generic
GABAPENTIN SOL 250/5ML Generic
GABITRIL TAB 12MG Brand
GABITRIL TAB 16MG Brand
LEVETIRACETA SOL 100MG/ML Generic
LEVETIRACETA TAB 500MG Generic
LEVETIRACETA TAB 750MG Generic
LEVETIRACETA TAB 1000MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
65
Drug Name Dosage Form/Strength Drug Type Requirements
LEVETIRACETA SOL 100MG/ML Generic
LEVETIRACETA SOL 500/5ML Generic
LEVETIRACETA TAB 500MG ER Generic
LEVETIRACETA TAB 750MG ER Generic
LYRICA CAP 150MG Brand PA QL 3 per day
LYRICA CAP 25MG Brand PA QL 3 per day
LYRICA CAP 50MG Brand PA QL 3 per day
LYRICA CAP 75MG Brand PA QL 3 per day
LYRICA CAP 100MG Brand PA QL 3 per day
LYRICA CAP 200MG Brand PA QL 3 per day
LYRICA CAP 225MG Brand PA QL 2 per day
LYRICA CAP 300MG Brand PA QL 2 per day
LYRICA SOL 20MG/ML Brand PA
OXCARBAZEPIN TAB 150MG Generic
OXCARBAZEPIN TAB 300MG Generic
OXCARBAZEPIN TAB 600MG Generic
OXCARBAZEPIN SUS 300MG/5M Generic AR PA > 6 years of age
OXCARBAZEPIN SUS 300MG/5M Generic AR PA > 6 years of age
PEGANONE TAB 250MG Brand
PHENYTOIN CHW 50MG Generic
PHENYTOIN SUS 125/5ML Generic
PHENYTOIN INJ 50MG/ML Generic
PHENYTOIN EX CAP 100MG Generic
PHENYTOIN EX CAP 200MG Generic
PHENYTOIN EX CAP 300MG Generic
PRIMIDONE TAB 50MG Generic
PRIMIDONE TAB 250MG Generic
SABRIL TAB 500MG Brand PA
TIAGABINE TAB 2MG Generic
TIAGABINE TAB 4MG Generic
TOPIRAGEN TAB 25MG Generic
TOPIRAGEN TAB 50MG Generic
TOPIRAGEN TAB 100MG Generic
TOPIRAGEN TAB 200MG Generic
TOPIRAMATE TAB 25MG Generic
TOPIRAMATE TAB 50MG Generic
TOPIRAMATE TAB 100MG Generic
TOPIRAMATE TAB 200MG Generic
TOPIRAMATE CAP 15MG Generic
TOPIRAMATE CAP 25MG Generic
TRILEPTAL SUS 300MG/5M Brand AR PA > 6 years of age
VIGABATRIN (GENERIC SABRIL) PAK 500MG Generic PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
66
Drug Name Dosage Form/Strength Drug Type Requirements
VIMPAT TAB 100MG Brand PA; QL 2 tabs per day
VIMPAT TAB 150MG Brand PA
VIMPAT TAB 50MG Brand PA
VIMPAT TAB 200MG Brand PA
VIMPAT INJ 200MG/20 Brand PA
VIMPAT SOL 10MG/ML Generic PA
ZONISAMIDE CAP 25MG Generic
ZONISAMIDE CAP 50MG Generic
ZONISAMIDE CAP 100MG Generic
NEUROMUSCULAR DRUGS ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE TAB 0.5MG Generic AR PA required >64
BENZTROPINE TAB 1MG Generic AR PA required >64
BENZTROPINE TAB 2MG Generic AR PA required >64
BENZTROPINE INJ 1MG/ML Generic
TRIHEXYPHEN TAB 2MG Generic AR PA required >64
TRIHEXYPHEN TAB 5MG Generic AR PA required >64
TRIHEXYPHEN ELX 0.4MG/ML Generic AR PA required >64
ANTIPARKINSON ENTACAPONE TAB 200MG Generic
SELEGILINE CAP 5MG Generic
SELEGILINE TAB 5MG Generic
TOLCAPONE TAB 100MG Generic
DOPAMINERGICS BROMOCRIPTIN CAP 5MG Generic
BROMOCRIPTIN TAB 2.5MG Generic
CARBIDOPA/LEVODOPA TAB 10‐100MG Generic
CARBIDOPA/LEVODOPA TAB 25‐100MG Generic
CARBIDOPA/LEVODOPA TAB 25‐250MG Generic
CARBIDOPA/LEVODOPA ER TAB 25‐100MG Generic
CARBIDOPA/LEVODOPA ER TAB 50‐200MG Generic
PRAMIPEXOLE TAB 0.125MG Generic QL 3 per day
PRAMIPEXOLE TAB 0.25MG Generic QL 3 per day
PRAMIPEXOLE TAB 0.5MG Generic QL 3 per day
PRAMIPEXOLE TAB 0.75MG Generic QL 3 per day
PRAMIPEXOLE TAB 1MG Generic QL 3 per day
PRAMIPEXOLE TAB 1.5MG Generic QL 3 per day
ROPINIROLE TAB 0.25MG Generic
ROPINIROLE TAB 0.5MG Generic
ROPINIROLE TAB 1MG Generic
ROPINIROLE TAB 2MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
67
Drug Name Dosage Form/Strength Drug Type Requirements
ROPINIROLE TAB 3MG Generic
ROPINIROLE TAB 4MG Generic
ROPINIROLE TAB 5MG Generic
CENTRAL NERVOUS SYSTEM AGENTS, MISC. RILUZOLE TAB 50MG Generic
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT BACLOFEN TAB 10MG Generic
BACLOFEN TAB 20MG Generic
CHLORZOXAZONE TAB 500MG Generic AR PA required >64
CYCLOBENZAPRINE TAB 5MG Generic AR PA required >64
CYCLOBENZAPRINE TAB 10MG Generic AR PA required >64
METHOCARBAMOL TAB 500MG Generic AR PA required >64
METHOCARBAMOL TAB 750MG Generic AR PA required >64
TIZANIDINE TAB 2MG Generic
TIZANIDINE TAB 4MG Generic
DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS DANTROLENE CAP 25MG Generic
DANTROLENE CAP 50MG Generic
DANTROLENE CAP 100MG Generic
NUTRITIONAL PRODUCTS VITAMIN B COMPLEX B1 NATURAL TAB 250MG Brand
CYANOCOBALAM INJ 1000MCG Generic
ENDUR‐ACIN TAB 250MG SR Generic
ENDUR‐ACIN TAB 500MG SR Generic
EQL B‐12 TAB 1000MCG Generic
FOLIC ACID TAB 400MCG Generic 90‐day supply available
FOLIC ACID TAB 800MCG Generic 90‐day supply available
FOLIC ACID TAB 1MG Generic 90‐day supply available
FOLIC ACID TAB 1000MCG Generic 90‐day supply available
FOLIC ACID INJ 5MG/ML Generic 90‐day supply available
FOLIC ACID TAB XTRA Brand 90‐day supply available
NIACIN CAP 250MG TR Generic
NIACIN CAP 250MG TD Generic
NIACIN CAP 250MG ER Generic
NIACIN CAP 250MG SR Generic
NIACIN CAP 500MG TR Generic
NIACIN CAP 500MG SR Generic
NIACIN TAB 50MG Generic
NIACIN TAB 100MG Generic
NIACIN TAB 250MG Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
68
Drug Name Dosage Form/Strength Drug Type Requirements
NIACIN TAB 500MG Generic
NIACIN TAB 250MG SR Generic
NIACIN TAB 500MG CR Generic
NIACIN TAB 500MG ER Generic
NIACIN TAB 500MG PR Generic
NIACIN TAB 750MG TR Generic
NIACIN ER CAP 250MG Generic
NIACIN ER CAP 500MG Generic
NIACIN TR TAB 1000MG Generic
NIACINAMIDE TAB 100MG Generic
NIACINAMIDE TAB 500MG Generic
PYRIDOXINE TAB 25MG Generic
PYRIDOXINE TAB 50MG Generic
PYRIDOXINE TAB 100MG Generic
SLO‐NIACIN TAB 250MG CR Generic
THIAMINE HCL TAB 100MG Generic
VITAMIN B‐1 TAB 50MG Generic
VITAMIN B‐1 TAB 100MG Generic
VITAMIN B‐12 TAB 50MCG Generic
VITAMIN B‐12 TAB 100MCG Generic
VITAMIN B‐12 TAB 250MCG Generic
VITAMIN B‐12 TAB 500MCG Generic
VITAMIN B‐12 TAB 1000MCG Generic
VITAMIN B‐12 TAB 2000MCG Generic
VITAMIN B‐12 TAB 1000 CR Generic
VITAMIN B‐12 TAB 1000 TR Generic
VITAMIN B‐12 SUB 500MCG Generic
VITAMIN B‐12 SUB 1000MCG Generic
MULTIVITAMIN PREPARATIONS ACD/FLUORIDE DRO 0.25MG Generic AR PA required > 2
B COMPLEX WITH VITAMIN C TAB Generic
B COMPLEX W/C & FOLIC ACID TAB Generic
BIOTIN FORTE TAB Brand
BPROTECTED SOL TRI‐VITE Generic AR PA required > 2
CALCIUM SOFT CHEW Generic
CALNA TAB Brand AR PA required >50;
covered for females only
CAVAN‐EC SOD MIS DHA Generic AR PA required >50;
covered for females only
CENTRUM SPEC PAK PRENATAL Brand AR PA required >50;
covered for females only
CHEW CALCIUM CHW Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
69
Drug Name Dosage Form/Strength Drug Type Requirements
CITRANATAL PAK DHA Brand AR PA required >50;
covered for females only
CITRANATAL PAK ASSURE Brand AR PA required >50;
covered for females only
CL PRENATAL TAB 28‐0.8MG Generic AR PA required >50;
covered for females only
COMP PRNATAL MIS DHA Generic AR PA required >50;
covered for females only
COMPL PRENAT MIS +DHA Brand AR PA required >50;
covered for females only
COMPLETENATE CHW Generic AR PA required >50;
covered for females only
CO‐NATAL FA TAB 29‐1MG Generic AR PA required >50;
covered for females only
CONCEPT OB CAP Brand AR PA required >50;
covered for females only
CVS PRENATAL TAB 28‐0.8MG Brand AR PA required >50;
covered for females only
CVS PRENATAL TAB Generic AR PA required >50;
covered for females only
CVS STRESS TAB FORMULA Generic
CVS SUPER B TAB COMPLX/C Generic
DIALYVITE TAB 800 Generic
DIALYVITE TAB Generic
DIALYVITE/ TAB ZINC Brand
ELITE‐OB TAB Generic AR PA required >50;
covered for females only
ENFAMIL MIS EXPECTA Brand AR PA required >50;
covered for females only
EQL PRENATAL TAB FORMULA Generic AR PA required >50;
covered for females only
FOCALGIN CA MIS Brand AR PA required >50;
covered for females only
FOLCAPS CAP OMEGA 3 Brand AR PA required >50;
covered for females only
FOLIVANE‐OB CAP Brand AR PA required >50;
covered for females only
FOLIVANE‐PRX CAP DHA NF Brand AR PA required >50;
covered for females only
FULL SPECT TAB B/ VIT C Generic
GESTICARE PAK DHA Brand AR PA required >50;
covered for females only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
70
Drug Name Dosage Form/Strength Drug Type Requirements
GNP PRENATAL TAB 28‐0.8MG Generic AR PA required >50;
covered for females only
GOODSENSE TAB 28‐0.8MG Brand AR PA required >50;
covered for females only
HM B COMPLEX TAB WITH C Generic
HM PRENATAL TAB Brand AR PA required >50;
covered for females only
INATAL ADV TAB Generic AR PA required >50;
covered for females only
INATAL GT TAB Generic AR PA required >50;
covered for females only
INATAL ULTRA TAB Generic AR PA required >50;
covered for females only
KP B COMPLEX TAB /C Generic
KP PRENATAL TAB MULTIVIT Brand AR PA required >50;
covered for females only
KPN PRENATAL TAB Brand AR PA required >50;
covered for females only
MISSION PREN TAB Brand AR PA required >50;
covered for females only
MISSION PREN TAB HP Generic AR PA required >50;
covered for females only
MULTI PRENAT TAB Generic AR PA required >50;
covered for females only
MULTI‐VIT/FE DRO /FL 0.25 Generic AR PA required > 2
MULTI‐VIT/FL DRO 0.25MG Generic AR PA required > 2
MULTI‐VIT/FL DRO 0.5MG/ML Generic AR PA required > 2
MULTI‐VIT/FL DRO /FE 0.25 Generic AR PA required > 2
MULTI‐VIT/FL CHEW TAB 0.5MG Generic AR Covered for members 18
and younger
MULTI‐VIT/FL CHEW TAB 0.25MG Generic AR Covered for members 18
and younger
MULTI‐VIT/FL CHEW TAB 1MG Generic AR Covered for members 18
and younger
M‐VIT TAB 27‐1MG Generic AR PA required >50;
covered for females only
MYNATAL CAP Brand AR PA required >50;
covered for females only
MYNATAL TAB Generic AR PA required >50;
covered for females only
MYNATAL TAB ADVANCE Generic AR PA required >50;
covered for females only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
71
Drug Name Dosage Form/Strength Drug Type Requirements
MYNATAL PLUS TAB Generic AR PA required >50;
covered for females only
MYNATAL‐Z TAB Generic AR PA required >50;
covered for females only
MYNEPHROCAPS CAP Generic
NATAL‐V RX TAB 29‐1MG Brand AR PA required >50;
covered for females only
NATALVIRT CA PAK Brand AR PA required >50;
covered for females only
NATALVIT TAB 75‐1MG Brand AR PA required >50;
covered for females only
NEPHPLEX RX TAB Brand
NEPHRONEX TAB 1MG Generic
NEPHRO‐VITE TAB Brand
NIVA‐PLUS TAB Brand AR PA required >50;
covered for females only
NOVAFERRUM DRO 10MG/ML Generic AR PA required > 2
OB COMPLETE TAB Brand AR PA required >50;
covered for females only
OB‐NATAL ONE CAP 27‐1MG Generic AR PA required >50;
covered for females only
O‐CAL TAB PRENATAL Brand AR PA required >50;
covered for females only
O‐CAL FA TAB Brand AR PA required >50;
covered for females only
PNV FE FUM TAB DOC/FA Brand AR PA required >50;
covered for females only
PNV FOLIC AC TAB + IRON Brand AR PA required >50;
covered for females only
PNV OB+DHA PAK Brand AR PA required >50;
covered for females only
PNV PRENATAL TAB PLUS Brand AR PA required >50;
covered for females only
PNV TABS TAB 29‐1MG Brand AR PA required >50;
covered for females only
PNV‐DHA CAP Generic AR PA required >50;
covered for females only
PNV‐SELECT TAB Brand AR PA required >50;
covered for females only
PNV‐VP‐U CAP 106.5‐1 Brand AR PA required >50;
covered for females only
POLY‐VI‐SOL DRO Brand AR PA required > 2
POLY‐VI‐SOL DRO/IRON Brand AR PA required > 2
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
72
Drug Name Dosage Form/Strength Drug Type Requirements
POLY‐VITA DRO Generic AR PA required > 2
POLY‐VITA DRO/IRON Generic AR PA required > 2
POLYVITAMIN DRO Generic AR PA required > 2
POLYVITAMIN DRO/IRON Generic AR PA required > 2
POLY‐VITE DRO Generic AR PA required > 2
POLY‐VITE SOL/IRON Generic AR PA required > 2
PRENAISSANCE PAK DHA Brand AR PA required >50;
covered for females only
PRENAISSANCE PAK PROMISE Brand AR PA required >50;
covered for females only
PRENAPLUS TAB Generic AR PA required >50;
covered for females only
PRENAT PLUS TAB 27‐1MG Brand AR PA required >50;
covered for females only
PRENATABS FA TAB Generic AR PA required >50;
covered for females only
PRENATABS RX TAB Generic AR PA required >50;
covered for females only
PRENATAL TAB Generic AR PA required >50;
covered for females only
PRENATAL TAB FORTE Generic AR PA required >50;
covered for females only
PRENATAL TAB VITAMINS Generic AR PA required >50;
covered for females only
PRENATAL TAB PLUS FE Brand AR PA required >50;
covered for females only
PRENATAL TAB COMPLETE Brand AR PA required >50;
covered for females only
PRENATAL TAB 27‐0.8MG Generic AR PA required >50;
covered for females only
PRENATAL TAB LOW IRON Generic AR PA required >50;
covered for females only
PRENATAL TAB 27‐1MG Brand AR PA required >50;
covered for females only
PRENATAL TAB PLUS Brand AR PA required >50;
covered for females only
PRENATAL TAB 28‐0.8MG Generic AR PA required >50;
covered for females only
PRENATAL TAB FORMULA Generic AR PA required >50;
covered for females only
PRENATAL TAB PLUS DHA Brand AR PA required >50;
covered for females only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
73
Drug Name Dosage Form/Strength Drug Type Requirements
PRENATAL 1 CAP Brand AR PA required >50;
covered for females only
PRENATAL 19 CHW 29‐1MG Brand AR PA required >50;
covered for females only
PRENATAL 19 CHW TAB Generic AR PA required >50;
covered for females only
PRENATAL 19 TAB 29‐1MG Brand AR PA required >50;
covered for females only
PRENATAL AD TAB Generic AR PA required >50;
covered for females only
PRENATAL FRM TAB A‐FREE Brand AR PA required >50;
covered for females only
PRENATAL MV MIS + DHA Brand AR PA required >50;
covered for females only
PRENATAL VIT TAB 28‐0.8MG Generic AR PA required >50;
covered for females only
PRENATAL/FE TAB Generic AR PA required >50;
covered for females only
PRENATAL+DHA MIS Brand AR PA required >50;
covered for females only
PRENATAL+DHA MIS WOMENS Brand AR PA required >50;
covered for females only
PRENATAL+FE TAB 29‐1MG Brand AR PA required >50;
covered for females only
PRENATAL‐U CAP 106.5‐1 Generic AR PA required >50;
covered for females only
PRENATL MULT CAP + DHA Brand AR PA required >50;
covered for females only
PREPLUS TAB 27‐1MG Brand AR PA required >50;
covered for females only
PRETAB TAB 29‐1MG Brand AR PA required >50;
covered for females only
PX PRENATAL TAB MULTIVIT Generic AR PA required >50;
covered for females only
QC PRENATAL TAB 28‐0.8MG Brand AR PA required >50;
covered for females only
QUFLORA PED DRO 0.25MG Generic AR PA required > 2
QUFLORA PED DRO 0.5MG/ML Generic AR PA required > 2
RA CALCIUM CHW CARAMEL Generic
RA CALCIUM CHW MLK CHOC Generic
RA PRENATAL TAB FORMULA Brand AR PA required >50;
covered for females only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
74
Drug Name Dosage Form/Strength Drug Type Requirements
RA PRENATAL TAB 28‐0.8MG Generic AR PA required >50;
covered for females only
RENAL CAP SOFTGEL Generic
RENAL TAB MULTIVIT Generic
RENALPREN CAP Generic
RENA‐VITE TAB Generic
RENA‐VITE RX TAB Generic
RENO CAP Generic
RULAVITE DHA CAP Brand AR PA required >50;
covered for females only
SE‐NATAL 19 CHW Generic AR PA required >50;
covered for females only
SE‐TAN DHA CAP Generic AR PA required >50;
covered for females only
SIMILAC PREN PAK EARLY SH Brand AR PA required >50;
covered for females only
SM CALCIUM CHW Generic
SM PRENATAL TAB VITAMINS Generic AR PA required >50;
covered for females only
STRESS 500 TAB B‐COMPLE Generic
STRESS FORM TAB Generic
STUART PREN TAB Brand AR PA required >50;
covered for females only
SUPER B‐COMP TAB VIT C/FA Generic
SUPER B‐COMP TAB /VIT C Generic
SUPERPLEX‐T TAB Generic
TH PRENATAL TAB VITAMINS Brand AR PA required >50;
covered for females only
THERANATAL MIS COMPLETE Brand AR PA required >50;
covered for females only
THERANATAL MIS PLUS Brand AR PA required >50;
covered for females only
THRIVITE 19 TAB Brand AR PA required >50;
covered for females only
THRIVITE RX TAB 29‐1MG Brand AR PA required >50;
covered for females only
TOTAL B/C TAB Generic
TRIADVANCE TAB Generic AR PA required >50;
covered for females only
TRICARE TAB PRENATAL Generic AR PA required >50;
covered for females only
TRINATAL TAB ULTRA Brand AR PA required >50;
covered for females only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
75
Drug Name Dosage Form/Strength Drug Type Requirements
TRINATAL GT TAB Brand AR PA required >50;
covered for females only
TRINATAL RX TAB 1 Generic AR PA required >50;
covered for females only
TRINATE TAB Generic AR PA required >50;
covered for females only
TRIPHROCAPS CAP Generic
TRI‐VI‐SOL SOL Brand AR PA required > 2
TRI‐VIT/FL DRO 0.25MG Generic AR PA required > 2
TRI‐VIT/FL DRO 0.5MG Generic AR PA required > 2
TRI‐VIT/FLUO DRO 0.25MG Generic AR PA required > 2
TRI‐VIT/FLUO DRO 0.5MG Generic AR PA required > 2
TRI‐VITA SOL Generic AR PA required > 2
TRI‐VITA/FL DRO 0.25MG Generic AR PA required > 2
TRI‐VITAMIN DRO Generic AR PA required > 2
ULTIMATECARE CAP ONE Generic AR PA required >50;
covered for females only
ULTRA TABS TAB Generic AR PA required >50;
covered for females only
VENATAL‐FA TAB Brand AR PA required >50;
covered for females only
VINATE AZ EX TAB Brand AR PA required >50;
covered for females only
VINATE CAL TAB Brand AR PA required >50;
covered for females only
VINATE GT TAB Generic AR PA required >50;
covered for females only
VINATE IC CAP Generic AR PA required >50;
covered for females only
VINATE II TAB Generic AR PA required >50;
covered for females only
VINATE ONE TAB Generic AR PA required >50;
covered for females only
VINATE ULTRA TAB Generic AR PA required >50;
covered for females only
VIRT NATE TAB Brand AR PA required >50;
covered for females only
VIRT NATE TAB 28‐1MG Brand AR PA required >50;
covered for females only
VIRT‐ADVANCE TAB 90‐1MG Brand AR PA required >50;
covered for females only
VIRT‐CAPS CAP Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
76
Drug Name Dosage Form/Strength Drug Type Requirements
VIRT‐CARE CAP ONE Brand AR PA required >50;
covered for females only
VIRT‐PN TAB Brand AR PA required >50;
covered for females only
VIRT‐PN DHA CAP Brand AR PA required >50;
covered for females only
VIRT‐VITE GT TAB 90‐1MG Brand AR PA required >50;
covered for females only
VITA‐BEE/C TAB Generic
VITAFOL‐OB TAB 65‐1MG Generic AR PA required >50;
covered for females only
VITAFOL‐PN TAB Brand AR PA required >50;
covered for females only
VOL‐CARE RX TAB Generic
VOL‐NATE TAB Brand AR PA required >50;
covered for females only
VOL‐PLUS TAB Brand AR PA required >50;
covered for females only
VOL‐TAB RX TAB Brand AR PA required >50;
covered for females only
VP‐ERA OB PAK PLUS Brand AR PA required >50;
covered for females only
VP‐VITE RX TAB Generic
ZATEAN‐PN TAB Brand AR PA required >50;
covered for females only
ZATEAN‐PN CAP DHA Brand AR PA required >50;
covered for females only
FLUORIDE CAVAREST GEL 1.1% Generic AR > 18 not covered
CONTROLRX CRE 1.1% Generic AR > 18 not covered
DENTA 5000 CRE PLUS Generic AR > 18 not covered
DENTA 5000 CRE PLUS 2PK Generic AR > 18 not covered
DENTAGEL GEL 1.1% Generic AR > 18 not covered
FLUORABON DRO Brand AR > 18 not covered
FLUOR‐A‐DAY DRO 0.125MG Generic AR > 18 not covered
FLUOR‐A‐DAY CHW 0.25MG F Brand AR > 18 not covered
FLUOR‐A‐DAY CHW 0.5MG F Brand AR > 18 not covered
FLUOR‐A‐DAY CHW 1MG F Brand AR > 18 not covered
FLUORIDE CHW 0.25MG F Generic AR > 18 not covered
FLUORIDE CHW 0.5MG F Generic AR > 18 not covered
FLUORIDE CHW 1MG F Generic AR > 18 not covered
FLUORIDEX GEL 1.1% Generic AR > 18 not covered
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
77
Drug Name Dosage Form/Strength Drug Type Requirements
FLUORIDEX GEL WHITENIN Generic AR > 18 not covered
FLUORITAB CHW 0.25MG F Generic AR > 18 not covered
FLUORITAB CHW 0.5MG F Generic AR > 18 not covered
FLUORITAB CHW 1MG F Generic AR > 18 not covered
FLUORITAB CHW 2.2MG Generic AR > 18 not covered
FLUORITAB DRO 0.125MG Generic AR > 18 not covered
FLURA‐DROPS DRO 0.125MG Generic AR > 18 not covered
FLURA‐DROPS DRO 0.25MG F Generic AR > 18 not covered
KARIDIUM DRO 0.125MG Generic AR > 18 not covered
KARIGEL GEL 0.5% Generic AR > 18 not covered
KARIGEL‐N GEL 1.1% Generic AR > 18 not covered
LUDENT CHW 0.25MG F Generic AR > 18 not covered
LUDENT CHW 0.5MG F Generic AR > 18 not covered
LUDENT CHW 1MG F Generic AR > 18 not covered
NAFRINSE CHW 1MG F Generic AR > 18 not covered
NAFRINSE DRO 0.125MG Generic AR > 18 not covered
NEUTRAGARD GEL 1.1% Generic AR > 18 not covered
PHOS‐FLUR GEL 1.1% Generic AR > 18 not covered
SF GEL 1.1% Generic AR > 18 not covered
SF 5000 PLUS CRE 1.1% Generic AR > 18 not covered
SOD FLUORIDE CHW 0.25MG F Generic AR > 18 not covered
SOD FLUORIDE CHW 0.5MG F Generic AR > 18 not covered
SOD FLUORIDE CHW 1.1MG Generic AR > 18 not covered
SOD FLUORIDE CHW 1MG F Generic AR > 18 not covered
SOD FLUORIDE CHW 2.2MG Generic AR > 18 not covered
SOD FLUORIDE DRO 0.5MG/ML Generic AR > 18 not covered
REPLACEMENT PREPARATIONS CALCIUM CARBONATE CHW 500MG Generic
CALCIUM CARBONATE CHW 600‐400 Generic
CALCIUM W/VIT D & POTASSIUM CHEW TAB 500MG‐100 Generic
CALCIUM/PLUS D TAB Generic
CALCIUM CITRATE TAB Generic
CALCIUM W/VIT D TAB 600MG‐200 Generic
CALCIUM CITRATE PLUS VIT D TAB Generic
CALCIUM PLUS D/ MINERALS TAB Generic
CALCIUM PLUS D3 TAB Generic
CALCIUM CARBONATE CHEW TAB Generic
CALCIUM CARBONATE 1250/5ML SUSP Generic
CALCIUM CARBONATE TAB Generic
CALCIUM CITRATE PLUS VITAMIN D TAB Generic
CALCIUM GLUCONATE TAB Generic
CALCIUM LACTATE TAB Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
78
Drug Name Dosage Form/Strength Drug Type Requirements
CERALYTE 70 LIQ Brand
CERASPORT SOL Brand
CERASPORT SOL EX1 Brand
CIT CALC/D TAB 200‐250 Generic
CIT CALC/D TAB 315‐250 Generic
D5W/NACL INJ 0.45% Generic
D5W/NACL INJ 0.9% Generic
EFFER‐K TAB 25MEQ EF Generic
ENFALYTE SOL Brand
ENFAMIL SOL ENFALYTE Brand
FLUSH SYRING INJ 0.9% Generic
GERBER SOL REPLENSH Generic
GNP CALCIUM TAB 500/D Generic
K‐EFFERVESCE TAB 25MEQ EF Generic
KLOR‐CON 10 TAB 10MEQ ER Generic
KLOR‐CON 8 TAB 8MEQ ER Generic
KLOR‐CON M10 TAB 10MEQ ER Generic
KLOR‐CON M20 TAB 20MEQ ER Generic
KLOR‐CON SPR CAP 8MEQ Generic
KLOR‐CON SPR CAP 10MEQ Generic
KLOR‐CON/EF TAB 25MEQ EF Generic
KLOR‐CON/EF TAB 25MEQ FR Generic
KP CALCIUM TAB 600+D Generic
K‐PHOS TAB Brand
K‐PRIME TAB 25MEQ EF Generic
K‐SOL SOL 10% Generic
K‐SOL SOL 20% Generic
K‐VESCENT TAB 25MEQ EF Generic
K‐VESCENT POW 20MEQ Generic
LIQ CA/VIT D CAP 600MG Generic
MAG OXIDE TAB 400MG Generic
MAG OXIDE TAB 500MG Generic
NATURALYTE SOL Generic
NORML SALINE INJ IV FLUSH Generic
ORAL ELECTRO SOL H‐E‐B Generic
ORALYTE SOL Generic
OS‐CAL CHW 500‐600 Generic
OS‐CAL 500 CHW Generic
OSCAL TAB 500/200 D‐3 Generic
OYS SHELL CA TAB 500MG Generic
OYS SHELL+D TAB 250‐125 Generic
OYS SHELL+D CHW 500‐400 Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
79
Drug Name Dosage Form/Strength Drug Type Requirements
OYSCO 500 + D CHW Generic
OYST CAL/D TAB 250MG Generic
OYST CAL/D TAB 500MG Generic
OYST SHELL/D TAB 250MG Generic
OYST SHELL/D TAB 500MG Generic
OYST SHELL/D TAB 500‐200 Generic
OYST SHELL/D TAB 600MG Generic
OYST SHELL/D TAB 500‐125 Generic
OYST SHELL/D TAB 500‐400 Generic
PEDIALYTE SOL Brand
PHOSPHA 250 TAB NEUTRAL Generic
POT ACETATE INJ 2MEQ/ML Generic
POT ACETATE INJ 4MEQ/ML Generic
POT CHLORIDE CAP 8MEQ ER Generic
POT CHLORIDE CAP 10MEQ ER Generic
POT CHLORIDE TAB 8MEQ ER Generic
POT CHLORIDE TAB 8MEQ SR Generic
POT CHLORIDE TAB 10MEQ ER Generic
POT CHLORIDE TAB 10MEQ CR Generic
POT CHLORIDE TAB 20MEQ ER Generic
POT CHLORIDE INJ 2MEQ/ML Generic
POT CHLORIDE INJ 10MEQ Generic
POT CHLORIDE INJ 20MEQ Generic
POT CHLORIDE INJ 40MEQ Generic
POT CHLORIDE SOL 10% SF Generic
POT CHLORIDE SOL 10% Generic
POT CHLORIDE SOL 20% SF Generic
POT CHLORIDE SOL 20% Generic
POT CHLORIDE TAB 25MEQ EF Generic
POT CL MICRO TAB 10MEQ ER Generic
POT CL MICRO TAB 10MEQ CR Generic
POT CL MICRO TAB 20MEQ ER Generic
POT GLUCONAT TAB 2MEQ Generic
POT GLUCONAT TAB 550MG Generic
POT GLUCONAT TAB 2.5MEQ Generic
POT GLUCONAT TAB 99MG Generic
POT GLUCONAT TAB 595MG Generic
POTASSIUM TAB 99MG Generic
SALINE FLUSH INJ 0.9% Generic
SALINE FLUSH INJ ZR 0.9% Generic
SOD CHLORIDE INJ 0.45% Generic
SOD CHLORIDE INJ 0.9% Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
80
Drug Name Dosage Form/Strength Drug Type Requirements
SOD CHLORIDE INJ 3% Generic
SOD CHLORIDE INJ 5% Generic
SOD CHLORIDE INJ 23.4% Generic
SOD CHLORIDE INJ 4MEQ/ML Generic
SOD CHLORIDE INJ 2.5/ML Generic
TH CALCIUM/D TAB 600‐400 Generic
VIRT‐PHOS TAB 250 NEUT Generic
CALORIC AGENTS (most nutritional supplements covered with prior authorization required; not all products listed)
BOOST PA
ENSURE PA
GLUCERNA PA
PEDIASURE PA
DEXTROSE INJ 5% Generic
DEXTROSE INJ 5% PGBK Generic
DEXTROSE INJ 10% Generic
DEXTROSE INJ 20% Generic
DEXTROSE INJ 25% Generic
DEXTROSE INJ 30% Generic
DEXTROSE INJ 40% Generic
DEXTROSE INJ 50% Generic
DEXTROSE INJ 70% Generic
HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ARANESP INJ 25MCG Brand PA
ARANESP INJ 40MCG Brand PA
ARANESP INJ 60MCG Brand PA
ARANESP INJ 100MCG Brand PA
ARANESP INJ 150MCG Brand PA
ARANESP INJ 200MCG Brand PA
ARANESP INJ 300MCG Brand PA
ARANESP INJ 10MCG Brand PA
ARANESP INJ 500MCG Brand PA
FULPHILA (NEULASTA BIOSIMILAR) INJ 6MG/0.6ML Brand PA QL 0.6mls per month
PROMACTA TAB 12.5MG Brand PA QL 1 per day
PROMACTA TAB 25MG Brand PA QL 1 per day
PROMACTA TAB 50MG Brand PA QL 1 per day
PROMACTA TAB 75MG Brand PA QL 2 per day
RETACRIT (PROCRIT/EPOGEN BIOSIMILAR) INJ 2000 UNIT/ML Brand PA
RETACRIT (PROCRIT/EPOGEN BIOSIMILAR) INJ 3000 UNIT/ML Brand PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
81
Drug Name Dosage Form/Strength Drug Type Requirements
RETACRIT (PROCRIT/EPOGEN BIOSIMILAR) INJ 4000 UNIT/ML Brand PA
RETACRIT (PROCRIT/EPOGEN BIOSIMILAR) INJ 10000 UNIT/ML Brand PA
RETACRIT (PROCRIT/EPOGEN BIOSIMILAR) INJ 40000 UNIT/ML Brand PA
TAVALISSE TAB 100MG Brand PA QL 2 per day
TAVALISSE TAB 150MG Brand PA QL 2 per day
ZARXIO (NEUPOGEN BIOSIMILAR) INJ 300 MCG/0.5ML Brand PA
ZARXIO (NEUPOGEN BIOSIMILAR) INJ 480 MCG/0.8ML Brand PA
IRON PREPARATIONS FE GLUCONATE TAB 325MG Generic
FE TABS TAB 325MG EC Generic
FEOSOL TAB 65MG Generic
FERATE TAB 27MG Generic
FERATE TAB 28MG Generic
FERGON TAB 27MG Generic
FER‐IRON DRO 15MG/ML Generic
FEROSUL ELX 220/5ML Generic
FERREX 150 CAP 150MG Generic
FERRIC X‐150 CAP 150MG Generic
FERRO‐BOB TAB 325MG Generic
FERROTABS TAB Generic
FERROUS DRO 15MG/ML Generic
FERROUS GLUCONATE TAB 240MG Generic
FERROUS GLUCONATE TAB 324MG Generic
FERROUS GLUCONATE TAB 325MG Generic
FERROUS GLUCONATE TAB 225MG Generic
FERROUS SULFATE LIQ 220/5ML Generic
FERROUS SULFATE TAB 325MG Generic
FERROUS SULFATE TAB 325MG FC Generic
FERROUS SULFATE TAB 5GR Generic
FERROUS SULFATE TAB 324MG EC Generic
FERROUS SULFATE TAB 325MG EC Generic
FERROUS SULFATE ELX 220/5ML Generic
FERROUS SULFATE SYP 300/5ML Generic
FERROUS SULFATE DRO 15MG/ML Generic
FERUS CAP 150MG Generic
IFEREX 150 CAP Generic
IRON TAB 65MG Generic
IRON TAB 325MG Generic
IRON TAB 27MG Generic
IRON TAB 28MG Generic
IRON SUPPLEM TAB THERAPY Generic
IRON SUPPLMT DRO 15MG/ML Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
82
Drug Name Dosage Form/Strength Drug Type Requirements
IRON THERAPY TAB 200MG Generic
MYFERON 150 CAP 150MG Generic
NEPHRON FA TAB Brand
NU‐IRON 150 CAP 150MG Generic
PEDIA IRON DRO 15MG/ML Generic
POLY‐IRON CAP 150MG Generic
SLOW IRON TAB 160MG CR Generic
SLOW REL FE TAB 143MG CR Brand
SLOW REL FE TAB 160MG CR Generic
SLOW RELEASE TAB 143MG Generic
SLOW RELEASE TAB 47.5MG Generic
SM IRON TAB 325MG Generic
SM IRON SLOW TAB 160MG CR Generic
TH IRON TAB 65MG Generic
ANTICOAGULANTS COUMADIN TAB 1MG Brand
COUMADIN TAB 2MG Brand
COUMADIN TAB 2.5MG Brand
COUMADIN TAB 3MG Brand
COUMADIN TAB 4MG Brand
COUMADIN TAB 5MG Brand
COUMADIN TAB 6MG Brand
COUMADIN TAB 7.5MG Brand
COUMADIN TAB 10MG Brand
COUMADIN INJ 5 MG Brand
ELIQUIS TAB 2.5MG Brand QL 2 per day
ELIQUIS TAB 5MG Brand QL 4 per day
ENOXAPARIN INJ 30/0.3ML Generic QL 0.6mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 40/0.4ML Generic QL 0.8mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 60/0.6ML Generic QL 1.2mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 80/0.8ML Generic QL 1.6mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 100MG/ML Generic QL 2mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 120/0.8 Generic QL 1.6mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 150MG/ML Generic QL 2mls per day; 14‐day
supply per fill
ENOXAPARIN INJ 300/3ML Generic 14‐day supply per fill
FONDAPARINUX INJ 2.5/0.5 Generic QL 0.5mls per day
FONDAPARINUX INJ 5/0.4ML Generic QL 0.4mls per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
83
Drug Name Dosage Form/Strength Drug Type Requirements
FONDAPARINUX INJ 7.5/0.6 Generic QL 0.6mls per day
FONDAPARINUX INJ 10/0.8ML Generic QL 0.8mls per day
FRAGMIN INJ 10000/ML Brand QL 10mls per 30 days
FRAGMIN INJ 2500/0.2 Brand QL 2mls per 30 days
FRAGMIN INJ 5000/0.2 Brand QL 2mls per 30 days
FRAGMIN INJ 7500/0.3 Brand QL 3mls per 30 days
FRAGMIN INJ 12500UNT Brand QL 5mls per 30 days
FRAGMIN INJ 15000UNT Brand QL 6mls per 30 days
FRAGMIN INJ 18000UNT Brand QL 7.2mls per 30 days
FRAGMIN INJ 25000/ML Brand QL 10mls per 30 days
FRAGMIN INJ 95000UNT Brand
HEPARIN SOD INJ 1000/ML Generic
HEPARIN SOD INJ 5000/ML Generic
HEPARIN SOD INJ 5000/0.5 Generic
HEPARIN SOD INJ 10000/ML Generic
HEPARIN SOD INJ 20000/ML Generic
JANTOVEN TAB 1MG Generic
JANTOVEN TAB 2MG Generic
JANTOVEN TAB 2.5MG Generic
JANTOVEN TAB 3MG Generic
JANTOVEN TAB 4MG Generic
JANTOVEN TAB 5MG Generic
JANTOVEN TAB 6MG Generic
JANTOVEN TAB 7.5MG Generic
JANTOVEN TAB 10MG Generic
PRADAXA CAP 75MG Brand QL 2 per day
PRADAXA CAP 110MG Brand QL 2 per day;
#70 per 180 days
PRADAXA CAP 150MG Brand QL 2 per day
WARFARIN TAB 1MG Generic
WARFARIN TAB 2MG Generic
WARFARIN TAB 2.5MG Generic
WARFARIN TAB 3MG Generic
WARFARIN TAB 4MG Generic
WARFARIN TAB 5MG Generic
WARFARIN TAB 6MG Generic
WARFARIN TAB 7.5MG Generic
WARFARIN SOD TAB 10MG Generic
WARFARIN TAB 10MG Generic
XARELTO TAB 10MG Brand QL 1 per day
XARELTO TAB 20MG Brand
XARELTO TAB 15MG Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
84
Drug Name Dosage Form/Strength Drug Type Requirements
XARELTO STAR TAB 15/20MG Brand QL 1 per 365 days
HEMOSTATICS
AMINOCAPROIC ACID SYRUP 25% Generic
TRANEXAMIC ACID TAB 650MG Generic PA Required
HEMORRHEOLOGIC AGENTS PENTOXIFYLLI TAB 400MG ER Generic
PLATELET‐ACTING AGENTS AGGRENOX CAP 25‐200MG Brand
ANAGRELIDE CAP 0.5MG Generic
ANAGRELIDE CAP 1MG Generic
ASA/DIPYRIDA CAP 25‐200MG Generic
CILOSTAZOL TAB 50MG Generic
CILOSTAZOL TAB 100MG Generic
CLOPIDOGREL TAB 75MG Generic
TICLOPIDINE TAB 250MG Generic AR PA required >64
TOPICAL PRODUCTS ALPHA‐ADRENERGIC AGONISTS (EENT) BRIMONIDINE SOL 0.2% OP Generic
BRIMONIDINE SOL 0.15% Generic
ANTIBACTERIALS (EENT) AK‐POLY‐BAC OIN OP Generic
BACIT/POLYMY OIN OP Generic
BACITRACIN OIN OP Generic
CILOXAN OIN 0.3% OP Brand
CIPROFLOXACIN SOL 0.3% OP Generic
CIPROFLOXACIN OTIC SOL 0.2% Generic
ERYTHROMYCIN OIN 5MG/GM Generic
ERYTHROMYCIN OIN OP Generic
GARAMYCIN OIN 0.3% OP Generic
GATIFLOXACIN SOL 0.5% Generic
GENTAK OIN 0.3% OP Generic
GENTAMICIN SOL 0.3% OP Generic
GENTAMICIN OIN 0.3% OP Generic
ILOTYCIN OIN OP Generic
ILOTYCIN OIN OP Generic
NEO/BAC/POLY OIN OP Generic
NEO/POLY/GRA SOL OP Generic
NEO‐POLYCIN OIN OP Generic
OFLOXACIN DRO 0.3% OP Generic
OFLOXACIN DRO 0.3%OTIC Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
85
Drug Name Dosage Form/Strength Drug Type Requirements
POLYCIN OIN OP Generic
POLYCIN OIN OP Generic
POLYCIN B OIN OP Generic
POLYMYXIN B/SOL TRIMETHOPRIM SULFATE SOL Generic
ROMYCIN Generic
SULFACET SOD SOL 10% OP Generic
TOBRAMYCIN SOL 0.3% OP Generic
TRIMETHOPRIM SOL POLYMYXN SOL Generic
ANTIVIRALS (EENT) TRIFLURIDINE SOL 1% OP Generic
ZIRGAN GEL 0.15% Brand
BETA‐ADRENERGIC BLOCKING AGENTS (EENT) BETOPTIC‐S SUS 0.25% OP Brand
LEVOBUNOLOL SOL 0.25% OP Generic
LEVOBUNOLOL SOL 0.5% OP Generic
METIPRANOLOL SOL 0.3% OPH Generic
TIMOLOL GEL SOL 0.25% OP Generic
TIMOLOL GEL SOL 0.5% OP Generic
TIMOLOL MAL SOL 0.25% OP Generic
TIMOLOL MAL SOL 0.5% OP Generic
CORTICOSTEROIDS (EENT) ACETASOL HC SOL OTIC Generic
BLEPHAMIDE SUS OP Brand
BLEPHAMIDE OIN S.O.P. Brand
CIPRODEX SUS 0.3‐0.1% Brand PA
DEXAMETH PHO SOL 0.1% OP Generic
FLUOROMETHOL SUS 0.1% OP Generic
FML OIN 0.1% OP Brand
FML FORTE SUS 0.25% OP Brand
HC/ACET ACID SOL OTIC Generic
NEO/POLY/BAC OIN /HC 1%OP Generic
NEO/POLY/DEX SUS 0.1% OP Generic
NEO/POLY/DEX OIN 0.1% OP Generic
NEO/POLY/HC SUS OP Generic
NEO/POLY/HC SUS 1% OTIC Generic
NEO/POLY/HC SOL 1% OTIC Generic
NEO‐POLYCIN OIN HC 1%OP Generic
POLY‐DEX OIN 0.1% OP Generic
PRED MILD SUS 0.12% OP Brand
PRED SOD PHO SOL 1% OP Generic
PREDNISOLONE SUS 1% OP Generic
SULF/PRED NA SOL OP Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
86
Drug Name Dosage Form/Strength Drug Type Requirements
TOBRA/DEXAME SUS 0.3‐0.1% Generic
TOBRADEX OIN 0.3‐0.1% Brand
EENT DRUGS, MISCELLANEOUS ACETIC ACID SOL 2% OTIC Generic
APRACLONIDIN SOL 0.5% OP Generic
EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS DICLOFENAC SOL 0.1% OP Generic
FLURBIPROFEN SOL 0.03% OP Generic
KETOROLAC SOL 0.5% Generic
MIOTICS PHOSPHOLINE SOL 0.125%OP Brand
PILOCARPINE SOL 1% OP Generic
PILOCARPINE SOL 2% OP Generic
PILOCARPINE SOL 4% OP Generic
MYDRIATICS ATROPIN‐CARE SOL 1% OP Generic
ATROPINE SUL SOL 1% OP Generic
CYCLOMYDRIL SOL OP Brand
CYCLOPENTOL SOL 1% OP Generic
CYCLOPENTOL SOL 2% OP Generic
CYCLOPENTOLATE SOL 0.5% OP Generic
HOMATROPAIRE SOL 5% OP Generic
HOMATROPINE SOL 5% OP Generic
MYDRAL SOL 0.5% OP Generic
MYDRAL SOL 1% OP Generic
TROPICAMIDE SOL 0.5% OP Generic
TROPICAMIDE SOL 1% OP Generic
PROSTAGLANDIN ANALOGS LATANOPROST SOL 0.005% Generic
TRAVOPROST DRO 0.004% Generic
LOCAL ANESTHETICS (EENT) ANTIPY/BENZO SOL OTIC Generic
AURODEX SOL OTIC Generic
LIDOCAINE SOL 2% VISC Generic
EENT ANTI‐INFECTIVES, MISCELLANEOUS CHLORHEX GLU SOL 0.12% Generic
PAROEX SOL 0.12% Generic
PERIOGARD SOL 0.12% Generic
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) ANTIBIOTIC OIN Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
87
Drug Name Dosage Form/Strength Drug Type Requirements
ANTIBIOTIC OIN PAIN RLF Brand
BAC/NEO/POLY OIN Generic
BACITR ZINC OIN 500/GM Generic
GENTAMICIN CRE 0.1% Generic
GENTAMICIN OIN 0.1% Generic
LANABIOTIC OIN Generic
MUPIROCIN OIN 2% Generic
NEOPORACIN OIN Generic
NEOSPORIN+PN OIN RELF MAX Generic
SM FIRST AID OIN 500/GM Generic
ANTIPRURITICS AND LOCAL ANESTHETICS GLYDO GEL 2% Generic
LIDO/PRILOCN CRE 2.5‐2.5% Generic QL 2 grams per day
LIDOCAINE GEL 2% JELLY Generic
LIDOCAINE SOL 4% Generic
LOCAL ANTI‐INFECTIVES, MISCELLANEOUS ALCOHOL MIS WIPES Generic
ALCOHOL WIPE MIS 70% Generic
AVC CRE 15% Brand
RA ALCOHOL MIS WIPES Brand
SILVER SULFA CRE 1% Generic
SSD CRE 1% Generic
THERMAZENE CRE 1% Generic
SCABICIDES AND PEDICULICIDES ACTICIN CRE 5% Generic
LICE KILLING SHA 0.33‐4% Generic
LICE TREATMENT LOT 1% Generic
LICE TRTMNT LIQ 1% Generic
LICE TRTMNT LIQ CRM RNSE Generic
LICIDE LIQ MAX ST Generic
LICIDE SHA 0.33‐4% Generic
LINDANE LOT 1% Generic
LINDANE SHA 1% Generic
PERMETHRIN CRE 5% Generic
PERMETHRIN LOT 1% Generic
PRONTO PLUS LIQ MOUSSE Generic
SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ACITRETIN CAP 10MG Generic PA, QL 2 caps per day
ACITRETIN CAP 17.5MG Generic PA, QL 2 caps per day
ACITRETIN CAP 25MG Generic PA QL 2 caps per day
CALCIPOTRIEN SOL 0.005% Generic PA
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
88
Drug Name Dosage Form/Strength Drug Type Requirements
CALCIPOTRIEN CRE 0.005% Generic PA
CAPREX + CRE 0.075% Generic
CAPSAICIN CRE 0.025% Generic
CAPSAICIN CRE 0.1% Generic
CAPZASIN‐P CRE 0.035% Brand
CONDYLOX GEL 0.5% Brand
FLUOROURACIL DRO 5% Generic PA
FLUOROURACIL SOL 5% Generic PA
FLUOROURACIL CRE 5% Generic PA
IMIQUIMOD CRE 5% Generic PA
PODOFILOX SOL 0.5% Generic
PSORIASIN LIQ 3% Generic
RA ARTH PAIN CRE 0.075% Generic
REGRANEX GEL 0.01% Brand PA QL 2
SCALPICIN LIQ 3% Generic
SILIQ INJ 210/1.5 Brand PA QL .108mls per fill
STELARA INJ 45MG/0.5 Brand PA 0.006mls per day
Max 84‐day supply per fill
STELARA INJ 90MG/ML Brand PA 0.012mls per day
Max 84‐day supply per fill
THERAGEN HP CRE 0.075% Generic
TREMFYA INJ 100MG/ML Brand PA QL 0.018ml per day; max 56‐day supply per fill
TRIXAICIN HP CRE 0.075% Generic
VEREGEN OIN 15% Brand
TOPICAL CORTICOSTEROIDS ANTI‐ITCH LOT 1% Generic
ANTI‐ITCH CRE 1% Generic
AUGMENTED BETAMETHASONE CRE 0.05% Generic
BETAMETH DIP LOT 0.05% Generic
BETAMETHASONE CRE 0.1% Generic
COLOCORT ENE 100MG Generic QL 60mls per day
CORT INTENSE CRE 1% Generic
CORTAID CRE 1% Generic
CORTAID SPR 1% Generic
CORTAID ADV CRE 1% 12 HR Generic
CORTIFOAM AER 90MG Brand
CORTISONE CRE 1% Generic
CORTISONE LOT 1% Generic
CORTISONE OIN 1%MAX ST Generic
CORTIZONE‐10 OIN 1% Generic
CORTIZONE‐10 CRE /ALOE 1% Generic
CORTIZONE‐10 CRE HEALING Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
89
Drug Name Dosage Form/Strength Drug Type Requirements
CORTIZONE‐10 CRE PLUS Generic
CORTIZONE‐10 LOT ECZEMA Generic
CORTIZONE‐10 LOT HYDRATEN Generic
DESOXIMETAS CRE 0.25% Generic
FLUTICASONE CRE 0.05% Generic
FLUTICASONE OIN 0.005% Generic
GYNECORT 10 CRE 1% Generic
HYDROSKIN LOT 1% Generic
HYDROCORTISONE OIN 0.5% Generic
HYDROCORTISONE CRE 0.5% Generic
HYDROCORTISONE CRE 1% Generic
HYDROCORTISONE CRE 2.5% Generic
HYDROCORTISONE ENE 100MG Generic QL 60mls per day
HYDROCORTISONE LOT 1% Generic
HYDROCORTISONE LOT 2.5% Generic
HYDROCORTISONE OIN 1% Generic
HYDROCORTISONE OIN 2.5% Generic
HYDROCORT AC CRE 1% Generic
HYDROCORT/AB OIN 1% Generic
HYDROCREAM CRE 1% Generic
HYDRO‐LOTION LOT 1% Generic
HYDROSKIN CRE 1% Generic
INSTACORT 5 CRE 0.5% Generic
KERICORT 10 CRE 1% Generic
K HYDROCORTISON CRE PLS 1% Generic
LANACORT 10 CRE 1% Generic
MED‐DERM HC CRE 1% Generic
MED‐DERM HC CRE 0.5% Generic
MEDI‐CORT CRE 1% Generic
MOMETASONE CRE 1% Generic
MOMETASONE OIN 0.1% Generic
MOMETASONE SOL 0.1% Generic
NEOSPORIN CRE ECZEMA Generic
NOBLE FORMUL CRE HC 1% Generic
NOBLE FORMUL SPR 1% Generic
NYSTAT/TRIAM CRE Generic PA
NYSTAT/TRIAM OIN Generic PA
PREP H HC CRE 1% Generic
PROCTO‐PAK CRE 1% Generic
PROCTOSOL HC CRE 2.5% Generic
PROCTOZONE CRE ‐HC 2.5% Generic
QC HYDROCORT CRE 1% Generic
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
90
Drug Name Dosage Form/Strength Drug Type Requirements
RECORT PLUS CRE 1% Generic
REDERM LOT 1% Generic
SARNOL‐HC LOT 1% Generic
SB HYDROCORT CRE 1% Generic
SCALP RELIEF SOL 1% Generic
SCALPICIN SOL 1% Generic
TRIAMCINOLON OIN 0.1% Generic
TRIAMCINOLON CRE 0.025% Generic
TRIAMCINOLON CRE 0.1% Generic
TRIAMCINOLON CRE 0.5% Generic
TRIAMCINOLON LOT 0.025% Generic
TRIDERM CRE 0.1% Generic
MISCELLANEOUS PRODUCTSCOMPLEMENT INHIBITORS HAEGARDA INJ 2000 UNIT Brand PA
HAEGARDA INJ 4000 UNIT Brand PA
EMETICS IPECAC SYP Generic
SM IPECAC SYP Generic
OPIATE ANTAGONISTS
NALOXONE INJ 0.4MG/ML Generic QL 2 per fill; max 1 fill per 180 days
NALOXONE INJ 1MG/ML Generic QL 4 MLs per fill;
max 1 fill per 180 days
NALTREXONE TAB 50MG Generic
NARCAN SPRAY 4MG/0.1ML Brand QL 2 per fill;
max 1 fill per 180 days
ADRENOCORTICAL INSUFFICIENCY COSYNTROPIN INJ 0.25MG Generic
MISCL OTHER BUBBLE GUM SYP Generic
CHERRY SYP Generic
CHERRY SYP CONCENTR Generic
COTTONSEED OIL Generic
FLAVOR BLEND SUS Brand
FLAVOR PLUS LIQ Brand
FLAVOR SWEET SYP Brand
FLAVOR SWEET LIQ S/F Brand
GRAPE SYP Generic
ORA‐BLEND SUS Brand
ORA‐BLEND SF SUS Brand
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
91
Drug Name Dosage Form/Strength Drug Type Requirements
ORAL MIX LIQ SUSPENDI Brand
ORAL MIX SF LIQ Brand
ORAL SUSPEND LIQ Generic
ORAL SYRUP LIQ FLAVORED Generic
ORAL SYRUP LIQ SF Generic
ORA‐PLUS LIQ Brand
ORA‐SWEET SYP Brand
ORA‐SWEET SF SYP Brand
PCCA SWEET SYP ‐SF Brand
PCCA SYRUP SYP VEHICLE Brand
PCCA‐PLUS SUS Brand
SIMPLE SYP Generic
STERIL WATER INJ Generic
SUSPENSION SUS VEHICLE Generic
SYRPALTA SYP Brand
SYRSPEND SF LIQ Brand
SYRUP SYP VEHICLE Generic
SYRUP SF SYP VEHICLE Generic
VERSAFREE SYP Brand
VERSAPLUS SYP Brand
DEVICES AERCHMBR PLS MIS SM MASK Brand QL 2 per 365 days
AERCHMBR PLS MIS FLOW‐VU Brand QL 2 per 365 days
AERCHMBR PLS MIS LRG MASK Brand QL 2 per 365 days
AERCHMBR Z‐ MIS STAT PLS Brand QL 2 per 365 days
AEROCHAMBER MIS PLUS Brand QL 2 per 365 days
AEROCHAMBER MIS FLOSIGNA Brand QL 2 per 365 days
AEROCHAMBER MIS PLUS Brand QL 2 per 365 days
AEROCHAMBER MIS MV Brand QL 2 per 365 days
AEROCHAMBER MIS CHAMBER Brand QL 2 per 365 days
AEROCHAMBER KIT ACTION Brand
AIRZONE PEAK MIS FLOW MTR Brand QL 2 per 365 days
ALCOHOL PREP PAD Generic
ALCOHOL PREP SWAB PAD Generic
ALCOHOL SWAB PAD Generic
ALCOHOL WIPE PAD Generic
ARIAL MIS CHAMBER Brand QL 2 per 365 days
ASSESS METER MIS FULL RNG Brand QL 2 per 365 days
ASSESS METER MIS LOW RANG Brand QL 2 per 365 days
ASSESS METER MIS FULL Brand QL 2 per 365 days
ASSESS METER MIS LOW Brand QL 2 per 365 days
ASTHMA CHECK MIS SYSTEM Brand QL 2 per 365 days
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
92
Drug Name Dosage Form/Strength Drug Type Requirements
ASTHMAMENTOR MIS Brand QL 2 per 365 days
BAND‐AID PAD 2"X2" Brand
BD SWAB BFLY PAD SNGL USE Brand
BD SWAB REG PAD SNGL USE Brand
BREATHERITE MIS Brand QL 2 per 365 days
BREATHERITE MIS W/MASK Brand QL 2 per 365 days
BREATHERITE MIS LG MASK Brand QL 2 per 365 days
BREATHERITE MIS MED MASK Brand QL 2 per 365 days
BREATHERITE MIS SM MASK Brand QL 2 per 365 days
BREATHERITE MIS SPACER Brand QL 2 per 365 days
DERMACEA PAD 2"X2" Brand
EASIVENT MIS Brand QL 2 per 365 days
EASIVENT MIS MASK SM Brand QL 2 per 365 days
EASIVENT MIS MASK MED Brand QL 2 per 365 days
EASIVENT MIS MASK LG Brand QL 2 per 365 days
EQL GAUZE PAD 2"X2" Brand
E‐Z SPACER MIS Brand QL 2 per 365 days
E‐Z SPACER MIS BODY GRD Brand QL 2 per 365 days
INSPIREASE MIS DD SYST Brand QL 2 per 365 days
LITEAIRE MIS Brand QL 2 per 365 days
MASK VORTEX/ MIS BABY DUC Brand QL 2 per 365 days
MASK VORTEX/ MIS DUCK Brand QL 2 per 365 days
MASK VORTEX/ MIS LADY BUG Brand QL 2 per 365 days
MASK VORTEX/ MIS FROG Brand QL 2 per 365 days
MICROCHAMBER MIS Brand QL 2 per 365 days
MICROLIFE MIS PEAK FLO Brand QL 2 per 365 days
MICROSPACER MIS Brand QL 2 per 365 days
MINI WRIGHT MIS PFM Brand QL 2 per 365 days
MINI WRIGHT MIS PFM LOW Brand QL 2 per 365 days
MIRASORB MIS 2" X 2" Brand
NESSI SPACER MIS MOUTHPC Brand QL 2 per 365 days
NESSI SPACER MIS SM/MED Brand QL 2 per 365 days
NESSI SPACER MIS LARGE Brand QL 2 per 365 days
OPTICHAMBER MIS ADVANTAG Brand QL 2 per 365 days
OPTICHAMBER MIS ADV SM Brand QL 2 per 365 days
OPTICHAMBER MIS ADV MED Brand QL 2 per 365 days
OPTICHAMBER MIS ADV LRG Brand QL 2 per 365 days
OPTICHAMBER MIS FACE MAS Brand QL 2 per 365 days
OPTICHAMBER MIS DIAMOND Brand QL 2 per 365 days
OPTICHAMBER MIS DIA SM Brand QL 2 per 365 days
OPTICHAMBER MIS DIA MD Brand QL 2 per 365 days
OPTICHAMBER MIS DIA LG Brand QL 2 per 365 days
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
93
Drug Name Dosage Form/Strength Drug Type Requirements
PANDA MASK MIS PEDIATRI Brand QL 2 per 365 days
PANDA MASK MIS SMALL Brand QL 2 per 365 days
PANDA MASK MIS MEDIUM Brand QL 2 per 365 days
PANDA MASK MIS LARGE Brand QL 2 per 365 days
PEAK AIR FLO MIS ADLT/PED Brand QL 2 per 365 days
PEAK FLOW MIS METER Generic QL 2 per 365 days
PEAK FLW MTR MIS UNIVERSL Generic QL 2 per 365 days
PERSONAL BES MIS FULL RNG Brand QL 2 per 365 days
PERSONAL BES MIS LOW RANG Brand QL 2 per 365 days
PIKO 1 MIS ELECTRON Brand QL 2 per 365 days
POCKET PEAK MIS METER Generic QL 2 per 365 days
POCKETPEAK MIS UNIVERSA Brand QL 2 per 365 days
POCKETPEAK MIS MTR LOW Brand QL 2 per 365 days
PRIMEAIRE MIS CHAMBER Brand
TABLET CUTTER Brand QL 1 per 365 days
RITEFLO MIS Brand QL 2 per 365 days
TRUZONE PEAK MIS FLOW MTR Brand QL 2 per 365 days
VALVD HOLDNG MIS CHAMBER Brand QL 2 per 365 days
VORTEX VALVE MIS CHAMBER Brand QL 2 per 365 days
VORTEX/MASK MIS TODDLER Brand
VORTEX/MASK MIS CHILDS Brand
WATCHHALER MIS Brand QL 2 per 365 days
IMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 50MG Generic
BENLYSTA INJ 200 MG/ML Brand PA QL 4 syringes per 28
days
CYCLOSPORINE CAP 25MG Generic
CYCLOSPORINE CAP 100MG Generic
CYCLOSPORINE CAP 25MG MOD Generic
CYCLOSPORINE CAP 50MG MOD Generic
CYCLOSPORINE CAP 100MG MD Generic
CYCLOSPORINE SOL MODIFIED Generic
GENGRAF CAP 25MG Generic
GENGRAF CAP 100MG Generic
GENGRAF SOL 100MG/ML Generic
HECORIA CAP 0.5MG Generic
HECORIA CAP 1MG Generic
HECORIA CAP 5MG Generic
MYCOPHENOLAT CAP 250MG Generic
MYCOPHENOLAT TAB 500MG Generic
MYCOPHENOLAT SUS 200MG/ML Generic
RAPAMUNE SOL 1MG/ML Brand QL 2mls per day
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over‐the‐Counter
94
Drug Name Dosage Form/Strength Drug Type Requirements
SIROLIMUS TAB 0.5MG Generic QL 2 per day
SIROLIMUS TAB 1MG Generic QL 2 per day
SIROLIMUS TAB 2MG Generic QL 2 per day
TACROLIMUS CAP 0.5MG Generic
TACROLIMUS CAP 1MG Generic
TACROLIMUS CAP 5MG Generic
ZORTRESS TAB 0.25MG Brand
ZORTRESS TAB 0.5MG Brand
ZORTRESS TAB 0.75MG Brand
POTASSIUM‐REMOVING AGENTS KIONEX SUS 15GM/60 Generic
KIONEX POW Generic
SOD POLY SUL SUS 15GM/60 Generic
SOD POLY SUL SUS 30/120ML Generic
SOD POLY SUL SUS 50/200ML Generic
SOD POLY SUL POW Generic
SPS SUS 15GM/60 Generic
VELTASSA POW 8.4GM Brand PA QL 1 packet per day
VELTASSA POW 16.8GM Brand PA QL 1 packet per day
VELTASSA POW 25.2GM Brand PA QL 1 packet per day
95
INDEX OF DRUGS
3
3 DAY VAGINAL ............................................................... 5
A
ABACAVIR ........................................................................ 7
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ............ 7
ABACAVIR/LAMIVUDINE ................................................. 7
ACAMPRO CAL .............................................................. 56
ACARBOSE ..................................................................... 24
ACD/FLUORIDE .............................................................. 68
ACEBUTOLOL ................................................................. 33
ACETAMINOPHEN ......................................................... 58
ACETAMINOPHEN/CAFF/PYRILAMINE .......................... 58
ACETASOL HC ................................................................ 85
ACETAZOLAMIDE ........................................................... 39
ACETIC ACID .................................................................. 86
ACID CONTROL .............................................................. 48
ACID REDUCER .............................................................. 48
ACID RELIEF ................................................................... 48
ACITRETIN ..................................................................... 87
ACTEMRA ...................................................................... 62
ACTICIN ......................................................................... 87
ACTIMMUNE ................................................................. 13
ACYCLOVIR ...................................................................... 6
ADACEL .......................................................................... 11
ADEFOVIR DIPIVOXIL ....................................................... 6
ADEMPAS ...................................................................... 42
ADENOSINE ................................................................... 36
ADLYXIN ........................................................................ 25
ADMELOG ...................................................................... 25
ADMELOG SOLO ............................................................ 25
ADVAIR DISKUS ............................................................. 44
ADVAIR HFA .................................................................. 44
AERCHMBR PLS ............................................................. 91
AERCHMBR Z‐ ................................................................ 91
AEROCHAMBER ............................................................. 91
AFEDITAB....................................................................... 34
AFINITOR ....................................................................... 13
AFINITOR DIS ................................................................. 13
AFLURIA ........................................................................ 11
AFLURIA QUAD ............................................................. 11
AFTERA .......................................................................... 20
AGGRENOX ................................................................... 84
AIMOVIG ....................................................................... 63
AIRZONE PEAK .............................................................. 91
AK‐POLY‐BAC ................................................................ 84
ALA‐HIST IR ................................................................... 42
ALAVERT........................................................................ 42
ALBENZA ....................................................................... 10
ALBUTEROL ............................................................. 44, 45
ALCALAK ........................................................................ 46
ALCOHOL ....................................................................... 87
ALCOHOL PREP ............................................................. 91
ALCOHOL PREP SWAB ................................................... 91
ALCOHOL SWAB ............................................................ 91
ALCOHOL WIPE ....................................................... 87, 91
ALECENSA ..................................................................... 13
ALENDRONATE .............................................................. 29
ALER‐DRYL ..................................................................... 42
ALFERON N.................................................................... 13
ALKERAN ....................................................................... 13
ALLOPURINOL ............................................................... 64
ALMACONE SUS ........................................................ 46
ALOGLIPTIN ................................................................... 26
ALTAVERA ..................................................................... 20
ALUNBRIG ..................................................................... 13
ALYACEN ....................................................................... 20
AMANTADINE ................................................................. 6
AMBIZINE ...................................................................... 49
AMETHIA ....................................................................... 20
AMETHIA LO.................................................................. 20
AMETHYST .................................................................... 20
AMILORIDE .................................................................... 40
AMILORIDE/HYDROCHLOROTHIAZIDE .......................... 40
AMINOCAPROIC ACID ................................................... 84
AMIODARONE ............................................................... 36
AMLODIPINE ................................................................. 34
AMOXICILLIN ................................................................... 1
AMOXICILLIN/CLAVULANATE POTASSIUM ..................... 1
96
AMPHETAMINE (Generic Adderall IR) .......................... 55
AMPHETAMINE (Generic Adderall XR) ................... 55, 56
AMPHOTERICIN ............................................................... 4
AMPICILLIN ...................................................................... 1
AMP‐SULBACTA ............................................................... 1
ANAGRELIDE .................................................................. 84
ANASTROZOLE ............................................................... 13
ANDRODERM ................................................................ 19
ANORO ELLIPTA ............................................................. 44
ANTACID ........................................................................ 47
ANTIBIOTIC .............................................................. 86, 87
ANTI‐ITCH ...................................................................... 88
ANTIPY/BENZO .............................................................. 86
APAP/CODEINE.............................................................. 59
APRACLONIDIN .............................................................. 86
APREPITANT .................................................................. 49
APRI ............................................................................... 20
APRISO .......................................................................... 51
APTIVUS........................................................................... 7
ARALAST NP .................................................................. 45
ARANELLE ...................................................................... 20
ARANESP ....................................................................... 80
ARGYL SALINE ................................................................ 54
ARIAL ............................................................................. 91
ARMONAIR .................................................................... 45
ARMOUR THYROID ........................................................ 27
ASA/DIPYRIDA ............................................................... 84
ASHLYNA ....................................................................... 21
ASPIRIN .......................................................................... 58
ASSESS METER ............................................................... 91
ASTHMA CHECK ............................................................. 91
ASTHMAMENTOR .......................................................... 92
ATAZANAVIR ................................................................... 7
ATENOLOL ..................................................................... 33
ATENOLOL/CHLORTHALIDONE ..................................... 38
ATHLETE FOOT ................................................................ 5
ATORVASTATIN ............................................................. 41
ATOVAQUONE ............................................................... 10
ATRIPLA ........................................................................... 7
ATROPIN‐CARE .............................................................. 86
ATROPINE SUL ............................................................... 86
ATROVENT ..................................................................... 44
AUBAGIO ....................................................................... 57
AUBRA ........................................................................... 21
AUGMENTED BETAMETHASONE .................................. 88
AURODEX ...................................................................... 86
AVC ............................................................................... 87
AVIANE .......................................................................... 21
AVONEX ........................................................................ 57
AVONEX PEN ................................................................. 57
AVONEX PREFL .............................................................. 57
AZATHIOPRINE .............................................................. 93
AZITHROMYCIN ............................................................... 3
AZOPT ........................................................................... 39
AZURETTE ..................................................................... 21
B
B COMPLEX W/C & FOLIC ACID .................................... 68
B COMPLEX WITH VITAMIN C ....................................... 68
B1 NATURAL.................................................................. 67
BAC/NEO/POLY ............................................................. 87
BACIT/POLYMY ............................................................. 84
BACITR ZINC .................................................................. 87
BACITRACIN .................................................................. 84
BACLOFEN ..................................................................... 67
BALSALAZIDE ................................................................. 51
BALZIVA ......................................................................... 21
BAND‐AID ...................................................................... 92
BARACLUDE .................................................................... 6
BASAGLAR ..................................................................... 25
BAYCADRON ................................................................. 18
BD SWAB BFLY .............................................................. 92
BD SWAB REG ............................................................... 92
BELLA/OPIUM ............................................................... 47
BENAZEPRIL ............................................................ 37, 38
BENAZEPRIL/HYDROCHLOROTHIAZIDE ........................ 38
BENLYSTA ...................................................................... 93
BENZNIDAZOLE ............................................................. 10
BENZONATATE .............................................................. 43
BENZTROPINE ............................................................... 66
BETAMETH DIP .............................................................. 88
BETAMETHASONE ......................................................... 88
BETHANECHOL .............................................................. 52
BETHKIS ........................................................................... 4
BETOPTIC‐S ................................................................... 85
BEXSERO ....................................................................... 11
BICALUTAMIDE ............................................................. 13
BIKTARVY ........................................................................ 7
97
BIO‐STATIN ...................................................................... 4
BIOTIN FORTE ................................................................ 68
BISACODYL .................................................................... 46
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ..... 39
BLEPHAMIDE ................................................................. 85
BOOST ........................................................................... 80
BOOSTRIX ...................................................................... 11
BOSULIF ......................................................................... 13
BPROTECTED ................................................................. 68
BRAFTOVI ...................................................................... 13
BREATHERITE ................................................................ 92
BRIELLYN ....................................................................... 21
BRIMONIDINE ................................................................ 84
BROMOCRIPTIN ............................................................. 66
BUBBLE GUM ................................................................ 90
BUDESONIDE ................................................................. 45
BUMETANIDE ................................................................ 40
BUPRENORPHINE .......................................................... 59
BUPRENORPHINE/NALOXONE ...................................... 59
BUPROBAN .................................................................... 58
BYDUREON .................................................................... 25
BYETTA .......................................................................... 25
C
CABERGOLINE ............................................................... 29
CABOMETYX .................................................................. 13
CAFFEINE CIT ................................................................. 56
CALC ANTACID ............................................................... 47
CALCIPOTRIEN ......................................................... 87, 88
CALCITONIN................................................................... 29
CALCITRIOL .................................................................... 31
CALCIUM ....................................................................... 68
CALCIUM ACETATE ........................................................ 51
CALCIUM CARB .............................................................. 47
CALCIUM CARBONATE .................................................. 77
CALCIUM CITRATE ......................................................... 77
CALCIUM CITRATE PLUS VIT D ...................................... 77
CALCIUM CITRATE PLUS VITAMIN D ............................. 77
CALCIUM GLUCONATE .................................................. 77
CALCIUM LACTATE ........................................................ 77
CALCIUM PLUS D/ MINERALS ........................................ 77
CALCIUM PLUS D3 ......................................................... 77
CALCIUM W/VIT D ......................................................... 77
CALCIUM W/VIT D & POTASSIUM ................................. 77
CALCIUM/D ................................................................... 80
CALCIUM/PLUS D .......................................................... 77
CALNA ........................................................................... 68
CALQUENCE .................................................................. 13
CAMILA ......................................................................... 21
CAMRESE ...................................................................... 21
CAMRESE LO ................................................................. 21
CANASA ......................................................................... 51
CANDESARTAN .............................................................. 37
CANDESARTAN/HCTZ .................................................... 37
CAPECITABINE ............................................................... 13
CAPRELSA ...................................................................... 13
CAPREX + ....................................................................... 88
CAPSAICIN ..................................................................... 88
CAPTOPRIL .................................................................... 38
CAPTOPRIL/HYDROCHLOROTHIAZIDE .......................... 39
CAPZASIN‐P ................................................................... 88
CARAFATE ..................................................................... 49
CARBAMAZEPINE .......................................................... 64
CARBIDOPA/LEVODOPA ............................................... 66
CARTIA XT ............................................................... 34, 35
CARVEDILOL .................................................................. 33
CASCARA SAGRADA ...................................................... 46
CAVAN‐EC SOD ............................................................. 68
CAVAREST ..................................................................... 76
CAYSTON ....................................................................... 11
CAZIANT ........................................................................ 21
CEFACLOR ....................................................................... 2
CEFADROXIL .................................................................... 2
CEFAZOLIN ...................................................................... 2
CEFAZOLIN/DEXTROSE .................................................... 2
CEFDINIR ......................................................................... 2
CEFIXIME ......................................................................... 2
CEFPODOXIME ................................................................ 2
CEFPROZIL ....................................................................... 2
CEFTRIAXONE .................................................................. 2
CEFUROXIME .................................................................. 2
CELECOXIB .................................................................... 62
CELONTIN ...................................................................... 64
CENTRUM SPEC ............................................................. 68
CEPHALEXIN .................................................................... 2
CERALYTE 70 ................................................................. 78
CERASPORT ................................................................... 78
CERVICAL CAP ............................................................... 52
98
CESIA ............................................................................. 21
CETIRIZINE ..................................................................... 43
CHANTIX ........................................................................ 58
CHATEAL ........................................................................ 21
CHERRY .......................................................................... 90
CHEW CALCIUM ............................................................ 68
CHILD ASPIRIN ............................................................... 58
CHILD SOOTHE .............................................................. 47
CHILD VIT D ................................................................... 31
CHILDRENS .................................................................... 47
CHLORHEX GLU ............................................................. 86
CHLOROQUINE .............................................................. 10
CHLORPHENIRAMINE MALEATE ............................. 42, 43
CHLORTHALIDONE ........................................................ 40
CHLORZOXAZONE ......................................................... 67
CHOLESTYRAM .............................................................. 41
CHOLINE MAG TRISALICYLATE ...................................... 59
CIDOFOVIR ...................................................................... 6
CILOSTAZOL ................................................................... 84
CILOXAN ........................................................................ 84
CIMDUO .......................................................................... 7
CIMETIDINE ................................................................... 48
CIPRODEX ...................................................................... 85
CIPROFLOXACIN .................................................... 3, 4, 84
CIT CALC/D .................................................................... 78
CITRANATAL .................................................................. 69
CITRIC ACID/SODIUM CITRATE ...................................... 53
CL PRENATAL ................................................................. 69
CLARITHROMYCIN ........................................................... 3
CLEOCIN ........................................................................ 53
CLINDAMYCIN ......................................................... 10, 53
CLONAZEPAM ................................................................ 55
CLONIDINE .................................................................... 38
CLOPIDOGREL ................................................................ 84
CLOTRIMAZOLE ............................................................... 5
COARTEM ...................................................................... 10
CODEINE SULF ............................................................... 59
COLCHICINE ................................................................... 64
COLCRYS ........................................................................ 64
COLESTIPOL ................................................................... 41
COLOCORT..................................................................... 88
COMBIPATCH ................................................................ 19
COMBIVENT .................................................................. 44
COMETRIQ ..................................................................... 13
COMFORT GEL .............................................................. 47
COMP PRNATAL ............................................................ 69
COMPAZINE .................................................................. 49
COMPL PRENAT ............................................................ 69
COMPLERA ...................................................................... 7
COMPLETENATE ............................................................ 69
COMPOZ ....................................................................... 54
COMPRO ....................................................................... 49
CO‐NATAL FA ................................................................ 69
CONCEPT OB ................................................................. 69
CONDYLOX .................................................................... 88
CONSTULOSE ................................................................ 11
CONTROLRX .................................................................. 76
CORLANOR .................................................................... 32
CORT INTENSE ............................................................... 88
CORTAID ....................................................................... 88
CORTAID ADV ................................................................ 88
CORTIFOAM .................................................................. 88
CORTISONE ................................................................... 88
CORTIZONE‐10 ........................................................ 88, 89
COSENTYX ..................................................................... 62
COSENTYX PEN .............................................................. 62
COSYNTROPIN ............................................................... 90
COTELLIC ....................................................................... 13
COTTONSEED ................................................................ 90
COUMADIN ................................................................... 82
CREON ........................................................................... 50
CRIXIVAN ......................................................................... 7
CROMOLYN ................................................................... 45
CRYSELLE‐28 .................................................................. 21
CURITY SALIN ................................................................ 54
CVS PRENATAL .............................................................. 69
CVS STRESS ................................................................... 69
CVS SUPER B ................................................................. 69
CYANOCOBALAM .......................................................... 67
CYCLAFEM ..................................................................... 21
CYCLOBENZAPRINE ....................................................... 67
CYCLOMYDRIL ............................................................... 86
CYCLOPENTOL ............................................................... 86
CYCLOPENTOLATE ......................................................... 86
CYCLOPHOSPH .............................................................. 13
CYCLOSPORINE ............................................................. 93
CYPROHEPTADINE ........................................................ 43
CYRED ........................................................................... 21
99
CYTRA K CRYSTALS ........................................................ 53
CYTRA‐2 ......................................................................... 53
CYTRA‐3 ......................................................................... 53
CYTRA‐K ......................................................................... 53
D
D 400 ............................................................................. 31
D‐3 GUMMY .................................................................. 31
D3 KIDS .......................................................................... 31
D5W/NACL .................................................................... 78
DAKLINZA ........................................................................ 6
DANAZOL ....................................................................... 19
DANTROLENE ................................................................ 67
DAPSONE ....................................................................... 47
DAPTACEL ...................................................................... 11
DARAPRIM ..................................................................... 10
DASETTA ........................................................................ 21
DAYSEE .......................................................................... 21
DEBLITANE .................................................................... 21
DELTASONE ................................................................... 18
DELYLA .......................................................................... 21
DELZICOL ....................................................................... 51
DENTA 5000 .................................................................. 76
DENTAGEL ..................................................................... 76
DEPO‐ESTRADIOL .......................................................... 20
DEPO‐PROVERA ............................................................. 17
DERMACEA .................................................................... 92
DESCOVY ......................................................................... 7
DESENEX .......................................................................... 5
DESMOPRESSIN ............................................................. 30
DESO/ETHINYL............................................................... 21
DESOXIMETAS ............................................................... 89
DEX4 .............................................................................. 24
DEXAMETH PHO ............................................................ 85
DEXAMETHASONE ......................................................... 18
DEXMETHYLPHENIDATE ................................................ 56
DEXTROAMPHETAMINE ................................................ 56
DEXTROSE ..................................................................... 80
DIABET TUSS .................................................................. 43
DIALYVITE ...................................................................... 69
DIALYVITE/ .................................................................... 69
DIAZEPAM ..................................................................... 55
DICLOFEN POTASSIUM .................................................. 62
DICLOFENAC ............................................................ 62, 86
DICLOXACILLIN SODIUM ................................................. 1
DICYCLOMINE ............................................................... 47
DIDANOSINE ................................................................... 7
DIGITEK ......................................................................... 32
DIGOX ........................................................................... 32
DIGOXIN ........................................................................ 32
DIHYDROERGOT ............................................................ 63
DILANTIN ....................................................................... 64
DILANTIN‐125 ............................................................... 64
DILATRATE SR ............................................................... 33
DILAUDID‐HP ................................................................ 59
DILT‐CD ......................................................................... 35
DILTIAZEM..................................................................... 35
DILT‐XR .......................................................................... 35
DILTZAC ......................................................................... 35
DIMENHYDRIN .............................................................. 49
DIPHENHYDRAM ........................................................... 54
DIPHENHYDRAMINE ..................................................... 43
DISOPYRAMIDE ............................................................. 36
DISULFIRAM .................................................................. 56
DOCUSATE SODIUM ...................................................... 46
DOFETILIDE ................................................................... 36
DONEPEZIL .................................................................... 57
DORZOLAMIDE .............................................................. 39
DORZOLAMIDE/TIMOLOL MALEATE ............................. 39
DOXAZOSIN ................................................................... 54
DOXYCYCLINE HYCLATE .................................................. 3
DOXYCYCLINE MONOHYDRATE ...................................... 3
DRAMAMINE ................................................................. 49
DRIMINATE ................................................................... 49
DRONABINOL ................................................................ 49
DROSPIR/ETHI ............................................................... 21
DROSPIRENONE ............................................................ 21
DROXIA ......................................................................... 14
D‐VI‐SOL ........................................................................ 31
D‐VITA ........................................................................... 31
DYRENIUM .................................................................... 40
E
EASIVENT ...................................................................... 92
ECONTRA EZ .................................................................. 21
ED‐SPAZ ........................................................................ 47
EDURANT ........................................................................ 7
EFFER‐K ......................................................................... 78
100
ELIGARD ........................................................................ 14
ELINEST .......................................................................... 21
ELIQUIS .......................................................................... 82
ELITE‐OB ........................................................................ 69
ELIXOPHYLLIN ................................................................ 45
ELLA ............................................................................... 21
ELMIRON ....................................................................... 54
EMCYT ........................................................................... 14
EMEND .......................................................................... 49
EMOQUETTE ................................................................. 21
EMTRIVA ......................................................................... 7
ENALAPRIL ..................................................................... 38
ENALAPRIL/HYDROCHLOROTHIAZIDE ........................... 39
ENBREL .......................................................................... 61
ENBREL SRCLK ............................................................... 61
ENDOCET ....................................................................... 59
ENDODAN ...................................................................... 59
ENDUR‐ACIN .................................................................. 67
ENEMA .......................................................................... 46
ENFALYTE ...................................................................... 78
ENFAMIL .................................................................. 69, 78
ENGERIX‐B ..................................................................... 11
ENOXAPARIN ................................................................. 82
ENPRESSE‐28 ................................................................. 21
ENSKYCE ........................................................................ 21
ENSURE ......................................................................... 80
ENTACAPONE ................................................................ 66
ENTECAVIR ...................................................................... 6
ENTRESTO ..................................................................... 32
ENULOSE ....................................................................... 11
EPCLUSA .......................................................................... 6
EPINEPHRINE AUTO‐INJECTOR ..................................... 41
EPITOL ........................................................................... 64
EPIVIR HBV ...................................................................... 7
EPOPROSTENOL ............................................................ 42
EQL B‐12 ........................................................................ 67
EQL GAUZE .................................................................... 92
EQL HEARTBRN.............................................................. 48
EQL PRENATAL .............................................................. 69
ERGOCALCIFER .............................................................. 31
ERGOMAR ..................................................................... 63
ERIVEDGE ...................................................................... 14
ERLEADA ........................................................................ 14
ERRIN ............................................................................. 21
ERYTHROMYCIN ............................................................ 84
ESTARYLLA .................................................................... 21
ESTRADIOL .................................................................... 19
ESTRADIOL (Generic Climara) ....................................... 19
ESTRADIOL (Generic Vivelle Dot) ............................ 19, 20
ESTRADIOL VALERATE ................................................... 20
ESTRING ........................................................................ 20
ESTROPIPATE ................................................................ 20
ETHAMBUTOL ................................................................. 4
ETHOSUXIMIDE ............................................................. 64
ETIDRONATE DISODIUM ............................................... 29
ETODOLAC .................................................................... 62
ETOPOSIDE .................................................................... 14
EVOTAZ ........................................................................... 7
EXEMESTANE ................................................................ 14
EXTAVIA ........................................................................ 57
E‐Z SPACER .................................................................... 92
EZETIMIBE ..................................................................... 41
F
FALLBACK ...................................................................... 21
FALMINA ....................................................................... 21
FAMCICLOVIR .................................................................. 6
FAMOTIDINE ................................................................. 48
FARESTON ..................................................................... 14
FARYDAK ....................................................................... 14
FAYOSIM ....................................................................... 21
FE GLUCONATE ............................................................. 81
FE TABS ......................................................................... 81
FELBAMATE ................................................................... 64
FEMALE CONDOMS ...................................................... 52
FENOFIBRATE ................................................................ 41
FENOFIBRIC ................................................................... 41
FENTANYL ..................................................................... 59
FEOSOL .......................................................................... 81
FERATE .......................................................................... 81
FERGON ........................................................................ 81
FER‐IRON ....................................................................... 81
FEROSUL ....................................................................... 81
FERREX 150 ................................................................... 81
FERRIC X‐150 ................................................................. 81
FERRO‐BOB ................................................................... 81
FERROTABS ................................................................... 81
FERROUS ....................................................................... 81
101
FERROUS GLUCONATE .................................................. 81
FERROUS SULFATE ........................................................ 81
FERUS ............................................................................ 81
FEXOFENADINE ............................................................. 43
FINASTERIDE ................................................................. 54
FIRST‐OMEPRA .............................................................. 49
FIRST‐TESTOSTERONE ................................................... 19
FIRVANQ ........................................................................ 10
FISH OIL ................................................................... 29, 30
FLAVOR BLEND .............................................................. 90
FLAVOR PLUS ................................................................. 90
FLAVOR SWEET ............................................................. 90
FLECAINIDE .................................................................... 36
FLOVENT ........................................................................ 45
FLOVENT DISK ............................................................... 45
FLUAD ............................................................................ 11
FLUBLOK QUAD ............................................................. 11
FLUCELVAX QUAD ......................................................... 11
FLUCONAZOLE ................................................................. 4
FLUCYTOSINE .................................................................. 4
FLUDROCORTISONE ...................................................... 18
FLULAVAL QUAD ........................................................... 12
FLUMIST QUAD ............................................................. 12
FLUNISOLIDE ................................................................. 43
FLUORABON .................................................................. 76
FLUOR‐A‐DAY ................................................................ 76
FLUORIDE ...................................................................... 76
FLUORIDEX .............................................................. 76, 77
FLUORITAB .................................................................... 77
FLUOROMETHOL ........................................................... 85
FLUOROURACIL ............................................................. 88
FLURA‐DROPS ................................................................ 77
FLURBIPROFEN ........................................................ 62, 86
FLUSH SYRING ............................................................... 78
FLUTAMIDE ................................................................... 14
FLUTICASONE .......................................................... 43, 89
FLUTICASONE INH SALMETEROL (GENERIC AIRDUO) ... 44
FLUVIRIN ....................................................................... 12
FLUZONE ....................................................................... 12
FLUZONE HD .................................................................. 12
FLUZONE QUAD ............................................................ 12
FML ................................................................................ 85
FML FORTE .................................................................... 85
FOCALGIN CA ................................................................ 69
FOLCAPS ........................................................................ 69
FOLIC ACID .................................................................... 67
FOLIVANE‐OB ................................................................ 69
FOLIVANE‐PRX .............................................................. 69
FONDAPARINUX ...................................................... 82, 83
FOSAMPRENAVIR ............................................................ 7
FOSINOPRIL ................................................................... 38
FOSPHENYTOIN ............................................................. 64
FOSRENOL ..................................................................... 51
FRAGMIN ...................................................................... 83
FULL SPECT .................................................................... 69
FULPHILA (NEULASTA BIOSIMILAR) .............................. 80
FUROSEMIDE ................................................................ 40
FUZEON ........................................................................... 7
G
GABAPENTIN ................................................................. 64
GABITRIL ....................................................................... 64
GALANTAMINE .............................................................. 57
GARAMYCIN .................................................................. 84
GARDASIL 9 ................................................................... 12
GATIFLOXACIN .............................................................. 84
GAVILYTE‐C ................................................................... 46
GAVILYTE‐G ................................................................... 46
GAVILYTE‐N ................................................................... 46
GEMFIBROZIL ................................................................ 41
GENERLAC ..................................................................... 11
GENGRAF ...................................................................... 93
GENOTROPIN ................................................................ 30
GENPRIL ........................................................................ 62
GENTAK ......................................................................... 84
GENTAMICIN ........................................................... 84, 87
GENVOYA ........................................................................ 8
GERBER ......................................................................... 78
GESTICARE .................................................................... 69
GIANVI .......................................................................... 21
GILDAGIA ...................................................................... 21
GILDESS ......................................................................... 21
GILDESS 24 .................................................................... 21
GILDESS FE .............................................................. 21, 22
GILOTRIF ....................................................................... 14
GLATIRAMER (Generic Copaxone 40mg) ...................... 57
GLATOPA (Generic Copaxone 20 mg) ........................... 57
GLEOSTINE .................................................................... 14
102
GLIMEPIRIDE ................................................................. 26
GLIPIZIDE ....................................................................... 26
GLIPIZIDE ER .................................................................. 26
GLIPIZIDE XL .................................................................. 27
GLIPIZIDE/METFORMIN ................................................ 25
GLUCAGEN .................................................................... 25
GLUCAGON .................................................................... 25
GLUCERNA ..................................................................... 80
GLUCOSE ....................................................................... 24
GLUCOSE BITS ............................................................... 24
GLUTOSE 15 .................................................................. 24
GLUTOSE 45 .................................................................. 25
GLYBURID MCR ............................................................. 27
GLYBURIDE .............................................................. 25, 27
GLYBURIDE/METFORMIN .............................................. 25
GLYCERIN ....................................................................... 46
GLYDO ........................................................................... 87
GNP CALCIUM ............................................................... 78
GNP PRENATAL ............................................................. 70
GOODSENSE .................................................................. 70
GRANISETRON ............................................................... 49
GRANISOL ...................................................................... 49
GRAPE ........................................................................... 90
GRISEOFULVIN ................................................................ 4
GUANFACINE ................................................................. 38
GYNECORT 10 ................................................................ 89
H
HAEGARDA .................................................................... 90
HAVRIX .......................................................................... 12
HC/ACET ACID ............................................................... 85
HEARTBRN REL .............................................................. 48
HEARTBURN .................................................................. 48
HEATHER ....................................................................... 22
HECORIA ........................................................................ 93
HEPARIN SOD ................................................................ 83
HEPLISAV‐B.................................................................... 12
HEXALEN ....................................................................... 14
HM B COMPLEX ............................................................. 70
HM PRENATAL ............................................................... 70
HOMATROPAIRE ........................................................... 86
HOMATROPINE ............................................................. 86
HUMALOG ..................................................................... 25
HUMATROPE ........................................................... 30, 31
HUMIRA ........................................................................ 61
HUMIRA PEDIA .............................................................. 61
HUMIRA PEN ........................................................... 61, 62
HUMULIN ................................................................ 25, 26
HYCAMTIN .................................................................... 14
HYDRALAZINE ............................................................... 39
HYDROCHLOROTHIAZIDE .............................................. 40
HYDROCODONE/APAP .................................................. 59
HYDROCODONE/IBUPROFEN ........................................ 60
HYDROCORT .................................................................. 89
HYDROCORT AC ............................................................ 89
HYDROCORT/AB ............................................................ 89
HYDROCORTISONE .................................................. 18, 89
HYDROCREAM .............................................................. 89
HYDRO‐LOTION ............................................................. 89
HYDROMORPHONE ....................................................... 60
HYDROSKIN ................................................................... 89
HYDROXYCHLOR ........................................................... 10
HYDROXYPROG ............................................................. 17
HYDROXYUREA ............................................................. 14
HYDROXYZINE HCL ........................................................ 54
HYDROXYZINE PAMOATE .............................................. 54
HYOMAX‐SL ................................................................... 47
HYOSCYAMINE .............................................................. 47
HYOSYNE ....................................................................... 47
I
IBANDRONATE .............................................................. 29
IBRANCE ........................................................................ 14
IBU‐DROPS .................................................................... 62
IBUPROFEN ............................................................. 54, 62
IBUPROFEN IB ............................................................... 62
IBUPROFEN JR ............................................................... 62
IBUPROFEN PM ............................................................. 54
ICLUSIG ......................................................................... 14
IDHIFA ........................................................................... 14
IFEREX 150 .................................................................... 81
ILOTYCIN ....................................................................... 84
IMATINIB MESYLATE ..................................................... 14
IMBRUVICA ................................................................... 14
IMIQUIMOD .................................................................. 88
IMPAVIDO ..................................................................... 10
IMPLANON .................................................................... 22
INATAL ADV .................................................................. 70
103
INATAL GT ..................................................................... 70
INATAL ULTRA ............................................................... 70
INCRELEX ....................................................................... 31
INCRUSE ELLIPTA ........................................................... 44
INDAPAMIDE ................................................................. 40
INDOCIN ........................................................................ 62
INDOMETHACIN ...................................................... 62, 63
INFANRIX ....................................................................... 12
INFERGEN ........................................................................ 6
INLYTA ........................................................................... 14
INSPIREASE .................................................................... 92
INSTACORT 5 ................................................................. 89
INSTA‐GLUCOS .............................................................. 25
INTELENCE ....................................................................... 8
INTRON A ................................................................ 14, 15
INTROVALE .................................................................... 22
INVIRASE ......................................................................... 8
IPECAC ........................................................................... 90
IPRATROPIUM ............................................................... 47
IPRATROPIUM/ .............................................................. 44
IRBESARTAN .................................................................. 37
IRBESARTAN/HYDROCHLOROTHIAZIDE ........................ 39
IRESSA ........................................................................... 15
IRON .............................................................................. 81
IRON SUPPLEM .............................................................. 81
IRON SUPPLMT .............................................................. 81
IRON THERAPY .............................................................. 82
ISENTRESS ....................................................................... 8
ISENTRESS HD .................................................................. 8
ISONIAZID ........................................................................ 4
ISORDIL .......................................................................... 33
ISOSORBIDE DINITRATE ................................................. 33
ISOSORBIDE MONONITRATE ......................................... 33
ITRACONAZOLE ............................................................... 4
IVERMECTIN .................................................................. 10
J
JAKAFI ............................................................................ 15
JANTOVEN ..................................................................... 83
JENCYCLA....................................................................... 22
JOCK ITCH ........................................................................ 5
JOLESSA ......................................................................... 22
JOLIVETTE ...................................................................... 22
JULEBER ......................................................................... 22
JUNEL 1.5/30 ................................................................. 22
JUNEL 1/20 .................................................................... 22
JUNEL FE ....................................................................... 22
JUNEL FE 24 .................................................................. 22
JUST D ........................................................................... 31
JYNARQUE ..................................................................... 30
K
K HYDROCORTISON ....................................................... 89
KALETRA .......................................................................... 8
KALYDECO ..................................................................... 43
KARIDIUM ..................................................................... 77
KARIGEL ........................................................................ 77
KARIGEL‐N ..................................................................... 77
KARIVA .......................................................................... 22
K‐EFFERVESCE ............................................................... 78
KELNOR ......................................................................... 22
KERICORT 10 ................................................................. 89
KETOCONAZOLE .............................................................. 4
KETOPROFEN ................................................................ 63
KETOROLAC ................................................................... 86
KIMIDESS ....................................................................... 22
KIONEX .......................................................................... 94
KISQALI .......................................................................... 15
KLOR‐CON 10 ................................................................ 78
KLOR‐CON 8 .................................................................. 78
KLOR‐CON M10 ............................................................. 78
KLOR‐CON M20 ............................................................. 78
KLOR‐CON SPR .............................................................. 78
KLOR‐CON/EF ................................................................ 78
KONSYL ......................................................................... 46
KP B COMPLEX .............................................................. 70
KP CALCIUM .................................................................. 78
KP PRENATAL ................................................................ 70
K‐PHOS .......................................................................... 78
KPN PRENATAL .............................................................. 70
K‐PRIME ........................................................................ 78
K‐SOL ............................................................................. 78
KURVELO ....................................................................... 22
KUVAN .......................................................................... 30
K‐VESCENT .................................................................... 78
L
LABETALOL .............................................................. 33, 34
104
LACTULOSE .................................................................... 11
LAMIVUDINE ................................................................... 8
LAMIVUDINE/ZIDOVUDINE ............................................. 8
LANABIOTIC ................................................................... 87
LANACORT 10 ................................................................ 89
LANSOPRAZOLE ............................................................. 49
LARIN ............................................................................. 22
LARIN 24 ........................................................................ 22
LARIN FE ........................................................................ 22
LATANOPROST .............................................................. 86
LAYOLIS FE ..................................................................... 22
LEENA ............................................................................ 22
LEFLUNOMIDE ............................................................... 62
LENVIMA ....................................................................... 15
LESSINA ......................................................................... 22
LETAIRIS ......................................................................... 42
LETROZOLE .................................................................... 15
LEUCOVOR CA ............................................................... 12
LEUKERAN ..................................................................... 15
LEUPROLIDE .................................................................. 15
LEVETIRACETA ......................................................... 64, 65
LEVOBUNOLOL .............................................................. 85
LEVOCARNITINE ............................................................ 30
LEVO‐ETH EST ................................................................ 22
LEVOFLOXACIN ................................................................ 4
LEVONEST ...................................................................... 22
LEVONOR/ETHI .............................................................. 22
LEVONORGESTR ............................................................ 22
LEVORA‐28 .................................................................... 22
LEVOTHYROXINE ........................................................... 27
LEVOXYL .................................................................. 27, 28
LEXIVA ............................................................................. 8
LICE KILLING .................................................................. 87
LICE TREATMENT ........................................................... 87
LICE TRTMNT ................................................................. 87
LICIDE ............................................................................ 87
LIDO/PRILOCN ............................................................... 87
LIDOCAINE ......................................................... 36, 86, 87
LINDANE ........................................................................ 87
LINEZOLID ...................................................................... 10
LIOTHYRONINE .............................................................. 28
LIQ CA/VIT D .................................................................. 78
LISINOPRIL ..................................................................... 38
LISINOPRIL/HYDROCHLOROTHIAZIDE ........................... 39
LITEAIRE ........................................................................ 92
LO LOESTRIN ................................................................. 22
LO MINASTRIN .............................................................. 22
LOMEDIA 24 .................................................................. 22
LOMUSTINE ................................................................... 15
LONSURF ....................................................................... 15
LORATADINE ................................................................. 43
LORAZEPAM .................................................................. 55
LORCET .......................................................................... 60
LORCET HD .................................................................... 60
LORCET PLUS ................................................................. 60
LORTAB ......................................................................... 60
LORYNA ......................................................................... 22
LOSARTAN POTASSIUM ................................................ 37
LOSARTAN/HYDROCHLOROTHIAZIDE ........................... 39
LOVASTATIN .................................................................. 41
LOW‐OGESTREL ............................................................ 22
LUDENT ......................................................................... 77
LUPANETA ..................................................................... 15
LUPR DEP‐PED ............................................................... 15
LUPRON DEPOT............................................................. 15
LUTERA .......................................................................... 22
LYNPARZA ..................................................................... 15
LYRICA ........................................................................... 65
LYSODREN ..................................................................... 15
LYZA .............................................................................. 22
M
MAALOX ........................................................................ 47
MAG OXIDE ............................................................. 47, 78
MAGNESIUM CITRATE .................................................. 46
MALE CONDOMS .......................................................... 52
MARLISSA ...................................................................... 22
MASK VORTEX/ ............................................................. 92
MATULANE ................................................................... 16
MAVYRET ........................................................................ 6
MECLIZINE ..................................................................... 49
MED‐DERM HC .............................................................. 89
MEDI‐CORT ................................................................... 89
MEDI‐MECLIZI ............................................................... 49
MEDI‐PROFEN ............................................................... 63
MEDROXYPR AC ............................................................ 17
MEFLOQUINE ................................................................ 10
MEGESTROL AC ............................................................. 16
105
MEKINIST ....................................................................... 16
MEKTOVI ....................................................................... 16
MELOXICAM .................................................................. 63
MEMANTINE ................................................................. 57
MEMANTINE HC ............................................................ 57
MENACTRA .................................................................... 12
MENEST ......................................................................... 20
MENOMUNE ................................................................. 12
MENVEO ........................................................................ 12
MERCAPTOPURINE ........................................................ 12
MESALAMINE ................................................................ 51
MESALAMINE (generic Asacol HD) ................................ 51
MESALAMINE (generic Lialda)....................................... 51
METAMUCIL .................................................................. 46
METAPROTEREN ........................................................... 45
METFORMIN .................................................................. 25
METHAZOLAMIDE ......................................................... 39
METHIMAZOLE .............................................................. 27
METHITEST .................................................................... 19
METHLPHENIDATE (generic Ritalin LA) ......................... 56
METHOCARBAMOL ....................................................... 67
METHOTREXATE ...................................................... 12, 13
METHYLDOPA ................................................................ 38
METHYLERGON ............................................................. 29
METHYLPHENIDATE ...................................................... 56
METHYLPHENIDATE (generic Concerta) ........................ 56
METHYLPHENIDATE (generic Metadate CD) ................. 56
METHYLPHENIDATE (generic Ritalin LA) ....................... 56
METHYLPREDNISOLONE ................................................ 18
METIPRANOLOL ............................................................ 85
METOCLOPRAMIDE ....................................................... 52
METOLAZONE................................................................ 40
METOPROLOL ................................................................ 34
METOPROLOL TARTRATE .............................................. 34
METOPROLOL/HYDROCHLOROTHIAZIDE ...................... 39
METRONIDAZOLE .................................................... 10, 53
MEXILETINE ............................................................. 36, 37
MIBELAS 24 ................................................................... 22
MICADERM ...................................................................... 5
MICONAZOLE .................................................................. 5
MICONAZOLE CRE 2% .................................................... 5
MICONAZOLE POW ........................................................ 5
MICONAZOLE 3 ............................................................... 5
MICONAZOLE 7 ............................................................... 5
MICRO GUARD ................................................................ 6
MICROCHAMBER .......................................................... 92
MICROGESTIN ......................................................... 22, 23
MICROLIFE .................................................................... 92
MICROSPACER .............................................................. 92
MIDODRINE ............................................................ 40, 41
MIDOL ........................................................................... 63
MILK OF MAGNESIUM .................................................. 46
MINERAL OIL ................................................................. 46
MINI WRIGHT ................................................................ 92
MINITRAN ..................................................................... 33
MINOXIDIL .................................................................... 39
MIRASORB .................................................................... 92
MISOPROSTOL .............................................................. 48
MISSION PREN .............................................................. 70
M‐M‐R II ........................................................................ 12
MODERIBA ...................................................................... 6
MOMETASONE ............................................................. 89
MONO‐LINYAH .............................................................. 23
MONONESSA ................................................................ 23
MONTELUKAST ............................................................. 45
MORPHINE SULFATE ..................................................... 60
MOTION RELF ............................................................... 49
MOTION SICK ................................................................ 49
MOTION‐TIME .............................................................. 49
MOTRIN PM .................................................................. 54
MOXIFLOXACIN ............................................................... 4
MULTAQ ........................................................................ 37
MULTI PRENAT .............................................................. 70
MULTI‐VIT/FE ................................................................ 70
MULTI‐VIT/FL ................................................................ 70
MUPIROCIN ................................................................... 87
M‐VIT ............................................................................ 70
MY WAY ........................................................................ 23
MYCOPHENOLAT .......................................................... 93
MYDRAL ........................................................................ 86
MYFERON 150 ............................................................... 82
MYLERAN ...................................................................... 16
MYNATAL ...................................................................... 70
MYNATAL PLUS ............................................................. 71
MYNATAL‐Z ................................................................... 71
MYNEPHROCAPS ........................................................... 71
MYZILRA ........................................................................ 23
106
N
NABUMETONE .............................................................. 63
NADOLOL....................................................................... 34
NAFRINSE ...................................................................... 77
NALOXONE .................................................................... 90
NALTREXONE ................................................................. 90
NAPROXEN .................................................................... 63
NARATRIPTAN ............................................................... 63
NARCAN ........................................................................ 90
NATAL‐V RX ................................................................... 71
NATALVIRT CA ............................................................... 71
NATALVIT ...................................................................... 71
NATEGLINIDE ................................................................. 26
NATURALYTE ................................................................. 78
NEBUPENT ..................................................................... 10
NEBUSAL ....................................................................... 43
NECON ........................................................................... 23
NEO/BAC/POLY ............................................................. 84
NEO/POLY/BAC ............................................................. 85
NEO/POLY/DEX ............................................................. 85
NEO/POLY/GRA ............................................................. 84
NEO/POLY/HC ............................................................... 85
NEOMYCIN ...................................................................... 4
NEO‐POLYCIN .......................................................... 84, 85
NEOPORACIN ................................................................ 87
NEOSPORIN ................................................................... 89
NEOSPORIN AF ................................................................ 6
NEOSPORIN+PN ............................................................ 87
NEPHPLEX RX ................................................................. 71
NEPHRON FA ................................................................. 82
NEPHRONEX .................................................................. 71
NEPHRO‐VITE ................................................................ 71
NERLYNX ........................................................................ 16
NESSI SPACER ................................................................ 92
NEUT ............................................................................. 53
NEUTRAGARD ................................................................ 77
NEUTREXIN .................................................................... 10
NEVIRAPINE ..................................................................... 8
NEXAVAR ....................................................................... 16
NEXT CHOICE ................................................................. 23
NIACIN ............................................................... 41, 67, 68
NIACIN ER ................................................................ 41, 68
NIACIN TR ...................................................................... 68
NIACINAMIDE ................................................................ 68
NICOTINE ...................................................................... 58
NICOTINE SYS ................................................................ 58
NICOTROL ..................................................................... 58
NIFEDIAC CC .................................................................. 35
NIFEDICAL XL ................................................................. 35
NIFEDIPINE .............................................................. 35, 36
NIKKI ............................................................................. 23
NINLARO ....................................................................... 16
NITRO‐BID ..................................................................... 33
NITRO‐DUR ................................................................... 33
NITROFURANTOIN ........................................................ 10
NITROFURANTOIN MACROCRYSTALS ........................... 10
NITROGLYCERIN ............................................................ 33
NIVA‐PLUS ..................................................................... 71
NIZATIDINE ................................................................... 48
NOBLE FORMUL ............................................................ 89
NORA‐BE ....................................................................... 23
NORDITROPIN ............................................................... 31
NORETH/ETHIN ............................................................. 23
NORETHIN ACE .............................................................. 17
NORETHINDRON ........................................................... 23
NORGEST/ETHI .............................................................. 23
NORINYL ........................................................................ 23
NORLYROC .................................................................... 23
NORPACE ...................................................................... 37
NORTREL ....................................................................... 23
NORVIR ........................................................................... 8
NOVAFERRUM .............................................................. 71
NOVOLIN ....................................................................... 26
NOVOLOG ..................................................................... 26
NOXAFIL .......................................................................... 5
NP THYROID .................................................................. 28
NU‐IRON 150 ................................................................ 82
NULEV ........................................................................... 47
NUTROPIN ..................................................................... 31
NUTROPIN AQ ............................................................... 31
NUVARING .................................................................... 23
NYSTAT/TRIAM ............................................................. 89
NYSTATIN ........................................................................ 5
O
OB COMPLETE ............................................................... 71
OB‐NATAL ONE ............................................................. 71
O‐CAL ............................................................................ 71
107
O‐CAL FA ....................................................................... 71
OCELLA .......................................................................... 23
OCTREOTIDE .................................................................. 31
ODEFSY ............................................................................ 8
ODOMZO ....................................................................... 16
OFLOXACIN .................................................................... 84
OGESTREL ...................................................................... 23
OMEGA III ...................................................................... 30
OMEPRAZOLE ................................................................ 49
OMEPRAZOLE + ............................................................. 49
OMNITROPE .................................................................. 31
ONDANSETRON ....................................................... 49, 50
OPCICON ....................................................................... 23
OPTICHAMBER .............................................................. 92
ORA‐BLEND ................................................................... 90
ORA‐BLEND SF ............................................................... 90
ORAL ELECTRO .............................................................. 78
ORAL MIX ...................................................................... 91
ORAL MIX SF .................................................................. 91
ORAL SUSPEND .............................................................. 91
ORAL SYRUP .................................................................. 91
ORALYTE ........................................................................ 78
ORA‐PLUS ...................................................................... 91
ORA‐SWEET ................................................................... 91
ORA‐SWEET SF .............................................................. 91
ORKAMBI ....................................................................... 43
ORSYTHIA ...................................................................... 23
ORTHO COIL .................................................................. 52
ORTHO FLAT ............................................................ 52, 53
ORTHO FLEX .................................................................. 53
ORTHO TRI‐CYCLN LO .................................................... 23
ORTHO‐EST .................................................................... 20
OSCAL ............................................................................ 78
OS‐CAL ........................................................................... 78
OSCIMIN ........................................................................ 47
OSCIMIN SR ................................................................... 47
OSELTAMIVIR ............................................................ 9, 10
OTEZLA .......................................................................... 62
OXANDROLONE ............................................................. 19
OXCARBAZEPIN ............................................................. 65
OXYBUTYNIN ................................................................. 52
OXYCODONE ................................................................. 61
OXYCODONE/APAP ....................................................... 60
OXYCODONE/ASA ......................................................... 60
OXYCONTIN ................................................................... 61
OXYTROL/WOMN ......................................................... 52
OYS SHELL CA ................................................................ 78
OYS SHELL+D ................................................................. 78
OYSCO 500+D ................................................................ 79
OYST CAL/D ................................................................... 79
OYST SHELL/D ............................................................... 79
P
PACERONE .................................................................... 37
PANCREAZE ................................................................... 50
PANDA MASK ................................................................ 93
PANTOPRAZOLE ............................................................ 49
PARICALCITOL ............................................................... 31
PAROEX ......................................................................... 86
PAROMOMYCIN .............................................................. 4
PCCA SWEET ................................................................. 91
PCCA SYRUP .................................................................. 91
PCCA‐PLUS .................................................................... 91
PEAK AIR FLO ................................................................ 93
PEAK FLOW ................................................................... 93
PEAK FLW MTR ............................................................. 93
PEDIA IRON ................................................................... 82
PEDIA‐LAX ..................................................................... 46
PEDIALYTE ..................................................................... 79
PEDIASURE .................................................................... 80
PEGANONE .................................................................... 65
PENICILLIN G POTASSIUM ............................................... 1
PENTAM 300 ................................................................. 10
PENTASA ....................................................................... 51
PENTOXIFYLLI ................................................................ 84
PEPCID AC ..................................................................... 48
PERIOGARD ................................................................... 86
PERMETHRIN ................................................................ 87
PERSONAL BES .............................................................. 93
PHENADOZ .................................................................... 50
PHENAZO ...................................................................... 54
PHENAZOPYRID ............................................................. 54
PHENERGAN .................................................................. 50
PHENOBARB .................................................................. 55
PHENYTOIN ................................................................... 65
PHENYTOIN EX .............................................................. 65
PHILITH ......................................................................... 23
PHOS‐FLUR .................................................................... 77
108
PHOSPHA 250 ................................................................ 79
PHOSPHOLINE ............................................................... 86
PHYTONADIONE ............................................................ 32
PIKO 1 ............................................................................ 93
PILOCARPINE ........................................................... 52, 86
PIMTREA ........................................................................ 23
PINDOLOL ...................................................................... 34
PINWORM ..................................................................... 10
PIN‐X .............................................................................. 10
PIOGLITAZONE ........................................................ 25, 27
PIOGLITAZONE/METFORMIN ........................................ 25
PIPER/TAZOBA ................................................................ 1
PIRMELLA ...................................................................... 23
PLAN B ........................................................................... 23
PLEGRIDY ....................................................................... 57
PLEGRIDY PEN ............................................................... 57
PNEUMOVAX 23 ............................................................ 12
PNV FE FUM .................................................................. 71
PNV FOLIC AC ................................................................ 71
PNV OB+DHA ................................................................. 71
PNV PRENATAL .............................................................. 71
PNV TABS ...................................................................... 71
PNV‐DHA ....................................................................... 71
PNV‐SELECT ................................................................... 71
PNV‐VP‐U ...................................................................... 71
POCKET PEAK ................................................................ 93
POCKETPEAK ................................................................. 93
PODACTIN ....................................................................... 6
PODOFILOX ................................................................... 88
POLYCIN ........................................................................ 85
POLYCIN B ..................................................................... 85
POLY‐DEX ...................................................................... 85
POLYETHYLENE GLYCOL ................................................ 46
POLY‐IRON ..................................................................... 82
POLYMYXIN B/SOL TRIMETHOPRIM SULFATE .............. 85
POLY‐VI‐SOL .................................................................. 71
POLY‐VITA ..................................................................... 72
POLYVITAMIN ................................................................ 72
POLY‐VITE ...................................................................... 72
POMALYST ..................................................................... 16
PORTIA‐28 ..................................................................... 23
POT ACETATE ................................................................ 79
POT CHLORIDE .............................................................. 79
POT CL MICRO ............................................................... 79
POT GLUCONAT ............................................................ 79
POTASSIUM ................................................................... 79
POTASSIUM CITRATE .................................................... 53
POTASSIUM CITRATE/CITRIC ACID ................................ 53
PRADAXA ...................................................................... 83
PRAMIPEXOLE ............................................................... 66
PRAVASTATIN ......................................................... 41, 42
PRAZIQUANTEL ............................................................. 10
PRAZOSIN ...................................................................... 54
PRED MILD .................................................................... 85
PRED SOD PHO .............................................................. 85
PREDNISOLONE ....................................................... 18, 85
PREDNISOLONE SODIUM PHOSPHATE ......................... 18
PREDNISONE ................................................................. 18
PREMARIN VAG............................................................. 20
PRENAISSANCE ............................................................. 72
PRENAPLUS ................................................................... 72
PRENAT PLUS ................................................................ 72
PRENATABS FA .............................................................. 72
PRENATABS RX .............................................................. 72
PRENATAL ......................................................... 71, 72, 74
PRENATAL 1 .................................................................. 73
PRENATAL 19 ................................................................ 73
PRENATAL AD ............................................................... 73
PRENATAL FRM ............................................................. 73
PRENATAL MV ............................................................... 73
PRENATAL VIT ............................................................... 73
PRENATAL/FE ................................................................ 73
PRENATAL+DHA ............................................................ 73
PRENATAL+FE ............................................................... 73
PRENATAL‐U ................................................................. 73
PRENATL MULT ............................................................. 73
PREP H HC ..................................................................... 89
PREPLUS ........................................................................ 73
PRETAB .......................................................................... 73
PREVALITE ..................................................................... 41
PREVIFEM...................................................................... 23
PREVNAR 13 .................................................................. 12
PREVYMIS........................................................................ 6
PREZCOBIX ...................................................................... 8
PREZISTA ......................................................................... 8
PRIMEAIRE .................................................................... 93
PRIMIDONE ................................................................... 65
PROAIR HFA .................................................................. 44
109
PROBEN/COLCH ............................................................ 64
PROBENECID ................................................................. 64
PROCAINAMIDE ............................................................ 37
PROCHLORPER .............................................................. 50
PROCTO‐PAK ................................................................. 89
PROCTOSOL HC ............................................................. 89
PROCTOZONE ................................................................ 89
PROGESTERONE ............................................................ 18
PROGLYCEM .................................................................. 25
PROMACTA.................................................................... 80
PROMETHAZINE ............................................................ 50
PROMETHEGAN ............................................................ 50
PRONTO PLUS ............................................................... 87
PROPAFENONE .............................................................. 37
PROPANTHELIN ............................................................. 47
PROPRANOLOL .............................................................. 34
PROPYLTHIOUR ............................................................. 27
PROVENTIL .................................................................... 44
PROVIL ........................................................................... 63
PSORIASIN ..................................................................... 88
PSYLLIUM FIBER ............................................................ 46
PULMOSAL .................................................................... 43
PULMOZYME ................................................................. 43
PX PRENATAL ................................................................ 73
PYRAZINAMIDE ............................................................... 4
PYRIDOSTIGMINE BROMIDE ......................................... 52
PYRIDOXINE ................................................................... 68
Q
QC PRENATAL ................................................................ 73
QUASENSE ..................................................................... 23
QUFLORA PED ............................................................... 73
QUINAPRIL .................................................................... 38
QUINIDINE GLUCONATE ............................................... 37
QUINIDINE SULFATE ...................................................... 37
QVAR ............................................................................. 45
QVAR REDIHALER .......................................................... 45
R
RA ALCOHOL .................................................................. 87
RA ARTH PAIN ............................................................... 88
RA CALCIUM .................................................................. 73
RA PRENATAL .......................................................... 73, 74
RABEPRAZOLE ............................................................... 49
RAJANI .......................................................................... 23
RALOXIFENE .................................................................. 29
RAMIPRIL ...................................................................... 38
RANEXA ......................................................................... 32
RANITIDINE ................................................................... 48
RAPAMUNE ................................................................... 93
REBIF ............................................................................. 57
REBIF REBIDO ................................................................ 57
REBIF TITRTN ................................................................. 57
RECLIPSEN ..................................................................... 24
RECOMBIVA HB ............................................................. 12
RECORT PLUS ................................................................ 90
REDERM ........................................................................ 90
REESES MED .................................................................. 10
REGONOL ...................................................................... 52
REGRANEX .................................................................... 88
RELENZA ........................................................................ 10
RELION .......................................................................... 26
REMODULIN .................................................................. 42
RENAGEL ....................................................................... 51
RENAL ........................................................................... 74
RENALPREN ................................................................... 74
RENA‐VITE ..................................................................... 74
RENA‐VITE RX ................................................................ 74
RENO ............................................................................. 74
REPATHA ....................................................................... 41
RESCRIPTOR .................................................................... 8
RETACRIT (PROCRIT/EPOGEN BIOSIMILAR) ............ 80, 81
RETROVIR ........................................................................ 8
REVLIMID ...................................................................... 16
REYATAZ .......................................................................... 8
RIBASPHERE .................................................................... 7
RIBAVIRIN ....................................................................... 7
RIFABUTIN ....................................................................... 4
RIFAMPIN ........................................................................ 4
RILUZOLE ....................................................................... 67
RIMANTADINE ................................................................ 6
RINGWORM .................................................................... 6
RISEDRONATE ............................................................... 29
RITEFLO ......................................................................... 93
RITONAVIR ...................................................................... 8
RIVASTIGMINE .............................................................. 57
RIVELSA ......................................................................... 24
RIZATRIPTAN ................................................................. 63
110
ROMYCIN ....................................................................... 85
ROPINIROLE ............................................................. 66, 67
ROSUVASTATIN ............................................................. 42
ROXICET ......................................................................... 61
RUBRACA ....................................................................... 16
RULAVITE DHA .............................................................. 74
RYDAPT .......................................................................... 16
S
SABRIL ........................................................................... 65
SAFYRAL ........................................................................ 24
SALINE ........................................................................... 46
SALINE FLUSH ................................................................ 79
SALSALATE ..................................................................... 59
SAM‐E.P.A. .................................................................... 30
SARNOL‐HC ................................................................... 90
SB HYDROCORT ............................................................. 90
SCALP RELIEF ................................................................. 90
SCALPICIN ................................................................ 88, 90
SEGLUROMET ................................................................ 26
SELEGILINE .................................................................... 66
SELZENTRY ................................................................... 8, 9
SE‐NATAL 19 .................................................................. 74
SENNA ........................................................................... 46
SENNA‐DOCUSATE SODIUM ......................................... 46
SENSIPAR ....................................................................... 30
SEREVENT DISKUS ......................................................... 44
SE‐TAN DHA................................................................... 74
SETLAKIN ....................................................................... 24
SEVELAMER ............................................................. 51, 52
SF 77
SF 5000 PLUS ................................................................. 77
SHAROBEL ..................................................................... 24
SHINGRIX ....................................................................... 12
SIGNIFOR ....................................................................... 31
SILDENAFIL .................................................................... 42
SILIQ .............................................................................. 88
SILVER SULFA ................................................................ 87
SIMILAC PREN ............................................................... 74
SIMPLE ........................................................................... 91
SIMVASTATIN ................................................................ 42
SIROLIMUS .................................................................... 94
SLEEP AID ...................................................................... 54
SLO‐NIACIN.................................................................... 68
SLOW IRON ................................................................... 82
SLOW REL FE ................................................................. 82
SLOW RELEASE .............................................................. 82
SM ACID REDU .............................................................. 48
SM ANTIFUNGL ............................................................... 6
SM CALCIUM ................................................................. 74
SM FIRST AID ................................................................. 87
SM IPECAC .................................................................... 90
SM IRON ........................................................................ 82
SM IRON SLOW ............................................................. 82
SMZ/TMP DS ................................................................. 10
SMZ‐TMP ...................................................................... 11
SOD BICARB .................................................................. 53
SOD CHLORIDE ........................................................ 79, 80
SOD FLUORIDE .............................................................. 77
SOD POLY ...................................................................... 94
SODIUM BICAR .............................................................. 47
SODIUM CHLOR ............................................................ 54
SODIUM CHLORIDE ....................................................... 43
SOLIA ............................................................................. 24
SOLIQUA ....................................................................... 26
SOMAVERT .................................................................... 31
SOOTHE&COOL ............................................................... 6
SORINE .......................................................................... 34
SOTALOL AF .................................................................. 34
SOTALOL HCL ................................................................ 34
SOVALDI .......................................................................... 7
SPIRIVA ......................................................................... 44
SPIRONOLACTONE .................................................. 39, 40
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE .............. 39
SPONGE ......................................................................... 53
SPORANOX ...................................................................... 5
SPRINTEC 28 .................................................................. 24
SPRYCEL ........................................................................ 16
SPS ................................................................................ 94
SRONYX ......................................................................... 24
SSD ................................................................................ 87
SSKI ............................................................................... 27
STAVUDINE ..................................................................... 9
STEGLATRO ................................................................... 26
STELARA ........................................................................ 88
STERIL WATER ......................................................... 54, 91
STIOLTO ........................................................................ 44
STIVARGA ...................................................................... 16
111
STOMACH RLF ............................................................... 47
STRESS 500 .................................................................... 74
STRESS FORM ................................................................ 74
STRIBILD .......................................................................... 9
STUART PREN ................................................................ 74
SUCRALFATE .................................................................. 49
SULF/PRED NA ............................................................... 85
SULFACET SOD .............................................................. 85
SULFADIAZINE ............................................................... 51
SULFASALAZIN ............................................................... 51
SULFATRIM PD .............................................................. 11
SULFAZINE ..................................................................... 51
SULFAZINE EC ................................................................ 51
SULINDAC ...................................................................... 63
SUMATRIPTAN .............................................................. 63
SUPER B‐COMP ............................................................. 74
SUPER DHA .................................................................... 30
SUPER OMEGA .............................................................. 30
SUPERPLEX‐T ................................................................. 74
SUPRAX ........................................................................... 2
SUSPENSION .................................................................. 91
SUTENT .......................................................................... 16
SYEDA ............................................................................ 24
SYMAX FASTAB .............................................................. 47
SYMAX‐SL ...................................................................... 47
SYMAX‐SR ...................................................................... 47
SYMBICORT ................................................................... 44
SYMDEKO ...................................................................... 44
SYMFI .............................................................................. 9
SYMFI LO ......................................................................... 9
SYMTUZA ......................................................................... 9
SYNAGIS ........................................................................ 11
SYNTHROID ................................................................... 28
SYRPALTA ...................................................................... 91
SYRSPEND SF ................................................................. 91
SYRUP ............................................................................ 91
SYRUP SF ....................................................................... 91
T
TABLET .......................................................................... 93
TABLOID ........................................................................ 16
TACROLIMUS ................................................................. 94
TADALAFIL ..................................................................... 42
TAFINLAR ....................................................................... 16
TAGRISSO ................................................................ 16, 17
TAKE ACTION ................................................................ 24
TALTZ ............................................................................ 62
TAMOXIFEN .................................................................. 17
TAMSULOSIN ................................................................ 54
TANZEUM ...................................................................... 25
TARCEVA ....................................................................... 17
TARINA FE ..................................................................... 24
TASIGNA ........................................................................ 17
TAVALISSE ..................................................................... 81
TAZTIA XT ...................................................................... 36
TECFIDERA .................................................................... 57
TEMOZOLOMIDE ........................................................... 17
TENOFOVIR ..................................................................... 9
TERAZOSIN .................................................................... 54
TERBINAFINE ................................................................... 5
TERBUTALINE ................................................................ 45
TESTIM .......................................................................... 19
TESTOSTERONE ............................................................. 19
TESTOSTERONE CYPIONATE ......................................... 19
TESTOSTERONE ENATHATE .......................................... 19
TEV‐TROPIN .................................................................. 31
TH IRON ........................................................................ 82
TH PRENATAL ................................................................ 74
THEO‐24 ........................................................................ 45
THEOCHRON ................................................................. 46
THEOPHYLLINE .............................................................. 46
THERA‐D ........................................................................ 32
THERAGEN HP ............................................................... 88
THERANATAL ................................................................ 74
THERMAZENE ................................................................ 87
THIAMINE HCL .............................................................. 68
THRIVITE 19 .................................................................. 74
THRIVITE RX .................................................................. 74
THYROLAR‐1 .................................................................. 28
THYROLAR‐1/2 .............................................................. 28
THYROLAR‐1/4 .............................................................. 28
THYROLAR‐2 .................................................................. 28
THYROLAR‐3 .................................................................. 28
TIAGABINE .................................................................... 65
TIBSOVO ........................................................................ 17
TICLOPIDINE .................................................................. 84
TILIA FE.......................................................................... 24
TIMOLOL GEL ................................................................ 85
112
TIMOLOL MAL ............................................................... 85
TINEACIDE ....................................................................... 6
TIVICAY ............................................................................ 9
TIZANIDINE .................................................................... 67
TOBRA/DEXAME ............................................................ 86
TOBRADEX ..................................................................... 86
TOBRAMYCIN ............................................................ 4, 85
TOLAZAMIDE ................................................................. 27
TOLCAPONE ................................................................... 66
TOLTERODINE ................................................................ 52
TOPIRAGEN ................................................................... 65
TOPIRAMATE ................................................................. 65
TORSEMIDE ................................................................... 40
TOTAL B/C ..................................................................... 74
TOUJEO ......................................................................... 26
TRACLEER ...................................................................... 42
TRAMADL/APAP ............................................................ 61
TRAMADOL HCL ............................................................ 61
TRANEXAMIC ACID ........................................................ 84
TRAVEL SICK .................................................................. 50
TRAVOPROST................................................................. 86
TRAV‐TABS .................................................................... 50
TRELEGY ........................................................................ 44
TREMFYA ....................................................................... 88
TRETINOIN ..................................................................... 17
TRIADVANCE ................................................................. 74
TRIAMCINOLON ............................................................ 90
TRIAMCINOLONE NASAL ............................................... 43
TRIAMTERENE/HYDROCHLOROTHIAZIDE ..................... 39
TRICARE ......................................................................... 74
TRIDERM ....................................................................... 90
TRI‐ESTARYLL ................................................................. 24
TRIFLURIDINE ................................................................ 85
TRIHEXYPHEN ................................................................ 66
TRI‐LEGEST .................................................................... 24
TRILEPTAL ...................................................................... 65
TRI‐LINYAH .................................................................... 24
TRILYTE .......................................................................... 46
TRIMETHOPRIM ............................................................ 11
TRIMETHOPRIM SOL POLYMYXN .................................. 85
TRINATAL ....................................................................... 74
TRINATAL GT ................................................................. 75
TRINATAL RX ................................................................. 75
TRINATE ......................................................................... 75
TRINESSA ....................................................................... 24
TRIPHROCAPS ............................................................... 75
TRI‐PREVIFEM ............................................................... 24
TRIPTONE ...................................................................... 50
TRI‐SPRINTEC ................................................................ 24
TRIUMEQ ........................................................................ 9
TRI‐VI‐SOL ..................................................................... 75
TRI‐VIT/FL ...................................................................... 75
TRI‐VIT/FLUO ................................................................ 75
TRI‐VITA ........................................................................ 75
TRI‐VITA/FL ................................................................... 75
TRI‐VITAMIN ................................................................. 75
TRIVORA‐28 .................................................................. 24
TRIXAICIN HP ................................................................ 88
TROPICAMIDE ............................................................... 86
TRUMENBA ................................................................... 12
TRUVADA ........................................................................ 9
TRUZONE PEAK ............................................................. 93
TWINRIX ........................................................................ 12
TYBOST ............................................................................ 9
TYKERB .......................................................................... 17
TYMLOS ......................................................................... 29
TYZEKA ............................................................................ 7
U
ULTIMATECARE ............................................................. 75
ULTRA TABS .................................................................. 75
UNITHROID ................................................................... 29
UNITHROID DIRECT ................................................. 28, 29
URSODIOL ..................................................................... 51
V
VAGISTAT‐3 ..................................................................... 6
VALACYCLOVIR ................................................................ 6
VALGANCICLOVIR ........................................................... 6
VALSARTAN ................................................................... 37
VALSARTAN/HCTZ ......................................................... 37
VALVD HOLDNG ............................................................ 93
VANCOMYCIN ............................................................... 11
VANCOMYCIN (compound kit) ..................................... 11
VANCOMYCIN/DEXTROSE ............................................. 11
VANDAZOLE .................................................................. 53
VAQTA ........................................................................... 12
VARIVAX ........................................................................ 12
113
VCF VAGINAL ................................................................. 53
VELETRI .......................................................................... 42
VELIVET ......................................................................... 24
VELTASSA ...................................................................... 94
VENATAL‐FA .................................................................. 75
VENCLEXTA .................................................................... 17
VENTAVIS ...................................................................... 42
VENTOLIN HFA .............................................................. 44
VERAPAMIL ................................................................... 36
VEREGEN ....................................................................... 88
VERSAFREE .................................................................... 91
VERSAPLUS .................................................................... 91
VERZENIO ...................................................................... 17
VESTURA ....................................................................... 24
VIBRAMYCIN.................................................................... 3
VICTOZA ........................................................................ 25
VIDEX ............................................................................... 9
VIGABATRIN (GENERIC SABRIL) ..................................... 65
VIMPAT ......................................................................... 66
VINATE AZ EX ................................................................ 75
VINATE CAL ................................................................... 75
VINATE GT ..................................................................... 75
VINATE IC ...................................................................... 75
VINATE II ........................................................................ 75
VINATE ONE .................................................................. 75
VINATE ULTRA ............................................................... 75
VIORELE ......................................................................... 24
VIRACEPT ......................................................................... 9
VIREAD ............................................................................ 9
VIRT NATE ..................................................................... 75
VIRT‐ADVANCE .............................................................. 75
VIRT‐CAPS ...................................................................... 75
VIRT‐CARE ..................................................................... 76
VIRT‐PHOS ..................................................................... 80
VIRT‐PN ......................................................................... 76
VIRT‐PN DHA ................................................................. 76
VIRTRATE‐2 ................................................................... 53
VIRTRATE‐K ................................................................... 53
VIRT‐VITE GT ................................................................. 76
VIT D GUMMIE .............................................................. 32
VITA‐BEE/C .................................................................... 76
VITAFOL‐OB ................................................................... 76
VITAFOL‐PN ................................................................... 76
VITAJOY DALY ................................................................ 32
VITAMIN B‐1 ................................................................. 68
VITAMIN B‐12 ............................................................... 68
VITAMIN D .................................................................... 32
VITAMIN D3 .................................................................. 32
VITEKTA ........................................................................... 9
VOGELXO ...................................................................... 19
VOL‐CARE RX ................................................................. 76
VOL‐NATE ...................................................................... 76
VOL‐PLUS ...................................................................... 76
VOL‐TAB RX ................................................................... 76
VORICONAZOLE .............................................................. 5
VORTEX VALVE .............................................................. 93
VORTEX/MASK .............................................................. 93
VOSEVI ............................................................................ 7
VOTRIENT ...................................................................... 17
VP‐ERA OB .................................................................... 76
VP‐VITE RX .................................................................... 76
VYFEMLA ....................................................................... 24
W
WAL‐DRAM ................................................................... 50
WAL‐DRAM II ................................................................ 50
WAL‐ZAN ....................................................................... 48
WAL‐ZAN 75 .................................................................. 48
WARFARIN .................................................................... 83
WATCHHALER ............................................................... 93
WERA ............................................................................ 24
WIDE‐SEAL .................................................................... 53
WYMZYA FE .................................................................. 24
X
XALKORI ........................................................................ 17
XARELTO ....................................................................... 83
XARELTO STAR .............................................................. 84
XIFAXAN ........................................................................ 11
XOPENEX HFA ............................................................... 44
XTANDI .......................................................................... 17
XULANE ......................................................................... 24
Y
YODOXIN ......................................................................... 4
YUVAFEM ...................................................................... 20
114
Z
ZAFIRLUKAST ................................................................. 45
ZARAH ........................................................................... 24
ZARXIO (NEUPOGEN BIOSIMILAR) ................................ 81
ZATEAN‐PN .................................................................... 76
ZEJULA ........................................................................... 17
ZELBORAF ...................................................................... 17
ZEMAIRA ....................................................................... 46
ZENCHENT ..................................................................... 24
ZENCHENT FE ................................................................ 24
ZENPEP .......................................................................... 51
ZEPATIER ......................................................................... 7
ZIAGEN ............................................................................ 9
ZIDOVUDINE ................................................................... 9
ZINBRYTA ...................................................................... 57
ZIRGAN .......................................................................... 85
ZITHROMAX .................................................................... 3
ZOLINZA ........................................................................ 17
ZOLMITRIPTAN .............................................................. 63
ZOLPIDEM ..................................................................... 55
ZOMACTON ................................................................... 31
ZONISAMIDE ................................................................. 66
ZORTRESS ...................................................................... 94
ZOVIA ............................................................................ 24
ZYDELIG ......................................................................... 17
ZYKADIA ........................................................................ 17
ZYTIGA ........................................................................... 17