prior quantity limit step therapy tier brand name …

Tier BRAND NAME GENERIC NAMEPRIOR

AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 1ST CHOICE LANCETS LANCETS

2 1ST TIER UNIFINE PENTIPS NEEDLES, INSULIN DISPOSABLE

2 1ST TIER UNIFINE PENTIPS PLUS NEEDLES, INSULIN DISPOSABLE

2 1ST TIER UNILET COMFORTOUCH LANCETS

2 8-MOP METHOXSALEN

1 ABACAVIR ABACAVIR SULFATE QL

1 ABACAVIR-LAMIVUDINE-ZIDOVUDINE ABACAVIR/LAMIVUDINE/ZIDOVUDINE PA

3 ABILIFY ARIPIPRAZOLE QL ST

Excluded ABSTRAL FENTANYL

2 ACANYA CLINDAMYCIN PHOS/BENZOYL PEROX

1 ACARBOSE ACARBOSE

3 ACCUPRIL QUINAPRIL HCL

3 ACCURETIC QUINAPRIL/HYDROCHLOROTHIAZIDE

1 ACEBUTOLOL HCL ACEBUTOLOL HCL

1 ACETAMINOPHEN-BUTALBITAL BUTALBITAL/ACETAMINOPHEN

1 ACETAMINOPHEN-CODEINE ACETAMINOPHEN WITH CODEINE

1 ACETASOL HC ACETIC ACID/HYDROCORTISONE

1 ACETAZOLAMIDE ACETAZOLAMIDE

1 ACETIC ACID ACETIC ACID

1 ACETIC ACID-ALUMINUM ACETIC ACID/ALUMINUM ACETATE

1 ACETYLCYSTEINE ACETYLCYSTEINE

1 ACITRETIN ACITRETIN

1 ACLOMETASONE DIPROPIONATE 0.05% CREAM, OINTMENT [LOW] ACLOMETASONE

3 ACTIGALL URSODIOL

2 ACTI-LANCE LANCETS

3 ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL ST

2 ACTOPLUS MET XR PIOGLITAZONE HCL/METFORMIN HCL ST

3 ACTOS PIOGLITAZONE HCL

3 ACULAR KETOROLAC TROMETHAMINE

3 ACULAR LS KETOROLAC TROMETHAMINE

1 ACYCLOVIR ACYCLOVIR

3 ADALAT CC NIFEDIPINE

2 ADAPALENE 0.05% GEL ADAPALENE

1 ADAPALENE 0.1% GEL ADAPALENE

2 ADAPALENE 0.1% LOTION ADAPALENE

2 ADAPALENE 0.3% GEL, GEL WIT HPUMP ADAPALENE

2 ADCIRCA TADALAFIL PA

3 ADDERALL DEXTROAMPHETAMINE/AMPHETAMINE QL

3 ADDERALL XR DEXTROAMPHETAMINE/AMPHETAMINE QL

Excluded ADDYI FLIBANSERIN

1 ADEFOVIR DIPIVOXIL ADEFOVIR DIPIVOXIL

2 ADEMPAS RIOCIGUAT PA

2 ADVAIR DISKUS FLUTICASONE/SALMETEROL QL

2 ADVAIR HFA FLUTICASONE/SALMETEROL QL

2 ADVANCED TRAVEL LANCETS LANCETS

2 ADVOCATE LANCET LANCETS

2 ADVOCATE LANCETS LANCETS


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 ADVOCATE PEN NEEDLES NEEDLES, INSULIN DISPOSABLE

2 ADVOCATE SYRINGES SYRINGE & NEEDLE,INSULIN,1 ML

1 AFEDITAB CR NIFEDIPINE

2 AFINITOR EVEROLIMUS PA QL

2 AFINITOR DISPERZ EVEROLIMUS PA

3 AGRYLIN ANAGRELIDE HCL

1 AK-POLY-BAC BACITRACIN/POLYMYXIN B SULFATE

1 ALA-CORT HYDROCORTISONE

1 ALA-SCALP HYDROCORTISONE

1 ALBUTEROL SOLUTION FOR INHALATION ALBUTEROL

1 ALBUTEROL SULFATE ALBUTEROL SULFATE

1 ALCLOMETASONE DIPROPIONATE ALCLOMETASONE DIPROPIONATE

Excluded ALCORTIN-A IODOQUINAL-HYDROCORTISONE-ALOE

3 ALDACTONE SPIRONOLACTONE

3 ALDARA IMIQUIMOD PA QL

1 ALENDRONATE SODIUM ALENDRONATE SODIUM

1 ALFUZOSIN HCL ER ALFUZOSIN HCL

2 ALKERAN MELPHALAN

1 ALLOPURINOL ALLOPURINOL

2 ALMOTRIPTAN ALMOTRIPTAN

2 ALOCRIL NEDOCROMIL SODIUM

2 ALOMIDE LODOXAMIDE TROMETHAMINE

2 ALORA ESTRADIOL QL

3 ALPHAGAN P BRIMONIDINE TARTRATE

2 ALPRAZOLAM INTENSOL ALPRAZOLAM

VC ALPRAZOLAM IR TABS ALPRAZOLAM

2 ALPRAZOLAM ODT ALPRAZOLAM

2 ALREX LOTEPREDNOL ETABONATE

3 ALTACE RAMIPRIL

1 ALTAVERA LEVONORGESTREL-ETHIN ESTRADIOL

2 ALTERNATE SITE LANCETS LANCETS

Excluded ALTOPREV LOVASTATIN EXTENDED-RELEASE

Excluded ALVESCO CICLESONIDE

1 ALYACEN NORETHINDRONE-ETHINYL ESTRAD

1 AMANTADINE AMANTADINE HCL

3 AMARYL GLIMEPIRIDE

3 AMBIEN ZOLPIDEM TARTRATE QL

3 AMBIEN CR ZOLPIDEM TARTRATE QL ST

2 AMCINONIDE 0.1% CREAM, LOTION [HIGH] AMCINONIDE

3 AMERGE NARATRIPTAN HCL QL

1 AMIODARONE HCL AMIODARONE HCL

2 AMITIZA LUBIPROSTONE QL

1 AMITRIPTYLINE AMITRIPTYLINE

VC AMLODIPINE BESYLATE AMLODIPINE BESYLATE

1 AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL

1 AMLODIPINE TABLET/ATORVASTATIN TABLET AMLOAMLODIPINE/ATORVASTATIN

2 AMLODIPINE/ATORVASTATIN COMBINATION TABLET QL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 AMLODIPINE/TELMISARTAN COMBINATION TABLET

1 AMLODIPINE/VALSARTAN COMBINATION 10 MG-320MG TABLET

2

AMLODIPINE/VALSARTAN COMBINATION TABLET (5/160, 5/320,

10/160) ST

2 AMLODIPINE/VALSARTAN/HCTZ COMINATION TABLET

1 AMNESTEEM ISOTRETINOIN

1 AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAV

1 AMOXAPINE AMOXAPINE

VC AMOXICILLIN AMOXICILLIN

1 AMOXICILLIN-CLAVULANATE ER AMOXICILLIN/POTASSIUM CLAV

1 AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE/AMPHETAMINE

2 AMPHETAMINE SALT COMBO ER DEXTROAMPHETAMINE/AMPHETAMINE QL

2 AMPHETAMINE/DEXTROAMPHETAMINE SALTS ER CAPSULE DEXTROAMPHETAMINE/AMPHETAMINE

1 AMPHETAMINE/DEXTROAMPHETAMINE SALTS TABLET DEXTROAMPHETAMINE/AMPHETAMINE

1 AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE

Excluded AMRIX CYCLOBENZAPRINE EXTENDED-RELEASE

3 ANAFRANIL CLOMIPRAMINE HCL

1 ANAGRELIDE HCL ANAGRELIDE HCL

3 ANALPRAM HC HYDROCORTISONE/PRAMOXINE

3 ANAPROX NAPROXEN SODIUM

3 ANAPROX DS NAPROXEN SODIUM

3 ANASPAZ HYOSCYAMINE SULFATE

1 ANASTROZOLE ANASTROZOLE

3 ANDROGEL TESTOSTERONE PA

2 ANDROID METHYLTESTOSTERONE

1 ANDROXY FLUOXYMESTERONE QL

2 ANORO ELLIPTA UMECLIDINIUM BRM/VILANTEROL TR QL

3 ANTABUSE DISULFIRAM

Excluded ANTARA FENOFIBRATE

3 ANTIVERT MECLIZINE HCL

1 ANUCORT-HC HYDROCORTISONE ACETATE

3 ANUSOL-HC HYDROCORTISONE

2 APEXICON E DIFLORASONE DIACETATE/EMOLL

Excluded APIDRA INSULIN

1 APRI DESOGESTREL-ETHINYL ESTRADIOL

2 APRISO MESALAMINE

Excluded APTENSIO XR METHYLPHENIDATE EXTENDED-RELEASE

2 APTIVUS TIPRANAVIR/VITAMIN E TPGS PA

1 ARANELLE NORETHINDRONE-ETHINYL ESTRAD

3 ARAVA LEFLUNOMIDE

Excluded ARESTIN MINOCYCLINE

3 ARICEPT DONEPEZIL HCL

3 ARIMIDEX ANASTROZOLE

2 ARIPIPRAZOLE/ARIPIPRAZOLE ODT ARIPIPRAZOLE QL ST

3 ARIXTRA FONDAPARINUX SODIUM QL

2 ARMOUR THYROID THYROID,PORK

3 AROMASIN EXEMESTANE PA


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORExcluded ASACOL HD MESALAMINE DELAYED-RELEASE

1 ASCOMP WITH CODEINE CODEINE/BUTALBITAL/ASA/CAFFEIN

2 ASMANEX MOMETASONE FUROATE QL

2 ASMANEX HFA MOMETASONE FUROATE QL

2 ASSURE HAEMOLANCE PLUS BLADE LANCET, SAFETY

2 ASSURE ID INSULIN SAFETY SYRINGE,NEEDLE,INSULN,SAFE,1ML

2 ASSURE LANCE LANCETS

2 ASSURE LANCE PLUS LANCETS

3 ASTEPRO AZELASTINE HCL QL ST

VC ATENOLOL ATENOLOL

VC ATENOLOL-CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE

3 ATIVAN LORAZEPAM

1 ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM

2 ATRIPLA EFAVIRENZ/EMTRICITAB/TENOFOVIR QL

1 ATROPINE SULFATE ATROPINE SULFATE

3 ATROVENT IPRATROPIUM BROMIDE

2 ATROVENT HFA IPRATROPIUM BROMIDE QL

Excluded AUBAGIO TERIFLUNOMIDE

1 AUBRA LEVONORGESTREL-ETHIN ESTRADIOL

3 AUGMENTIN AMOXICILLIN/POTASSIUM CLAV

3 AUGMENTIN ES-600 AMOXICILLIN/POTASSIUM CLAV

3 AUGMENTIN XR AMOXICILLIN/POTASSIUM CLAV

2 AUTOSHIELD DUO PEN NEEDLE PEN NEEDLE, DIABETIC, SAFETY

2 AUTOSHIELD PEN NEEDLE NEEDLES, INSULIN DISP., SAFETY

Excluded AUVI-Q EPINEPHRINE INJECTION

3 AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE

3 AVAPRO IRBESARTAN

2 AVC SULFANILAMIDE

3 AVELOX MOXIFLOXACIN HCL

3 AVELOX ABC PACK MOXIFLOXACIN HCL

1 AVIANE LEVONORGESTREL-ETHIN ESTRADIOL

2 AVODART DUTASTERIDE ST

2 AVONEX INTERFERON BETA-1A PA

2 AVONEX ADMINISTRATION PACK INTERFERON BETA-1A/ALBUMIN PA

2 AVONEX PEN INTERFERON BETA-1A PA

2 AXIRON TESTOSTERONE PA

3 AYGESTIN NORETHINDRONE ACETATE

1 AZATHIOPRINE AZATHIOPRINE

1 AZELASTINE 0.1% NASAL SPRAY

2 AZELASTINE 0.15% NASAL SPRAY

2 AZELASTINE HCL FLUTICASONE NASAL SPRAY QL

2 AZILECT RASAGILINE MESYLATE QL

1 AZITHROMYCIN AZITHROMYCIN

2 AZOPT BRINZOLAMIDE

3 AZULFIDINE SULFASALAZINE

1 AZURETTE DESOG-E.ESTRADIOL/E.ESTRADIOL

1 BACITRACIN BACITRACIN


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 BACITRACIN-POLYMYXIN BACITRACIN/POLYMYXIN B SULFATE

1 BACLOFEN BACLOFEN

3 BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM

3 BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM

3 BACTROBAN MUPIROCIN

2 BACTROBAN NASAL MUPIROCIN CALCIUM

1 BALSALAZIDE DISODIUM BALSALAZIDE DISODIUM

3 BARACLUDE ENTECAVIR

Excluded BAYER (CONTOUR) TEST STRIPS/BAYER BLOOD GLUCOSE TEST STRIPS

2 BD MICROTAINER LANCETS LANCETS

2 BD ULTRA-FINE LANCETS

2 BD ULTRA-FINE II LANCETS

2 BD ULTRA-FINE PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

Excluded BEAU RX

Excluded BECONASE AQ BECLOMETHASONE NASAL

Excluded BELBUCA BUPPRENORPHINE FILM

VC BENAZEPRIL BENAZEPRIL

1 BENAZEPRIL-HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE

2 BENICAR OLMESARTAN MEDOXOMIL ST

2 BENICAR HCT OLMESARTAN/HYDROCHLOROTHIAZIDE ST

3 BENTYL DICYCLOMINE HCL

3 BENZACLIN CLINDAMYCIN PHOS/BENZOYL PEROX

Excluded BENZACLIN PUMP CLINDAMYCIN, BENZOYL PEROXIDE

3 BENZAMYCIN ERYTHROMYCIN/BENZOYL PEROXIDE

2 BENZAMYCINPAK ERYTHROMYCIN/BENZOYL PEROXIDE

1 BENZTROPINE MESYLATE BENZTROPINE MESYLATE

Excluded BEPREVE BEPOTASTINE BESILATE

2 BESIVANCE BESIFLOXACIN HCL

3 BETAGAN LEVOBUNOLOL HCL

2 BETAMETHASONE DIPROPIONATE BETAMETHASONE

1

BETAMETHASONE DIPROPIONATE 0.05% LOTION, OINTMENT [SUPER

HIGH], 0.05% CREAM, GEL, OINTMENT [HIGH] BETAMETHASONE

2 BETAMETHASONE VALERATE BETAMETHASONE

1

BETAMETHASONE VALERATE 0.1% OINTMENT [HIGH], [LOWER MID-

STRENGTH], 0.12% LOTION [LOW] BETAMETHASONE

3 BETAPACE SOTALOL HCL

3 BETAPACE AF SOTALOL HCL

Excluded BETASERON INTERFERON BETA-1B

1 BETAXOLOL HCL BETAXOLOL HCL

1 BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE

2 BETIMOL TIMOLOL

2 BETOPTIC S BETAXOLOL HCL

1 BEXAROTENE BEXAROTENE PA

3 BIAXIN CLARITHROMYCIN

1 BICALUTAMIDE BICALUTAMIDE

2 BILTRICIDE PRAZIQUANTEL

2 BIMATOPROST DROPS BIMATOPROST QL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORExcluded BINOSTO ALENDRONATE

VC BISOPROLOL BISOPROLOL

VC BISOPROLOL-HYDROCHLOROTHIAZIDE BISOPROLOL FUMARATE/HCTZ

1 BLEPH-10 SULFACETAMIDE SODIUM

2 BLEPHAMIDE SULFACETM NA/PREDNISOL AC

2 BLEPHAMIDE S.O.P. SULFACETM NA/PREDNISOL AC

3 BONIVA IBANDRONATE SODIUM

2 BOSULIF BOSUTINIB PA QL

1 BPO BENZOYL PEROXIDE

2 BREO ELLIPTA FLUTICASONE/VILANTEROL QL

1 BREVICON NORETHINDRONE-ETHINYL ESTRAD

2 BRILINTA TICAGRELOR QL

1 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE

2 BROMFENAC OPHTHALMIC SOLUTION BROMFENAC

1 BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE

1 BUDESONIDE BUDESONIDE QL

1 BUDESONIDE EC BUDESONIDE

2 BUDESONIDE NASAL SPRAY BUDESONIDE

2 BULLSEYE MINI SAFETY LANCETS LANCETS

1 BUMETANIDE BUMETANIDE

3 BUPHENYL SODIUM PHENYLBUTYRATE

1 BUPRENORPHINE HCL BUPRENORPHINE HCL PA

1 BUPRENORPHINE-NALOXONE BUPRENORPHINE HCL/NALOXONE HCL PA

1 BUPROPION HCL BUPROPION HCL

1 BUPROPION HCL SR BUPROPION HCL

1 BUPROPION XL BUPROPION HCL

1 BUSPIRONE HCL BUSPIRONE HCL

1 BUTALBITAL COMPOUND-CODEINE CODEINE/BUTALBITAL/ASA/CAFFEINE

2

BUTALBITAL-ACETAMINOPHEN-CAFFEINE (500-300-40, 500-325-40)

CAPSULE BUTALB/ACETAMINOPHEN/CAFFEINE

1 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 500-325-40 TABLET BUTALB/ACETAMINOPHEN/CAFFEINE

1 BUTALBITAL-ASPIRIN-CAFFEINE BUTALBITAL/ASPIRIN/CAFFEINE

1 BUTALBITAL-CAFFEINE-ACETAMINOPH-CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE

2 BUTRANS BUPRENORPHINE QL

Excluded BYDUREON EXENATIDE EXTENDED-RELEASE

Excluded BYETTA EXENATIDE

2 BYSTOLIC NEBIVOLOL HCL

1 CABERGOLINE CABERGOLINE

3 CADUET AMLODIPINE/ATORVASTATIN QL

2 CAFERGOT ERGOTAMINE TARTRATE/CAFFEINE QL

3 CALAN VERAPAMIL HCL

3 CALAN SR VERAPAMIL HCL

1 CALCIPOTRIENE CALCIPOTRIENE ST

1 CALCITRENE CALCIPOTRIENE ST

1 CALCITRIOL CALCITRIOL

1 CALCIUM ACETATE CALCIUM ACETATE

1 CAMILA NORETHINDRONE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 CANASA MESALAMINE

2 CANDESARTAN

2 CANDESARTAN/HCTZ COMBINATION TABLET

1 CAPECITABINE CAPECITABINE PA QL

2 CAPITAL W-CODEINE ACETAMINOPHEN WITH CODEINE

2 CAPTOPRIL CAPTOPRIL

2 CAPTOPRIL-HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE

2 CARAFATE SUCRALFATE

1 CARBAMAZEPINE CARBAMAZEPINE

1 CARBAMAZEPINE ER CARBAMAZEPINE

1 CARBAMAZEPINE XR CARBAMAZEPINE

3 CARBATROL CARBAMAZEPINE

1 CARBIDOPA CARBIDOPA

1 CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA

1 CARBIDOPA-LEVODOPA ER CARBIDOPA/LEVODOPA

1 CARBIDOPA-LEVODOPA-ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE

3 CARDIZEM DILTIAZEM HCL

3 CARDIZEM CD DILTIAZEM HCL

3 CARDURA DOXAZOSIN MESYLATE

2 CAREFINE PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

2 CAREONE LANCETS

2 CARESENS LANCETS

1 CARISOPRODOL CARISOPRODOL

1 CARISOPRODOL COMPOUND CARISOPRODOL/ASPIRIN

1 CARISOPRODOL COMPOUND-CODEINE CODEINE/CARISOPRODOL/ASPIRIN

1 CARISOPRODOL-ASPIRIN CARISOPRODOL/ASPIRIN

1 CARISOPRODOL-ASPIRIN-CODEINE CODEINE/CARISOPRODOL/ASPIRIN

1 CARTEOLOL HCL CARTEOLOL HCL

1 CARTIA XT DILTIAZEM HCL

VC CARVEDILOL CARVEDILOL

3 CASODEX BICALUTAMIDE

3 CATAPRES CLONIDINE HCL

2 CAYSTON AZTREONAM LYSINE PA

1 CAZIANT DESOGESTREL-ETHINYL ESTRADIOL

1 CEFACLOR CEFACLOR

1 CEFACLOR ER CEFACLOR

1 CEFADROXIL CEFADROXIL

1 CEFDINIR CEFDINIR

1 CEFIXIME CEFIXIME

1 CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL

1 CEFPROZIL CEFPROZIL

3 CEFTIN CEFUROXIME AXETIL

1 CEFUROXIME CEFUROXIME AXETIL

3 CELEBREX CELECOXIB

2 CELECOXIB CELECOXIB

3 CELEXA CITALOPRAM HYDROBROMIDE

3 CELLCEPT MYCOPHENOLATE MOFETIL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR3 CENTANY MUPIROCIN

1 CEPHALEXIN CEPHALEXIN

VC CETIRIZINE HCL CETIRIZINE HCL

2 CEVIMELINE CAPSULE CEVIMELINE

1 CEVIMELINE HCL TABLET CEVIMELINE

1 CHATEAL LEVONORGESTREL-ETHIN ESTRADIOL

1 CHERATUSSIN AC GUAIFENESIN/CODEINE PHOSPHATE

1 CHERATUSSIN DAC P-EPHED HCL/CODEINE/GUAIFEN

1 CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL

1 CHLORDIAZEPOXIDE-CLIDINIUM CHLORDIAZEPOXIDE/CLIDINIUM BR

1 CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE

1 CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE

1 CHLOROQUINE TABLET CHLOROQUINE

1 CHLORPROMAZINE HCL CHLORPROMAZINE HCL

1 CHLORPROPAMIDE CHLORPROPAMIDE

VC CHLORTHALIDONE CHLORTHALIDONE

1 CHLORZOXAZONE CHLORZOXAZONE

1 CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR)

1 CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME

2 CIALIS (if covered, see your Benefit Summary) TADALAFIL QL

3 CICLODAN CICLOPIROX OLAMINE

2 CICLOPIROX 0.01% SHAMPOO CICLOPIROX OLAMINE

1 CICLOPIROX 0.77% CREAM CICLOPIROX OLAMINE

2 CICLOPIROX 0.77% GEL CICLOPIROX OLAMINE

1 CILOSTAZOL CILOSTAZOL

2 CILOXAN CIPROFLOXACIN HCL

1 CIMETIDINE CIMETIDINE

Excluded CIMZIA CERTOLIZUMAB PEGOL

3 CIPRO CIPROFLOXACIN HCL

2 CIPRODEX CIPROFLOXACIN HCL/DEXAMETH

1 CIPROFLOXACIN CIPROFLOXACIN

1 CIPROFLOXACIN HCL CIPROFLOXACIN HCL

VC CITALOPRAM HBR CITALOPRAM HBR

1 CLARAVIS ISOTRETINOIN

1 CLARITHROMYCIN CLARITHROMYCIN

1 CLARITHROMYCIN ER CLARITHROMYCIN

3 CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL

3 CLEOCIN T CLINDAMYCIN PHOSPHATE

2 CLEVER CHEK LANCETS LANCETS

2 CLICKFINE NEEDLES, INSULIN DISPOSABLE

3 CLIMARA ESTRADIOL QL

3 CLINDACIN ETZ CLINDAMYCIN

3 CLINDACIN P CLINDAMYCIN

1 CLINDAMYCIN CAPSULE CLINDAMYCIN

1 CLINDAMYCIN HCL CLINDAMYCIN

1 CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PALMITATE HCL

1 CLINDAMYCIN PEDIATRIC CLINDAMYCIN PALMITATE HCL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 CLINDAMYCIN PHOSPHATE FOAM CLINDAMYCIN PHOSPHATE

1 CLINDAMYCIN PHOSPHATE SOLUTION/GEL CLINDAMYCIN PHOSPHATE

2 CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL CLINDAMYCIN PHOSPHATE

2 CLINDAMYCIN-BENZOYL PEROXIDE CLINDAMYCIN PHOS/BENZOYL PEROX

1 CLOBETASOL EMOLLIENT CLOBETASOL PROPIONATE/EMOLL

2

CLOBETASOL PROPIONATE 0.05% CREAM, EMOLLIENT CREAM, FOAM,

GEL, LOTION, OINTMENT, SHAMPOO, SPRAY [SUPER HIGH] CLOBETASOL PROPIONATE

1

CLOBETASOL PROPIONATE 0.05% EMOLLIENT CREAM, SOLUTION [SUPER

HIGH] CLOBETASOL PROPIONATE

3 CLOBEX CLOBETASOL PROPIONATE

2 CLOCORTOLONE PIVALATE 0.1% CREAM [MEDIUM] CLOCORTOLONE

3 CLODAN CLOBETASOL PROPIONATE

2 CLOMIPRAMINE CLOMIPRAMINE

1 CLONAZEPAM CLONAZEPAM

1 CLONIDINE HCL CLONIDINE HCL

1 CLOPIDOGREL CLOPIDOGREL BISULFATE

1 CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM

1 CLOTRIMAZOLE CLOTRIMAZOLE

1 CLOTRIMAZOLE-BETAMETHASONE 1% - 0.05% CREAM CLOTRIMAZOLE/BETAMETHASONE

2 CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE 2% - 0.05% LOTION CLOTRIMAZOLE/BETAMETHASONE

1 CLOZAPINE CLOZAPINE QL

3 CLOZARIL CLOZAPINE QL

2 COAGUCHEK LANCETS

1 CODEINE-GUAIFENESIN GUAIFENESIN/CODEINE PHOSPHATE

3 COLAZAL BALSALAZIDE DISODIUM

1 COLCHICINE COLCHICINE

3 COLCRYS COLCHICINE

3 COLESTID COLESTIPOL HCL

1 COLESTIPOL HCL COLESTIPOL HCL

1 COLOCORT HYDROCORTISONE

2 COLOR LANCETS LANCETS

3 COLYTE WITH FLAVOR PACKETS PEG 3350/NA SULF,BICARB,CL/KCL

2 COMBIGAN BRIMONIDINE TARTRATE/TIMOLOL

2 COMBIPATCH ESTRADIOL/NORETHINDRONE ACET QL

2 COMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL SULFATE

3 COMBIVIR LAMIVUDINE/ZIDOVUDINE QL

2 COMETRIQ CABOZANTINIB S-MALATE PA QL

2 COMFORT EZ NEEDLES, INSULIN DISPOSABLE

2 COMFORT LANCETS LANCETS

3 COMPAZINE PROCHLORPERAZINE MALEATE

2 COMPLERA EMTRICITAB/RILPIVIRINE/TENOFOV PA

1 COMPRO PROCHLORPERAZINE

3 COMTAN ENTACAPONE

3 CONCERTA METHYLPHENIDATE HCL QL

2 CONDYLOX PODOFILOX

1 CONSTULOSE LACTULOSE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 COPAXONE GLATIRAMER ACETATE PA

3 COPEGUS RIBAVIRIN

3 CORDARONE AMIODARONE HCL

2 CORDRAN FLURANDRENOLIDE

3 COREG CARVEDILOL

2 COREG CR CARVEDILOL PHOSPHATE

3 CORGARD NADOLOL

1 CORMAX CLOBETASOL PROPIONATE

3 CORTEF HYDROCORTISONE

3 CORTENEMA HYDROCORTISONE

1 CORTISONE ACETATE CORTISONE ACETATE

2 CORTISPORIN NEOMYCIN/BACITRA/POLYMYXIN/HC

3 COSENTYX SECUKINUMAB PA

3 COSOPT DORZOLAMIDE HCL/TIMOLOL MALEAT

2 COUMADIN WARFARIN SODIUM

1 COVARYX ESTROGEN,ESTER/ME-TESTOSTERONE

1 COVARYX H.S. ESTROGEN,ESTER/ME-TESTOSTERONE

3 COZAAR LOSARTAN POTASSIUM

3 CREON LIPASE/PROTEASE/AMYLASE

2 CRESTOR ROSUVASTATIN CALCIUM QL ST

2 CRIXIVAN INDINAVIR SULFATE

1 CROMOLYN SODIUM CROMOLYN SODIUM

1 CRYSELLE NORGESTREL-ETHINYL ESTRADIOL

2 CUPRIMINE PENICILLAMINE

3 CUTIVATE FLUTICASONE PROPIONATE

1 CYCLAFEM NORETHINDRONE-ETHINYL ESTRAD

3 CYCLESSA DESOGESTREL-ETHINYL ESTRADIOL ST

1 CYCLOBENZAPRINE TABLET CYCLOBENZAPRINE HCL

2 CYCLOGYL CYCLOPENTOLATE HCL

1 CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL

2 CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE

1 CYCLOSPORINE CYCLOSPORINE, MODIFIED

1 CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED

3 CYMBALTA DULOXETINE HCL QL

1 CYPROHEPTADINE HCL CYPROHEPTADINE HCL

2 CYSTARAN CYSTEAMINE HCL PA

3 CYTOMEL LIOTHYRONINE SODIUM

3 CYTOTEC MISOPROSTOL

2 DALIRESP ROFLUMILAST QL ST

1 DANAZOL DANAZOL

3 DANTRIUM DANTROLENE SODIUM

1 DANTROLENE SODIUM DANTROLENE SODIUM

1 DAPSONE DAPSONE

2 DARAPRIM PYRIMETHAMINE

1 DASETTA NORETHINDRONE-ETHINYL ESTRAD

3 DAYPRO OXAPROZIN

3 DDAVP DESMOPRESSIN ACETATE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 DEBLITANE NORETHINDRONE

3 DELATESTRYL TESTOSTERONE ENANTHATE PA

1 DELYLA LEVONORGESTREL-ETHIN ESTRADIOL

Excluded DELZICOL MESALAMINE

3 DEMADEX TORSEMIDE

Excluded DENAVIR CREAM PENCICLOVIR

1 DEPADE NALTREXONE HCL

3 DEPAKENE VALPROIC ACID

3 DEPAKOTE DIVALPROEX SODIUM

3 DEPAKOTE ER DIVALPROEX SODIUM

3 DEPAKOTE SPRINKLE DIVALPROEX SODIUM

2 DEPEN PENICILLAMINE

3 DEPO-PROVERA MEDROXYPROGESTERONE ACETATE QL

3 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE PA

Excluded DERMACINRX TRIAMCINOLONE 0.1%/DIMETHICONE 5%

Excluded DERMACINRX PUREFOLIX FOLIC ACID/VITAMIN D

Excluded DERMAPAK PLUS ZINC OXIDE/MENTHOL/TRETINOIN

Excluded DERMASILKRX TRIAMCINOLONE ACETONIDE CREAM/DIMETHICONE CREAM

1 DERMAZENE HYDROCORTISONE/IODOQUINOL

2 DESIPRAMINE DESIPRAMINE

2 DESLORATADINE ODT DESLORATADINE

1 DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE

3 DESOGEN DESOGESTREL-ETHINYL ESTRADIOL ST

1 DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL

1 DESOGESTR-ETH ESTRAD ETH ESTRA DESOG-E.ESTRADIOL/E.ESTRADIOL

2 DESONIDE DESONIDE

3 DESOWEN DESONIDE

1 DESOXIMETASONE 0.25% CREAM [HIGH] DESOXIMETASONE

2

DESOXIMETASONE 0.25% OINTMENT [HIGH], 0.05% GEL [HIGH], 0.05%

CREAM, OINTMENT [MEDIUM] DESOXIMETASONE

Excluded DESVENLAFAXINE ER TABLET DESVENLAFAXINE QL ST

3 DETROL TOLTERODINE TARTRATE ST

3 DETROL LA TOLTERODINE TARTRATE ST

Excluded DEUTETRABENAZINE

1 DEXAMETHASONE DEXAMETHASONE

3 DEXEDRINE DEXTROAMPHETAMINE SULFATE QL

Excluded DEXILANT DEXLANSOPRAZOLE

2 DEXMETHYLPHENIDATE ER CAPSULE

1 DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL QL

2 DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL QL

1 DEXMETHYLPHENIDATE TABLET DEXMETHYLPHENIDATE

2 DEXTROAMPHETAMINE ER CAPSULE

2 DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE QL

2 DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHETAMINE SULFATE QL

2 DEXTROAMPHETAMINE TABLET DEXTROAMPHETAMINE

2 DIABETA GLYBURIDE

3 DIAMOX SEQUELS ACETAZOLAMIDE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 DIASTAT DIAZEPAM QL

2 DIASTAT ACUDIAL DIAZEPAM QL

1 DIAZEPAM DIAZEPAM

2 DIBENZYLINE PHENOXYBENZAMINE HCL

1 DICLOFENAC SODIUM DICLOFENAC SODIUM

2 DICLOFENAC SODIUM 0.5%/1.5% TOPICAL SOLUTION DICLOFENAC SODIUM

2 DICLOFENAC SODIUM 1%/3% GEL DICLOFENAC SODIUM

1 DICLOFENAC SODIUM ER DICLOFENAC SODIUM

1 DICLOFENAC SODIUM OPHTHALMIC SOLUTION DICLOFENAC SODIUM

2 DICLOFENAC SODIUM/MISOPROSTOL COMBINATION TABLET DICLOFENAC SODIUM TABLET & MISOPROSTOL TABLET

Excluded DICLOPACK DICLOFENAC SODIUM

1 DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM

1 DICYCLOMINE HCL DICYCLOMINE HCL

1 DIDANOSINE DIDANOSINE QL

3 DIFFERIN ADAPALENE

2 DIFICID FIDAXOMICIN QL ST

2 DIFLORASONE DIACETATE 0.05% OINTMENT, CREAM [HIGH] DIFLORASONE DIACETATE

3 DIFLUCAN FLUCONAZOLE

1 DIFLUNISAL DIFLUNISAL

1 DIGITEK DIGOXIN

1 DIGOX DIGOXIN

2 DIGOXIN DIGOXIN

2 DILANTIN PHENYTOIN

2 DILANTIN-125 PHENYTOIN

3 DILAUDID HYDROMORPHONE HCL

1 DILTIAZEM 12HR ER CAPSULE DILTIAZEM HCL

2 DILTIAZEM 24HR CD DILTIAZEM HCL

1 DILTIAZEM 24HR ER CAPSULE, 120 MG, 180 MG, 240 MG, 300 MG DILTIAZEM HCL

2 DILTIAZEM 24HR ER TABLET/ER CAPSULE 360 MG DILTIAZEM HCL

VC DILTIAZEM HCL DILTIAZEM HCL IR

2 DILT-XR DILTIAZEM XR HCL

3 DIOVAN VALSARTAN

3 DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE

Excluded DIPENTUM OLSALAZINE

1 DIPHENHYDRAMINE CREAM (OTC) DIPHENHYDRAMINE

1 DIPHENOXYLATE-ATROPINE DIPHENOXYLATE HCL/ATROPINE

3 DIPROLENE BETAMETHASONE/PROPYLENE GLYC

3 DIPROLENE AF BETAMETHASONE/PROPYLENE GLYC

1 DIPYRIDAMOLE DIPYRIDAMOLE

3 DISALCID SALSALATE

1 DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE

1 DISULFIRAM DISULFIRAM

3 DITROPAN XL OXYBUTYNIN CHLORIDE

1 DIVALPROEX SODIUM DIVALPROEX SODIUM

1 DIVALPROEX SODIUM ER DIVALPROEX SODIUM

3 DOLOPHINE HCL METHADONE HCL

1 DONEPEZIL 10 MG TABLET DONEPEZIL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 DONEPEZIL 23 MG TABLET DONEPEZIL

1 DONEPEZIL HCL DONEPEZIL HCL

1 DONEPEZIL HCL ODT DONEPEZIL HCL

2 DONNATAL PHENOBARB/HYOSCY/ATROPINE/SCOP

1 DORZOLAMIDE HCL DORZOLAMIDE HCL

1 DORZOLAMIDE-TIMOLOL DORZOLAMIDE HCL/TIMOLOL MALEAT

3 DOVONEX CALCIPOTRIENE ST

1 DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE

2 DOXEPIN 5% CREAM DOXEPIN

1 DOXYCYCLINE HYCLATE 20 MG TABLET DOXYCYCLINE HYCLATE

2 DOXYCYCLINE HYCLATE 75/150 DR TABLET DOXYCYCLINE HYCLATE QL ST

1 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE/TABLET DOXYCYCLINE MONOHYDRATE QL

2 DOXYCYCLINE MONOHYDRATE 40 MG CAPSULE/BIPHASIC RELEASE DOXYCYCLINE MONOHYDRATE

2 DOXYCYCLINE MONOHYDRATE 75/150 MG CAPSULE DOXYCYCLINE MONOHYDRATE

1 DOXYCYCLINE MONOHYDRATE 75/150 MG TABLET DOXYCYCLINE MONOHYDRATE

3 DRISDOL ERGOCALCIFEROL (VITAMIN D2)

2 DRITHOCREME HP ANTHRALIN ST

2 DRONABINOL DRONABINOL QL ST

2 DROPLET LANCETS LANCETS

1 DROSPIRENONE-ETHINYL ESTRADIOL ETHINYL ESTRADIOL/DROSPIRENONE ST

2 DRYSOL ALUMINUM CHLORIDE

2 DUAVEE ESTROGENS,CONJ/BAZEDOXIFENE

3 DUETACT PIOGLITAZONE HCL/GLIMEPIRIDE ST

Excluded DUEXIS FAMOTIDINE/IBUPROFEN

2 DULERA MOMETASONE/FORMOTEROL QL

1 DULOXETINE 20 MG (2 CAPSULES) DULOXETINE QL

2 DULOXETINE 40 MG DULOXETINE

3 DURAGESIC FENTANYL PA QL

2 DUREZOL DIFLUPREDNATE

Excluded DURLAZA ASPRIN

3 DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZID

1 E.E.S. 200 ERYTHROMYCIN ETHYLSUCCINATE

1 E.E.S. 400 ERYTHROMYCIN ETHYLSUCCINATE

2 EASY COMFORT LANCETS

2 EASY COMFORT INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.5 ML

2 EASY COMFORT PEN NEEDLES NEEDLES, INSULIN DISPOSABLE

2 EASY TOUCH LANCETS

2 EASY TOUCH INSULIN SAFETY SYRINGE,NEEDLE,INSULN,SF 0.5ML

2 EASY TOUCH INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 EASY TOUCH LANCETS LANCETS

2 EASY TOUCH PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

2 EASY TWIST & CAP LANCETS LANCETS

2 EASY-TOUCH INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 ECLIPSE SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

3 EC-NAPROSYN NAPROXEN

2 ECONAZOLE NITRATE 0.01% CREAM ECONAZOLE

1 ECONTRA EZ LEVONORGESTREL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORExcluded EDARBI AZILSARTAN MEDOXOMIL

Excluded EDARBYCLOR AZILSARTAN MEDOXOMIL AND CHLORTHALIDONE

Excluded EDLUAR ZOLPIDEM TARTRATE

1 ED-SPAZ HYOSCYAMINE SULFATE

2 EDURANT RILPIVIRINE HCL PA

1 EEMT ESTROGEN,ESTER/ME-TESTOSTERONE

1 EEMT H.S. ESTROGEN,ESTER/ME-TESTOSTERONE

1 EFFER-K POTASSIUM BICARBONATE/CIT AC

3 EFFEXOR XR VENLAFAXINE HCL

2 EFFIENT PRASUGREL HCL QL

3 EFUDEX FLUOROURACIL

3 ELDEPRYL SELEGILINE HCL

2 ELIGARD LEUPROLIDE ACETATE PA

3 ELIMITE PERMETHRIN

1 ELINEST NORGESTREL-ETHINYL ESTRADIOL

1 ELIPHOS CALCIUM ACETATE

2 ELIQUIS APIXABAN QL

1 ELIXOPHYLLIN THEOPHYLLINE ANHYDROUS

2 ELMIRON PENTOSAN POLYSULFATE SODIUM

3 ELOCON MOMETASONE FUROATE

Excluded EMADINE EMEDASTINE

2 EMBRACE LANCETS

2 EMCYT ESTRAMUSTINE PHOSPHATE SODIUM

2 EMEND APREPITANT QL

1 EMOQUETTE DESOGESTREL-ETHINYL ESTRADIOL

2 EMTRIVA EMTRICITABINE QL

VC ENALAPRIL MALEATE ENALAPRIL MALEATE

VC ENALAPRIL-HYDROCHLOROTHIAZIDE ENALAPRIL/HYDROCHLOROTHIAZIDE

2 ENBREL ETANERCEPT PA

1 ENDOCET OXYCODONE HCL/ACETAMINOPHEN QL

1 ENDODAN OXYCODONE HCL/ASPIRIN

1 ENOXAPARIN SODIUM ENOXAPARIN SODIUM QL

1 ENPRESSE LEVONORGESTREL-ETHIN ESTRADIOL

1 ENSKYCE DESOGESTREL-ETHINYL ESTRADIOL

1 ENTACAPONE ENTACAPONE

1 ENTECAVIR ENTECAVIR

3 ENTOCORT EC BUDESONIDE

1 ENULOSE LACTULOSE

1 EPINEPHRINE EPINEPHRINE

2 EPIPEN 2-PAK EPINEPHRINE

2 EPIPEN JR 2-PAK EPINEPHRINE

1 EPITOL CARBAMAZEPINE

3 EPIVIR LAMIVUDINE QL

3 EPIVIR HBV LAMIVUDINE

2 EPLERENONE EPLERENONE

Excluded EPROSARTAN EPROSARTAN

2 EPZICOM ABACAVIR SULFATE/LAMIVUDINE QL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 ERIVEDGE VISMODEGIB PA QL

1 ERRIN NORETHINDRONE

3 ERYGEL ERYTHROMYCIN BASE/ETHANOL

3 ERYPED 200 ERYTHROMYCIN ETHYLSUCCINATE

2 ERYPED 400 ERYTHROMYCIN ETHYLSUCCINATE

1 ERY-TAB ERYTHROMYCIN BASE

1 ERYTHROCIN STEARATE ERYTHROMYCIN STEARATE

VC ERYTHROMYCIN ERYTHROMYCIN BASE/ETHANOL

2 ERYTHROMYCIN BASE/BENZOYL PEROXIDE GEL ERYTHROMYCIN/BENZOYL PEROXIDE

1 ERYTHROMYCIN BASE/ETHANOL SOLUTION ERYTHROMYCIN/ETHANOL

1 ERYTHROMYCIN BASE/ETHANOL SOLUTION & BENZOYL PEROXIDE OTC ERYTHROMYCIN/ETHANOL

1 ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE

1 ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN/BENZOYL PEROXIDE

2 ESBRIET PIRFENIDONE PA

1 ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE

3 ESGIC BUTALB/ACETAMINOPHEN/CAFFEINE

1 ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL

1 ESTAZOLAM ESTAZOLAM

3 ESTRACE ESTRADIOL

1 ESTRADIOL ESTRADIOL

Excluded ESTROGEL ESTRADIOL

1 ESTROGEN & METHYLTESTOSTERONE ESTROGEN,ESTER/ME-TESTOSTERONE

1 ESTROPIPATE ESTROPIPATE

1 ESZOPICLONE ESZOPICLONE QL

1 ETHAMBUTOL HCL ETHAMBUTOL HCL

1 ETHOSUXIMIDE ETHOSUXIMIDE

2 ETIDRONATE ETIDRONATE

2 ETODOLAC ETODOLAC

1 ETODOLAC ER ETODOLAC

1 ETOPOSIDE ETOPOSIDE

2 EURAX CROTAMITON

Excluded EVEKEO AMPHETAMINE SULFATE

3 EVISTA RALOXIFENE HCL PA QL

3 EVOCLIN CLINDAMYCIN PHOSPHATE

2 EVOTAZ ATAZANAVIR SULFATE/COBICISTAT QL

3 EVOXAC CEVIMELINE HCL

2 EXELDERM SULCONAZOLE NITRATE

3 EXELON RIVASTIGMINE TARTRATE

1 EXEMESTANE EXEMESTANE PA

3 EXFORGE AMLODIPINE/VALSARTAN ST

3 EXFORGE HCT AMLODIPINE/VALSARTAN/HCTHIAZID ST

Excluded EXTAVIA INTERFERON BETA-1B

2 E-Z JECT LANCETS LANCETS

2 EZ SMART LANCETS LANCETS

2 E-ZJECT LANCETS LANCETS

1 FABB CYANOCOBALAMIN/FA/PYRIDOXINE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 FABIOR TAZAROTENE

1 FALLBACK SOLO LEVONORGESTREL

1 FALMINA LEVONORGESTREL-ETHIN ESTRADIOL

2 FAMOTIDINE ORAL SUSPENSION FAMOTIDINE

1 FAMOTIDINE TABLET OTC FAMOTIDINE

2 FARESTON TOREMIFENE CITRATE PA

Excluded FARXIGA DAPAGLIFLOZIN

2 FARYDAK PANOBINOSTAT LACTATE PA

3 FELDENE PIROXICAM

1 FELODIPINE ER FELODIPINE

3 FEMARA LETROZOLE

3 FEMHRT NORETHINDRONE AC-ETH ESTRADIOL

2 FENOFIBRATE (LIPOFEN/TRILIPIX DR/ANTARA/FENOGLIDE) FENOFIBRATE

1 FENOFIBRATE (LOFIBRA/TRICOR/LOFIBRA) FENOFIBRATE

2 FENOGLIDE FENOFIBRATE ST

2 FENOPROFEN CALCIUM TABLET FENOPROFEN CALCIUM

1 FENTANYL FENTANYL PA QL

1 FENTANYL CITRATE FENTANYL CITRATE PA

1

FENTANYL TRANSDERMAL PATCH 12 MCG/HR, 25 MCG/HR, 50 MCG/HR,

75 MCG/HR FENTANYL

2

FENTANYL TRANSDERMAL PATCH 37.5 MCG/HR, 62.5 MCG/HR, 87.5

MCG/HR FENTANYL

Excluded FENTORA FENTANYL CITRATE

Excluded FEXMID CYCLOBENZAPRINE

Excluded FEXOFENADINE HCL FEXOFENADINE HCL

2 FIFTY50 SAFETY SEAL LANCETS LANCETS

1 FINASTERIDE FINASTERIDE

2 FINE 30 UNIVERSAL LANCETS LANCETS

2 FINGERSTIX LANCETS

3 FIORINAL BUTALBITAL/ASPIRIN/CAFFEINE

3 FIORINAL WITH CODEINE #3 CODEINE/BUTALBITAL/ASA/CAFFEIN

2 FIRAZYR ICATIBANT ACETATE PA

3 FLAGYL METRONIDAZOLE

2 FLAGYL ER METRONIDAZOLE

2 FLAREX FLUOROMETHOLONE ACETATE

1 FLECAINIDE ACETATE FLECAINIDE ACETATE

Excluded FLECTOR PATCH DICLOFENAC

Excluded FLEXEPACX CYCLOBENZAPRINE

3 FLOMAX TAMSULOSIN HCL

Excluded FLOVENT DISKUS FLUTICASONE PROPIONATE

Excluded FLOVENT HFA FLUTICASONE PROPIONATE HFA

1 FLUCONAZOLE FLUCONAZOLE

1 FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE

Excluded FLUMIST

1 FLUNISOLIDE FLUNISOLIDE QL

1 FLUOCINOLONE ACETONIDE 0.01% CREAM [LOW] FLUOCINOLONE ACETONIDE

2 FLUOCINOLONE ACETONIDE 0.01% SOLUTION [LOW] FLUOCINOLONE ACETONIDE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR

1

FLUOCINONIDE 0.05% CREAM, EMOLLIENT CREAM, GEL, OINTMENT

[HIGH] FLUOCINONIDE

2 FLUOCINONIDE 0.05% OINTMENT [HIGH], 0.1% CREAM [SUPER HIGH] FLUOCINONIDE

1 FLUORIDE SODIUM FLUORIDE

3 FLUORITAB SODIUM FLUORIDE

1 FLUOROMETHOLONE FLUOROMETHOLONE

1 FLUOROURACIL FLUOROURACIL

1 FLUOXETINE CAPSULE FLUOXETINE

1 FLUOXETINE DR FLUOXETINE

VC FLUOXETINE HCL CAPSULE FLUOXETINE

2 FLUOXETINE TABLET FLUOXETINE

1 FLUPHENAZINE HCL FLUPHENAZINE HCL

2 FLURA-DROPS SODIUM FLUORIDE

2 FLURANDRENOLIDE 0.05% CREAM [LOWER MID-STRENGTH]

1 FLURAZEPAM HCL FLURAZEPAM HCL

1 FLURBIPROFEN FLURBIPROFEN

1 FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM

1 FLUTAMIDE FLUTAMIDE

VC FLUTICASONE NASAL SPRAY FLUTICASONE

1 FLUTICASONE PROPIONATE 0.05% CREAM [LOWER MID-STRENGTH] FLUTICASONE

2

FLUTICASONE PROPIONATE 0.05% LOTION [LOWER MID-STRENGTH],

0.005% OINTMENT [HIGH] FLUTICASONE QL

2 FLUVASTATIN

2 FLUVOXAMINE ER CAPSULE FLUVOXAMINE

1 FLUVOXAMINE MALEATE FLUVOXAMINE

1 FLUVOXAMINE TABLET FLUVOXAMINE

3 FML FLUOROMETHOLONE

2 FML FORTE FLUOROMETHOLONE

2 FML S.O.P. FLUOROMETHOLONE

3 FOCALIN DEXMETHYLPHENIDATE HCL QL

3 FOCALIN XR DEXMETHYLPHENIDATE HCL QL

3 FOLGARD RX CYANOCOBALAMIN/FA/PYRIDOXINE

1 FOLIC ACID FOLIC ACID

1 FONDAPARINUX SODIUM FONDAPARINUX SODIUM QL

2 FORACARE LANCETS LANCETS

Excluded FORFIVO XL BUPROPION HYDROCHLORIDE

2 FORTEO TERIPARATIDE QL

Excluded FORTESTA TESTOSTERONE

3 FOSAMAX ALENDRONATE SODIUM

2 FOSAMAX PLUS D ALENDRONATE SODIUM/VITAMIN D3

1 FOSINOPRIL SODIUM FOSINOPRIL SODIUM

1 FOSINOPRIL-HYDROCHLOROTHIAZIDE FOSINOPRIL/HYDROCHLOROTHIAZIDE

2 FRAGMIN DALTEPARIN SODIUM,PORCINE QL

1 FREESTYLE INSULINX BLOOD SUGAR DIAGNOSTIC

1 FREESTYLE INSULINX TEST STRIPS BLOOD SUGAR DIAGNOSTIC

1 FREESTYLE LANCETS LANCETS


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 FREESTYLE LITE STRIPS BLOOD SUGAR DIAGNOSTIC

1 FREESTYLE PRECISION SYRINGE & NEEDLE,INSULIN,1 ML

1 FREESTYLE TEST STRIPS BLOOD SUGAR DIAGNOSTIC

1 FREESTYLE UNISTIK 2 LANCETS

Excluded FROVA FROVATRIPTAN

3 FURADANTIN NITROFURANTOIN

VC FUROSEMIDE FUROSEMIDE

2 FUZEON ENFUVIRTIDE QL ST

1 GABAPENTIN GABAPENTIN

1 GALANTAMINE HBR GALANTAMINE HBR QL

1 GALANTAMINE HYDROBROMIDE GALANTAMINE HBR QL

3 GARAMYCIN GENTAMICIN SULFATE

1 GATIFLOXACIN GATIFLOXACIN

2 GATTEX TEDUGLUTIDE PA

1 GAVILYTE-C PEG 3350/NA SULF,BICARB,CL/KCL

1 GAVILYTE-G PEG 3350/NA SULF,BICARB,CL/KCL

1 GAVILYTE-N SODIUM CHLORIDE/NAHCO3/KCL/PEG

1 GEMFIBROZIL TABLET GEMFIBROZIL

1 GENERLAC LACTULOSE

1 GENGRAF CYCLOSPORINE, MODIFIED

Excluded GENOTROPIN SOMATROPIN

1 GENTAK GENTAMICIN SULFATE

1 GENTAMICIN SULFATE GENTAMICIN SULFATE

3 GEODON ZIPRASIDONE HCL QL

1 GIANVI ETHINYL ESTRADIOL/DROSPIRENONE ST

1 GILDESS NORETHINDRONE AC-ETH ESTRADIOL

1 GILDESS FE NORETHINDRONE-E.ESTRADIOL-IRON

2 GILENYA FINGOLIMOD HCL PA

2 GILOTRIF AFATINIB DIMALEATE PA

1 GLATOPA GLATIRAMER ACETATE PA

2 GLEEVEC IMATINIB MESYLATE PA QL

3 GLEOSTINE LOMUSTINE

VC GLIMEPIRIDE GLIMEPIRIDE

VC GLIPIZIDE GLIPIZIDE

1 GLIPIZIDE ER GLIPIZIDE

1 GLIPIZIDE XL GLIPIZIDE

1 GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL

2 GLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT

2 GLUCOCOM LANCETS

2 GLUCOCOM LANCETS LANCETS

3 GLUCOPHAGE METFORMIN HCL

3 GLUCOPHAGE XR METFORMIN HCL

2 GLUCOSOURCE LANCETS

3 GLUCOTROL GLIPIZIDE

3 GLUCOTROL XL GLIPIZIDE

3 GLUCOVANCE GLYBURIDE/METFORMIN HCL

Excluded GLUMETZA METFORMIN


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORVC GLYBURIDE GLYBURIDE

VC GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL

2 GLYXAMBI EMPAGLIFLOZIN/LINAGLIPTIN QL ST

2 GMATE LANCETS

3 GOLYTELY PEG 3350/NA SULF,BICARB,CL/KCL

Excluded GRALISE GABAPENTIN

2 GRANISETRON

2 GRASTEK GRASS POLLEN-TIMOTHY, STD PA

2 GRISEOFULVIN GRISEOFULVIN, MICROSIZE

2 GRISEOFULVIN MICROSIZE/ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE

3 GRIS-PEG GRISEOFULVIN ULTRAMICROSIZE

1 GUAIATUSSIN AC GUAIFENESIN/CODEINE PHOSPHATE

1 GUAIFENESIN AC GUAIFENESIN/CODEINE PHOSPHATE

1 GUAIFENESIN DAC P-EPHED HCL/CODEINE/GUAIFEN

1 GUAIFENESIN-CODEINE GUAIFENESIN/CODEINE PHOSPHATE

1 GUANFACINE HCL GUANFACINE HCL

2 GYNAZOLE 1 BUTOCONAZOLE NITRATE

3 HALCION TRIAZOLAM

1 HALOBETASOL PROPIONATE HALOBETASOL PROPIONATE

1 HALOPERIDOL HALOPERIDOL

1 HALOPERIDOL LACTATE HALOPERIDOL LACTATE

2 HARVONI LEDIPASVIR/SOFOSBUVIR PA

2 HEALTHY ACCENTS UNIFINE PENTIP NEEDLES, INSULIN DISP., SAFETY

2 HEALTHY ACCENTS UNILET LANCET LANCETS

1 HEATHER NORETHINDRONE

1 HEPARIN FLUSH HEPARIN SODIUM,PORCINE/PF

1 HEPARIN LOCK HEPARIN SODIUM,PORCINE

1 HEPARIN SODIUM HEPARIN SODIUM,PORCINE

3 HEPSERA ADEFOVIR DIPIVOXIL

2 HEXALEN ALTRETAMINE

1 HOMATROPAIRE HOMATROPINE HBR

1 HOMATROPINE HYDROBROMIDE HOMATROPINE HBR

Excluded HORIZANT GABAPENTIN ENACARBIL EXTENDED-RELEASE

2 HUMALOG INSULIN LISPRO QL

2 HUMALOG KWIKPEN INSULIN LISPRO QL

2 HUMALOG MIX 50-50 INSULIN NPL/INSULIN LISPRO QL

2 HUMALOG MIX 50-50 KWIKPEN INSULIN NPL/INSULIN LISPRO QL

2 HUMALOG MIX 75-25 INSULIN NPL/INSULIN LISPRO QL

2 HUMALOG MIX 75-25 KWIKPEN INSULIN NPL/INSULIN LISPRO QL

Excluded HUMATROPE SOMATROPIN

2 HUMIRA ADALIMUMAB PA

2 HUMIRA CROHN'S ADALIMUMAB PA

2 HUMIRA PEDIATRIC CROHN'S ADALIMUMAB PA

2 HUMIRA PSORIASIS ADALIMUMAB PA

2 HUMULIN 70/30 KWIKPEN INSULIN NPH HUM/REG INSULIN HM QL

2 HUMULIN 70-30 INSULIN NPH HUM/REG INSULIN HM QL

2 HUMULIN N INSULIN NPH HUMAN ISOPHANE QL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 HUMULIN N KWIKPEN INSULIN NPH HUMAN ISOPHANE QL

2 HUMULIN R INSULIN REGULAR, HUMAN QL

2 HUMULIN R U-500 INSULIN REGULAR, HUMAN QL

2 HYCAMTIN TOPOTECAN HCL

3 HYCET HYDROCODONE/ACETAMINOPHEN QL

Excluded HYCOFENIX HYDROCODONE/PSEUDOEPHEDRINE/GUAIFENESIN

1 HYDRALAZINE HCL HYDRALAZINE HCL

3 HYDREA HYDROXYUREA

VC HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

1 HYDROCODONE BT-HOMATROPINE MBR HYDROCODONE BIT/HOMATROP ME-BR

1 HYDROCODONE-ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN QL

1 HYDROCODONE-APAP (NORCO) HYDROCODONE

2 HYDROCODONE-APAP (VICODIN) HYDROCODONE

1 HYDROCODONE-CHLORPHENIRAMNE ER HYDROCODONE/CHLORPHEN P-STIREX

1 HYDROCODONE-HOMATROPINE MBR HYDROCODONE BIT/HOMATROP ME-BR

1 HYDROCORTISONE HYDROCORTISONE

1 HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE

2

HYDROCORTISONE BUTYRATE 0.1% SOLUTION [LOWER MID-STRENGTH],

0.1% CREAM, OINTMENT, EMOLLIENT CREAM [LOWER MID-STRENGTH] HYDROCORTISONE BUTYRATE

2

HYDROCORTISONE VALERATE 0.2% CREAM [LOWER MID-STRENGTH],

0.2% OINTMENT [MEDIUM] HYDROCORTISONE VALERATE

1 HYDROCORTISONE-ACETIC ACID ACETIC ACID/HYDROCORTISONE

1 HYDROCORTISONE-IODOQUINOL HYDROCORTISONE/IODOQUINOL

1 HYDROCORTISONE-PRAMOXINE HYDROCORTISONE/PRAMOXINE

1 HYDROCORTISONE-PRAMOXINE HCL HYDROCORTISONE/PRAMOXINE

1 HYDROMET HYDROCODONE BIT/HOMATROP ME-BR

1 HYDROMORPHONE HCL HYDROMORPHONE HCL

1 HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE

1 HYDROXYUREA HYDROXYUREA

1 HYDROXYZINE HCL HYDROXYZINE HCL

1 HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE

1 HYOPHEN METHENAM/ME BLUE/BA/SALICY/HYO

1 HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE

1 HYOSCYAMINE SULFATE ER HYOSCYAMINE SULFATE

1 HYOSCYAMINE SULFATE SR HYOSCYAMINE SULFATE

1 HYOSYNE HYOSCYAMINE SULFATE

3 HYPER-SAL SODIUM CHLORIDE FOR INHALATION

3 HYZAAR LOSARTAN/HYDROCHLOROTHIAZIDE

1 IBANDRONATE SODIUM IBANDRONATE SODIUM

2 IBRANCE PALBOCICLIB PA

VC IBUPROFEN IBUPROFEN

2 ICLUSIG PONATINIB HCL PA QL

2 ILEVRO NEPAFENAC

3 ILOTYCIN ERYTHROMYCIN BASE

2 IMBRUVICA IBRUTINIB PA

2 IMIPRAMINE IMIPRAMINE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 IMIQUIMOD IMIQUIMOD PA QL

3 IMITREX SUMATRIPTAN SUCCINATE QL

3 IMURAN AZATHIOPRINE

2 IN CONTROL PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

1 INATAL ADVANCE PRENATAL VIT 15/IRON CB/FA/DSS

1 INATAL ULTRA PRENATAL VIT 18/IRON CB/FA/DSS

2 INCONTROL NEEDLES, INSULIN DISPOSABLE

2 INCONTROL SUPER THIN LANCETS LANCETS

2 INCONTROL ULTRA THIN LANCETS LANCETS

1 INDAPAMIDE INDAPAMIDE

3 INDERAL LA PROPRANOLOL HCL

2 INDOCIN INDOMETHACIN

1 INDOMETHACIN 25 MG/50 MG CASPSULE INDOMETHACIN

2 INDOMETHACIN 75 MG ER CAPSULE INDOMETHACIN

2 INJECT EASE LANCETS LANCETS

2 INLYTA AXITINIB PA QL

3 INSPRA EPLERENONE

2 INSULIN PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

2 INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 INSUPEN NEEDLES, INSULIN DISPOSABLE

2 INTEGRA SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 INTELENCE ETRAVIRINE PA

Excluded INTERMEZZO ZOLPIDEM TARTRATE

2 INTRON A INTERFERON ALFA-2B,RECOMB. PA

1 INTROVALE LEVONORGESTREL-ETHIN ESTRADIOL QL

2 INVACARE LANCETS LANCETS

2 INVIRASE SAQUINAVIR MESYLATE QL ST

2 INVOKAMET CANAGLIFLOZIN/METFORMIN HCL QL ST

2 INVOKANA CANAGLIFLOZIN QL ST

1 IOPHEN-C NR GUAIFENESIN/CODEINE PHOSPHATE

1 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE

1 IPRATROPIUM NASAL SPRAY IPRATROPIUM NASAL SPRAY

1 IPRATROPIUM-ALBUTEROL IPRATROPIUM/ALBUTEROL SULFATE

1 IRBESARTAN IRBESARTAN

1 IRBESARTAN-HYDROCHLOROTHIAZIDE IRBESARTAN/HYDROCHLOROTHIAZIDE

Excluded IRENKA DULOXETINE

2 IRESSA GEFITINIB PA

2 ISENTRESS RALTEGRAVIR POTASSIUM

3 ISOCHRON ISOSORBIDE DINITRATE

1 ISOMETHEPT-DICHLORALP-ACETAMIN ISOMETHEPT/DICHLPHN/ACETAMINOP

1 ISONIAZID ISONIAZID

3 ISOPTO ATROPINE ATROPINE SULFATE

3 ISOPTO CARPINE PILOCARPINE HCL

2 ISORDIL ISOSORBIDE DINITRATE

3 ISORDIL TITRADOSE ISOSORBIDE DINITRATE

1 ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE

1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE

1 ISRADIPINE ISRADIPINE

1 ITRACONAZOLE ITRACONAZOLE

2 JAKAFI RUXOLITINIB PHOSPHATE PA QL

2 JALYN DUTASTERIDE/TAMSULOSIN HCL ST

1 JANTOVEN WARFARIN SODIUM

2 JANUMET SITAGLIPTIN PHOS/METFORMIN HCL QL

2 JANUMET XR SITAGLIPTIN PHOS/METFORMIN HCL QL

2 JANUVIA SITAGLIPTIN PHOSPHATE QL

Excluded JARDIANCE EMPAGLIFLOZIN

1 JENCYCLA NORETHINDRONE

2 JENTADUETO LINAGLIPTIN/METFORMIN HCL QL

1 JINTELI NORETHINDRONE AC-ETH ESTRADIOL

1 JOLESSA LEVONORGESTREL-ETHIN ESTRADIOL QL

1 JOLIVETTE NORETHINDRONE

1 JUNEL NORETHINDRONE AC-ETH ESTRADIOL

1 JUNEL FE NORETHINDRONE-E.ESTRADIOL-IRON

2 JUXTAPID LOMITAPIDE MESYLATE PA

1 K EFFERVESCENT POTASSIUM BICARBONATE/CIT AC

Excluded KADIAN MORPHINE

2 KALETRA LOPINAVIR/RITONAVIR QL

2 KALYDECO IVACAFTOR PA

1 KARIVA DESOG-E.ESTRADIOL/E.ESTRADIOL

3 KAYEXALATE SODIUM POLYSTYRENE SULFONATE

Excluded KAZANO ALOGLIPTIN AND METFORMIN

3 KEFLEX CEPHALEXIN

1 KELNOR 1-35 ETHYNODIOL D-ETHINYL ESTRADIOL

3 KENALOG TRIAMCINOLONE ACETONIDE

3 KEPPRA LEVETIRACETAM

2 KETEK TELITHROMYCIN

1 KETOCONAZOLE KETOCONAZOLE

2 KETOPROFEN SR CAPSULE KETOPROFEN

1 KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE

1 KETOROLAC TROMETHAMINE OPHTHALMIC SOLUTION KETOROLAC TROMETHAMINE

VC KETOTIFEN EYE DROPS KETOTIFEN

Excluded KHEDEZLA DESVENLAFAXINE

1 KIMIDESS DESOG-E.ESTRADIOL/E.ESTRADIOL

2 KINNEY BRAND LANCETS LANCETS

1 KIONEX SODIUM POLYSTYRENE SULFONATE

3 KLARON SULFACETAMIDE SODIUM

2 KLONOPIN CLONAZEPAM

3 KLOR-CON POTASSIUM CHLORIDE

3 KLOR-CON 10 POTASSIUM CHLORIDE

3 KLOR-CON 8 POTASSIUM CHLORIDE

1 KLOR-CON M10 POTASSIUM CHLORIDE

1 KLOR-CON M20 POTASSIUM CHLORIDE

3 KLOR-CON-EF POTASSIUM BICARBONATE/CIT AC


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORExcluded KOMBIGLYZE XR SAXAGLIPTIN AND METFORMIN

2 KORLYM MIFEPRISTONE PA

2 KRISTALOSE LACTULOSE

3 K-SOL POTASSIUM CHLORIDE

3 K-TAB ER POTASSIUM CHLORIDE

1 KURVELO LEVONORGESTREL-ETHIN ESTRADIOL

2 KYNAMRO MIPOMERSEN SODIUM PA

1 LABETALOL HCL LABETALOL HCL

1 LACTULOSE LACTULOSE

2 LAMICTAL LAMOTRIGINE

2 LAMICTAL (BLUE) LAMOTRIGINE

2 LAMICTAL (GREEN) LAMOTRIGINE

2 LAMICTAL (ORANGE) LAMOTRIGINE

3 LAMISIL TERBINAFINE HCL

1 LAMIVUDINE LAMIVUDINE

1 LAMIVUDINE HBV LAMIVUDINE

1 LAMIVUDINE-ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE QL

1 LAMOTRIGINE LAMOTRIGINE

2 LANCETS LANCETS

2 LANCETS THIN LANCETS

2 LANCETS ULTRA THIN LANCETS

2 LANOXIN DIGOXIN

1 LANSOPRAZOL-AMOXICIL-CLARITHRO LANSOPRAZOLE/AMOXICILN/CLARITH QL

1 LANSOPRAZOLE LANSOPRAZOLE

2 LANTUS INSULIN GLARGINE,HUM.REC.ANLOG QL

2 LANTUS SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG QL

1 LARIN NORETHINDRONE AC-ETH ESTRADIOL

1 LARIN FE NORETHINDRONE-E.ESTRADIOL-IRON

3 LASIX FUROSEMIDE

Excluded LASTACAFT ALCAFTADINE

1 LATANOPROST LATANOPROST

Excluded LAZANDA FENTANYL CITRATE

Excluded LDO PLUS LIDOCAINE HCI

1 LEENA NORETHINDRONE-ETHINYL ESTRAD

1 LEFLUNOMIDE LEFLUNOMIDE

Excluded LEMTRADA ALEMTUZUMAB

2 LENVIMA LENVATINIB MESYLATE PA

Excluded LESCOL XL FLUVASTATIN

1 LESSINA LEVONORGESTREL-ETHIN ESTRADIOL

2 LETAIRIS AMBRISENTAN PA

1 LETROZOLE LETROZOLE

1 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM

2 LEUKERAN CHLORAMBUCIL

2 LEUKINE SARGRAMOSTIM PA

2 LEVALBUTEROL SOLUTION FOR INHALATION

3 LEVAQUIN LEVOFLOXACIN

3 LEVBID HYOSCYAMINE SULFATE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORExcluded LEVEMIR INSULIN DETEMIR

1 LEVETIRACETAM LEVETIRACETAM

Excluded LEVITRA VARDENAFIL

1 LEVOBUNOLOL HCL LEVOBUNOLOL HCL

1 LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZINE DIHYDROCHLORIDE

1 LEVOFLOXACIN LEVOFLOXACIN

1 LEVONEST LEVONORGESTREL-ETHIN ESTRADIOL

1 LEVONORGESTREL LEVONORGESTREL

1 LEVONORGESTREL-ETH ESTRADIOL LEVONORGESTREL-ETHIN ESTRADIOL

1 LEVORA-28 LEVONORGESTREL-ETHIN ESTRADIOL

Excluded LEVORPHANOL

1 LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM

2 LEVOXYL LEVOTHYROXINE SODIUM

3 LEVSIN HYOSCYAMINE SULFATE

3 LEVSIN-SL HYOSCYAMINE SULFATE

3 LEXAPRO ESCITALOPRAM OXALATE

2 LEXIVA FOSAMPRENAVIR CALCIUM PA

3 LIBRAX CHLORDIAZEPOXIDE/CLIDINIUM BR

1 LIDOCAINE HCL VISCOUS LIDOCAINE HCL

Excluded LIDORX KIT LIDOCAINE

1 LINDANE LINDANE

1 LINEZOLID LINEZOLID PA

2 LINZESS LINACLOTIDE QL

1 LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM

3 LIPITOR ATORVASTATIN CALCIUM

VC LISINOPRIL LISINOPRIL

VC LISINOPRIL-HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE

2 LITE TOUCH SYRING W-NDL,DISP,INSUL,0.5 ML

1 LITHIUM LITHIUM CITRATE

1 LITHIUM CARBONATE LITHIUM CARBONATE

1 LITHIUM CARBONATE ER LITHIUM CARBONATE

2 LITHOBID LITHIUM CARBONATE

Excluded LIVALO PITAVASTATIN

2 LO LOESTRIN FE NORETHINDRONE-E.ESTRADIOL-IRON ST

3 LOCOID HYDROCORTISONE BUTYRATE

3 LOCOID LIPOCREAM HYDROCORTISONE BUTYRATE/EMOLL

3 LODOSYN CARBIDOPA

3 LOESTRIN NORETHINDRONE AC-ETH ESTRADIOL ST

3 LOESTRIN FE NORETHINDRONE-E.ESTRADIOL-IRON ST

3 LOFIBRA FENOFIBRATE MICRONIZED

3 LOMOTIL DIPHENOXYLATE HCL/ATROPINE

1 LOMUSTINE LOMUSTINE

3 LOPID GEMFIBROZIL

3 LOPRESSOR METOPROLOL TARTRATE

3 LOPROX CICLOPIROX

VC LORATADINE LORATADINE

VC LORATADINE-PSEUDOEPHEDRINE LORATADINE-PSEUDOEPHEDRINE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 LORAZEPAM LORAZEPAM

1 LORAZEPAM INTENSOL LORAZEPAM

1 LORCET HYDROCODONE/ACETAMINOPHEN QL

1 LORCET HD HYDROCODONE/ACETAMINOPHEN QL

1 LORCET PLUS HYDROCODONE/ACETAMINOPHEN QL

3 LORTAB HYDROCODONE/ACETAMINOPHEN QL

1 LORTUSS EX P-EPHED HCL/CODEINE/GUAIFEN

1 LORYNA ETHINYL ESTRADIOL/DROSPIRENONE ST

VC LOSARTAN LOSARTAN

1 LOSARTAN-HYDROCHLOROTHIAZIDE COMBINATION TABLET LOSARTAN/HYDROCHLOROTHIAZIDE

2 LOTEMAX LOTEPREDNOL ETABONATE

3 LOTENSIN BENAZEPRIL HCL

3 LOTENSIN HCT BENAZEPRIL/HYDROCHLOROTHIAZIDE

3 LOTREL AMLODIPINE BESYLATE/BENAZEPRIL

3 LOTRISONE CLOTRIMAZOLE/BETAMETHASONE DIP

VC LOVASTATIN LOVASTATIN

3 LOVAZA OMEGA-3 ACID ETHYL ESTERS QL

3 LOVENOX ENOXAPARIN SODIUM QL

1 LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL

1 LOXAPINE LOXAPINE SUCCINATE

3 LUDENT FLUORIDE SODIUM FLUORIDE

2 LUER-LOK SYRINGE SYRINGE W-O NEEDL,INSULIN,1 ML

2 LUMIGAN BIMATOPROST QL

3 LUNESTA ESZOPICLONE QL

1 LUTERA LEVONORGESTREL-ETHIN ESTRADIOL

2 LYNPARZA OLAPARIB PA QL

2 LYRICA PREGABALIN

2 LYSODREN MITOTANE

1 LYZA NORETHINDRONE

3 MACROBID NITROFURANTOIN MONOHYD/M-CRYST

2 MACRODANTIN NITROFURANTOIN MACROCRYSTAL

2 MAGELLAN INSULIN SAFETY SYRNG SYRINGE,NEEDLE,INSULN,SAFE,1ML

2 MAGELLAN INSULIN SYRINGE SYRINGE,NEEDLE,INSULN,SF,0.3ML

1 MALATHION MALATHION

2 MALATHION LOTION MALATHION

1 MAPROTILINE HCL MAPROTILINE HCL

3 MARINOL DRONABINOL QL ST

1 MARLEXATE SODIUM POLYSTYRENE SULFONATE

1 MARLISSA LEVONORGESTREL-ETHIN ESTRADIOL

1 MARTEN-TAB BUTALBITAL/ACETAMINOPHEN

2 MATULANE PROCARBAZINE HCL

3 MAVIK TRANDOLAPRIL

3 MAXALT RIZATRIPTAN BENZOATE QL

3 MAXALT MLT RIZATRIPTAN BENZOATE QL

2 MAXI-COMFORT SYRING W-NDL,DISP,INSUL,0.5 ML

3 MAXITROL NEO/POLYMYX B SULF/DEXAMETH

3 MAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZID


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR3 MAXZIDE-25 MG TRIAMTERENE/HYDROCHLOROTHIAZID

1 MECLIZINE HCL MECLIZINE HCL

2 MECLOFENAMATE SODIUM CAPSULE MECLOFENAMATE SODIUM

2 MEDI-LANCE LANCETS

2 MEDISENSE THIN LANCETS LANCETS

2 MEDLANCE PLUS LANCETS

2 MEDLANCE PLUS SPECIAL BLADE BLADE LANCET, SAFETY

2 MEDROL METHYLPREDNISOLONE

1 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE

2 MEFENAMIC ACID CAPSULE MEFENAMIC ACID

2 MEFLOQUINE HCL MEFLOQUINE HCL

3 MEGACE MEGESTROL ACETATE

2 MEGACE ES MEGESTROL ACETATE

1 MEGESTROL ACETATE MEGESTROL ACETATE

2 MEKINIST TRAMETINIB DIMETHYL SULFOXIDE PA

VC MELOXICAM MELOXICAM

1 MEMANTINE HCL MEMANTINE HCL QL

2 MENEST ESTROGENS,ESTERIFIED

2 MEPHYTON PHYTONADIONE

2 MEPROBAMATE MEPROBAMATE

1 MERCAPTOPURINE MERCAPTOPURINE

1 MESALAMINE MESALAMINE

3 MESTINON PYRIDOSTIGMINE BROMIDE

3 METADATE CD METHYLPHENIDATE HCL QL

1 METADATE ER METHYLPHENIDATE HCL QL

1 METAPROTERENOL SULFATE METAPROTERENOL SULFATE

2 METAXALONE METAXALONE

2 METFORMIN ER TABLET 500/1000 (FORTAMET/GLUMETZA) METFORMIN

1 METFORMIN ER TABLET 500/750 (GLUCOPHAGE XR GENERIC) METFORMIN

VC METFORMIN HCL METFORMIN

1 METHADONE HCL METHADONE HCL

2 METHAZOLAMIDE METHAZOLAMIDE

1 METHIMAZOLE METHIMAZOLE

2 METHITEST METHYLTESTOSTERONE

1 METHOCARBAMOL METHOCARBAMOL

1 METHOTREXATE METHOTREXATE

1 METHOXSALEN METHOXSALEN, RAPID

1 METHYLDOPA METHYLDOPA

1 METHYLERGONOVINE MALEATE METHYLERGONOVINE MALEATE

3 METHYLIN METHYLPHENIDATE HCL

1 METHYLPHENIDATE METHYLPHENIDATE

2 METHYLPHENIDATE ER METHYLPHENIDATE HCL QL

1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL QL

2 METHYLPHENIDATE HCL CD METHYLPHENIDATE HCL QL

2 METHYLPHENIDATE LA METHYLPHENIDATE HCL QL

1 METHYLPREDNISOLONE METHYLPREDNISOLONE

1 METIPRANOLOL METIPRANOLOL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL

1 METOLAZONE METOLAZONE

1 METOPROLOL ER TABLET METOPROLOL TARTRATE

1 METOPROLOL SUCCINATE METOPROLOL SUCCINATE

VC METOPROLOL TARTRATE 25 MG, 50 MG, 100 MG METOPROLOL TARTRATE

2 METOPROLOL TARTRATE 37.5 MG, 75 MG METOPROLOL TARTRATE

VC METOPROLOL-HYDROCHLOROTHIAZIDE METOPROLOL/HYDROCHLOROTHIAZIDE

3 METROCREAM METRONIDAZOLE

3 METROGEL-VAGINAL METRONIDAZOLE

3 METROLOTION METRONIDAZOLE

1 METRONIDAZOLE METRONIDAZOLE

1 MEXILETINE HCL MEXILETINE HCL

1 MICONAZOLE 3 MICONAZOLE NITRATE

2 MICRO THIN LANCETS LANCETS

1 MICROGESTIN NORETHINDRONE AC-ETH ESTRADIOL

1 MICROGESTIN FE NORETHINDRONE-E.ESTRADIOL-IRON

2 MICROLET LANCETS

2 MICROTAINER LANCETS BLADE LANCET, SAFETY

3 MICROZIDE HYDROCHLOROTHIAZIDE

1 MIDODRINE HCL MIDODRINE HCL

2 MIGERGOT ERGOTAMINE TARTRATE/CAFFEINE QL

1 MIGRAGESIC IDA ISOMETHEPT/DICHLPHN/ACETAMINOP

2 MILLIPRED PREDNISOLONE

2 MILLIPRED DP PREDNISOLONE

2 MINI ULTRA-THIN II NEEDLES, INSULIN DISPOSABLE

3 MINIPRESS PRAZOSIN HCL

1 MINITRAN NITROGLYCERIN

2 MINIVELLE ESTRADIOL QL

3 MINOCIN MINOCYCLINE HCL

2 MINOCYCLINE 24HR SR TABLET MINOCYCLINE

1 MINOCYCLINE CAPSULE MINOCYCLINE

1 MINOCYCLINE HCL MINOCYCLINE HCL

3 MIRAPEX PRAMIPEXOLE DI-HCL

3 MIRCETTE DESOG-E.ESTRADIOL/E.ESTRADIOL ST

1 MIRTAZAPINE MIRTAZAPINE

1 MISOPROSTOL MISOPROSTOL

Excluded MITIGARE COLCHICINE

3 MOBIC MELOXICAM

2 MODAFINIL TABLET MODAFINIL

3 MODERIBA RIBAVIRIN

3 MODICON NORETHINDRONE-ETHINYL ESTRAD ST

1 MOEXIPRIL HCL MOEXIPRIL HCL

1 MOEXIPRIL-HYDROCHLOROTHIAZIDE MOEXIPRIL/HYDROCHLOROTHIAZIDE

1 MOMETASONE FUROATE MOMETASONE FUROATE

2 MONOJECT SYRING W-NDL,DISP,INSUL,0.5 ML

2 MONOJECT INSULIN SAFETY SYRNG SYRINGE W-NDL, DISP., INSULIN

2 MONOJECT INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 MONOJECT PREFILL HEPARIN SODIUM,PORCINE/PF

1 MONOJECT PREFILL ADVANCED HEPARIN SODIUM,PORCINE/PF

2 MONOLET LANCETS LANCETS

2 MONOLET THIN LANCETS LANCETS

1 MONO-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL

1 MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL

1 MONTELUKAST SODIUM MONTELUKAST SODIUM

3 MORGIDOX DOXYCYCLINE HYCLATE QL ST

2 MORPHINE SULFATE MORPHINE SULFATE

1 MORPHINE SULFATE ER MORPHINE SULFATE QL

2 MOVANTIK NALOXEGOL OXALATE QL

2 MOXEZA MOXIFLOXACIN HCL

1 MOXIFLOXACIN HCL MOXIFLOXACIN HCL

3 MS CONTIN MORPHINE SULFATE QL

2 MULTAQ DRONEDARONE HCL

1 MULTIVITAMIN AND FLUORIDE PEDI MULTIVIT NO.2 W-FLUORIDE

1 MULTI-VITAMIN W-FLUORIDE PEDI MULTIVIT NO.2 W-FLUORIDE

1 MULTI-VITAMIN W-FLUORIDE-IRON PEDI MV #45/FLUORIDE/IRON

1 MULTI-VITAMIN WITH FLUORIDE PEDI M.VIT NO.17 WITH FLUORIDE

1 MULTIVITAMINS W-FLUORIDE-IRON PEDI MV #75/FLUORIDE/IRON

1 MULTIVITAMINS WITH FLUORIDE PEDI MVI NO.82 WITH FLUORIDE

2 MUPIROCIN CREAM MUPIROCIN

1 MUPIROCIN OINTMENT MUPIROCIN

1 MY WAY LEVONORGESTREL

3 MYAMBUTOL ETHAMBUTOL HCL

1 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL

2 MYGLUCOHEALTH LANCETS LANCETS

2 MYLERAN BUSULFAN

1 MYNATAL PNV/IRON,CARBONYL/DOCUSATE/FA

1 MYNATAL ADVANCE PRENATAL VIT 15/IRON CB/FA/DSS

1 MYORISAN ISOTRETINOIN

3 MYSOLINE PRIMIDONE

1 MYZILRA LEVONORGESTREL-ETHIN ESTRADIOL

1 NABUMETONE NABUMETONE

2 NADOLOL TABLET NADOLOL

2 NAFTIFINE 1%, 2% CREAM NAFTIFINE HCL

1 NAFTIFINE HCL NAFTIFINE HCL

2 NAFTIN NAFTIFINE HCL

3 NALFON FENOPROFEN CALCIUM

1 NALTREXONE HCL NALTREXONE HCL

3 NAMENDA MEMANTINE HCL QL

2 NAMENDA XR MEMANTINE HCL QL

2 NAMZARIC MEMANTINE HCL/DONEPEZIL HCL QL ST

Excluded NAPRELAN NAPROXEN

Excluded NAPROPACK COOL NAPROXEN

Excluded NAPROPAX NAPROXEN

3 NAPROSYN NAPROXEN


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATORVC NAPROXEN NAPROXEN

2 NAPROXEN SODIUM (ANAPROX DS/NAPRELAN CR) NAPROXEN

1 NAPROXEN TABLET (NAPROSYN/EC-NAPROSYN) NAPROXEN

2 NARATRIPTAN NARATRIPTAN HCL QL

1 NARATRIPTAN HCL NARATRIPTAN HCL QL

3 NARDIL PHENELZINE SULFATE

2 NASONEX MOMETASONE FUROATE QL

1 NATEGLINIDE NATEGLINIDE

Excluded NATESTO TESTOSTERONE

1 NATURE-THROID THYROID,PORK

2 NEBUPENT PENTAMIDINE ISETHIONATE

1 NECON NORETHINDRONE-ETHINYL ESTRAD

2 NEEDLES NEEDLES, INSULIN DISPOSABLE

2 NEFAZONDONE NEFAZODONE

1 NEOMYCIN SULFATE NEOMYCIN SULFATE

1 NEOMYCIN-BACITRACIN-POLY-HC NEOMYCIN SU/BACI ZN/POLY/HC

1 NEOMYCIN-BACITRACIN-POLYMYXIN NEOMYCIN SU/BACITRA/POLYMYXIN

1 NEOMYCIN-POLYMYXIN-DEXAMETH NEO/POLYMYX B SULF/DEXAMETH

1 NEOMYCIN-POLYMYXIN-GRAMICIDIN NEOMYCIN/POLYMYXN B/GRAMICIDIN

1 NEOMYCIN-POLYMYXIN-HC NEOMYCIN/POLYMYXIN B SULF/HC

1 NEOMYCIN-POLYMYXIN-HYDROCORT NEOMYCIN/POLYMYXIN B SULF/HC

1 NEO-POLYCIN NEOMYCIN SU/BACITRA/POLYMYXIN

1 NEO-POLYCIN HC NEOMYCIN SU/BACI ZN/POLY/HC

2 NEORAL CYCLOSPORINE, MODIFIED

3 NEOSPORIN NEOMYCIN/POLYMYXN B/GRAMICIDIN

3 NEPTAZANE METHAZOLAMIDE

Excluded NESINA ALOGLIPTIN

2 NEULASTA PEGFILGRASTIM PA

2 NEUPOGEN FILGRASTIM PA

2 NEUPRO ROTIGOTINE QL ST

2 NEURONTIN GABAPENTIN

2 NEVANAC NEPAFENAC

1 NEVIRAPINE NEVIRAPINE QL

1 NEVIRAPINE ER NEVIRAPINE

2 NEXAVAR SORAFENIB TOSYLATE PA QL

2 NEXIUM ESOMEPRAZOLE MAGNESIUM QL ST

1 NEXT CHOICE ONE DOSE LEVONORGESTREL

1 NIACIN ER NIACIN ST

3 NIASPAN NIACIN ST

1 NICARDIPINE HCL NICARDIPINE HCL

1 NIFEDICAL XL NIFEDIPINE

1 NIFEDIPINE NIFEDIPINE

1 NIFEDIPINE ER NIFEDIPINE

1 NIKKI ETHINYL ESTRADIOL/DROSPIRENONE ST

2 NILANDRON NILUTAMIDE QL

1 NIMODIPINE NIMODIPINE

2 NISOLDIPINE ER TABLET NISOLDIPINE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 NITRO-BID NITROGLYCERIN

2 NITRO-DUR NITROGLYCERIN

1 NITROFURANTOIN NITROFURANTOIN

1 NITROFURANTOIN MACROCRYSTAL CAPSULE NITROFURANTOIN

1 NITROFURANTOIN MONO-MACRO NITROFURANTOIN

2 NITROFURANTOIN ORAL SUSPENSION NITROFURANTOIN

1 NITROGLYCERIN NITROGLYCERIN

1 NITROGLYCERIN PATCH NITROGLYCERIN

1 NITROGLYCERIN SUBLINGUAL TABLET NITROGLYCERIN

2 NITROGLYCERINE TRANSLINGUAL SPRAY NITROGLYCERIN

3 NITROLINGUAL NITROGLYCERIN SUBLINGUAL TABLET

2 NITROSTAT NITROGLYCERIN

1 NIZATIDINE NIZATIDINE

3 NIZORAL KETOCONAZOLE

1 NODOLOR ISOMETHEPT/DICHLPHN/ACETAMINOP

1 NORA-BE NORETHINDRONE

3 NORCO HYDROCODONE/ACETAMINOPHEN QL

Excluded NORDITROPIN SOMATROPIN

1 NORETHINDRONE NORETHINDRONE

1 NORETHINDRONE ACETATE NORETHINDRONE ACETATE

1 NORETHINDRON-ETHINYL ESTRADIOL NORETHINDRONE AC-ETH ESTRADIOL

1 NORETHIN-ETH ESTRA FERROUS FUM NORETHINDRONE-E.ESTRADIOL-IRON

1 NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL

1 NORINYL 1+35 NORETHINDRONE-ETHINYL ESTRAD

3 NORINYL 1+50 NORETHINDRONE-MESTRANOL ST

Excluded NORITATE METRONIDAZOLE

1 NORLYROC NORETHINDRONE

3 NORPACE DISOPYRAMIDE PHOSPHATE

2 NORPACE CR DISOPYRAMIDE PHOSPHATE

3 NORPRAMIN DESIPRAMINE HCL

3 NOR-Q-D NORETHINDRONE ST

1 NORTREL NORETHINDRONE-ETHINYL ESTRAD

1 NORTRIPTYLINE NORTRIPTYLINE

3 NORVASC AMLODIPINE BESYLATE

2 NORVIR RITONAVIR QL

2 NOVA SAFETY LANCETS LANCETS

2 NOVA SUREFLEX LANCETS

2 NOVOFINE NEEDLES, INSULIN DISPOSABLE

2 NOVOFINE 32 NEEDLES, INSULIN DISPOSABLE

2 NOVOFINE AUTOCOVER NEEDLES, INSULIN DISP., SAFETY

2 NOVOFINE PLUS NEEDLES, INSULIN DISPOSABLE

Excluded NOVOLIN INSULIN

Excluded NOVOLOG INSULIN

2 NOVOTWIST NEEDLES, INSULIN DISPOSABLE

1 NP THYROID THYROID,PORK

Excluded NUCALA MEPOLIZUMAB

2 NUCYNTA TAPENTADOL HCL QL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 NUCYNTA ER TAPENTADOL HCL QL

3 NULEV HYOSCYAMINE SULFATE

3 NULYTELY WITH FLAVOR PACKS SODIUM CHLORIDE/NAHCO3/KCL/PEG

Excluded NUPLAZID PIMAVANSERIN

Excluded NUTROPIN SOMATROPIN

Excluded NUTROPIN AQ SOMATROPIN

2 NUVARING ETONOGESTREL/ETHINYL ESTRADIOL QL ST

Excluded NUVIGIL ARMODAFINIL

1 NYAMYC NYSTATIN

1 NYSTATIN NYSTATIN

2 NYSTATIN-TRIAMCINOLONE 100,000 - 0.1% CREAM/OINTMENT NYSTATIN/TRIAMCIN

1 NYSTOP NYSTATIN

1 OCELLA ETHINYL ESTRADIOL/DROSPIRENONE ST

1 OCTREOTIDE ACETATE OCTREOTIDE ACETATE

3 OCUFEN FLURBIPROFEN SODIUM

3 OCUFLOX OFLOXACIN

2 OFEV NINTEDANIB ESYLATE PA

1 OFLOXACIN OFLOXACIN

1 OGESTREL NORGESTREL-ETHINYL ESTRADIOL

2 OLANZAPINE ODT OLANZAPINE

1 OLANZAPINE TABLET OLANZAPINE QL

2 OLANZAPINE-FLUOXETINE COMBINATION CAPSULE

2 OLANZAPINE-FLUOXETINE HCL QL

2 OLOPATADINE NASAL SPRAY

3 OLUX CLOBETASOL PROPIONATE

2 OMEGA-3 ACID ETHYL ESTERS OMEGA-3 ACID ETHYL ESTERS QL

VC OMEPRAZOLE OMEPRAZOLE

1 OMEPRAZOLE 40 MG, ANTACIDS OTC OMEPRAZOLE

1 OMEPRAZOLE OTC, ANTACIDS OTC OMEPRAZOLE

Excluded OMEPRAZOLE-SODIUM BICARBONATE OMEPRAZOLE

Excluded OMNARIS CICLESONIDE

3 OMNIPRED PREDNISOLONE ACETATE

2 OMNITROPE SOMATROPIN PA

2 ON CALL LANCET LANCETS

2 ON CALL PLUS LANCET LANCETS

1 ONDANSETRON HCL ONDANSETRON QL

1 ONDANSETRON ODT ONDANSETRON

1 ONETOUCH DELICA LANCETS

1 ONETOUCH FINEPOINT LANCETS LANCETS

1 ONETOUCH LANCETS LANCETS

1 ONETOUCH SURESOFT LANCETS

1 ONETOUCH ULTRA TEST STRIPS BLOOD SUGAR DIAGNOSTIC

1 ONETOUCH VERIO BLOOD SUGAR DIAGNOSTIC

Excluded ONGLYZA SAXAGLIPTIN

Excluded ONSOLIS FENTANYL CITRATE

2 ON-THE-GO LANCETS

1 OPCICON ONE-STEP LEVONORGESTREL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 OPSUMIT MACITENTAN PA

Excluded ORACEA DOXYCYCLINE ER

2 ORALAIR GR POL-ORC/SW VER/RYE/KENT/TIM PA

1 ORALONE TRIAMCINOLONE ACETONIDE

1 ORPHENADRINE CITRATE ORPHENADRINE CITRATE

1 ORSYTHIA LEVONORGESTREL-ETHIN ESTRADIOL

3 ORTHO EVRA NORELGESTROMIN/ETHIN.ESTRADIOL QL ST

3 ORTHO MICRONOR NORETHINDRONE ST

3 ORTHO TRI-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL ST

2 ORTHO TRI-CYCLEN LO NORGESTIMATE-ETHINYL ESTRADIOL ST

3 ORTHO-CEPT DESOGESTREL-ETHINYL ESTRADIOL ST

3 ORTHO-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL ST

3 ORTHO-NOVUM NORETHINDRONE-ETHINYL ESTRAD ST

1 OSCIMIN HYOSCYAMINE SULFATE

1 OSCIMIN SL HYOSCYAMINE SULFATE

1 OSCIMIN SR HYOSCYAMINE SULFATE

Excluded OSENI ALOGLIPTIN AND PIOGLITAZONE

3 OTEZLA APREMILAST PA

2 OVACE PLUS SULFACETAMIDE SODIUM

3 OVIDE MALATHION

2 OXAPROZIN OXAPROZIN

1 OXAZEPAM OXAZEPAM

1 OXCARBAZEPINE OXCARBAZEPINE

2 OXICONAZOLE NITRATE 1% CREAM OXICONAZOLE

2 OXSORALEN METHOXSALEN

3 OXSORALEN-ULTRA METHOXSALEN, RAPID

1 OXYBUTYNIN OXYBUTYNIN

1 OXYBUTYNIN ER OXYBUTYNIN

1 OXYCODONE HCL OXYCODONE HCL

1 OXYCODONE HCL ER OXYCODONE HCL QL

1 OXYCODONE HCL-ASPIRIN OXYCODONE HCL/ASPIRIN

1 OXYCODONE-ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN QL

3 OXYCONTIN OXYCODONE HCL QL

1 PACERONE AMIODARONE HCL

3 PAMELOR NORTRIPTYLINE HCL

Excluded PANCREAZE LIPASE/PROTEASE/AMYLASE

1 PANCRELIPASE 5,000 LIPASE/PROTEASE/AMYLASE

2 PANDEL HYDROCORTISONE PROBUTATE

VC PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM

3 PARAFON FORTE DSC CHLORZOXAZONE

1 PARICALCITOL PARICALCITOL

3 PARLODEL BROMOCRIPTINE MESYLATE

3 PARNATE TRANYLCYPROMINE SULFATE

1 PAROEX CHLORHEXIDINE GLUCONATE

1 PAROMOMYCIN SULFATE PAROMOMYCIN SULFATE

2 PAROXETINE HCL PAROXETINE

2 PAROXETINE SR TABLETS PAROXETINE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 PAROXETINE TABLET PAROXETINE

2 PATADAY OLOPATADINE HCL

2 PATANOL OLOPATADINE HCL

2 PAXIL PAROXETINE HCL

2 PCE ERYTHROMYCIN BASE

Excluded PEDIAPALM LANOLIN, AMMONIUM LACTATE, GLYCERIN

3 PEDIAPRED PREDNISOLONE SOD PHOSPHATE

Excluded PEDIPAK CICLOPIROX

1 PEG 3350-ELECTROLYTE PEG 3350/NA SULF,BICARB,CL/KCL

1 PEG-3350 SODIUM CHLORIDE/NAHCO3/KCL/PEG

1 PEG-3350 WITH FLAVOR PACKS SODIUM CHLORIDE/NAHCO3/KCL/PEG

2 PEGASYS PEGINTERFERON ALFA-2A PA

2 PEGASYS PROCLICK PEGINTERFERON ALFA-2A PA

2 PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

2 PEN NEEDLES NEEDLES, INSULIN DISPOSABLE

1 PENICILLIN VK PENICILLIN V POTASSIUM

Excluded PENNSAID DICLOFENAC

2 PENTIPS NEEDLES, INSULIN DISPOSABLE

1 PENTOXIFYLLINE PENTOXIFYLLINE

3 PEPCID FAMOTIDINE

3 PERCOCET OXYCODONE HCL/ACETAMINOPHEN QL

2 PERFOROMIST FORMOTEROL FUMARATE QL

3 PERIDEX CHLORHEXIDINE GLUCONATE

1 PERIOGARD CHLORHEXIDINE GLUCONATE

1 PERMETHRIN CREAM PERMETHRIN

1 PERPHENAZINE PERPHENAZINE

3 PERSANTINE DIPYRIDAMOLE

Excluded PERTZYE LIPASE/PROTEASE/AMYLASE

Excluded PEXEVA PAROXETINE MESYLATE

1 PHENADOZ PROMETHAZINE HCL

1 PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL

1 PHENELZINE SULFATE PHENELZINE SULFATE

3 PHENERGAN PROMETHAZINE HCL

1 PHENOBARBITAL PHENOBARBITAL

1 PHENYLHISTINE DH P-EPHED HCL/COD/CHLORPHENIR

3 PHENYTEK PHENYTOIN SODIUM EXTENDED

1 PHENYTOIN PHENYTOIN

1 PHENYTOIN SODIUM EXTENDED RELEASE RELEASEPHENYTOIN SODIUM EXTENDED

3 PHOSLO CALCIUM ACETATE

2 PHOSPHASAL MTH/ME BLUE/SOD PHOS/PHEN/HYOS

2 PICATO INGENOL MEBUTATE QL

1 PILOCARPINE HCL PILOCARPINE HCL

1 PIMTREA DESOG-E.ESTRADIOL/E.ESTRADIOL

1 PINDOLOL PINDOLOL

1 PIOGLITAZONE HCL PIOGLITAZONE HCL

2 PIOGLITAZONE-GLIMEPIRIDE COMBINATION TABLET PIOGLITAZONE/GLIMEPIRIDE ST

2 PIOGLITAZONE-METFORMIN COMBINATION TABLET PIOGLITAZONE/METFORMIN ST


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 PIRMELLA NORETHINDRONE-ETHINYL ESTRAD

2 PIROXICAM PIROXICAM

3 PLAN B ONE-STEP LEVONORGESTREL

3 PLAQUENIL HYDROXYCHLOROQUINE SULFATE

3 PLAVIX CLOPIDOGREL BISULFATE

2 PLEGRIDY PEGINTERFERON BETA-1A PA

2 PLEGRIDY PEN PEGINTERFERON BETA-1A PA

3 PLETAL CILOSTAZOL

1 PODOFILOX PODOFILOX

1 POLYCIN BACITRACIN/POLYMYXIN B SULFATE

1 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350

1 POLYMYXIN B SUL-TRIMETHOPRIM POLYMYXIN B SULF/TRIMETHOPRIM

3 POLYTRIM POLYMYXIN B SULF/TRIMETHOPRIM

2 POMALYST POMALIDOMIDE PA

1 PORTIA LEVONORGESTREL-ETHIN ESTRADIOL

1 POTASSIUM BICARBONATE POTASSIUM BICARBONATE/CIT AC

1 POTASSIUM CHLORIDE POTASSIUM CHLORIDE

Excluded PRALUENT ALIROCUMAB

3 PRAMCORT HYDROCORTISONE/PRAMOXINE

1 PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL

2 PRAMOSONE HYDROCORTISONE/PRAMOXINE

2 PRANDIMET REPAGLINIDE/METFORMIN HCL

3 PRANDIN REPAGLINIDE

3 PRAVACHOL PRAVASTATIN SODIUM

1 PRAVASTATIN PRAVASTATIN

1 PRAZOSIN HCL PRAZOSIN HCL

2 PRECISION XTRA BLOOD SUGAR DIAGNOSTIC

3 PRECOSE ACARBOSE

3 PRED FORTE PREDNISOLONE ACETATE

2 PRED MILD PREDNISOLONE ACETATE

1 PREDNISOLONE PREDNISOLONE

1 PREDNISOLONE ACETATE PREDNISOLONE ACETATE

1 PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE

1 PREDNISONE PREDNISONE

2 PREDNISONE INTENSOL PREDNISONE

2 PREMARIN ESTROGENS, CONJUGATED

2 PREMPHASE ESTROGEN,CON/M-PROGEST ACET

2 PREMPRO ESTROGEN,CON/M-PROGEST ACET

2 PRESSURE ACTIVATED LANCETS LANCETS

Excluded PRESTALIA AMLODIPINE/PERONDOPRIL

3 PREVACID LANSOPRAZOLE

1 PREVALITE CHOLESTYRAMINE/ASPARTAME

1 PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL

3 PREVPAC LANSOPRAZOLE/AMOXICILN/CLARITH QL

2 PREZCOBIX DARUNAVIR/COBICISTAT QL

2 PREZISTA DARUNAVIR ETHANOLATE QL

3 PRILOSEC OMEPRAZOLE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 PRIMAQUINE PRIMAQUINE PHOSPHATE

1 PRIMIDONE PRIMIDONE

2 PRIMSOL TRIMETHOPRIM

3 PRINIVIL LISINOPRIL

2 PRISTIQ ER DESVENLAFAXINE SUCCINATE QL ST

2 PROAIR HFA ALBUTEROL SULFATE

2 PROAIR RESPICLICK ALBUTEROL SULFATE

1 PROBENECID PROBENECID

1 PROBENECID-COLCHICINE COLCHICINE/PROBENECID

3 PROCARDIA NIFEDIPINE

3 PROCARDIA XL NIFEDIPINE

1 PROCHLORPERAZINE PROCHLORPERAZINE

2 PROCRIT EPOETIN ALFA PA

3 PROCTOCORT HYDROCORTISONE

2 PROCTOFOAM-HC HYDROCORTISONE/PRAMOXINE

1 PROCTO-PAK HYDROCORTISONE

1 PROCTOSOL-HC HYDROCORTISONE

1 PROCTOZONE-HC HYDROCORTISONE

2 PRODIGY INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 PRODIGY LANCETS LANCETS

2 PRODIGY TWIST TOP LANCET LANCETS

1 PROGESTERONE PROGESTERONE,MICRONIZED

2 PROGRAF TACROLIMUS

2 PROMACTA ELTROMBOPAG OLAMINE PA

1 PROMETHAZINE HCL PROMETHAZINE HCL

1 PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL

1 PROMETHAZINE VC-CODEINE PROMETHAZINE/PHENYLEPH/CODEINE

1 PROMETHAZINE-CODEINE PROMETHAZINE HCL/CODEINE

1 PROMETHAZINE-DM D-METHORPHAN HB/PROMETH HCL

1 PROMETHEGAN PROMETHAZINE

3 PROMETRIUM PROGESTERONE,MICRONIZED

1 PROPAFENONE HCL PROPAFENONE

1 PROPAFENONE HCL ER PROPAFENONE

2 PROPRANOLOL ER CAPSULE PROPRANOLOL

VC PROPRANOLOL HCL PROPRANOLOL

1 PROPRANOLOL-HYDROCHLOROTHIAZIDE PROPRANOLOL/HYDROCHLOROTHIAZIDE

1 PROPYLTHIOURACIL PROPYLTHIOURACIL

3 PROSCAR FINASTERIDE

2 PROSED-DS METHENAM/ME BLUE/BA/SALICY/HYO

3 PROTONIX PANTOPRAZOLE SODIUM

3 PROTOPIC TACROLIMUS ST

2 PROTRIPTYLINE

Excluded PROVENTIL HFA ALBUTEROL SULFATE

3 PROVERA MEDROXYPROGESTERONE ACETATE

3 PROZAC FLUOXETINE HCL

3 PROZAC WEEKLY FLUOXETINE HCL

3 PSORCON DIFLORASONE DIACETATE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR3 PULMICORT BUDESONIDE QL

2 PULMICORT FLEXHALER BUDESONIDE QL

3 PULMOSAL SODIUM CHLORIDE FOR INHALATION

2 PULMOZYME DORNASE ALFA PA

2 PURIXAN MERCAPTOPURINE ST

2 PUSH BUTTON SAFETY LANCETS LANCETS

1 PYRAZINAMIDE PYRAZINAMIDE

3 PYRIDIUM PHENAZOPYRIDINE HCL

1 PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE

1 PYRIDOSTIGMINE BROMIDE ER PYRIDOSTIGMINE BROMIDE

2 QNASL BECLOMETHASONE DIPROPIONATE QL ST

2 QNASL CHILDREN BECLOMETHASONE DIPROPIONATE QL ST

Excluded QSYMIA PHENTERMINE AND TOPIRATMATE EXTENDED-RELEASE

3 QUALAQUIN QUININE SULFATE

1 QUASENSE LEVONORGESTREL-ETHIN ESTRADIOL QL

3 QUESTRAN CHOLESTYRAMINE (WITH SUGAR)

3 QUESTRAN LIGHT CHOLESTYRAMINE/ASPARTAME

1 QUETIAPINE FUMARATE QUETIAPINE QL

1 QUETIAPINE TABLET QUETIAPINE

2 QUILLIVANT XR METHYLPHENIDATE HCL QL ST

1 QUINAPRIL HCL QUINAPRIL HCL

1 QUINAPRIL-HYDROCHLOROTHIAZIDE QUINAPRIL/HYDROCHLOROTHIAZIDE

1 QUINIDINE GLUCONATE QUINIDINE GLUCONATE

1 QUINIDINE SULFATE QUINIDINE SULFATE

1 QUININE SULFATE QUININE SULFATE

2 QVAR BECLOMETHASONE DIPROPIONATE QL

2 RAGWITEK WEED POLLEN-SHORT RAGWEED PA

1 RALOXIFENE HCL RALOXIFENE HCL PA QL

VC RAMIPRIL RAMIPRIL

2 RANEXA RANOLAZINE QL

1 RANITIDINE HCL RANITIDINE HCL

1 RANITIDINE SYRUP RANITIDINE

2 RAPAMUNE SIROLIMUS

Excluded RAYOS PREDNISONE

3 REBETOL RIBAVIRIN

2 REBIF INTERFERON BETA-1A/ALBUMIN PA

2 REBIF REBIDOSE INTERFERON BETA-1A/ALBUMIN PA

Excluded RECLAST-ZOLEDRONIC ACID (Brand Excluded - Generic Covered) ZOLEDRONIC ACID PA

1 RECLIPSEN DESOGESTREL-ETHINYL ESTRADIOL

3 REGLAN METOCLOPRAMIDE HCL

2 REGRANEX BECAPLERMIN

2 RELIAMED LANCETS

2 RELIAMED SAFETY SEAL LANCETS LANCETS

2 RELION PEN NEEDLES NEEDLES, INSULIN DISPOSABLE

2 RELION THIN LANCETS

2 RELISTOR METHYLNALTREXONE BROMIDE PA

3 REMERON MIRTAZAPINE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 RENAGEL SEVELAMER HCL

2 RENVELA SEVELAMER CARBONATE

2 REPAGLINIDE REPAGLINIDE

Excluded REPATHA EVOLOCUMAB

3 REQUIP ROPINIROLE HCL

3 REQUIP XL ROPINIROLE HCL QL ST

2 RESCRIPTOR DELAVIRDINE MESYLATE

1 RESERPINE RESERPINE

2 RESTASIS CYCLOSPORINE QL

3 RESTORIL TEMAZEPAM

3 RETROVIR ZIDOVUDINE QL

3 REVATIO SILDENAFIL CITRATE QL

3 REVIA NALTREXONE HCL

2 REVLIMID LENALIDOMIDE PA QL

2 REYATAZ ATAZANAVIR SULFATE

2 RHEUMATREX METHOTREXATE SODIUM

1 RIBASPHERE RIBAVIRIN

1 RIBAVIRIN RIBAVIRIN

3 RIFADIN RIFAMPIN

2 RIFAMATE RIFAMPIN/ISONIAZID

1 RIFAMPIN RIFAMPIN

2 RIGHTEST GL300 LANCETS LANCETS

2 RIOMET METFORMIN HCL

2 RISEDRONATE RISEDRONATE

3 RISPERDAL RISPERIDONE QL

3 RISPERDAL M-TAB RISPERIDONE QL

2 RISPERIDONE ODT RISPERIDONE QL

1 RISPERIDONE TABLET RISPERIDONE QL

3 RITALIN METHYLPHENIDATE HCL QL

3 RITALIN LA METHYLPHENIDATE HCL QL

1 RIVASTIGMINE RIVASTIGMINE TARTRATE

1 RIZATRIPTAN RIZATRIPTAN BENZOATE QL

3 ROBAXIN METHOCARBAMOL

3 ROBAXIN-750 METHOCARBAMOL

3 ROCALTROL CALCITRIOL

Excluded ROCHE (ACCU-CHEK) TEST STRIPS/BLOOD GLUCOSE TEST STRIPS

1 ROPINIROLE HCL ROPINIROLE HCL

1 ROSADAN METRONIDAZOLE

3 ROWASA MESALAMINE W/CLEANSING WIPES

3 ROXICODONE OXYCODONE HCL

Excluded ROZEREM RAMELTEON

3 RYTHMOL PROPAFENONE HCL

3 RYTHMOL SR PROPAFENONE HCL

Excluded SABRIL VIGABATRIN

2 SAFESNAP INSULIN SYRINGE SYR,NDL,INS,SAFE,DISP UN,0.3ML

2 SAFETY LANCETS LANCETS

2 SAFETY SEAL LANCETS LANCETS


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 SAFETYGLIDE INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.5 ML

2 SAFETYGLIDE SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 SAFETY-LET LANCETS

Excluded SAIZEN SOMATROPIN

3 SALAGEN PILOCARPINE HCL

2 SALICYLIC ACID FOAM SALICYCLIC ACID

1 SALICYLIC ACID GEL SALICYLIC ACID

2 SALICYLIC ACID/CERAMIDES KIT, CLEANSER & CREAM SALICYCLIC ACID

VC SALSALATE SALSALATE

2 SANDIMMUNE CYCLOSPORINE

3 SANDOSTATIN OCTREOTIDE ACETATE

Excluded SARILUMAB SARILUMAB

2 SAVELLA MILNACIPRAN HCL

3 SCALACORT HYDROCORTISONE

2 SCALACORT DK HYDROCORT/SAL ACID/SULF/SHMP#1

3 SECTRAL ACEBUTOLOL HCL

Excluded SEEBRI NEOHALER GLYCOPYRROLATE

1 SELEGILINE HCL SELEGILINE HCL

1 SELENIUM SULFIDE SELENIUM SULFIDE

2 SELZENTRY MARAVIROC PA

1 SE-NATAL 19 PNV119/IRON FUMARATE/FA/DSS

2 SEREVENT DISKUS SALMETEROL XINAFOATE QL

3 SEROQUEL QUETIAPINE FUMARATE QL

2 SEROQUEL XR QUETIAPINE FUMARATE QL ST

1 SERTRALINE SERTRALINE

3 SFROWASA MESALAMINE

1 SHAROBEL NORETHINDRONE

Excluded SILAPAK TRIAMCINOLONE 0.1%/DIMETHICONE 5%

Excluded SILAZONE TRIAMCINOLONE 0.1%/DIMETHICONE 5%

1 SILDENAFIL SILDENAFIL CITRATE QL

Excluded SILIQ BRODALUMAB

3 SILVADENE SILVER SULFADIAZINE

1 SILVER SULFADIAZINE SILVER SULFADIAZINE

2 SIMBRINZA BRINZOLAMIDE/BRIMONIDINE TART

2 SIMCOR NIACIN/SIMVASTATIN QL ST

Excluded SIMPONI GROLIMUMAB

VC SIMVASTATIN SIMVASTATIN

Excluded SINELEE PATCH CAPSAICIN-MENTHOL

3 SINEMET 10-100 CARBIDOPA/LEVODOPA



3 SINEMET CR CARBIDOPA/LEVODOPA

2 SINGLE-LET LANCETS

3 SINGULAIR MONTELUKAST SODIUM

1 SIROLIMUS SIROLIMUS

2 SIVEXTRO TEDIZOLID PHOSPHATE PA

3 SKELAXIN METAXALONE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 SMART SENSE LANCETS

2 SMART SENSE LANCETS LANCETS

2 SMARTEST LANCET LANCETS

1 SODIUM CHLORIDE SODIUM CHLORIDE FOR INHALATION

1 SODIUM FLUORIDE SODIUM FLUORIDE

1 SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE

1 SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE

1 SODIUM SULFACETAMIDE SULFACETAMIDE SODIUM

2 SOFT TOUCH LANCETS

2 SOFTCLIX LANCETS

2 SOLTAMOX TAMOXIFEN CITRATE

2 SOLUS V2 LANCETS

2 SOLUS V2 LANCETS LANCETS

3 SOMA CARISOPRODOL

2 SOMAVERT PEGVISOMANT

3 SONATA ZALEPLON QL

3 SORIATANE ACITRETIN

1 SORINE SOTALOL HCL

1 SOTALOL SOTALOL HCL

1 SOTALOL AF SOTALOL HCL

2 SOVALDI SOFOSBUVIR PA

2 SPINOSAD SUSPENSION SPINOSAD

2 SPIRIVA TIOTROPIUM BROMIDE QL

2 SPIRIVA RESPIMAT TIOTROPIUM BROMIDE QL

1 SPIRONOLACTONE SPIRONOLACTONE

3 SPORANOX ITRACONAZOLE

1 SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL

2 SPRYCEL DASATINIB PA QL

1 SPS SODIUM POLYSTYRENE SULFONATE

1 SRONYX LEVONORGESTREL-ETHIN ESTRADIOL

1 SSD SILVER SULFADIAZINE

1 SSKI POTASSIUM IODIDE

3 STALEVO 50, 75, 100, 125,150, 200 CARBIDOPA/LEVODOPA/ENTACAPONE

3 STARLIX NATEGLINIDE

1 STAVUDINE STAVUDINE QL

Excluded STAXYN VARDENAFIL

3 STELARA USEKINUMAB PA

Excluded STENDRA AVANAFIL

2 STERILANCE TL LANCETS

2 STIVARGA REGORAFENIB PA QL

2 STRATTERA ATOMOXETINE HCL QL

2 STRIBILD ELVITEGR/COBICIST/EMTRIC/TENOF QL

2 SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL PA

Excluded SUBSYS FENTANYL CITRATE

1 SUCRALFATE SUCRALFATE

2 SULFACETAMIDE 10% SHAMPOO, WASH, CLEANSING GEL SULFACETAMIDE SODIUM

1 SULFACETAMIDE LOTION SULFACETAMIDE SODIUM


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM

1 SULFACETAMIDE/PREDNISOLONE SULFACETAMIDE/PREDNISOLONE SP

2 SULFACETAMIDE/SULFUR SUSPENSION SULFACETAMIDE SODIUM

1 SULFADIAZINE SULFADIAZINE

1 SULFAMETHOXAZOLE-TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM

1 SULFASALAZINE DR SULFASALAZINE

1 SULFATRIM SULFAMETHOXAZOLE/TRIMETHOPRIM

1 SULFAZINE SULFASALAZINE

1 SULFAZINE EC SULFASALAZINE

1 SULINDAC SULINDAC

2 SUMATRIPTAN NASAL SPRAY SUMATRIPTAN

2 SUMATRIPTAN SUBCUTANEOUS PEN INJECTOR SUMATRIPTAN

1 SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE QL

1 SUMATRIPTAN TABLET SUMATRIPTAN QL

2 SUPER THIN LANCETS LANCETS

2 SUPRAX CEFIXIME

2 SURE COMFORT NEEDLES, INSULIN DISPOSABLE

2 SURE COMFORT LANCETS LANCETS

2 SURE-FINE PEN NEEDLES NEEDLES, INSULIN DISPOSABLE

2 SURE-JECT INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 SURE-LANCE LANCETS

2 SURE-TOUCH LANCETS

2 SUSTIVA EFAVIRENZ

2 SUTENT SUNITINIB MALATE PA QL

1 SYEDA ETHINYL ESTRADIOL/DROSPIRENONE ST

3 SYMAX HYOSCYAMINE SULFATE

3 SYMAX-SL HYOSCYAMINE SULFATE

3 SYMAX-SR HYOSCYAMINE SULFATE

Excluded SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE

3 SYMBYAX OLANZAPINE/FLUOXETINE HCL QL

2 SYMLINPEN 120 PRAMLINTIDE ACETATE

2 SYMLINPEN 60 PRAMLINTIDE ACETATE

3 SYNALAR FLUOCINOLONE ACETONIDE

2 SYNTHROID LEVOTHYROXINE SODIUM

2 TABLOID THIOGUANINE

1 TACROLIMUS TACROLIMUS ST

2 TAFINLAR DABRAFENIB MESYLATE PA

2 TAMIFLU OSELTAMIVIR PHOSPHATE QL

1 TAMOXIFEN CITRATE TAMOXIFEN CITRATE

1 TAMSULOSIN HCL TAMSULOSIN HCL

Excluded TANZEUM ALBIGLUTIDE

3 TAPAZOLE METHIMAZOLE

2 TARCEVA ERLOTINIB HCL PA QL

2 TARGRETIN BEXAROTENE PA

1 TARINA FE NORETHINDRONE-E.ESTRADIOL-IRON

2 TASIGNA NILOTINIB HCL PA QL

2 TAZORAC TAZAROTENE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 TAZTIA XT DILTIAZEM HCL

2 TECFIDERA DIMETHYL FUMARATE PA

2 TECHLITE LANCETS LANCETS

3 TEGRETOL CARBAMAZEPINE

2 TEGRETOL XR CARBAMAZEPINE

2 TELCARE LANCETS

2 TELMISARTAN/HCTZ COMBINATION TABLET

VC TEMAZEPAM TEMAZEPAM

3 TEMODAR TEMOZOLOMIDE PA

3 TEMOVATE CLOBETASOL PROPIONATE

3 TEMOVATE EMOLLIENT CLOBETASOL PROPIONATE/EMOLL

1 TEMOZOLOMIDE TEMOZOLOMIDE PA

1 TENCON BUTALBITAL/ACETAMINOPHEN

3 TENEX GUANFACINE HCL

3 TENORETIC 100 ATENOLOL/CHLORTHALIDONE

3 TENORETIC 50 ATENOLOL/CHLORTHALIDONE

3 TENORMIN ATENOLOL

1 TERAZOSIN HCL TERAZOSIN HCL

1 TERBINAFINE HCL TERBINAFINE HCL

1 TERBUTALINE SULFATE TERBUTALINE SULFATE

1 TERFINAFINE TERFINAFINE

2 TERUMO INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.3 ML

Excluded TESTIM TESTOSTERONE

1 TESTOSTERONE TESTOSTERONE PA

1 TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE PA

1 TESTOSTERONE ENANTHATE TESTOSTERONE ENANTHATE PA

2 TESTRED METHYLTESTOSTERONE

1 TETRACYCLINE HCL TETRACYCLINE HCL

Excluded TEVETEN EPROSARTAN

Excluded TEVETEN HCT EPROSARTAN/HYDROCHLOROTHIAZIDE

Excluded TEV-TROPIN SOMATROPIN

2 TEXACORT HYDROCORTISONE

2 THALOMID THALIDOMIDE PA QL

2 THEO-24 THEOPHYLLINE ANHYDROUS

1 THEOCHRON THEOPHYLLINE ANHYDROUS

1 THEOPHYLLINE THEOPHYLLINE ANHYDROUS

1 THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS

1 THERAPEUTIC VITAMIN W-MINERALS MULTIVITAMINS WITH MIN NO.7/FA

3 THERMAZENE SILVER SULFADIAZINE

2 THIN LANCETS LANCETS

2 THINPRO INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.3 ML

1 THIORIDAZINE HCL THIORIDAZINE HCL

1 THIOTHIXENE THIOTHIXENE

1 THRIVITE 19 PNV119/IRON FUMARATE/FA/DSS

3 TIAZAC DILTIAZEM HCL

2 TIKOSYN DOFETILIDE

1 TIMOLOL MALEATE TIMOLOL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 TIMOLOL TABLET TIMOLOL

3 TIMOPTIC TIMOLOL MALEATE

3 TIMOPTIC-XE TIMOLOL MALEATE

2 TINADAZOLE TABLET TINADAZOLE

Excluded TIROSINT LEVOTHYROXINE

2 TIVICAY DOLUTEGRAVIR SODIUM PA

Excluded TIVORBEX INDOMETHACIN

2 TIZANIDINE CAPSULE TIZANIDINE HCL

1 TIZANIDINE TABLET TIZANIDINE HCL

1 TL GARD RX CYANOCOBALAMIN/FA/PYRIDOXINE

3 TOBI TOBRAMYCIN IN 0.225% NACL PA

2 TOBI PODHALER TOBRAMYCIN PA

3 TOBRADEX TOBRAMYCIN/DEXAMETHASONE

1 TOBRAMYCIN TOBRAMYCIN IN 0.225% NACL PA

1 TOBRAMYCIN-DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE

3 TOBREX TOBRAMYCIN

3 TOFRANIL IMIPRAMINE HCL

2 TOLAZAMIDE 500 MG TABLET TOLAZAMIDE

1 TOLBUTAMIDE TOLBUTAMIDE

2 TOLMETIN SODIUM TABLET TOLMETIN SODIUM TABLET

2 TOLTERODINE TOLTERODINE TARTRATE

2 TOLTERODINE ER TOLTERODINE TARTRATE ST

3 TOPAMAX TOPIRAMATE

2 TOPCARE CLICKFINE NEEDLES, INSULIN DISPOSABLE

2 TOPCARE ULTRA COMFORT SYRING W-NDL,DISP,INSUL,0.3 ML

2 TOPCARE UNIVERSAL THIN LANCET LANCETS

3 TOPICORT DESOXIMETASONE

1 TOPIRAMATE TOPIRAMATE

3 TOPROL XL METOPROLOL SUCCINATE

1 TORSEMIDE TORSEMIDE

2 TOUJEO SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG QL

2 TOVIAZ FESOTERODINE FUMARATE ST

2 TRACLEER BOSENTAN PA

2 TRADJENTA LINAGLIPTIN QL

1 TRAMADOL HCL TRAMADOL HCL

1 TRAMADOL HCL-ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN

3 TRANDATE LABETALOL HCL

1 TRANDOLAPRIL TRANDOLAPRIL

3 TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM

1 TRANYLCYPROMINE SULFATE TRANYLCYPROMINE SULFATE

2 TRAVATAN Z TRAVOPROST QL

2 TRAVOPROST DROPS TRAVOPROST QL

1 TRAZODONE HCL TRAZODONE HCL

Excluded TRESIBA INSULIN DEGLUDEC INJECTION

2 TRETINOIN TRETINOIN

1 TRETINOIN 0.05% CREAM/EMOLLIENT CREAM TRETINOIN

2 TRETINOIN 0.05% GEL TRETINOIN


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 TRETINOIN 0.1%/0.04% GEL MICRO TUBE, GEL MICRO WITH PUMP TRETINOIN

1 TRETINOIN 0.1/0.025% CREAM/GEL TRETINOIN

2 TREXALL METHOTREXATE SODIUM

Excluded TREXIMET SUMATRIPTAN-NAPROXEN

1 TRIADVANCE PRENATAL VIT 15/IRON CB/FA/DSS

2 TRIAMCINOLONE 0.147% MG/G TOPICAL SPRAY [MEDIUM] TRIAMCINOLONE

VC TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE QL

2 TRIAMCINOLONE ACETONIDE 0.05% ABSORBASE OINTMENT[MEDIUM] TRIAMCINOLONE

2 TRIAMCINOLONE ACETONIDE/DIMETHICONE 0.1%-5% KIT TRIAMCINOLONE

2 TRIAMCINOLONE NASAL SPRAY TRIAMCINOLONE

1 TRIAMTERENE-HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID

1 TRIANEX TRIAMCINOLONE ACETONIDE

1 TRIAZOLAM TRIAZOLAM

3 TRICOR FENOFIBRATE NANOCRYSTALLIZED

1 TRIDERM TRIAMCINOLONE ACETONIDE

1 TRI-ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL

1 TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL

1 TRIFLURIDINE TRIFLURIDINE

2 TRIGLIDE FENOFIBRATE NANOCRYSTALLIZED ST

1 TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL

3 TRILEPTAL OXCARBAZEPINE

1 TRI-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL

1 TRILYTE WITH FLAVOR PACKETS SODIUM CHLORIDE/NAHCO3/KCL/PEG

2 TRIMETHOBENZAMIDE CAPSULE

1 TRIMETHOPRIM TRIMETHOPRIM

1 TRINATAL GT PRENATAL VIT 16/IRON CB/FA/DSS

1 TRINESSA NORGESTIMATE-ETHINYL ESTRADIOL

3 TRI-NORINYL NORETHINDRONE-ETHINYL ESTRAD ST

1 TRIPLE-VITAMIN W-FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE

1 TRI-PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL

1 TRI-SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL

2 TRIUMEQ ABACAVIR/DOLUTEGRAVIR/LAMIVUDI QL

1 TRI-VIT WITH FLUORIDE-IRON FLUORIDE/IRON/VIT A,C&D

1 TRI-VITAMIN WITH FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE

1 TRIVORA-28 LEVONORGESTREL-ETHIN ESTRADIOL

3 TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE PA

2 TROSPIUM TROSPIUM

2 TRUEPLUS INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.5 ML

2 TRUEPLUS LANCETS LANCETS

2 TRULICITY DULAGLUTIDE QL ST

3 TRUSOPT DORZOLAMIDE HCL

2 TRUVADA EMTRICITABINE/TENOFOVIR QL

Excluded TUDORZA ACLIDINIUM BROMIDE

3 TUSNEL C P-EPHED HCL/CODEINE/GUAIFEN

3 TUSSIGON HYDROCODONE BIT/HOMATROP ME-BR

3 TUSSIONEX HYDROCODONE/CHLORPHEN P-STIREX


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 TYBOST COBICISTAT PA

2 TYKERB LAPATINIB DITOSYLATE PA

3 TYLENOL-CODEINE NO.3 ACETAMINOPHEN WITH CODEINE

3 TYLENOL-CODEINE NO.4 ACETAMINOPHEN WITH CODEINE

2 TYZEKA TELBIVUDINE

1 U-CORT HYDROCORTISONE ACETATE/UREA

2 ULORIC FEBUXOSTAT QL ST

2 ULTICARE SYRNGE&NEEDLE,INSLN,1ML&SHARPS

2 ULTILET BASIC LANCETS

2 ULTILET CLASSIC LANCETS

2 ULTILET INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML

2 ULTILET LANCETS LANCETS

2 ULTILET PEN NEEDLE NEEDLES, INSULIN DISPOSABLE

2 ULTILET SAFETY LANCETS

2 ULTRA COMFORT SYRING W-NDL,DISP,INSUL,0.5 ML

2 ULTRA THIN LANCETS LANCETS

2 ULTRA THIN PLUS LANCETS

2 ULTRA THIN PLUS LANCETS LANCETS

2 ULTRALANCE LANCETS

3 ULTRAM TRAMADOL HCL

2 ULTRA-THIN II SYRING W-NDL,DISP,INSUL,0.5 ML

2 ULTRATLC LANCETS LANCETS

3 ULTRAVATE HALOBETASOL PROPIONATE

2 UNIFINE PENTIPS NEEDLES, INSULIN DISPOSABLE

2 UNIFINE PENTIPS PLUS PEN NEEDLE, DIABETIC,DISP UNIT

2 UNILET COMFORTOUCH LANCETS

2 UNILET EXCELITE LANCETS

2 UNILET EXCELITE II LANCETS

2 UNILET GP LANCET LANCETS

2 UNILET LANCET LANCETS

2 UNILET LANCETS LANCETS

2 UNISTIK 3 LANCETS

2 UNISTIK 3 EXTRA LANCETS

2 UNISTIK CZT LANCETS

2 UNISTIK SAFETY LANCETS

2 UNITHROID LEVOTHYROXINE SODIUM

2 UNIVERSAL 1 LANCETS

1 UR N-C MTH/ME BLUE/SOD PHOS/PHEN/HYOS

3 URECHOLINE BETHANECHOL CHLORIDE

2 URETRON D-S MTH/ME BLUE/SOD PHOS/PHEN/HYOS

2 URIN D.S. MTH/ME BLUE/SOD PHOS/PHEN/HYOS

3 UROXATRAL ALFUZOSIN HCL

3 URSO URSODIOL

3 URSO FORTE URSODIOL

1 URSODIOL URSODIOL

Excluded UTIBRON INDACATEROL/GLYCOPYRROLATE

2 VAGIFEM ESTRADIOL


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 VALACYCLOVIR VALACYCLOVIR HCL

2 VALCHLOR MECHLORETHAMINE HCL PA

2 VALIUM DIAZEPAM

1 VALPROIC ACID VALPROIC ACID (AS SODIUM SALT)

1 VALSARTAN VALSARTAN

1 VALSARTAN-HYDROCHLOROTHIAZIDE COMBINATION TABLET VALSARTAN/HYDROCHLOROTHIAZIDE

3 VALTREX VALACYCLOVIR HCL

3 VANCOCIN HCL VANCOMYCIN HCL QL

1 VANCOMYCIN HCL VANCOMYCIN HCL QL

2 VANDAZOLE METRONIDAZOLE

2 VANISHPOINT SYRINGE & NEEDLE,INSULIN,1 ML

3 VANOS FLUOCINONIDE

2 VANOXIDE-HC BENZOYL PEROXIDE/HYDROCORTISON

2 VASCEPA ICOSAPENT ETHYL QL

3 VASERETIC ENALAPRIL/HYDROCHLOROTHIAZIDE

3 VASOTEC ENALAPRIL MALEATE

1 V-C FORTE MULTIVITAMINS WITH MIN NO.7/FA

3 VECTICAL CALCITRIOL ST

1 VELIVET DESOGESTREL-ETHINYL ESTRADIOL

Excluded VELTIN CLINDAMYCIN/TRETINOIN

1 VENLAFAXINE ER CAPSULE VENLAFAXINE

2 VENLAFAXINE ER TABLET VENLAFAXINE

1 VENLAFAXINE HCL VENLAFAXINE

1 VENLAFAXINE HCL ER VENLAFAXINE

2 VENTOLIN HFA ALBUTEROL SULFATE

Excluded VERAMYST FLUTICASONE FUROATE

1 VERAPAMIL ER VERAPAMIL HCL

1 VERAPAMIL ER PM VERAPAMIL HCL

1 VERAPAMIL HCL VERAPAMIL HCL

VC VERAPAMIL SR VERAPAMIL HCL

3 VERELAN VERAPAMIL HCL

3 VERELAN PM VERAPAMIL HCL

2 VESICARE SOLIFENACIN SUCCINATE ST

1 VESTURA ETHINYL ESTRADIOL/DROSPIRENONE ST

3 VFEND VORICONAZOLE

2 VIAGRA (if covered, see your Benefit Summary) SILDENAFIL CITRATE QL

3 VIBRAMYCIN DOXYCYCLINE HYCLATE QL ST

1 VIC-FORTE MULTIVITAMINS WITH MIN NO.7/FA

1 VICODIN HP HYDROCODONE/ACETAMINOPHEN QL

2 VICTOZA 2-PAK LIRAGLUTIDE QL ST

2 VICTOZA 3-PAK LIRAGLUTIDE QL ST

2 VIDEX DIDANOSINE QL

3 VIDEX EC DIDANOSINE QL

Excluded VIEKIRA PAK

OMBITASVIR/PARITAPREVIR/RITONAVIR TABLETS CO-PACKAGED WITH DASABUVIR

TABLETS

2 VIGAMOX MOXIFLOXACIN HCL

Excluded VIMOVO NAPROXEN/ESOMEPRAZOLE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR1 VINATE GT PRENATAL VIT 16/IRON CB/FA/DSS

1 VINATE ULTRA PRENATAL VIT 18/IRON CB/FA/DSS

1 VIORELE DESOG-E.ESTRADIOL/E.ESTRADIOL

2 VIRACEPT NELFINAVIR MESYLATE

3 VIRAMUNE NEVIRAPINE QL

3 VIRAMUNE XR NEVIRAPINE

2 VIRAZOLE RIBAVIRIN

2 VIREAD TENOFOVIR DISOPROXIL FUMARATE QL

3 VIROPTIC TRIFLURIDINE

1 VIRT-ADVANCE PRENATAL VIT 15/IRON CB/FA/DSS

1 VIRTUSSIN AC GUAIFENESIN/CODEINE PHOSPHATE

1 VIRTUSSIN DAC P-EPHED HCL/CODEINE/GUAIFEN

1 VIRT-VITE GT PRENATAL VIT 16/IRON CB/FA/DSS

3 VISTARIL HYDROXYZINE PAMOATE

1 VITAMIN D2 ERGOCALCIFEROL (VITAMIN D2)

1 VITAMINS A,C,D & FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE

2 VITEKTA ELVITEGRAVIR QL ST

3 VIVELLE-DOT ESTRADIOL QL

Excluded VOGELXO TESTOSTERONE

2 VOLTAREN DICLOFENAC SODIUM

3 VOLTAREN-XR DICLOFENAC SODIUM

2 VORICONAZOLE VORICONAZOLE

2 VOTRIENT PAZOPANIB HCL PA QL

2 VYVANSE LISDEXAMFETAMINE DIMESYLATE QL ST

1 WARFARIN SODIUM WARFARIN SODIUM

2 WELCHOL COLESEVELAM HCL

3 WELLBUTRIN BUPROPION HCL

3 WELLBUTRIN SR BUPROPION HCL

3 WELLBUTRIN XL BUPROPION HCL

1 WERA NORETHINDRONE-ETHINYL ESTRAD

1 WESTHROID THYROID,PORK

Excluded WHYTEDERMTD PAK TRIAMCINOLONE 0.1%/DIMETHICONE 5%

1 WP THYROID THYROID,PORK

3 XALATAN LATANOPROST

2 XALKORI CRIZOTINIB PA QL

3 XANAX ALPRAZOLAM

2 XARELTO RIVAROXABAN QL

3 XELODA CAPECITABINE PA QL

Excluded XENAZINE TETRABENAZINE

2 XIFAXAN RIFAXIMIN QL ST

Excluded XIGDUO XR DAPAGLIFLOZIN/METFORMIN

3 XODOL 10-300 HYDROCODONE/ACETAMINOPHEN QL

Excluded XOPENEX HFA LEVALBUTEROL

2 XTANDI ENZALUTAMIDE PA QL

1 XULANE NORELGESTROMIN/ETHIN.ESTRADIOL QL

3 XYZAL LEVOCETIRIZINE DIHYDROCHLORIDE

3 YASMIN 28 ETHINYL ESTRADIOL/DROSPIRENONE ST


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR3 YAZ ETHINYL ESTRADIOL/DROSPIRENONE ST

2 ZAFIRLUKAST ZAFIRLUKAST

1 ZALEPLON ZALEPLON QL

3 ZANAFLEX TIZANIDINE HCL

3 ZANTAC RANITIDINE HCL

1 ZARAH ETHINYL ESTRADIOL/DROSPIRENONE ST

2 ZARONTIN ETHOSUXIMIDE

3 ZEBETA BISOPROLOL FUMARATE

2 ZELBORAF VEMURAFENIB PA QL

3 ZEMPLAR PARICALCITOL

1 ZENATANE ISOTRETINOIN

3 ZENPEP LIPASE/PROTEASE/AMYLASE

2 ZENZEDI DEXTROAMPHETAMINE SULFATE QL ST

3 ZERIT STAVUDINE QL

3 ZESTORETIC LISINOPRIL/HYDROCHLOROTHIAZIDE

3 ZESTRIL LISINOPRIL

2 ZETIA EZETIMIBE QL

Excluded ZETONNA CICLESONIDE

3 ZIAC BISOPROLOL FUMARATE/HCTZ

3 ZIAGEN ABACAVIR SULFATE QL

2 ZIANA CLINDAMYCIN/TRETINOIN

1 ZIDOVUDINE ZIDOVUDINE QL

Excluded ZINBRYTA DACLIZUMAB

Excluded ZIOPTAN TAFLUPROST OPTHALMIC

2 ZIPRASIDONE HCL ZIPRASIDONE HCL QL

Excluded ZIPSOR DICLOFENAC

2 ZIRGAN GANCICLOVIR

3 ZITHROMAX AZITHROMYCIN

3 ZITHROMAX TRI-PAK AZITHROMYCIN

2 ZMAX AZITHROMYCIN

3 ZOCOR SIMVASTATIN ST

3 ZOFRAN ONDANSETRON HCL

3 ZOFRAN ODT ONDANSETRON

2 ZOLINZA VORINOSTAT

2 ZOLMITRIPTAN ZOLMITRIPTAN QL ST

2 ZOLMITRIPTAN ODT ZOLMITRIPTAN QL ST

3 ZOLOFT SERTRALINE HCL

2 ZOLPIDEM ER TABLET ZOLPIDEM TARTRATE QL

1 ZOLPIDEM TABLET ZOLPIDEM TARTRATE

1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE QL

1 ZOLPIDEM TARTRATE ER ZOLPIDEM TARTRATE QL ST

Excluded ZOLPIMIST ZOLPIDEM TARTRATE

Excluded ZOMACTON SOMATROPIN (rDNA ORIGIN)

3 ZOMIG ZOLMITRIPTAN QL ST

3 ZOMIG ZMT ZOLMITRIPTAN QL ST

3 ZONEGRAN ZONISAMIDE

1 ZONISAMIDE ZONISAMIDE


AUTHORIZATION

QUANTITY LIMIT

INDICATOR

STEP THERAPY

INDICATOR2 ZORTRESS EVEROLIMUS

Excluded ZORVOLEX DICLOFENAC

1 ZOVIA 1-35E ETHYNODIOL D-ETHINYL ESTRADIOL

1 ZOVIA 1-50E ETHYNODIOL D-ETHINYL ESTRADIOL

3 ZOVIRAX ACYCLOVIR

Excluded ZUBSOLV BUPRENORPHINE/NALOXONE

Excluded ZUPLENZ ONDANSETRON

2 ZYDELIG IDELALISIB PA

2 ZYKADIA CERITINIB PA

2 ZYLET TOBRAMYCIN/LOTEPRED ETAB

3 ZYLOPRIM ALLOPURINOL

3 ZYMAXID GATIFLOXACIN

3 ZYPREXA OLANZAPINE QL

2 ZYTIGA ABIRATERONE ACETATE PA QL

3 ZYVOX LINEZOLID PA

prior quantity limit step therapy tier brand name …

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