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Blue Rx Complete Formulary ©2016 Wellmark, Inc. 1

Blue Rx Complete Formulary

EFFECTIVE 10/01/2016

INTRODUCTION

The Blue Rx Complete formulary is a list of drugs covered under your

pharmacy benefit and developed to serve as a guide for physicians,

pharmacists, healthcare professionals and members in the selection of

cost-effective drug therapy. Wellmark recognizes that drug therapy is an

integral part of effective health management. The vast availability of

drug options, however, warrants a reasonable program for drug selection

and use.

Wellmark continually reviews new and existing drugs to ensure the

formulary remains responsive to the needs of our members and health

professionals. Criteria used to evaluate drug selection for the formulary

includes, but is not limited to safety, efficacy and cost-effectiveness data,

as well as comparison of relevant benefits of similar prescription or over-

the-counter (OTC) agents while minimizing potential duplications.

The formulary is a continually reviewed and modified document that

represents covered drugs under your pharmacy benefit. This dynamic

process does not allow this document to be completely accurate at all

times. To accommodate regular changes, an updated electronic version

of this formulary is available online at www.Wellmark.com. Wellmark

welcomes your input and feedback on the information provided in this

document.

FORMULARY OVERVIEW

The Blue Rx Complete formulary is continually changing to reflect new

advances in drug treatment therapies and current practices of Wellmark

providers. Due to the rapidly changing environment, this process ensures

appropriate formulary review and tier placement. To continue to provide

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sustainable pharmacy benefits and access to needed cost-effective

treatments, concentrated evaluation and analysis of drug products in

formularies is accomplished through this process.

Wellmark has developed the Pharmacy and Therapeutics Committee

(P&T) to ensure all drugs in the Blue Rx Complete formulary and new

drugs approved by the United States Food and Drug Administration

(FDA) are reviewed by licensed physicians actively practicing medicine in

Iowa and South Dakota. In addition, the process allows P&T members

the opportunity to receive evidence-based clinical data and make clinical

recommendations for formulary placement and utilization management.

The entire Wellmark formulary is reviewed annually by P&T including all

new drugs approved by the FDA.

The P&T includes licensed physicians and pharmacists. These clinicians

serve in an evaluation, education and advisory capacity to the Wellmark

Pharmacy program specific to the coverage and limitations of drugs on

the Wellmark formularies. Through review and discussion, P&T votes

whether the drug or drug class is therapeutically unique, similar or

inferior to existing treatment options. In addition, the P&T makes

utilization management recommendations to Wellmark for consideration

when there are therapeutically interchangeable alternatives.

The P&T meets quarterly to evaluate drugs requested for addition to the

Wellmark formularies, reviews existing drugs in the Wellmark formularies

and establishes recommendations for utilization management.

HOW TO READ THE FORMULARY

All drugs are listed by their generic names and/or most common

proprietary (brand) name. Specific drug listings may be accessed either

by generic (in lowercase) or brand name (in uppercase) and by

therapeutic drug tier. Any drug not found in this formulary listing, or any

formulary updates published by Wellmark, shall be considered excluded

from your benefit.

Once the product is located, the following items can be viewed:


Drug Tier: Drugs are categorized within tiers on the formulary. Each tier

is assigned a cost, which is determined by the member's pharmacy

benefit plan.

Specialty Drugs (SP-P): Specialty drugs are high-cost injectable,

infused, oral or inhaled drugs for the ongoing treatment of a chronic

condition. These drugs generally require close supervision and

monitoring of the patient's drug therapy. Specialty drugs may be

categorized within tiers on the formulary or as drugs covered under your

medical benefit.

Specialty Drugs Preferred (SP-P): Drugs in this category will

process with the preferred specialty drug cost-share.

Specialty Drugs Non-Preferred (SP-NP): Drugs in this category

will process with the non-preferred specialty cost-share, and will

have a higher cost share than preferred specialty drugs.

Specialty pharmacies specialize in the delivery and clinical management

of specialty drugs. Wellmark has two preferred specialty pharmacy

providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy

Solutions. You can find more information about their services at

www.Wellmark.com.

Drug Name: This lists the generic name for the product (lowercase) OR

the brand name or common reference name for the product

(UPPERCASE).

Requirements/Limits: This lists Wellmark Pharmacy programs that

may impact a particular drug or class of drugs and are described below:

Prior Authorization (PA): This indicates a drug requires prior

authorization before it is covered under your benefit. Your health

care provider will need to contact our Pharmacy program at 1-800-

http://www.wellmark.com/


600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6

p.m. CST

Prior authorization review of prescribing guidelines will be evaluated

utilizing the established drug review criteria approved by Wellmark.

If the request does not meet the approved criteria, the request will

not be approved and alternative therapy may be recommended

along with the proper course of alternative action. A list of edits

recommended by Wellmark is available upon request. Members

should call Wellmark Customer Service at the number listed on the

back of their ID card if they have questions regarding their specific

coverage.

Medical Necessity Prior Authorization (MN-PA): This indicates

a drug requires prior authorization before it is covered under your

benefit. Your health care provider will need to contact our Pharmacy

program at 1-800-600-8065. Hours of operation are Monday -

Friday: 8 a.m. to 6 p.m. CST

The intent of formulary medical necessity prior authorization is to

confirm the appropriate coverage of the target drugs when evidence

is provided documenting a trial and failure of the preferred

formulary alternatives or a clinical reason such as expected adverse

reaction or contraindication that prevents the patient from trying

the formulary alternatives. These criteria apply to all medications

subject to formulary medical necessity not otherwise managed

through drug specific criteria. Members should call Wellmark

Customer Service at the number listed on the back of their ID card

if they have questions regarding their specific coverage.

Quantity Limits (QL): Wellmark typically covers a 30-day supply

for prescriptions per co-pay. Some drugs, however, have a quantity

limit. Amounts over the specified quantity limits are not a covered

benefit. Quantity limits are in place to ensure the drug is being used

correctly and other treatments are not appropriate. Most people

would not need to take these drugs more often than what Wellmark

allows.

No special steps are necessary by the physician or member to have

these drugs covered as long as the drugs prescribed do not exceed

quantity limits. A few drugs may also require prior authorization


(for example, Viagra). If you require one of these drugs in a larger

quantity than is allowed, your physician may make a special

request for coverage. Your physician may be asked to provide

details about your medical condition and treatment plan. After

reviewing the information, coverage will be evaluated based on

medical necessity.

Your benefits certificate, coverage manual, or policy has specific

information about your plan's prior authorization requirements.

Preventive Drugs (PV): Preventive drugs are defined by the

Internal Revenue Service. Preventive drugs are prescribed to

prevent the occurrence of a disease or condition with risk factors

such as high blood pressure, high cholesterol, diabetes, asthma,

heart attack and stroke, or to prevent the recurrence of the disease

or condition for individuals who have recovered. Preventive drugs

do not include drugs used to treat an existing illness, injury or

condition.

For some pharmacy plans that require you to pay a certain amount

before the plan coverage begins, preventive drugs may be covered

before you reach that amount. To be sure, you should read your

enrollment information to see how preventive drugs are covered

specific to your plan.

Generic Available (GA): Indicates a generic equivalent is

available for a brand name drug. In most cases, when you purchase

a brand name drug that has an FDA-approved "A"-rated generic

equivalent, Wellmark will pay only what it would have paid for the

equivalent generic drug. You will be responsible for your payment

obligation for the equivalent generic drug and any remaining cost

difference up to the maximum allowed fee for the brand name drug

HEALTH CARE REFORM PREVENTIVE DRUGS

Preventive drugs with an "A" or "B" rating in the current

recommendations of the United States Preventive Services Task Force

(USPSTF) and immunizations as recommended by the Advisory

Committee on Immunization Practices of the Centers for Disease Control

and Prevention are not associated with any cost share for members on

plans with this benefit.


A complete list of recommendations and guidelines related to preventive

services can be found at Healthcare.gov. Recommended preventive items

and services are subject to change and are subject to medical

management.

BENEFIT COVERAGE AND LIMITATIONS

This printed formulary does not define benefit coverage and limitations.

Many members have specific benefit inclusions, exclusions, copayments

or a lack of coverage, which are not reflected in the Blue Rx Essentials

formulary. Members should contact their Plan Sponsor or Wellmark

Customer Service at the number on the back of their ID card if they have

questions regarding their coverage. Please note that the formulary

process is evolutionary and changes can occur throughout the year. The

following topics may or may not be applicable depending on the

parameters of your specific benefits.

FORMULARY EXCEPTION PROCESS

Drugs not included in this list shall be considered non-formulary and are

NOT COVERED. In some instances, Wellmark will consider coverage

exceptions. Coverage of non-formulary drugs may be requested by the

health professional through an exception request for a non-formulary

prescription drug (outlined below). Generally, the following guidelines

must be documented in order for an exception to be granted:

All covered formulary drugs on any tier will be ineffective; OR

All covered formulary drugs on any tier have been ineffective; OR

All covered formulary drugs on any tier would not be as effective as

the non-formulary drug; OR

All covered formulary drugs would have adverse effects

COMMON DRUG EXCLUSIONS

Due to benefit design parameters, some plan sponsors may choose to

exclude certain drug classes. Prior authorization is generally not available

for drugs that are specifically excluded by benefit design. Common

excluded drugs may include, but are not limited to:


OTC drugs or their equivalents unless otherwise specified in the

formulary listing.

Drug products used for cosmetic purposes

Experimental drug products, or any drug product used in an

experimental manner

Replacement of a lost or stolen drug

Foreign drugs or drugs not approved by the United States Food &

Drug Administration (FDA)

GENERIC DRUG SUBSTITUTION

In most cases, Wellmark promotes the use of equally effective generic

drugs whenever possible. If a member or physician requests a brand-

name product when the prescription is filled and a generic equivalent is

available, the member will typically be required to pay the difference in

cost between the brand and the generic drug.

When a brand-name drug becomes available as a generic, the brand-

name product may move to a higher tier. Members may be required to

pay more for a prescription when a higher-tier brand-name product is

dispensed.

Members will not be responsible for the cost difference between brands

and generics when choosing one of the products listed below:

Coumadin Lanoxin

Cytomel Stavzor

Depakene Synthroid

Depakote/Depakote ER Tegretol/Tegretol XR

Dilantin Theophylline products

Equetro Thyrolar

Tirosint


LEGEND

GA Generic Available

PA Prior Authorization

PV Preventive Medication

QL Quantity Limit

SP-P Specialty Preferred

SP-NP Specialty Non-Preferred

lowercase Indicates generic availability

UPPERCASE Indicates brand availability

CONTACT INFORMATION

The Blue Rx formulary is designed to assist physicians, members and

other health care professionals in the selection of cost-effective agents.

Wellmark encourages your input and feedback on how we can assist in

improving this document and the formulary management process.

Please direct your communications to:

Wellmark Blue Cross and Blue Shield

1331 Grand Avenue

P.O. Box 9232

Des Moines, IA 50306

In addition to the Blue Rx formulary, other quick-reference guides are

available on our web site at Wellmark.com.


Wellmark Blue Rx Complete Formulary

Requirements/

Drug Name Drug Tier Limits

ANALGESICS

COX-II INHIBITORS

CELEBREX 4 GA; QL

celecoxib 1 QL

GOUT

allopurinol 1

colchicine 1 colchicine/probenecid 1

COLCRYS 4 GA MITIGARE 4 GA

probenecid 1

ULORIC 2 PA; QL

ZURAMPIC 4 PA ZYLOPRIM 4 GA

NON-OPIOID ANALGESICS

acetaminophen/salicylamide/phenyltoloxamine 1

BUPAP 4

butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1

butalbital/aspirin/caffeine 1 EQUAGESIC 4

ESGIC 4 GA FIORICET 4 GA

FIORINAL 4 GA LEVACET 4

VANATOL LQ 4

NSAIDS

ANAPROX 4 GA

ANAPROX DS 4 GA choline/magnesium trisalicylates 1

DAYPRO 4 GA diclofenac potassium 1

diclofenac sodium delayed-rel 1

diclofenac sodium ext-rel 1

diflunisal 1

EC-NAPROSYN 4 GA etodolac 1



Requirements/


etodolac ext-rel 1

FELDENE 4 GA

fenoprofen 1

flurbiprofen 1

ibuprofen 1

INDOCIN SUPP 3

INDOCIN SUSP 2

indomethacin 1

indomethacin ext-rel 1

ketoprofen 1

ketoprofen ext-rel 1

ketorolac 1

meclofenamate sodium 1

mefenamic acid 1

meloxicam 1

MOBIC 4 GA nabumetone 1

NALFON 4

NAPRELAN 375MG, 500MG 4 GA

NAPRELAN 750MG 4

NAPROSYN 4 GA

naproxen 1

naproxen delayed-rel 1

naproxen sodium 1

naproxen sodium ext-rel 1

oxaprozin 1

piroxicam 1

PONSTEL 4 GA

salsalate 1

SPRIX 4

sulindac 1

TIVORBEX 4

tolmetin sodium 1

ZIPSOR 4

NSAIDS, COMBINATIONS

ARTHROTEC 4 GA diclofenac/misoprostol 1

NSAIDS, TOPICAL

diclofenac gel 1% 1

diclofenac sodium soln 4



Requirements/


FLECTOR 4

PENNSAID 4

REXAPHENAC 4

VOLTAREN GEL 4 GA

OPIOID ANALGESICS

ABSTRAL 4 PA ACTIQ 4 PA; GA

alfentanil injection 1

butalbital/acetaminophen/caffeine/codeine 1

butalbital/aspirin/caffeine/codeine 1

butorphanol nasal spray 1 QL

BUTRANS 4 QL CAPITAL W/CODEINE 1

codeine 1

codeine/acetaminophen 1

CONZIP 4 GA DEMEROL 4 GA

dihydrocodeine/acetaminophen/caffeine 1

dihydrocodeine/aspirin/caffeine 1

DILAUDID 4 GA

DOLOPHINE 4 GA DURAGESIC 4 GA; QL

EMBEDA 4 QL EXALGO 4 GA; QL

fentanyl transdermal 12mcg, 25mcg, 50mcg,

75mcg, 100mcg 1 QL

FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG,

87.5MCG 1 QL fentanyl transmucosal lozenge 1 PA FENTORA 4 PA

FIORICET W/CODEINE 4 GA FIORINAL W/CODEINE 4 GA

HYCET 4 GA

hydrocodone/acetaminophen 1

hydrocodone/ibuprofen 1

hydromorphone 1

hydromorphone ext-rel 1 QL

HYDROMORPHONE SUPP 1

HYSINGLA ER 4 QL

KADIAN 10MG, 20MG, 30MG, 50MG, 60MG,



Requirements/


80MG, 100MG 4 GA; QL KADIAN 40MG, 200MG 4 QL

LAZANDA 4

levorphanol 1

LORTAB ELIXIR 4

meperidine 1

methadone 1

METHADOSE CONCENTRATE 4 GA

morphine 1

morphine ext-rel 1 QL morphine ext-rel beads 4 QL

morphine supp 5mg, 10mg, 20mg 1

MORPHINE SUPP 30MG 1

MS CONTIN 4 GA; QL NORCO 4 GA

NUCYNTA 4

NUCYNTA ER 4 QL

OPANA 4 GA OPANA ER 4 QL

OXAYDO 4

oxycodone 1

oxycodone ext-rel 2 QL oxycodone/acetaminophen 1

oxycodone/aspirin 1

oxycodone/ibuprofen 1

OXYCONTIN 2 QL

oxymorphone 1

oxymorphone ext-rel 1 QL

pentazocine/naloxone 1

PERCOCET 4 GA

PRIMLEV 4

REPREXAIN 4 GA

ROXICET SOLN 4 GA ROXICODONE 4 GA

SUBSYS 4 PA tramadol 1

tramadol ext-rel caps 100mg, 200mg, 300mg 4

TRAMADOL EXT-REL CAPS 150MG 4

tramadol ext-rel tabs 1

tramadol/acetaminophen 1

TREZIX 4 GA



Requirements/


TYLENOL W/CODEINE 4 GA ULTRACET 4 GA

ULTRAM 4 GA ULTRAM ER 4 GA

VICOPROFEN 4 GA XARTEMIS XR 4 QL

ZOHYDRO ER

ANTI-INFECTIVES

4 QL

AMINOGLYCOSIDES

neomycin 1

paromomycin 1

ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN

cefadroxil 1

cephalexin 1

KEFLEX 4 GA

ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN

cefaclor 1

CEFACLOR ER 3 cefprozil 1

CEFTIN 4 GA CEFTIN SUSP 4

cefuroxime axetil 1

ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN

CEDAX CAPS 4 GA

CEDAX SUSP 90MG/5ML 4

CEDAX SUSP 180MG/5ML 4 GA

cefdinir 1

cefditoren 3

cefixime 1

cefpodoxime 1

ceftibuten 1

ceftriaxone 1

SUPRAX 3

SUPRAX SUSP 4 GA

SUPRAX SUSP 500MG/5ML 3



Requirements/


ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES

azithromycin 1

BIAXIN 4 GA

clarithromycin 1

clarithromycin ext-rel 1

DIFICID 4

e.e.s. 400 4

ERYPED 200 4 GA ERYPED 400 2

erythromycin base 1

erythromycin delayed-rel 1

erythromycin ethylsuccinate 1

erythromycin stearate 1

ZITHROMAX 4 GA ZMAX SUSP 4

ANTIBACTERIALS, FLUOROQUINOLONES

AVELOX 4 GA CIPRO 4 GA

CIPRO XR 4 GA ciprofloxacin 1

ciprofloxacin ext-rel 1

ciprofloxacin oral susp 1

FACTIVE 4

LEVAQUIN 4 GA

levofloxacin 1

levofloxacin oral soln 1

moxifloxacin 1

ofloxacin 1

ANTIBACTERIALS, KETOLIDES

KETEK 4

ANTIBACTERIALS, PENICILLINS

amoxicillin 1

amoxicillin/clavulanate 1 amoxicillin/clavulanate ext-rel 1

ampicillin 1 AUGMENTIN 4 GA

AUGMENTIN SUSP 4 GA AUGMENTIN SUSP 125MG/5ML 4



Requirements/


AUGMENTIN XR 4 GA dicloxacillin 1

penicillin vk 1

ANTIBACTERIALS, SULFONAMIDES

BACTRIM 4 GA

BACTRIM DS 4 GA SULFADIAZINE 1

sulfamethoxazole/trimethoprim 1

ANTIBACTERIALS, TETRACYCLINES

ADOXA 4 PA; GA demeclocycline 1

DORYX 4 PA

doxycycline hyclate 1

doxycycline hyclate delayed-rel 1 PA

doxycycline monohydrate caps 50mg, 75mg, 100mg 1

doxycycline monohydrate caps 150mg 1 PA doxycycline monohydrate susp 1

doxycycline monohydrate tabs 1 PA MINOCIN 4 GA

minocycline 1

minocycline ext-rel 1 PA

MONODOX 4 GA SOLODYN 4 PA

tetracycline 1

VIBRAMYCIN CAPS, SUSP 4 GA VIBRAMYCIN SYRUP 3

ANTIFUNGALS

ANCOBON 4 GA BIO-STATIN 4

clotrimazole troche 1

CRESEMBA 4

DIFLUCAN 4 GA

fluconazole 1

flucytosine 1

GRIS-PEG 4 GA

griseofulvin microsize 1

griseofulvin ultramicrosize 1

itraconazole 1 PA



Requirements/


ketoconazole tabs 1

LAMISIL 4 GA

NOXAFIL 4

nystatin oral 1

ONMEL 4 PA ORAVIG 4

SPORANOX 4 PA; GA SPORANOX SOLN 3 PA

terbinafine 1

VFEND 4 GA voriconazole 1

ANTIMALARIALS

ARALEN 4 GA atovaquone/proguanil 1 PV chloroquine 1 PV

COARTEM 4

DARAPRIM 2

MALARONE 4 GA

mefloquine 1 PV PRIMAQUINE 1 PV

QUALAQUIN 4 GA quinine sulfate 1

ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS

TYBOST 2

ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS

abacavir/lamivudine/zidovudine 1

ATRIPLA 2

COMBIVIR 4 GA COMPLERA 2

DESCOVY 2

EPZICOM 3

EVOTAZ 3

GENVOYA 2

lamivudine/zidovudine 1

ODEFSEY 2

PREZCOBIX 3

STRIBILD 2

TRIUMEQ 2

TRIZIVIR 4 GA



Requirements/


TRUVADA 2

ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS

SELZENTRY 2

ANTIRETROVIRALS, FUSION INHIBITORS

FUZEON SP-P

ANTIRETROVIRALS, INTEGRASE INHIBITORS

ISENTRESS 2 ISENTRESS POWDER 3

TIVICAY 2 VITEKTA 2

ANTIRETROVIRALS, PROTEASE INHIBITORS

APTIVUS 2

APTIVUS SOLN 3

CRIXIVAN 2 INVIRASE 2

KALETRA 2 LEXIVA 2

LEXIVA SUSP 3 NORVIR 2

NORVIR SOLN 3 PREZISTA SUSP 3

PREZISTA TABS 2 REYATAZ 2

REYATAZ POWDER 3 VIRACEPT 2

ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NON-NUCLEOSIDE

EDURANT 2

INTELENCE 2

nevirapine 1 nevirapine ext-rel 1

RESCRIPTOR 2 SUSTIVA 2

VIRAMUNE 4 GA VIRAMUNE XR 4 GA



Requirements/



NUCLEOSIDE

abacavir 1

didanosine 1

EMTRIVA 2

EPIVIR 4 GA lamivudine soln, tabs 1

RETROVIR 4 GA stavudine 1

VIDEX EC 4 GA

VIDEX SOLN 3

ZERIT 4 GA

ZIAGEN 4 GA ZIAGEN SOLN 2

zidovudine 1


NUCLEOTIDE

VIREAD 2 VIREAD POWDER 3

ANTITUBERCULAR AGENTS

cycloserine 1

ethambutol 1

isoniazid 1 PASER GRANULES 1

PRIFTIN 3 pyrazinamide 1

RIFADIN 4 GA rifampin 1

RIFATER 4

SIRTURO 4

TRECATOR 3

ANTIVIRALS, CMV AGENTS

VALCYTE 4 GA

VALCYTE SOLN 4 GA valganciclovir 1

valganciclovir soln 1



Requirements/


ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B

adefovir dipivoxil 1

BARACLUDE SOLN 4

BARACLUDE TABS 4 GA entecavir 1

EPIVIR HBV 4 GA EPIVIR HBV SOLN 3

lamivudine tabs 1

TYZEKA SP-P

ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C

COPEGUS 4 GA DAKLINZA SP-NP PA; QL

HARVONI SP-P PA; QL OLYSIO SP-NP PA; QL

REBETOL CAPS 4 GA REBETOL SOLN 4

ribavirin 1

SOVALDI SP-P PA; QL

TECHNIVIE SP-NP PA; QL VIEKIRA PAK SP-NP PA; QL

VIEKIRA XR SP-NP PA; QL ZEPATIER SP-NP PA; QL

ANTIVIRALS, HERPES AGENTS

acyclovir 1

famciclovir 1

FAMVIR 4 GA SITAVIG 4

valacyclovir 1

VALTREX 4 GA

ZOVIRAX 4 GA

ANTIVIRALS, INFLUENZA AGENTS

FLUMADINE 4 GA

RELENZA 2

rimantadine 1

TAMIFLU 2

MISCELLANEOUS

ALBENZA 3


Requirements/


©2016 Wellmark, Inc. 20

ALINIA 3

atovaquone 1

BILTRICIDE 3 CLEOCIN 4 GA

clindamycin caps, oral soln 1

dapsone 1

FLAGYL 4 GA FLAGYL ER 4

FURADANTIN SUSP 4 GA

IMPAVIDO 3

ivermectin 1

linezolid 1

MACROBID 4 GA

MACRODANTIN 4 GA MEPRON SUSP 4 GA

metronidazole 1

MONUROL 2

MYCOBUTIN 4 GA NEBUPENT 3

nitrofurantoin 1

PRIMSOL 3

rifabutin 1

SIVEXTRO 3

STROMECTOL 4 GA

TINDAMAX 4 GA tinidazole 1

trimethoprim 1

VANCOCIN 4 GA

vancomycin caps 1

vancomycin inj 500mg, 1000mg 1

VANCOMYCIN INJECTION 750MG 1

XIFAXAN 2

ZYVOX SUSP 4 GA

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS

ALKERAN 2 CYCLOPHOSPHAMIDE CAPS 1

EMCYT SP-P GLEOSTINE 5MG 2

GLEOSTINE 10MG, 40MG, 100MG 4



Requirements/



HEXALEN 2

LEUKERAN 2

MYLERAN

TEMODAR temozolomide

VALCHLOR

2

SP-NP

SP-P 2

GA

ANTIMETABOLITES

capecitabine

mercaptopurine

SP-P

1

methotrexate 1

TABLOID 2

TREXALL 4

XELODA SP-NP GA

HORMONAL ANTINEOPLASTICS, ANTIANDROGENS

bicalutamide 1

flutamide 1

NILANDRON 4 GA nilutamide 1

XTANDI SP-P

ZYTIGA SP-P

HORMONAL ANTINEOPLASTICS, ANTIESTROGENS

FARESTON 2

SOLTAMOX 2

tamoxifen 1 PA; PV

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS

anastrozole 1

ARIMIDEX 4 GA

AROMASIN 4 GA

exemestane 1

FEMARA 4 GA

letrozole 1

HORMONAL ANTINEOPLASTICS, PROGESTINS

megestrol acetate 1

IMMUNOMODULATORS

POMALYST SP-P

REVLIMID SP-P


Requirements/



THALOMID SP-P

KINASE INHIBITORS

AFINITOR SP-P QL AFINITOR DISPERZ SP-P

ALECENSA SP-P

BOSULIF SP-P

CABOMETYX SP-P

CAPRELSA 2

COMETRIQ 2

COTELLIC SP-P

GILOTRIF 2

GLEEVEC SP-NP GA IBRANCE SP-P

ICLUSIG SP-P

imatinib mesylate SP-P

IMBRUVICA SP-P

INLYTA SP-P

JAKAFI SP-P

LENVIMA 2

MEKINIST SP-P

NEXAVAR SP-P

SPRYCEL SP-P

STIVARGA SP-P

SUTENT SP-P

TAFINLAR SP-P

TAGRISSO SP-P

TARCEVA SP-P

TASIGNA SP-P

TYKERB SP-P QL VOTRIENT SP-P

XALKORI SP-P

ZELBORAF SP-P

ZYDELIG 2

ZYKADIA SP-P

MISCELLANEOUS

bexarotene SP-P

DROXIA 3 ERIVEDGE 2

etoposide SP-P

FARYDAK SP-P


Requirements/



HYDREA 4 GA hydroxyurea 1

leucovorin 1

LONSURF SP-P

LYNPARZA 2

LYSODREN 2

MATULANE 2

NINLARO SP-P

ODOMZO SP-P

TARGRETIN CAPS SP-NP GA TARGRETIN GEL SP-P

tretinoin caps 1

VENCLEXTA SP-P

VISTOGARD SP-P

ZOLINZA SP-P

TOPOISOMERASE INHIBITORS

HYCAMTIN SP-P

CARDIOVASCULAR

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/benazepril 1 PV LOTREL 4 GA

PRESTALIA 4

TARKA 4 GA

trandolapril/verapamil 1 PV

ACE INHIBITOR/DIURETIC COMBINATIONS

benazepril/hydrochlorothiazide 1 PV captopril/hydrochlorothiazide 1 PV

enalapril/hydrochlorothiazide 1 PV

fosinopril/hydrochlorothiazide 1 PV lisinopril/hydrochlorothiazide 1 PV

LOTENSIN HCT 4 GA moexipril/hydrochlorothiazide 1 PV

quinapril/hydrochlorothiazide 1 PV ZESTORETIC 4 GA

ACE INHIBITORS

ACCUPRIL 4 GA ALTACE 4 GA


Requirements/



benazepril 1 PV captopril 1 PV

enalapril 1 PV EPANED 4

fosinopril 1 PV lisinopril 1 PV

LOTENSIN 4 GA MAVIK 4 GA

moexipril 1 PV

perindopril 1 PV PRINIVIL 4 GA

QBRELIS SOLN 4

quinapril 1 PV

ramipril 1 PV trandolapril 1 PV

VASOTEC 4 GA ZESTRIL 4 GA

ADRENOLYTICS, CENTRAL

CATAPRES 4 GA CATAPRES-TTS 4 GA

clonidine 1 PV clonidine transdermal 1 PV

guanfacine 1 PV TENEX 4 GA

ALDOSTERONE RECEPTOR ANTAGONISTS

ALDACTONE 4 GA eplerenone 1

spironolactone 1

ALPHA BLOCKERS

CARDURA 4 GA doxazosin 1

prazosin 1

terazosin 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS

amlodipine/valsartan 1 PV AZOR 4


Requirements/



EXFORGE 4 GA telmisartan/amlodipine 1 PV

TWYNSTA 4 GA

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS

amlodipine/valsartan/hydrochlorothiazide 1 PV EXFORGE HCT 4 GA

TRIBENZOR 4

ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS

ATACAND HCT 4 GA AVALIDE 4 GA

BENICAR HCT 4

candesartan/hydrochlorothiazide 1 PV DIOVAN HCT 4 GA

EDARBYCLOR 4

HYZAAR 4 GA

irbesartan/hydrochlorothiazide 1 PV losartan/hydrochlorothiazide 1 PV

MICARDIS HCT 4 GA telmisartan/hydrochlorothiazide 1 PV

valsartan/hydrochlorothiazide 1 PV

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 4 GA AVAPRO 4 GA BENICAR 4

candesartan 1 PV COZAAR 4 GA

DIOVAN 4 GA EDARBI 4

eprosartan 1 PV irbesartan 1 PV

losartan 1 PV MICARDIS 4 GA

telmisartan 1 PV

valsartan 1 PV


Requirements/



ANTIARRHYTHMICS

amiodarone 1 PV

BETAPACE 4 GA

disopyramide 1 PV dofetilide 1

flecainide 1 PV mexiletine 1

MULTAQ 3

NORPACE 4 GA

NORPACE CR 3

propafenone 1 PV

propafenone ext-rel 1 PV quinidine gluconate 1

quinidine sulfate 1

quinidine sulfate ext-rel 1

RYTHMOL 4 GA RYTHMOL SR 4 GA

sotalol 1 PV

sotalol af 1 PV TIKOSYN 4 GA

ANTILIPEMICS, BILE ACID RESINS

cholestyramine powder 1 PV

cholestyramine powder light 1 PV COLESTID 4 GA

colestipol 1 PV

QUESTRAN 4 GA QUESTRAN LIGHT 4 GA

WELCHOL 4

ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS

ZETIA 2 PV

ANTILIPEMICS, FIBRATES

ANTARA 4

fenofibrate caps, tabs 1 PV fenofibric acid 1 PV

fenofibric acid delayed-rel 1 PV FENOGLIDE 4 GA

gemfibrozil 1 PV LIPOFEN 4 GA


Requirements/



LOFIBRA 4 GA TRICOR 4 GA

TRIGLIDE 4

TRILIPIX 4 GA

ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS

ALTOPREV 4

atorvastatin 1 PV CRESTOR 4 GA

fluvastatin 1 PV

fluvastatin ext-rel 1

LESCOL XL 4 GA

LIPITOR 4 GA LIVALO 2 PV

lovastatin 1 PV MEVACOR 4 GA

PRAVACHOL 4 GA pravastatin 1 PV

rosuvastatin 1 PV simvastatin 1 PV

VYTORIN 4

ZOCOR 4 GA

ANTILIPEMICS, MISCELLANEOUS

JUXTAPID SP-P PA; QL KYNAMRO SP-P PA; QL

ANTILIPEMICS, NIACINS/COMBINATIONS

ADVICOR 4

niacin 4

niacin ext-rel 1 PV NIASPAN 4 GA

SIMCOR 4

ANTILIPEMICS, PCSK9 INHIBITORS

PRALUENT SP-NP MN-PA; QL REPATHA SP-P PA; QL

BETA-BLOCKER/DIURETIC COMBINATIONS

atenolol/chlorthalidone 1 PV


Requirements/



bisoprolol/hydrochlorothiazide 1 PV CORZIDE 4 GA

DUTOPROL 4

LOPRESSOR HCT 4 GA

metoprolol/hydrochlorothiazide 1 PV nadolol/bendroflumethiazide 1 PV

propranolol/hydrochlorothiazide 1 PV ZIAC 4 GA

BETA-BLOCKERS

acebutolol 1 PV atenolol 1 PV

betaxolol 1 PV bisoprolol 1 PV

BYSTOLIC 4

carvedilol 1 PV

COREG 4 GA COREG CR 4

CORGARD 4 GA

HEMANGEOL 4

INDERAL LA 4 GA

labetalol 1 PV LEVATOL 4

LOPRESSOR 4 GA metoprolol succinate ext-rel 1 PV

metoprolol tartrate 1 PV nadolol 1 PV

pindolol 1 PV propranolol 1 PV

propranolol ext-rel 1 PV SECTRAL 4 GA

TENORMIN 4 GA timolol 1 PV

TOPROL-XL 4 GA

TRANDATE 4 GA

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

amlodipine/atorvastatin 1 PV CADUET 4 GA

CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES

ADALAT CC 4 GA


Requirements/



amlodipine 1 PV felodipine ext-rel 1 PV

isradipine 1 PV nicardipine 1 PV

nifedipine 1 PV nifedipine ext-rel 1 PV

nimodipine 1

nisoldipine ext-rel 1 PV

NYMALIZE 4

PROCARDIA 4 GA PROCARDIA XL 4 GA

CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES

CALAN 4 GA CALAN SR 4 GA CARDIZEM 4 GA

CARDIZEM CD 4 GA CARDIZEM LA 120MG 4

CARDIZEM LA 180MG, 240MG, 300MG,

360MG, 420MG 4 GA diltiazem 1 PV

diltiazem ext-rel 1 PV verapamil 1 PV

verapamil ext-rel 1 PV VERELAN 4 GA

VERELAN PM 4 GA

DIGITALIS GLYCOSIDES

digoxin 1

LANOXIN 62.5MCG, 187.5MCG 4

LANOXIN 125MCG, 250MCG 4 GA

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

TEKTURNA 4 TEKTURNA HCT 4

DIURETICS

ALDACTAZIDE 25/25 4 GA ALDACTAZIDE 50/50 4

amiloride 1

amiloride/hydrochlorothiazide 1 PV bumetanide 1



Requirements/



chlorothiazide 1 PV chlorthalidone 1 PV

DEMADEX 4 GA DIURIL 3

DYAZIDE 4 GA DYRENIUM 3

EDECRIN 4 GA ethacrynic acid 1

furosemide 1

FUROSEMIDE SOLN 8 MG/ML 4

furosemide soln 10mg/ml 1

hydrochlorothiazide 1 PV indapamide 1 PV

LASIX 4 GA MAXZIDE 4 GA

methyclothiazide 1 PV metolazone 1

MICROZIDE 4 GA spironolactone/hydrochlorothiazide 1 PV

torsemide 1

triamterene/hydrochlorothiazide 1 PV

MISCELLANEOUS

clonidine/chlorthalidone 4

CORLANOR 4

DEMSER 2 DIBENZYLINE 4 GA

hydralazine 1 PV isoxsuprine 10mg 1

isoxsuprine 20mg 4

methyldopa 1 PV

methyldopa/hydrochlorothiazide 1 PV midodrine 1

minoxidil 1 PV

phenoxybenzamine 1

RANEXA 3

reserpine 1 PV

NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR

ANTAGONIST COMBINATIONS

ENTRESTO 3 PA; QL


Requirements/



NITRATE/VASODILATOR COMBINATIONS

BIDIL 4

NITRATES, ORAL

DILATRATE SR 4

ISORDIL 5MG 4 GA

ISORDIL 40MG 4

isosorbide dinitrate 1 PV

isosorbide dinitrate ext-rel 1 PV isosorbide mononitrate 1 PV

isosorbide mononitrate ext-rel 1 PV

nitroglycerin caps 1 PV

NITRATES, SUBLINGUAL/TRANSLINGUAL

nitroglycerin lingual aerosol 1

nitroglycerin lingual spray 1 PV

nitroglycerin sublingual 1

NITROLINGUAL SPRAY 4 GA

NITROMIST 4 GA NITROSTAT 4 GA

NITRATES, TRANSDERMAL

NITRO-BID 3

NITRO-DUR 0.1MG, 0.2MG, 0.4MG, 0.6MG 4 GA

NITRO-DUR 0.3MG, 0.8MG 4

nitroglycerin transdermal 1 PV

PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONIST

LETAIRIS SP-P PA; QL

OPSUMIT SP-P PA; QL TRACLEER SP-P PA; QL

PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITOR

ADCIRCA SP-P PA; QL REVATIO INJ SP-NP PA; GA; QL

REVATIO SUSP SP-NP PA; QL REVATIO TABS SP-NP PA; GA; QL

sildenafil SP-P PA; QL


Requirements/



PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN

RECEPTOR AGONIST

UPTRAVI SP-P PA; QL

PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS

ORENITRAM SP-P PA

TYVASO SP-P PA; QL VENTAVIS SP-P PA; QL

PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS

ADEMPAS SP-P PA; QL

CENTRAL NERVOUS SYSTEM

ANTIANXIETY, BENZODIAZEPINES

alprazolam 1

alprazolam ext-rel 1

ALPRAZOLAM INTENSOL 1 ATIVAN 4 GA

chlordiazepoxide 1

clonazepam 1 PV

clorazepate 1

diazepam 1

KLONOPIN 4 GA lorazepam 1

NIRAVAM 4 GA oxazepam 1

VALIUM 4 GA XANAX 4 GA

XANAX XR 4 GA

ANTIANXIETY, MISCELLANEOUS

ANAFRANIL 4 GA

buspirone 1

clomipramine 1 PV

fluvoxamine 1 PV fluvoxamine ext-rel 1 PA; PV

meprobamate 1


Requirements/



ANTICONVULSANTS

APTIOM 4

BANZEL 2 PA; PV; QL

BRIVIACT 4

carbamazepine 1 PV

carbamazepine ext-rel 1 PV CARBATROL 4 GA

CELONTIN 2 PV DEPAKENE 4 GA

DEPAKOTE 4 GA DEPAKOTE ER 4 GA

DIASTAT 4 GA diazepam gel 1

DILANTIN 30MG 4

DILANTIN 100MG 4 GA

DILANTIN CHEW 50MG 4 GA DILANTIN-125 SUSP 4 GA

divalproex sodium 1 PV

divalproex sodium delayed-rel 1 PV divalproex sodium ext-rel 1 PV

ethosuximide 1 PV felbamate 1 PV

FELBATOL 4 GA FYCOMPA 4

gabapentin 1

GABITRIL 2MG, 4MG 4 GA

GABITRIL 12MG, 16MG 4

KEPPRA 4 GA

KEPPRA XR 4 GA LAMICTAL 4 GA

LAMICTAL CHEW 2MG 4

LAMICTAL CHEW 5MG, 25MG 4 GA

LAMICTAL ODT 4 GA

LAMICTAL XR 4 GA lamotrigine 1 PV

lamotrigine ext-rel 1 PV levetiracetam 1 PV

MYSOLINE 4 GA NEURONTIN 4 GA

ONFI 4 PA; QL oxcarbazepine 1 PV


Requirements/



OXTELLAR XR 4

PEGANONE 2 PV

phenobarbital 1 PV PHENYTEK 4 GA

phenytoin 1 PV phenytoin sodium extended 1 PV

POTIGA 4

primidone 1 PV

QUDEXY XR 4 GA

SABRIL POWDER SP-P PA; QL SABRIL TABS SP-P QL

STAVZOR 4

TEGRETOL 4 GA

TEGRETOL-XR 100MG, 200MG, 400MG 4 GA tiagabine 1 PV

TOPAMAX 4 GA TOPAMAX SPRINKLE 4 GA

topiramate 1 PV TRILEPTAL 4 GA

TROKENDI XR 4

valproic acid 1 PV

VIMPAT 2 PV ZARONTIN 4 GA

ZONEGRAN 4 GA

zonisamide 1 PV

ANTIDEMENTIA

ARICEPT 4 GA donepezil 1

EXELON 4 GA galantamine 1

galantamine ext-rel 1

memantine 1

NAMENDA 4 GA

NAMENDA XR 4

rivastigmine 1

rivastigmine transdermal 1

ANTIDEPRESSANTS, MAOIS

EMSAM 3

MARPLAN 2

NARDIL 4 GA


Requirements/



PARNATE 4 GA phenelzine 1 PV

tranylcypromine 1 PV

ANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN 4

bupropion 1 PV bupropion delayed-rel 1 PV

bupropion ext-rel (12hr) 1 PV bupropion ext-rel (24hr) 1 PV

chlordiazepoxide/amitriptyline 1

FORFIVO XL 4

maprotiline 1 PV mirtazapine 1 PV

nefazodone 1 PV OLEPTRO 4

REMERON 4 GA trazodone 1 PV

WELLBUTRIN 4 GA

WELLBUTRIN SR 4 GA WELLBUTRIN XL 4 GA

ANTIDEPRESSANTS, SNRIS

CYMBALTA 4 GA

DESVENLAFAXINE ER 50MG, 100MG 4 PA; QL desvenlafaxine ext-rel 50mg, 100mg 1 PA; PV; QL

duloxetine 1 PV

EFFEXOR XR 4 GA FETZIMA 4 PA; QL

IRENKA 4

KHEDEZLA 4 PA; GA; QL

PRISTIQ 50MG, 100MG 4 PA; QL venlafaxine 1 PV

venlafaxine ext-rel 1 PV

ANTIDEPRESSANTS, SSRIS

CELEXA 4 GA

citalopram 1 PV escitalopram 1 PV

fluoxetine 1 PV FLUOXETINE 60MG 1 PV

fluoxetine delayed-rel 1 PV


Requirements/



LEXAPRO 4 GA paroxetine 1 PV

paroxetine ext-rel 1 PV PAXIL 4 GA

PAXIL CR 4 GA PAXIL SUSP 4

PEXEVA 4 PA PROZAC 4 GA

PROZAC WEEKLY 4 GA

SARAFEM 4

sertraline 1 PV

VIIBRYD 4 PA ZOLOFT 4 GA

ANTIDEPRESSANTS, TCAS

amitriptyline 1 PV

amoxapine 1 PV desipramine 1 PV

doxepin 1 PV

imipramine hcl 1 PV imipramine pamoate 1 PV

nortriptyline 1 PV PAMELOR 4 GA

protriptyline 1 PV SURMONTIL 25MG, 50MG 4

SURMONTIL 100MG 4 GA TOFRANIL 4 GA

trimipramine 1 PV

ANTIPARKINSONIAN AGENTS

amantadine 1

AZILECT 2 benztropine 1

bromocriptine 1 carbidopa 1

carbidopa/levodopa 1 carbidopa/levodopa ext-rel 1

carbidopa/levodopa/entacapone 1 COMTAN 4 GA

ELDEPRYL 4 GA entacapone 1

LODOSYN 4 GA


Requirements/



MIRAPEX 4 GA MIRAPEX ER 4 PA; GA

NEUPRO 4

PARLODEL 4 GA

pramipexole 1

pramipexole ext-rel 1 PA

REQUIP 4 GA REQUIP XL 4 PA; GA

ropinirole 1

ropinirole ext-rel 1 PA selegiline 1

SINEMET 4 GA SINEMET CR 4 GA

STALEVO 4 GA TASMAR 4 GA

tolcapone 1

trihexyphenidyl 1

ZELAPAR 4

ANTIPSYCHOTICS, ATYPICALS

ABILIFY 4 GA ABILIFY DISCMELT 4 GA aripiprazole 1 PV

aripiprazole odt 1

aripiprazole soln 1

clozapine 1 PV CLOZARIL 4 GA

FANAPT 4 QL FAZACLO 4 GA

GEODON 4 GA INVEGA 4 GA

LATUDA 4

loxapine 1 PV

olanzapine 1 PV

olanzapine/fluoxetine 1

paliperidone ext-rel 1

quetiapine 1 PV REXULTI 4 PA; QL

RISPERDAL 4 GA RISPERDAL-M TAB 4 GA

risperidone 1 PV


Requirements/



SAPHRIS 4

SEROQUEL 4 GA

SEROQUEL XR 4

SYMBYAX 4 GA

VERSACLOZ 4

VRAYLAR 4 PA; QL

ziprasidone 1 PV ZYPREXA 4 GA

ZYPREXA ZYDIS 4 GA

ANTIPSYCHOTICS, MISCELLANEOUS

chlorpromazine 1 PV

fluphenazine 1 PV haloperidol 1 PV

ORAP 4 GA perphenazine 1 PV

perphenazine/amitriptyline 1

pimozide 1

thioridazine 1 PV

thiothixene 1 PV trifluoperazine 1 PV

ATTENTION DEFICIT HYPERACTIVITY DISORDER

ADDERALL 4 GA

ADDERALL XR 4 PA; GA amphetamine/dextroamphetamine 1

amphetamine/dextroamphetamine ext-rel 1 PA

APTENSIO XR 4 PA clonidine ext-rel 1 PA

CONCERTA 4 PA; GA DAYTRANA 4 PA; QL

DEXEDRINE CR 4 PA; GA dexmethylphenidate 1

dexmethylphenidate ext-rel 1 PA dextroamphetamine 2.5mg, 7.5mg, 15mg,

20mg, 30mg 4

dextroamphetamine 5mg, 10mg 1

dextroamphetamine ext-rel 5mg, 10mg, 15mg 1 PA dextroamphetamine soln 1

FOCALIN 4 GA FOCALIN XR 5MG, 10MG, 15MG, 20MG,

30MG, 40MG 4 PA; GA


Requirements/



FOCALIN XR 25MG, 35MG 4 PA guanfacine ext-rel 1

INTUNIV 4 GA; QL KAPVAY 4 PA; GA

METADATE CD 4 PA; GA methamphetamine tabs 5mg 1

METHYLIN CHEW 2.5MG, 5MG, 10MG 4 GA METHYLIN SOLN 4 GA

methylphenidate chew 2.5mg, 5mg, 10mg 1

METHYLPHENIDATE ER 20MG, 30MG, 40MG 4 PA; GA methylphenidate ext-rel 18mg, 27mg, 36mg,

54mg 1 PA methylphenidate ext-rel caps 10mg, 20mg,

30mg, 40mg, 50mg, 60mg 1 PA

methylphenidate ext-rel caps 20mg, 30mg, 40mg 1 PA

methylphenidate ext-rel tabs 10mg, 20mg 1 PA

methylphenidate soln 1

methylphenidate tabs 5mg, 10mg, 20mg 1

PROCENTRA 4 GA QUILLIVANT XR 4 PA; QL

RITALIN 4 GA RITALIN LA 10MG, 60MG 4 PA

RITALIN LA 20MG, 30MG, 40MG 4 PA; GA

STRATTERA 2 PA; QL VYVANSE 3 PA

FIBROMYALGIA

LYRICA 3

SAVELLA 4

HUNTINGTON'S DISEASE AGENTS

tetrabenazine SP-P QL XENAZINE SP-NP GA; QL

HYPNOTICS, TRICYCLICS

SILENOR 4 PA

HYPNOTICS: BENZODIAZEPINES

estazolam 1

flurazepam 1

HALCION 4 GA


Requirements/



temazepam 1

triazolam 1

HYPNOTICS: NON-BENZODIAZEPINES

AMBIEN 4 GA AMBIEN CR 4 PA; GA

BELSOMRA 4 PA; QL BUTISOL SODIUM 3

EDLUAR 4 PA eszopiclone 1 PA

HETLIOZ SP-P PA; QL INTERMEZZO 4 PA; GA

LUNESTA 4 PA; GA ROZEREM 4 PA

SECONAL 3

SONATA 4 GA

zaleplon 1

zolpidem 1

zolpidem ext-rel 1 PA

zolpidem sublingual 1 PA ZOLPIMIST 4 PA

MIGRAINE, ERGOTAMINE DERIVATIVES

CAFERGOT 4

D.H.E. 4 GA dihydroergotamine inj 1

dihydroergotamine nasal spray 1 QL

ERGOMAR 4

migergot supp 1

MIGRANAL 4 GA; QL

MIGRAINE, MISCELLANEOUS

isometheptene/caffeine/acetaminophen

isometheptene/dichloralphenazone /acetaminophen

1

1

PRODRIN 4 GA

MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID

TREXIMET 4 PA; QL

MIGRAINE, SELECTIVE SEROTONIN AGONISTS

almotriptan 1 QL


Requirements/



ALSUMA 4 PA; QL AMERGE 4 GA; QL

AXERT 4 GA; QL FROVA 4 PA; GA; QL

frovatriptan 1 PA; QL IMITREX 4 GA; QL

MAXALT 4 GA; QL MAXALT-MLT 4 GA; QL

naratriptan 1 QL

RELPAX 4 PA; QL rizatriptan 1 QL

sumatriptan 1 QL SUMAVEL DOSEPRO 4 PA; QL

zolmitriptan 1 QL ZOMIG 4 GA; QL

ZOMIG NASAL SPRAY 4 PA; QL ZOMIG ZMT 4 GA; QL

MISCELLANEOUS

ergoloid mesylates 1

GUANIDINE 3

RILUTEK 4 GA riluzole 1

MOOD STABILIZERS

EQUETRO 4

LITHIUM 3

lithium carbonate 1

lithium carbonate ext-rel 1

LITHOBID 4 GA

MULTIPLE SCLEROSIS

AMPYRA SP-P QL AUBAGIO SP-P PA; QL

AVONEX SP-P PA; QL AVONEX PEN SP-P PA; QL

AVONEX PREFILLED SYG SP-P PA; QL

BETASERON SP-P PA; QL COPAXONE 20 MG SP-NP PA; GA; QL

COPAXONE 40 MG SP-NP PA; QL EXTAVIA SP-P PA; QL

GILENYA SP-P PA; QL



Requirements/



glatopa 20 mg SP-P PA; QL PLEGRIDY SP-P PA; QL

REBIF SP-P PA; QL TECFIDERA SP-P PA; QL

MUSCULOSKELETAL THERAPY AGENTS

AMRIX 4

baclofen 1

carisoprodol 1 carisoprodol/aspirin 1

carisoprodol/aspirin/codeine 1 chlorzoxazone 1

cyclobenzaprine 1 DANTRIUM 4 GA

dantrolene 1

FEXMID 4 GA

LORZONE 4

metaxalone 1

methocarbamol 1

orphenadrine ext-rel 1

orphenadrine/aspirin/caffeine 1

PARAFON FORTE DSC 4 GA ROBAXIN 4 GA

ROBAXIN-750 4 GA SKELAXIN 4 GA

SOMA 4 GA tizanidine 1

ZANAFLEX 4 GA

MYASTHENIA GRAVIS

MESTINON 4 GA MESTINON SYRUP 4

MESTINON TIMESPAN 4 GA

pyridostigmine 1

pyridostigmine ext-rel 1

NARCOLEPSY/CATAPLEXY

armodafinil 1 PA; QL modafinil 1 PA; QL

NUVIGIL 4 PA; GA; QL PROVIGIL 4 PA; GA; QL

XYREM 2 PA; QL


Requirements/



PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS

acamprosate calcium 1 PV

ANTABUSE 4 GA

disulfiram 1 PV

PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST

naltrexone 1 PV

PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID

ANTAGONIST COMBINATIONS

buprenorphine/naloxone sublingual 1 PV SUBOXONE 4

ZUBSOLV 4

PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS

buprenorphine sublingual 1 PV

PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT

NUEDEXTA 4

PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS

bupropion ext-rel 1

CHANTIX 3

NICOTROL INHALER 3

NICOTROL NS 3

ZYBAN 4 GA

ENDOCRINE AND METABOLIC

ANDROGENS

ANADROL-50 2

ANDRODERM 4 PA ANDROGEL 1% (25MG PAK) 4 PA; GA

ANDROGEL 1% (50MG PAK) 4 PA ANDROGEL 1% PUMP 4 PA; GA

ANDROGEL 1.62% 2 PA ANDROXY 3

AXIRON 4 PA DEPO-TESTOSTERONE 100MG/ML 4 GA

DEPO-TESTOSTERONE 200MG/ML 4 GA FORTESTA 4 PA; GA


Requirements/



OXANDRIN 4 GA oxandrolone 1

STRIANT 4 PA TESTIM 4 PA; GA

testosterone cypionate 1

testosterone enanthate 1

testosterone gel 1% 2 PA testosterone gel 10mg/act 2 PA

VOGELXO 4 PA; GA

ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR

acarbose 1 PV GLYSET 4

ANTIDIABETICS, AMYLIN ANALOGS

SYMLINPEN 2 PV

ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS

glipizide/metformin 1 PV

GLUCOVANCE 4 GA glyburide/metformin 1 PV

ANTIDIABETICS, BIGUANIDES

FORTAMET 4 GA GLUCOPHAGE 4 GA

GLUCOPHAGE XR 4 GA metformin 1 PV

metformin ext-rel 1 PV RIOMET 2

ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS

JANUMET 2 PV

JANUMET XR 2 PV

JENTADUETO 2 PV JENTADUETO XR 2 PV

KAZANO 4 MN-PA KOMBIGLYZE XR 4 MN-PA


Requirements/



ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/INSULIN SENSITIZER COMBINATIONS

OSENI 4 MN-PA

ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

JANUVIA 2 PV NESINA 4 MN-PA

ONGLYZA 4 MN-PA TRADJENTA 2 PV

ANTIDIABETICS, INCRETIN MIMETIC AGENTS

BYDUREON 2 PV; QL

BYETTA 3 QL TANZEUM 4 MN-PA; QL

TRULICITY 4 MN-PA; QL

VICTOZA 2 PV; QL

ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE

COMBINATION

ACTOPLUS MET 4 GA ACTOPLUS MET XR 4

pioglitazone/metformin 1 PV

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO

pioglitazone/glimepiride 1 PV

ANTIDIABETICS, INSULIN SENSITIZERS

ACTOS 4 GA

AVANDIA 4

pioglitazone 1 PV

ANTIDIABETICS, INSULINS

AFREZZA 4 PA; QL APIDRA 4 MN-PA

HUMALOG 4 MN-PA HUMALOG MIX 4 MN-PA

HUMULIN 70/30 4 MN-PA HUMULIN N 4 MN-PA

HUMULIN R 4 MN-PA HUMULIN R U-500 2 PV

LANTUS 2 PV


Requirements/



LEVEMIR See Appendix A PV NOVOLIN 70/30 2 PV

NOVOLIN 70/30 RELION 2 PV NOVOLIN N 2 PV

NOVOLIN N RELION 2 PV NOVOLIN R 2 PV

NOVOLIN R RELION 2 PV NOVOLOG 2 PV

NOVOLOG MIX 2 PV

ANTIDIABETICS, MEGLITINIDE

nateglinide 1 PV

PRANDIN 4 GA repaglinide 1 PV

STARLIX 4 GA

ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS

repaglinide/metformin 1

ANTIDIABETICS, MISCELLANEOUS

CYCLOSET 4

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS

INVOKAMET See Appendix B INVOKAMET XR See Appendix B SYNJARDY See Appendix B

XIGDUO XR See Appendix A

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS

FARXIGA See Appendix A

INVOKANA See Appendix B

JARDIANCE See Appendix B

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2

INHIBITOR/DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI 4

ANTIDIABETICS, SULFONYLUREAS

AMARYL 4 GA


Requirements/



chlorpropamide 1 PV glimepiride 1 PV

glipizide 1 PV glipizide ext-rel 1 PV

GLUCOTROL 4 GA GLUCOTROL XL 4 GA

glyburide 1 PV glyburide micronized 1 PV

tolazamide 1 PV

tolbutamide 1 PV

ANTIDIABETICS, SUPPLIES

ACCU-CHEK BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL ALL NON-PREFERRED BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL ASCENSIA BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL

BLOOD KETONE TEST STRIPS 2 PV BREEZE 2 BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL

CONTOUR BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL

CONTOUR NEXT BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL

FREESTYLE BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL INSULIN SYRINGES 2 PV

LANCETS 2 PV; QL ONETOUCH BLOOD GLUCOSE TEST STRIPS 2 PV; QL

PEN NEEDLES 2 PV PRECISION XTRA BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL SURE-TEST BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL

TRUETEST BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL TRUETRACK BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL

URINE TEST STRIPS 2 PV

CALCIUM RECEPTOR ANTAGONISTS

SENSIPAR SP-P

CALCIUM REGULATORS, BISPHOSPHONATES

ACTONEL 4 GA alendronate 5mg, 10mg, 35mg, 70mg 1 PV

alendronate 40mg 1

alendronate soln 4

ATELVIA 4 GA



Requirements/



BONIVA TABS 4 GA etidronate 1

FOSAMAX 4 GA FOSAMAX PLUS D 4

ibandronate 1 PV risedronate 1 PV

risedronate delayed-rel 1 PV

CALCIUM REGULATORS, CALCITONINS

calcitonin nasal spray 1 PV

FORTICAL 4

MIACALCIN 4 GA

CALCIUM REGULATORS, PARATHYROID HORMONES

FORTEO SP-P

CONTRACEPTIVES, BIPHASIC

azurette 1 PV desogestrel/ethinyl estradiol 1 PV

kariva 1 PV kimidess 1 PV

MIRCETTE 4 GA

NECON 10/11 4

pimtrea 1 PV

viorele 1 PV

CONTRACEPTIVES, CONTINUOUS

amethyst 1

levonorgestrel/ethinyl estradiol 1

CONTRACEPTIVES, EMERGENCY CONTRACEPTION

ELLA 4

CONTRACEPTIVES, EXTENDED CYCLE

amethia 1 amethia lo 1

ashlyna 1 camrese 1 camrese lo 1

daysee 1 introvale 1

jolessa 1


Requirements/




LOSEASONIQUE 4 GA

QUARTETTE 4

quasense 1

SEASONIQUE 4 GA setlakin 1

CONTRACEPTIVES, FOUR PHASE

NATAZIA 4

CONTRACEPTIVES, INJECTABLE

DEPO-PROVERA 4 GA

DEPO-SUBQ PROVERA 104 4

medroxyprogesterone acetate 150mg/ml 1

CONTRACEPTIVES, MONOPHASIC

altavera 1

alyacen 1 apri 1 PV

aubra 1

aviane 1

balziva 1

BEYAZ 4

BREVICON 4 GA

briellyn 1

chateal 1

cryselle 1

cyclafem 1

cyred 1 PV dasetta 1

delyla 1

DESOGEN 4 GA

desogestrel/ethinyl estradiol 1 PV drospirenone/ethinyl estradiol 1

elinest 1

emoquette 1 PV

enskyce 1 PV

estarylla 1

FALESSA 4

falmina 1

FEMCON FE 4 GA

GENERESS FE 4 GA


Requirements/



gianvi 1

gildagia 1

gildess 1 PV gildess fe 1 PV

gildess fe 24 1

juleber 1 PV

junel 1 PV junel fe 1 PV

junel fe 24 1

kelnor 1

kurvelo 1

larin 1 PV larin fe 1 PV

larin fe 24 1

layolis fe chew 1

lessina 1


levora 1

LO LOESTRIN 4

LOESTRIN 4 GA LOESTRIN FE 4 GA

lomedia fe 24 1

loryna 1

low-ogestrel 1

lutera 1

marlissa 1

microgestin 1 PV microgestin fe 1 PV

microgestin fe 24 1

MINASTRIN FE 24 4

MODICON 4 GA mono-linyah 1

mononessa 1

necon 1

necon 4

nikki 1

norethindrone/ethinyl estradiol 1 PV norethindrone/ethinyl estradiol fe 1

norethindrone/ethinyl estradiol fe 1 PV

norethindrone/ethinyl estradiol fe chew 1

norgestimate/ethinyl estradiol 1


Requirements/



NORINYL 4 GA nortrel 1

ocella 1

ogestrel 1

orsythia 1

ORTHO-CYCLEN 4 GA

ORTHO-NOVUM 4 GA OVCON-35 4 GA

philith 1

pirmella 1

portia 1

previfem 1

reclipsen 1 PV

SAFYRAL 4

sprintec 1

sronyx 1

syeda 1

tarina fe 1 PV vestura 1

vyfemla 1

wera 1

wymzya fe chew 1 PV YASMIN 4 GA

YAZ 4 GA

zarah 1

zenchent 1

zenchent fe chew 1 PV zovia 1

CONTRACEPTIVES, PROGESTIN ONLY

camila 1

deblitane 1 errin 1

heather 1

jencycla 1 jolivette 1

lyza 1 NOR-QD 4 GA

nora-be 1

norethindrone 1

norlyroc 1


Requirements/



ORTHO MICRONOR 4 GA

sharobel 1

CONTRACEPTIVES, TRANSDERMAL

xulane 1

CONTRACEPTIVES, TRIPHASIC

alyacen 1

aranelle 1

caziant 1 PV cyclafem 1

CYCLESSA 4 GA dasetta 1

enpresse 1 ESTROSTEP FE 4 GA

leena 1 levonorgestrel/ethinyl estradiol 1

myzilra 1 necon 1

norgestimate/ethinyl estradiol 1 nortrel 1 ORTHO TRI-CYCLEN 4 GA

ORTHO TRI-CYCLEN LO 4 GA ORTHO-NOVUM 7/7/7 4 GA

pirmella 1 tilia fe 1 PV

tri-estaryll 1 tri-legest fe 1 PV

tri-linyah 1 tri-lo-sprintec 1

TRI-NORINYL 4 GA tri-previfem 1 tri-sprintec 1

trinessa 1 trivora 1

velivet 1 PV

CONTRACEPTIVES, VAGINAL

NUVARING 3

ENDOMETRIOSIS

danazol 1


Requirements/



ESTROGEN/PROGESTIN, ORAL

ACTIVELLA 4 GA

ANGELIQ 4

estradiol/norethindrone 1

ethinyl estradiol/norethindrone 1

FEMHRT LOW DOSE 4 GA JEVANTIQUE LO 4 GA

jinteli 1

lopreeza 1

mimvey 1

mimvey lo 1

PREFEST 4

PREMPHASE 2

PREMPRO 2

ESTROGEN/PROGESTIN, TRANSDERMAL

CLIMARA PRO 3

COMBIPATCH 3

ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR

COMBINATIONS

DUAVEE 4

ESTROGENS, ORAL

covaryx 1

covaryx hs 1 eemt 1

eemt hs 1 ENJUVIA 4

esterified estrogens/methyltestosterone 1 ESTRACE 4 GA

estradiol 1

estropipate 1

MENEST 4

PREMARIN 2

ESTROGENS, TRANSDERMAL

CLIMARA 4 GA DIVIGEL 4

ELESTRIN 4

estradiol transdermal twice weekly 1 QL


Requirements/



estradiol transdermal weekly 1

ESTROGEL 4

EVAMIST 4

MENOSTAR 4

MINIVELLE 4 QL VIVELLE-DOT 4 GA; QL

ESTROGENS, VAGINAL

ESTRACE CREAM 2 ESTRING 3

FEMRING 4 PREMARIN CREAM 2

VAGIFEM 3

GLUCOCORTICOIDS

CORTEF 4 GA

cortisone 4

dexamethasone 1

DEXAMETHASONE INTENSOL 1

dexamethasone oral soln 0.5mg/5ml 1

DEXPAK 4

FLO-PRED 4

fludrocortisone 1

hydrocortisone 1

KENALOG INJ 4

MEDROL 4 GA

MEDROL 2MG 4

methylprednisolone 1

MILLIPRED 4

ORAPRED ODT 4 GA PEDIAPRED 4 GA

prednisolone sodium phosphate odt, soln 1

prednisolone syrup 1

prednisone 1

PREDNISONE INTENSOL 1

RAYOS 4

VERIPRED 4

GLUCOSE ELEVATING AGENT

GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT 2


Requirements/



HUMAN GROWTH HORMONES

GENOTROPIN SP-NP PA

HUMATROPE SP-NP PA

NORDITROPIN SP-P PA NUTROPIN AQ SP-NP PA

OMNITROPE SP-NP PA SAIZEN SP-NP PA

SEROSTIM SP-NP PA ZOMACTON SP-NP PA

ZORBTIVE SP-NP PA

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

calcitriol caps 1

calcitriol soln 4 doxercalciferol 1

HECTOROL 4 GA paricalcitol 1

ROCALTROL 4 GA ZEMPLAR 4 GA

INSULIN-LIKE GROWTH FACTOR

INCRELEX SP-P

LYSOSOMAL STORAGE DISORDERS

CERDELGA SP-P

ZAVESCA SP-P

MISCELLANEOUS

cabergoline 1

CARBAGLU 4

CARNITOR 4 GA CYSTADANE 4

KORLYM 2

levocarnitine 1

methylergonovine 1

octreotide SP-P

ORFADIN 3

ORFADIN SUSP 3

RAVICTI SP-P

SANDOSTATIN SP-NP GA SOMAVERT SP-P


Requirements/



STRENSIQ SP-P

SYPRINE 3

PHENYLKETONURIA TREATMENT AGENTS

KUVAN SP-P PA

PHOSPHATE BINDER AGENTS

calcium acetate 1

ELIPHOS 4 GA

FOSRENOL 3

PHOSLO 4 GA

PHOSLYRA 4

RENAGEL 4

RENVELA 3

VELPHORO 4

PROGESTINS, INJECTABLE

progesterone 50mg/ml 1

PROGESTINS, ORAL

AYGESTIN 4 GA

medroxyprogesterone acetate 1

MEGACE ES 4 GA

megestrol susp 1

norethindrone acetate 1

progesterone micronized 1

PROMETRIUM 4 GA

PROVERA 4 GA

PROGESTINS, VAGINAL

CRINONE GEL 4% 3

SELECTIVE ESTROGEN RECEPTOR MODULATOR

EVISTA 4 PA; GA

OSPHENA 4

raloxifene 1 PA; PV

THYROID AGENTS, ANTITHYROID AGENTS

iodine soln strong (lugol's) 4 methimazole 1

propylthiouracil 1 SSKI 4


Requirements/



THYROID SUPPLEMENTS

ARMOUR THYROID 15MG, 120MG, 180MG, 240MG, 300MG 4

ARMOUR THYROID 30MG, 60MG, 90MG 4 GA CYTOMEL 4 GA

levothyroxine 1

levoxyl 1

liothyronine 1

NATURE THROID 4

SYNTHROID 2 GA thyroid tab 1

THYROLAR 4

TIROSINT 4

unithroid 1

WESTHROID 4

WP THYROID 4

VASOPRESSIN RECEPTOR ANTAGONISTS

SAMSCA 3 QL

VASOPRESSINS

DDAVP 4 GA desmopressin 1

STIMATE 4

GASTROINTESTINAL

ANTIDIARRHEALS

diphenoxylate/atropine 1

LOMOTIL 4 GA

MOTOFEN 4

opium tincture 1

ANTIEMETICS

AKYNZEO 4

ANZEMET 2

CESAMET 2

COMPAZINE 4 GA

dronabinol 1

EMEND 2

granisetron 1


Requirements/



MARINOL 4 GA metoclopramide 1

METOZOLV ODT 4 GA ondansetron 1

ondansetron soln 1 QL prochlorperazine 1

prochlorperazine supp 1

promethazine 1

promethazine supp 1

REGLAN 4 GA SANCUSO 4 PA; QL

TIGAN 4 GA TRANSDERM-SCOP 4

trimethobenzamide 1

VARUBI 4 QL

ZOFRAN 4 GA ZOFRAN SOLN 4 GA; QL

ZUPLENZ 4

ANTISPASMODICS

ANASPAZ 4 GA BELLADONNA/OPIUM SUPP 1

BENTYL 4 GA

CANTIL 2

chlordiazepoxide/clidinium 1

CUVPOSA 3

dicyclomine 1

DONNATAL 4

GASTRINEX NF 4

glycopyrrolate 1

hyoscyamine sulfate 1

hyoscyamine sulfate ext-rel 1

LEVBID 4 GA

LEVSIN 4 GA

LIBRAX 4 GA methscopolamine 1

propantheline 1

ROBINUL 4 GA

ROBINUL FORTE 4 GA SYMAX DUOTAB 4


Requirements/



CHOLELITHOLYTICS

ACTIGALL 4 GA

CHENODAL 2

URSO 250 4 GA URSO FORTE 4 GA

ursodiol 1

H2-RECEPTOR ANTAGONISTS

cimetidine 1

famotidine 1

nizatidine 1

PEPCID 4 GA ranitidine 1

ZANTAC 4 GA

INFLAMMATORY BOWEL DISEASE, ORAL AGENTS

APRISO 4

ASACOL HD 4 GA

AZULFIDINE 4 GA AZULFIDINE EN-TABS 4 GA

balsalazide 1

budesonide caps 1

COLAZAL 4 GA

DELZICOL 4

DIPENTUM 2

ENTOCORT EC 4 GA GIAZO 4

LIALDA 4

mesalamine delayed-rel 1

PENTASA 3

sulfasalazine 1

sulfasalazine delayed-rel 1

UCERIS 4

INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS

CANASA 2 CORTIFOAM 4

hydrocortisone enema 1 mesalamine enema 1

SFROWASA 4 UCERIS FOAM 4


Requirements/



IRRITABLE BOWEL SYNDROME WITH CONSTIPATION

AMITIZA 3 LINZESS 4

IRRITABLE BOWEL SYNDROME WITH DIARRHEA

alosetron 1

LOTRONEX 4 GA VIBERZI 4

LAXATIVES/STOOL SOFTENERS

CASCARA SAGRADA 2

COLYTE/FLAVOR PACKS 4 GA

GOLYTELY 4

GOLYTELY 4 GA

KRISTALOSE 1

lactulose 1

MOVIPREP 2 PV NULYTELY 4 GA

OSMOPREP 2 PV peg 3350/electrolytes 1 PV

PREPOPIK 4

SUPREP 2 PV

MISCELLANEOUS

BUPHENYL 4

BUPHENYL POWDER 4 GA

CARAFATE 4 GA CARAFATE SUSP 4

cromolyn sodium 100mg/5ml 1

ENTEREG 3

GASTROCROM 4 GA

lactulose (encephalopathy) 1

RECTIV 4

SUCRAID 2

sucralfate 1

OPIOID-INDUCED CONSTIPATION

MOVANTIK 4 PA

RELISTOR 3 PA; QL


Requirements/



PANCREATIC ENZYMES

CREON 2

PANCREAZE 2

PERTZYE 2 VIOKACE 2

ZENPEP 2 ZENPEP 5000 UNIT 4

PROSTAGLANDINS

CYTOTEC 4 GA

misoprostol 1

PROTON PUMP INHIBITORS (PPI)

ACIPHEX 4 GA; QL

ACIPHEX SPRINKLE 4 PA; QL DEXILANT 4 PA; QL

esomeprazole 1 PA; QL lansoprazole 1 QL

NEXIUM 4 PA; GA; QL NEXIUM GRANULES 4 PA; QL

omeprazole 1 QL pantoprazole 1 QL

PREVACID 4 GA; QL PREVACID SOLUTAB 4 PA; QL

PRILOSEC 4 GA; QL PRILOSEC POWDER 4 PA; QL

PROTONIX 4 GA; QL

PROTONIX PAK 4 PA; QL rabeprazole 1 QL

SALIVA STIMULANTS

cevimeline 1

EVOXAC 4 GA pilocarpine 1

SALAGEN 4 GA

STEROIDS, RECTAL

ANALPRAM-HC CREAM 4 GA

ANALPRAM-HC LOTION 4

ANUSOL-HC 4 GA

EPIFOAM 3

hydrocortisone acetate supp 1


Requirements/



hydrocortisone cream 1

hydrocortisone/pramoxine 1

lidazone 1 lidocaine/hydrocortisone 1

LIDOCAINE/HYDROCORTISONE GEL 1 PROCORT 3

PROCTOCORT 4 GA PROCTOFOAM HC 3

ULCER THERAPY COMBINATION

lansoprazole/amoxicillin/clarithromycin 1

OMECLAMOX-PAK 4

PREVPAC 4 GA PYLERA 4

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA

alfuzosin 1

AVODART 4 GA CARDURA XL 4

dutasteride 1

dutasteride/tamsulosin 1

finasteride 1

FLOMAX 4 GA JALYN 4 GA

PROSCAR 4 GA RAPAFLO 4 QL

tamsulosin 1

UROXATRAL 4 GA

ERECTILE DYSFUNCTION, ALPROSTADIL AGENTS

CAVERJECT 4 QL EDEX 4 QL

MUSE 4 QL

ERECTILE DYSFUNCTION, PHOSPHODIESTERASE INHIBITORS

CIALIS 4 PA; QL LEVITRA 4 PA; QL

STAXYN 4 PA; QL

STENDRA 4 PA; QL VIAGRA 2 PA; QL


Requirements/



MISCELLANEOUS

bethanechol 1

CYSTAGON 2

ELMIRON 3 LITHOSTAT 3

methenamine hippurate 1 methenamine mandelate 1

methenamine/hyoscyamine/methylene blue/

phenyl salicylate/benzoic acid 1


phenyl salicylate/sodium bisphosphonate 1


phenyl salicylate/sodium phosphate 1


sodium phosphate 1

ORACIT 4

phenazopyridine 1

potassium citrate 1

potassium citrate/citric acid 1

potassium citrate/sodium citrate/citric acid 1

PROCYSBI 4

PYRIDIUM 4 GA

RIMSO-50 4

SHOHLS SOLN MODIFIED 4 GA

sodium citrate/citric acid 1

THIOLA 2

UROCIT-K 4 GA UROGESIC-BLUE 4 GA

UROQID #2 2

URINARY ANTISPASMODICS

darifenacin ext-rel 1

DETROL 4 GA DETROL LA 4 GA

DITROPAN XL 4 GA ENABLEX 4 GA

flavoxate 1

GELNIQUE 4

MYRBETRIQ 4

oxybutynin 1

oxybutynin ext-rel 1


Requirements/



tolterodine 1

tolterodine ext-rel 1

TOVIAZ 4 QL trospium 1

trospium ext-rel 1

VESICARE 4

VAGINAL ANTI-INFECTIVES

AVC 4

CLEOCIN CREAM 4 GA

CLEOCIN SUPP 3

clindamycin cream 1

CLINDESSE 4

GYNAZOLE-1 4

METROGEL-VAGINAL 4 GA metronidazole gel 0.75% 1

NUVESSA 4

TERAZOL 3 4 GA

TERAZOL 7 4 GA

terconazole cream 0.4% 1

terconazole cream 0.8% 1 PV

terconazole supp 1

HEMATOLOGIC

ANTICOAGULANTS, INJECTABLE

ARIXTRA 4 GA enoxaparin 1

fondaparinux 1

FRAGMIN 2

LOVENOX 4 GA

ANTICOAGULANTS, ORAL

COUMADIN 2 GA; PV

ELIQUIS 2 PV PRADAXA See Appendix A PV

SAVAYSA 4 MN-PA warfarin 1 PV

XARELTO 2 PV

HEMATOPOIETIC GROWTH FACTORS

ARANESP SP-P


Requirements/



EPOGEN SP-P

GRANIX SP-P LEUKINE SP-P

NEULASTA SP-P NEUPOGEN SP-P

PROCRIT SP-P

ZARXIO SP-P

HEMOSTATICS, SYSTEMIC

AMICAR 4

LYSTEDA 4 GA tranexamic acid 1

HEREDITARY ANGIOEDEMA AGENTS

FIRAZYR SP-P PA

IDIOPATHIC THROMBOCYTOPENIC PURPURA

PROMACTA SP-P PA; QL

MISCELLANEOUS

CHEMET 2

cilostazol 1 EXJADE 2

FERRIPROX 4 pentoxifylline 1

PLATELET AGGREGATION INHIBITORS

AGGRENOX 4 GA aspirin/dipyridamole ext-rel 1

BRILINTA See Appendix B

clopidogrel 1 PV

dipyridamole 1 PV EFFIENT 3

PLAVIX 4 GA

PLATELET SYNTHESIS INHIBITORS

anagrelide 1

IMMUNOLOGIC AGENTS

ALLERGENIC EXTRACTS

GRASTEK 4 PA; QL


Requirements/



ORALAIR 4 PA; QL RAGWITEK 4 PA; QL

BIOLOGIC DISEASE-MODIFYING AGENTS

ACTEMRA SP-P PA; QL CIMZIA SP-NP PA; QL

ENBREL SP-P PA; QL HUMIRA SP-P PA; QL

KINERET SP-P PA; QL ORENCIA SP-P PA; QL

SIMPONI SP-NP PA; QL

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS)

ARAVA 4 GA DEPEN 2

hydroxychloroquine 1

leflunomide 1

PLAQUENIL 4 GA

RHEUMATREX 2

RIDAURA 2

XELJANZ SP-P PA; QL

IMMUNOMODULATORS, INTERFERONS

ACTIMMUNE SP-P

PEGASYS SP-P PA; QL PEGINTRON SP-P PA; QL

SYLATRON SP-P

IMMUNOMODULATORS, MISCELLANEOUS

OTEZLA SP-P PA; QL

IMMUNOSUPPRESSANTS, ANTIMETABOLITES

AZASAN 1

azathioprine 1 CELLCEPT 2 GA

IMURAN 4 GA mycophenolate mofetil 1 PV

mycophenolate sodium delayed-rel 1 PV MYFORTIC 4 GA

IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS

ASTAGRAF XL 2 PV


Requirements/



cyclosporine 1 PV cyclosporine modified 1 PV

NEORAL 3 GA PROGRAF 3 GA

SANDIMMUNE 3 GA SANDIMMUNE SOLN 3

tacrolimus 1 PV

IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE

RAPAMUNE SOLN 2 PV

RAPAMUNE TABS 4 GA sirolimus

ZORTRESS

1

SP-P

PV

VACCINES

ACTHIB 2 PV ADACEL 2 PV AFLURIA 2 PV

BEXSERO 2 PV BOOSTRIX 2 PV

CERVARIX 2 PV DAPTACEL 2 PV

DIPHTHERIA/TETANUS TOXOID 2 PV ENGERIX-B 2 PV

FLUARIX 2 PV FLUBLOK 2 PV

FLUCELVAX 2 PV

FLULAVAL 2 PV FLUVIRIN 2 PV

FLUZONE 2 PV GARDASIL 2 PV

HAVRIX 2 PV HIBERIX 2 PV

INFANRIX 2 PV IPOL INACTIVATED IPV 2 PV

KINRIX 2 PV M-M-R II 2 PV

MENACTRA 2 PV MENHIBRIX 2 PV

MENOMUNE 2 PV MENVEO 2 PV

PEDIARIX 2 PV



Requirements/



PEDVAX HIB 2 PV PENTACEL 2 PV

PNEUMOVAX 23 2 PV PREVNAR 13 2 PV

PROQUAD 2 PV QUADRACEL 2 PV

RECOMBIVAX HB 2 PV ROTARIX 2 PV

ROTATEQ 2 PV

TENIVAC 2 PV TRUMENBA 2 PV

TWINRIX 2 PV VAQTA 2 PV

VARIVAX 2 PV ZOSTAVAX

MISCELLANEOUS

2 PV

DIAGNOSTIC PRODUCTS

CHEMSTRIP 2 PV

COMBISTIX 2 PV HEMA-COMBISTIX 2 PV

LABSTIX 2 PV MULTISTIX 2 PV

URISTIX 2 PV

NUTRITIONAL / SUPPLEMENTS

ELECTROLYTES, MISCELLANEOUS

K-PHOS 3

K-PHOS NEUTRAL 4 GA

K-PHOS NO 2 4

potassium/sodium phosphates 1

ELECTROLYTES, POTASSIUM

EFFER-K 4

K-TAB 4 GA

KLOR-CON M15 1

KLOR-CON/25 4

MICRO-K 4 GA

potassium bicarbonate effervescent 1

potassium bicarbonate/chloride effervescent 1


Requirements/



potassium chloride ext-rel 1

potassium chloride powder 1

potassium chloride soln 1

ELECTROLYTES, POTASSIUM-REMOVING AGENTS

sodium polystyrene sulfonate susp 1 VELTASSA SP-P

VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS

folic acid 1

VITAMINS AND MINERALS, MISCELLANEOUS

ergocalciferol 50,000 IU 1 MAGNEBIND 400 4 MEPHYTON 2

VITAMINS AND MINERALS, PRENATAL VITAMINS

ACTIVE OB 2 PV

ATABEX EC 2 PV BAL-CARE DHA 2 PV C-NATE DHA 2 PV

CALCIUM PNV 2 PV CITRANATAL 2 PV

CO-NATAL FA 2 PV COMPLETE NATAL DHA 2 PV COMPLETENATE 2 PV

CONCEPT 2 PV DOTHELLE DHA 2 PV

DUET DHA 2 PV elite-ob 2 PV ENBRACE HR 2 PV

EXTRA-VIRT PLUS DHA 2 PV FOCALGIN 2 PV FOLCAL DHA 2 PV

FOLCAPS OMEGA 3 2 PV FOLET 2 PV

folinatal plus b 2 PV FOLIVANE-OB 2 PV HEMENATAL 2 PV

inatal advance 2 PV inatal gt 2 PV

inatal ultra 2 PV


Requirements/



INFANATE BALANCE 2 PV LEVOMEFOLATE DHA 2 PV

MACNATAL CN DHA 2 PV MARNATAL-F 2 PV

multinatal plus 2 PV MYNATAL 2 PV

MYNATE 90 PLUS 2 PV NATACHEW 2 PV

NATALVIT 2 PV

NATELLE ONE 2 PV NEEVO DHA 2 PV

NESTABS 2 PV NEWGEN 2 PV

NEXA PLUS 2 PV O-CAL PRENATAL 2 PV

OB COMPLETE 2 PV OB COMPLETE GOLD 2 PV

OBSTETRIX 2 PV PAIRE OB 2 PV

PNV OB+DHA 2 PV PNV TABS 29-1 2 PV

pnv-dha 2 PV PNV-DHA+DOCUSATE 2 PV

PNV-OMEGA 2 PV

pnv-select 2 PV PNV-TOTAL 2 PV

PNV-VP-U 2 PV PR NATAL 2 PV

PREFERAOB 2 PV PRENA1 2 PV

PRENAISSANCE 2 PV PRENATA 2 PV

prenatabs fa 2 PV prenatabs rx 2 PV

PRENATAL 2 PV PRENATAL 19 CHEW 2 PV

PRENATAL 19 TABS 2 PV PRENATAL VITAMINS/FERROUS FUMARATE/

DOCUSATE 2 PV

PRENATE 2 PV PREQUE 10 2 PV


Requirements/



PRETAB 2 PV PROVIDA 2 PV

PUREFE OB PLUS 2 PV R-NATAL OB 2 PV

REDICHEW RX 2 PV RELNATE DHA 2 PV

RULAVITE DHA 2 PV SE-NATAL 19 2 PV

SE-TAN DHA 2 PV

SELECT-OB 2 PV TARON-BC 2 PV

TARON-C DHA 2 PV TARON-PREX 2 PV

THRIVITE 2 PV TL FOLATE 2 PV

TL-CARE DHA 2 PV TL-SELECT 2 PV

TRI-TABS DHA 2 PV triadvance 2 PV

TRICARE 2 PV TRINATAL 2 PV

trinate 2 PV TRISTART DHA 2 PV

TRIVEEN-DUO DHA 2 PV

TRIVEEN-PRX 2 PV ULTIMATECARE 2 PV

ultra tabs 2 PV VEMAVITE 2 PV

VENA-BAL DHA 2 PV VINACAL B 2 PV

VINATE 2 PV VIRT NATE 2 PV

VIRT-ADVANCE 2 PV VIRT-C DHA 2 PV

VIRT-CARE ONE 2 PV VIRT-PN 2 PV

VIRT-SELECT 2 PV VIRT-VITE GT 2 PV

VIRTPREX 2 PV

VITA-PREN 2 PV VITAFOL 2 PV


Requirements/



VITAMEDMD 2 PV VITAPEARL 2 PV

VITATRUE 2 PV VIVA DHA 2 PV

VOL-NATE 2 PV VOL-TAB RX 2 PV

VP-CH 2 PV VP-GGR-B6 PRENATAL 2 PV

VP-HEME 2 PV

VP-PNV-DHA 2 PV ZATEAN

RESPIRATORY

2 PV

ANAPHYLAXIS TREATMENT AGENTS

ADRENACLICK 3 GA epinephrine inj 3

EPIPEN 2

EPIPEN JR 2

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ANORO ELLIPTA 4 COMBIVENT RESPIMAT 2 ipratropium/albuterol nebulizer soln 1

STIOLTO RESPIMAT 4

ANTICHOLINERGICS

ATROVENT HFA 2 ipratropium nebulizer soln 1

SPIRIVA HANDIHALER 2 SPIRIVA RESPIMAT 3

TUDORZA PRESSAIR 4

ANTIHISTAMINE/DECONGESTANT COMBINATIONS

CLARINEX-D 12 HOUR 4 DECON-A 4 promethazine/phenylephrine 1

RELHIST 4 RESCON-MX 4

SEMPREX-D 4


Requirements/



ANTIHISTAMINES, LOW-SEDATING

levocetirizine 1 XYZAL 4 GA

ANTIHISTAMINES, NONSEDATING

CLARINEX 4 GA

CLARINEX SYRUP 4

desloratadine 1

ANTIHISTAMINES, SEDATING

brompheniramine 1

carbinoxamine 1

clemastine 1

cyproheptadine 1

hydroxyzine hcl 1

hydroxyzine pamoate 1

KARBINAL ER 4

RESPA-BR 3

VISTARIL 4 GA

ANTITUSSIVE COMBINATIONS, NON-OPIOID

CARBAPHEN 4 DECON-G 4

dextromethorphan/brompheniramine/

pseudoephedrine 1 dextromethorphan/brompheniramine/

pseudoephedrine 4 dextromethorphan/chlorpheniramine/

phenylephrine 4

dextromethorphan/guaifenesin/phenylephrine 1

EXACTUSS 3 GA

GILTUSS 3 GA giltuss pediatric 1

NEOTUSS PLUS 4

NORTUSS-EX 4

PEDIATEX TDM 4

promethazine/dextromethorphan 1

TGQ DM/BPM/PSE 4

TGQ DM/CPM/PE 4

TGQ DM/GFN/PSE 4

TUSNEL 4


Requirements/



ANTITUSSIVE COMBINATIONS, OPIOID

FLOWTUSS 4

GILTUSS PED-C 4

HYCOFENIX 4

hydrocodone polistirex/chlorpheniramine 1

hydrocodone/chlorpheniramine/

pseudoephedrine 1

hydrocodone/homatropine 1

OBREDON 4

promethazine/codeine 1

promethazine/phenylephrine/codeine 1

REZIRA 4

SUTTAR-2 4 GA

SUTTAR-SF 4 GA TUSSICAPS 4

TUSSIONEX 4 GA TUZISTRA XR 4

VITUZ 4

ZUTRIPRO 4 GA

ANTITUSSIVES

benzonatate 1

TESSALON PERLES 4 GA

ZONATUSS 4 GA

BETA AGONISTS, INHALANTS, LONG ACTING

ARCAPTA NEOHALER 4

BROVANA 2 PV FORADIL AEROLIZER 2 PV

PERFOROMIST 2 PV SEREVENT DISKUS 2 PV

STRIVERDI RESPIMAT 3

BETA AGONISTS, INHALANTS, SHORT ACTING

albuterol nebulizer soln 1

levalbuterol nebulizer soln 1

metaproterenol 1

PROAIR HFA 1

PROVENTIL HFA 2

VENTOLIN HFA 2

XOPENEX HFA 4 MN-PA


Requirements/



XOPENEX NEBULIZER 4 GA

BETA AGONISTS, ORAL AGENTS

albuterol 1

albuterol ext-rel 1

terbutaline 1

VOSPIRE ER 4 GA

CYSTIC FIBROSIS

CAYSTON KALYDECO

3 SP-P

PA; QL

ORKAMBI PULMOZYME

TOBI NEBULIZER tobramycin nebulizer soln

SP-P SP-P

SP-NP SP-P

PA; QL

GA

DECONGESTANT/EXPECTORANT COMBINATIONS

phenylephrine/guaifenesin 1

LEUKOTRIENE MODIFIERS

ACCOLATE 4 GA

montelukast 1 PV SINGULAIR 4 GA

zafirlukast 1 PV ZYFLO 4

ZYFLO CR 4

MAST CELL STABILIZERS

cromolyn sodium nebulizer soln 1 PV

MISCELLANEOUS

acetylcysteine 1

ATROVENT NASAL 4 GA caffeine citrate 1

dyphylline-guaifenesin 1

HYPERSAL 3.5% 4

HYPERSAL 7% 4 GA

ipratropium nasal spray 1

NEBUSAL 4

sodium chloride nebulizer soln 1

XOLAIR SP-P PA; QL


Requirements/



NASAL ANTIHISTAMINE/STEROID COMBINATIONS

DYMISTA 4 PA

NASAL ANTIHISTAMINES

ASTEPRO 4 GA azelastine spray 1

olopatadine spray 1

PATANASE 4 GA

NASAL STEROIDS

BECONASE AQ 4 PA flunisolide spray 1

mometasone spray 1 PA NASONEX 4 PA; GA

OMNARIS 4 PA QNASL 4 PA

VERAMYST 4 PA ZETONNA 4 PA

PHOSPHODIESTERASE-4 INHIBITORS

DALIRESP 4

PULMONARY FIBROSIS AGENTS

ESBRIET SP-P PA; QL OFEV SP-P PA; QL

STEROID INHALANTS

AEROSPAN 4 MN-PA ALVESCO 4 MN-PA

ASMANEX 1 PV budesonide nebulizer susp 1 PV

FLOVENT DISKUS 4 MN-PA FLOVENT HFA 4 MN-PA

PULMICORT 4 GA

PULMICORT FLEXHALER 4 MN-PA QVAR 1 PV

STEROID/BETA AGONIST COMBINATIONS

ADVAIR DISKUS 2 PV ADVAIR HFA 2 PV BREO ELLIPTA See Appendix B PA


Requirements/



DULERA 2 PV SYMBICORT 4 MN-PA

TOPICAL DECONGESTANTS

ADRENALIN 3 TYZINE 4

XANTHINES

ELIXOPHYLLIN 4

LUFYLLIN 3 THEO-24 1

theophylline ext-rel 1

theophylline soln 1

TOPICAL

DERMATOLOGY, ACNE: ORAL

claravis 1 myorisan 1

zenatane 1

DERMATOLOGY, ACNE: TOPICAL

ACANYA 4

ACZONE 4

adapalene 1

ATRALIN 4 PA; GA AVAR 4

AVAR LS 4

AVAR LS CLEANSER 4 GA

AVAR-E LS 4 GA AZELEX 4

BENZACLIN 4

BENZACLIN PUMP 4 GA

BENZAMYCIN 4 GA BENZAMYCIN PAK 4

BENZEFOAM 4 GA BENZIQ 4

benzoyl peroxide 1

BPO 1

CLEOCIN-T 4 GA

CLINDAGEL 4

clindamycin 1


Requirements/



clindamycin/benzoyl peroxide 1

clindamycin/tretinoin 1 PA

DIFFERIN 4 GA DUAC GEL 4 GA

EPIDUO 4

ERYGEL 4 GA

erythromycin gel, pads, soln 1

erythromycin/benzoyl peroxide 1

EVOCLIN 4 GA

KLARON 4 GA NUOX 4

PLEXION CLEANSER, CREAM, LOTION 4 GA PLEXION PADS 4

RETIN-A 4 PA; GA RIAX 4

ROSULA 4

sulfacetamide lotion 1

sulfacetamide/sulfur 1

SULFOAM 4

SUMADAN WASH 4 GA SUMAXIN 4 GA

TAZORAC 4

TRETIN-X 4

tretinoin 1 PA

VANOXIDE-HC 4

VELTIN 4 PA

ZACLIR 4

ZIANA 4 PA; GA

DERMATOLOGY, ACTINIC KERATOSIS

CARAC 4 PA; GA

diclofenac gel 3% 1 PA EFUDEX 4 GA

FLUOROPLEX 3 PA

fluorouracil cream 0.5% 1 PA fluorouracil cream, drop, soln 5% 1

fluorouracil drop, soln 2% 1

LEVULAN KERASTICK 3

METVIXIA 3

PICATO 4 PA

SOLARAZE 4 PA; GA


Requirements/



ZYCLARA 4 PA

DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS

CORTISPORIN CREAM 0.5% 4 CORTISPORIN OINT 1% 4

NEO-SYNALAR 4

DERMATOLOGY, ANTIBIOTICS

ALTABAX 4

BACTROBAN 4 GA BACTROBAN NASAL 4

CENTANY 4

gentamicin 1

mupirocin 1

SILVADENE 4 GA

silver sulfadiazine 1

DERMATOLOGY, ANTIFUNGALS

ciclopirox 1

clotrimazole/betamethasone 1 econazole 1

ECOZA 4 ERTACZO 4

EXELDERM 4 EXTINA 4 GA

HALOTIN 1

ketoconazole 1

LOPROX SHAMPOO 4 GA LOTRISONE 4 GA

LUZU 4

naftifine cream 1

NAFTIN CREAM 4 GA

NAFTIN GEL 4

NIZORAL 4 GA

nystatin topical 1

nystatin/triamcinolone 1

oxiconazole cream 1

OXISTAT CREAM 4 GA

OXISTAT LOTION 4

PENLAC 4 GA


Requirements/



VUSION 4

DERMATOLOGY, ANTIPSORIATICS, INJECTABLE

COSENTYX SP-P PA; QL COSENTYX PEN SP-P PA; QL

DERMATOLOGY, ANTIPSORIATICS, ORAL

acitretin 1

methoxsalen 1

8-MOP 4 OXSORALEN-ULTRA 4 GA

SORIATANE 4 GA

DERMATOLOGY, ANTIPSORIATICS, TOPICAL

calcipotriene 1

calcitriol oint 1

DOVONEX 4 GA

DRITHO-CREME HP 4

SORILUX 4

TACLONEX OINT 4 GA TACLONEX SUSP 4

VECTICAL 4 GA

ZITHRANOL 4

ZITHRANOL-RR 4

DERMATOLOGY, ANTISEBORRHEICS

OVACE PLUS CREAM, FOAM, LOTION 4

OVACE PLUS SHAMPOO, WASH 4 GA OVACE WASH 4 GA

selenium sulfide 1

SELRX 4

sulfacetamide gel, shampoo, wash 1

DERMATOLOGY, ANTISEPTICS/DISINFECTANTS

triple dye soln 4

DERMATOLOGY, CORTICOSTEROID COMBINATIONS

PRAMOSONE CREAM 1-1% 1

PRAMOSONE CREAM 1-2.5% 4 GA

PRAMOSONE E 4

PRAMOSONE LOTION 1

PRAMOSONE OINT 4


Requirements/



pramoxine/hydrocortisone 1-2.5% 1

DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY

amcinonide cream, lotion 0.1% 1 AMCINONIDE OINT 0.1% 1 APEXICON E 4

betamethasone dipropionate augmented

cream, lotion 0.05% 1

betamethasone dipropionate cream,

lotion, oint 0.05% 1

desoximetasone cream, oint 0.25% 1

desoximetasone gel 0.05% 1

diflorasone 1

DIPROLENE 4 GA

DIPROLENE AF 4 GA fluocinonide cream 0.1% 1

fluocinonide cream, gel, oint, soln 0.05% 1

fluocinonide-e cream 0.05% 1

HALOG 4

TOPICORT CREAM, OINT 0.25% 4 GA TOPICORT GEL 0.05% 4 GA

TOPICORT SPRAY 0.25% 4

triamcinolone cream, oint 0.5% 1

VANOS 4 GA

DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY

ALA SCALP 4 GA

alclometasone 1

CAPEX 4

DERMA-SMOOTHE/FS BODY, SCALP 4 GA DESONATE 4

desonide cream, lotion, oint 0.05% 1

DESOWEN CREAM, LOTION, OINT 0.05% 4 GA

fluocinolone acetonide cream, soln 0.01% 1

fluocinolone acetonide oil body, scalp 1

hydrocortisone cream, lotion, oint 2.5% 1

hydrocortisone lotion 2% 1

NUCORT 3

SYNALAR 4 GA

TEXACORT 4

VERDESO 4


Requirements/



DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY

betamethasone valerate cream, lotion,

oint 0.1% 1

betamethasone valerate foam 1

clocortolone cream 0.1% 4

CLODERM 4 GA CORDRAN CREAM, LOTION, OINT 0.05% 4

CORDRAN TAPE 4

CUTIVATE CREAM, LOTION 0.05% 4 GA

desoximetasone cream, oint 0.05% 1

ELOCON CREAM, LOTION, OINT 0.1% 4 GA

fluocinolone acetonide cream, oint 0.025% 1

fluticasone cream, lotion 0.05% 1

fluticasone oint 0.005% 1

hydrocortisone butyrate cream, oint, soln 0.1% 1

hydrocortisone valerate cream, oint 0.2% 1

KENALOG SPRAY 4 GA

LOCOID CREAM, OINT, SOLN 0.1% 4 GA

LOCOID LIPOCREAM 0.1% 4 GA LOCOID LOTION 0.1% 4

LUXIQ 4 GA mometasone cream, oint, soln 0.1% 1

PANDEL 4

prednicarbate cream, oint 0.1% 1

SYNALAR CREAM, OINT 0.025% 4 GA TOPICORT CREAM, OINT 0.05% 4 GA

triamcinolone cream 0.1% 1

triamcinolone cream, lotion, oint 0.1% 1

triamcinolone cream, lotion, oint 0.025% 1

triamcinolone spray 1

TRIANEX 3

DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY

betamethasone dipropionate augmented gel, oint 0.05% 1

clobetasol cream, gel, lotion, oint, shampoo,

soln, spray 0.05% 1

clobetasol emollient cream 0.05% 1

clobetasol foam 1 CLOBEX LOTION, SHAMPOO, SPRAY 0.05% 4 GA

diflorasone oint 0.05% 1


Requirements/



DIPROLENE OINT 0.05% 4 GA halobetasol cream, oint 0.05% 1

OLUX 4 GA OLUX-E 4 GA

TEMOVATE CREAM, GEL, OINT, SOLN 0.05% 4 GA TEMOVATE E CREAM 0.05% 4 GA

ULTRAVATE CREAM, OINT 0.05% 4 GA ULTRAVATE LOTION 0.05% 4

DERMATOLOGY, EMOLLIENTS

CEM-UREA 4

GORDONS UREA 4

HYDRO 40 FOAM 4 GA KERAFOAM 4

KERALAC 4 GA LATRIX XM 4

RYNODERM 4

UMECTA 4

UMECTA NAIL FILM 4 GA

UMECTA PD 4

URAMAXIN 4 GA

URAMAXIN FOAM 3

urea cream 1

urea emulsion 1

urea foam 1

urea gel 1

urea lotion 1

UREA NAIL 4

urea nail gel 45% 1

urea nail susp 1

urea susp 1

UTOPIC 4

DERMATOLOGY, IMMUNOMODULATORS

ELIDEL 4

PROTOPIC 4 GA tacrolimus oint 1

DERMATOLOGY, LOCAL ANALGESIC

lidocaine pad 5% 1 LIDODERM 4 GA


Requirements/



DERMATOLOGY, LOCAL ANESTHETICS

EMLA 4 GA

lidocaine oint 5% 1

lidocaine soln 4% 1

lidocaine/prilocaine 1

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

acyclovir oint 1

ALDARA 4 GA ARZOL SILVER NITRATE APPLICATORS 4 GA

CONDYLOX GEL 4 PA

CONDYLOX SOLN 4 GA DENAVIR 4

doxepin cream 5% 1

imiquimod 1

PANRETIN 3

PODOCON 25 1

podofilox soln 0.5% 1

PRUDOXIN CREAM 5% 4 GA

SALICYLIC ACID 26% 1

salicylic acid soln 27.5% 1

SANTYL 3

silver nitrate applicators 1

SILVER NITRATE OINT, SOLN 10% 1

SILVER NITRATE SOLN 0.5%, 25%, 50% 1

SULFAMYLON CREAM 3

SULFAMYLON PAK 4 GA TRI-CHLOR 1

VEREGEN 3 PA VIRASAL 4 GA

XERESE 4

ZONALON CREAM 5% 4 GA

ZOVIRAX CREAM 4

ZOVIRAX OINT 4 GA

DERMATOLOGY, ROSACEA

DOXYCYCLINE DELAYED-REL 40MG 4 PA FINACEA 4

METROCREAM 4 GA METROGEL 4 GA

METROLOTION 4 GA


Requirements/



metronidazole cream, gel, lotion 0.75% 1

metronidazole gel 1% 1

MIRVASO 4

NORITATE 4

ORACEA 4 PA

DERMATOLOGY, SCABICIDES AND PEDICULICIDES

ELIMITE 4 GA EURAX 3

lindane 1

malathion 1

NATROBA 4 GA

OVIDE 4 GA permethrin 1

SKLICE 4

spinosad 4

ULESFIA 3

DERMATOLOGY, WOUND CARE PRODUCTS

REGRANEX 3

MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS

ARESTIN 2

chlorhexidine gluconate 1

DEBACTEROL 3 PERIDEX 4 GA

triamcinolone dental paste 1

viscous lidocaine 1

OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 3 MAXITROL 4 GA

neomycin/polymyxin b/bacitracin/

hydrocortisone 1

neomycin/polymyxin b/dexamethasone 1

neomycin/polymyxin b/hydrocortisone 1

PRED-G 3

PRED-G S.O.P 3

sulfacetamide/prednisolone 1


Requirements/



TOBRADEX OINT 3

TOBRADEX ST 4

TOBRADEX SUSP 4 GA tobramycin/dexamethasone 1

ZYLET 3

OPHTHALMIC, ANTI-INFECTIVES

AZASITE 3

bacitracin 1 bacitracin/polymyxin b 1

BESIVANCE 3 BETADINE OPHTHALMIC PREP 3

BLEPH-10 4 GA CILOXAN OINT 3

CILOXAN SOLN 4 GA ciprofloxacin ophth 1

erythromycin oint 1

GARAMYCIN 4 GA

gatifloxacin 1

gentamicin ophth 1

levofloxacin soln 1

MOXEZA 3

neomycin/bacitracin/polymyxin b 1

neomycin/polymyxin b/gramicidin 1

OCUFLOX 4 GA

ofloxacin ophth 1

polymyxin b/trimethoprim 1

POLYTRIM 4 GA sulfacetamide ophth 1

tobramycin soln 1

TOBREX OINT 3

TOBREX SOLN 4 GA VIGAMOX 3

ZYMAXID 4 GA

OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL

ACULAR 4 GA ACULAR LS 4 GA ACUVAIL 3

bromfenac 1

diclofenac 1

flurbiprofen soln 1


Requirements/



ILEVRO 4 ketorolac soln 1

NEVANAC 4 PROLENSA 4

OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL

ALREX 3

dexamethasone soln 1

DUREZOL 3 FLAREX 3

fluorometholone 1 FML FORTE 4

FML LIQUIFILM 4 GA FML OINT 3

LOTEMAX 3

MAXIDEX 3

OMNIPRED 3 GA PRED FORTE 3 GA

PRED MILD 3

prednisolone acetate 1% 1

PREDNISOLONE PHOSPHATE 1% 1

VEXOL 3

OPHTHALMIC, ANTIALLERGICS

ALOCRIL 3

ALOMIDE 3

azelastine 1

BEPREVE 3 cromolyn sodium 1

ELESTAT 4 GA EMADINE 3

epinastine 1

LASTACAFT 4

olopatadine 1

PATADAY 4

PATANOL 4 GA PAZEO 4

OPHTHALMIC, ANTIFUNGALS

NATACYN 3


Requirements/



OPHTHALMIC, ANTIVIRAL

trifluridine 1

VIROPTIC 4 GA

ZIRGAN 4

OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE

BETIMOL 2

carteolol 1

ISTALOL 3 levobunolol 1

metipranolol 1

timolol gel soln 1 timolol soln 1

TIMOPTIC 0.25%, 0.5% 4 GA TIMOPTIC OCUDOSE 0.25%, 0.5% 4

TIMOPTIC-XE 4 GA

OPHTHALMIC, BETA-BLOCKERS: SELECTIVE

betaxolol soln 1 BETOPTIC-S 2

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS

COSOPT 4 GA COSOPT PF 4

dorzolamide/timolol 1

OPHTHALMIC, CARBONIC ANHYDRASE

INHIBITOR/SYMPATHOMIMETIC COMBINATIONS

SIMBRINZA 4

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL

acetazolamide 1

acetazolamide ext-rel 1

DIAMOX SEQUELS 4 GA

methazolamide 1

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL

AZOPT 3

dorzolamide 1

TRUSOPT 4 GA


Requirements/



OPHTHALMIC, IMMUNOMODULATOR

RESTASIS 3

OPHTHALMIC, LOCAL ANESTHETIC

AKTEN 3

OPHTHALMIC, MISCELLANEOUS

CYSTARAN 2

LACRISERT 3 naphazoline 1

phenylephrine 1 proparacaine 1

tetracaine 1

OPHTHALMIC, MYDRIATICS

ATROPINE OINT 1

atropine soln 1 CYCLOGYL 0.5%, 1%, 2% 4 GA

CYCLOMYDRIL 4

cyclopentolate 1

homatropine 1

ISOPTO HOMATROPINE 2% 4

ISOPTO HOMATROPINE 5% 4 GA ISOPTO HYOSCINE 4

tropicamide 1

OPHTHALMIC, PARASYMPATHOMIMETICS

ISOPTO CARBACHOL 4

MIOCHOL-E 4 pilocarpine soln 1

OPHTHALMIC, PROSTAGLANDINS

bimatoprost 1

latanoprost 1

LUMIGAN 2 TRAVATAN Z 4

travoprost 4 XALATAN 4 GA

ZIOPTAN 4


Requirements/



OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER

COMBINATIONS

COMBIGAN 4

OPHTHALMIC, SYMPATHOMIMETICS

ALPHAGAN P 0.1% 4

ALPHAGAN P 0.15% 4 GA

apraclonidine 1

brimonidine 0.15%, 0.2% 1

IOPIDINE 0.5% 4 GA IOPIDINE 1% 3

PHOSPHOLINE IODIDE 3

OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS

CIPRO HC 3

CIPRODEX 3 COLY-MYCIN S 3

CORTISPORIN 4 GA CORTISPORIN-TC 3

hydrocortisone/acetic acid 1

neomycin/polymyxin b/hydrocortisone soln 1

neomycin/polymyxin b/hydrocortisone susp 1

OTIC, ANTI-INFECTIVES

acetic acid 1

acetic acid/aluminum acetate 1 CETRAXAL 4 GA

ciprofloxacin otic 1

ofloxacin otic 1

OTIC, MISCELLANEOUS

antipyrine/benzocaine 1

antipyrine/benzocaine/polycosanol 1

CORTANE-B 4 GA DERMOTIC 4 GA

fluocinolone acetonide oil 0.01% 1

MYOXIN 1

OTICIN HC DRO 4 GA pramoxine/chloroxylenol 1

pramoxine/hydrocortisone/chloroxylenol 1

TREAGAN OTIC 4 GA



APPENDIX A


Drug Use Update

Levemir

# of members

impacted: 4

A long-acting insulin

used to treat high blood

sugar in adults and

children with diabetes.

Moving from Tier 2 to Tier 4 in the formulary and

applying prior authorization criteria.

Grandfathered: Prior authorization not required for

members currently prescribed Levemir.

Farxiga

# of members

impacted: 5

Used to lower blood

sugar in adults with

type 2 diabetes.

Remains on Tier 4 in the formulary.

Applying prior authorization criteria.

Members are required to first try the lower cost alternatives of Invokana and Jardiance.

Xigduo XR

# of members

impacted: 0

Used to lower blood

sugar in adults with

type 2 diabetes.

Remains on Tier 4 in the formulary.

Applying prior authorization criteria.

Members are required to first try the lower cost

alternatives of Invokamet and Synjardy. Or,

Invokana and Jardiance when combined with Metformin.

Pradaxa

# of members

impacted: 5

A blood thinner that

lowers the chance of

blood clots forming in

the body.

Moving from Tier 2 to Tier 4 in the formulary and applying prior authorization criteria.

Grandfathered: Prior authorization not required for members currently prescribed Pradaxa.

Aspirin

# of members

impacted: 9

Used for the prevention

of cardiovascular

disease and colorectal

cancer.

Plan benefits for aspirin at no cost are changing to

meet new standard coverage guidelines for the

Affordable Care Act (ACA). This is due to a recent

change in the aspirin recommendations from the

United States Preventive Services Task Force

(USPSTF).

A prescription for 75 mg and 81 mg of aspirin have

new age ranges:

50-59 for men

12-59 for women

Aspirin 325 mg will no longer be included at no

member cost share.

Standard plan benefits apply for aspirin

prescriptions outside the specified age ranges

and/or strengths.



APPENDIX B


Drug Use Update

Jardiance Used to lower blood sugar in adults with type 2

diabetes.

Tier 4 → Tier 2

Invokana Used to lower blood sugar in adults with type 2

diabetes.

Tier 3 → Tier 2

Invokamet Used to lower blood sugar in adults with type 2

diabetes.

Tier 4 → Tier 2

Synjardy Used to lower blood sugar in adults with type 2

diabetes.

Tier 4 → Tier 2

Breo Ellipta Used to prevent and control symptoms of

asthma.

Tier 4 → Tier 2

Brilinta Used for people who have had a heart attack

or severe chest pain.

Tier 3→ Tier 2

Toujeo A long-acting insulin used to treat high blood

sugar in adults and children with diabetes.

Non-formulary → Tier 2

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