2016 generic centric formulary reference guide - optum · 2016 generic-centric formulary reference...
TRANSCRIPT
2016 Generic-Centric Formulary Reference Guide Effective 1/1/2016
Your formulary utilizes a Pharmacy and Therapeutics Committee (P & T Committee),
made up of practicing physicians, pharmacists, and nurses to help ensure that our
formulary is medically sound and that it supports patient health. This committee reviews
and evaluates medications on the formulary based on safety and efficacy to help
maintain clinical integrity in all therapeutic categories.
FORMULARY DESIGN
Optum has chosen a closed formulary structure for our Generic-Centric Formulary. The
formulary structure features a closed formulary which limits preferred formulary options
to primarily generic medications across most major therapeutic drug categories. In
classes where there are limited generics options, the formulary is supplemented with
preferred brand drugs. Non-preferred brand drugs are excluded from coverage. In
keeping with the specialty drug clinical philosophy, most specialty medications are
included in coverage within the Generic-Centric Formulary and the Specialty Benefit
Design has been added to the formulary to provide clients with flexible, yet clinically
appropriate, coverage options. Standard specialty utilization management is required
to be used with this formulary in order to maintain control over this expensive category.
• Low Cost Generic drugs: Select low cost generic drugs are listed under “LOW
COST GENERIC”. Drugs listed under “LOW COST GENERIC” have the same
active ingredient as the brand-name versions but at a lower cost.
• Generic drugs: Most generic drugs are listed under “GENERIC”. Drugs listed
under “GENERIC” have the same active ingredient as the brand-name versions
but at a lower cost.
• Brand drugs: Drugs listed under “BRAND” include preferred brand name drugs
to supplement the formulary where generic options are limited.
• Specialty drugs: Drugs listed under “GENERIC SPECIALTY”, “PREFERRED
BRAND SPECIALTY”, and “NON-PREFERRED BRAND SPECIALTY”
generally have the highest co-payment(s) and cost. Specialty drugs are
prescription medications that are sometimes used to treat complex and chronic
conditions. They may require special monitoring or handling.
Generic-Centric Formulary Reference Guide
REASONABLE MEDICAL MANAGEMENT
Optum’s formulary also uses medical and utilization management functions to
determine whether a prescription is medically necessary. These industry recognized
and accepted management functions include but are not limited to quantity limits, step
therapy, and prior authorization and help Optum and its clients determine whether the
prescribed medication was prescribed in accordance with generally accepted medical
practice standards, is clinically appropriate, and confirm that the prescribed medication
is not more costly than an alternative product that is as likely to produce therapeutically
equivalent results. As recommended by the United States Department of Labor,
Optum’s reasonable medical and utilization management functions apply to ACA
preventive drugs.
USING THIS FORMULARY REFERENCE GUIDE TO HELP
CONTAIN COSTS
Many health plans use the Optum formulary to help manage the overall cost of
providing prescription drug benefits. This formulary offers a wide range of medications
from which to choose. We realize that this formulary reference guide may not include
every drug from every manufacturer. However, choosing a generic or preferred drug
when it is appropriate can provide access to the necessary medications to stay
healthy, at a cost that is more affordable.
SAVING ON OUT-OF-POCKET COSTS
Your health plan sets the co-payments for each formulary drug status which include
low cost generic, generic, preferred brand-name, non-preferred brand-name, and
specialty medications. Co-payments and deductibles for preventive products follow
health care reform rules. Health plans often design prescription drug plans to
encourage the use of generic and preferred brand-name drugs. Choosing non-preferred
drugs (or specialty drugs) may mean paying higher out-of-pocket expenses (such as
coinsurance, co-payments, and deductible amounts) or not receiving coverage at all.
Patients may also pay less for generic drugs.
PLEASE NOTE: Brand-name drugs may become non-formulary if a generic
version becomes available.
Generic-Centric Formulary Reference Guide
CONSULTING THE PRESCRIBER’S OFFICE WHEN
APPROPRIATE
When employers and other health plans design their prescription drug plans, they may
choose to provide coverage only for certain medications, time periods, doses,
quantities, or for a specific indications (e.g. they may exclude coverage for medications
for unapproved, unproven, or cosmetic indications). When coverage for medications is
provided based on use or quantity, your pharmacy benefit may contact your prescriber’s
office for additional information to determine whether coverage is available under your
plan. Patients who are unsure whether these coverage rules apply for a particular
medication can consult their prescription drug benefit manual or contact a Member
Services representative to determine specific coverage requirements.
KNOWING HOW THE FORMULARY INFORMATION IS
ORGANIZED
The following formulary reference guide is designed in the following order: low cost
generics, generics, brand name, and specialty drugs.
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer
health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at
optum.com.
All OptumTM
trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or
registered marks of their respective owners. © 2015 Optum, Inc. All rights reserved.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is
covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management
activities of Optum. The presence of a medication on this formulary list does not guarantee coverage. To determine the most up-to-date formulary
status of your medication, please visit your member website or call member services at the number listed on your ID card.
Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTINEOPLASTICS, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIBIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTINEOPLASTIC ENZYMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANGIOGENESIS INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTIBODIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHEMOTHERAPY ADJUNCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
PHOSPHODIESTERASE INHBTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
GHRH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HEMATOLOGICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
DIABETIC SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Erythromycin Base
TETRACYCLINES
GENERIC
July 2016
demeclocycline HCL
doxycycline
ANTI-INFECTIVES
doxycycline hyclate
doxycycline hyclate DR
PENICILLINS
doxycycline monohydrate
LOW COST GENERIC
minocycline HCL
amoxicillin
minocycline HCL ER
dicloxacillin sodium
tetracycline hydrochloride
penicillin v potassium
Tetracycline HCL
GENERIC
amoxicillin/clavulanate potassium
QUINOLONES
amoxicillin/clavulanate potassium ER
LOW COST GENERIC
ampicillin
ciprofloxacin HCL
ampicillin sodium
GENERIC
ampicillin-sulbactam
ciprofloxacin
ampicillin/sulbactam
ciprofloxacin ER
nafcillin sodium
ciprofloxacin I.V.-IN D5W
oxacillin sodium
levofloxacin
penicillin G potassium
levofloxacin IN D5W
piperacillin sodium/ tazobactam sodium
moxifloxacin HCL
piperacillin sodium/tazobactam sodium
ofloxacin
piperacillin/tazobactam
Ciprofloxacin HCL
Amoxicillin/Clavulanate Potassium
Ofloxacin
Ampicillin-sulbactam
AMINOGLYCOSIDES
CEPHALOSPORIN GENERIC SPECIALTY
tobramycin
FIRST GENERATION
LOW COST GENERIC
LOW COST GENERIC
neomycin sulfate
cephalexin
PREFERRED BRAND SPECIALTY
GENERIC
Bethkis
cefadroxil
cefazolin sodium
SECOND GENERATION GENERIC
GENERIC amikacin sulfate
cefaclor gentamicin sulfate
cefotetan gentamicin sulfate pediatric
cefoxitin sodium gentamicin sulfate/0.9% sodium chloride
cefprozil isotonic gentamicin
cefuroxime axetil paromomycin sulfate
cefuroxime sodium tobramycin sulfate
Cefaclor
Cefuroxime Sodium ANTIMYCOBACTERIAL AGENTS
THIRD GENERATION
LOW COST GENERIC
GENERIC
isoniazid
cefdinir
GENERIC
cefixime
ethambutol HCL
cefotaxime sodium
pyrazinamide
cefpodoxime proxetil
rifabutin
ceftazidime
rifampin
ceftriaxone sodium
Ceftriaxone IN Iso-osmotic Dextrose
ANTIFUNGALS
FOURTH GENERATION
LOW COST GENERIC
GENERIC
fluconazole
cefepime
fluconazole IN NACL
ketoconazole
MACROLIDES
terbinafine HCL
LOW COST GENERIC
azithromycin
GENERIC
fluconazole IN dextrose
GENERIC
flucytosine
clarithromycin
griseofulvin microsize
clarithromycin ER
griseofulvin ultramicrosize
erythromycin
itraconazole
nystatin
voriconazole
Effective July 1, 2016 v.1
PA=Prior Auth Required; QL=Quantity Limits; All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2016 Optum, Inc. All rights reserved.
1
ANTIVIRALS BRAND
Albenza
GENERIC SPECIALTY
Biltricide
adefovir dipivoxil
entecavirQL
MISC. ANTI-INFECTIVES
ribavirin
Moderiba 1200 Dose Pack LOW COST GENERIC
Moderiba 800 Dose Pack metronidazole
Ribasphere metronidazole IN NACL 0.79%
Ribasphere Ribapak sulfamethoxazole/trimethoprim
Ribatab sulfamethoxazole/trimethoprim DS
LOW COST GENERIC trimethoprim
acyclovir NON-PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY CaystonPA
BaracludeQL
Moderiba
OlysioPA
GENERIC
Peg-intronPA
atovaquone
Peg-intron RedipenPA
aztreonam
Peg-intron Redipen PAK 4PA
bacitracin
PegintronPA
clindamycin
Rebetol
clindamycin palmitate HCL
TechnivieQL,PA
clindamycin phosphate
Tyzeka
clindamycin phosphate add-vantage
Victrelis
clindamycin phosphate pharmacy bulk package
Viekira PAKQL,PA
clindamycin phosphate IN D5W
Virazole
clindamycin HCL
PREFERRED BRAND SPECIALTY
colistimethate sodium
Daklinza
dapsone
HarvoniPA
imipenem/cilastatin
PegasysPA
lincomycin HCL
Pegasys ProclickPA
linezolid
SovaldiPA
meropenem
ZepatierPA
polymyxin b sulfate
GENERIC
tinidazole
abacavir
vancomycin HCL
abacavir sulfate/lamivudine/zidovudine
Linezolid
acyclovir sodium
cidofovir
ANTINEOPLASTICS, ETC
didanosine
ALKYLATING AGENTS
famciclovir
GENERIC SPECIALTY
ganciclovir
carboplatin
lamivudine
cisplatin
lamivudine/zidovudine
ifosfamide
nevirapine
melphalan hydrochloride
nevirapine ER
oxaliplatin
rimantadine HCL
temozolomidePA
stavudine
Lomustine
valacyclovir HCL
NON-PREFERRED BRAND SPECIALTY
valganciclovir
Cisplatin
zidovudine
Cyclophosphamide
BRAND
Gleostine
Evotaz
Ifex
Prezcobix
Ifosfamide
Vitekta
Thiotepa
ValchlorPA
ANTIMALARIALS
PREFERRED BRAND SPECIALTY
LOW COST GENERIC
Bicnu
chloroquine phosphate
Busulfex
hydroxychloroquine sulfate
Leukeran
GENERIC
Mustargen
atovaquone/proguanil HCL
Temodar
mefloquine HCL
Treanda
quinine sulfate
Zanosar
Primaquine Phosphate
GENERIC
cyclophosphamide
ANTHELMINTICS
GENERIC
ANTIBIOTICS
ivermectin
GENERIC SPECIALTY
bleomycin sulfate
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 2
daunorubicin HCL GazyvaPA
doxorubicin HCL KadcylaPA
doxorubicin HCL liposome KeytrudaPA
epirubicin HCL OpdivoPA
idarubicin HCL RituxanPA
mitomycin Unituxin
mitoxantrone HCLPA Vectibix
Doxorubicin HCL Zevalin Y-90
Mitomycin PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY AdcetrisPA
Adriamycin ArzerraPA
Cosmegen ErbituxPA
Epirubicin HCL HerceptinPA
Valstar PerjetaPA
PREFERRED BRAND SPECIALTY YervoyPA
Daunoxome
HORMONAL AGENTS
GENERIC SPECIALTY
ANTINEOPLASTIC ENZYMES leuprolide acetatePA
NON-PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY
FirmagonQL,PA
Erwinaze
Hydroxyprogesterone Caproate
TrelstarQL,PA
Trelstar MixjectQL,PA
PREFERRED BRAND SPECIALTY
VantasQL,PA
Oncaspar
XtandiPA
ZytigaPA
PREFERRED BRAND SPECIALTY
ANTIMETABOLITES
EligardQL,PA
GENERIC SPECIALTY
Faslodex
azacitidine
Lupron DepotQL,PA
capecitabinePA
ZoladexQL
cytarabine
GENERIC
cytarabine aqueous
anastrozole
decitabinePA
bicalutamide
floxuridine
exemestane
fludarabine phosphate
flutamide
fluorouracil
letrozole
gemcitabine
megestrol acetate
gemcitabine HCL
tamoxifen citrate
mercaptopurine
Floxuridine
IMMUNOMODULATORS
NON-PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY
Cytarabine
PomalystPA
Depocyt
RevlimidPA
Purixan
PREFERRED BRAND SPECIALTY
PREFERRED BRAND SPECIALTY
Alimta
ThalomidPA
Arranon
Clolar
GENERIC
FolotynPA
azathioprine
GENERIC
cyclosporine
cladribine
cyclosporine modified
methotrexate
mycophenolate mofetil
methotrexate sodium
mycophenolic acid DR
Methotrexate Sodium
sirolimus
tacrolimus
ANGIOGENESIS INHIBITORS
Azathioprine
NON-PREFERRED BRAND SPECIALTY
CyramzaPA
BRAND
Atgam
Cellcept Intravenous
PREFERRED BRAND SPECIALTY
Prograf
Avastin
ZaltrapPA
MITOTIC INHIBITORS
GENERIC SPECIALTY
ANTIBODIES
docetaxel
NON-PREFERRED BRAND SPECIALTY
etoposide
BlincytoPA
paclitaxel
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 3
vincristine sulfate NON-PREFERRED BRAND SPECIALTY
vinorelbine tartrate Camptosar
NON-PREFERRED BRAND SPECIALTY Hycamtin
Docefrez Irinotecan
Docetaxel Topotecan HCL
Etopophos
Marqibo ANTINEOPLASTICS MISC.
Paclitaxel
GENERIC SPECIALTY
Teniposide
bexarotenePA
Vinblastine Sulfate
dacarbazine
PREFERRED BRAND SPECIALTY
tretinoin
Abraxane
NON-PREFERRED BRAND SPECIALTY
Etoposide
Dacarbazine
HalavenPA
Intron APA
Ixempra Kit
Intron A W/DiluentPA
JevtanaPA
Nipent
Photofrin
ENZYME INHIBITORS
SylatronPA
GENERIC SPECIALTY SynriboPA
imatinib mesylatePA PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY Actimmune
Afinitor DisperzPA Alferon N
BeleodaqPA Matulane
BosulifPA Proleukin
CometriqPA Theracys
FarydakQL,PA Tice Bcg
GilotrifQL,PA Trisenox
IbrancePA GENERIC
IclusigPA hydroxyurea
ImbruvicaPA
InlytaPA CHEMOTHERAPY RESCUE
IressaPA
GENERIC SPECIALTY
Lenvima 10MG Daily DosePA
amifostine
Lenvima 14MG Daily DosePA
dexrazoxane
Lenvima 18MG Daily DosePA
mesna
Lenvima 20MG Daily DosePA
NON-PREFERRED BRAND SPECIALTY
Lenvima 24MG Daily DosePA
Fusilev
Lenvima 8MG Daily DosePA
Mesnex
LynparzaPA
Totect
SprycelPA
GENERIC
StivargaPA
leucovorin calcium
SutentPA
levoleucovorin
TarcevaQL,PA
levoleucovorin calcium
VotrientPA
ZelborafPA
CHEMOTHERAPY ADJUNCTS
ZydeligPA
PREFERRED BRAND SPECIALTY
ZykadiaPA
Kepivance
PREFERRED BRAND SPECIALTY
AfinitorQL,PA
CaprelsaQL,PA
ANTINEOPLASTIC COMBO
GleevecPA
NON-PREFERRED BRAND SPECIALTY
IstodaxPA
LonsurfQL,PA
JakafiPA
KyprolisPA
MekinistPA
NexavarPA
CARDIOVASCULAR DRUGS
TafinlarPA
PHOSPHODIESTERASE INHBTR
TasignaPA
GENERIC
Torisel
milrinone lactate
TykerbPA
milrinone IN dextrose
VelcadePA
XalkoriPA
CARDIAC GLYCOSIDES
ZolinzaPA
LOW COST GENERIC
TOPOISOMERASE I INHIBITOR digoxin
GENERIC SPECIALTY
ANTIANGINAL AGENTS
irinotecan
irinotecan HCL LOW COST GENERIC
topotecan HCL isosorbide mononitrate ER
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 4
GENERIC Quinidine Sulfate ER
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin lingual ACE INHIBITORS
nitroglycerin transdermal
LOW COST GENERIC
nitroglycerin ER
benazepril HCL
nitroglycerin IN dextrose 5%
enalapril maleate
nitroglycerin IN 5% dextrose
fosinopril sodium
Isosorbide Dinitrate
lisinopril
Nitroglycerin Lingual
moexipril HCL
quinapril HCL
BETA BLOCKERS
ramipril
LOW COST GENERIC trandolapril
atenolol GENERIC
bisoprolol fumarate captopril
carvedilol enalaprilat
metoprolol tartrate perindopril erbumine
GENERIC ANGIOTENSIN RCPTR BLOCKER
acebutolol HCL
LOW COST GENERIC
betaxolol HCL
losartan potassium
esmolol HCL
GENERIC
labetalol HCL
candesartan cilexetil
metoprolol succinate ER
irbesartan
nadolol
telmisartan
pindolol
valsartan
propranolol HCL
Eprosartan Mesylate
propranolol HCL ER
sotalol HCL
ANTIHYPERTENSIVES MISC.
sotalol HCL (AF)
LOW COST GENERIC
Metoprolol Tartrate
clonidine HCL
doxazosin
CALCIUM CHANNEL BLOCKERS
doxazosin mesylate
LOW COST GENERIC
guanfacine HCL
amlodipine besylate
methyldopa
verapamil HCL
prazosin HCL
GENERIC
terazosin HCL
diltiazem CD
GENERIC
diltiazem HCL
eplerenone
diltiazem HCL ER
fenoldopam mesylate
felodipine ER
hydralazine HCL
isradipine
minoxidil
nicardipine HCL
phenoxybenzamine hydrochloride
nifedipine
nifedipine ER
ANTIHYPERTENSIVE COMBO
nimodipine
LOW COST GENERIC
nisoldipine
atenolol/chlorthalidone
verapamil HCL ER
bisoprolol fumarate/hydrochlorothiazide
verapamil HCL SR
lisinopril/hydrochlorothiazide
losartan potassium/hydrochlorothiazide
ANTIARRHYTHMICS
GENERIC
GENERIC
adenosine
amlodipine besylate/benazepril hydrochloride
amiodarone hydrochloride
amlodipine besylate/benazepril HCL
amiodarone HCL
amlodipine besylate/valsartan
disopyramide phosphate
amlodipine/valsartan/hctz
dofetilide
benazepril HCL/hydrochlorothiazide
flecainide acetate
candesartan cilexetil/hydrochlorothiazide
ibutilide fumarate
enalapril maleate/hydrochlorothiazide
lidocaine HCL
fosinopril sodium/hydrochlorothiazide
lidocaine HCL IN D5W
irbesartan/hydrochlorothiazide
lidocaine HCL/dextrose
metoprolol/hydrochlorothiazide
mexiletine HCL
moexipril/hydrochlorothiazide
propafenone HCL
nadolol/bendroflumethiazide
propafenone HCL ER
quinapril/hydrochlorothiazide
quinidine gluconate CR
telmisartan/amlodipine
quinidine gluconate ER
telmisartan/hydrochlorothiazide
quinidine sulfate
trandolapril/verapamil HCL
Quinidine Sulfate
trandolapril/verapamil HCL ER
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 5
valsartan/hydrochlorothiazide SPECIALTY
GENERIC
DIURETICS cholestyramine
cholestyramine light
LOW COST GENERIC
colestipol HCL
amiloride/hydrochlorothiazide
fenofibrate
bumetanide
fenofibrate micronized
chlorothiazide
fenofibric acid DR
chlorthalidone
fluvastatin
furosemide
fluvastatin sodium ER
hydrochlorothiazide
lovastatin
indapamide
niacin ER
spironolactone
omega-3-acid ethyl esters
spironolactone/hydrochlorothiazide
pravastatin sodium
torsemide
rosuvastatin calcium
triamterene/hydrochlorothiazide
Fenofibrate
Chlorothiazide
Fenofibric Acid
Chlorthalidone
Triamterene/Hydrochlorothiazide
CARDIOVASCULAR - MISC.
NON-PREFERRED BRAND SPECIALTY
KeveyisQL,PA GENERIC SPECIALTY
epoprostenol sodiumPA
sildenafilQL,PA
sildenafil citrateQL,PA
GENERIC
NON-PREFERRED BRAND SPECIALTY
acetazolamide
AdcircaQL,PA
acetazolamide sodium
OrenitramPA
acetazolamide ER
RevatioQL,PA
amiloride HCL
TyvasoQL,PA
chlorothiazide sodium
Tyvaso RefillQL,PA
ethacrynate sodium
Tyvaso StarterQL,PA
mannitol
VentavisQL,PA
methazolamide
PREFERRED BRAND SPECIALTY
metolazone
AdempasQL,PA
Acetazolamide
LetairisQL,PA
OpsumitQL,PA
VASOPRESSORS
RemodulinPA
NON-PREFERRED BRAND SPECIALTY
TracleerQL,PA
NortheraPA
VeletriPA
GENERIC
amlodipine besylate/atorvastatin calcium
GENERIC
cardioplegic
dobutamine HCL
papaverine HCL
dobutamine HCL/D5W
Papaverine-alprostadil
dobutamine/dextrose 5%
Papaverine-phentolamine Mes/Alprostadil
dopamine HCL
Papaverine-phentolamine Mesylate
dopamine HCL-dextrose 5%
Papaverine/Phentolamine Mes/Alprostadil
dopamine HCL/dextrose 5%
Phentolamine Mesylate-alprostadil
dopamine/D5W
BRAND
ephedrine sulfate
Cialis
midodrine HCL
Stendra
norepinephrine bitartrate
phenylephrine HCL
DERMATOLOGICALS
Dopamine HCL
ACNE PRODUCTS
Epinephrine
BRAND GENERIC
Epipen 2-PAK adapalene
Epipen-JR 2-PAK adapalene P.M.
benzoyl peroxide
ANTIHYPERLIPIDEMICS benzoyl peroxide SHORT contact
clindamycin phosphate
LOW COST GENERIC
clindamycin/benzoyl peroxide
atorvastatin calcium
erythromycin
gemfibrozil
erythromycin/benzoyl peroxide
simvastatin
sodium sulfacetamide
NON-PREFERRED BRAND SPECIALTY
sodium sulfacetamide/sulfur
JuxtapidQL,PA
sodium sulfacetamide/sulfur cleanser
KynamroQL,PA
sodium sulfacetamide/sulfur cleansing cloths
RepathaQL,PA
sodium sulfacetamide/sulfur green
Repatha SureclickQL,PA
sodium sulfacetamide/sulfur w/sunscreen
PREFERRED BRAND SPECIALTY
sodium sulfacetamide/sulfur wash
PraluentQL,PA
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 6
sulfacetamide sodium GENERIC
sulfacetamide sodium/sulfur alclometasone dipropionate
sulfacetamide sodium/sulfur cleanser augmented betamethasone dipropionate
tretinoin betamethasone dipropionate
tretinoin microsphere betamethasone valerate
tretinoin microsphere P.M. calcipotriene/betamethasone dipropionate
clobetasol propionate
ROSACEA AGENTS clobetasol propionate emollient
desonide
GENERIC
desoximetasone
metronidazole
fluocinolone acetonide
Doxycycline
fluocinonide
fluocinonide-e
ANTIBIOTICS - TOPICAL
flurandrenolide
GENERIC
fluticasone propionate
mupirocin
halobetasol propionate
mupirocin calcium
hydrocortisone
hydrocortisone acetate/aloe
ANTIFUNGALS - TOPICAL
hydrocortisone butyrate
LOW COST GENERIC
hydrocortisone butyrate (lipid)
clotrimazole
hydrocortisone butyrate (lipophilic)
GENERIC
hydrocortisone valerate
ciclopirox
hydrocortisone IN absorbase
ciclopirox nail lacquer
mometasone furoate
ciclopirox olamine
prednicarbate
clotrimazole/betamethasone dipropionate
Amcinonide
econazole nitrate
Desoximetasone
ketoconazole
Diflorasone Diacetate
naftifine hydrochloride
nystatin
IMMUNOMODULATING AGENTS
nystatin/triamcinolone
GENERIC
oxiconazole nitrate
imiquimod
tacrolimus
ANTIVIRALS - TOPICAL
GENERIC
DERMATOLOGICALS - MISC.
acyclovir
GENERIC
ammonium lactate
ANTI-INFLAMMATORY AGENTS
episone CRE
GENERIC
lactic acid
diclofenac sodium
lactic acid e
lactic acid w/vitamin e
ANTIPRURITICS
lidocaine
GENERIC
lidocaine HCL
Doxepin Hydrochloride
lidocaine HCL jelly
lidocaine-prilocaine-cream base
ANTIPSORIATICS
lidocaine/prilocaine
NON-PREFERRED BRAND SPECIALTY
lindane
CosentyxPA
malathion
Cosentyx Sensoready PenPA
permethrin
podofilox
PREFERRED BRAND SPECIALTY
salicylic acid
StelaraPA
salicylic acid cream
salicylic acid lotion
GENERIC
salicylic acid ER
acitretin
sodium hyaluronate
calcipotriene
urea
methoxsalen
urea topical
Calcitriol
urea IN zinc undecylenate/lactic acid vehicle
urea 40% nail film
ANTISEBORRHEIC AGENTS
GENERIC
ENDOCRINE AND METABOLIC
selenium sulfide
CORTICOSTEROIDS
sodium sulfacetamide
LOW COST GENERIC
sodium sulfacetamide wash
dexamethasone
dexamethasone sodium phosphate
CORTICOSTEROIDS - TOPICAL
hydrocortisone
LOW COST GENERIC
methylprednisolone
triamcinolone acetonide
methylprednisolone acetate
methylprednisolone dose pack
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 7
methylprednisolone sodiumsuccinate Humulin R U-500 (concentrated)
prednisolone Humulin R U-500 Kwikpen
prednisolone sodium phosphate Humulin 70/30
prednisone Humulin 70/30 Kwikpen
Dexamethasone Lantus
Dexamethasone Sodium Phosphate Lantus Solostar
Prednisone Relion R
GENERIC Toujeo Solostar
betamethasone sodium phosphate/betamethasone acetate
Tresiba Flextouch
AMYLIN ANALOGS
budesonide
BRAND
fludrocortisone acetate
Symlinpen 120
prednisolone sodium phosphate odt
Symlinpen 60
INCRETIN MIMETIC AGENTS
ANDROGENS-ANABOLIC
BRAND
GENERIC
Bydureon
danazol
Byetta
methyltestosterone
Trulicity
oxandrolone
Victoza
testosterone cypionate
SULFONYLUREAS
testosterone enanthate
LOW COST GENERIC
BRAND
glimepiride
Androderm
glipizide
glipizide ER
ESTROGENS
glyburide
LOW COST GENERIC glyburide micronized
estradiol Glyburide
Estropipate
GENERIC GENERIC
estradiol valerate tolazamide
estradiol/norethindrone acetate Tolazamide
norethindrone acetate/ethinyl estradiol BIGUANIDES
LOW COST GENERIC
metformin HCL
CONTRACEPTIVES
GENERIC
LOW COST GENERIC
metformin HCL ER
levonorgestrel/ethinyl estradiol
MEGLITINIDE ANALOGUES
norethindrone
GENERIC
GENERIC
nateglinide
desogestrel/ethinyl estradiol
repaglinide
drospirenone/ethinyl estradiol
DIABETIC OTHER
levonorgestrel
NON-PREFERRED BRAND SPECIALTY
levonorgestrel and ethinyl estradiol
Korlym
norethindrone & ethinyl estradiol ferrous fumarate
norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous fumarate
norgestimate/ethinyl estradiol BRAND
Levonorgestrel Glucagon Emergency Kit
Invokana
PROGESTINS Jardiance
ALPHA-GLUCOSIDASE INHIBIT
LOW COST GENERIC
GENERIC
medroxyprogesterone acetate
acarbose
GENERIC
miglitol
megestrol acetate
DPP-4 INHIBITORS
norethindrone acetate
GENERIC
progesterone
Alogliptin
BRAND
ANTIDIABETIC AGENTS
Januvia
INSULIN
Onglyza
BRAND
INSULIN SENSITIZING AGENT
Afrezza
GENERIC
Humalog
pioglitazone HCL
Humalog Kwikpen
ANTIDIABETIC COMBINATIONS
Humalog Mix 50/50
GENERIC
Humalog Mix 50/50 Kwikpen
glipizide/metformin HCL
Humalog Mix 75/25
glyburide/metformin HCL
Humalog Mix 75/25 Kwikpen
pioglitazone HCL-glimepiride
Humulin N
pioglitazone HCL/metformin HCL
Humulin N Kwikpen
Alogliptin/Metformin HCL
Humulin R
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 8
Alogliptin/Pioglitazone Supprelin LAQL,PA
Repaglinide/Metformin Hydrochloride
BRAND GNRH/LHRH ANTAGONISTS
Invokamet
NON-PREFERRED BRAND SPECIALTY
Janumet
Ganirelix AcetatePA
Janumet XR
Kombiglyze XR
Synjardy
PREFERRED BRAND SPECIALTY
CetrotidePA
BISPHOSPHONATES
GENERIC SPECIALTY
pamidronate disodium
GROWTH HORMONES
zoledronic acid
NON-PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY
ZorbtivePA
Pamidronate Disodium
Zoledronic Acid
Zometa
PREFERRED BRAND SPECIALTY
GENERIC
Norditropin CartridgePA
alendronate sodium
Norditropin FlexproPA
ibandronate sodium
Norditropin Nordiflex PenPA
risedronate sodium
Nutropin AQ Nuspin 10PA
risedronate sodium DR
Nutropin AQ Nuspin 20PA
Nutropin AQ Nuspin 5PA
CALCITONINS
Nutropin AQ PenPA
GENERIC
SaizenPA
calcitonin salmon
Saizen Click.easyPA
calcitonin-salmon
SerostimPA
PARATHYROID HORMONE
GHRH
NON-PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY
NatparaQL,PA
EgriftaQL,PA
PREFERRED BRAND SPECIALTY
ForteoQL,PA
SOMATOMEDINS
PREFERRED BRAND SPECIALTY
IncrelexPA
RANK LIGAND INHIBITORS
PREFERRED BRAND SPECIALTY
ProliaQL,PA
SOMATOSTATIC AGENTS
XgevaPA
GENERIC SPECIALTY
octreotide acetatePA
HORMONE RECEPTOR MDLTR
NON-PREFERRED BRAND SPECIALTY
GENERIC
Sandostatin Lar DepotPA
raloxifene hydrochloride
SigniforQL,PA
Signifor LarQL,PA
FERTILITY REGULATORS
Somatuline DepotPA
GENERIC SPECIALTY
chorionic gonadotropinPA GH RECEPTOR ANTAGONISTS
LOW COST GENERIC
NON-PREFERRED BRAND SPECIALTY
clomiphene citrate
SomavertPA
NON-PREFERRED BRAND SPECIALTY
BravellePA
MenopurPA
Ovidrel
POSTERIOR PITUITARY
PREFERRED BRAND SPECIALTY
GENERIC
Follistim AQPA
desmopressin acetate
Gonal-fPA
vasopressin
Gonal-f RFFPA
Gonal-f RFF RedijectPA
CORTICOTROPIN
NON-PREFERRED BRAND SPECIALTY
LHRH/GNRH AGONIST
H.p. ActharPA
NON-PREFERRED BRAND SPECIALTY
Lupaneta PackQL,PA
PROLACTIN INHIBITORS
PREFERRED BRAND SPECIALTY
GENERIC
Lupron Depot-PEDQL,PA
cabergoline
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 9
VASOPRESSIN ANTAGONISTS cimetidine
cimetidine HCL
PREFERRED BRAND SPECIALTY
esomeprazole magnesium
SamscaQL
esomeprazole sodium
famotidine
glycopyrrolate
METABOLIC MODIFIERS
hyoscyamine sulfate
GENERIC SPECIALTY
hyoscyamine sulfate odt
sodium phenylbutyrate
hyoscyamine sulfate ER
NON-PREFERRED BRAND SPECIALTY
hyoscyamine sulfate SR
Buphenyl
lansoprazole
MyaleptPA
lansoprazole/amoxicillin/clarithromycin
Orfadin
methscopolamine bromide
RavictiPA
misoprostol
VimizimPA
nizatidine
PREFERRED BRAND SPECIALTY
omeprazole/sodium bicarbonate
AldurazymePA
rabeprazole sodium
Carbaglu
ranitidine HCL
ElaprasePA
Esomeprazole Sodium
FabrazymePA
Famotidine
KuvanPA
Nizatidine
LumizymePA
MyozymePA
NaglazymePA
ANTIEMETICS
GENERIC
LOW COST GENERIC
calcitriol
meclizine HCL
doxercalciferol
GENERIC
levocarnitine
dronabinol
paricalcitol
granisetron HCL
sodium phenylacetate/sodium benzoate
ondansetron odt
BRAND
ondansetron HCL
Sensipar
trimethobenzamide HCL
THYROID AGENTS
LOW COST GENERIC
DIGESTIVE AIDS
levothyroxine sodium
NON-PREFERRED BRAND SPECIALTY
GENERIC
Sucraid
liothyronine sodium
methimazole
propylthiouracil
BRAND
BRAND
Creon
Synthroid
Pancrelipase
Zenpep
GASTROINTESTINAL
LAXATIVES
GASTROINTESTINAL - MISC.
LOW COST GENERIC
LOW COST GENERIC
lactulose
metoclopramide HCL
GENERIC
NON-PREFERRED BRAND SPECIALTY
peg 3350/electrolytes
EntyvioPA
peg-3350/electrolytes
GattexPA
peg-3350/NACL/NA bicarbonate/KCL
polyethylene glycol 3350
PREFERRED BRAND SPECIALTY
CimziaPA
ANTIDIARRHEALS
Cimzia Starter KitPA
GENERIC
RemicadePA
diphenoxylate/atropine
GENERIC
loperamide HCL
alosetron hydrochloride
opium
balsalazide disodium
opium tincture
calcium acetate
cromolyn sodium
ULCER DRUGS
hydrocort ene 100MG
LOW COST GENERIC
hydrocortisone
dicyclomine HCL
hydrocortisone acetate/lidocaine HCL
omeprazole
hydrocortisone acetate/pramoxine
pantoprazole sodium
lactulose
sucralfate
lidocaine HCL/hydrocortisone acetate
GENERIC
mesalamine
atropine sulfate
metoclopramide odt
chlordiazepoxide HCL/clidinium bromide
sulfasalazine
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 10
ursodiol NON-PREFERRED BRAND SPECIALTY
CerdelgaPA
BRAND ElelysoPA
Amitiza LeukinePA
Lialda MirceraPA
NeulastaPA
GENITOURINARY Neulasta Onpro KitPA
Omontys
URINARY ANTI-INFECTIVES
PromactaPA
GENERIC
VprivPA
methenamine hippurate
ZavescaPA
methenamine mandelate
PREFERRED BRAND SPECIALTY
nitrofurantoin
CerezymePA
nitrofurantoin macrocrystals
GranixPA
nitrofurantoin monohydrate
MozobilQL,PA
nitrofurantoin monohydrate/macrocrystals
NeumegaPA
NeupogenPA
URINARY ANTISPASMODICS
NplatePA
GENERIC
ProcritPA
bethanechol chloride
GENERIC
darifenacin hydrobromide ER
cyanocobalamin
darifenacin ER
folic acid
flavoxate HCL
folic acid/vitamin b-6/vitamin b-12
oxybutynin chloride
sodium ferric gluconate complex/sucrose
oxybutynin chloride ER
Iron Asp Gly/ Polysacch Compl/Ascorb CAL/B12/Fa/C Threon/Suc
tolterodine tartrate
tolterodine tartrate ER
trospium chloride
ANTICOAGULANTS
trospium chloride ER
GENERIC SPECIALTY
BRAND
enoxaparin sodiumQL
Gelnique
fondaparinux sodiumQL
LOW COST GENERIC
VAGINAL PRODUCTS
warfarin sodium
GENERIC
NON-PREFERRED BRAND SPECIALTY
clindamycin phosphate
FragminQL
metronidazole vaginal
terconazole
GENERIC
GENITOURINARY - MISC.
argatroban
LOW COST GENERIC
bivalirudin
citric acid/sodium citrate
heparin lock
finasteride
heparin lock flush
phenazopyridine HCL
heparin lock flush for flushing vascular access devices
sodium citrate/citric acid
heparin lock flush/NACL for flushing vascular access devices
tamsulosin HCL
NON-PREFERRED BRAND SPECIALTY
heparin sodium
Cystagon
heparin sodium dcu
ProcysbiPA
heparin sodium lock flush
heparin sodium/sodium chloride 0.9% premix
GENERIC
heparin sodium/D5W
acetic acid 0.25%
heparin sodium/NACL 0.9%
alfuzosin HCL ER
BRAND
aminoacetic acid
Pradaxa
dutasteride
Savaysa
dutasteride/tamsulosin hydrochloride
Xarelto
dutasteride/tamsulosin HCL
Xarelto Starter Pack
glycine
neomycin/polymyxin b sulfates
HEMOSTATICS
potassium citrate ER
GENERIC
potassium citrate-citric acid crystals
aminocaproic acid
potassium citrate/citric acid
tranexamic acid
potassium citrate/sodium citrate/citric acid
sodium chloride
HEMATOLOGICAL - MISC.
sodium chloride 0.9%
NON-PREFERRED BRAND SPECIALTY
tricitrates
Alprolix
Ceprotin
HEMATOLOGICAL
Eloctate
HEMATOPOIETIC AGENTS
Helixate FS
NON-
Ixinity
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 11
KalbitorPA LOW COST GENERIC
Kogenate FS buspirone HCL
Kogenate FS Bio-set hydroxyzine pamoate
Kovaltry hydroxyzine HCL
Novoeight Hydroxyzine Pamoate
Nuwiq GENERIC
RuconestPA alprazolam
Thrombate Iii W/10 ML Sterile Water alprazolam odt
Thrombate Iii W/20 ML Sterile Water alprazolam ER
Tretten chlordiazepoxide HCL
Xyntha clorazepate dipotassium
Xyntha Solofuse diazepam
PREFERRED BRAND SPECIALTY droperidol
Advate gene-xene TAB 15MG
Alphanate/Von Willebrand Factor Complex/Human gene-xene TAB 3.75MG
Alphanine SD gene-xene TAB 7.5MG
Bebulin lorazepam
Benefix meprobamate
BerinertPA oxazepam
CinryzePA Diazepam
Corifact
Feiba ANTIDEPRESSANTS
Feiba NF
LOW COST GENERIC
FirazyrPA
amitriptyline HCL
Hemofil M
doxepin HCL
Humate-p
fluoxetine HCL
Koate-dvi
mirtazapine
Monoclate-p
mirtazapine odt
Mononine
nortriptyline HCL
Novoseven
paroxetine HCL
Novoseven Rt
Doxepin HCL
Profilnine
GENERIC
Profilnine SD
bupropion HCL
Recombinate
bupropion HCL ER
Riastap
bupropion HCL SR
SolirisPA
bupropion HCL XL
Wilate
citalopram hydrobromide
GENERIC
clomipramine HCL
albumin human
desipramine HCL
anagrelide hydrochloride
duloxetine HCL
cilostazol
escitalopram oxalate
clopidogrel
fluoxetine DR
dipyridamole
fluvoxamine maleate
eptifibatide
fluvoxamine maleate ER
hetastarch 6%/NACL
imipramine pamoate
pentoxifylline ER
imipramine HCL
ticlopidine HCL
nefazodone HCL
Aspirin/Dipyridamole
paroxetine HCL ER
phenelzine sulfate
MOUTH/THROAT/DENTAL AGENT
protriptyline HCL
sertraline HCL
tranylcypromine sulfate
LOW COST GENERIC
trazodone HCL
chlorhexidine gluconate
trimipramine maleate
chlorhexidine gluconate oral rinse
venlafaxine HCL
lidocaine viscous
venlafaxine HCL ER
lidocaine HCL viscous
Amoxapine
GENERIC
Nefazodone HCL
cevimeline HCL
Nortriptyline HCL
clotrimazole
Venlafaxine HCL ER
nystatin
pilocarpine hydrochloride
pilocarpine HCL
ANTIPSYCHOTICS
stannous fluoride oral rinse
triamcinolone acetonide LOW COST GENERIC
triamcinolone IN orabase fluphenazine HCL
lithium carbonate
NEUROLOGY, CNS, PSYCH lithium carbonate ER
GENERIC
ANTIANXIETY AGENTS
aripiprazole
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 12
chlorpromazine HCL Methylphenidate HCL ER
clozapine
clozapine odt ANTICONVULSANTS
fluphenazine decanoate
LOW COST GENERIC
haloperidol
carbamazepine
haloperidol decanoate
primidone
haloperidol lactate
valproate sodium
loxapine
valproic acid
loxapine succinate
olanzapine
NON-PREFERRED BRAND SPECIALTY
olanzapine odt
SabrilPA
paliperidone ER
perphenazine
prochlorperazine
GENERIC
prochlorperazine edisylate
carbamazepine ER
prochlorperazine maleate
clonazepam
quetiapine fumarate
clonazepam odt
risperidone
divalproex sodium
risperidone odt
divalproex sodium DR
thioridazine HCL
divalproex sodium ER
thiothixene
ethosuximide
trifluoperazine HCL
felbamate
ziprasidone HCL
fosphenytoin sodium
Aripiprazole Odt
gabapentin
Clozapine Odt
lamotrigine
lamotrigine odt
lamotrigine titration
HYPNOTICS
lamotrigine ER
NON-PREFERRED BRAND SPECIALTY
levetiracetam
HetliozQL,PA
levetiracetam ER
oxcarbazepine
phenytoin
GENERIC phenytoin sodium
dexmedetomidine HCL phenytoin sodium extended
estazolam tiagabine hydrochloride
eszopiclone topiramate
flurazepam HCL zonisamide
phenobarbital
temazepam ANTIPARKINSON AGENTS
triazolam
PREFERRED BRAND SPECIALTY
zaleplon
ApokynQL,PA
zolpidem tartrate
zolpidem tartrate ER
GENERIC
Flurazepam HCL
amantadine HCL
Phenobarbital
benztropine mesylate
Phenobarbital Sodium
bromocriptine mesylate
Quazepam
carbidopa
Triazolam
carbidopa/levodopa
carbidopa/levodopa odt
ADHD, NARCOLEPSY, ETC.
carbidopa/levodopa ER
GENERIC
entacapone
amphetamine/dextroamphetamine
pramipexole dihydrochloride
armodafinil
pramipexole dihydrochloride ER
caffeine citrate
ropinirole ER
clonidine HCL ER
ropinirole HCL
dexmethylphenidate HCL
selegiline HCL
dexmethylphenidate HCL ER
tolcapone
dextroamphetamine sulfate
trihexyphenidyl HCL
dextroamphetamine sulfate ER
Carbidopa/Levodopa/Entacapone
doxapram HCL
guanfacine ER
NEUROLOGY, PSYCH - MISC.
methamphetamine HCL
GENERIC SPECIALTY
methylphenidate hydrochloride
glatopaQL,PA
methylphenidate HCL
tetrabenazinePA
methylphenidate HCL CD
NON-PREFERRED BRAND SPECIALTY
methylphenidate HCL ER
AubagioQL,PA
methylphenidate HCL SR
GilenyaQL,PA
modafinil
LemtradaPA
Armodafinil
TysabriQL,PA
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 13
XyremQL,PA tizanidine HCL
PREFERRED BRAND SPECIALTY Metaxalone
AmpyraQL,PA Orphenadrine/Asa/Caffeine
AvonexQL,PA
CopaxoneQL,PA ANTIMYASTHENIC AGENTS
PlegridyQL,PA
GENERIC
Plegridy Starter PackQL,PA
neostigmine methylsulfate
TecfideraQL,PA
pyridostigmine bromide
Tecfidera Starter PackQL,PA
GENERIC
OPHTHALMOLOGY AND OTIC
acamprosate calcium DR
ANTI-INFECTIVES
disulfiram
LOW COST GENERIC
donepezil HCL
polymyxin b sulfate/trimethoprim sulfate
ergoloid mesylates
tobramycin sulfate
galantamine hydrobromide
trimethoprim sulfate/polymyxin b sulfate
memantine hydrochloride
GENERIC
memantine HCL
bacitracin/polymyxin b
memantine HCL titration PAK
ciprofloxacin HCL
olanzapine/fluoxetine
erythromycin
pimozide
gatifloxacin
rivastigmine tartrate
gentamicin sulfate
rivastigmine transdermal system
levofloxacin
Ergoloid Mesylates
neomycin/bacitracin/polymyxin
Galantamine Hydrobromide
neomycin/polymyxin/bacitracin zinc
Perphenazine/Amitriptyline
neomycin/polymyxin/gramicidin
ofloxacin
NEUROMUSCULAR AGENTS
sodium sulfacetamide
NON-PREFERRED BRAND SPECIALTY
sulfacetamide sodium
DysportPA
trifluridine
MyoblocPA
Bacitracin
XeominPA
PREFERRED BRAND SPECIALTY
BETA-BLOCKERS
BotoxPA
LOW COST GENERIC
timolol maleate
GENERIC
GENERIC
atracurium besylate
betaxolol HCL
cisatracurium besylate
carteolol HCL
pancuronium bromide
dorzolamide HCL/timolol maleate
riluzole
levobunolol HCL
rocuronium bromide
timolol maleate ophthalmic gel forming
vecuronium bromide
Metipranolol
MUSCULOSKELETAL AGENTS
OPHTHALMIC STEROIDS
LOW COST GENERIC
LOW COST GENERIC
baclofen
neomycin/polymyxin/dexamethasone
carisoprodol
cyclobenzaprine HCL
NON-PREFERRED BRAND SPECIALTY
methocarbamol
Iluvien
NON-PREFERRED BRAND SPECIALTY
Gel-onePA
GENERIC
Genvisc 850PA
dexamethasone sodium phosphate
HyalganPA
fluorometholone
MonoviscPA
neomycin/polymyxin/bacitracin/hydrocortisone
OrthoviscPA
prednisolone acetate
SupartzPA
sulfacetamide sodium/prednisolone sodium phosphate
Supartz FxPA
tobramycin/dexamethasone
PREFERRED BRAND SPECIALTY
BRAND
EuflexxaPA
FML Forte
SynviscPA
Synvisc OnePA
PROSTAGLANDINS
GENERIC
GENERIC
carisoprodol/aspirin
latanoprost
carisoprodol/aspirin/codeine
Bimatoprost
chlorzoxazone
BRAND
dantrolene sodium
Lumigan
metaxalone
Travatan Z
orphenadrine citrate
orphenadrine citrate ER
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 14
CYCLOPLEGIC MYDRIATICS butalbital/acetaminophen/caffeine
butalbital/aspirin/caffeine
LOW COST GENERIC
choline magnesium trisalicylate
atropine sulfate
clonidine HCL
GENERIC
diflunisal
cyclopentolate hydrochloride
salsalate
cyclopentolate HCL
homatropine HBR
ANALGESICS - OPIOID
DECONGESTANTS GENERIC
acetaminophen/caffeine/dihydrocodeine
GENERIC
acetaminophen/codeine
phenylephrine HCL
acetaminophen/codeine #2
acetaminophen/codeine #3
MIOTICS
acetaminophen/codeine #4
GENERIC
acetaminophen/codeine phosphate
pilocarpine HCL
alfentanil
buprenorphine HCL
ADRENERGIC AGENTS
buprenorphine HCL/naloxone HCL
GENERIC
butalbital/acetaminophen/caffeine/codeine
apraclonidine
butalbital/aspirin/caffeine/codeine
brimonidine tartrate
butorphanol tartrate
codeine sulfate
LOCAL ANESTHETICS
fentanyl
GENERIC
fentanyl citrate oral transmucosal
proparacaine HCL
hydrocodone bitartrate/acetaminophen
tetracaine HCL
hydrocodone/acetaminophen
hydrocodone/ibuprofen
OPHTHALMICS - MISC.
hydromorphone HCL
NON-PREFERRED BRAND SPECIALTY
hydromorphone HCL dosette
CystaranQL,PA
hydromorphone HCL ER
Jetrea
meperidine HCL
methadone HCL
GENERIC
morphine sulfate
azelastine HCL
morphine sulfate ER
bromfenac
nalbuphine HCL
cromolyn sodium
oxycodone hydrochloride
diclofenac sodium
oxycodone HCL
dorzolamide HCL
oxycodone/acetaminophen
epinastine HCL
oxycodone/aspirin
flurbiprofen sodium
oxycodone/ibuprofen
ketorolac tromethamine
oxymorphone hydrochloride
olopatadine HCL
oxymorphone hydrochloride ER
pentazocine/naloxone HCL
tramadol hydrochloride
OTIC AGENTS
tramadol hydrochloride/acetaminophen
LOW COST GENERIC
tramadol HCL
antipyrine/benzocaine
tramadol HCL ER
GENERIC
Aspirin-caffeine-dihydrocodeine
acetic acid
Fentanyl
fluocinolone acetonide
Hydrocodone/Acetaminophen
fluocinolone acetonide ear drops
Hydromorphone HCL ER
hydrocortisone/acetic acid
Hydromorphone HCL/Sodium Chloride
neomycin/polymyxin/hydrocortisone
Morphine Sulfate
neomycin/polymyxin/HC
Morphine Sulfate ER
ofloxacin
Oxycodone HCL ER
Tramadol HCL ER
OXYTOCICS
BRAND
GENERIC
Opana ER (crush Resistant)
methylergonovine maleate
Oxycontin
oxytocin
ANTI-INFLAMMATORY
PAIN MANAGEMENT
LOW COST GENERIC
ANALGESICS - NONNARCOTIC indomethacin
meloxicam
PREFERRED BRAND SPECIALTY
NON-PREFERRED BRAND SPECIALTY
Prialt
ActemraPA
ArcalystPA
GENERIC
EnbrelPA
butalbital/acetaminophen
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 15
Enbrel SureclickPA SPECIALTY
KineretPA GENERIC
OrenciaPA probenecid
OtezlaPA probenecid/colchicine
XeljanzPA BRAND
PREFERRED BRAND SPECIALTY Colchicine
HumiraPA Colcrys
Humira Pediatric Crohns Disease Starter PackPA
Humira PenPA LOCAL ANESTHETICS-INJ
Humira Pen-crohns DiseasestarterPA
GENERIC
Humira Pen-psoriasis StarterPA
bupivacaine HCL
IlarisQL,PA
bupivacaine/epinephrine
SimponiPA
chloroprocaine HCL
Simponi AriaPA
lidocaine HCL
GENERIC
lidocaine/epinephrine
celecoxib
ropivacaine
diclofenac potassium
ropivacaine HCL
diclofenac sodium DR
Tetracaine HCL
diclofenac sodium ER
diclofenac sodium/misoprostol
RESPIRATORY, ALLERGY, ETC
etodolac
ANTIHISTAMINES
etodolac ER
LOW COST GENERIC
flurbiprofen
promethazine HCL plain
ibuprofen
GENERIC
ibuprofen lysine
carbinoxamine maleate
indomethacin ER
cetirizine HCL
ketoprofen
clemastine fumarate
ketorolac tromethamine
cyproheptadine HCL
leflunomide
desloratadine
mefenamic acid
diphenhydramine HCL
nabumetone
levocetirizine dihydrochloride
naproxen
promethazine HCL
naproxen sodium
Clemastine Fumarate
naproxen sodium CR
Desloratadine Odt
naproxen sodium DS
naproxen sodium ER
NASAL AGENTS
oxaprozin
LOW COST GENERIC
piroxicam
ipratropium bromide
sulindac
GENERIC
tolmetin sodium
azelastine HCL
Fenoprofen Calcium
budesonide
Meclofenamate Sodium
flunisolide
Naproxen
fluticasone propionate
Tolmetin Sodium
mometasone furoate
olopatadine HCL
MIGRAINE PRODUCTS
triamcinolone acetonide
GENERIC
almotriptan malate
COUGH/COLD/ALLERGY
dihydroergotamine mesylate
LOW COST GENERIC
frovatriptan succinate
benzonatate
naratriptan HCL
promethazine-DM
rizatriptan benzoate
promethazine/dextromethorphan
rizatriptan benzoate odt
GENERIC
sumatriptan succinate
acetylcysteine
sumatriptan succinate refill
bromphen/pseudoephedrine HCL/dextromethorphan HBR
zolmitriptan
hydrocodone bitartrate/chlorpheniramine maleate/PSE
zolmitriptan odt
hydrocodone bitartrate/homatropine methylbromide
Dihydroergotamine Mesylate
hydrocodone polistirex/chlorpheniramine polistirex
Sumatriptan Succinate
hydrocodone/homatropine
phenylephrine/guaifenesin
BRAND
promethazine/codeine
Cafergot
promethazine/phenylephrine
promethazine/phenylephrine/codeine
GOUT AGENTS
sodium chloride
LOW COST GENERIC
allopurinol
ANTIASTHMATIC/COPD AGENTS
NON-PREFERRED BRAND SPECIALTY
LOW COST GENERIC
KrystexxaPA
ipratropium bromide
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 16
PREFERRED BRAND SPECIALTY MEDICAL DEVICES
XolairPA
DIABETIC SUPPLIES
GENERIC
BRAND
albuterol
Accu-chek Safe-t-pro Lancets
albuterol sulfate
Accu-chek Safe-t-pro Pluslancets
albuterol sulfate ER
Accu-chek Soft Touch Lancets
albuterol TAB 4MG
Accu-chek Softclix Lancets
aminophylline
Active 1ST Blood Lancets 30G/Easy Twist CAP
budesonide
Advocate Lancets
epinephrine HCL
Advocate Lancets 30G
ipratropium bromide/albuterol sulfate
Advocate Safety Lancets
levalbuterol
Advocate Safety Lancets 26G
levalbuterol HCL
Agamatrix Ultra-thin Lancets 33G
montelukast sodium
Assure Haemolance Plus High Flow 18G
terbutaline sulfate
Assure Haemolance Plus Low Flow 25G
theophylline
Assure Haemolance Plus Micro Flow 28G
theophylline CR
Assure Haemolance Plus Normal Flow 21G
theophylline ER
Assure Haemolance Plus Pediatric Blade
zafirlukast
Assure Lance Lancets
Cromolyn Sodium
Assure Lance Lancets 21G
Assure Lance Plus Safety Lancets 25G
BRAND
Assure Lance Plus Safety Lancets 30G
Advair Diskus
Assure Lancets
Advair HFA
Aurora Lancet Super Thin 30G
Arnuity Ellipta
Aurora Lancet Thin 23G
Breo Ellipta
AF Lancets Super Thin
Combivent Respimat
AT Last Lancets
Daliresp
Bayer Microlet Lancets
Flovent Diskus
Bullseye Safety Lancets
Flovent HFA
BD Insulin Syringe LUER-LOK/U-100/1ML
Incruse Ellipta
BD Insulin Syringe Microfine IV/U-100/0.3ML/28G X 1/2"
Proair HFA
BD Insulin Syringe Microfine IV/U-100/0.5ML/28G X 1/2"
Pulmicort Flexhaler
BD Insulin Syringe Microfine IV/U-100/1ML/27G X 5/8"
Serevent Diskus
BD Insulin Syringe Microfine IV/U-100/1ML/28G X 1/2"
Spiriva Handihaler
BD Insulin Syringe Microfine/U-100/0.3ML/28G X 1/2"
Spiriva Respimat
BD Insulin Syringe Microfine/U-100/0.5ML/28G X 1/2"
Symbicort
BD Insulin Syringe Microfine/U-100/1ML/27G X 5/8"
Ventolin HFA
BD Insulin Syringe Microfine/U-100/1ML/28G X 1/2"
BD Insulin Syringe Safetyglide/U-100/0.3ML/31G X 5/16"
RESPIRATORY AGENTS - MISC
BD Insulin Syringe Safetyglide/0.5ML/29G X 1/2"
NON-PREFERRED BRAND SPECIALTY
BD Insulin Syringe Safetyglide/1ML/29G X 1/2"
Aralast NPPA
BD Insulin Syringe Slip Tip/U-100/1ML
EsbrietPA
BD Insulin Syringe U-40/1ML/25G X 5/8"
GlassiaPA
BD Insulin Syringe Ultrafine Half-unit/0.3ML/31G X 5/16"
KalydecoPA
BD Insulin Syringe Ultrafine II/SHORT/0.5ML/31G X 5/16"
OfevPA
BD Insulin Syringe Ultrafine II/SHORT/1ML/31G X 5/16"
OrkambiQL,PA
BD Insulin Syringe Ultrafine/U-100/0.3ML/29G X 1/2"
Prolastin-cPA
BD Insulin Syringe Ultrafine/U-100/0.5ML/29G X 1/2"
ZemairaPA
BD Insulin Syringe Ultrafine/U-100/1ML/29G X 1/2"
PREFERRED BRAND SPECIALTY
BD Insulin Syringe Ultrafine/U-100/1ML/30G X 1/2"
PulmozymePA
BD Insulin Syringe Ultrafine/0.3ML/30G X 1/2"
BD Insulin Syringe Ultrafine/0.3ML/31G X 5/16"
BD Insulin Syringe Ultrafine/0.5ML/30G X 1/2"
VITAMINS
BD Insulin Syringe Ultrafine/0.5ML/31G X 5/16"
BD Insulin Syringe Ultrafine/1ML/30G X 1/2"
VITAMINS
BD Insulin Syringe Ultrafine/1ML/31G X 5/16"
GENERIC
BD Insulin Syringe/Detachable Needle/U-100/1ML/25G X 1"
ascorbic acid
ergocalciferol
BD Insulin Syringe/Detachable Needle/U-100/1ML/25G X 5/8"
phytonadione
thiamine HCL
BD Insulin Syringe/Detachable Needle/U-100/1ML/26G X 1/2"
vitamin c 222MG
vitamin d
BD Insulin Syringe/U-100/0.5ML/30G X 1/2"
vitamin k1
BD Insulin Syringe/U-100/1ML/27G X 1/2"
BD Insulin Syringe/U-100/1ML/28G X 1/2"
MULTIVITAMINS
BD Insulin Syringe/U-100/2ML/27.5G X 5/8"
GENERIC
BD Insulin Syringe/U-100/2ML/29G X 1/2"
b-complex 100
BD Lancet Ultrafine 30G
niacinamide/azelaic ac/ turmer/fa/b6/zinc ox/copper
BD Lancet Ultrafine 33G
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 17
BD LO-dose Insulin Syringe Microfine IV/0.5ML/28G X 1/2"
Gentle-let Lancets General Purpose Style/Medium Point
Gentle-let Lancets Safety Style/Fine Point
BD Microtainer Lancets
Gentle-let Lancets Safety Style/Medium Point
BD Pen Needle/Mini/Ultrafine/31G X 3/16"
Glucocom Lancets 28G
BD Pen Needle/Nano/Ultra Fine/32G X 4MM
Glucocom Lancets 30G
BD Pen Needle/SHORT/Ultrafine/31G X 5/16"
Glucocom Lancets 33G
BD Pen Needle/Ultrafine/29G X 12.7MM
Glucosource Lancets
BD Pen Needle/Ultrafine/29GX1/2" 12.7MM
Gmate Lancets 30G
BD Pen Needles SHORT/Ultrafine/31G X 5/16"
H&h Thinlet Lancets 26G
Careone Lancet Thin
H&h Thinlet Super Thin Lancets 30G
Careone Lancet Ultra Thin
Haemolance
Cleanlet Lancets 28G
Haemolance Low Flow Lancets
Clever Chek Lancets Ultrathin
Haemolance Plus
Clever Chek Lancets Ultrathin 30G
Haemolance Plus High Flow
Coaguchek Lancets
Haemolance Plus Low Flow
Comfort Lancets
Haemolance Plus Max Flow
Diastar Easy Test II Lancets 30G
Haemolance Plus Pediatric Flow
Diastar Easy Test Lancets30G
Hy-vee Lancets
Droplet Lancets Ultra Thin 30G
IN Touch Sterile Lancets 30G
Drug Mart On-the-go Lancets Gentle 30G
Lancets
Drug Mart Unilet Lancets Super Thin 30G
Lancets Bullseye Safety
Drug Mart Unilet Lancets Ultra Thin 28G
Lancets Safety Seal 21G
E-z Ject Lancets
Lancets Safety Seal 26G
E-z Ject Lancets Color
Lancets Safety Seal 28G
E-z Ject Lancets Super Thin
Lancets Safety Seal 30G
E-z Ject Lancets Super Thin 30G
Lancets Thin
E-z Ject Lancets Thin 26G
Lancets Twist Top
E-z Ject Lancets 21G
Lancets Ultra Fine
E-ZJECT Lancets Micro-thin 33G
Lancets Ultra Thin
Easy Touch Lancets 21G/Pressure Activated
Lancets 26G Twist Top
Easy Touch Lancets 23G/Pressure Activated
Lancets 28G
Easy Touch Lancets 26G/Pressure Activated
Lancets 30G
Easy Touch Lancets 26G/Pull-top
Lancets 30G Twist Top
Easy Touch Lancets 26G/Twist
Lancets 30G/Twist Top
Easy Touch Lancets 28G/Pressure Activated
Lancets 31G Twist Top
Easy Touch Lancets 28G/Pull-top
Lancets 33G Universal Design
Easy Touch Lancets 28G/Twist
Liberty Glucose Control Mid
Easy Touch Lancets 30G/Button-activated
Liberty Glucose Control Normal
Easy Touch Lancets 30G/Pressure Activated
Liberty Medical Lancets 30G
Easy Touch Lancets 30G/Pull-top
Lifescan Unistik II Lancets
Easy Touch Lancets 30G/Twist
Lifescan Unistik 2 Deep Penetration
Easy Touch Lancets 32G/Pressure Activated
Litetouch Lancets Micro Thin 33G
Easy Touch Lancets 32G/Pull-top
Live Better Lancet Super Thin 30G
Easy Touch Lancets 32G/Twist
Live Better Lancet Ultra Thin 28G
Easy Touch Lancets 33G/Twist
Medisense Thin Lancets
Easy Touch Safety Lancets21G/Pressure Activated
Medlance Plus Extra Lancets 21G
Easy Touch Safety Lancets23G/Pressure Activated
Medlance Plus Lancets
Easy Touch Safety Lancets26G/Button Activated
Medlance Plus Lancets Lite 25G
Easy Touch Safety Lancets26G/Pressure Activated
Medlance Plus Lite Lancets 25G
Easy Touch Safety Lancets28G/Button Activated
Medlance Plus Special Lancets 0.8MM
Easy Touch Safety Lancets28G/Pressure Activated
Medlance Plus Superlite 30G
Easy Twist & CAP Lancets
Medlance Plus Superlite 30G/Comfort Max
Easytest II Lancets
Medlance Plus Universal Lancets 21G
Easytest Lancets
Medlance Plus/Lite 25G
Embrace Lancets Ultra Thin 30G
Medlance/Extra
EZ Smart Blood Glucose Lancets
Medlance/Lite
EZ-lets Lancets 21G
Medlance/Universal
EZ-lets Lancets 23G
Meijer Lancets Universal 30G
EZ-lets Lancets 26G Super-soft
Meijer Super Thin Lancets
EZ-lets Lancets 28G Ultra-soft
Microlet Lancets
EZ-lets Lancets 30G
Microtainer Safety Flow Lancet/Sterile/Single-use
Fifty50 Safety Seal Lancets 30G
Monolet Lancets
Fifty50 Safety Seal Lancets 32G
Monolet Opd Lancets
Fifty50 Unilet Lancets 33G
Monolettor Safety Lancets
Fine 30
Myglucohealth Mgh Softlance Lancets 30G
Fingerstix Lancets
Netgroup Lancets
Fora Lancets
Nova Safety Lancets 23G
Freestyle Lancets
Nova Safety Lancets 28G
Freestyle Unistick II Lancets
Nova Sureflex Lancets
Gentle-let GP Lancets
Novofine Autocover 30GX8MM
Gentle-let Lancets General Purpose Style/Fine Point
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 18
Novofine 30GX8MM Safety Lancets
Novofine 32GX6MM Safety Lancets 21G
Novotwist 30GX8MM Safety Lancets 28G
Novotwist 32GX5MM Safety Let Lancets
On Call Lancets Safety Seal Lancets 28G
On Call Plus Lancets Safety Seal Lancets 30G
Onetouch Club Lancets Fine Point Shopko On-the-go Comfort Lancets 30G
Onetouch Combo Pack Shopko Unilet Lancets Super Thin 30G
Onetouch Delica Lancets Extra Fine 33G Shopko Unilet Lancets Ultra Thin 28G
Onetouch Delica Lancets Fine 30G Single-let
Onetouch Finepoint Lancets Smart Diabetes Vantage Universal Lancets 30G
Onetouch Lancets Smart Sense Color Lancets Universal 33G
Onetouch Ping Meter Remote Smart Sense Standard Lancets Universal 21G
Onetouch Ultra Blue Smart Sense Super Thin Lancets Universal 30G
Onetouch Ultra Control Smart Sense Thin Lancets Universal 26G
Onetouch Ultra Mini Smartest Lancets 28G
Onetouch Ultra 2 Solus V2 Pressure Activated Safety Lancets 28G
Onetouch Ultralink System (hex) Solus V2 Twist Lancets 30G
Onetouch Ultralink System (DEC) Sterilance TL
Onetouch Ultrasoft Lancets Sure-lance Flat Lancets
Onetouch Verio Control Solution High Sure-lance Lancets 26G
Onetouch Verio IQ Blood Glucose Monitoring System Sure-lance Thin Lancets 28G
Onetouch Verio Mid Control Solution Sure-lance Ultra Thin Lancets
Onetouch Verio Sync Bloodglucose Monitoring System Sure-touch Lancets Universal
Onetouch Verio Test Strips Surelite Lancets
Pen Needles 29G X 12MM Surestep Glucose Control
Pen Needles 29GX1/2" Surestep Glucose Control Solution
Pen Needles 30GX5/16" Surestep Pro High Glucosecontrol
Pen Needles 31G X 1/4" SHORT Surestep Pro Low Glucose Control
Pen Needles 31G X 3/16" Surestep Pro Normal Glucose Control
Pen Needles 31G X 6MM Techlite AST Lancets
Pen Needles 31GX5/16" Techlite Lancets
Perfect Lancets 30G Techlite Lancets 30G
Perfect Pressure Activated Safety Lancets 28G Thinlets GP Lancets
Pharmacist Choice Ultra Thin Lancets Thinlets Lancet
Pharmacist Choice Ultra Thin Lancets 28G Trueplus Lancets 26G
Pharmacist Choice Ultra Thin Lancets 30G Trueplus Lancets 28G
Pharmacist Choice Ultra Thin Lancets 31G Trueplus Lancets 28G Super Thin
Pharmacist Choice Ultra Thin Lancets 33G Trueplus Lancets 30G
Pharmacy Counter Lancets Trueplus Lancets 30G Ultra Thin
Precision Thin Lancets Trueplus Lancets 33G
Precision Thins GP Lancet Trueplus Lancets 33G Micro Thin
Precision Ultra Lancet Trueplus Safety Lancets 28G
Prodigy Pressure Activated Safety Lancets Ulticare Thin Lancets 30G
Prodigy Safety Lancets Ultilet Classic Lancets
Prodigy Twist Top Lancets Ultilet Lancets
Pss Select GP Lancets Ultilet Lancets 33G
Pss Select Safety Lancets Ultilet Safety Lancets 23G
Px Lancets Ultra Thin Ultra-thin II Auto Lancet
Qc Lancets Super Thin Ultra-thin II Lancets 28G
Qc Lancets Ultra Thin Ultra-thin II Lancets 30G
Relion Lancets Micro-thin33G Ultra-thin II Safety Autolancets 26G
Relion Lancets Standard 21G Unilet Comfortouch Lancet
Relion Lancets Thin 26G Unilet Excelite
Relion Lancets Ultra-thin30G Unilet Excelite II
Relion Thin Lancets Unilet G.p. Lancet
Relion Ultra Thin Lancets Unilet G.p. Superlite Lancet
Relion Ultra Thin Lancets30G Unilet GP 28 Ultra Thin
Relion Ultra Thin Plus Lancets 32G Unilet Lancet
Relion Ultra Thin Plus Lancets 33G Unilet Lancets Micro-thin33G
Renew Advanced Lancing Cartridge Refills Unilet Lancets Super-thin30G
Rexall Lancets Ultra Thin Unilet Lancets Ultra-thin 28G
Rightest Gl300 Lancets Unilet Superlite Lancet
Safe-t-lance Low Flow 25G Unistik Safety Lancets 28G
Safe-t-lance Normal Flow 21G Unistik Safety Lancets 30G
Safe-t-lance Plus Safety Lancet High Flow Unistik Touch Safety Lancets 21G
Safe-t-lance Plus Safety Lancet Low Flow Unistik Touch Safety Lancets 23G
Safe-t-lance Plus Safety Lancet Normal Flow Unistik Touch Safety Lancets 28G
Safety Lancet 21G/Pressure Activated Unistik Touch Safety Lancets 30G
Safety Lancet 28G/Pressure Activated Unistik 3 Gentle
Effective July 1, 2016
PA=Prior Auth Required; QL=Quantity Limits; 19
Universal 1 Lancets Thin 26G
Universal 1 Lancets Ultra Thin 30G
Valumark Lancet Super Thin 30G
Valumark Lancet Ultra Thin 28G
Vida Mia Unilet Lancets Super Thin 30G
Vida Mia Unilet Lancets Ultra Thin 28G
Vitalet Pro Lancets
Vitalet Pro Plus Lancets
W&f Lancets Colored 21G
W&f Lancets 26G
Walgreens Lancets
Walgreens Thin Lancets
Walgreens Ultra Thin Lancets
1ST Choice Lancets Super Thin
1ST Choice Lancets Thin
1ST Choice Lancets Ultra Thin
MISCELLANEOUS
NON-PREFERRED BRAND SPECIALTY
ExjadePA
FerriproxPA
JadenuPA
Effective July 1, 2016 v.1
PA=Prior Auth Required; QL=Quantity Limits; All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2016 Optum, Inc. All rights reserved.
20
Index
A
allopurinol, 16 Aspirin/Dipyridamole, 12
almotriptan malate, 16 Assure Haemolance Plus High Flow 18G, 17
abacavir, 2
Alogliptin, 8
abacavir sulfate/lamivudine/zidovudine, 2
Alogliptin/Metformin HCL, 8 Assure Haemolance Plus Low Flow 25G, 17
Abraxane, 4
Alogliptin/Pioglitazone, 9
acamprosate calcium DR, 14
alosetron hydrochloride, 10 Assure Haemolance Plus Micro Flow 28G, 17
acarbose, 8
Alphanate/Von Willebrand Factor Complex/Human, 12
Accu-chek Safe-t-pro Lancets, 17
Assure Haemolance Plus Normal Flow 21G, 17
Accu-chek Safe-t-pro Pluslancets, 17
Alphanine SD, 12
Accu-chek Soft Touch Lancets, 17
alprazolam, 12 Assure Haemolance Plus Pediatric Blade, 17
Accu-chek Softclix Lancets, 17
alprazolam ER, 12
acebutolol HCL, 5
alprazolam odt, 12 Assure Lance Lancets, 17
acetaminophen/caffeine/dihydrocodeine, 15
Alprolix, 11 Assure Lance Lancets 21G, 17
amantadine HCL, 13 Assure Lance Plus Safety Lancets 25G, 17
acetaminophen/codeine, 15
Amcinonide, 7
acetaminophen/codeine #2, 15
amifostine, 4 Assure Lance Plus Safety Lancets 30G, 17
acetaminophen/codeine #3, 15
amikacin sulfate, 1
acetaminophen/codeine #4, 15
amiloride HCL, 6 Assure Lancets, 17
acetaminophen/codeine phosphate, 15
amiloride/hydrochlorothiazide, 6 AT Last Lancets, 17
acetazolamide, 6
aminoacetic acid, 11 atenolol, 5
Acetazolamide, 6
aminocaproic acid, 11 atenolol/chlorthalidone, 5
acetazolamide ER, 6
aminophylline, 17 Atgam, 3
acetazolamide sodium, 6
amiodarone HCL, 5 atorvastatin calcium, 6
acetic acid, 15
amiodarone hydrochloride, 5 atovaquone, 2
acetic acid 0.25%, 11
Amitiza, 11 atovaquone/proguanil HCL, 2
acetylcysteine, 16
amitriptyline HCL, 12 atracurium besylate, 14
acitretin, 7
amlodipine besylate, 5 atropine sulfate, 10, 15
Actemra, 15
amlodipine besylate/atorvastatin calcium, 6
Aubagio, 13
Actimmune, 4
augmented betamethasone dipropionate, 7
Active 1ST Blood Lancets 30G/Easy Twist CAP, 17
amlodipine besylate/benazepril HCL, 5
amlodipine besylate/benazepril hydrochloride, 5
Aurora Lancet Super Thin 30G, 17
acyclovir, 2, 7
Aurora Lancet Thin 23G, 17
acyclovir sodium, 2
amlodipine besylate/valsartan, 5 Avastin, 3
adapalene, 6
amlodipine/valsartan/hctz, 5 Avonex, 14
adapalene P.M., 6
ammonium lactate, 7 azacitidine, 3
Adcetris, 3
Amoxapine, 12 azathioprine, 3
Adcirca, 6
amoxicillin, 1 Azathioprine, 3
adefovir dipivoxil, 2
amoxicillin/clavulanate potassium, 1 azelastine HCL, 15, 16
Adempas, 6
Amoxicillin/Clavulanate Potassium, 1 azithromycin, 1
adenosine, 5
amoxicillin/clavulanate potassium ER, 1 aztreonam, 2
Adriamycin, 3
amphetamine/dextroamphetamine, 13 B
Advair Diskus, 17
ampicillin, 1
Advair HFA, 17
b-complex 100, 17
ampicillin sodium, 1
Advate, 12
bacitracin, 2
ampicillin-sulbactam, 1
Advocate Lancets, 17
Bacitracin, 14
Ampicillin-sulbactam, 1
Advocate Lancets 30G, 17
bacitracin/polymyxin b, 14
ampicillin/sulbactam, 1
Advocate Safety Lancets, 17
baclofen, 14
Ampyra, 14
Advocate Safety Lancets 26G, 17
balsalazide disodium, 10
anagrelide hydrochloride, 12
AF Lancets Super Thin, 17
Baraclude, 2
anastrozole, 3
Afinitor, 4
Bayer Microlet Lancets, 17
Androderm, 8
Afinitor Disperz, 4
BD Insulin Syringe LUER-LOK/U-100/1ML, 17
antipyrine/benzocaine, 15
Afrezza, 8
Apokyn, 13
Agamatrix Ultra-thin Lancets 33G, 17
BD Insulin Syringe Microfine IV/U-100/0.3ML/28G X 1/2", 17
apraclonidine, 15
Albenza, 2
Aralast NP, 17
albumin human, 12
BD Insulin Syringe Microfine IV/U-100/0.5ML/28G X 1/2", 17
Arcalyst, 15
albuterol, 17
argatroban, 11
albuterol sulfate, 17
BD Insulin Syringe Microfine IV/U-100/1ML/27G X 5/8", 17
aripiprazole, 12
albuterol sulfate ER, 17
Aripiprazole Odt, 13
albuterol TAB 4MG, 17
BD Insulin Syringe Microfine IV/U-100/1ML/28G X 1/2", 17
armodafinil, 13
alclometasone dipropionate, 7
Armodafinil, 13
Aldurazyme, 10
BD Insulin Syringe Microfine/U-100/0.3ML/28G X 1/2", 17
Arnuity Ellipta, 17
alendronate sodium, 9
Arranon, 3
alfentanil, 15
BD Insulin Syringe Microfine/U-100/0.5ML/28G X 1/2", 17
Arzerra, 3
Alferon N, 4
ascorbic acid, 17
alfuzosin HCL ER, 11
BD Insulin Syringe Microfine/U-100/1ML/27G X 5/8", 17
Aspirin-caffeine-dihydrocodeine, 15
Alimta, 3
BD Insulin Syringe Microfine/U-100/1ML/28G X 1/2", 17
MM, 18 calcipotriene/betamethasone dipropionate, 7
BD Pen Needles SHORT/Ultrafine/31G X 5/16", 18
BD Insulin Syringe Safetyglide/0.5ML/29G X 1/2", 17
calcitonin salmon, 9
Bebulin, 12 calcitonin-salmon, 9
BD Insulin Syringe Safetyglide/1ML/29G X 1/2", 17
Beleodaq, 4 Calcitriol, 7
benazepril HCL, 5 calcitriol, 10
BD Insulin Syringe Safetyglide/U-100/0.3ML/31G X 5/16", 17
benazepril HCL/hydrochlorothiazide, 5 calcium acetate, 10
Benefix, 12 Camptosar, 4
BD Insulin Syringe Slip Tip/U-100/1ML, 17
benzonatate, 16 candesartan cilexetil, 5
benzoyl peroxide, 6 candesartan cilexetil/hydrochlorothiazide, 5
BD Insulin Syringe U-40/1ML/25G X 5/8", 17
benzoyl peroxide SHORT contact, 6
benztropine mesylate, 13 capecitabine, 3
BD Insulin Syringe Ultrafine Half-unit/0.3ML/31G X 5/16", 17
Berinert, 12 Caprelsa, 4
betamethasone dipropionate, 7 captopril, 5
BD Insulin Syringe Ultrafine II/SHORT/0.5ML/31G X 5/16", 17
betamethasone sodium phosphate/betamethasone acetate, 8
Carbaglu, 10
carbamazepine, 13
BD Insulin Syringe Ultrafine II/SHORT/1ML/31G X 5/16", 17
betamethasone valerate, 7 carbamazepine ER, 13
betaxolol HCL, 5, 14 carbidopa, 13
BD Insulin Syringe Ultrafine/0.3ML/30G X 1/2", 17
bethanechol chloride, 11 carbidopa/levodopa, 13
Bethkis, 1 carbidopa/levodopa ER, 13
BD Insulin Syringe Ultrafine/0.3ML/31G X 5/16", 17
bexarotene, 4 carbidopa/levodopa odt, 13
bicalutamide, 3 Carbidopa/Levodopa/Entacapone, 13
BD Insulin Syringe Ultrafine/0.5ML/30G X 1/2", 17
Bicnu, 2 carbinoxamine maleate, 16
Biltricide, 2 carboplatin, 2
BD Insulin Syringe Ultrafine/0.5ML/31G X 5/16", 17
Bimatoprost, 14 cardioplegic, 6
bisoprolol fumarate, 5 Careone Lancet Thin, 18
BD Insulin Syringe Ultrafine/1ML/30G X 1/2", 17
bisoprolol fumarate/hydrochlorothiazide, 5
Careone Lancet Ultra Thin, 18
carisoprodol, 14
BD Insulin Syringe Ultrafine/1ML/31G X 5/16", 17
bivalirudin, 11 carisoprodol/aspirin, 14
bleomycin sulfate, 2 carisoprodol/aspirin/codeine, 14
BD Insulin Syringe Ultrafine/U-100/0.3ML/29G X 1/2", 17
Blincyto, 3 carteolol HCL, 14
Bosulif, 4 carvedilol, 5
BD Insulin Syringe Ultrafine/U-100/0.5ML/29G X 1/2", 17
Botox, 14 Cayston, 2
Bravelle, 9 cefaclor, 1
BD Insulin Syringe Ultrafine/U-100/1ML/29G X 1/2", 17
Breo Ellipta, 17 Cefaclor, 1
brimonidine tartrate, 15 cefadroxil, 1
BD Insulin Syringe Ultrafine/U-100/1ML/30G X 1/2", 17
bromfenac, 15 cefazolin sodium, 1
bromocriptine mesylate, 13 cefdinir, 1
BD Insulin Syringe/Detachable Needle/U-100/1ML/25G X 1", 17
bromphen/pseudoephedrine HCL/dextromethorphan HBR, 16
cefepime, 1
cefixime, 1
BD Insulin Syringe/Detachable Needle/U-100/1ML/25G X 5/8", 17
budesonide, 8, 16, 17 cefotaxime sodium, 1
Bullseye Safety Lancets, 17 cefotetan, 1
BD Insulin Syringe/Detachable Needle/U-100/1ML/26G X 1/2", 17
bumetanide, 6 cefoxitin sodium, 1
Buphenyl, 10 cefpodoxime proxetil, 1
BD Insulin Syringe/U-100/0.5ML/30G X 1/2", 17
bupivacaine HCL, 16 cefprozil, 1
bupivacaine/epinephrine, 16 ceftazidime, 1
BD Insulin Syringe/U-100/1ML/27G X 1/2", 17
buprenorphine HCL, 15 Ceftriaxone IN Iso-osmotic Dextrose, 1
buprenorphine HCL/naloxone HCL, 15 ceftriaxone sodium, 1
BD Insulin Syringe/U-100/1ML/28G X 1/2", 17
bupropion HCL, 12 cefuroxime axetil, 1
bupropion HCL ER, 12 cefuroxime sodium, 1
BD Insulin Syringe/U-100/2ML/27.5G X 5/8", 17
bupropion HCL SR, 12 Cefuroxime Sodium, 1
bupropion HCL XL, 12 celecoxib, 16
BD Insulin Syringe/U-100/2ML/29G X 1/2", 17
buspirone HCL, 12 Cellcept Intravenous, 3
Busulfex, 2 cephalexin, 1
BD Lancet Ultrafine 30G, 17
butalbital/acetaminophen, 15 Ceprotin, 11
BD Lancet Ultrafine 33G, 17
butalbital/acetaminophen/caffeine, 15 Cerdelga, 11
BD LO-dose Insulin Syringe Microfine IV/0.5ML/28G X 1/2", 17
butalbital/acetaminophen/caffeine/codeine, 15
Cerezyme, 11
cetirizine HCL, 16
BD Microtainer Lancets, 18
butalbital/aspirin/caffeine, 15 Cetrotide, 9
BD Pen Needle/Mini/Ultrafine/31G X 3/16", 18
butalbital/aspirin/caffeine/codeine, 15 cevimeline HCL, 12
butorphanol tartrate, 15 chlordiazepoxide HCL, 12
BD Pen Needle/Nano/Ultra Fine/32G X 4MM, 18
Bydureon, 8 chlordiazepoxide HCL/clidinium bromide, 10
Byetta, 8
BD Pen Needle/SHORT/Ultrafine/31G X 5/16", 18
C chlorhexidine gluconate, 12
chlorhexidine gluconate oral rinse, 12
cabergoline, 9
BD Pen Needle/Ultrafine/29G X 12.7MM, 18
chloroprocaine HCL, 16
Cafergot, 16
chloroquine phosphate, 2
caffeine citrate, 13
BD Pen Needle/Ultrafine/29GX1/2" 12.7
chlorothiazide, 6
calcipotriene, 7
Chlorothiazide, 6
Colcrys, 16 diclofenac sodium, 7, 15
chlorothiazide sodium, 6
colestipol HCL, 6 diclofenac sodium DR, 16
chlorpromazine HCL, 13
colistimethate sodium, 2 diclofenac sodium ER, 16
chlorthalidone, 6
Combivent Respimat, 17 diclofenac sodium/misoprostol, 16
Chlorthalidone, 6
Cometriq, 4 dicloxacillin sodium, 1
chlorzoxazone, 14
Comfort Lancets, 18 dicyclomine HCL, 10
cholestyramine, 6
Copaxone, 14 didanosine, 2
cholestyramine light, 6
Corifact, 12 Diflorasone Diacetate, 7
choline magnesium trisalicylate, 15
Cosentyx, 7 diflunisal, 15
chorionic gonadotropin, 9
Cosentyx Sensoready Pen, 7 digoxin, 4
Cialis, 6
Cosmegen, 3 dihydroergotamine mesylate, 16
ciclopirox, 7
Creon, 10 Dihydroergotamine Mesylate, 16
ciclopirox nail lacquer, 7
cromolyn sodium, 10, 15 diltiazem CD, 5
ciclopirox olamine, 7
Cromolyn Sodium, 17 diltiazem HCL, 5
cidofovir, 2
cyanocobalamin, 11 diltiazem HCL ER, 5
cilostazol, 12
cyclobenzaprine HCL, 14 diphenhydramine HCL, 16
cimetidine, 10
cyclopentolate HCL, 15 diphenoxylate/atropine, 10
cimetidine HCL, 10
cyclopentolate hydrochloride, 15 dipyridamole, 12
Cimzia, 10
Cyclophosphamide, 2 disopyramide phosphate, 5
Cimzia Starter Kit, 10
cyclophosphamide, 2 disulfiram, 14
Cinryze, 12
cyclosporine, 3 divalproex sodium, 13
ciprofloxacin, 1
cyclosporine modified, 3 divalproex sodium DR, 13
ciprofloxacin ER, 1
cyproheptadine HCL, 16 divalproex sodium ER, 13
ciprofloxacin HCL, 1, 14
Cyramza, 3 dobutamine HCL, 6
Ciprofloxacin HCL, 1
Cystagon, 11 dobutamine HCL/D5W, 6
ciprofloxacin I.V.-IN D5W, 1
Cystaran, 15 dobutamine/dextrose 5%, 6
cisatracurium besylate, 14
cytarabine, 3 Docefrez, 4
cisplatin, 2
Cytarabine, 3 docetaxel, 3
Cisplatin, 2
cytarabine aqueous, 3 Docetaxel, 4
citalopram hydrobromide, 12
D dofetilide, 5
citric acid/sodium citrate, 11
donepezil HCL, 14
dacarbazine, 4
cladribine, 3
dopamine HCL, 6
Dacarbazine, 4
clarithromycin, 1
Dopamine HCL, 6
Daklinza, 2
clarithromycin ER, 1
dopamine HCL-dextrose 5%, 6
Daliresp, 17
Cleanlet Lancets 28G, 18
dopamine HCL/dextrose 5%, 6
danazol, 8
clemastine fumarate, 16
dopamine/D5W, 6
dantrolene sodium, 14
Clemastine Fumarate, 16
dorzolamide HCL, 15
dapsone, 2
Clever Chek Lancets Ultrathin, 18
dorzolamide HCL/timolol maleate, 14
darifenacin ER, 11
Clever Chek Lancets Ultrathin 30G, 18
doxapram HCL, 13
darifenacin hydrobromide ER, 11
clindamycin, 2
doxazosin, 5
daunorubicin HCL, 3
clindamycin HCL, 2
doxazosin mesylate, 5
Daunoxome, 3
clindamycin palmitate HCL, 2
doxepin HCL, 12
decitabine, 3
clindamycin phosphate, 2, 6, 11
Doxepin HCL, 12
demeclocycline HCL, 1
clindamycin phosphate add-vantage, 2
Doxepin Hydrochloride, 7
Depocyt, 3
clindamycin phosphate IN D5W, 2
doxercalciferol, 10
desipramine HCL, 12
clindamycin phosphate pharmacy bulk package, 2
doxorubicin HCL, 3
desloratadine, 16
Doxorubicin HCL, 3
Desloratadine Odt, 16
clindamycin/benzoyl peroxide, 6
doxorubicin HCL liposome, 3
desmopressin acetate, 9
clobetasol propionate, 7
doxycycline, 1
desogestrel/ethinyl estradiol, 8
clobetasol propionate emollient, 7
Doxycycline, 7
desonide, 7
Clolar, 3
doxycycline hyclate, 1
desoximetasone, 7
clomiphene citrate, 9
doxycycline hyclate DR, 1
Desoximetasone, 7
clomipramine HCL, 12
doxycycline monohydrate, 1
dexamethasone, 7
clonazepam, 13
dronabinol, 10
Dexamethasone, 8
clonazepam odt, 13
droperidol, 12
dexamethasone sodium phosphate, 7, 14
clonidine HCL, 5, 15
Droplet Lancets Ultra Thin 30G, 18
clonidine HCL ER, 13
drospirenone/ethinyl estradiol, 8
Dexamethasone Sodium Phosphate, 8
clopidogrel, 12
Drug Mart On-the-go Lancets Gentle 30G, 18
dexmedetomidine HCL, 13
clorazepate dipotassium, 12
dexmethylphenidate HCL, 13
clotrimazole, 7, 12
Drug Mart Unilet Lancets Super Thin 30G, 18
dexmethylphenidate HCL ER, 13
clotrimazole/betamethasone dipropionate, 7
dexrazoxane, 4
Drug Mart Unilet Lancets Ultra Thin 28G, 18
dextroamphetamine sulfate, 13
clozapine, 13
dextroamphetamine sulfate ER, 13
clozapine odt, 13
duloxetine HCL, 12
Diastar Easy Test II Lancets 30G, 18
Clozapine Odt, 13
dutasteride, 11
Diastar Easy Test Lancets30G, 18
Coaguchek Lancets, 18
dutasteride/tamsulosin HCL, 11
diazepam, 12
codeine sulfate, 15
dutasteride/tamsulosin hydrochloride, 11
Diazepam, 12
Colchicine, 16
Dysport, 14
diclofenac potassium, 16
E
epirubicin HCL, 3 Fifty50 Safety Seal Lancets 32G, 18
Epirubicin HCL, 3 Fifty50 Unilet Lancets 33G, 18
E-z Ject Lancets, 18
episone CRE, 7 finasteride, 11
E-z Ject Lancets 21G, 18
eplerenone, 5 Fine 30, 18
E-z Ject Lancets Color, 18
epoprostenol sodium, 6 Fingerstix Lancets, 18
E-z Ject Lancets Super Thin, 18
Eprosartan Mesylate, 5 Firazyr, 12
E-z Ject Lancets Super Thin 30G, 18
eptifibatide, 12 Firmagon, 3
E-z Ject Lancets Thin 26G, 18
Erbitux, 3 flavoxate HCL, 11
E-ZJECT Lancets Micro-thin 33G, 18
ergocalciferol, 17 flecainide acetate, 5
Easy Touch Lancets 21G/Pressure Activated, 18
ergoloid mesylates, 14 Flovent Diskus, 17
Ergoloid Mesylates, 14 Flovent HFA, 17
Easy Touch Lancets 23G/Pressure Activated, 18
Erwinaze, 3 floxuridine, 3
erythromycin, 1, 6, 14 Floxuridine, 3
Easy Touch Lancets 26G/Pressure Activated, 18
Erythromycin Base, 1 fluconazole, 1
erythromycin/benzoyl peroxide, 6 fluconazole IN dextrose, 1
Easy Touch Lancets 26G/Pull-top, 18
Esbriet, 17 fluconazole IN NACL, 1
Easy Touch Lancets 26G/Twist, 18
escitalopram oxalate, 12 flucytosine, 1
Easy Touch Lancets 28G/Pressure Activated, 18
esmolol HCL, 5 fludarabine phosphate, 3
esomeprazole magnesium, 10 fludrocortisone acetate, 8
Easy Touch Lancets 28G/Pull-top, 18
esomeprazole sodium, 10 flunisolide, 16
Easy Touch Lancets 28G/Twist, 18
Esomeprazole Sodium, 10 fluocinolone acetonide, 7, 15
Easy Touch Lancets 30G/Button-activated, 18
estazolam, 13 fluocinolone acetonide ear drops, 15
estradiol, 8 fluocinonide, 7
Easy Touch Lancets 30G/Pressure Activated, 18
estradiol valerate, 8 fluocinonide-e, 7
estradiol/norethindrone acetate, 8 fluorometholone, 14
Easy Touch Lancets 30G/Pull-top, 18
Estropipate, 8 fluorouracil, 3
Easy Touch Lancets 30G/Twist, 18
eszopiclone, 13 fluoxetine DR, 12
Easy Touch Lancets 32G/Pressure Activated, 18
ethacrynate sodium, 6 fluoxetine HCL, 12
ethambutol HCL, 1 fluphenazine decanoate, 13
Easy Touch Lancets 32G/Pull-top, 18
ethosuximide, 13 fluphenazine HCL, 12
Easy Touch Lancets 32G/Twist, 18
etodolac, 16 flurandrenolide, 7
Easy Touch Lancets 33G/Twist, 18
etodolac ER, 16 flurazepam HCL, 13
Easy Touch Safety Lancets21G/Pressure Activated, 18
Etopophos, 4 Flurazepam HCL, 13
etoposide, 3 flurbiprofen, 16
Easy Touch Safety Lancets23G/Pressure Activated, 18
Etoposide, 4 flurbiprofen sodium, 15
Euflexxa, 14 flutamide, 3
Easy Touch Safety Lancets26G/Button Activated, 18
Evotaz, 2 fluticasone propionate, 7, 16
exemestane, 3 fluvastatin, 6
Easy Touch Safety Lancets26G/Pressure Activated, 18
Exjade, 20 fluvastatin sodium ER, 6
EZ Smart Blood Glucose Lancets, 18 fluvoxamine maleate, 12
Easy Touch Safety Lancets28G/Button Activated, 18
EZ-lets Lancets 21G, 18 fluvoxamine maleate ER, 12
EZ-lets Lancets 23G, 18 FML Forte, 14
Easy Touch Safety Lancets28G/Pressure Activated, 18
EZ-lets Lancets 26G Super-soft, 18 folic acid, 11
EZ-lets Lancets 28G Ultra-soft, 18 folic acid/vitamin b-6/vitamin b-12, 11
Easy Twist & CAP Lancets, 18
EZ-lets Lancets 30G, 18 Follistim AQ, 9
Easytest II Lancets, 18
F Folotyn, 3
Easytest Lancets, 18
fondaparinux sodium, 11
econazole nitrate, 7
Fabrazyme, 10
Fora Lancets, 18
Egrifta, 9
famciclovir, 2
Forteo, 9
Elaprase, 10
famotidine, 10
fosinopril sodium, 5
Elelyso, 11
Famotidine, 10
fosinopril sodium/hydrochlorothiazide, 5
Eligard, 3
Farydak, 4
fosphenytoin sodium, 13
Eloctate, 11
Faslodex, 3
Fragmin, 11
Embrace Lancets Ultra Thin 30G, 18
Feiba, 12
Freestyle Lancets, 18
enalapril maleate, 5
Feiba NF, 12
Freestyle Unistick II Lancets, 18
enalapril maleate/hydrochlorothiazide, 5
felbamate, 13
frovatriptan succinate, 16
enalaprilat, 5
felodipine ER, 5
furosemide, 6
Enbrel, 15
fenofibrate, 6
Fusilev, 4
Enbrel Sureclick, 16
Fenofibrate, 6
G
enoxaparin sodium, 11
fenofibrate micronized, 6
entacapone, 13
Fenofibric Acid, 6 gabapentin, 13
entecavir, 2
fenofibric acid DR, 6 galantamine hydrobromide, 14
Entyvio, 10
fenoldopam mesylate, 5 Galantamine Hydrobromide, 14
ephedrine sulfate, 6
Fenoprofen Calcium, 16 ganciclovir, 2
epinastine HCL, 15
fentanyl, 15 Ganirelix Acetate, 9
Epinephrine, 6
Fentanyl, 15 gatifloxacin, 14
epinephrine HCL, 17
fentanyl citrate oral transmucosal, 15 Gattex, 10
Epipen 2-PAK, 6
Ferriprox, 20 Gazyva, 3
Epipen-JR 2-PAK, 6
Fifty50 Safety Seal Lancets 30G, 18 Gel-one, 14
Gelnique, 11
Harvoni, 2 hydromorphone HCL, 15
gemcitabine, 3
Helixate FS, 11 hydromorphone HCL dosette, 15
gemcitabine HCL, 3
Hemofil M, 12 hydromorphone HCL ER, 15
gemfibrozil, 6
heparin lock, 11 Hydromorphone HCL ER, 15
gene-xene TAB 15MG, 12
heparin lock flush, 11 Hydromorphone HCL/Sodium Chloride, 15
gene-xene TAB 3.75MG, 12
heparin lock flush for flushing vascular access devices, 11
gene-xene TAB 7.5MG, 12
hydroxychloroquine sulfate, 2
gentamicin sulfate, 1, 14
heparin lock flush/NACL for flushing vascular access devices, 11
Hydroxyprogesterone Caproate, 3
gentamicin sulfate pediatric, 1
hydroxyurea, 4
gentamicin sulfate/0.9% sodium chloride, 1
heparin sodium, 11 hydroxyzine HCL, 12
heparin sodium dcu, 11 hydroxyzine pamoate, 12
Gentle-let GP Lancets, 18
heparin sodium lock flush, 11 Hydroxyzine Pamoate, 12
Gentle-let Lancets General Purpose Style/Fine Point, 18
heparin sodium/D5W, 11 hyoscyamine sulfate, 10
heparin sodium/NACL 0.9%, 11 hyoscyamine sulfate ER, 10
Gentle-let Lancets General Purpose Style/Medium Point, 18
heparin sodium/sodium chloride 0.9% premix, 11
hyoscyamine sulfate odt, 10
hyoscyamine sulfate SR, 10
Gentle-let Lancets Safety Style/Fine Point, 18
Herceptin, 3 I
hetastarch 6%/NACL, 12
ibandronate sodium, 9
Gentle-let Lancets Safety Style/Medium Point, 18
Hetlioz, 13
Ibrance, 4
homatropine HBR, 15
ibuprofen, 16
Genvisc 850, 14
Humalog, 8
ibuprofen lysine, 16
Gilenya, 13
Humalog Kwikpen, 8
ibutilide fumarate, 5
Gilotrif, 4
Humalog Mix 50/50, 8
Iclusig, 4
Glassia, 17
Humalog Mix 50/50 Kwikpen, 8
idarubicin HCL, 3
glatopa, 13
Humalog Mix 75/25, 8
Ifex, 2
Gleevec, 4
Humalog Mix 75/25 Kwikpen, 8
ifosfamide, 2
Gleostine, 2
Humate-p, 12
Ifosfamide, 2
glimepiride, 8
Humira, 16
Ilaris, 16
glipizide, 8
Humira Pediatric Crohns Disease Starter Pack, 16
Iluvien, 14
glipizide ER, 8
imatinib mesylate, 4
glipizide/metformin HCL, 8
Humira Pen, 16
Imbruvica, 4
Glucagon Emergency Kit, 8
Humira Pen-crohns Diseasestarter, 16
imipenem/cilastatin, 2
Glucocom Lancets 28G, 18
Humira Pen-psoriasis Starter, 16
imipramine HCL, 12
Glucocom Lancets 30G, 18
Humulin 70/30, 8
imipramine pamoate, 12
Glucocom Lancets 33G, 18
Humulin 70/30 Kwikpen, 8
imiquimod, 7
Glucosource Lancets, 18
Humulin N, 8
IN Touch Sterile Lancets 30G, 18
glyburide, 8
Humulin N Kwikpen, 8
Increlex, 9
Glyburide, 8
Humulin R, 8
Incruse Ellipta, 17
glyburide micronized, 8
Humulin R U-500 (concentrated), 8
indapamide, 6
glyburide/metformin HCL, 8
Humulin R U-500 Kwikpen, 8
indomethacin, 15
glycine, 11
Hy-vee Lancets, 18
indomethacin ER, 16
glycopyrrolate, 10
Hyalgan, 14
Inlyta, 4
Gmate Lancets 30G, 18
Hycamtin, 4
Intron A, 4
Gonal-f, 9
hydralazine HCL, 5
Intron A W/Diluent, 4
Gonal-f RFF, 9
hydrochlorothiazide, 6
Invokamet, 9
Gonal-f RFF Rediject, 9
hydrocodone bitartrate/acetaminophen, 15
Invokana, 8
granisetron HCL, 10
ipratropium bromide, 16(2)
Granix, 11
hydrocodone bitartrate/chlorpheniramine maleate/PSE, 16
ipratropium bromide/albuterol sulfate, 17
griseofulvin microsize, 1
irbesartan, 5
griseofulvin ultramicrosize, 1
hydrocodone bitartrate/homatropine methylbromide, 16
irbesartan/hydrochlorothiazide, 5
guanfacine ER, 13
Iressa, 4
guanfacine HCL, 5
hydrocodone polistirex/chlorpheniramine polistirex, 16
irinotecan, 4
H
Irinotecan, 4
hydrocodone/acetaminophen, 15
H&h Thinlet Lancets 26G, 18
irinotecan HCL, 4
Hydrocodone/Acetaminophen, 15
H&h Thinlet Super Thin Lancets 30G, 18
Iron Asp Gly/ Polysacch Compl/Ascorb CAL/B12/Fa/C Threon/Suc, 11
hydrocodone/homatropine, 16
H.p. Acthar, 9
hydrocodone/ibuprofen, 15
Haemolance, 18
isoniazid, 1
hydrocort ene 100MG, 10
Haemolance Low Flow Lancets, 18
isosorbide dinitrate, 5
hydrocortisone, 7(2), 10
Haemolance Plus, 18
Isosorbide Dinitrate, 5
hydrocortisone acetate/aloe, 7
Haemolance Plus High Flow, 18
isosorbide mononitrate, 5
hydrocortisone acetate/lidocaine HCL, 10
Haemolance Plus Low Flow, 18
isosorbide mononitrate ER, 4
hydrocortisone acetate/pramoxine, 10
Haemolance Plus Max Flow, 18
isotonic gentamicin, 1
hydrocortisone butyrate, 7
Haemolance Plus Pediatric Flow, 18
isradipine, 5
hydrocortisone butyrate (lipid), 7
Halaven, 4
Istodax, 4
hydrocortisone butyrate (lipophilic), 7
halobetasol propionate, 7
itraconazole, 1
hydrocortisone IN absorbase, 7
haloperidol, 13
ivermectin, 2
hydrocortisone valerate, 7
haloperidol decanoate, 13
Ixempra Kit, 4
hydrocortisone/acetic acid, 15
haloperidol lactate, 13
Ixinity, 11
J
Lemtrada, 13 Lumigan, 14
Lenvima 10MG Daily Dose, 4 Lumizyme, 10
Jadenu, 20
Lenvima 14MG Daily Dose, 4 Lupaneta Pack, 9
Jakafi, 4
Lenvima 18MG Daily Dose, 4 Lupron Depot, 3
Janumet, 9
Lenvima 20MG Daily Dose, 4 Lupron Depot-PED, 9
Janumet XR, 9
Lenvima 24MG Daily Dose, 4 Lynparza, 4
Januvia, 8
Lenvima 8MG Daily Dose, 4 M
Jardiance, 8
Letairis, 6
Jetrea, 15
malathion, 7
letrozole, 3
Jevtana, 4
mannitol, 6
leucovorin calcium, 4
Juxtapid, 6
Marqibo, 4
Leukeran, 2
K
Matulane, 4
Leukine, 11
meclizine HCL, 10
leuprolide acetate, 3
Kadcyla, 3
Meclofenamate Sodium, 16
levalbuterol, 17
Kalbitor, 12
Medisense Thin Lancets, 18
levalbuterol HCL, 17
Kalydeco, 17
Medlance Plus Extra Lancets 21G, 18
levetiracetam, 13
Kepivance, 4
Medlance Plus Lancets, 18
levetiracetam ER, 13
ketoconazole, 1, 7
Medlance Plus Lancets Lite 25G, 18
levobunolol HCL, 14
ketoprofen, 16
Medlance Plus Lite Lancets 25G, 18
levocarnitine, 10
ketorolac tromethamine, 15, 16
Medlance Plus Special Lancets 0.8MM, 18
levocetirizine dihydrochloride, 16
Keveyis, 6
levofloxacin, 1, 14
Keytruda, 3
Medlance Plus Superlite 30G, 18
levofloxacin IN D5W, 1
Kineret, 16
Medlance Plus Superlite 30G/Comfort Max, 18
levoleucovorin, 4
Koate-dvi, 12
levoleucovorin calcium, 4
Kogenate FS, 12
Medlance Plus Universal Lancets 21G, 18
levonorgestrel, 8
Kogenate FS Bio-set, 12
Levonorgestrel, 8
Kombiglyze XR, 9
Medlance Plus/Lite 25G, 18
levonorgestrel and ethinyl estradiol, 8
Korlym, 8
Medlance/Extra, 18
levonorgestrel/ethinyl estradiol, 8
Kovaltry, 12
Medlance/Lite, 18
levothyroxine sodium, 10
Krystexxa, 16
Medlance/Universal, 18
Lialda, 11
Kuvan, 10
medroxyprogesterone acetate, 8
Liberty Glucose Control Mid, 18
Kynamro, 6
mefenamic acid, 16
Liberty Glucose Control Normal, 18
Kyprolis, 4
mefloquine HCL, 2
Liberty Medical Lancets 30G, 18
L
megestrol acetate, 3, 8
lidocaine, 7
Meijer Lancets Universal 30G, 18
labetalol HCL, 5
lidocaine HCL, 5, 7, 16
Meijer Super Thin Lancets, 18
lactic acid, 7
lidocaine HCL IN D5W, 5
Mekinist, 4
lactic acid e, 7
lidocaine HCL jelly, 7
meloxicam, 15
lactic acid w/vitamin e, 7
lidocaine HCL viscous, 12
melphalan hydrochloride, 2
lactulose, 10(2)
lidocaine HCL/dextrose, 5
memantine HCL, 14
lamivudine, 2
lidocaine HCL/hydrocortisone acetate, 10
memantine HCL titration PAK, 14
lamivudine/zidovudine, 2
lidocaine viscous, 12
memantine hydrochloride, 14
lamotrigine, 13
lidocaine-prilocaine-cream base, 7
Menopur, 9
lamotrigine ER, 13
lidocaine/epinephrine, 16
meperidine HCL, 15
lamotrigine odt, 13
lidocaine/prilocaine, 7
meprobamate, 12
lamotrigine titration, 13
Lifescan Unistik 2 Deep Penetration, 18
mercaptopurine, 3
Lancets, 18
Lifescan Unistik II Lancets, 18
meropenem, 2
Lancets 26G Twist Top, 18
lincomycin HCL, 2
mesalamine, 10
Lancets 28G, 18
lindane, 7
mesna, 4
Lancets 30G, 18
linezolid, 2
Mesnex, 4
Lancets 30G Twist Top, 18
Linezolid, 2
metaxalone, 14
Lancets 30G/Twist Top, 18
liothyronine sodium, 10
Metaxalone, 14
Lancets 31G Twist Top, 18
lisinopril, 5
metformin HCL, 8
Lancets 33G Universal Design, 18
lisinopril/hydrochlorothiazide, 5
metformin HCL ER, 8
Lancets Bullseye Safety, 18
Litetouch Lancets Micro Thin 33G, 18
methadone HCL, 15
Lancets Safety Seal 21G, 18
lithium carbonate, 12
methamphetamine HCL, 13
Lancets Safety Seal 26G, 18
lithium carbonate ER, 12
methazolamide, 6
Lancets Safety Seal 28G, 18
Live Better Lancet Super Thin 30G, 18
methenamine hippurate, 11
Lancets Safety Seal 30G, 18
Live Better Lancet Ultra Thin 28G, 18
methenamine mandelate, 11
Lancets Thin, 18
Lomustine, 2
methimazole, 10
Lancets Twist Top, 18
Lonsurf, 4
methocarbamol, 14
Lancets Ultra Fine, 18
loperamide HCL, 10
methotrexate, 3
Lancets Ultra Thin, 18
lorazepam, 12
methotrexate sodium, 3
lansoprazole, 10
losartan potassium, 5
Methotrexate Sodium, 3
lansoprazole/amoxicillin/clarithromycin, 10
losartan potassium/hydrochlorothiazide, 5
methoxsalen, 7
methscopolamine bromide, 10
Lantus, 8
lovastatin, 6
methyldopa, 5
Lantus Solostar, 8
loxapine, 13
methylergonovine maleate, 15
latanoprost, 14
loxapine succinate, 13
methylphenidate HCL, 13
leflunomide, 16
methylphenidate HCL CD, 13
Myozyme, 10 fumarate, 8
methylphenidate HCL ER, 13
norethindrone acetate, 8
N
Methylphenidate HCL ER, 13
norethindrone acetate/ethinyl estradiol, 8(2)
nabumetone, 16
methylphenidate HCL SR, 13
nadolol, 5
methylphenidate hydrochloride, 13
norethindrone acetate/ethinyl estradiol/ferrous fumarate, 8
nadolol/bendroflumethiazide, 5
methylprednisolone, 7
nafcillin sodium, 1
methylprednisolone acetate, 7
norgestimate/ethinyl estradiol, 8
naftifine hydrochloride, 7
methylprednisolone dose pack, 7
Northera, 6
Naglazyme, 10
methylprednisolone sodiumsuccinate, 8
nortriptyline HCL, 12
nalbuphine HCL, 15
methyltestosterone, 8
Nortriptyline HCL, 12
naproxen, 16
Metipranolol, 14
Nova Safety Lancets 23G, 18
Naproxen, 16
metoclopramide HCL, 10
Nova Safety Lancets 28G, 18
naproxen sodium, 16
metoclopramide odt, 10
Nova Sureflex Lancets, 18
naproxen sodium CR, 16
metolazone, 6
Novoeight, 12
naproxen sodium DS, 16
metoprolol succinate ER, 5
Novofine 30GX8MM, 19
naproxen sodium ER, 16
metoprolol tartrate, 5
Novofine 32GX6MM, 19
naratriptan HCL, 16
Metoprolol Tartrate, 5
Novofine Autocover 30GX8MM, 18
nateglinide, 8
metoprolol/hydrochlorothiazide, 5
Novoseven, 12
Natpara, 9
metronidazole, 2, 7
Novoseven Rt, 12
nefazodone HCL, 12
metronidazole IN NACL 0.79%, 2
Novotwist 30GX8MM, 19
Nefazodone HCL, 12
metronidazole vaginal, 11
Novotwist 32GX5MM, 19
neomycin sulfate, 1
mexiletine HCL, 5
Nplate, 11
neomycin/bacitracin/polymyxin, 14
Microlet Lancets, 18
Nutropin AQ Nuspin 10, 9
neomycin/polymyxin b sulfates, 11
Microtainer Safety Flow Lancet/Sterile/Single-use, 18
Nutropin AQ Nuspin 20, 9
neomycin/polymyxin/bacitracin zinc, 14
Nutropin AQ Nuspin 5, 9
neomycin/polymyxin/bacitracin/hydrocortisone, 14
midodrine HCL, 6
Nutropin AQ Pen, 9
miglitol, 8
Nuwiq, 12
neomycin/polymyxin/dexamethasone, 14
milrinone IN dextrose, 4
nystatin, 1, 7, 12
neomycin/polymyxin/gramicidin, 14
milrinone lactate, 4
nystatin/triamcinolone, 7
neomycin/polymyxin/HC, 15
minocycline HCL, 1
O
neomycin/polymyxin/hydrocortisone, 15
minocycline HCL ER, 1
octreotide acetate, 9
neostigmine methylsulfate, 14
minoxidil, 5
Ofev, 17
Netgroup Lancets, 18
Mircera, 11
ofloxacin, 1, 14, 15
Neulasta, 11
mirtazapine, 12
Ofloxacin, 1
Neulasta Onpro Kit, 11
mirtazapine odt, 12
olanzapine, 13
Neumega, 11
misoprostol, 10
olanzapine odt, 13
Neupogen, 11
mitomycin, 3
olanzapine/fluoxetine, 14
nevirapine, 2
Mitomycin, 3
olopatadine HCL, 15, 16
nevirapine ER, 2
mitoxantrone HCL, 3
Olysio, 2
Nexavar, 4
modafinil, 13
omega-3-acid ethyl esters, 6
niacin ER, 6
Moderiba, 2
omeprazole, 10
niacinamide/azelaic ac/ turmer/fa/b6/zinc ox/copper, 17
Moderiba 1200 Dose Pack, 2
omeprazole/sodium bicarbonate, 10
Moderiba 800 Dose Pack, 2
Omontys, 11
nicardipine HCL, 5
moexipril HCL, 5
On Call Lancets, 19
nifedipine, 5
moexipril/hydrochlorothiazide, 5
On Call Plus Lancets, 19
nifedipine ER, 5
mometasone furoate, 7, 16
Oncaspar, 3
nimodipine, 5
Monoclate-p, 12
ondansetron HCL, 10
Nipent, 4
Monolet Lancets, 18
ondansetron odt, 10
nisoldipine, 5
Monolet Opd Lancets, 18
Onetouch Club Lancets Fine Point, 19
nitrofurantoin, 11
Monolettor Safety Lancets, 18
Onetouch Combo Pack, 19
nitrofurantoin macrocrystals, 11
Mononine, 12
Onetouch Delica Lancets Extra Fine 33G, 19
nitrofurantoin monohydrate, 11
Monovisc, 14
nitrofurantoin monohydrate/macrocrystals, 11
montelukast sodium, 17
Onetouch Delica Lancets Fine 30G, 19
morphine sulfate, 15
Onetouch Finepoint Lancets, 19
nitroglycerin ER, 5
Morphine Sulfate, 15
Onetouch Lancets, 19
nitroglycerin IN 5% dextrose, 5
morphine sulfate ER, 15
Onetouch Ping Meter Remote, 19
nitroglycerin IN dextrose 5%, 5
Morphine Sulfate ER, 15
Onetouch Ultra 2, 19
nitroglycerin lingual, 5
moxifloxacin HCL, 1
Onetouch Ultra Blue, 19
Nitroglycerin Lingual, 5
Mozobil, 11
Onetouch Ultra Control, 19
nitroglycerin transdermal, 5
mupirocin, 7
Onetouch Ultra Mini, 19
nizatidine, 10
mupirocin calcium, 7
Onetouch Ultralink System (DEC), 19
Nizatidine, 10
Mustargen, 2
Onetouch Ultralink System (hex), 19
Norditropin Cartridge, 9
Myalept, 10
Onetouch Ultrasoft Lancets, 19
Norditropin Flexpro, 9
mycophenolate mofetil, 3
Onetouch Verio Control Solution High, 19
Norditropin Nordiflex Pen, 9
mycophenolic acid DR, 3
norepinephrine bitartrate, 6
Myglucohealth Mgh Softlance Lancets 30G, 18
Onetouch Verio IQ Blood Glucose Monitoring System, 19
norethindrone, 8
norethindrone & ethinyl estradiol ferrous
Myobloc, 14
Onetouch Verio Mid Control Solution, 19
Onetouch Verio Sync Bloodglucose Monitoring System, 19
Pen Needles 29GX1/2", 19 Pradaxa, 11
Pen Needles 30GX5/16", 19 Praluent, 6
Onetouch Verio Test Strips, 19
Pen Needles 31G X 1/4" SHORT, 19 pramipexole dihydrochloride, 13
Onglyza, 8
Pen Needles 31G X 3/16", 19 pramipexole dihydrochloride ER, 13
Opana ER (crush Resistant), 15
Pen Needles 31G X 6MM, 19 pravastatin sodium, 6
Opdivo, 3
Pen Needles 31GX5/16", 19 prazosin HCL, 5
opium, 10
penicillin G potassium, 1 Precision Thin Lancets, 19
opium tincture, 10
penicillin v potassium, 1 Precision Thins GP Lancet, 19
Opsumit, 6
pentazocine/naloxone HCL, 15 Precision Ultra Lancet, 19
Orencia, 16
pentoxifylline ER, 12 prednicarbate, 7
Orenitram, 6
Perfect Lancets 30G, 19 prednisolone, 8
Orfadin, 10
Perfect Pressure Activated Safety Lancets 28G, 19
prednisolone acetate, 14
Orkambi, 17
prednisolone sodium phosphate, 8
orphenadrine citrate, 14
perindopril erbumine, 5 prednisolone sodium phosphate odt, 8
orphenadrine citrate ER, 14
Perjeta, 3 prednisone, 8
Orphenadrine/Asa/Caffeine, 14
permethrin, 7 Prednisone, 8
Orthovisc, 14
perphenazine, 13 Prezcobix, 2
Otezla, 16
Perphenazine/Amitriptyline, 14 Prialt, 15
Ovidrel, 9
Pharmacist Choice Ultra Thin Lancets, 19
Primaquine Phosphate, 2
oxacillin sodium, 1
primidone, 13
oxaliplatin, 2
Pharmacist Choice Ultra Thin Lancets 28G, 19
Proair HFA, 17
oxandrolone, 8
probenecid, 16
oxaprozin, 16
Pharmacist Choice Ultra Thin Lancets 30G, 19
probenecid/colchicine, 16
oxazepam, 12
prochlorperazine, 13
oxcarbazepine, 13
Pharmacist Choice Ultra Thin Lancets 31G, 19
prochlorperazine edisylate, 13
oxiconazole nitrate, 7
prochlorperazine maleate, 13
oxybutynin chloride, 11
Pharmacist Choice Ultra Thin Lancets 33G, 19
Procrit, 11
oxybutynin chloride ER, 11
Procysbi, 11
oxycodone HCL, 15
Pharmacy Counter Lancets, 19 Prodigy Pressure Activated Safety Lancets, 19
Oxycodone HCL ER, 15
phenazopyridine HCL, 11
oxycodone hydrochloride, 15
phenelzine sulfate, 12 Prodigy Safety Lancets, 19
oxycodone/acetaminophen, 15
phenobarbital, 13 Prodigy Twist Top Lancets, 19
oxycodone/aspirin, 15
Phenobarbital, 13 Profilnine, 12
oxycodone/ibuprofen, 15
Phenobarbital Sodium, 13 Profilnine SD, 12
Oxycontin, 15
phenoxybenzamine hydrochloride, 5 progesterone, 8
oxymorphone hydrochloride, 15
Phentolamine Mesylate-alprostadil, 6 Prograf, 3
oxymorphone hydrochloride ER, 15
phenylephrine HCL, 6, 15 Prolastin-c, 17
oxytocin, 15
phenylephrine/guaifenesin, 16 Proleukin, 4
P
phenytoin, 13 Prolia, 9
phenytoin sodium, 13 Promacta, 11
paclitaxel, 3
phenytoin sodium extended, 13 promethazine HCL, 16
Paclitaxel, 4
Photofrin, 4 promethazine HCL plain, 16
paliperidone ER, 13
phytonadione, 17 promethazine-DM, 16
pamidronate disodium, 9
pilocarpine HCL, 12, 15 promethazine/codeine, 16
Pamidronate Disodium, 9
pilocarpine hydrochloride, 12 promethazine/dextromethorphan, 16
Pancrelipase, 10
pimozide, 14 promethazine/phenylephrine, 16
pancuronium bromide, 14
pindolol, 5 promethazine/phenylephrine/codeine, 16
pantoprazole sodium, 10
pioglitazone HCL, 8 propafenone HCL, 5
papaverine HCL, 6
pioglitazone HCL-glimepiride, 8 propafenone HCL ER, 5
Papaverine-alprostadil, 6
pioglitazone HCL/metformin HCL, 8 proparacaine HCL, 15
Papaverine-phentolamine Mes/Alprostadil, 6
piperacillin sodium/ tazobactam sodium, 1
propranolol HCL, 5
propranolol HCL ER, 5
Papaverine-phentolamine Mesylate, 6
piperacillin sodium/tazobactam sodium, 1 propylthiouracil, 10
Papaverine/Phentolamine Mes/Alprostadil, 6
piperacillin/tazobactam, 1 protriptyline HCL, 12
piroxicam, 16 Pss Select GP Lancets, 19
paricalcitol, 10
Plegridy, 14 Pss Select Safety Lancets, 19
paromomycin sulfate, 1
Plegridy Starter Pack, 14 Pulmicort Flexhaler, 17
paroxetine HCL, 12
podofilox, 7 Pulmozyme, 17
paroxetine HCL ER, 12
polyethylene glycol 3350, 10 Purixan, 3
peg 3350/electrolytes, 10
polymyxin b sulfate, 2 Px Lancets Ultra Thin, 19
peg-3350/electrolytes, 10
polymyxin b sulfate/trimethoprim sulfate, 14
pyrazinamide, 1
peg-3350/NACL/NA bicarbonate/KCL, 10
pyridostigmine bromide, 14
Peg-intron, 2
Pomalyst, 3 Q
Peg-intron Redipen, 2
potassium citrate ER, 11
Peg-intron Redipen PAK 4, 2
Qc Lancets Super Thin, 19
potassium citrate-citric acid crystals, 11
Pegasys, 2
Qc Lancets Ultra Thin, 19
potassium citrate/citric acid, 11
Pegasys Proclick, 2
Quazepam, 13
potassium citrate/sodium citrate/citric acid, 11
Pegintron, 2
quetiapine fumarate, 13
Pen Needles 29G X 12MM, 19
quinapril HCL, 5
quinapril/hydrochlorothiazide, 5
Flow, 19 sodium sulfacetamide/sulfur, 6
quinidine gluconate CR, 5
Safe-t-lance Plus Safety Lancet Low Flow, 19
sodium sulfacetamide/sulfur cleanser, 6
quinidine gluconate ER, 5
sodium sulfacetamide/sulfur cleansing cloths, 6
quinidine sulfate, 5
Safe-t-lance Plus Safety Lancet Normal Flow, 19
Quinidine Sulfate, 5
sodium sulfacetamide/sulfur green, 6
Quinidine Sulfate ER, 5
Safety Lancet 21G/Pressure Activated, 19
sodium sulfacetamide/sulfur w/sunscreen, 6
quinine sulfate, 2
R
Safety Lancet 28G/Pressure Activated, 19
sodium sulfacetamide/sulfur wash, 6
Soliris, 12
rabeprazole sodium, 10
Safety Lancets, 19 Solus V2 Pressure Activated Safety Lancets 28G, 19
raloxifene hydrochloride, 9
Safety Lancets 21G, 19
ramipril, 5
Safety Lancets 28G, 19 Solus V2 Twist Lancets 30G, 19
ranitidine HCL, 10
Safety Let Lancets, 19 Somatuline Depot, 9
Ravicti, 10
Safety Seal Lancets 28G, 19 Somavert, 9
Rebetol, 2
Safety Seal Lancets 30G, 19 sotalol HCL, 5
Recombinate, 12
Saizen, 9 sotalol HCL (AF), 5
Relion Lancets Micro-thin33G, 19
Saizen Click.easy, 9 Sovaldi, 2
Relion Lancets Standard 21G, 19
salicylic acid, 7 Spiriva Handihaler, 17
Relion Lancets Thin 26G, 19
salicylic acid cream, 7 Spiriva Respimat, 17
Relion Lancets Ultra-thin30G, 19
salicylic acid ER, 7 spironolactone, 6
Relion R, 8
salicylic acid lotion, 7 spironolactone/hydrochlorothiazide, 6
Relion Thin Lancets, 19
salsalate, 15 Sprycel, 4
Relion Ultra Thin Lancets, 19
Samsca, 10 stannous fluoride oral rinse, 12
Relion Ultra Thin Lancets30G, 19
Sandostatin Lar Depot, 9 stavudine, 2
Relion Ultra Thin Plus Lancets 32G, 19
Savaysa, 11 Stelara, 7
Relion Ultra Thin Plus Lancets 33G, 19
selegiline HCL, 13 Stendra, 6
Remicade, 10
selenium sulfide, 7 Sterilance TL, 19
Remodulin, 6
Sensipar, 10 Stivarga, 4
Renew Advanced Lancing Cartridge Refills, 19
Serevent Diskus, 17 Sucraid, 10
Serostim, 9 sucralfate, 10
repaglinide, 8
sertraline HCL, 12 sulfacetamide sodium, 7, 14
Repaglinide/Metformin Hydrochloride, 9
Shopko On-the-go Comfort Lancets 30G, 19
sulfacetamide sodium/prednisolone sodium phosphate, 14
Repatha, 6
Repatha Sureclick, 6
Shopko Unilet Lancets Super Thin 30G, 19
sulfacetamide sodium/sulfur, 7
Revatio, 6
sulfacetamide sodium/sulfur cleanser, 7
Revlimid, 3
Shopko Unilet Lancets Ultra Thin 28G, 19
sulfamethoxazole/trimethoprim, 2
Rexall Lancets Ultra Thin, 19
sulfamethoxazole/trimethoprim DS, 2
Riastap, 12
Signifor, 9 sulfasalazine, 10
Ribasphere, 2
Signifor Lar, 9 sulindac, 16
Ribasphere Ribapak, 2
sildenafil, 6 sumatriptan succinate, 16
Ribatab, 2
sildenafil citrate, 6 Sumatriptan Succinate, 16
ribavirin, 2
Simponi, 16 sumatriptan succinate refill, 16
rifabutin, 1
Simponi Aria, 16 Supartz, 14
rifampin, 1
simvastatin, 6 Supartz Fx, 14
Rightest Gl300 Lancets, 19
Single-let, 19 Supprelin LA, 9
riluzole, 14
sirolimus, 3 Sure-lance Flat Lancets, 19
rimantadine HCL, 2
Smart Diabetes Vantage Universal Lancets 30G, 19
Sure-lance Lancets 26G, 19
risedronate sodium, 9
Sure-lance Thin Lancets 28G, 19
risedronate sodium DR, 9
Smart Sense Color Lancets Universal 33G, 19
Sure-lance Ultra Thin Lancets, 19
risperidone, 13
Sure-touch Lancets Universal, 19
risperidone odt, 13
Smart Sense Standard Lancets Universal 21G, 19
Surelite Lancets, 19
Rituxan, 3
Surestep Glucose Control, 19
rivastigmine tartrate, 14
Smart Sense Super Thin Lancets Universal 30G, 19
Surestep Glucose Control Solution, 19
rivastigmine transdermal system, 14
Surestep Pro High Glucosecontrol, 19
rizatriptan benzoate, 16
Smart Sense Thin Lancets Universal 26G, 19
Surestep Pro Low Glucose Control, 19
rizatriptan benzoate odt, 16
Surestep Pro Normal Glucose Control, 19
rocuronium bromide, 14
Smartest Lancets 28G, 19
ropinirole ER, 13
sodium chloride, 11, 16 Sutent, 4
ropinirole HCL, 13
sodium chloride 0.9%, 11 Sylatron, 4
ropivacaine, 16
sodium citrate/citric acid, 11 Symbicort, 17
ropivacaine HCL, 16
sodium ferric gluconate complex/sucrose, 11
Symlinpen 120, 8
rosuvastatin calcium, 6
Symlinpen 60, 8
Ruconest, 12
sodium hyaluronate, 7 Synjardy, 9
S
sodium phenylacetate/sodium benzoate, 10
Synribo, 4
Synthroid, 10
Sabril, 13
sodium phenylbutyrate, 10 Synvisc, 14
Safe-t-lance Low Flow 25G, 19
sodium sulfacetamide, 6, 7, 14 Synvisc One, 14
Safe-t-lance Normal Flow 21G, 19
sodium sulfacetamide wash, 7
Safe-t-lance Plus Safety Lancet High
T
Toujeo Solostar, 8 Unilet Excelite II, 19
Tracleer, 6 Unilet G.p. Lancet, 19
tacrolimus, 3, 7
tramadol HCL, 15 Unilet G.p. Superlite Lancet, 19
Tafinlar, 4
tramadol HCL ER, 15 Unilet GP 28 Ultra Thin, 19
tamoxifen citrate, 3
Tramadol HCL ER, 15 Unilet Lancet, 19
tamsulosin HCL, 11
tramadol hydrochloride, 15 Unilet Lancets Micro-thin33G, 19
Tarceva, 4
tramadol hydrochloride/acetaminophen, 15
Unilet Lancets Super-thin30G, 19
Tasigna, 4
Unilet Lancets Ultra-thin 28G, 19
Tecfidera, 14
trandolapril, 5 Unilet Superlite Lancet, 19
Tecfidera Starter Pack, 14
trandolapril/verapamil HCL, 5 Unistik 3 Gentle, 19
Techlite AST Lancets, 19
trandolapril/verapamil HCL ER, 5 Unistik Safety Lancets 28G, 19
Techlite Lancets, 19
tranexamic acid, 11 Unistik Safety Lancets 30G, 19
Techlite Lancets 30G, 19
tranylcypromine sulfate, 12 Unistik Touch Safety Lancets 21G, 19
Technivie, 2
Travatan Z, 14 Unistik Touch Safety Lancets 23G, 19
telmisartan, 5
trazodone HCL, 12 Unistik Touch Safety Lancets 28G, 19
telmisartan/amlodipine, 5
Treanda, 2 Unistik Touch Safety Lancets 30G, 19
telmisartan/hydrochlorothiazide, 5
Trelstar, 3 Unituxin, 3
temazepam, 13
Trelstar Mixject, 3 Universal 1 Lancets Thin 26G, 20
Temodar, 2
Tresiba Flextouch, 8 Universal 1 Lancets Ultra Thin 30G, 20
temozolomide, 2
tretinoin, 4, 7 urea, 7
Teniposide, 4
tretinoin microsphere, 7 urea 40% nail film, 7
terazosin HCL, 5
tretinoin microsphere P.M., 7 urea IN zinc undecylenate/lactic acid vehicle, 7
terbinafine HCL, 1
Tretten, 12
terbutaline sulfate, 17
triamcinolone acetonide, 7, 12, 16 urea topical, 7
terconazole, 11
triamcinolone IN orabase, 12 ursodiol, 11
testosterone cypionate, 8
triamterene/hydrochlorothiazide, 6 V
testosterone enanthate, 8
Triamterene/Hydrochlorothiazide, 6
tetrabenazine, 13
valacyclovir HCL, 2
triazolam, 13
tetracaine HCL, 15
Valchlor, 2
Triazolam, 13
Tetracaine HCL, 16
valganciclovir, 2
tricitrates, 11
Tetracycline HCL, 1
valproate sodium, 13
trifluoperazine HCL, 13
tetracycline hydrochloride, 1
valproic acid, 13
trifluridine, 14
Thalomid, 3
valsartan, 5
trihexyphenidyl HCL, 13
theophylline, 17
valsartan/hydrochlorothiazide, 6
trimethobenzamide HCL, 10
theophylline CR, 17
Valstar, 3
trimethoprim, 2
theophylline ER, 17
Valumark Lancet Super Thin 30G, 20
trimethoprim sulfate/polymyxin b sulfate, 14
Theracys, 4
Valumark Lancet Ultra Thin 28G, 20
thiamine HCL, 17
vancomycin HCL, 2
trimipramine maleate, 12
Thinlets GP Lancets, 19
Vantas, 3
Trisenox, 4
Thinlets Lancet, 19
vasopressin, 9
trospium chloride, 11
thioridazine HCL, 13
Vectibix, 3
trospium chloride ER, 11
Thiotepa, 2
vecuronium bromide, 14
Trueplus Lancets 26G, 19
thiothixene, 13
Velcade, 4
Trueplus Lancets 28G, 19
Thrombate Iii W/10 ML Sterile Water, 12
Veletri, 6
Trueplus Lancets 28G Super Thin, 19
Thrombate Iii W/20 ML Sterile Water, 12
venlafaxine HCL, 12
Trueplus Lancets 30G, 19
tiagabine hydrochloride, 13
venlafaxine HCL ER, 12
Trueplus Lancets 30G Ultra Thin, 19
Tice Bcg, 4
Venlafaxine HCL ER, 12
Trueplus Lancets 33G, 19
ticlopidine HCL, 12
Ventavis, 6
Trueplus Lancets 33G Micro Thin, 19
timolol maleate, 14
Ventolin HFA, 17
Trueplus Safety Lancets 28G, 19
timolol maleate ophthalmic gel forming, 14
verapamil HCL, 5
Trulicity, 8
verapamil HCL ER, 5
Tykerb, 4
tinidazole, 2
verapamil HCL SR, 5
Tysabri, 13
tizanidine HCL, 14
Victoza, 8
Tyvaso, 6
tobramycin, 1
Victrelis, 2
Tyvaso Refill, 6
tobramycin sulfate, 1, 14
Vida Mia Unilet Lancets Super Thin 30G, 20
Tyvaso Starter, 6
tobramycin/dexamethasone, 14
Tyzeka, 2
tolazamide, 8
Vida Mia Unilet Lancets Ultra Thin 28G, 20
U
Tolazamide, 8
tolcapone, 13
Ulticare Thin Lancets 30G, 19 Viekira PAK, 2
tolmetin sodium, 16
Ultilet Classic Lancets, 19 Vimizim, 10
Tolmetin Sodium, 16
Ultilet Lancets, 19 Vinblastine Sulfate, 4
tolterodine tartrate, 11
Ultilet Lancets 33G, 19 vincristine sulfate, 4
tolterodine tartrate ER, 11
Ultilet Safety Lancets 23G, 19 vinorelbine tartrate, 4
topiramate, 13
Ultra-thin II Auto Lancet, 19 Virazole, 2
topotecan HCL, 4
Ultra-thin II Lancets 28G, 19 Vitalet Pro Lancets, 20
Topotecan HCL, 4
Ultra-thin II Lancets 30G, 19 Vitalet Pro Plus Lancets, 20
Torisel, 4
Ultra-thin II Safety Autolancets 26G, 19 vitamin c 222MG, 17
torsemide, 6
Unilet Comfortouch Lancet, 19 vitamin d, 17
Totect, 4
Unilet Excelite, 19 vitamin k1, 17
Vitekta, 2
voriconazole, 1
Votrient, 4
Vpriv, 11
W
W&f Lancets 26G, 20
W&f Lancets Colored 21G, 20
Walgreens Lancets, 20
Walgreens Thin Lancets, 20
Walgreens Ultra Thin Lancets, 20
warfarin sodium, 11
Wilate, 12
X
Xalkori, 4
Xarelto, 11
Xarelto Starter Pack, 11
Xeljanz, 16
Xeomin, 14
Xgeva, 9
Xolair, 17
Xtandi, 3
Xyntha, 12
Xyntha Solofuse, 12
Xyrem, 14
Y
Yervoy, 3
Z
zafirlukast, 17
zaleplon, 13
Zaltrap, 3
Zanosar, 2
Zavesca, 11
Zelboraf, 4
Zemaira, 17
Zenpep, 10
Zepatier, 2
Zevalin Y-90, 3
zidovudine, 2
ziprasidone HCL, 13
Zoladex, 3
zoledronic acid, 9
Zoledronic Acid, 9
Zolinza, 4
zolmitriptan, 16
zolmitriptan odt, 16
zolpidem tartrate, 13
zolpidem tartrate ER, 13
Zometa, 9
zonisamide, 13
Zorbtive, 9
Zydelig, 4
Zykadia, 4
Zytiga, 3
1
1ST Choice Lancets Super Thin, 20
1ST Choice Lancets Thin, 20
1ST Choice Lancets Ultra Thin, 20