essentials by messa covered drug listmedications covered under the essentials by messa prescription...

Updated 2/11/2021 1

Drug name Generic name Tier LimitsSpecialty

drug?Abilify aripiprazole 1 NoAbiraterone acetate 1 QL NoAccolate zafirlukast 1 QL NoAccupril quinapril hcl 1 NoAccuretic quinapril/hydrochlorothiazide 1 NoAccutane capsule 1 NoAceon perindopril erbumine 1 NoAcetic Acid acetic acid 1 NoAciphex tablet rabeprazole sodium 1 NoAclovate alclometasone dipropionate 1 NoActemra Actpen, syringe 2 PA, QL YesActigall ursodiol 1 No

Medications covered under the Essentials by MESSA prescription plan

● Prior Authorization (PA): plan approval is required for coverage - Member must meet clinical criteria or additional information must be provided before coverage is approved.● Step therapy (ST): previous treatment with one or more preferred drugs is required before coverage is approved.● Quantity limits (QL): prescriptions cannot exceed a specific quantity per fill - These limits are set based on clinical appropriateness and manufacturer-recommended dosing for particular drugs.

We encourage you to talk to your doctor to find the right drug therapies covered by your health plan.

Note: The amount you pay for brand name medications varies because coinsurance is based on the price of the drug when it is filled. A drug may switch from one tier to another. Up to a 90-day supply of insulin may be obtained for the same amount as a 34-day supply from any in-network provider. All over the counter (OTC) medications are excluded from coverage unless mandated by the Affordable Care Act (ACA).

When a new generic version of a brand-names drug becomes available, the generic version is generally added to Tier 1. Once the generic drug is added, the original, brand-name version won’t be covered. This list is current as of 2/10/2021. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013.

*If a generic equivalent is available, the brand name drug will appear in grey font for informational purposes only as the brand name drug is not covered and the tier applies to the generic*

Use this list to find information about drug coverage and therapeutic options. This list is ordered alphabetically and includes generic and brand name drugs. Drugs are identified according to their tier placement. If a generic equivalent is available, the brand name drug will appear in grey font for informational purposes only as the brand name drug is not covered. Prior authorization (PA), step therapy (ST) or quantity limit (QL) requirements are noted where applicable.

Updated 2/11/2021 2


drug?Actimmune 2 YesActiq fentanyl citrate 1 PA, QL NoActivella estradiol/norethindrone acet 1 NoActonel risedronate sodium 1 QL NoActoplus Met pioglitazone hcl/metformin hcl 1 NoActos pioglitazone hcl 1 NoAcular, LS ketorolac tromethamine 1 No

AdacelFree as

preventiveQL No

Adalat CC; Procardia, XL nifedipine 1 NoAdapin; Sinequan doxepin hcl 1 NoAdcirca tadalafil, alyq 1 PA, QL YesAdderall, XR dextroamphetamine/amphetamine 1 QL NoAdempas 2 PA, QL YesAdoxa tablet doxycycline monohydrate 1 NoAdvair Diskus fluticasone/salmeterol 1 QL NoAdvair HFA fluticasone/salmeterol, wixela inhub 2 QL NoAfinitor, Disperz Everolimus 1 PA, QL Yes

AfluriaFree as

preventiveQL No

Aggrenox aspirin/dipyridamole 1 NoAgrylin anagrelide hcl 1 NoAimovig 2 PA, QL NoAjovy 2 PA, QL NoAkynzeo 3 PA, QL NoAlbenza albendazole 1 QL NoAlbuterol nebulizer solution albuterol sulfate 1 NoAldactazide spironolact/hydrochlorothiazid 1 NoAldactazide 50/50mg 3 NoAldactone spironolactone 1 NoAldara imiquimod 1 NoAldomet methyldopa 1 NoAldoril methyldopa/hydrochlorothiazide 1 NoAlecensa 2 PA, QL Yes

Alesse; Levlite levonorgestrel-ethin estradiol, afirmelleFree as

preventiveNo

Alferon N 2 NoAlinia Nitazoxanide 1 NoAlkeran tablet melphalan 1 NoAlocril 3 NoAlomide 3 NoAlora 2 NoAlphagan 0.2%, P 0.15% brimonidine tartrate 1 NoAlphagan P 0.1% 2 NoAlrex 3 NoAlsuma sumatriptan succinate 1 QL NoAltace ramipril 1 NoAltreno 3 QL NoAlunbrig 2 PA, QL YesAlupent metaproterenol sulfate 1 NoAmaryl glimepiride 1 NoAmbien zolpidem tartrate 1 QL NoAmbien CR zolpidem tartrate 1 QL NoAmerge naratriptan hcl 1 QL NoAmicar aminocaproic acid 1 NoAmicar solution 2 No

Updated 2/11/2021 3


drug?Amitiza 2 QL No

Amnesteem; Claravis; Myorisan; Zenatane isotretinoin 1 QL No

Amoxapine amoxapine 1 NoAmoxil amoxicillin 1 NoAmpicillin ampicillin trihydrate 1 NoAmpyra dalfampridine 1 PA, QL YesAnadrol-50 3 NoAnafranil clomipramine hcl 1 NoAnalpram-HC 1-1% cream 2 NoAnalpram-HC cream 2.5-1%, 1-1% hydrocortisone/pramoxine 1 NoAnamantle HC cream with lidocaine/hydrocortisone ac 1 NoAnaprox, DS naproxen sodium 1 NoAncobon flucytosine 1 NoAndroderm 2 PA, QL NoAndrogel testosterone 1 PA, QL NoAngeliq 3 NoAnoro Ellipta 2 QL NoAnsaid flurbiprofen 1 NoAntabuse disulfiram 1 NoAntara fenofibrate,micronized 1 NoAntara 30, 90mg 3 NoApokyn 2 QL YesApresoline hydralazine hcl 1 NoApriso Mesalamine Er 1 NoAptivus 2 NoArakoda 3 QL NoAralen chloroquine phosphate 1 NoAranesp 3 PA YesArava leflunomide 1 NoArcalyst 2 PA YesArcapta Neohaler 3 QL NoAricept 5, 10mg; ODT donepezil hcl 1 NoArikayce 2 PA, QL Yes

Arimidex anastrozoleFree as

preventivePA No

Aristocort; Kenalog 0.5% triamcinolone acetonide 1 NoArixtra fondaparinux sodium 1 NoArmour Thyroid thyroid,pork 1 NoArmour Thyroid 15mg, 30mg, 60mg, 3 NoArnuity Ellipta 2 QL No

Aromasin exemestaneFree as

preventivePA No

Artane trihexyphenidyl hcl 1 NoAsacol HD mesalamine 1 NoAsmanex, HFA 2 QL No

Aspirin; Ecotrin 81mg, 325mg (OTC) aspirinFree as

preventiveNo

Astagraf XL 3 YesAstelin nasal spray azelastine hcl 1 QL NoAtacand candesartan cilexetil 1 NoAtacand HCT candesartan/hydrochlorothiazid 1 NoAtarax hydroxyzine hcl 1 NoAtelvia risedronate sodium 1 ST, QL NoAtivan lorazepam 1 NoAtripla Efavirenz-Emtric-Tenof Disop 1 No

Updated 2/11/2021 4


drug?Atrovent HFA 2 QL NoAtrovent nasal spray ipratropium bromide 1 QL NoAtrovent solution ipratropium bromide 1 NoAubagio 3 QL Yes

Augmentin 125mg-31.25mg/ml suspension 2 No

Augmentin, ES, XR amoxicillin/potassium clav 1 NoAuryxia 3 NoAustedo 3 PA, QL YesAvalide irbesartan/hydrochlorothiazide 1 NoAvandia 3 NoAvapro irbesartan 1 NoAvelox moxifloxacin hcl 1 NoAventyl; Pamelor nortriptyline hcl 1 NoAvodart dutasteride 1 NoAvonex 2 QL YesAxert almotriptan malate 1 ST, QL NoAxid (Rx only) nizatidine 1 NoAygestin norethindrone acetate 1 NoAzasan 3 NoAzasite 3 NoAzilect rasagiline mesylate 1 NoAzopt 2 NoAzor amlodipine bes/olmesartan med 1 NoAzulfidine, EN-tab sulfasalazine 1 NoBacitracin bacitracin 1 NoBaciguent ointment 3 NoBaclofen baclofen 1 NoBaclofen 5mg 3 NoBactroban ointment mupirocin 1 NoBalcoltra 3 NoBanzel Rufinamide suspension 1 PA, QL NoBaraclude entecavir 1 YesBaraclude solution 2 YesBasaglar Kwikpen U-100 3 NoBaxdela tablet 3 NoBelladonna & Opium opium/belladonna alkaloids 1 QL NoBelversa 3 YesBenadryl capsule (Rx Only) diphenhydramine hcl 1 NoBenicar olmesartan medoxomil 1 NoBenicar HCT olmesartan/hydrochlorothiazide 1 NoBenlysta 2 PA, QL YesBentyl dicyclomine hcl 1 NoBenzaclin clindamycin phos/benzoyl perox 1 NoBenzamycin erythromycin/benzoyl peroxide 1 NoBenznidazole 2 QL NoBepreve 3 NoBesivance 3 NoBetagan levobunolol hcl 1 NoBetapace, AF sotalol hcl 1 NoBetaseron 3 QL YesBetoptic S 2 NoBetoptic solution betaxolol hcl 1 NoBevyxxa tablet 3 QL No

Beyaz drospir/eth estra/levomefol caFree as

preventiveNo

Updated 2/11/2021 5


drug?Biaxin, XL clarithromycin 1 NoBidil 2 NoBiktarvy 2 QL NoBiltricide praziquantel 1 No

Bisacodyl OTC bisacodylFree as

preventiveQL No

Bleph-10, Sodium Sulamyde drops sulfacetamide sodium 1 NoBlephamide 2 NoBlocadren timolol maleate 1 NoBoniva ibandronate sodium 1 QL No

BoostrixFree as

preventiveQL No

Bosulif 2 PA, QL YesBraftovi 2 PA, QL YesBreo Ellipta 2 QL NoBrethine terbutaline sulfate 1 NoBrilinta 2 NoBriviact 3 PA, QL NoBromday; Xibrom bromfenac sodium 1 NoBrovana 3 NoBryhali 3 QL NoBumex bumetanide 1 NoBunavail 3 QL NoBuphenyl powder sodium phenylbutyrate 1 NoBuphenyl tablet sodium phenylbutyrate 1 QL NoBuprenorphine 7.5 MCG/HR patch 2 QL NoBuspar buspirone hcl 1 NoButrans buprenorphine 2 QL NoButrans 7.5 MCG/HR 2 QL NoBystolic 2.5, 5, 10mg 3 ST NoBystolic 20mg 3 ST NoCabometyx 2 PA, QL YesCaduet amlodipine/atorvastatin 1 QL NoCafcit caffeine citrate 1 NoCafergot ergotamine tartrate/caffeine 1 NoCalan SR; Isoptin SR verapamil hcl 1 NoCalciferol (Rx Only) ergocalciferol (vitamin d2) 1 NoCalquence 2 PA, QL YesCampral acamprosate calcium 1 NoCanasa mesalamine 1 NoCapex shampoo 2 NoCapoten captopril 1 NoCapozide captopril/hydrochlorothiazide 1 NoCaprelsa 2 PA, QL YesCarafate sucralfate 1 NoCarafate suspension 2 NoCarbaglu 2 PA YesCarbatrol carbamazepine 1 NoCardene nicardipine hcl 1 NoCardizem LA 120mg 3 NoCardizem, CD, LA, SR diltiazem hcl, diltiazem 24hr ER 1 NoCardura doxazosin mesylate 1 NoCardura XL 3 NoCarnitor levocarnitine 1 NoCarnitor SF levocarnitine SF 1 NoCarnitor solution levocarnitine (with sugar) 1 No

Updated 2/11/2021 6


drug?Casodex bicalutamide 1 NoCataflam diclofenac potassium, Cataflam 1 NoCatapres clonidine hcl 1 NoCatapres-TTS clonidine 1 NoCayston 3 PA, QL YesCeclor, ER cefaclor 1 NoCeftin cefuroxime axetil 1 NoCefzil cefprozil 1 NoCelebrex celecoxib 1 NoCelexa citalopram hydrobromide 1 NoCellcept mycophenolate mofetil 1 YesCelontin 3 NoCerdelga 3 PA, QL YesCesamet 3 NoCetraxal ciprofloxacin hcl 1 NoCetylev 3 NoChantix 2 QL No

Chantix Free as

preventiveST, QL No

Chemet 2 NoChenodal 3 PA YesCholbam 2 PA, QL YesChorionic Gonadotropin 3 PA, QL YesChorionic Gonadotropin vial 3 PA, QL YesCiloxan ciprofloxacin hcl 1 NoCiloxan ointment 2 NoCimduo 2 QL NoCimzia syringe 3 PA, QL YesCipro HC 3 NoCipro suspension ciprofloxacin 1 NoCipro tablet ciprofloxacin hcl 1 NoCipro XR ciprofloxacin/ciprofloxa hcl 1 NoCiprodex 2 NoCiprofloxacin HCL- Fluocinolone 2 No

Citrate of Magnesia OTC magnesium citrateFree as

preventiveQL No

Clenpiq 3 NoCleocin capsule clindamycin hcl 1 NoCleocin solution clindamycin palmitate hcl 1 NoCleocin vaginal cream clindamycin phosphate 1 NoCleocin vaginal ovules 3 NoCleocin-T swabs clindamycin phosphate 1 NoClimara estradiol 1 NoClimara Pro 3 NoClindesse 3 NoClinoril sulindac 1 NoClobevate; Temovate clobetasol propionate 1 NoClobex shampoo clobetasol propionate 1 NoClomid clomiphene citrate 1 QL NoClozapine 200mg clozapine 1 NoClozapine ODT clozapine ODT 1 NoClozaril clozapine 1 NoCoartem 2 NoCodeine sulfate tablet codeine sulfate 1 QL NoCogentin benztropine mesylate 1 NoColazal balsalazide disodium 1 No

Updated 2/11/2021 7


drug?Colbenemid colchicine/probenecid 1 NoColchicine tablet 2 NoColcrys 2 NoColestid colestipol hcl 1 NoColestid granules, packet 3 NoColy-Mycin S 3 NoColyte peg3350/sod sulf,bicarb,cl/kcl 1 No

Colyte peg3350/sod sulf,bicarb,cl/kclFree as

preventiveQL No

Combipatch 3 NoCombivent Respimat 2 NoCombivir lamivudine/zidovudine 1 NoCometriq 2 PA, QL Yes

Commit Lozenge OTC nicotine polacrilexFree as

preventiveQL No

Compazine suppository prochlorperazine 1 NoCompazine tablet prochlorperazine maleate 1 NoComplera 2 QL NoComtan entacapone 1 No

Conceptrol Free as

preventiveQL No

Concerta methylphenidate hcl 1 NoCondylox podofilox 1 NoCondylox gel 2 NoCopaxone glatiramer acetate 1 QL YesCopegus ribavirin 1 YesCopiktra 2 PA, QL YesCordarone; Pacerone amiodarone hcl 1 NoCoreg immediate-release carvedilol 1 NoCorgard nadolol 1 NoCorlanor 2 PA, QL NoCortef; Hydrocortisone hydrocortisone 1 NoCortenema hydrocortisone 1 NoCortifoam 3 NoCortisone acetate cortisone acetate 1 NoCortisporin neomycin/polymyxin b sulf/hc 1 NoCortisporin cream 0.5% 3 NoCortisporin eye drops neomycin/polymyxin b sulf/hc 1 NoCortisporin eye ointment neomycin su/baci zn/poly/hc 1 NoCortisporin ointment 1% 3 NoCorzide nadolol/bendroflumethiazide 1 NoCosopt dorzolamide hcl/timolol maleat 1 NoCosopt PF dorzolamide/timolol/pf 1 NoCotellic 2 PA, QL YesCoumadin warfarin sodium 1 NoCovaryx, H.S. estrogen,ester/me-testosterone 1 NoCoverject syringe 2 NoCozaar losartan potassium 1 NoCreon 2 NoCresemba capsule 2 QL NoCrestor rosuvastatin calcium 1 QL No

Crestor* 5mg, 10mg rosuvastatin calciumFree as

preventiveQL No

Crotan crotamiton 1 NoCutaquig vial 3 PA YesCutivate fluticasone propionate, Beser 1 No

Updated 2/11/2021 8


drug?Cuvitru vial 3 YesCuvposa 3 NoCyanocobalamin injection cyanocobalamin (vitamin b-12) 1 No

Cyclessa desogestrel-ethinyl estradiolFree as

preventiveNo

Cyclomydril 3 NoCyclophosphamide capsule cyclophosphamide 1 NoCycloserine 2 NoCycloset 3 PA, QL NoCymbalta duloxetine hcl 1 NoCystadane 3 YesCystagon 2 YesCystaran 2 PA, QL YesCytomel liothyronine sodium 1 NoCytotec misoprostol 1 NoD.H.E.45 dihydroergotamine mesylate 1 NoDaliresp 3 PA, QL NoDalmane flurazepam hcl 1 QL NoDanocrine danazol 1 NoDantrium dantrolene sodium 1 NoDapsone dapsone 1 NoDaraprim 2 PA YesDaurismo 3 PA, QL YesDaypro oxaprozin 1 NoDaytrana 3 NoDDAVP desmopressin acetate 1 NoDecadron dexamethasone 1 NoDecadron ophthalmic dexamethasone sod phosphate 1 NoDeclomycin demeclocycline hcl 1 NoDelatestryl testosterone enanthate 1 NoDelestrogen estradiol valerate 1 NoDelestrogen 10mg/mL 3 NoDelstrigo 2 QL NoDeltasone prednisone 1 NoDelzicol Mesalamine Dr 1 NoDemadex torsemide 1 NoDemser metyrosine 1 No

Demulen ethynodiol d-ethinyl estradiolFree as

preventiveNo

Depakene capsule valproic acid 1 NoDepakene solution valproic acid (as sodium salt) 1 NoDepakote, ER, Sprinkles divalproex sodium 1 NoDepen Penicillamine 1 No

Depo-Provera 150mg medroxyprogesterone acetateFree as

preventiveNo

Depo-Provera 400mg 2 NoDepo-subq Provera 104 2 NoDepo-Testosterone testosterone cypionate 1 NoDermacort, Hytone 2.5% hydrocortisone 1 NoDerma-smoothe-FS fluocinolone acetonide 1 NoDescovy 2 PA, QL NoDesferal deferoxamine mesylate 1 No

Desogen; Ortho-cept desogestrel-ethinyl estradiol, kalligaFree as

preventiveNo

Desowen desonide 1 NoDesoxyn methamphetamine hcl 1 No

Updated 2/11/2021 9


drug?Desyrel trazodone hcl 1 NoDetrol, LA tolterodine tartrate 1 NoDexedrine dextroamphetamine sulfate 1 NoDexpak dexamethasone 1 NoDiabeta; Micronase glyburide 1 NoDiabinese chlorpropamide 1 NoDiacomit capsule 3 YesDiacomit powder pack 3 YesDiamox, Sequels acetazolamide 1 NoDiastat 2.5mg diazepam 1 NoDiastat 2.5mg 2 NoDiastat Acudial diazepam 1 NoDibenzyline phenoxybenzamine hcl 1 PA, QL NoDicloxacillin dicloxacillin sodium 1 NoDidronel etidronate disodium 1 QL NoDifferin 0.1% cream, gel adapalene 1 NoDificid 3 QL NoDiflucan fluconazole 1 NoDilacor XR diltiazem 24hr ER 1 NoDilantin phenytoin 1 NoDilantin 30mg capsule 2 NoDilantin; Phenytek capsule phenytoin sodium extended 1 NoDilatrate-SR 2 NoDilaudid hydromorphone hcl 1 QL NoDiovan valsartan 1 NoDiovan HCT valsartan/hydrochlorothiazide 1 NoDipentum 3 NoDiprolene cream, lotion; AF betamethasone/propylene glyc 1 NoDiprolene gel, ointment betamethasone/propylene glyc/diprop A 1 NoDiprolene ointment betamethasone dipropionate Augmented 1 No

Diprosone cream, ointment; Maxivate betamethasone dipropionate 1 No

Diprosone lotion betamethasone dipropionate 1 NoDisalcid salsalate 1 NoDitropan, XL oxybutynin chloride 1 NoDiuril chlorothiazide 1 NoDiuril suspension 3 NoDivigel 3 NoDolobid diflunisal 1 NoDoptelet 3 PA, QL YesDostinex cabergoline 1 NoDovato tablet 3 NoDovonex calcipotriene 1 NoDroxia 2 NoDrysol 2 NoDuavee 3 NoDuetact pioglitazone hcl/glimepiride 1 NoDulera 2 QL NoDulera HFA 2 QL NoDuoneb ipratropium/albuterol sulfate 1 NoDuopa 2 PA, QL YesDupixent 3 PA, QL YesDuragesic fentanyl 1 QL NoDurezol 3 NoDuricef cefadroxil 1 NoDutoprol 3 No

Updated 2/11/2021 10


drug?Dyazide; Maxzide triamterene/hydrochlorothiazid 1 NoDynacirc isradipine 1 NoDyrenium Triamterene capsule 1 NoE.E.S. erythromycin ethylsuccinate 1 NoEC-Naproxyn naproxen 1 NoEdarbi 3 ST, QL NoEdarbyclor 3 ST, QL NoEdecrin ethacrynic acid 1 NoEdurant 2 QL NoEffexor venlafaxine hcl 1 No

Effexor XR; Venlafaxine hcl ER capsule venlafaxine hcl 1 No

Effexor XR; Venlafaxine hcl ER tablet venlafaxine hcl 1 NoEffient prasugrel hcl 1 NoEfudex fluorouracil 1 NoElavil amitriptyline hcl 1 NoEldepryl selegiline hcl 1 NoElestat epinastine hcl 1 NoElestrin 3 NoElidel pimecrolimus 1 NoEligard 3 YesElimite permethrin 1 NoEliquis 2 QL No

Ella Free as

preventiveQL No

Elmiron 2 NoElocon cream, lotion, solution mometasone furoate 1 NoElocon ointment mometasone furoate 1 NoEmadine 3 NoEmbeda 3 PA, QL NoEmcyt 2 NoEmend 40mg aprepitant 1 QL NoEmend 80mg, 125mg, 125mg-80mg aprepitant 1 QL NoEmend suspension 2 QL NoEmflaza 3 PA YesEmgality 2 PA, QL NoEmla lidocaine/prilocaine 1 NoEmsam 3 PA, QL NoEmtriva Emtricitabine 1 NoEnbrel 2 PA, QL YesEndari 3 PA, QL NoEnduron methyclothiazide 1 NoEntocort EC budesonide 1 NoEntresto 2 QL NoEnvarsus XR 3 YesEpclusa 2 PA, QL YesEpidiolex 3 PA, QL YesEpifoam 2 NoEpinephrine auto-injector 2 QL NoEpipen 0.3mg auto-injector epinephrine 1 QL NoEpivir lamivudine 1 NoEpivir HBV lamivudine 1 NoEpivir HBV solution 2 NoEpogen 3 PA YesEpzicom abacavir sulfate/lamivudine 1 NoEquanil; Miltown meprobamate 1 No

Updated 2/11/2021 11


drug?Equetro 3 NoErgoloid Mesylates ergoloid mesylates 1 NoErivedge 2 PA, QL YesErleada 2 PA, QL YesEryped 200mg/5ml 3 NoEryped 400mg/5ml erythromycin ethylsuccinate 1 NoEry-tab erythromycin base 1 NoEry-tab 500mg erythromycin 1 NoErythromycin Base erythromycin base 1 NoErythromycin Stearate erythromycin stearate 1 NoEsbriet 2 PA, QL YesEsgic; Fioricet 50/325/40mg butalb/acetaminophen/caffeine 1 QL NoEskalith, CR; Lithobid lithium carbonate 1 NoEstrace estradiol 1 NoEstring 2 NoEstrogel 2 No

Estrostep Fe norethindrone-e.estradiol-ironFree as

preventiveNo

Ethambutol ethambutol hcl 1 NoEtrafon perphenazine/amitriptyline hcl 1 NoEulexin flutamide 1 NoEurax 2 NoEvamist 3 NoEvista raloxifene hcl 1 QL No

Evista raloxifene hclFree as

preventivePA, QL No

Evotaz 2 QL NoEvoxac cevimeline hcl 1 NoExalgo hydromorphone hcl 1 QL NoExelderm 3 NoExelon capsule rivastigmine tartrate 1 NoExelon patch rivastigmine 1 NoExforge amlodipine besylate/valsartan 1 NoExforge HCT amlodipine/valsartan/hcthiazid 1 NoExjade deferasirox 1 PA, QL YesExtavia 3 QL YesExtina ketoconazole 1 No

Ez Flu (flucelvax)Free as

preventiveQL No

Factive 3 NoFamvir famciclovir 1 NoFanapt 3 ST NoFareston toremifene citrate 1 NoFarxiga 2 QL NoFarydak 2 PA, QL YesFaslodex fulvestrant 1 NoFazaclo clozapine 1 NoFazaclo 150, 200mg 3 No

FC2 female condom Free as

preventiveQL No

Felbatol felbamate 1 NoFeldene piroxicam 1 NoFemara letrozole 1 No

Femcon Fe noreth-ethinyl estradiol/ironFree as

preventiveNo

FemHRT norethindrone ac-eth estradiol 1 No

Updated 2/11/2021 12


drug?Femring 3 NoFenobibric acid 1 NoFerriprox Deferiprone table 1 PA, QL YesFiasp, Flextouch, penfill 2 NoFibricor fenofibric acid 1 NoFinacea gel azelaic acid 1 NoFioricet 50/300/40mg butalb/acetaminophen/caffeine 1 NoFioricet w/codeine 50/325/30mg butalbit/acetamin/caff/codeine 1 QL NoFiorinal butalbital/aspirin/caffeine 1 NoFiorinal w/codeine codeine/butalbital/asa/caffein 1 QL NoFirazyr icatibant 1 PA, QL YesFirvanq 3 QL NoFlagyl metronidazole 1 NoFlexeril cyclobenzaprine hcl 1 NoFlomax tamsulosin hcl 1 NoFlonase (Rx Only) fluticasone propionate 1 QL NoFlorinef fludrocortisone acetate 1 NoFlovent HFA, Diskus 2 QL NoFloxin Otic ofloxacin 1 NoFloxin tablet ofloxacin 1 No

FluadFree as

preventiveQL No

FluarixFree as

preventiveQL No

Flublok QuadFree as

preventiveQL No

Flucelvax QuadFree as

preventiveQL No

FlulavalFree as

preventiveQL No

Flumadine rimantadine hcl 1 No

FlumistFree as

preventiveQL No

Fluoroplex 3 NoFluoxetine 60mg fluoxetine hcl 1 QL No

FluzoneFree as

preventiveQL No

Fluzone High-doseFree as

preventiveQL No

FML fluorometholone 1 NoFML Forte, S.O.P. 2 NoFocalin dexmethylphenidate hcl 1 NoFocalin XR dexmethylphenidate hcl 1 QL No

Folic Acid 0.4mg, 0.8mg (OTC) folic acidFree as

preventiveNo

Follistim AQ 3 PA, QL YesForteo 2 PA, QL YesFosamax alendronate sodium 1 QL NoFosrenol tablet lanthanum carbonate 1 NoFragmin 3 NoFrova frovatriptan succinate 1 ST, QL NoFuradantin nitrofurantoin 1 NoFuzeon 2 NoFycompa suspension 3 QL NoFycompa tablet 3 QL NoGabitril tiagabine hcl 1 No

Updated 2/11/2021 13


drug?Galafold 2 PA, QL YesGalzin 3 NoGammagard liquid 3 PA YesGammaked 3 PA YesGamunex-C sub-q 3 PA YesGaramycin gentamicin sulfate 1 No

Gardasil, 9*Free as

preventiveQL No

Gastrocrom cromolyn sodium 1 NoGattex 2 PA, QL Yes

Generess Fe noreth-ethinyl estradiol/ironFree as

preventiveNo

Gengraf; Neoral cyclosporine, modified 1 YesGenotropin 2 PA YesGentamicin cream, ointment gentamicin sulfate 1 NoGenvoya 2 QL NoGeodon ziprasidone hcl 1 NoGilenya 2 QL YesGilotrif 2 PA, QL YesGlassia 2 PA, QL YesGlatopa glatiramer acetate 1 QL YesGleevec imatinib mesylate 1 QL YesGleostine; Lomustine 2 NoGlucaGen HypoKit 2 NoGlucagon Emergency Kit 2 NoGlucophage, XR metformin hcl 1 NoGlucotrol, XL glipizide 1 NoGlucovance glyburide/metformin hcl 1 No

Glycolax OTC polyethylene glycol 3350Free as

preventiveQL No

Glynase glyburide,micronized 1 NoGlyset miglitol 1 NoGlyxambi 2 QL NoGolytely peg 3350/na sulf,bicarb,cl/kcl 1 No

Golytely peg 3350/na sulf,bicarb,cl/kclFree as

preventiveQL No

Golytely flavored 2 NoGonal-F, RFF, Redi-ject 2 PA, QL YesGranix 3 YesGrifulvin V griseofulvin, microsize 1 NoGris-PEG griseofulvin ultramicrosize 1 NoGuanidine hcl guanidine hcl 1 NoGvoke Hypogen auto injector 2 NoGynazole-1 3 No

Gynol II nonoxynol 9Free as

preventiveQL No

Haegarda 2 PA YesHalcion triazolam 1 QL NoHaldol liquid haloperidol lactate 1 NoHaldol tablet haloperidol 1 NoHarvoni 3 PA, QL Yes

HavrixFree as

preventiveQL No

Hectorol doxercalciferol 1 NoHeparin heparin sodium,porcine 1 NoHeparin Sodium syringe 3 Yes

Updated 2/11/2021 14


drug?Hepsera adefovir dipivoxil 1 YesHetlioz 3 PA, QL YesHiprex/Urex methenamine hippurate 1 NoHizentra vial and syringe 3 PA YesHumatin paromomycin sulfate 1 NoHumatrope 3 PA YesHumira 2 PA, QL YesHumulin R U-500 2 NoHycamtin capsule 2 YesHycet hydrocodone/acetaminophen 1 QL NoHydrea hydroxyurea 1 NoHydrodiuril; Microzide hydrochlorothiazide 1 NoHydroxocobalamin hydroxocobalamin 1 NoHygroton; Thalitone chlorthalidone 1 NoHyper-Sal 3 NoHyQvia 3 PA YesHytrin terazosin hcl 1 NoHyzaar losartan/hydrochlorothiazide 1 NoIbrance 2 PA, QL YesIclusig 2 PA, QL YesIdhifa 2 PA, QL YesIlotycin erythromycin base 1 NoImbruvica capsules; 280mg, 420mg, 560mg tablets

2 PA, QL Yes

Imdur; Ismo; Monoket isosorbide mononitrate 1 NoImitrex sumatriptan succinate 1 QL NoImitrex nasal spray sumatriptan 1 QL NoImpavido 2 QL NoImuran azathioprine 1 NoImvexxy 3 QL NoInbrija capsule 3 NoIncrelex 3 PA YesInderal, LA propranolol hcl 1 NoInderide propranolol/hydrochlorothiazid 1 NoIndocin suppository 3 NoIndocin, SR indomethacin 1 NoInflamase, Forte prednisolone sod phosphate 1 NoIngrezza 3 PA, QL YesIngrezza initiation pack 3 PA, QL YesInlyta 2 PA, QL YesInqovi tablet 2 YesInspra eplerenone 1 NoInsulin Lispro Junior Kwikpen 3 NoIntal solution cromolyn sodium 1 NoIntelence 2 NoIntrarosa 3 QL NoIntron A 2 YesIntuniv guanfacine hcl 1 PA, QL NoInvega paliperidone 1 QL NoInvirase 2 NoInvokamet 2 QL NoInvokamet XR 2 QL NoInvokana 2 QL NoIopidine droperette 3 NoIopidine drops apraclonidine hcl 1 NoIressa 2 PA, QL Yes

Updated 2/11/2021 15


drug?Isentress 2 NoIsentress HD 2 NoIsoniazid isoniazid 1 NoIsopto Atropine atropine sulfate 1 NoIsopto-Carpine; Pilocar pilocarpine hcl 1 NoIsordil isosorbide dinitrate 1 NoIsordil 40mg 3 NoIsturisa tablet 3 PA, QL YesJakafi 2 PA, QL YesJalyn dutasteride/tamsulosin hcl 1 QL NoJanumet 2 NoJanumet XR 2 QL NoJanuvia 2 QL NoJardiance 2 QL NoJentadueto 2 QL NoJentadueto XR 2 QL NoJuluca 3 QL NoJynarque 2 PA, QL YesKaletra lopinavir/ritonavir 1 NoKaletra tablet 2 NoKalydeco 2 PA, QL YesKapvay clonidine hcl 1 QL NoKayexalate sodium polystyrene sulfonate 1 NoKeflex cephalexin 1 NoKenalog 0.025% cream, lotion triamcinolone acetonide 1 NoKenalog 0.025% ointment, 0.05%, triamcinolone acetonide 1 NoKenalog spray triamcinolone acetonide 1 NoKeppra, XR levetiracetam 1 NoKerlone betaxolol hcl 1 NoKetoprofen ketoprofen 1 PA, QL NoKeveyis 3 PA, QL YesKevzara 3 PA, QL YesKineret 3 PA, QL YesKisqali Femara co-pack 2 PA, QL YesKisqali, Femara co-pack 2 PA, QL YesKlonopin, Wafer clonazepam 1 NoK-Lor; Klor-Con packet potassium chloride 1 NoKlor-Con M15 potassium chloride 1 NoK-Lyte; Klor-con/EF potassium bicarbonate/cit ac 1 NoKorlym 2 PA, QL YesKrintafel 2 QL NoK-Sol; Potassium Chloride potassium chloride 1 No

K-Tab; K-Dur; Slow-K; Kaon CL; Klor-con potassium chloride 1 No

Kuvan Sapropterin Dihydrochloride powder pack and tablet 1 PA YesKytril granisetron hcl 1 QL NoLac-Hydrin ammonium lactate 1 NoLacrisert 2 NoLactulose lactulose 1 NoLamictal dose pack lamotrigine 1 NoLamictal ODT, XR lamotrigine 1 NoLamictal XR dose pack 3 NoLamictal, dispertabs lamotrigine 1 NoLamisil tablet terbinafine hcl 1 No

Lanoxin solution; 125mcg, 250mcg tablets digoxin 1 No

Updated 2/11/2021 16


drug?Lantus, Solostar 2 NoLariam mefloquine hcl 1 NoLasix furosemide 1 NoLastacaft 3 NoLatuda 3 ST NoLedipasvir-sofosbuvir 2 PA, QL YesLenvima 2 PA, QL YesLescol, XL fluvastatin sodium 1 QL No

Lescol, XL* (all strengths) fluvastatin sodiumFree as

preventiveQL No

Letairis Ambrisentan 1 PA, QL YesLeucovorin tablet leucovorin calcium 1 NoLeukeran 2 NoLeukine 2 YesLevalbuterol Tartrate HFA; Xopenex 3 QL NoLevaquin levofloxacin 1 NoLevbid hyoscyamine sulfate 1 NoLevemir, Flextouch 2 No

Levlen; Nordette levonorgestrel-ethin estradiol, ayunaFree as

preventiveNo

Levorphanol Tartrate levorphanol tartrate 1 QL NoLevorphanol Tartrate 3mg 3 QL NoLevoxyl; Synthroid levothyroxine sodium 1 NoLevsin, SL hyoscyamine sulfate 1 NoLexapro escitalopram oxalate 1 NoLexiva fosamprenavir calcium 1 NoLexiva suspension 2 NoLialda mesalamine 1 NoLibrax chlordiazepoxide/clidinium br 1 NoLibrium chlordiazepoxide hcl 1 NoLidex fluocinonide 1 QL NoLidex E fluocinonide/emollient base 1 QL NoLimbitrol, DS amitrip hcl/chlordiazepoxide 1 NoLindane lindane 1 NoLinzess 2 QL NoLipitor atorvastatin calcium 1 QL No

Lipitor* 10mg, 20mg atorvastatin calciumFree as

preventiveQL No

Lithium Citrate lithium citrate 1 NoLithostat 3 NoLivalo 3 ST, QL NoLo Loestrin Fe 3 No

Lo/Ovral norgestrel-ethinyl estradiolFree as

preventiveNo

Locoid cream, ointment, solution hydrocortisone butyrate 1 NoLodine, XL etodolac 1 NoLodosyn carbidopa 1 No

Loestrin norethindrone ac-eth estradiol, Aurovela, HaileyFree as

preventiveNo

Loestrin 24 Fe norethindrone-e.estradiol-iron, Hailey 24 FeFree as

preventiveNo

Loestrin Fe norethindrone-e.estradiol-iron, Aurovela Fe, Hailey FeFree as

preventiveNo

Lofibra capsule fenofibrate,micronized 1 NoLofibra tablet fenofibrate 1 NoLokelma 3 PA, QL No

Updated 2/11/2021 17


drug?Lomotil diphenoxylate hcl/atropine 1 NoLonhala Magnair 3 QL NoLoniten minoxidil 1 NoLonsurf 2 PA, QL YesLopid gemfibrozil 1 NoLopressor metoprolol tartrate 1 NoLopressor HCT metoprolol/hydrochlorothiazide 1 NoLoprox cream, suspension ciclopirox olamine 1 NoLoprox gel, shampoo ciclopirox 1 NoLorazepam intensol lorazepam 1 NoLorbrena 3 PA, QL Yes

Loseasonique l-norgest/e.estradiol-e.estrad, Lojaimiess tabletFree as

preventiveQL No

Lotemax Loteprednol Etabonate 1 NoLotensin benazepril hcl 1 NoLotensin HCT benazepril/hydrochlorothiazide 1 NoLotrel amlodipine besylate/benazepril 1 NoLotrimin clotrimazole 1 NoLotrisone clotrimazole/betamethasone dip 1 NoLotronex alosetron hcl 1 NoLovaza omega-3 acid ethyl esters 1 QL NoLovenox enoxaparin sodium 1 NoLoxitane loxapine succinate 1 NoLozol indapamide 1 NoLucemyra 2 QL NoLumigan bimatoprost 1 NoLumigan 0.01% 2 NoLunesta eszopiclone 1 QL NoLupron leuprolide acetate 1 YesLupron Depot 2 YesLupron Depot 3.75mg, 11.25mg 2 YesLupron Depot-PED 2 YesLuvox fluvoxamine maleate 1 NoLuvox CR fluvoxamine maleate 1 No

Lybrel levonorgestrel-ethin estradiolFree as

preventiveNo

Lynparza 2 PA, QL YesLyrica pregabalin 1 PA, QL NoLysodren 2 NoLysteda tranexamic acid 1 QL NoMacrobid nitrofurantoin monohyd/m-cryst 1 NoMacrodantin nitrofurantoin macrocrystal 1 NoMalarone atovaquone/proguanil hcl 1 NoMaprotiline hcl maprotiline hcl 1 NoMarinol dronabinol 1 NoMarplan 3 NoMatulane 2 YesMavenclad tablet 3 YesMavik trandolapril 1 NoMavyret 3 PA, QL YesMaxalt, MLT rizatriptan benzoate 1 QL NoMaxidex 3 NoMaxitrol neo/polymyx b sulf/dexameth 1 NoMayzent tablet 3 YesMeclomen meclofenamate sodium 1 NoMedrol 2mg 3 No

Updated 2/11/2021 18


drug?Medrol, dose pack methylprednisolone, methylpred dp 1 NoMegace, ES megestrol acetate 1 NoMekinist 2 PA, QL YesMektovi 2 PA, QL YesMellaril thioridazine hcl 1 No

MenactraFree as

preventiveQL No

Menest 3 NoMenostar 3 No

MenveoFree as

preventiveQL No

Mephyton phytonadione (vit k1) 1 NoMepron atovaquone 1 NoMesnex tablet 2 NoMestinon syrup pyridostigmine bromide syrup 1 NoMestinon, Timespan pyridostigmine bromide 1 NoMetadate CD methylphenidate hcl 1 NoMetaglip glipizide/metformin hcl 1 NoMethadone methadone hcl 1 QL NoMethergine methylergonovine maleate 1 QL NoMethitest 3 NoMethotrexate methotrexate sodium 1 NoMethotrexate PF injection methotrexate sodium/pf 1 NoMethylin, ER methylphenidate hcl 1 NoMetrocream, gel, lotion 0.75% metronidazole 1 NoMetrogel-Vaginal metronidazole 1 NoMevacor lovastatin 1 QL No

Mevacor* (all strengths) lovastatinFree as

preventiveQL No

Mexitil mexiletine hcl 1 NoMiacalcin injection 2 NoMiacalcin nasal spray calcitonin,salmon,synthetic 1 NoMicardis telmisartan 1 NoMicardis HCT telmisartan/hydrochlorothiazid 1 NoMicro-K potassium chloride 1 NoMidamor amiloride hcl 1 NoMigergot ergotamine tartrate/caffeine 1 No

Milk of Magnesia OTC magnesium hydroxideFree as

preventiveQL No

Millipred solution prednisolone sod phosphate 1 NoMillipred tablet, dose pack prednisolone 1 No

Minastrin 24 FE norethindrone-e.estradiol-iron, charlotte 24 FeFree as

preventiveNo

Minipress prazosin hcl 1 NoMinivelle, Vivelle-Dot estradiol, dotti/Lyllana transdermal patch 1 NoMinocin capsule minocycline hcl 1 NoMirapex immediate-release pramipexole di-hcl 1 No

Mircette desog-e.estradiol/e.estradiol, Simliya, Volnea tabletFree as

preventiveNo

Mobic meloxicam 1 No

Modicon norethindrone-ethinyl estradFree as

preventiveNo

Moduretic amiloride/hydrochlorothiazide 1 NoMonistat 3 miconazole nitrate 1 NoMonodox doxycycline monohydrate 1 NoMonopril fosinopril sodium 1 No

Updated 2/11/2021 19


drug?Monopril HCT fosinopril/hydrochlorothiazide 1 NoMonurol Fosfomycin Tromethamine 1 NoMotrin (Rx Only) ibuprofen 1 NoMoviprep Peg3350-Sod Sul-Nacl-K powder pack 1 NoMoxeza Moxifloxacin drops 1 NoMS Contin morphine sulfate 1 QL NoMSIR morphine sulfate 1 QL NoMucomyst acetylcysteine 1 NoMulpleta 2 PA, QL YesMultaq 2 QL NoMyalept 3 PA, QL YesMycelex Troche clotrimazole 1 NoMycobutin rifabutin 1 NoMycostatin nystatin 1 NoMydriacyl tropicamide 1 NoMyfortic mycophenolate sodium 1 YesMyleran 2 NoMyrbetriq 3 ST, QL NoMysoline primidone 1 NoMytesi 2 PA, QL NoNalfon 600mg fenoprofen calcium 1 PA, QL NoNaloxone hcl injection naloxone hcl 1 NoNamenda memantine hcl 1 QL NoNamenda dose pack 2 QL NoNaprosyn suspension (Rx Only) naproxen 1 NoNaprosyn tablet (Rx Only) naproxen 1 NoNarcan nasal spray 2 QL NoNardil phenelzine sulfate 1 NoNatacyn 2 NoNatazia 3 NoNatpara 2 PA, QL YesNatroba spinosad 1 NoNature-Throid thyroid,pork 1 NoNavane thiothixene 1 NoNayzalim spray 2 NoNebupent aerosol 2 NoNeomycin neomycin sulfate 1 NoNeosporin ophthalmic ointment neomycin su/bacitra/polymyxin 1 NoNeosporin ophthalmic solution neomycin/polymyxn b/gramicidin 1 NoNeo-Synephrine phenylephrine hcl 1 NoNeptazane methazolamide 1 NoNerlynx 2 PA, QL YesNeulasta 3 QL YesNeupogen 3 YesNeurontin gabapentin 1 NoNevanac 3 NoNexavar 2 PA, QL YesNexlizet 3 NoNiaspan niacin 1 No

Nicorette lozenge nicotine polacrilexFree as

preventiveQL No

Nicotine gum; Nicorette nicotine polacrilexFree as

preventiveQL No

Nicotine patch nicotineFree as

preventiveQL No

Nicotrol, NS 3 QL No

Updated 2/11/2021 20


drug?

Nicotrol, NS Free as

preventiveST, QL No

Nilandron nilutamide 1 NoNimotop nimodipine 1 NoNinlaro 2 PA, QL YesNiravam alprazolam 1 NoNitro-bid ointment nitroglycerin 1 NoNitro-Dur nitroglycerin 2 NoNitroglycerin capsule, patch nitroglycerin 1 NoNitrostat nitroglycerin 1 NoNityr 3 PA YesNizoral ketoconazole 1 NoNizoral cream, shampoo 2% ketoconazole 1 NoNorco; Vicodin; Xodol hydrocodone/acetaminophen 1 QL NoNorditropin FlexPro 2 PA YesNorflex orphenadrine citrate 1 No

Norinyl 1/35; Ortho-novum 1/35 norethindrone-ethinyl estrad, Nortrel, NyliaFree as

preventiveNo

Normodyne labetalol hcl 1 NoNorpace disopyramide phosphate 1 NoNorpace CR 2 NoNorpramin desipramine hcl 1 NoNorvasc amlodipine besylate 1 NoNorvir ritonavir 1 NoNorvir capsule, packet, solution 2 NoNovarel 3 PA, QL YesNovolin; 70/30 vial 2 NoNovolog, Mix (all forms) 2 NoNoxafil suspension 2 NoNoxafil tablet Posaconazole tablet 1 QL NoNP Thyroid thyroid,pork 1 NoNucynta, ER 3 PA, QL NoNuedexta 2 PA, QL NoNulytely sodium chloride/nahco3/kcl/peg 1 No

Nulytely sodium chloride/nahco3/kcl/pegFree as

preventiveQL No

Nulytely Soln Recon $3 NoNuplazid tablet 3 PA, QL NoNutropin AQ NuSpin 2 PA Yes

Nuvaring Eluryng, Etonogestrel-Ethinyl EFree as

preventiveQL No

Nuvigil armodafinil 1 QL NoNuzyra tablet 3 QL NoNymalize 3 QL NoNystatin nystatin 1 NoNystatin w/Triamcinolone nystatin/triamcin 1 NoOcaliva 2 PA, QL YesOcufen flurbiprofen sodium 1 NoOcuflox ofloxacin 1 NoOcupress carteolol hcl 1 NoOdefsey 2 QL NoOdomzo 2 PA, QL YesOfev 2 PA, QL YesOlumiant 3 PA, QL YesOmnicef cefdinir 1 NoOmnitrope 3 PA Yes

Updated 2/11/2021 21


drug?Onfi clobazam 1 QL NoOngentys capsule 3 PA, QL NoOpsumit 2 PA, QL YesOpticrom cromolyn sodium 1 NoOptipranolol metipranolol 1 NoOptivar azelastine hcl 1 No

Oral Saline Laxative liquid OTC sodium phosphate,mono-dibasicFree as

preventiveQL No

Oralone paste triamcinolone acetonide 1 NoOrap pimozide 1 NoOrapred solution prednisolone sod phosphate 1 NoOrencia Clickject, sub-q 3 PA, QL YesOrenitram ER 2 PA, QL YesOrfadin Nitisinone 1 PA YesOrilissa 3 PA, QL NoOrinase tolbutamide 1 NoOrkambi 2 PA, QL Yes

Ortho Evra norelgestromin/ethin.estradiolFree as

preventiveQL No

Ortho Micronor; Nor-QD norethindrone, LyleqFree as

preventiveNo

Ortho Tri-Cyclen norgestimate-ethinyl estradiol, Tri-NymyoFree as

preventiveNo

Ortho Tri-Cyclen Lo norgestimate-ethinyl estradiol, Tri-Lo-MiliFree as

preventiveNo

Ortho-Cyclen norgestimate-ethinyl estradiol, nymyoFree as

preventiveNo

Ortho-Novum 7/7/7 norethindrone-ethinyl estrad, Nortrel, NyliaFree as

preventiveNo

Osphena 3 NoOtezla 2 PA, QL YesOtovel 2 No

Ovcon 35 norethindrone-ethinyl estradFree as

preventiveNo

Ovide malathion 1 NoOvidrel 2 PA, QL Yes

Ovral norgestrel-ethinyl estradiolFree as

preventiveNo

Oxandrin oxandrolone 1 PA NoOxervate 2 PA, QL YesOxsoralen-Ultra methoxsalen, rapid 1 NoOxycodone hcl ER 3 PA, QL No

Oxycodone immediate release, solution oxycodone hcl 1 QL No

Oxycontin 3 PA, QL NoOzempic 2 QL NoPalynziq 2 PA, QL YesPamine, Forte methscopolamine bromide 1 NoPanretin 2 NoParafon Forte DSC 500mg chlorzoxazone 1 NoParcopa carbidopa/levodopa 1 NoParemyd 3 NoParlodel bromocriptine mesylate 1 NoParnate tranylcypromine sulfate 1 NoPaser 3 NoPataday olopatadine hcl 1 No

Updated 2/11/2021 22


drug?Patanol olopatadine hcl 1 NoPaxil paroxetine hcl 1 NoPaxil CR paroxetine hcl 1 NoPaxil suspension 3 NoPediapred solution prednisolone sod phosphate 1 NoPeganone 2 NoPegasys, Proclick 2 QL YesPeg-Intron, Redipen 2 QL YesPeg-Prep bisac/nacl/nahco3/kcl/peg 3350 1 No

Peg-Prep bisac/nacl/nahco3/kcl/peg 3350Free as

preventiveQL No

Penicillin VK penicillin v potassium 1 NoPenlac ciclopirox 1 NoPentasa 2 NoPepcid (Rx Only) famotidine 1 NoPercocet oxycodone hcl/acetaminophen 1 QL NoPercodan oxycodone hcl/aspirin 1 QL NoPerforomist 3 NoPeriactin tablet, 2mg/5 ml syrup cyproheptadine hcl 1 NoPeriostat doxycycline hyclate 1 NoPerphenazine perphenazine 1 NoPersantine dipyridamole 1 NoPexeva 3 ST NoPhenergan promethazine hcl 1 NoPhenobarbital phenobarbital 1 NoPhoslo calcium acetate 1 NoPhoslyra 3 NoPhospholine Iodide 2 NoPhrenilin 50mg/325mg butalbital/acetaminophen 1 NoPicato 3 PA, QL NoPifeltro 2 QL No

Plan B One-step levonorgestrelFree as

preventiveQL No

Plaquenil hydroxychloroquine sulfate 1 NoPlavix clopidogrel bisulfate 1 NoPlegridy 2 QL YesPlendil felodipine 1 NoPletal cilostazol 1 No

Pneumovax 23Free as

preventiveQL No

Polysporin bacitracin/polymyxin b sulfate 1 NoPolytrim polymyxin b sulf/trimethoprim 1 NoPomalyst 3 PA, QL YesPosaconazole (authorized generic) 2 NoPotassium Chloride effervescent pot chloride/pot bicarb/cit ac 1 NoPradaxa 3 QL NoPraluent 2 PA, QL NoPramosone cream hydrocortisone/pramoxine 1 NoPrandiMet repaglinide/metformin hcl 1 NoPrandin repaglinide 1 NoPravachol pravastatin sodium 1 QL No

Pravachol* (all strengths) pravastatin sodiumFree as

preventiveQL No

Precose acarbose 1 NoPred Forte prednisolone acetate 1 NoPred Mild 2 No

Updated 2/11/2021 23


drug?Pred-G 3 NoPrednisolone solution prednisolone 1 NoPrednisone prednisone 1 NoPrefest 3 NoPregnyl 2 PA, QL YesPremarin, cream, Low Dose 2 NoPrempro, Low Dose; Premphase 2 NoPretomanid tablet 2 NoPrevacid capsule (Rx Only) lansoprazole 1 QL No

Prevnar 13*Free as

preventiveQL No

Prevymis tablet 3 QL NoPrezcobix 2 QL NoPrezista 2 NoPriftin 3 NoPrilosec capsule (Rx Only) omeprazole 1 QL NoPrimaquine (branded version) 2 NoPrimaquine (generic version) 1 NoPrimsol 3 NoPrinivil; Zestril lisinopril 1 NoPrinzide; Zestoretic lisinopril/hydrochlorothiazide 1 NoPristiq desvenlafaxine succinate 1 NoProAir HFA; 2 QL NoProamatine midodrine hcl 1 NoPro-Banthine propantheline bromide 1 NoProbenecid probenecid 1 NoProcentra dextroamphetamine sulfate 1 NoProcrit 2 PA YesProctocort hydrocortisone 1 NoProctocort suppository hydrocortisone acetate 1 NoProctofoam-HC 2 NoProcto-Pak hydrocortisone 1 NoProctosol-HC suppository hydrocortisone acetate 1 NoProgesterone In Oil (inj) progesterone 1 NoProglycem Diazoxide suspension 1 NoPrograf tacrolimus 1 YesPrograf granule 3 NoProlixin fluphenazine hcl 1 NoPromacta 2 PA YesPrometrium progesterone,micronized 1 NoPropylthiouracil propylthiouracil 1 NoProscar finasteride 1 NoProsom estazolam 1 QL NoProtonix tablet pantoprazole sodium 1 QL NoProtopic tacrolimus 1 NoProventil HFA 3 QL NoProventil solution albuterol sulfate 1 NoProventil albuterol sulfate 1 NoProvera medroxyprogesterone acetate 1 NoProvigil modafinil 1 QL NoProzac fluoxetine hcl 1 NoProzac Weekly fluoxetine hcl 1 QL NoPrudoxin, Zonalon doxepin hcl 1 PA, QL NoPulmicort Flexhaler 2 QL NoPulmicort solution budesonide 1 NoPulmozyme 2 PA Yes

Updated 2/11/2021 24


drug?Purinethol mercaptopurine 1 NoPurixan 3 YesPyrazinamide pyrazinamide 1 NoQtern 2 QL NoQualaquin quinine sulfate 1 No

Quartette l-norgest-eth estr/ethin estraFree as

preventiveQL No

Questran cholestyramine (with sugar) 1 NoQuestran Light cholestyramine/aspartame 1 NoQuinidex quinidine sulfate 1 NoQuinidine Gluconate SA quinidine gluconate 1 NoQuixin levofloxacin 1 NoQvar RediHaler 2 QL NoRadiogardase 2 NoRanexa ranolazine ER 1 NoRapaflo silodosin 1 QL NoRapamune sirolimus 1 YesRavicti 3 PA, QL YesRazadyne, ER galantamine hbr 1 NoRebetol ribavirin 1 YesRebetol solution 2 YesRebif, Rebidose 2 QL YesRectiv 3 QL NoReglan metoclopramide hcl 1 NoRegranex 3 NoRelafen nabumetone 1 NoRelenza 2 QL NoRelpax eletriptan hbr 1 ST, QL NoRemeron mirtazapine 1 NoRemodulin treprostinil 1 YesRenacidin 2 NoRenagel sevelamer hcl 1 NoRenvela sevelamer carbonate 1 NoRepatha 2 PA, QL NoRequip ropinirole hcl 1 NoRequip XL ropinirole hcl 1 NoRestasis 2 NoRestoril temazepam 1 QL NoRetacrit vial 2 NoRetin-A; Avita tretinoin 1 NoRetrovir zidovudine 1 NoRevatio sildenafil citrate 1 PA, QL NoRevatio suspension 2 PA, QL NoRevia naltrexone hcl 1 NoRevlimid 3 QL YesReyataz atazanavir sulfate 1 NoReyataz packet 2 NoRibapak; Ribatab ribavirin 1 YesRibasphere Ribapak tablet ribavirin 1 YesRidaura 2 NoRifadin rifampin 1 NoRifamate 3 NoRifater 3 NoRilutek riluzole 1 NoRinvoq 2 NoRisperdal, M-Tab risperidone 1 No

Updated 2/11/2021 25


drug?Ritalin, LA, SR methylphenidate hcl 1 NoRMS Suppository morphine sulfate 1 QL NoRobaxin methocarbamol 1 NoRobinul tablet, Forte glycopyrrolate 1 NoRocaltrol calcitriol 1 NoRoxanol morphine sulfate 1 QL NoRozorem ramelteon 1 ST, QL NoRubraca 2 PA, QL YesRuconest 3 PA, QL YesRuzurgi tablet 3 YesRydapt 2 PA, QL YesRythmol, SR propafenone hcl 1 NoRyzolt tramadol hcl 1 QL NoSabril packet vigabatrin 1 PA, QL YesSabril tablet vigabatrin 1 ST, QL Yes

Safyral drospir/eth estra/levomefol caFree as

preventiveNo

Saizen, Saizenprep 3 PA YesSalagen pilocarpine hcl 1 NoSamsca tolvaptan 2 QL YesSanctura trospium chloride 1 QL NoSanctura XR trospium chloride 1 QL NoSancuso 3 PA, QL NoSandimmune capsule cyclosporine 1 YesSandimmune solution 3 YesSandostatin octreotide acetate 1 YesSandostatin LAR Depot 2 PA YesSantyl 2 NoSaphris Asenapine Maleate sublingual tablets 1 ST, QL NoSavaysa 3 QL NoSavella 3 PA, QL NoSavella dose pack 3 PA No

Seasonale levonorgestrel-ethin estradiol, icleviaFree as

preventiveQL No

Seasonique l-norgest/e.estradiol-e.estrad, simpesse, Jaimiess tabletFree as

preventiveQL No

Sectral acebutolol hcl 1 NoSecuado patch 3 PA, QL NoSelsun 2.5% (Rx Only) selenium sulfide 1 NoSelzentry 2 NoSensipar 2 YesSerax oxazepam 1 NoSerevent Diskus 2 QL NoSeroquel quetiapine fumarate 1 NoSeroquel XR quetiapine fumarate 1 QL NoSerostim 3 PA YesSerzone nefazodone hcl 1 NoSevenfact vial 2 NoSfRowasa enema mesalamine 1 No

Shingrix*Free as

preventiveQL No

Signifor 2 PA, QL YesSiklos 3 PA NoSilvadene silver sulfadiazine 1 NoSimponi 3 PA, QL YesSinemet, CR carbidopa/levodopa 1 No

Updated 2/11/2021 26


drug?Singulair montelukast sodium 1 QL NoSirturo 2 PA, QL NoSivextro 2 QL NoSkelaxin metaxalone 1 NoSklice Ivermectin lotion 1 QL NoSkyrizi syringe kit 2 YesSodium chloride inhalation sodium chloride for inhalation 1 NoSodium Fluoride 0.25mg, 0.5mg, fluoride (sodium) 1 No

Sodium Fluoride 0.25mg, 0.5mg, 1mg fluoride (sodium)Free as

preventiveNo

Sofosbuvir-velpatasvir 2 PA, QL YesSolaraze diclofenac sodium 1 PA, QL NoSoltamox 3 NoSolu-cortef hydrocortisone sod succinate 1 NoSolu-cortef (pf) 3 NoSoma carisoprodol 1 NoSoma vanadom 1 NoSomatuline Depot 2 PA, QL YesSomavert 2 PA YesSonata zaleplon 1 QL NoSoolantra * ivermectin cream 1 NoSoriatane acitretin 1 NoSovaldi 3 PA, QL YesSpectazole econazole nitrate 1 NoSpectracef cefditoren pivoxil 1 NoSpiriva, Respimat 2 QL NoSporanox itraconazole 1 NoSprycel 2 PA, QL YesSPS sodium polystyrene sulfonate 1 NoSPS (sorbitol free) sodium polystyrene sulfon/sorb 1 NoSPS 50g/200ml enema 3 NoSSKI 3 NoStadol NS butorphanol tartrate 1 QL NoStalevo carbidopa/levodopa/entacapone 1 NoStarlix nateglinide 1 NoStelara 45mg, 90mg 2 PA, QL YesStelazine trifluoperazine hcl 1 NoStimate 2 YesStiolto Respimat 2 QL NoStivarga 2 PA, QL YesStrattera atomoxetine hcl 1 NoStrensiq 2 PA, QL YesStribild 2 QL NoStromectol ivermectin 1 NoStrong Iodine potassium iodide/iodine 1 NoSuboxone buprenorphine hcl/naloxone hcl 1 QL NoSuboxone film buprenorphine hcl/naloxone hcl film 2 QL NoSubutex buprenorphine hcl 1 PA, QL NoSucraid 3 PA, QL YesSular nisoldipine 1 No

Sulconazole Nitrate cream and solution 3 NoSulfadiazine sulfadiazine 1 NoSunosi tablet 3 NoSuprax cefixime 1 NoSuprax capsule, chew tablet, 500mg/5ml suspension

3 No

Updated 2/11/2021 27


drug?Suprep 3 NoSurmontil trimipramine maleate 1 NoSustiva efavirenz 1 NoSutent 2 PA, QL YesSylatron 3 QL YesSymbicort 2 QL NoSymbyax olanzapine/fluoxetine hcl 1 NoSymdeko 2 PA, QL YesSymfi Efavirenz-Lamivu-Tenofov Disop 1 QL NoSymfi Lo Efavirenz-Lamivu-Tenofov Disop 1 QL NoSymjepi 2 QL NoSymlinpen 3 NoSymmetrel amantadine hcl 1 NoSymtuza 2 QL NoSynalar 0.01% fluocinolone acetonide 1 NoSynalar 0.025% fluocinolone acetonide 1 NoSynarel 2 NoSynjardy, XR 2 QL NoSyprine trientine hcl 1 PA, QL YesTabloid 2 NoTaclonex ointment calcipotriene/betamethasone 3 PA NoTaclonex topical suspension 3 PA NoTafinlar 2 PA, QL YesTagamet (Rx only) cimetidine 1 NoTagamet liquid (Rx only) cimetidine hcl 1 NoTagrisso 2 PA, QL YesTakhzyro 3 PA, QL YesTalwin NX pentazocine hcl/naloxone hcl 1 QL NoTalzenna 3 PA, QL YesTambocor flecainide acetate 1 NoTamiflu oseltamivir phosphate 1 QL NoTamoxifen tamoxifen citrate 1 QL No

Tamoxifen tamoxifen citrateFree as

preventivePA, QL No

Tapazole methimazole 1 NoTarceva Erlotinib 1 PA, QL YesTargretin capsule bexarotene 1 PA, QL YesTargretin gel 3 PA YesTarka trandolapril/verapamil hcl 1 NoTasigna 2 PA, QL YesTasmar tolcapone 1 NoTavalisse 3 PA, QL YesTavist tablet (Rx Only) clemastine fumarate 1 No

TaytullaGemmily capsule/Noresthin-Eth-Estra-Ferrous Fum, Merzee

Free as preventive

No

Tazorac tazarotene 1 NoTazorac 0.1%, 0.5% gel 2 NoTecfidera Dimethyl Fumarate 1 QL YesTechnivie 3 PA, QL YesTegretol carbamazepine 1 NoTegretol XR carbamazepine 1 NoTekturna, HCT aliskiren 1 NoTemixys tablet 2 NoTemodar temozolomide 1 YesTemovate Emollient clobetasol propionate/emoll 1 NoTenex guanfacine hcl 1 No

Updated 2/11/2021 28


drug?Tenoretic atenolol/chlorthalidone 1 NoTenormin atenolol 1 NoTerazol- 3, 7 terconazole 1 NoTetracycline tetracycline hcl 1 NoTeveten eprosartan mesylate 1 NoThalomid 2 YesTheo-24 2 NoTheophylline anhydrous theophylline anhydrous 1 NoThiola 3 PA NoThorazine chlorpromazine hcl 1 NoThyrolar 2 NoTiazac diltiazem hcl 1 NoTiazac Tiadylt Er 1 NoTibsovo 2 PA, QL YesTigan trimethobenzamide hcl 1 NoTiglutik 3 PA, QL YesTikosyn dofetilide 1 NoTimoptic, XE timolol maleate 1 NoTindamax tinidazole 1 NoTirosint capsule 3 NoTirosint-Sol solution 3 NoTivicay 2 NoTobi tobramycin in 0.225% nacl 1 QL YesTobradex ointment 2 NoTobradex ST 3 NoTobradex suspension tobramycin/dexamethasone 1 NoTobrex drops tobramycin 1 NoTobrex ointment 3 No

Today contraceptive sponge Free as

preventiveQL No

Tofranil imipramine hcl 1 NoTofranil-PM imipramine pamoate 1 NoTolak 2 QL NoTolectin, DS tolmetin sodium 1 NoTolinase tolazamide 1 NoTopamax, Sprinkle topiramate 1 NoToprol XL metoprolol succinate 1 NoToradol injection ketorolac tromethamine 1 NoToradol tablet ketorolac tromethamine 1 QL NoToujeo, Max Solostar 2 NoTracleer Bosentan 1 PA, QL YesTracleer tablet for suspension 2 PA YesTradjenta 2 QL NoTransderm-Scop scopolamine 1 NoTranxene T-Tab clorazepate dipotassium 1 NoTravatan Z Travoprost 1 NoTrecator 3 NoTrelegy Ellipta 2 QL NoTrelstar, Depot, LA 2 YesTremfya auto injector 3 PA, QL YesTremfya syringe 3 PA, QL YesTrental pentoxifylline 1 NoTresiba, Flextouch 2 NoTrexall 2 NoTribenzor olmesartan/amlodipin/hcthiazid 1 QL NoTricor fenofibrate nanocrystallized 1 No

Updated 2/11/2021 29


drug?Trikafta 3 PA, QL YesTrileptal suspension oxcarbazepine 1 NoTrileptal tablet oxcarbazepine 1 No

Trilevlen levonorgestrel-ethin estradiolFree as

preventiveNo

Trilipix fenofibric acid (choline) 1 NoTrimethoprim trimethoprim 1 NoTrimpex 3 No

Tri-Norinyl norethindrone-ethinyl estradFree as

preventiveNo

Trintellix 3 ST, QL NoTriumeq 2 QL NoTrulicity 2 QL NoTrusopt dorzolamide hcl 1 NoTruvada Emtricitabine-Tenofovir Disop 1 PA, QL No

Truvada 200mg/300mgFree as

preventivePA, QL No

Tudorza Pressair 3 QL NoTuralio capsule 3 YesTuxarin ER tablet 3 No

TwinrixFree as

preventiveQL No

Twynsta telmisartan/amlodipine 1 NoTybost 2 QL NoTykerb Lapatinib 1 PA YesTylenol w/codeine acetaminophen with codeine 1 QL NoTylenol w/codeine solution acetaminophen with codeine 1 QL NoTymlos 2 PA, QL NoTyvaso 2 PA, QL YesUlesfia 3 NoUloric febuxostat 1 ST, QL NoUltracet tramadol hcl/acetaminophen 1 QL NoUltram, ER tramadol hcl 1 QL NoUltravate cream, ointment halobetasol propionate 1 NoUnivasc moexipril hcl 1 NoUpneeq dropperette 2 NoUptravi 2 PA, QL YesUrecholine bethanechol chloride 1 NoUrispas flavoxate hcl 1 NoUrocit-K potassium citrate 1 NoUroxatral alfuzosin hcl 1 NoUrso; Forte ursodiol 1 NoVagifem estradiol 1 NoValchlor 3 PA YesValcyte valganciclovir hcl 1 NoValisone lotion betamethasone valerate 1 NoValisone ointment betamethasone valerate 1 NoValium diazepam 1 NoValtrex valacyclovir hcl 1 NoVancocin vancomycin hcl 1 NoVantin cefpodoxime proxetil 1 No

VaqtaFree as

preventiveQL No

Vascepa Icosapent Ethyl capsule 1 PA, QL NoVaseretic enalapril/hydrochlorothiazide 1 NoVasocidin sulfacetamide/prednisolone sp 1 No

Updated 2/11/2021 30


drug?Vasotec enalapril maleate 1 No

VCF film, gel Free as

preventiveQL No

VCF foam nonoxynol 9Free as

preventiveQL No

Vectical calcitriol 1 NoVeltassa 2 QL NoVemlidy 2 QL YesVenclexta 2 PA, QL YesVentavis 2 PA, QL YesVepesid etoposide 1 NoVeregen 3 NoVerelan, PM verapamil hcl 1 NoVersed syrup midazolam hcl 1 NoVerzenio 2 PA, QL YesVesanoid tretinoin 1 NoVesicare Solifenacin Succinate 1 ST, QL NoVfend voriconazole 1 NoVibramycin doxycycline hyclate 1 NoVibramycin suspension doxycycline monohydrate 1 NoVibramycin syrup 3 NoVicoprofen hydrocodone/ibuprofen 1 QL NoVictoza 2 QL NoVigamox moxifloxacin hcl 1 NoViibryd, dose pack 3 ST, QL NoVimpat 2 PA, QL NoViramune, XR nevirapine 1 NoViread tenofovir disoproxil fumarate 1 NoViread 150mg, 200mg, 250mg tablet; packet

2 No

Viroptic trifluridine 1 NoVisken pindolol 1 NoVistaril hydroxyzine pamoate 1 NoVistogard 2 QL YesVitamin K ampule phytonadione 1 NoVitrakvi 3 PA, QL YesVivactil protriptyline hcl 1 NoVizimpro 2 PA, QL YesVoltaren gel diclofenac sodium 1 QL NoVoltaren ophthalmic solution diclofenac sodium 1 NoVoltaren tablet diclofenac sodium 1 NoVoltaren-XR diclofenac sodium 1 NoVosevi 3 PA, QL YesVosol acetic acid 1 NoVospire ER albuterol sulfate 1 NoVotrient 2 PA, QL YesVraylar 3 ST, QL NoVyndamax capsule 2 NoVytorin ezetimibe/simvastatin 1 QL NoVyvanse 3 QL NoWelchol colesevelam hcl 1 NoWellbutrin, SR, XL bupropion hcl 1 NoWestcort hydrocortisone valerate 1 NoWesthroid thyroid,pork 1 NoWP Thyroid thyroid,pork 1 NoWP Thyroid 32.5mg, 65mg, 3 No

Updated 2/11/2021 31


drug?Xadago 3 QL NoXalatan latanoprost 1 NoXalkori 2 PA, QL YesXanax, XR alprazolam 1 NoXarelto, starter kit 2 QL NoXatmep 3 YesXcopri tablet 3 PA, QLXeljanz, XR 2 PA, QL YesXeloda capecitabine 1 YesXembify 3 PA, QL YesXenazine tetrabenazine 1 PA, QL YesXenleta 3 NoXermelo 2 PA, QL YesXifaxan 200mg 3 NoXifaxan 550mg 3 PA, QL NoXigduo XR 2 QL NoXiidra 2 QL NoXofluza 3 QL NoXopenex solution levalbuterol hcl 1 NoXospata 3 PA, QL NoXpovio tablet 2 QL YesXtandi 2 QL YesXultophy 100-3.6 2 QL NoXuriden 2 PA, QL YesXylocaine Viscous solution (Rx Only) lidocaine hcl 1 NoXyntha Solofuse 2 NoXyrem 3 PA, QL Yes

Yasmin 28 ethinyl estradiol/drospirenone, zumandimineFree as

preventiveNo

Yaz ethinyl estradiol/drospirenone, Jasmiel, lo-zumandimine

Free as preventive

No

Zanaflex tizanidine hcl 1 NoZantac (Rx Only) ranitidine hcl 1 NoZarontin ethosuximide 1 NoZaroxolyn metolazone 1 NoZarxio 3 YesZavesca miglustat 1 PA, QL YesZebeta bisoprolol fumarate 1 NoZejula 2 PA, QL YesZelboraf 2 PA, QL YesZemplar paricalcitol 1 NoZenpep 2 NoZenzedi 3 NoZepatier 2 PA, QL YesZetia ezetimibe 1 QL NoZiac bisoprolol fumarate/hctz 1 NoZiagen abacavir sulfate 1 NoZioptan 3 NoZirgan 2 NoZithromax azithromycin 1 NoZocor simvastatin 1 QL No

Zocor* 5mg, 10mg, 20mg, 40mg simvastatinFree as

preventiveQL No

Zofran ondansetron hcl 1 QL NoZofran ODT ondansetron 1 QL NoZohydro ER Hydrocodone Bitartrate 1 PA, QL No

Updated 2/11/2021 32


drug?Zoladex 2 QL YesZolinza 2 PA, QL YesZoloft sertraline hcl 1 NoZomacton 3 PA YesZomig nasal spray 3 ST, QL NoZomig, ZMT zolmitriptan 1 QL NoZonalon 30g 3 PA, QL NoZonegran zonisamide 1 NoZontivity 3 QL NoZorbtive 3 PA YesZortress Everolimus 2 YesZovirax capsule, solution, tablet acyclovir 1 NoZovirax ointment acyclovir 1 NoZubsolv 2 QL No

Zyban bupropion hclFree as

preventiveQL No

Zydelig 2 PA, QL YesZyflo 3 QL NoZyflo CR zileuton 1 QL NoZykadia 2 PA, QL YesZylet 3 NoZyloprim allopurinol 1 NoZymaxid gatifloxacin 1 NoZyprexa, Zydis olanzapine 1 NoZyvox linezolid 1 No

essentials by messa covered drug listmedications covered under the essentials by messa prescription...

Documents