prior quantity step name generic name authorization limit

TIER BRAND NAME GENERIC NAMEPrior

Authorization

Quantity

Limit

Step

Therapy1 ABACAVIR SULFATE ABACAVIR SULFATE X

1 ABACAVIR SULFATE/LAMIVUDINE ABACAVIR SULFATE/LAMIVUDINE X

1 ABACAVIR/LAMIVUDINE/ZIDOVUDINE ABACAVIR/LAMIVUDINE/ZIDOVUDINE X

2 ABILIFY ARIPIPRAZOLE X X

Excluded ABRSTRAL

3 ABSORICA ISOTRETINOIN X

1 ACAMPROSATE CALCIUM ACAMPROSATE CALCIUM

3 ACANYA CLINDAMYCIN PHOS/BENZOYL PEROX X

1 ACARBOSE TABLET ACARBOSE

3 ACCOLATE ZAFIRLUKAST

Excluded ACCUCAINE

3 ACCU‐CHEK INSULIN PUMP/INFUS. SET/METER

3 ACCU‐CHEK RAPID D SUB‐Q ADMINISTRATION SET

3 ACCU‐CHEK SPIRIT SUB‐Q INFUSION PUMP ACCESSORY

2 ACCUPRIL QUINAPRIL HCL

2 ACCURETIC QUINAPRIL/HYDROCHLOROTHIAZIDE

3 ACD DEXTROSE/SOD CITRATE/CITRIC AC

3 ACD‐A CITRATE DEXTROSE SOLUTION

3 ACE AEROSOL CLOUD ENHANCER INHALER, ASSIST DEVICES

1 ACEBUTOLOL HCL ACEBUTOLOL HCL

1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE X

1 ACETAMINOPHEN/CAFF/DIHYDROCOD ACETAMINOPHEN/CAFF/DIHYDROCOD X

1 ACETAZOLAMIDE ER 500MG CAPSULE ACETAZOLAMIDE

1 ACETAZOLAMIDE IR TABLET ACETAZOLAMIDE

1 ACETIC ACID/ALUMINUM ACETATE ACETIC ACID/ALUMINUM ACETATE

2 ACETIC ACID/HYDROCORTISONE 2%‐1% DROPS ACETIC ACID

1 ACETYLCYSTEINE ACETYLCYSTEINE

1 ACETYLCYSTEINE IN WATER/PF ACETYLCYSTEINE IN WATER/PF

3 ACIPHEX RABEPRAZOLE SODIUM X X

3 ACIPHEX SPRINKLE RABEPRAZOLE SODIUM X

3 ACTEMRA TOCILIZUMAB X

Excluded ACTHAR ADRENCORTICOTROPIC HORMONE

3 ACTICLATE DOXYCYCLINE HYCLATE X X

3 ACTICOAT SILVER

3 ACTICOAT 7 SILVER

3 ACTICOAT FLEX 3 SILVER

3 ACTICOAT FLEX 7 SILVER

3 ACTICOAT SURGICAL SILVER/FOAM BANDAGE

2 ACTIGALL URSODIOL

2 ACTIQ FENTANYL CITRATE X X

3 ACTIVE FE IRON,CARBONYL/FOLIC ACID/MV‐MN

3 ACTIVELLA ESTRADIOL/NORETHINDRONE ACET

Excluded ACTIVE‐PAC KIT

3 ACTONEL RISEDRONATE SODIUM X X

2 ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL X

2 ACTOPLUS MET XR PIOGLITAZONE HCL/METFORMIN HCL X

2 ACTOS PIOGLITAZONE HCL

3 ACUICYN HYPOCHLOROUS ACID/SODIUM CHLOR

2 ACULAR KETOROLAC TROMETHAMINE

2 ACULAR LS KETOROLAC TROMETHAMINE

3 ACUVAIL KETOROLAC TROMETHAMINE/PF

1 ACYCLOVIR ACYCLOVIR

3 ACZONE DAPSONE

2 ADALAT CC (30 MG) TABLET ER NIFEDIPINE

3 ADALAT CC (60, 90 MG) TABLET ER NIFEDIPINE

1 ADAPALENE (0.1 %) CREAM ADAPALENE

2 ADAPALENE (0.1 %) LOTION ADAPALENE

2 ADAPALENE (0.3 %) GEL ADAPALENE

3 ADASUVE LOXAPINE

3 ADAZIN LIDOCAINE/BENZOCAIN/ME‐SAL/CAP

1 ADDERALL XR (5, 10, 15, 20, 25, 30 MG) CAP ER 24H DEXTROAMPHETAMINE/AMPHETAMINE X

3 ADDYI FLIBANSERIN X X


Authorization

Quantity

Limit

Step

Therapy3 ADENOVIRUS TYPE 4 ADENOVIRUS VACCINE LIVE TYPE‐4

3 ADENOVIRUS TYPE 4 AND TYPE 7 ADENOVIRUS LIVE TYPES‐4,7 VACC

3 ADENOVIRUS TYPE 7 ADENOVIRUS VACCINE LIVE TYPE‐7

Excluded ADLYXIN

3 ADRENACLICK EPINEPHRINE

3 ADRENALIN CHLORIDE EPINEPHRINE HCL

2 ADVAIR DISKUS FLUTICASONE/SALMETEROL X

2 ADVAIR HFA FLUTICASONE/SALMETEROL X

3 ADVANCE PLUS INTERMITTENT CATHETER

3 ADVICOR X X

Excluded ADZEBYS XR ODT

3 AEROBIKA MUCUS CLEARING DEVICE

3 AEROCHAMBER MINI INHALER, ASSIST DEVICES

3 AEROCHAMBER MV INHALER, ASSIST DEVICES

3 AEROCHAMBER PLUS FLOW‐VU INHALER, ASSIST DEVICES

3 AEROCHAMBER PLUS Z STAT INHALER, ASSIST DEVICES

3 AEROCHAMBER WITH FLOWSIGNAL INHALER, ASSIST DEVICES

3 AEROCHAMBER Z‐STAT PLUS INHALER, ASSIST DEVICES

3 AEROECLIPSE NEBULIZER

3 AEROECLIPSE II NEBULIZER

3 AEROGEAR ASTHMA ACTION KIT PEAK FLOW METER/INH ASSIT DEV

3 AERONEB GO NEBULIZER ACCESSORIES

3 AERONEB GO NEBULIZER NEBULIZER

3 AEROSPAN FLUNISOLIDE X X

3 AEROTRACH PLUS INHALER, ASSIST DEVICES

3 AEROVENT PLUS INHALER, ASSIST DEVICES

3 AFREZZA INSULIN REGULAR, HUMAN X X

3 AGGRENOX ASPIRIN/DIPYRIDAMOLE

3 AKTEN LIDOCAINE HCL/PF

2 AKYNZEO NETUPITANT/PALONOSETRON HCL X

3 ALA‐QUIN CLIOQUINOL/HYDROCORTISONE

3 ALBENZA ALBENDAZOLE

1 ALBUTEROL INHALTION SOLUTION ALBUTEROL

1 ALBUTEROL/IPRATOPIUM ALBUTERAL/IPRATROPIUM

1 ALCLOMETASONE DIPROPIONATE 0.05% CREAM (LOW) ALCLOMETASONE DIPROPIONATE

Excluded ALCORTIN A HYDROCORTISONE/IODOQUIN/ALOE 2

3 ALDACTAZIDE SPIRONOLACT/HYDROCHLOROTHIAZID

2 ALDACTONE SPIRONOLACTONE

2 ALDARA IMIQUIMOD X X

1 ALENDRONATE ALENDRONATE X

3 ALEVICYN ANTIPRURITIC SG EMOLLIENT COMBINATION NO.60

3 ALEVICYN PLUS E101/NAMG FL/NA PH/NACL/HA‐NAH

1 ALFUZOSIN HCL ALFUZOSIN HCL

3 ALINIA NITAZOXANIDE

2 ALKERAN MELPHALAN

3 ALL FLOW 1000 NEBULIZER ACCESSORIES

3 ALL FLOW 3000 KIT NEBULIZER ACCESSORIES

3 ALL FLOW 3000 PFT NEBULIZER ACCESSORIES

3 ALL FLOW 4000, 5000, 6000 NEBULIZER ACCESSORIES

3 ALLEVYN FOAM BANDAGE

3 ALLEVYN ADHESIVE FOAM BANDAGE

3 ALLEVYN AG SILVER SULFADIAZ/FOAM BANDAGE

3 ALLEVYN AG ADHESIVE SILVER SULFADIAZ/FOAM BANDAGE

3 ALLEVYN AG GENTLE SILVER SULFADIAZ/FOAM BANDAGE

3 ALLEVYN HEEL FOAM BANDAGE

3 ALLEVYN LIFE FOAM BANDAGE

1 ALLOPURINOL ALLOPURINOL

Excluded ALLZITAL

2 ALMOTRIPTAN MALATE TABLET ALMOTRIPTAN MALATE

2 ALOCRIL NEDOCROMIL SODIUM

2 ALOMIDE LODOXAMIDE TROMETHAMINE

3 ALOQUIN IODOQUINOL/ALOE P‐SACCHARIDE 1


Authorization

Quantity

Limit

Step

Therapy2 ALORA ESTRADIOL X

2 ALOSETRON HCL (0.5 MG) TABLET ALOSETRON HCL

1 ALOSETRON HCL (1 MG) TABLET ALOSETRON HCL

2 ALPHAGAN P BRIMONIDINE TARTRATE

1 ALPRAZOLAM (0.5 MG) TAB ER 24H ALPRAZOLAM

2 ALPRAZOLAM (0.5 MG) TAB RAPDIS ALPRAZOLAM

1 ALPRAZOLAM (1 MG) TAB ER 24H ALPRAZOLAM

2 ALPRAZOLAM (1 MG) TAB RAPDIS ALPRAZOLAM


2 ALPRAZOLAM (2 MG) TAB RAPDIS ALPRAZOLAM


2 ALPRAZOLAM INTENSOL ALPRAZOLAM

2 ALPRAZOLAM ODT ALPRAZOLAM

3 ALPROLIX Factor IX X X

2 ALREX LOTEPREDNOL ETABONATE

3 ALSUMA SUMATRIPTAN SUCCINATE X

3 ALTABAX RETAPAMULIN

2 ALTACE RAMIPRIL

3 ALTERA NEBULIZER NEBULIZER

Excluded ALTOPREV

Excluded ALVESCO

1 AMANTADINE HCL AMANTADINE HCL

2 AMARYL GLIMEPIRIDE

2 AMBIEN ZOLPIDEM TARTRATE X

2 AMBIEN CR ZOLPIDEM TARTRATE X

2 AMCINONIDE 0.1% CREAM (HIGH) AMCINONIDE

2 AMCINONIDE 0.1% LOTION (HIGH) AMCINONIDE

2 AMCINONIDE 0.1% OINTMENT (HIGH) AMCINONIDE

3 AMELUZ AMINOLEVULINIC ACID HCL

2 AMERGE NARATRIPTAN HCL X

3 AMETHYST LEVONORGESTREL‐ETHIN ESTRADIOL X

3 AMICAR AMINOCAPROIC ACID

3 AMIELLE VAGINAL TRAINER MEDICAL SUPPLY, MISCELLANEOUS

1 AMILORIDE HCL AMILORIDE HCL

1 AMILORIDE/HYDROCHLOROTHIAZIDE AMILORIDE/HYDROCHLOROTHIAZIDE

3 AMINOACETIC ACID GLYCINE UROLOGIC SOLUTION

1 AMIODARONE HCL AMIODARONE HCL

3 AMITIZA LUBIPROSTONE X X

1 AMITRIPTYLINE TABLET AMITRIPTYLINE

2 AMITRIPTYLINE/CHLORDIAZEPOXIDE (12.5MG‐5MG) TABLET AMITRIPTYLINE/CHLORDIAZEPOXIDE

1 AMITRIPTYLINE/CHLORDIAZEPOXIDE (25 MG‐10MG) TABLET AMITRIPTYLINE/CHLORDIAZEPOXIDE

1 AMLODIPINE TABLET AMLODIPINE

1 AMLODIPINE TABLET & ATORVASTATIN TABLET AMLODIPINE & ATORVASTATIN

1 AMLODIPINE TABLET & VALSARTAN/HCTZ TABLET AMLODIPINE & VALSARTAN/HCTZ

2 AMLODIPINE/ATORVASTATIN COMBO TABLET AMLODIPINE/ATORVASTATIN

1 AMLODIPINE/BENAZEPRIL AMLODIPINE/BENAZEPRIL

1 AMLODIPINE/OLMESARTAN AMLODIPINE/OLMESARTAN

1 AMLODIPINE/VALSARTAN COMBO TABLET & HCTZ AMLODIPINE/VALSARTAN & HCTZ

2 AMLODIPINE/VALSARTAN/HCTZ COMBO TABLET AMLODIPINE/VALSARTAN/HCTZ

1 AMMONIUM LACTATE AMMONIUM LACTATE

1 AMOXAPINE AMOXAPINE

2 AMOXICILLIN/CLAVULANATE ER TABLET AMOXICILLIN/CLAVULANATE

1 AMOXICILLIN/CLAVULANATE IR TABLET AMOXICILLIN/CLAVULANATE

1 AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE

3 AMPYRA DALFAMPRIDINE X

Excluded AMRIX

3 AMTURNIDE X

1 AMYL NITRITE AMYL NITRITE

3 ANACAINE BENZOCAINE

3 ANADROL‐50 OXYMETHOLONE X


Authorization

Quantity

Limit

Step

Therapy2 ANAFRANIL CLOMIPRAMINE HCL

1 ANAGRELIDE HCL ANAGRELIDE HCL

3 ANALPRAM E HYDROCORT/PRAMOXIN/EMOL/PRAM 1

2 ANALPRAM HC HYDROCORTISONE/PRAMOXINE

2 ANALPRAM HC (1 %‐1 %) CREAM/APPL HYDROCORTISONE/PRAMOXINE

2 ANALPRAM HC (2.5 %‐1 %) CREAM/APPL HYDROCORTISONE/PRAMOXINE

3 ANALPRAM HC (2.5‐1%(4G)) CREAM/APPL HYDROCORTISONE/PRAMOXINE

2 ANAPROX DS NAPROXEN SODIUM

3 ANASCORP CENTRUROIDES(SCORPN) ANTIVENOM

2 ANASPAZ HYOSCYAMINE SULFATE

3 ANASTIA LIDOCAINE HCL

1 ANASTROZOLE ANASTROZOLE

3 ANCOBON FLUCYTOSINE

3 ANDRODERM TESTOSTERONE X

2 ANDROGEL 1%, 1.62% TESTOSTERONE X

3 ANDROID METHYLTESTOSTERONE X

3 ANGELIQ DROSPIRENONE/ESTRADIOL

3 ANIMAS VIBE SUB‐Q INSULIN PUMP, CGM SYSTEM

3 ANIMI‐3 OM‐3/DHA/EPA/D3/B12/FA/B‐6/PHY

3 ANORO ELLIPTA UMECLIDINIUM BRM/VILANTEROL TR X

2 ANTABUSE DISULFIRAM

Excluded ANTARA

2 ANUSOL‐HC HYDROCORTISONE

3 ANZEMET (50, 100 MG) TABLET DOLASETRON MESYLATE X X

2 APEXICON E DIFLORASONE DIACETATE/EMOLL

Excluded APIDRA

Excluded APIDRA SOLOSTAR

3 APLENZIN BUPROPION HBR X X

3 APLIGRAF CULT SKIN SUBST,HUMAN‐BOVINE

3 APOGEE HC INTERMITTENT CATHETER

1 APRACLONIDINE HCL APRACLONIDINE HCL

1 APREPITANT (125MG‐80MG) CAP DS PK APREPITANT X

1 APREPITANT (80 MG) CAPSULE APREPITANT X

1 APRI

2 APRISO MESALAMINE

Excluded APTENSIO XR

3 APTIOM (200, 400, 600, 800 MG) TABLET ESLICARBAZEPINE ACETATE X X

2 APTIVUS TIPRANAVIR X

3 AQUA GLYCOLIC HC HYDROCORTISONE/SKIN CLEANSER25

3 AQUORAL SALIVA SUBSTITUTE COMBO NO.3

3 ARANESP EPOETIN X

2 ARAVA LEFLUNOMIDE

3 ARCAPTA INDACATEROL MALEATE X X

Excluded ARESTIN

3 ARGYLE MEDICAL SUPPLY, MISCELLANEOUS

2 ARICEPT DONEPEZIL HCL

2 ARIMIDEX ANASTROZOLE

1 ARIPIPRAZOLE ARIPIPRAZOLE X

2 ARIPIPRAZOLE ODT ARIPIPRAZOLE X X

2 ARIXTRA (10MG/0.8ML) SYRINGE FONDAPARINUX SODIUM X

2 ARIXTRA (2.5 MG/0.5) SYRINGE FONDAPARINUX SODIUM X

2 ARIXTRA (5MG/0.4ML) SYRINGE FONDAPARINUX SODIUM X

2 ARIXTRA (7.5MG/0.6) SYRINGE FONDAPARINUX SODIUM X

2 ARMOUR THYROID THYROID,PORK

3 ARNUITY ELLIPTA FLUTICASONE FUROATE X X

2 AROMASIN EXEMESTANE

3 ARTHROTEC 50, 75 DICLOFENAC SODIUM/MISOPROSTOL

3 ARTISS THROMBIN/FIBRINOG/APROT/CAL CL

1 ASCORBIC ACID ASCORBIC ACID

2 ASMANEX HFA MOMETASONE FUROATE X

2 ASMANEX TWISTHALER MOMETASONE FUROATE X

1 ASPIRIN/CAFFEIN/DIHYDROCODEINE ASPIRIN/CAFFEIN/DIHYDROCODEINE X


Authorization

Quantity

Limit

Step

Therapy2 ASPIRIN/DIPYRIDAMOLE ASPIRIN/DIPYRIDAMOLE

3 ASTAGRAF XL TACROLIMUS

2 ASTEPRO AZELASTINE HCL X X

3 ASTHMAPACK CHILDREN'S PEAK FLOW METER/INH ASSIT DEV

3 ASTRINGYN FERRIC SUBSULFATE

3 ATABEX EC PNV COMB.NO43/IRON,CARB/FA/DSS

3 ATACAND CANDESARTAN CILEXETIL

3 ATELVIA RISEDRONATE SODIUM X X

1 ATENOLOL TABLET ATENOLOL

1 ATENOLOL/CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE

2 ATIVAN LORAZEPAM

3 ATOPICLAIR VITE AC/GRAPE/HYALURONIC ACID

1 ATORVASTATIN ATORVASTATIN

1 ATORVASTATIN TABLET

1 ATOVAQUONE ATOVAQUONE

1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE/PROGUANIL HCL

3 ATRALIN TRETINOIN

3 ATRAPRO CP EMOLLIENT COMBOS NO.47, NO.60

3 ATRAPRO DERMAL SPRAY HYPOC ACID/SOD HYPO/NACL/WATER

3 ATRAPRO HYDROGEL EMOLLIENT COMBINATION NO.60

2 ATRIPLA EFAVIRENZ/EMTRICITAB/TENOFOVIR X

3 ATROPEN ATROPINE SULFATE

1 ATROPINE SULFATE ATROPINE SULFATE

1 ATROPINE SULFATE IN 0.9% NACL ATROPINE SULFATE IN 0.9% NACL

2 ATROVENT HFA IPRATROPIUM BROMIDE X

2 AUBAGIO X

2 AUGMENTIN AMOXICILLIN/POTASSIUM CLAV

2 AUGMENTIN ES‐600 AMOXICILLIN/POTASSIUM CLAV

2 AUGMENTIN XR AMOXICILLIN/POTASSIUM CLAV

3 AURUMHEEL HOMEOPATHIC DRUGS

3 AURYXIA FERRIC CITRATE X

Excluded AUVI‐Q

2 AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE

3 AVANDAMET ROSIGLITAZONE/METFORMIN HCL X

3 AVANDARYL X

3 AVANDIA ROSIGLITAZONE MALEATE X

2 AVAPRO IRBESARTAN

3 AVAR SULFACETAMIDE SODIUM/SULFUR

3 AVAR LS SULFACETAMIDE SODIUM/SULFUR

3 AVAR‐E SULFACETAMIDE SODIUM/SULFUR

3 AVAR‐E GREEN SULFACETAMIDE SODIUM/SULFUR

3 AVAR‐E LS SULFACETAMIDE SODIUM/SULFUR

2 AVC SULFANILAMIDE

2 AVELOX MOXIFLOXACIN HCL

3 AVENOVA HYPOCHLOROUS ACID/SODIUM CHLOR

1 AVIANE

3 AVIDOXY DOXYCYCLINE MONOHYDRATE X

3 AVITENE MICROFIBRILLAR COLLAGEN

2 AVODART DUTASTERIDE

2 AVONEX X

3 AXERT ALMOTRIPTAN MALATE X X

2 AXIRON TESTOSTERONE X

2 AYGESTIN NORETHINDRONE ACETATE

3 AZASAN AZATHIOPRINE

3 AZASITE AZITHROMYCIN

1 AZATHIOPRINE AZATHIOPRINE

1 AZELASTINE HCL AZELASTINE HCL

1 AZELASTINE NASAL SPRAY AZELASTINE X

1 AZELASTINE OPHTHALMIC DROPS AZELASTINE

3 AZELEX AZELAIC ACID

2 AZILECT RASAGILINE MESYLATE X

1 AZITHROMYCIN AZITHROMYCIN


Authorization

Quantity

Limit

Step

Therapy2 AZOPT BRINZOLAMIDE

2 AZOR AMLODIPINE BES/OLMESARTAN MED X

2 AZULFIDINE SULFASALAZINE

1 B CMPLX 4/VIT D3/C/FA/ZINC OX B CMPLX 4/VIT D3/C/FA/ZINC OX

1 B COMPLEX W‐C NO.20/FOLIC ACID B COMPLEX W‐C NO.20/FOLIC ACID

1 BACITRACIN BACITRACIN

1 BACITRACIN/POLYMYXIN B SULFATE BACITRACIN/POLYMYXIN B SULFATE

1 BACLOFEN TABLET BACLOFEN

1 BACTERIOSTATIC SODIUM CHLORIDE BACTERIOSTATIC SODIUM CHLORIDE

2 BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM

2 BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM

2 BACTROBAN MUPIROCIN CALCIUM

2 BACTROBAN NASAL MUPIROCIN CALCIUM

1 BALSALAZIDE 750MG CAPSULE BALSALAZIDE

3 BANZEL (200 MG) TABLET RUFINAMIDE X X

3 BANZEL (40 MG/ML) ORAL SUSP RUFINAMIDE X X

3 BANZEL (400 MG) TABLET RUFINAMIDE X X

Excluded BASAGLAR

3 BCG (TICE STRAIN) BCG LIVE

Excluded BEAU RX

Excluded BECONASE AQ

Excluded BELBUCA

3 BELSOMRA SUVOREXANT X X

1 BENAZEPRIL TABLET BENAZEPRIL

1 BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE

2 BENICAR OLMESARTAN MEDOXOMIL X

1 BENOXINATE HCL/FLUORESCEIN NA BENOXINATE HCL/FLUORESCEIN NA

3 BENSAL HP SALICYLIC ACID

2 BENTYL DICYCLOMINE HCL

2 BENZACLIN (1 %‐5 %) GEL CLINDAMYCIN PHOS/BENZOYL PEROX

3 BENZACLIN (1 %‐5 %) GEL W/PUMP CLINDAMYCIN PHOS/BENZOYL PEROX

2 BENZAMYCIN ERYTHROMYCIN/BENZOYL PEROXIDE

3 BENZEFOAM BENZOYL PEROXIDE

3 BENZEFOAM ULTRA BENZOYL PEROXIDE

1 BENZONATATE BENZONATATE

1 BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE



2 BENZOYL PEROXIDE 6% TOWELETTE BENZOYL PEROXIDE


1 BENZTROPINE MESYLATE BENZTROPINE MESYLATE

Excluded BEPREVE

2 BESIVANCE BESIFLOXACIN HCL

3 BETADINE POVIDONE‐IODINE

2 BETAGAN LEVOBUNOLOL HCL

3 BETALOAN SUIK BETAMETH AC,NA PH/R 134A,245FA

1

BETAMETHASONE DIPROPIONATE 0.05% AUGMENTED

LOTION (SUPER HIGH) BETAMETHASONE DIPROPIONATE

1 BETAMETHASONE DIPROPIONATE 0.05% CREAM (HIGH) BETAMETHASONE DIPROPIONATE

1 BETAMETHASONE DIPROPIONATE 0.05% GEL (HIGH) BETAMETHASONE DIPROPIONATE

1

BETAMETHASONE DIPROPIONATE AUGMENTED 0.05%

CREAM (HIGH) BETAMETHASONE DIPROPIONATE

1


OINTMENT (HIGH) BETAMETHASONE DIPROPIONATE

1


OINTMENT (SUPER HIGH) BETAMETHASONE DIPROPIONATE

1 BETAMETHASONE VALERATE 0.025% LOTION (LOW) BETAMETHASONE VALERATE

1 BETAMETHASONE VALERATE 0.1 % CREAM (LOWER‐MID) BETAMETHASONE VALERATE

1 BETAMETHASONE VALERATE 0.1 % OINTMENT (HIGH) BETAMETHASONE VALERATE

2 BETAMETHASONE VALERATE 0.12 % FOAM (HIGH) BETAMETHASONE VALERATE

1 BETAMETHASONE/PROPYLENE GLYC BETAMETHASONE/PROPYLENE GLYC

2 BETAPACE SOTALOL HCL X


Authorization

Quantity

Limit

Step

Therapy2 BETAPACE AF SOTALOL HCL X

3 BETASERON X

1 BETAXOLOL HCL BETAXOLOL HCL

1 BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE

2 BETIMOL TIMOLOL

2 BETOPTIC S BETAXOLOL HCL

Excluded BEVESPI AEROSPHERE

3 BEYAZ DROSPIR/ETH ESTRA/LEVOMEFOL CA X

3 BIAFINE EMOLLIENT COMBINATION NO.10

2 BIAXIN CLARITHROMYCIN

1 BICALUTAMIDE BICALUTAMIDE

2 BIDIL ISOSORBIBE DINIT/HYDRALAZINE

3 BIFERA RX IRON POLYSAC/IRON HEME/FA/B12

2 BILTRICIDE PRAZIQUANTEL

1 BIMATOPROST 0.03% BIMATOPROST X

2 BIMATOPROST DROPS BIMATOPROST

Excluded BINOSTO

3 BIONECT HYALURONATE SODIUM

3 BIOSTEP COLLAGEN/SOD ALGIN/CARBOXYMETH

3 BIOSTEP AG DRESS,COLLAGEN/SILV/NA ALG/CMC

1 BISAC/NACL/NAHCO3/KCL/PEG 3350 BISAC/NACL/NAHCO3/KCL/PEG 3350

1 BISOPROL/HCTZ COMBO TABLET BISOPROL/HCTZ

2 BLEPHAMIDE SULFACETAMIDE/PREDNISOLONE

2 BLEPHAMIDE S.O.P. SULFACETAMIDE/PREDNISOLONE

3 BLUNT NEEDLE BLUNT NEEDLE, DISPOSABLE

2 BONIVA IBANDRONATE SODIUM

3 BOTOX ONABOTULINUMTOXIN A X X X

3 BREATHERITE INHALER, ASSIST DEVICES

3 BREATHRITE INHALER, ASSIST DEVICES

2 BREO ELLIPTA FLUTICASONE/VILANTEROL X

3 BRIJ L4 LAURETH 4

2 BRILINTA TICAGRELOR X

1 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE

Excluded BRINEURA CERLIPONASE ALFA

3 BRISDELLE PAROXETINE MESYLATE X X

3 BRIVIACT (10 MG) TABLET BRIVARACETAM X X

3 BRIVIACT (10 MG/ML) SOLUTION BRIVARACETAM X X




3 BRIVIACT (50 MG/5 ML) VIAL BRIVARACETAM X


2 BROMFENAC OPTHALMIC SOLUTION BROMFENAC

1 BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE

1 BROMPHENIRA/PSEUDOEPHED/CODEIN BROMPHENIRA/PSEUDOEPHED/CODEIN

1 BROMPHENIRAMINE/PSEUDOEPHED/DM BROMPHENIRAMINE/PSEUDOEPHED/DM

3 BROMSITE BROMFENAC SODIUM

3 BROVANA ARFORMOTEROL TARTRATE X

3 BUCALSEP B‐CAINE/ZINC CL/PINE/CETYLPYRD

2 BUDESONIDE EC 3MG CAPSULE BUDESONIDE

2 BUDESONIDE NASAL SPRAY BUDESONIDE

1 BUMETANIDE BUMETANIDE

3 BUNAVAIL BUPRENORPHINE HCL/NALOXONE HCL X

3 BUPAP BUTALBITAL/ACETAMINOPHEN X X

1 BUPIVACAINE HCL/0.9 % NACL/PF BUPIVACAINE HCL/0.9 % NACL/PF

3 BUPRENEX BUPRENORPHINE HCL

1 BUPRENORPHINE/NALOXONE SL TABS BUPRENORPHINE/NALOXONE X X

1 BUPROPION SR/XL (BEHAVIORAL HEALTH) BUPROPION HCL X X

1 BUSPIRONE TABLET BUSPIRONE

2 BUTALB/APAP/CAFFEINE 50‐300‐40 CAPSULE BUTALB/APAP/CAFFEINE

2 BUTALB/APAP/CAFFEINE 50‐325‐40 TABLET BUTALB/APAP/CAFFEINE

1 BUTALBITAL/ACETAMINOPHEN BUTALBITAL/ACETAMINOPHEN


Authorization

Quantity

Limit

Step

Therapy3 BUTISOL SODIUM BUTABARBITAL SODIUM

1 BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE

2 BUTRANS BUPRENORPHINE X

3 BUTYLATED HYDROXYTOLUENE(BHT) BUTYLATED HYDROXYTOLUENE

Excluded BYDUREON

Excluded BYETTA

2 BYSTOLIC NEBIVOLOL HCL

2 BYVALSON NEBIVOLOL HCL/VALSARTAN

1 CABERGOLINE CABERGOLINE

3 CADEAU DHA PRENATAL VIT #83/IRON/FA#6/DHA

2 CADUET AMLODIPINE/ATORVASTATIN X

2 CAFERGOT ERGOTAMINE TARTRATE/CAFFEINE X

1 CAFFEINE CITRATE CAFFEINE CITRATE

2 CALAN VERAPAMIL HCL

2 CALAN SR VERAPAMIL HCL

1 CALCIPOTRIENE CALCIPOTRIENE X

2 CALCIPOTRIENE/BETAMETHASONE CALCIPOTRIENE/BETAMETHASONE X

1 CALCITONIN, SALMON SYNTHETIC CALCITONIN, SALMON SYNTHETIC

1 CALCITRIOL CAPSULE CALCITRIOL

1 CALCIUM ACETATE (667 MG) CAPSULE, TABLET CALCIUM ACETATE

1 CALCIUM CARB/MAG CARB/FOLIC AC CALCIUM CARB/MAG CARB/FOLIC AC

1 CALCIUM/MAG/D3/B12/FA/B6/BORON CALCIUM/MAG/D3/B12/FA/B6/BORON

3 CAMBIA DICLOFENAC POTASSIUM X

2 CANASA MESALAMINE

2 CANDESARTAN TABLET CANDESARTAN

2 CANDESARTAN/HCTZ COMBO TABLET CANDESARTAN/HCTZ

3 CANTHARIS COMPOSITUM HOMEOPATHIC DRUGS

3 CAPCOF CHLORPHENIRAMINE/PE/CODEINE X

3 CAPEX SHAMPOO FLUOCINOLONE ACETONIDE

3 CAPHOSOL SALIVA SUBSTITUTE COMBO NO.2

2 CAPITAL W‐CODEINE ACETAMINOPHEN WITH CODEINE X

2 CAPTOPRIL TABLET CAPTOPRIL

1 CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE

Excluded CAPXIB

3 CARAC FLUOROURACIL

2 CARAFATE SUCRALFATE

1 CARBAMAZEPINE CARBAMAZEPINE

2 CARBATROL CARBAMAZEPINE

1 CARBIDOPA CARBIDOPA

1 CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA

1 CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE

1 CARBINOXAMINE CARBINOXAMINE

3 CARDENE SR DILTIAZEM HCL

1 CARDIOPLEGIC NO.14 (MAINT 8:1) CARDIOPLEGIC NO.14 (MAINT 8:1)

1 CARDIOPLEGIC NO.15(INDUCT 8:1) CARDIOPLEGIC NO.15(INDUCT 8:1)



1 CARDIOPLEGIC NO.19 (MAINT 4:1) CARDIOPLEGIC NO.19 (MAINT 4:1)

1 CARDIOPLEGIC SOLUTION NO.1 CARDIOPLEGIC SOLUTION NO.1



2 CARDIZEM DILTIAZEM HCL

2 CARDIZEM CD DILTIAZEM HCL

3 CARDIZEM LA DILTIAZEM HCL

2 CARDURA DOXAZOSIN MESYLATE

3 CARDURA XL DOXAZOSIN MESYLATE

1 CARISOPRODOL CARISOPRODOL

1 CARISOPRODOL/ASPIRIN CARISOPRODOL/ASPIRIN

1 CARISOPRODOL/ASPIRIN/CODEINE CARISOPRODOL/ASPIRIN/CODEINE X

3 CARNITOR LEVOCARNITINE

3 CARNITOR LEVOCARNITINE (WITH SUGAR)

3 CARNITOR SF LEVOCARNITINE


Authorization

Quantity

Limit

Step

Therapy3 CARRASYN HYDROGEL WOUND GEL DRESSING

1 CARTEOLOL HCL CARTEOLOL HCL

3 CARTICEL AUTOLOGOUS CULT. CHONDROCYTES

1 CARVEDILOL TABLET CARVEDILOL

2 CASODEX BICALUTAMIDE

2 CATAPRES CLONIDINE HCL

3 CATAPRES‐TTS 1 CLONIDINE



3 CAVERJECT ALPROSTADIL X

3 CAYA CONTOURED DIAPHRAGMS, CONTOURED

3 CEDAX CEFTIBUTEN

1 CEFACLOR CEFACLOR

1 CEFADROXIL CEFADROXIL

1 CEFDINIR CEFDINIR

1 CEFDITOREN PIVOXIL CEFDITOREN PIVOXIL

1 CEFIXIME CEFIXIME

1 CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL

1 CEFPROZIL CEFPROZIL

1 CEFTIBUTEN CEFTIBUTEN

2 CEFTIN CEFUROXIME AXETIL

1 CEFUROXIME AXETIL CEFUROXIME AXETIL

3 CELACYN EMOLLIENT COMBINATION NO.60

3 CELACYN POST PROCEDURE EMOL #60/HYPO/SOD CHL,SUL,PHOS

2 CELEBREX CELECOXIB

1 CELECOXIB CELECOXIB

2 CELEXA CITALOPRAM HYDROBROMIDE

2 CELLCEPT MYCOPHENOLATE MOFETIL

3 CELONTIN METHSUXIMIDE

3 CENESTIN

2 CENTANY MUPIROCIN

3 CENTANY AT MUPIROCIN

1 CEPHALEXIN CEPHALEXIN

3 CERACADE EMOLLIENT COMBINATION NO.103

3 CERAMAX EMOLLIENT COMBINATION NO.101

3 CERVIDIL DINOPROSTONE

3 CESAMET NABILONE X X

3 CETACAINE TETRACAINE/BENZOCAINE/BUTAMBEN

3 CETACAINE ANESTHETIC TETRACAINE/BENZOCAINE/BUTAMBEN

1 CETIRIZINE HCL (10 MG) CAPSULE (OTC) CETIRIZINE HCL

1 CETIRIZINE HCL/PSEUDOEPHEDRINE CETIRIZINE HCL/PSEUDOEPHEDRINE

3 CETRAXAL CIPROFLOXACIN HCL

3 CETYLEV ACETYLCYSTEINE

2 CEVIMELINE CAPSULE CEVIMELINE

3 CHEMET SUCCIMER

3 CHENODAL CHENODIOL

1 CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL

1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE/CLIDINIUM BR

1 CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE

1 CHLOROQUINE CAPSULE CHLOROQUINE PHOSPHATE

1 CHLOROTHIAZIDE CHLOROTHIAZIDE

1 CHLORPHENIRAMINE CHLORPHENIRAMINE

1 CHLORPROMAZINE HCL CHLORPROMAZINE HCL

2 CHLORPROPAMIDE TABLET CHLORPROPAMIDE

1 CHLORZOXAZONE TABLET CHLORZOXAZONE

3 CHOLBAM X

1 CHOLESTYRAMINE CHOLESTYRAMINE

1 CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE/ASPARTAME

1 CHOLINE SALICYL/MAG SALICYLATE CHOLINE SALICYL/MAG SALICYLATE

3 CIALIS TADALAFIL X X

2 CICLODAN CICLOPIROX

3 CICLODAN CICLOPIROX/URE/CAMPH/MENTH/EUC


Authorization

Quantity

Limit

Step

Therapy2 CICLOPIROX 0.77 % GEL CICLOPIROX

1 CICLOPIROX 0.77% CREAM CICLOPIROX

2 CICLOPIROX 1 % SHAMPOO CICLOPIROX

2 CICLOPIROX 8 % SOLUTION (CICLODAN GENERIC) CICLOPIROX

1 CICLOPIROX 8 % SOLUTION (PENLAC GENERIC) CICLOPIROX

1 CICLOPIROX OLAMINE CICLOPIROX OLAMINE

2 CICLOPIROX/URE/CAMPH/MENTH/EUC CICLOPIROX/URE/CAMPH/MENTH/EUC

3 CIDALEAZE LIDOCAINE HCL

1 CILOSTAZOL CILOSTAZOL

2 CILOXAN CIPROFLOXACIN HCL

1 CIMETIDINE CIMETIDINE

1 CIMETIDINE SOLUTION CIMETIDINE

Excluded CIMZIA CERTOLIZUMAB

Excluded CINQAIR RESLIZUMAB

2 CIPRO CIPROFLOXACIN

3 CIPRO HC CIPROFLOXACIN/HYDROCORTISONE

3 CIPRO XR CIPROFLOXACIN/CIPROFLOXA HCL

2 CIPRODEX CIPROFLOXACIN HCL/DEXAMETH

1 CIPROFLOXACIN CIPROFLOXACIN

1 CIPROFLOXACIN HCL CIPROFLOXACIN HCL

1 CIPROFLOXACIN/CIPROFLOXA HCL CIPROFLOXACIN/CIPROFLOXA HCL

1 CITALOPRAM CITALOPRAM

3 CITRANATAL 90 DHA PNV72/IRON,GLUC/FOLIC/DSS/DHA

3 CITRANATAL ASSURE PNV73/IRON,GLUC/FOLIC/DSS/DHA

3 CITRANATAL B‐CALM PRENATAL #48/IRON CB,GLU/FA/B6

3 CITRANATAL DHA PNV 76/IRON,GLUC/FOLIC/DSS/DHA

3 CITRANATAL HARMONY PNV59/IRON,CARB,FUM/FA/DSS/DHA

3 CITRANATAL RX PRENATAL81/IRON/FOLIC/DOCUSATE

1 CITRATE PHOSPHATE DEXTROS SOLN CITRATE PHOSPHATE DEXTROS SOLN

3 CITRIC ACID CITRIC ACID

3 CLARINEX (5 MG) TABLET DESLORATADINE X

3 CLARINEX D DESLORATADINE/PSEUDOEPHEDRINE X X

3 CLARINEX SYRUP DESLORATADINE X X

2 CLARITHROMYCIN 500 MG ER TABLET CLARITHROMYCIN

1 CLARITHROMYCIN IR TABLETS (250 MG, 500 MG) CLARITHROMYCIN

1 CLEMASTINE FUMARATE CLEMASTINE FUMARATE

3 CLEO 90 INFUSION SET INFUSION SET FOR INSULIN PUMP

3 CLEOCIN CLINDAMYCIN PHOSPHATE

2 CLEOCIN HCL CLINDAMYCIN HCL

2 CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL

2 CLEOCIN T CLINDAMYCIN PHOSPHATE

3 CLEVER CHOICE HOLDING CHAMBER INHALER, ASSIST DEVICES

3 CLEVER CHOICE NEBULIZER NEBULIZER AND COMPRESSOR

3 CLEVER CHOICE WHISPER AIRE PED NEBULIZER AND COMPRESSOR

2 CLIMARA ESTRADIOL X

3 CLIMARA PRO ESTRADIOL/LEVONORGESTREL X

2 CLINDACIN ETZ CLINDAMYCIN PHOSPHATE

2 CLINDACIN P CLINDAMYCIN PHOSPHATE

3 CLINDAGEL CLINDAMYCIN PHOSPHATE X

1 CLINDAMYCIN CAPSULE CLINDAMYCIN HCL

2

CLINDAMYCIN PHOS/BENZOYL PEROXIDE

(GEL OR GEL PUMP) CLINDAMYCIN PHOS/BENZOYL PEROX

1 CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE

1 CLINDAMYCIN PHOSPHATE 1 % GEL CLINDAMYCIN PHOSPHATE

2 CLINDAMYCIN PHOSPHATE FOAM CLINDAMYCIN PHOSPHATE

1 CLINDAMYCIN PHOSPHATE GEL 1%/TRETINION 0.025% GEL CLINDAMYCIN/TRETINOIN

1 CLINDAMYCIN PHOSPHATE SOLUTION CLINDAMYCIN PHOSPHATE

2 CLINDAMYCIN/TRETINOIN CLINDAMYCIN/TRETINOIN

3 CLINDESSE CLINDAMYCIN PHOSPHATE

3 CLINPRO 5000 SODIUM FLUORIDE

2 CLOBETASOL PROPIONATE 0.05 % FOAM (SUPER HIGH) CLOBETASOL PROPIONATE


Authorization

Quantity

Limit

Step

Therapy2 CLOBETASOL PROPIONATE 0.05 % GEL (SUPER HIGH) CLOBETASOL PROPIONATE

2 CLOBETASOL PROPIONATE 0.05 % LOTION (SUPER HIGH) CLOBETASOL PROPIONATE

2 CLOBETASOL PROPIONATE 0.05 % OINTMENT (SUPER HIGH) CLOBETASOL PROPIONATE

2 CLOBETASOL PROPIONATE 0.05 % SHAMPOO (SUPER HIGH) CLOBETASOL PROPIONATE

1 CLOBETASOL PROPIONATE 0.05 % SOLUTION (SUPER HIGH) CLOBETASOL PROPIONATE

1 CLOBETASOL PROPIONATE 0.05 % SOLUTION (SUPER HIGH) CLOBETASOL PROPIONATE

2 CLOBETASOL PROPIONATE 0.05 % SPRAY (SUPER HIGH) CLOBETASOL PROPIONATE

1

CLOBETASOL PROPIONATE EMOLLIENT 0.05 % CREAM

(SUPER HIGH) CLOBETASOL PROPIONATE/EMOLL

2

CLOBETASOL PROPIONATE/EMOLLIENT 0.05 % FOAM

(SUPER HIGH) CLOBETASOL PROPIONATE/EMOLL

2 CLOBEX CLOBETASOL PROPIONATE

2 CLOCORTOLONE PIVALATE 0.1% CREAM (MEDIUM) CLOCORTOLONE PIVALATE

2 CLODAN CLOBETASOL PROPIONATE

3 CLODAN CLOBETASOL/SKIN CLEANSER #28

3 CLODERM CLOCORTOLONE PIVALATE

2 CLOMIPRAMINE CAPSULE CLOMIPRAMINE

1 CLONAZEPAM CLONAZEPAM

2 CLONIDINE CLONIDINE

2 CLONIDINE HCL (BEHAVIORAL HEALTH) CLONIDINE HCL X

1 CLONIDINE HCL (CARDIOVASCULAR) CLONIDINE HCL

1 CLONIDINE HCL/CHLORTHALIDONE CLONIDINE HCL/CHLORTHALIDONE

1 CLONIDINE HCL/PF CLONIDINE HCL/PF

1 CLOPIDOGREL BISULFATE (300 MG) TABLET CLOPIDOGREL BISULFATE X

1 CLOPIDOGREL BISULFATE (75 MG) TABLET CLOPIDOGREL BISULFATE

1 CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM

1 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE

1 CLOTRIMAZOLE/BETAMETHASONE 1 %‐0.05 % CREAM CLOTRIMAZOLE/BETAMETHASONE

2 CLOTRIMAZOLE/BETAMETHASONE 2%‐0.05% LOTION CLOTRIMAZOLE/BETAMETHASONE

1 CLOZAPINE CLOZAPINE X

1 CLOZAPINE ODT CLOZAPINE X X

2 CLOZARIL CLOZAPINE X

3 CNL 8 CICLOPIROX/NAIL LACQUER REMOVR

3 COAGUCHEK XS PT/INR TEST METER

3 COARTEM ARTEMETHER/LUMEFANTRINE

1 COCAINE HCL COCAINE HCL

1 CODEINE PHOSPHATE/GUAIFENESIN CODEINE PHOSPHATE/GUAIFENESIN X

1 CODEINE SULFATE (15 MG) TABLET CODEINE SULFATE X

2 CODEINE SULFATE (30, 60 MG) TABLET CODEINE SULFATE X

1 CODEINE/BUTALBITAL/ASA/CAFFEIN CODEINE/BUTALBITAL/ASA/CAFFEIN X

3 CODITUSSIN DAC PSEUDOEPHED/CODEINE/GUAIFEN X

2 COLAZAL BALSALAZIDE DISODIUM

1 COLCHICINE (0.6 MG) CAPSULE COLCHICINE X

1 COLCHICINE (0.6 MG) TABLET COLCHICINE X

2 COLCRYS COLCHICINE X

2 COLESTID (1 G) TABLET COLESTIPOL HCL

2 COLESTID (5 G) GRANULES COLESTIPOL HCL

2 COLESTID (5 G) PACKET COLESTIPOL HCL

3 COLESTID (7.5 G) PACKET COLESTIPOL HCL

1 COLESTIPOL HCL COLESTIPOL HCL

3 COLY‐MYCIN S NEOMYC/COLIST/HYDROCORT/THONZN

2 COLYTE WITH FLAVOR PACKETS PEG3350/SOD SULF,BICARB,CL/KCL

2 COMBIGAN BRIMONIDINE TARTRATE/TIMOLOL

2 COMBIPATCH ESTRADIOL/NORETHINDRONE ACET X

2 COMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL SULFATE

2 COMBIVIR LAMIVUDINE/ZIDOVUDINE X

3 COMFORT PAC‐CYCLOBENZAPRINE CYCLOBENZAPRINE/IRR CNTR‐IRR 2

3 COMFORT PAC‐IBUPROFEN IBUPROFEN/IRR.COUNT‐IRRIT.NO.2


Authorization

Quantity

Limit

Step

Therapy3 COMFORT PAC‐MELOXICAM MELOXICAM/IRRIT.CNTR‐IRR CMB 2

3 COMFORT PAC‐NAPROXEN NAPROXEN/IRRITANT CNTR‐IRRIT 2

3 COMFORT PAC‐TIZANIDINE TIZANIDINE/IRR CNTR‐IRR COMB#2

3 COMFORT SHORT INFUSION SET FOR INSULIN PUMP

3 COMPACT SPACE CHAMBER INHALER, ASSIST DEVICES

3 COMPACT SPACE CHAMBER PLUS INHALER, ASSIST DEVICES

3 COMP‐AIR ELITE COMPRESSOR SYST NEBULIZER AND COMPRESSOR

3 COMP‐AIR NEBULIZER COMPRESSOR NEBULIZER AND COMPRESSOR

2 COMPAZINE PROCHLORPERAZINE

2 COMPLERA EMTRICITA/RILPIVIRINE/TENOF DF X

3 COMPLETE NATAL DHA PRENATAL 2/IRON/FOLIC ACID/OM3

2 COMTAN ENTACAPONE

3 CONCEPT DHA PNV 16/IRON FUM,PS/FOLIC/OM‐3

3 CONCEPT OB PNV #15/IRON FUM,PS/FOLIC ACID

3 CONCEPTION CONCEPTION ASSIST.SUPPLIES NO1

1 CONCERTA (18,27,36,54 MG) TAB ER 24 METHYLPHENIDATE HCL X

2 CONDYLOX PODOFILOX

3 CONTACT DETACH INFUSION SET INFUSION SET FOR INSULIN PUMP

3 CONZIP TRAMADOL HCL X X

2 COPAXONE GLATIRAMER X

2 COPEGUS RIBAVIRIN

2 CORDRAN FLURANDRENOLIDE

2 COREG CARVEDILOL

2 COREG CR CARVEDILOL PHOSPHATE

2 CORGARD NADOLOL

2 CORLANOR IVABRADINE HCL X X

3 CORTANE‐B HC/PRAMOXINE HCL/CHLOROXYLENOL

2 CORTEF HYDROCORTISONE

2 CORTENEMA HYDROCORTISONE

3 CORTIFOAM HYDROCORTISONE ACETATE

1 CORTISONE ACETATE CORTISONE ACETATE

2 CORTISPORIN NEOMYC/BACIT/POLYMYX/HYDROCORT

2 CORTISPORIN NEOMYCIN/POLYMYXIN B/HYDROCORT

3 CORVITA FOLIC/MVI THER‐MIN/LYCOP/LUT

3 CORVITE FOLIC/MVI THER‐MIN/LYCOP/LUT

3 CORVITE 150 IRON,CARB/FA#6/MV, MIN NO.41

3 CORVITE FE IRON/FOLATE NO.6/MV,MINS NO.40

3 CORVITE FREE MV‐MINS 6/FOLIC ACID/LUT/COQ10

3 CORZIDE NADOLOL/BENDROFLUMETHIAZIDE

2 COSOPT DORZOLAMIDE HCL/TIMOLOL MALEAT

3 COSOPT PF DORZOLAMIDE/TIMOLOL/PF X X

2 COUMADIN WARFARIN SODIUM

3 COVERA‐HS VERAPAMIL

2 COZAAR LOSARTAN POTASSIUM

3 CRALONIN HOMEOPATHIC DRUGS

2 CREON LIPASE/PROTEASE/AMYLASE

3 CRESEMBA ISAVUCONAZONIUM SULFATE

2 CRESTOR ROSUVASTATIN CALCIUM X

2 CRINONE PROGESTERONE, MICRONIZED

2 CRIXIVAN INDINAVIR SULFATE

1 CROMOLYN CROMOLYN

3 CRYOSERV DIMETHYL SULFOXIDE

3 CURAFIL GEL DRESSING

3 CURITY DRAINAGE BAG

3 CURITY AMD GAUZE BANDAGE

3 CURITY IODOFORM IODOFORM

3 CUROSURF PORACTANT ALFA

2 CUTIVATE FLUTICASONE PROPIONATE

3 CUVPOSA GLYCOPYRROLATE

1 CYANOCOBALAMIN (VITAMIN B‐12) CYANOCOBALAMIN (VITAMIN B‐12)

1 CYANOCOBALAMIN/FOLIC AC/VIT B6 CYANOCOBALAMIN/FOLIC AC/VIT B6

1 CYANOCOBALAMIN/MECOBALAMIN CYANOCOBALAMIN/MECOBALAMIN


Authorization

Quantity

Limit

Step

Therapy2 CYCLESSA DESOGESTREL‐ETHINYL ESTRADIOL X

1 CYCLOBENZAPRINE TABLET CYCLOBENZAPRINE HCL

2 CYCLOGYL CYCLOPENTOLATE HCL

3 CYCLOMYDRIL CYCLOPENTOLATE/PHENYLEPHRINE

1 CYCLOPENTOLAT/TROPIC/PHENYLEPH CYCLOPENTOLAT/TROPIC/PHENYLEPH

1 CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL

1 CYCLOSERINE CYCLOSERINE

3 CYCLOSET BROMOCRIPTINE MESYLATE X

1 CYCLOSPORINE CYCLOSPORINE

1 CYCLOSPORINE, MODIFIED CYCLOSPORINE, MODIFIED

2 CYMBALTA DULOXETINE HCL X

1 CYPROHEPTADINE HCL CYPROHEPTADINE HCL

3 CYSTAGON CYSTEAMINE BITARTRATE

2 CYTOMEL LIOTHYRONINE SODIUM

2 CYTOTEC MISOPROSTOL

3 D.H.E.45 DIHYDROERGOTAMINE MESYLATE X

Excluded DAKLINZA

2 DALIRESP ROFLUMILAST X X

1 DANAZOL DANAZOL

2 DANTRIUM DANTROLENE SODIUM

1 DANTROLENE SODIUM DANTROLENE SODIUM

1 DAPSONE DAPSONE

2 DARAPRIM PYRIMETHAMINE X

1 DARIFENACIN HYDROBROMIDE DARIFENACIN HYDROBROMIDE X

Excluded DAXBIA

2 DAYPRO OXAPROZIN

3 DAYTRANA METHYLPHENIDATE X X

2 DDAVP DESMOPRESSIN (NONREFRIGERATED)

2 DDAVP (0.1 MG) TABLET DESMOPRESSIN ACETATE

2 DDAVP (0.1 MG/ML) SOLUTION DESMOPRESSIN ACETATE

2 DDAVP (0.2 MG) TABLET DESMOPRESSIN ACETATE

3 DDAVP (4 MCG/ML) AMPUL DESMOPRESSIN ACETATE

3 DDAVP (4 MCG/ML) VIAL DESMOPRESSIN ACETATE

3 DEBACTEROL SULFURIC ACID/SULF PHENOL

1 DEFEROXAMINE MESYLATE DEFEROXAMINE MESYLATE

Excluded DELZICOL

2 DEMADEX TORSEMIDE

1 DEMECLOCYCLINE HCL DEMECLOCYCLINE HCL

3 DEMEROL MEPERIDINE HCL/PF

3 DEMEROL (100 MG) TABLET MEPERIDINE HCL X

3 DEMEROL (100 MG/ML) VIAL MEPERIDINE HCL

3 DEMEROL (50 MG/ML) VIAL MEPERIDINE HCL

3 DEMSER METYROSINE

2 DEMULEN 1‐50‐21 ETHYNODIOL D‐ETHINYL ESTRADIOL X

2 DEPAKENE VALPROIC ACID

2 DEPAKOTE DIVALPROEX SODIUM

2 DEPAKOTE ER DIVALPROEX SODIUM

2 DEPAKOTE SPRINKLE DIVALPROEX SODIUM

3 DEPO‐ESTRADIOL ESTRADIOL CYPIONATE

2 DEPO‐PROVERA MEDROXYPROGESTERONE ACETATE X

2 DEPO‐TESTOSTERONE TESTOSTERONE CYPIONATE X X

3 DERMACINRX EMPRICAINE LIDOCAINE/PRILOCAINE

3 DERMACINRX PRIZOPAK LIDOCAINE/PRILOCAINE

3 DERMAGRAFT CULT SKIN SUBST,HUMAN‐BOVINE

Excluded DERMAPAK PLUS

Excluded DERMASORB XM

3 DERMATOP PREDNICARBATE

3 DERMOTIC FLUOCINOLONE ACETONIDE OIL

2 DESCOVY EMTRICITABINE/TENOFOV ALAFENAM X

3 DESFERAL DEFEROXAMINE MESYLATE

3 DESFERAL MESYLATE DEFEROXAMINE MESYLATE

2 DESIPRAMINE TABLET DESIPRAMINE


Authorization

Quantity

Limit

Step

Therapy1 DESLORATADINE DESLORATADINE X

2 DESLORATADINE ODT DESLORATADINE X X

1 DESMOPRESSIN (NONREFRIGERATED) DESMOPRESSIN (NONREFRIGERATED)

1 DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE

2 DESOGEN DESOGESTREL‐ETHINYL ESTRADIOL X

3 DESONATE DESONIDE

2 DESONIDE 0.05% CREAM (LOW) DESONIDE

2 DESONIDE 0.05% LOTION (LOW) DESONIDE

2 DESONIDE 0.05% OINTMENT (LOWER‐MID) DESONIDE

2 DESOWEN DESONIDE

2 DESOXIMETASONE 0.05 % CREAM (MEDIUM) DESOXIMETASONE

2 DESOXIMETASONE 0.05 % GEL (HIGH) DESOXIMETASONE

2 DESOXIMETASONE 0.05 % OINTMENT (MEDIUM) DESOXIMETASONE

1 DESOXIMETASONE 0.25 % CREAM (HIGH) DESOXIMETASONE

2 DESOXIMETASONE 0.25 % OINTMENT (HIGH) DESOXIMETASONE

3 DESOXYN METHAMPHETAMINE HCL X

2 DESVENLAFAXINE ER (RANBAXY BRAND) DESVENLAFAXINE X X

3 DESVENLAFAXINE FUMARATE ER DESVENLAFAXINE FUMARATE X X

1 DESVENLAFAXINE SUCCINATE DESVENLAFAXINE SUCCINATE X

2 DETROL TOLTERODINE TARTRATE X

2 DETROL LA TOLTERODINE TARTRATE X

3 DEVILBISS NEBULIZER AND COMPRESSOR

3 DEVILBISS PULMO‐AIDE COMPRESSOR, FOR NEBULIZER

3 DEVILBISS PULMONEB LT COMP‐NEB NEBULIZER AND COMPRESSOR

1 DEXAMETHASONE DEXAMETHASONE

3 DEXAMETHASONE INTENSOL DEXAMETHASONE

1 DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SOD PHOSPHATE

3 DEXCOM G4 BLOOD‐GLUCOSE TRANSMITTER

3 DEXCOM G5 BLOOD‐GLUCOSE METER,CONTINUOUS

3 DEXCOM G5 BLOOD‐GLUCOSE TRANSMITTER

3 DEXCOM G5‐G4 SENSOR BLOOD‐GLUCOSE SENSOR

2 DEXEDRINE (10 MG) CAPSULE ER DEXTROAMPHETAMINE SULFATE X

2 DEXEDRINE (10 MG) TABLET DEXTROAMPHETAMINE SULFATE X



2 DEXEDRINE (5 MG) TABLET DEXTROAMPHETAMINE SULFATE X

3 DEXERYL EMOLLIENT COMBINATION NO.104

3 DEXILANT LANSOPRAZOLE X X

2 DEXMETHYLPHENIDATE ER CAPSULE DEXMETHYLPHENIDATE

2 DEXMETHYLPHENIDATE HCL (10 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X

1 DEXMETHYLPHENIDATE HCL (10 MG) TABLET DEXMETHYLPHENIDATE HCL X


1 DEXMETHYLPHENIDATE HCL (2.5 MG) TABLET DEXMETHYLPHENIDATE HCL X







1 DEXMETHYLPHENIDATE IR TABLET DEXMETHYLPHENIDATE HCL

2 DEXPAK DEXAMETHASONE

2 DEXTROAMPHETAMINE ER CAPSULE DEXTROAMPHETAMINE

2 DEXTROAMPHETAMINE TABLET DEXTROAMPHETAMINE

2 DEXTROAMPHETAMINE/AMPHETAMINE ER CAPSULE DEXTROAMPHETAMINE/AMPHETAMINE

3 DIALYVITE 5000 MULTIVIT‐MINS NO.11/FOLIC ACID

3 DIALYVITE SUPREME D MULTIVIT‐MINS 25/FOLIC ACID/D3

2 DIAMOX SEQUELS ACETAZOLAMIDE

2 DIASTAT DIAZEPAM X

1 DIAZEPAM (ANTI‐ANXIETY) DIAZEPAM

1 DIAZEPAM (SIEZURE DISORDER) DIAZEPAM X

3 DICLEGIS DOXYLAMINE/PYRIDOXINE HCL (B6) X

2 DICLOFENAC GEL DICLOFENAC


Authorization

Quantity

Limit

Step

Therapy2 DICLOFENAC SODIUM 1.5% TOPICAL SOLUTION DICLOFENAC SODIUM

1 DICLOFENAC SODIUM 24 HR TABLET DICLOFENAC SODIUM

1

DICLOFENAC SODIUM DELAYED RELEASE 50MG, 75MG

TABLET DICLOFENAC SODIUM

1 DICLOFENAC SODIUM OPTHALMIC SOLUTION DICLOFENAC SODIUM

1 DICLOFENAC SODIUM TABLET & MISOPROSTOL TABLET DICLOFENAC SODIUM & MISOPROSTOL

2

DICLOFENAC SODIUM/MISOPROSTOL COMBINATION

TABLET DICLOFENAC SODIUM/MISOPROSTOL

1 DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM

1 DICYCLOMINE HCL DICYCLOMINE HCL

1 DIDANOSINE (125, 200, 250, 400 MG) CAPSULE DR DIDANOSINE X

2 DIFFERIN ADAPALENE

2 DIFICID FIDAXOMICIN X X

2 DIFLORASONE DIACETATE 0.05% CREAM (HIGH) DIFLORASONE DIACETATE

2 DIFLORASONE DIACETATE 0.05% OINTMENT (HIGH) DIFLORASONE DIACETATE

2 DIFLUCAN FLUCONAZOLE

1 DIFLUNISAL DIFLUNISAL

1 DIGOXIN (125, 250 MCG) TABLET DIGOXIN

2 DIGOXIN (50 MCG/ML) SOLUTION DIGOXIN

1 DIHYDROERGOTAMINE DIHYDROERGOTAMINE X

2 DILANTIN PHENYTOIN

2 DILANTIN‐125 PHENYTOIN

3 DILATRATE‐SR ISOSORBIDE DINITRATE

2 DILAUDID HYDROMORPHONE HCL X

3 DILAUDID HYDROMORPHONE HCL/PF X

1 DILTIAZEM DILTIAZEM

1 DILTIAZEM CD DILTIAZEM

2 DILTIAZEM ER TABLET DILTIAZEM

1 DILTIAZEM ER/IR CAPSULE DILTIAZEM

3 DILUENT FOR ROTARIX DILUENT,LIVE ROTAVIRUS VACC,CA

3 DILUTING MEDIUM FOR NOVOLOG DILUENT, INSULIN ASPART NO.1

2 DIOVAN VALSARTAN

Excluded DIPENTUM

1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE HCL/ATROPINE

2 DIPROLENE BETAMETHASONE/PROPYLENE GLYC

2 DIPROLENE AF BETAMETHASONE/PROPYLENE GLYC

1 DIPYRIDAMOLE DIPYRIDAMOLE

2 DISALCID SALSALATE

3 DISKETS METHADONE HCL X X

1 DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE

1 DISULFIRAM DISULFIRAM

2 DITROPAN XL OXYBUTYNIN CHLORIDE

3 DIURIL CHLOROTHIAZIDE

1 DIVALPROEX SODIUM DIVALPROEX SODIUM

2 DIVIGEL ESTRADIOL

1 DOFETILIDE DOFETILIDE X

3 DOLOPHINE HCL (5, 10 MG) TABLET METHADONE HCL X X

1 DONEPEZIL 10 MG TABLET DONEPEZIL HCL

2 DONEPEZIL 23 MG TABLET DONEPEZIL

1 DONEPEZIL HCL (10 MG) TABLET DONEPEZIL HCL

1 DONEPEZIL HCL (5, 10 MG) TAB RAPDIS DONEPEZIL HCL

2 DONNATAL PHENOBARB/HYOSCY/ATROPINE/SCOP

3 DORAL QUAZEPAM

3 DORYX (50, 200 MG) TABLET DR DOXYCYCLINE HYCLATE X X

3 DORYX MPC DOXYCYCLINE HYCLATE X X

1 DORZOLAMIDE HCL DORZOLAMIDE HCL

3 DOVER ADVANTAGE DRAINAGE BAG

3 DOVER ADVANTAGE DRAINAGE DRAINAGE BAG

3 DOVER COATED LATEX FOLEY URINARY BAG/CATH TRAY

3 DOVER LATEX FOLEY CATHETER CATHETER

3 DOVER PREMIUM DRAINAGE BAG

3 DOVER RED RUBBER ROBIBSON CATH CATHETER


Authorization

Quantity

Limit

Step

Therapy3 DOVER UNIVERSAL CATHETERIZATION TRAY

2 DOVONEX CALCIPOTRIENE X

1 DOXAZOSIN DOXAZOSIN

2 DOXEPIN 5% CREAM DOXEPIN

1 DOXEPIN TABLET (BEHAVIORAL HEALTH) DOXEPIN

2 DOXERCALCIFEROL CAPSULE DOXERCALCIFEROL

1 DOXYCYCLINE HYCLATE 100 MG CAPSULE DOXYCYCLINE HYCLATE

1 DOXYCYCLINE HYCLATE 100 MG TABLET DOXYCYCLINE HYCLATE

2 DOXYCYCLINE HYCLATE 100 MG TABLET DR DOXYCYCLINE HYCLATE







1 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE DOXYCYCLINE MONOHYDRATE


1 DOXYCYCLINE MONOHYDRATE 150 MG TABLET DOXYCYCLINE MONOHYDRATE

2

DOXYCYCLINE MONOHYDRATE 40MG CAPSULE BIPHASIC

RELEASE DOXYCYCLINE MONOHYDRATE





2 DRITHOCREME HP ANTHRALIN X

2 DRONABINOL CAPSULE DRONABINOL X X

1 DROSPIR/ETH ESTRA/LEVOMEFOL CA DROSPIR/ETH ESTRA/LEVOMEFOL CA X

3 DROXIA HYDROXYUREA

2 DRYSOL ALUMINUM CHLORIDE

3 DUAC CLINDAMYCIN PHOS/BENZOYL PEROX

2 DUAVEE ESTROGENS,CONJ/BAZEDOXIFENE

3 DUET DHA 400 PNV106/IRON/FA/OM3/DHA/EPA

3 DUET DHA BALANCED PNV117/IRON/FA/OM3/DHA/EPA

2 DUETACT PIOGLITAZONE HCL/GLIMEPIRIDE X

Excluded DUEXIS

2 DULERA MOMETASONE/FORMOTEROL X

1 DULOXETINE HCL (30, 60 MG) CAPSULE DR DULOXETINE HCL X

2 DULOXETINE HCL 40 MG CAPSULE DULOXETINE

3 DUODOTE PRALIDOXIME CHLORIDE/ATROPINE

3 DUOPA CARBIDOPA/LEVODOPA X

3 DURACLON CLONIDINE HCL/PF

2 DURAGESIC FENTANYL X X

3 DURAMORPH MORPHINE SULFATE/PF

2 DUREZOL DIFLUPREDNATE

Excluded DURLAZA

1 DUTASTERIDE DUTASTERIDE X

1 DUTASTERIDE/TAMSULOSIN HCL DUTASTERIDE/TAMSULOSIN HCL X

3 DYANAVEL XR AMPHETAMINE X X

2 DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZID

3 DYMISTA AZELASTINE/FLUTICASONE X X

3 DYMISTA ER AZELASTINE/FLUTICASONE X X

3 DYNACRIC CR

3 DYRENIUM TRIAMTERENE

3 DYSPORT ABOBOTULINUMTOXIN A X X X

3 EAR POPPER MIDDLE EAR INFLATION DEVICE

3 EASIVENT INHALER, ASSIST DEVICES

3 EBASE CONTROLLER COMPRESSOR, FOR NEBULIZER

3 ECLIPSE NEEDLE NEEDLES, SAFETY

3 ECLIPSE SYRINGE SYRINGE,SAFETY WITH NEEDLE,3ML

2 EC‐NAPROSYN NAPROXEN

2 ECONAZOLE NITRATE 0.01% CREAM ECONAZOLE NITRATE

3 ECOZA ECONAZOLE NITRATE


Authorization

Quantity

Limit

Step

Therapy2 EDARBI AZILSARTAN MEDOXOMIL X

2 EDARBYCLOR AZILSARTAN MED/CHLORTHALIDONE X

3 EDECRIN ETHACRYNIC ACID

3 EDEX ALPROSTADIL X

Excluded EDLUAR

2 EDURANT RILPIVIRINE HCL X

3 EFFER‐K POTASSIUM BICARBONATE/CIT AC

2 EFFEXOR XR VENLAFAXINE HCL

2 EFFIENT PRASUGREL HCL X

2 EFUDEX FLUOROURACIL

2 ELDEPRYL SELEGILINE HCL

3 ELESTAT EPINASTINE HCL

3 ELESTRIN ESTRADIOL

3 ELETONE EMOLLIENT COMBINATION NO. 25

2 ELIDEL PIMECROLIMUS X

2 ELIMITE PERMETHRIN

2 ELIQUIS (2.5 MG) TABLET APIXABAN X

2 ELIQUIS (5 MG) TABLET APIXABAN X

3 ELITE‐OB IRON,CARBONYL/FOLIC ACID/MV‐MN

3 ELLA ULIPRISTAL ACETATE

3 ELLIOTTS B CHEMO THEAPY DILUENT NO.1/PF

2 ELMIRON PENTOSAN POLYSULFATE SODIUM

2 ELOCON MOMETASONE FUROATE

Excluded EMADINE

3 EMBEDA (100MG‐4MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X

3 EMBEDA (20MG‐0.8MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X


3 EMBEDA (50 MG‐2 MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X



2 EMEND (125 MG) CAPSULE APREPITANT X

2 EMEND (125 MG) SUSP RECON APREPITANT X

2 EMEND (125MG‐80MG) CAP DS PK APREPITANT X

2 EMEND (40, 80 MG) CAPSULE APREPITANT X

Excluded EMFLAZA

3 EMSAM SELEGILINE X

2 EMTRIVA (10 MG/ML) SOLUTION EMTRICITABINE X

2 EMTRIVA (200 MG) CAPSULE EMTRICITABINE X

2 EMVERM MEBENDAZOLE X

3 ENABLEX DARIFENACIN HYDROBROMIDE X

1 ENALAPRIL MALEATE ENALAPRIL MALEATE

1 ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL/HYDROCHLOROTHIAZIDE

3 ENBRACE HR PRENATAL #92/IRON/FA #8/PS‐DHA

2 ENBREL ETANERCEPT X X X

3 ENDO‐AVITENE MICROFIBRILLAR COLLAGEN

3 ENDOFORM EXTRACELLULAR MATRIX, OVINE

3 ENJUVIA

3 ENLITE BLOOD‐GLUC TRANSMITTER/SENSOR

3 ENLITE GLUCOSE SENSOR BLOOD‐GLUCOSE SENSOR

3 ENLITE SERTER DIABETIC SUPPLIES,MISCELL

1 ENOXAPARIN SODIUM (100 MG/ML) SYRINGE ENOXAPARIN SODIUM X

1 ENOXAPARIN SODIUM (120MG/.8ML) SYRINGE ENOXAPARIN SODIUM X

1 ENOXAPARIN SODIUM (150 MG/ML) SYRINGE ENOXAPARIN SODIUM X

1 ENOXAPARIN SODIUM (300MG/3ML) VIAL ENOXAPARIN SODIUM X

1 ENOXAPARIN SODIUM (30MG/0.3ML) SYRINGE ENOXAPARIN SODIUM X




3 ENSTILAR CALCIPOTRIENE/BETAMETHASONE X

1 ENTACAPONE ENTACAPONE

3 ENTEREG ALVIMOPAN

2 ENTOCORT EC BUDESONIDE


Authorization

Quantity

Limit

Step

Therapy2 ENTRESTO SACUBITRIL/VALSARTAN X

3 ENTYVIO VEDOLIZUMAB X X

3 ENVARSUS XR TACROLIMUS X X

3 EPANED ENALAPRIL MALEATE X X

2 EPCLUSA X

3 EPICERAM EMOLLIENT COMBINATION NO.32

2 EPIDUO ADAPALENE/BENZOYL PEROXIDE X

2 EPIDUO FORTE ADAPALENE/BENZOYL PEROXIDE X

3 EPIFIX AMNIOTIC MEMBRANE HUMAN REGENERATIVE TISSUE MTRX

3 EPIFOAM HYDROCORTISONE/PRAMOXINE

1 EPINASTINE HCL EPINASTINE HCL

1 EPINEPHRINE EPINEPHRINE

2 EPIPEN EPINEPHRINE

2 EPIPEN 2‐PAK EPINEPHRINE

2 EPIPEN JR 2‐PAK EPINEPHRINE

3 EPISIL MUCOSITIS AND STOMATITIS COMB2

2 EPIVIR (10 MG/ML) SOLUTION LAMIVUDINE X

2 EPIVIR (150 MG) TABLET LAMIVUDINE X

2 EPIVIR (300 MG) TABLET LAMIVUDINE X

2 EPIVIR HBV (100 MG) TABLET LAMIVUDINE X

2 EPIVIR HBV (25 MG/5 ML) SOLUTION LAMIVUDINE X

2 EPLERENONE TABLET EPLERENONE

3 EPOGEN EPOETIN X

Excluded EPROSARTAN

2 EPZICOM ABACAVIR SULFATE/LAMIVUDINE X

3 EQUETRO CARBAMAZEPINE

3 ERAPID NEBULIZER NEBULIZER

3 ERAPID NEBULIZER HANDSET NEBULIZER ACCESSORIES

1 ERGOCALCIFEROL (VITAMIN D2) ERGOCALCIFEROL (VITAMIN D2)

1 ERGOLOID MESYLATES ERGOLOID MESYLATES

3 ERGOMAR ERGOTAMINE TARTRATE X

1 ERGOTAMINE/CAFFEINE ERGOTAMINE/CAFFEINE X

3 ERTACZO SERTACONAZOLE NITRATE

2 ERYGEL ERYTHROMYCIN BASE/ETHANOL

2 ERYPED 200, 400 ERYTHROMYCIN ETHYLSUCCINATE

2 ERY‐TAB ERYTHROMYCIN BASE

1 ERYTHROMYCIN BASE ERYTHROMYCIN BASE

1 ERYTHROMYCIN BASE (250 MG) CAPSULE DR ERYTHROMYCIN BASE

1 ERYTHROMYCIN BASE (250 MG) TABLET DR ERYTHROMYCIN BASE

1 ERYTHROMYCIN BASE (500 MG) TABLET ERYTHROMYCIN BASE

1 ERYTHROMYCIN BASE (500 MG) TABLET DR ERYTHROMYCIN BASE

1 ERYTHROMYCIN BASE/ETHANOL (2 %) (MED. SWAB) ERYTHROMYCIN BASE/ETHANOL

2 ERYTHROMYCIN BASE/ETHANOL (2 %) GEL ERYTHROMYCIN BASE/ETHANOL

1 ERYTHROMYCIN BASE/ETHANOL (2 %) SOLUTION ERYTHROMYCIN BASE/ETHANOL

1 ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE

1 ERYTHROMYCIN STEARATE ERYTHROMYCIN STEARATE

2 ERYTHROMYCIN TOPICAL GEL ERYTHROMYCIN

1 ERYTHROMYCIN TOPICAL SOLUTION ERYTHROMYCIN

2 ERYTHROMYCIN/BENZOYL GEL ERYTHROMYCIN/BENZOYL PEROXIDE

3 ESCAVITE PEDI MULTIVIT 47/IRON/FLUORIDE

3 ESCAVITE D PEDI MULTIVIT 78/IRON/FLUORIDE

3 ESCAVITE LQ PEDI MULTIVIT 86/IRON/FLUORIDE

1 ESCITALOPRAM ESCITALOPRAM

3 ESGIC (50‐325‐40) CAPSULE BUTALB/ACETAMINOPHEN/CAFFEINE

2 ESGIC (50‐325‐40) TABLET BUTALB/ACETAMINOPHEN/CAFFEINE

1 ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM X X

1 ESOMEPRAZOLE STRONTIUM ESOMEPRAZOLE STRONTIUM X X

1 ESTAZOLAM ESTAZOLAM

2 ESTRACE ESTRADIOL

1 ESTRADIOL ESTRADIOL

1 ESTRADIOL PATCH ESTRADIOL X

1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL/NORETHINDRONE ACET


Authorization

Quantity

Limit

Step

Therapy3 ESTRING ESTRADIOL X

Excluded ESTROGEL

1 ESTROGEN,ESTER/ME‐TESTOSTERONE ESTROGEN,ESTER/ME‐TESTOSTERONE

1 ESTROPIPATE ESTROPIPATE

3 ESTROSTEP FE NORETHINDRONE‐E.ESTRADIOL‐IRON X

1 ESZOPICLONE ESZOPICLONE X

1 ETHACRYNIC ACID ETHACRYNIC ACID

1 ETHAMBUTOL HCL ETHAMBUTOL HCL

1 ETHOSUXIMIDE ETHOSUXIMIDE

3 ETHYL ACETATE ETHYL ACETATE

1 ETHYL CHLORIDE ETHYL CHLORIDE

2 ETIDRONATE TABLET ETIDRONATE

2 ETODOLAC ER TABLET ETODOLAC

1 ETOPOSIDE ETOPOSIDE

3 EUCRISA CRISABOROLE X

2 EURAX CROTAMITON

3 EVAMIST ESTRADIOL

3 EVARREST FIBRINOGEN/THROMBIN(HUMAN DER)

Excluded EVEKEO AMPHETAMINE SULFATE

3 EVICEL THROMBIN(HUM PLAS)/FIBRINOG/CA

2 EVISTA RALOXIFENE HCL X

2 EVOCLIN CLINDAMYCIN PHOSPHATE

2 EVOTAZ ATAZANAVIR SULFATE/COBICISTAT X

2 EVOXAC CEVIMELINE HCL

Excluded EVZIO

3 EXALGO (8, 12, 16, 32 MG) TAB ER 24H HYDROMORPHONE HCL X X

2 EXELDERM SULCONAZOLE NITRATE

2 EXELON RIVASTIGMINE X

1 EXEMESTANE EXEMESTANE

2 EXFORGE AMLODIPINE/VALSARTAN X

2 EXFORGE HCT AMLODIPINE/VALSARTAN/HCTHIAZID X

Excluded EXONDYS 51 ETEPLIRSEN

Excluded EXTAVIA

3 EXTINA KETOCONAZOLE

3 EYE HOMEOPATHIC DRUGS

3 E‐Z SPACER INHALER, ASSIST DEVICES

1 EZETIMIBE EZETIMIBE X

2 FABIOR TAZAROTENE

3 FACTIVE GEMIFLOXACIN MESYLATE

1 FAMCICLOVIR FAMCICLOVIR

2 FAMOTIDINE ORAL SUSPENSION FAMOTIDINE

1 FAMOTIDINE TABLET FAMOTIDINE

3 FANAPT ILOPERIDONE X X

Excluded FARXIGA

1 FAYOSIM

3 FAZACLO CLOZAPINE X X

1 FELBAMATE (400 MG) TABLET FELBAMATE X X

1 FELBAMATE (600 MG) TABLET FELBAMATE X X

1 FELBAMATE (600 MG/5ML) ORAL SUSP FELBAMATE X X

3 FELBATOL (400 MG) TABLET FELBAMATE X X

3 FELBATOL (600 MG) TABLET FELBAMATE X X

3 FELBATOL (600 MG/5ML) ORAL SUSP FELBAMATE X X

2 FELDENE PIROXICAM

1 FELODIPINE FELODIPINE

3 FEM PH ACETIC ACID/OXYQUINOLINE

3 FEMALE SELF CATHETER CATHETER

2 FEMARA LETROZOLE

3 FEMCAP CERVICAL CAP

3 FEMCON FE NORETH‐ETHINYL ESTRADIOL/IRON X

2 FEMHRT NORETHINDRONE AC‐ETH ESTRADIOL

3 FEMRING ESTRADIOL ACETATE X

3 FEMTRACE


Authorization

Quantity

Limit

Step

Therapy2 FENOFIBRATE 150 MG CAPSULE (LIPOFEN) FENOFIBRATE

2 FENOFIBRATE 40 MG, 120 MG TABLET (FENOGLIDE) FENOFIBRATE

1 FENOFIBRATE 50 MG CAPSULE (LIPOFEN) FENOFIBRATE

1 FENOFIBRATE 54 MG, 160 MG TABLET (LOFIBRA) FENOFIBRATE

1 FENOFIBRATE MICRONIZED FENOFIBRATE MICRONIZED

2

FENOFIBRATE MICRONIZED 43 MG, 130 MG CAPSULE

(ANTARA) FENOFIBRATE MICRONIZED

1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE NANOCRYSTALLIZED

1 FENOFIBRIC ACID FENOFIBRIC ACID X

1 FENOFIBRIC ACID FENOFIBRIC ACID

2 FENOGLIDE FENOFIBRATE X

2 FENOPROFEN CAPSULE FENOPROFEN

2 FENORTHO FENOPROFEN CALCIUM

1

FENTANYL TRANSDREMAL PATCH 12MCG/HR, 25MCG/HR,

50MCG/HR, 75MCG/HR FENTANYL

2

FENTANYL TRANSDREMAL PATCH 37.5MCG/HR,

62.5MCG/HR, 87.5MCG/HR FENTANYL

Excluded FENTORA

3 FERIVA IRON/FOLIC ACID/C/B12/BIOTIN

3 FERIVA 21‐7 IRON/FA#1/VIT C/B12/ZN/DSS/SUC

3 FERIVA FA IRON/FA#1/C/B12/BIOT/COPPR/DSS

3 FERRALET 90 IRON CARB,GL/FA/B12/C/DOCUSATE

1 FERRIC SUBSULFATE FERRIC SUBSULFATE

1 FERROUS FUM/FOLIC ACID/BCOMP,C FERROUS FUM/FOLIC ACID/BCOMP,C

1 FERROUS FUM/VIT C/B12/STOMC FERROUS FUM/VIT C/B12/STOMC

1 FERROUS FUM/VIT C/B12‐IF/FOLIC FERROUS FUM/VIT C/B12‐IF/FOLIC

1 FERROUS FUMARATE/FOLIC ACID FERROUS FUMARATE/FOLIC ACID

2 FETZIMA LEVOMILNACIPRAN HCL X X

Excluded FEXMID

2 FEXOFENADINE‐PSE COMBO TABLET (ALLEGRA D 24 HOUR)

3 FIBRICOR FENOFIBRIC ACID

3 FILTER NEEDLE NEEDLES, FILTER

3 FILTER PAD NEBULIZER ACCESSORIES

3 FILTER, VALVE SET FOR LL & LC NEBULIZER ACCESSORIES

3 FILTERED EXTENSION SET INTRAVENOUS EXTEN.SET‐FILTER

3 FINACEA AZELAIC ACID

1 FINASTERIDE FINASTERIDE

3 FIORICET BUTALB/ACETAMINOPHEN/CAFFEINE

3 FIORICET WITH CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE X

2 FIORINAL BUTALBITAL/ASPIRIN/CAFFEINE

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

2 FLAGYL METRONIDAZOLE

2 FLAGYL ER METRONIDAZOLE

2 FLAREX FLUOROMETHOLONE ACETATE

1 FLAVOXATE HCL FLAVOXATE HCL

1 FLECAINIDE ACETATE FLECAINIDE ACETATE

Excluded FLEXEPAX

3 FLEXICHAMBER INHALER, ASSIST DEVICES

3 FLEXI‐SEAL SIGNAL FMS FECAL COLL W‐CHARCOAL/CATH/SYR

2 FLOMAX TAMSULOSIN HCL

3 FLORIVA SODIUM FLUORIDE/VITAMIN D3

3 FLORIVA PEDI MULTIVIT NO.85/FLUORIDE

3 FLORIVA PLUS PEDI MULTIVIT NO.130/FLUORIDE

Excluded FLOVENT DISKUS

Excluded FLOVENT HFA

3 FLOWTUSS GUAIFENESIN/HYDROCODONE X X

2 FLOXIN OFLOXACIN

1 FLUCONAZOLE FLUCONAZOLE

1 FLUCYTOSINE FLUCYTOSINE

1 FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE

3 FLUMADINE RIMANTADINE HCL


Authorization

Quantity

Limit

Step

TherapyExcluded FLUMIST QUAD 2016‐2017 FLU VACC QV LIVE 2016(2‐49 YRS)

1 FLUNISOLIDE FLUNISOLIDE X

1 FLUOCINOLONE ACETONIDE 0.01 % CREAM (LOW) FLUOCINOLONE ACETONIDE

2 FLUOCINOLONE ACETONIDE 0.01 % SOLUTION (LOW) FLUOCINOLONE ACETONIDE

2 FLUOCINOLONE ACETONIDE 0.01% SOLUTION (LOW) FLUOCINOLONE ACETONIDE

1 FLUOCINOLONE ACETONIDE 0.025 % CREAM (LOWER‐MID) FLUOCINOLONE ACETONIDE

1 FLUOCINOLONE ACETONIDE 0.025 % OINTMENT (MEDIUM) FLUOCINOLONE ACETONIDE

1 FLUOCINONIDE 0.05 % CREAM (HIGH) FLUOCINONIDE

1 FLUOCINONIDE 0.05 % EMOLIENT CREAM (HIGH) FLUOCINONIDE

1 FLUOCINONIDE 0.05 % GEL (HIGH) FLUOCINONIDE

2 FLUOCINONIDE 0.05 % OINTMENT (HIGH) FLUOCINONIDE

1 FLUOCINONIDE 0.05 % SOLUTION (HIGH) FLUOCINONIDE

2 FLUOCINONIDE 0.1 % CREAM (SUPER HIGH) FLUOCINONIDE

3 FLUORABON SODIUM FLUORIDE

3 FLUOR‐A‐DAY SODIUM FLUORIDE

3 FLUORESCEIN‐BENOXINATE BENOXINATE HCL/FLUORESCEIN NA

1 FLUORIDE/IRON/VITAMINS A,C,D FLUORIDE/IRON/VITAMINS A,C,D

2 FLUORITAB SODIUM FLUORIDE

1 FLUOROMETHOLONE FLUOROMETHOLONE

3 FLUOROPLEX FLUOROURACIL

1 FLUOROURACIL FLUOROURACIL

1 FLUOXAMINE TABLET FLUOXAMINE

1 FLUOXETINE CAPSULE FLUOXETINE

1 FLUOXETINE ER FLUOXETINE

2 FLUOXETINE HCL CAPSULE DR WEEKLY 90MG FLUOXETINE

1 FLUOXETINE/OLANZAPINE FLUOXETINE/OLANZAPINE X

2 FLUOXYMESTERONE TABLET FLUOXYMESTERONE

2 FLUPHENAZINE HCL TABLET FLUPHENAZINE

2 FLURA‐DROPS SODIUM FLUORIDE

2 FLURANDRENOLIDE 0.05 % CREAM (LOWER‐MID) FLURANDRENOLIDE

1 FLURAZEPAM HCL FLURAZEPAM HCL

1 FLURBIPROFEN FLURBIPROFEN

1 FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM

3 FLUROX BENOXINATE HCL/FLUORESCEIN NA

1 FLUTAMIDE FLUTAMIDE

1 FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE X

1 FLUTICASONE PROPIONATE 0.005 % OINTMENT (HIGH) FLUTICASONE PROPIONATE

1 FLUTICASONE PROPIONATE 0.05 % CREAM (LOWER‐MID) FLUTICASONE PROPIONATE

2 FLUTICASONE PROPIONATE 0.05 % LOTION (LOWER‐MID) FLUTICASONE PROPIONATE

2 FLUVASTATIN CAPSULE FLUVASTATIN X X

2 FLUVASTATIN SODIUM ER 80 MG TABLET FLUVASTATIN SODIUM

2 FLUVOXAMINE ER CAPSULE FLUVOXAMINE MALEATE

1 FLUVOXAMINE TABLET FLUVOXAMINE

2 FML FLUOROMETHOLONE

2 FML FORTE FLUOROMETHOLONE

2 FML S.O.P. FLUOROMETHOLONE

2 FOCALIN DEXMETHYLPHENIDATE HCL X

2 FOCALIN XR DEXMETHYLPHENIDATE HCL X

3 FOLET ONE PNV NO.80/IRON/MFOLATE/DSS/DHA

3 FOLGARD OS CALCIUM/MAG/D3/B12/FA/B6/BORON

2 FOLGARD RX CYANOCOBALAMIN/FOLIC AC/VIT B6

1 FOLIC ACID (1 MG) TABLET FOLIC ACID

1 FOLIC ACID (5 MG/ML) VIAL FOLIC ACID

1 FOLIC ACID/B COMPLEX C NO.17 FOLIC ACID/B COMPLEX C NO.17

1 FOLIC ACID/B CPLX/C/SELEN/ZINC FOLIC ACID/B CPLX/C/SELEN/ZINC

1 FOLIC ACID/VIT B COMPLEX AND C FOLIC ACID/VIT B COMPLEX AND C

1 FOLIC ACID/VIT BCOMP,C/CU/ZINC FOLIC ACID/VIT BCOMP,C/CU/ZINC

3 FOLTRATE CYANOCOBALAMIN/FOLIC ACID

1 FONDAPARINUX SODIUM (10MG/0.8ML) SYRINGE FONDAPARINUX SODIUM X

1 FONDAPARINUX SODIUM (2.5 MG/0.5) SYRINGE FONDAPARINUX SODIUM X


Authorization

Quantity

Limit

Step

Therapy1 FONDAPARINUX SODIUM (5MG/0.4ML) SYRINGE FONDAPARINUX SODIUM X

1 FONDAPARINUX SODIUM (7.5MG/0.6) SYRINGE FONDAPARINUX SODIUM X

3 FORADIL FORMOTEROL FUMARATE X X

3 FORANE ISOFLURANE

Excluded FORFIVO XL

1 FORMALDEHYDE FORMALDEHYDE

3 FORMA‐RAY FORMALDEHYDE

3 FORTAMET METFORMIN HCL X

3 FORTAVIT MV,IRON,MINS/DIET.SUP4/DNA/RNA

2 FORTEO TERIPARATIDE X

Excluded FORTESTA

3 FORTICAL

2 FOSAMAX ALENDRONATE SODIUM

2 FOSAMAX PLUS D ALENDRONATE SODIUM/VITAMIN D3

1 FOSINOPRIL SODIUM FOSINOPRIL SODIUM

1 FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL/HYDROCHLOROTHIAZIDE

3 FOSRENOL LANTHANUM CARBONATE

2 FRAGMIN (10000/ML) SYRINGE DALTEPARIN SODIUM,PORCINE X

2 FRAGMIN (12500/0.5) SYRINGE DALTEPARIN SODIUM,PORCINE X



2 FRAGMIN (2500/0.2ML) SYRINGE DALTEPARIN SODIUM,PORCINE X

2 FRAGMIN (25000/ML) VIAL DALTEPARIN SODIUM,PORCINE X



3 FREESTYLE NAVIGATOR BLOOD‐GLUCOSE SENSOR

3 FROVA X X

2 FROVATRIPTAN TABLET FROVATRIPTAN

2 FURADANTIN NITROFURANTOIN

1 FUROSEMIDE (10 MG/ML) SOLUTION FUROSEMIDE

1 FUROSEMIDE (40MG/5ML) SOLUTION FUROSEMIDE

3 FUSION PLUS IRON,FM,PS/FOLIC/B,C18/L.CASEI

3 FUSION SPRINKLES IRON FUM, PS/FA/VIT C/L. CASEI

2 FUZEON ENFUVIRTIDE X

3 FYCOMPA (0.5 MG/ML) ORAL SUSP PERAMPANEL X X

3 FYCOMPA (2, 4, 6, 8, 10, 12 MG) TABLET PERAMPANEL X X

1 GABAPENTIN GABAPENTIN

3 GABITRIL (2, 4, 12, 16 MG) TABLET TIAGABINE HCL X X

3 GABLOFEN BACLOFEN

1 GALANTAMINE HBR (12 MG) TABLET GALANTAMINE HBR X

1 GALANTAMINE HBR (16 MG) CAP24H PEL GALANTAMINE HBR X



1 GALANTAMINE HBR (4 MG/ML) SOLUTION GALANTAMINE HBR X



3 GALZIN ZINC ACETATE

3 GASTROCROM CROMOLYN SODIUM

1 GATIFLOXACIN GATIFLOXACIN

3 GELCLAIR POT SOR/HE‐CELLULOS/POV/HYALUR

3 GELFILM GELATIN

3 GELFOAM GELATIN SPONGE,ABSORBABLE

3 GELFOAM COMPRESSED GELATIN SPONGE,ABSORBABLE

3 GELNIQUE OXYBUTYNIN CHLORIDE X

3 GELX POVID/TAUR/ZN/PEG40 CASTOR OIL

1 GEMFIBROZIL GEMFIBROZIL

3 GENADUR CARBIT/EQUIS XT/ETHAN/CHIT/MSM

3 GENERESS FE NORETH‐ETHINYL ESTRADIOL/IRON

Excluded GENOTROPIN

1 GENTAMICIN SULFATE GENTAMICIN SULFATE

1 GENTIAN VIOLET/BRGREEN/PROFLAV GENTIAN VIOLET/BRGREEN/PROFLAV

2 GENVOYA ELVITEG/COBI/EMTRIC/TENOFO ALA X


Authorization

Quantity

Limit

Step

Therapy2 GEODON ZIPRASIDONE HCL X

3 GIALAX PEG 3350/SOD CHLOR/POTASS CIT

1 GIANVI, LORYNA, VESTURA X

3 GIAZO BALSALAZIDE DISODIUM X

2 GILENYA X

1 GLATOPA GLITIRAMER X

1 GLIMEPIRIDE TABLET GLIMEPIRIDE

1 GLIPIZIDE TABLET GLIPIZIDE

1 GLIPIZIDE/METFORMIN GLIPIZIDE/METFORMIN

3 GLUCAGEN GLUCAGON,HUMAN RECOMBINANT

2 GLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT

3 GLUCOCOM AUTOLINK DIABETIC SUPPLIES,MISCELL

2 GLUCOPHAGE METFORMIN HCL

2 GLUCOPHAGE XR METFORMIN HCL

2 GLUCOTROL GLIPIZIDE

2 GLUCOTROL XL GLIPIZIDE

2 GLUCOVANCE GLYBURIDE/METFORMIN HCL

Excluded GLUMETZA

3 GLUTATHIONE GLUTATHIONE

3 GLUTATHIONE‐L GLUTATHIONE

1 GLYBURIDE GLYBURIDE

1 GLYBURIDE,MICRONIZED GLYBURIDE,MICRONIZED

1 GLYBURIDE/METFORMIN GLYBURIDE/METFORMIN

1 GLYCINE UROLOGIC SOLUTION GLYCINE UROLOGIC SOLUTION

1 GLYCOPYRROLATE GLYCOPYRROLATE

3 GLYNASE GLYBURIDE,MICRONIZED

3 GLYSET MIGLITOL

2 GLYXAMBI EMPAGLIFLOZIN/LINAGLIPTIN X X

Excluded GOCOVRI AMANTADINE

2 GOLYTELY PEG3350/SOD SULF,BICARB,CL/KCL

Excluded GONITRO

3 GORDO‐UREA UREA

3 GRAFIX CORE HUMAN REGENERATIVE TISSUE MTRX

3 GRAFIX PRIME HUMAN REGENERATIVE TISSUE MTRX

Excluded GRALISE

2 GRANISETRON HCL TABLET GRANISETRON HCL X X

2 GRASTEK GRASS POLLEN‐TIMOTHY, STANDARD X

2 GRISEOFULVIN MICROSIZE TABLET GRISEOFULVIN MICROSIZE

2 GRISEOFULVIN ULTRAMICROSIZE TABLET GRISEOFULVIN ULTRAMICROSIZE

2 GRIS‐PEG GRISEOFULVIN ULTRAMICROSIZE

3 GUAIACOL GUAIACOL

1 GUANFACINE HCL GUANFACINE HCL

1 GUANFACINE HCL (BEHAVIORAL HEALTH ‐ OTHER) GUANFACINE HCL X

1 GUANIDINE HCL GUANIDINE HCL

3 GUARDIAN RT CHARGER DIABETIC SUPPLIES,MISCELL

3 GUARDIAN RT STARTER KIT DIABETIC SUPPLIES,MISCELL

3 GUARDIAN RT SYSTEM DIABETIC SUPPLIES,MISCELL

3 GUARDIAN TEST PLUG DIABETIC SUPPLIES,MISCELL

2 GYNAZOLE 1 BUTOCONAZOLE NITRATE

2 HALCION TRIAZOLAM

1 HALOBETASOL PROPIONATE 0.05% CREAM (SUPER HIGH) HALOBETASOL PROPIONATE

1

HALOBETASOL PROPIONATE 0.05% OINTMENT

(SUPER HIGH) HALOBETASOL PROPIONATE

3 HALOG HALCINONIDE

1 HALOPERIDOL LACTATE HALOPERIDOL LACTATE

1 HALOPERIDOL TABLET HALOPERIDOL

2 HARVONI

1 HC/MINERAL OIL/PETROLAT,WHT HC/MINERAL OIL/PETROLAT,WHT

3 HECTOROL DOXERCALCIFEROL

3 HELIDAC

3 HEMANGEOL PROPRANOLOL HCL X X

3 HEMATRON‐AF IRON/DSS/B12‐IF/FOLIC AC/MV‐MN


Authorization

Quantity

Limit

Step

Therapy2 HEMMOREX‐HC HYDROCORTISONE ACETATE

3 HEMOCYTE PLUS IRON FUM/FOLIC ACID/MV,MIN 15

3 HEMOCYTE‐F FERROUS FUMARATE/FOLIC ACID

1 HEPARIN SOD,PORCINE/0.9 % NACL HEPARIN SOD,PORCINE/0.9 % NACL

1 HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE

1 HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM,PORCINE/D5W

1 HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF

3 HERCEPTIN TRASTUZUMAB X X X

3 HICON SODIUM IODIDE‐131

3 HIPREX METHENAMINE HIPPURATE

3 HISTEX‐AC TRIPROLIDINE/PHENYLEPH/CODEINE X

3 HI‐VOLUME PUMPING CHAMBER TRANSFER SETS

1 HOMATROPINE HBR HOMATROPINE HBR

Excluded HORIZANT

3 HPR EMOLLIENT COMBINATION NO.44

3 HPR PLUS EMOLLIENT COMBINATION NO.53

2 HUMALOG INSULIN LISPRO X

2 HUMALOG MIX 50‐50 INSULIN LISPRO PROTAMIN/LISPRO X

2 HUMALOG MIX 75‐25 INSULIN LISPRO PROTAMIN/LISPRO X

Excluded HUMATROPE

2 HUMIRA ADALIMUMAB X

2 HUMULIN 70‐30 INSULIN NPH HUM/REG INSULIN HM X

2 HUMULIN N INSULIN NPH HUMAN ISOPHANE X

2 HUMULIN R INSULIN REGULAR, HUMAN X

2 HUMULIN R U‐500 INSULIN REGULAR, HUMAN X

2 HYCET HYDROCODONE/ACETAMINOPHEN X

Excluded HYCOFENIX

1 HYDRALAZINE HCL HYDRALAZINE HCL

2 HYDREA HYDROXYUREA

3 HYDRO 35 UREA

3 HYDRO 40 UREA

1 HYDROCHLOROTHIAZIDE (12.5 MG) CAPSULE HYDROCHLOROTHIAZIDE

1 HYDROCHLOROTHIAZIDE (12.5 MG) TABLET HYDROCHLOROTHIAZIDE

1 HYDROCODONE BIT/HOMATROP ME‐BR HYDROCODONE BIT/HOMATROP ME‐BR X

2 HYDROCODONE/APAP 10MG‐300MG TABLET (VICODIN) HYDROCODONE/APAP X

1 HYDROCODONE/APAP 10MG‐325MG TABLET (NORCO) HYDROCODONE/APAP X

2 HYDROCODONE/APAP 5 MG‐300MG TABLET (VICODIN) HYDROCODONE/APAP X

1 HYDROCODONE/APAP 5 MG‐325MG TABLET (NORCO) HYDROCODONE/APAP X

2 HYDROCODONE/APAP 7.5‐300 MG TABLET (VICODIN) HYDROCODONE/APAP X

1 HYDROCODONE/APAP 7.5‐325 MG TABLET (NORCO) HYDROCODONE/APAP X

2 HYDROCORTISONE ACETATE/LIDOCAINE KIT HYDROCORTISONE/LIDOCAINE

1

HYDROCORTISONE ACETATE/LIDOCAINE RECTAL

CREAM 3‐0.5% HYDROCORTISONE/LIDOCAINE

1

HYDROCORTISONE ACETATE/LIDOCAINE/ALOE VERA GEL

(2.8‐9.55%) HYDROCORTISONE/LIDOCAINE

2 HYDROCORTISONE ACETATE/LIDOCAINE/ALOE VERA KIT HYDROCORTISONE/LIDOCAINE

2 HYDROCORTISONE BUTYRATE 0.1% CREAM (LOWER‐MID) HYDROCORTISONE BUTYRATE

2

HYDROCORTISONE BUTYRATE 0.1% LIPO CREAM

(LOWER‐MID) HYDROCORTISONE BUTYRATE

2

HYDROCORTISONE BUTYRATE 0.1% OINTMENT


2

HYDROCORTISONE BUTYRATE 0.1% SOLUTION


2 HYDROCORTISONE VALERATE 0.2% CREAM (LOWER‐MID) HYDROCORTISONE VALERATE

2 HYDROCORTISONE VALERATE 0.2% OINTMENT (MEDIUM) HYDROCORTISONE VALERATE

3 HYDROFERA BLUE PVA/GENTIAN VIOLET/METHYL BLUE

1 HYDROMORPHONE HCL (0.5MG/.5ML) SYRINGE HYDROMORPHONE HCL X

1 HYDROMORPHONE HCL (1 MG/ML) AMPUL HYDROMORPHONE HCL X

1 HYDROMORPHONE HCL (1 MG/ML) LIQUID HYDROMORPHONE HCL X

1 HYDROMORPHONE HCL (1 MG/ML) SYRINGE HYDROMORPHONE HCL X

2 HYDROMORPHONE HCL (12 MG) TAB ER 24H HYDROMORPHONE HCL X X



Authorization

Quantity

Limit

Step

Therapy1 HYDROMORPHONE HCL (2 MG) TABLET HYDROMORPHONE HCL X



1 HYDROMORPHONE HCL (2 MG/ML) VIAL HYDROMORPHONE HCL X

1 HYDROMORPHONE HCL (3 MG) SUPP RECT HYDROMORPHONE HCL X


1 HYDROMORPHONE HCL (4 MG) TABLET HYDROMORPHONE HCL X



1 HYDROMORPHONE HCL (60 MG/30ML) PCA SYRINGE HYDROMORPHONE HCL X


1 HYDROMORPHONE HCL (8 MG) TABLET HYDROMORPHONE HCL X

1 HYDROMORPHONE HCL/0.9% NACL/PF HYDROMORPHONE HCL/0.9% NACL/PF X

1 HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF X

1 HYDROMORPHONE/BUPIV/0.9NACL/PF HYDROMORPHONE/BUPIV/0.9NACL/PF X

1 HYDROMORPHONE/ROPIV/SOD CHL/PF HYDROMORPHONE/ROPIV/SOD CHL/PF X

1 HYDROXOCOBALAMIN HYDROXOCOBALAMIN

1 HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE

1 HYDROXYUREA HYDROXYUREA

1 HYDROXYZINE HYDROXYZINE

3 HYGEL HYALURONATE SODIUM/HE‐CELL/PEG

3 HYLATOPIC EMOLLIENT COMBINATION NO.44

3 HYLATOPICPLUS EMOLLIENT COMBINATION NO.53

1 HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE

3 HYPER‐SAL (3.5 %) VIAL‐NEB SODIUM CHLORIDE FOR INHALATION

2 HYPER‐SAL (7 %) VIAL‐NEB SODIUM CHLORIDE FOR INHALATION

3 HYPODERMIC NEEDLE NEEDLES, DISPOSABLE

2 HYSINGLA ER HYDROCODONE BITARTRATE X

2 HYZAAR LOSARTAN/HYDROCHLOROTHIAZIDE

1 IBANDRONATE SODIUM IBANDRONATE SODIUM

3 IBUDONE HYDROCODONE/IBUPROFEN X

1 IBUPROFEN TABLET IBUPROFEN

2 ILEVRO NEPAFENAC

1 IMIPRAMINE HCL TABLET IMIPRAMINE

2 IMIPRAMINE PAMOATE CAPSULE (TOFRANIL PM) IMIPRAMINE PAMOATE

1 IMIQUIMOD IMIQUIMOD X X

2 IMITREX SUMATRIPTAN X

2 IMITREX (25, 100 MG) TABLET SUMATRIPTAN SUCCINATE X

2 IMITREX (4 MG/0.5ML) CARTRIDGE SUMATRIPTAN SUCCINATE X

2 IMITREX (4 MG/0.5ML) PEN INJCTR SUMATRIPTAN SUCCINATE X

2 IMITREX (50 MG) TABLET SUMATRIPTAN SUCCINATE X

2 IMITREX (6 MG/0.5ML) CARTRIDGE SUMATRIPTAN SUCCINATE X

2 IMITREX (6 MG/0.5ML) PEN INJCTR SUMATRIPTAN SUCCINATE X

2 IMITREX (6 MG/0.5ML) VIAL SUMATRIPTAN SUCCINATE X

3 IMPAVIDO MILTEFOSINE X

2 IMURAN AZATHIOPRINE

3 INCRUSE ELLIPTA UMECLIDINIUM BROMIDE X X

1 INDAPAMIDE INDAPAMIDE

2 INDERAL LA PROPRANOLOL HCL

3 INDERAL XL PROPRANOLOL HCL X

3 INDICLOR INDIUM‐111 CHLORIDE

2 INDOCIN INDOMETHACIN

1 INDOMETHACIN INDOMETHACIN

3 INFASURF CALFACTANT

3 INFUSION SET INTRAVENOUS ADMINISTRATION SET

3 INNOPRAN XL PROPRANOLOL HCL X

3 INNOSPIRE DELUXE NEBULIZER AND COMPRESSOR

3 INNOSPIRE ELEGANCE NEBULIZER AND COMPRESSOR

3 INNOSPIRE ESSENCE NEBULIZER AND COMPRESSOR

3 INNOSPIRE MINI NEBULIZER AND COMPRESSOR

3 INNOSPIRE REPLACEMENT FILTER NEBULIZER ACCESSORIES

3 INOVA BENZOYL PEROXIDE/VIT E MIX


Authorization

Quantity

Limit

Step

Therapy3 INOVA 4‐1 SALICYLIC AC/BENZOYL PER/VIT E

3 INOVA 8‐2 SALICYLIC AC/BENZOYL PER/VIT E

3 INSET 30 INFUSION SET INFUSION SET FOR INSULIN PUMP

3 INSET 30 TUBING SUB‐Q INFUSION PUMP ACCESSORY

3 INSET INFUSION SET INFUSION SET FOR INSULIN PUMP

3 INSPIRACHAMBER INHALER, ASSIST DEVICES

3 INSPIRATION ELITE FILTER NEBULIZER ACCESSORIES

2 INSPRA EPLERENONE

3 INSUFLON SUB‐Q ADMINISTRATION SET

3 INSYTE AUTOGUARD INTRAVENOUS CATHETER

3 INSYTE IV CATHETER INTRAVENOUS CATHETER

3 INTEGRA F IRON FUM,PS/FOLIC ACID/VITC/B3

3 INTEGRA PLUS IRON FUM,PS/FA/VIT B WITH C #9

3 INTEGRA SYRINGE SYRINGE,SAFETY WITH NEEDLE,3ML

2 INTELENCE (100 MG) TABLET ETRAVIRINE X



3 INTERLINK SYRINGE W‐CANNULA SYRINGE W‐CANNULA,DISP, 10 ML

Excluded INTERMEZZO ZOLPIDEM

Excluded INTRON‐A INTERFERON ALFA 2B

3 INTUNIV GUANFACINE HCL X

3 INVEGA PALIPERIDONE X X

2 INVIRASE (200 MG) CAPSULE SAQUINAVIR MESYLATE X

2 INVIRASE (500 MG) TABLET SAQUINAVIR MESYLATE X

2 INVOKAMET CANAGLIFLOZIN/METFORMIN HCL X X

2 INVOKAMET XR CANAGLIFLOZIN/METFORMIN HCL X X

2 INVOKANA CANAGLIFLOZIN X X

1 IODINE/POTASSIUM IODIDE IODINE/POTASSIUM IODIDE

3 IODOFLEX CADEXOMER IODINE

3 IODOSORB CADEXOMER IODINE

3 IONSYS FENTANYL HCL

3 IOPIDINE APRACLONIDINE HCL

3 I‐PORT INJECTION PORTS

3 I‐PORT ADVANCE INJECTION PORTS

1 IPRATROPIUM IPRATROPIUM

1 IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM/ALBUTEROL SULFATE

3 IPRIVASK DESIRUDIN X X

1 IRBESARTAN IRBESARTAN

1 IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN/HYDROCHLOROTHIAZIDE

Excluded IRENKA

1 IRON ASPGLY,PS/C/B12/FA/CA/SUC IRON ASPGLY,PS/C/B12/FA/CA/SUC

1 IRON ASPGLY/C/B12/FA/CA‐TH/SUC IRON ASPGLY/C/B12/FA/CA‐TH/SUC

1 IRON BG,PS/VITC/B12/FA/CALCIUM IRON BG,PS/VITC/B12/FA/CALCIUM

1 IRON CARB,GL/FA/B12/C/DOCUSATE IRON CARB,GL/FA/B12/C/DOCUSATE

1 IRON FM,PS NO.1/FOLIC/MV NO.18 IRON FM,PS NO.1/FOLIC/MV NO.18

1 IRON FUM,AG/C/B12/FOLIC/CA/SUC IRON FUM,AG/C/B12/FOLIC/CA/SUC

1 IRON FUM,PS/FA/VIT B WITH C #9 IRON FUM,PS/FA/VIT B WITH C #9

1 IRON FUM,PS/FOLIC ACID/VITC/B3 IRON FUM,PS/FOLIC ACID/VITC/B3

1 IRON FUM/DOCUSAT/FOLIC/BCOMP,C IRON FUM/DOCUSAT/FOLIC/BCOMP,C

1 IRON FUMARATE/VIT C/VIT B12/FA IRON FUMARATE/VIT C/VIT B12/FA

1 IRON POLYSAC/IRON HEME/FA/B12 IRON POLYSAC/IRON HEME/FA/B12

1 IRON PS CMPLX/VIT B12/FA IRON PS CMPLX/VIT B12/FA

1 IRON,CARB/VIT C/VIT B12/FOLIC IRON,CARB/VIT C/VIT B12/FOLIC

1 IRON/C/FOLIC ACD/MV CMB11/CALC IRON/C/FOLIC ACD/MV CMB11/CALC

1 IRON/CALCIUM/E/FOLIC ACID/MVIT IRON/CALCIUM/E/FOLIC ACID/MVIT

1 IRON/DSS/B12‐IF/FOLIC AC/MV‐MN IRON/DSS/B12‐IF/FOLIC AC/MV‐MN

1 IRON/FOLATE 9/VIT C/D3/B6/B12 IRON/FOLATE 9/VIT C/D3/B6/B12

1 IRON/FOLIC AC/VIT BCOMP,C/MIN IRON/FOLIC AC/VIT BCOMP,C/MIN

1 IRON/FOLIC ACID/B12/C/DOCUSATE IRON/FOLIC ACID/B12/C/DOCUSATE

1 IRON/FOLIC ACID/C/B6/B12/ZINC IRON/FOLIC ACID/C/B6/B12/ZINC

3 IROSPAN IRON BG,PS/FOLIC/B,C NO.12/SUC

2 ISENTRESS (100 MG) POWD PACK RALTEGRAVIR POTASSIUM X


Authorization

Quantity

Limit

Step

Therapy2 ISENTRESS (25, 100 MG) TAB CHEW RALTEGRAVIR POTASSIUM X

2 ISENTRESS (400 MG) TABLET RALTEGRAVIR POTASSIUM X

2 ISOCHRON ISOSORBIDE DINITRATE

1 ISOFLURANE ISOFLURANE

1 ISOMETHEPT/DICHLPHN/ACETAMINOP ISOMETHEPT/DICHLPHN/ACETAMINOP

1 ISOMETHEPTEN/CAF/ACETAMINOPHEN ISOMETHEPTEN/CAF/ACETAMINOPHEN

1 ISONIAZID ISONIAZID

2 ISOPTO CARPINE PILOCARPINE HCL

2 ISORDIL ISOSORBIDE DINITRATE

2 ISORDIL TITRADOSE ISOSORBIDE DINITRATE

1 ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE

1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE

1 ISOTRETINOIN ISOTRETINOIN

1 ISOXSUPRINE HCL ISOXSUPRINE HCL

1 ISRADIPINE ISRADIPINE

3 ISTALOL TIMOLOL MALEATE

1 ITRACONAZOLE TABLET ITRACONAZOLE

1 IVERMECTIN IVERMECTIN

2 JALYN DUTASTERIDE/TAMSULOSIN HCL X

2 JANUMET SITAGLIPTIN PHOS/METFORMIN HCL X

2 JANUVIA SITAGLIPTIN PHOSPHATE X

2 JARDIANCE EMPAGLIFLOZIN X X

2 JENTADUETO LINAGLIPTIN/METFORMIN HCL X

3 JETCO‐SPRAY CANNULA MEDICAL SUPPLY, MISCELLANEOUS

2 JEVANTIQUE LO NORETHINDRONE AC‐ETH ESTRADIOL

3 JUBLIA EFINACONAZOLE X

2 JUXTABID X

Excluded KADIAN MORPHINE

2 KALETRA (100MG‐25MG) TABLET LOPINAVIR/RITONAVIR X

2 KALETRA (200MG‐50MG) TABLET LOPINAVIR/RITONAVIR X

2 KALETRA (400‐100/5) SOLUTION LOPINAVIR/RITONAVIR X

3 KANGAROO 924 SAFETY SCREW PUMP SET

3 KANGAROO EPUMP SET FEEDER CONTAINER WITH PUMP SET

3 KANGAROO GRAVITY SET FEEDER CONTAINER W‐GRAVITY SET

3 KAPVAY CLONIDINE HCL X

3 KARBINAL ER CARBINOXAMINE MALEATE X X

1 KARIVA

2 KAYEXALATE SODIUM POLYSTYRENE SULFONATE

Excluded KAZANO

2 KEFLEX (250, 500 MG) CAPSULE CEPHALEXIN

3 KEFLEX (750 MG) CAPSULE CEPHALEXIN

2 KENALOG TRIAMCINOLONE ACETONIDE

3 KENDALL DISINFECTANT CAP ALCOHOL SWAB CAP

3 KENGUARD CATHETER

2 KEPPRA LEVETIRACETAM

3 KEPPRA XR LEVETIRACETAM

3 KERAFOAM UREA

3 KERAGEL GEL DRESSING

3 KERAGELT GEL DRESSING

Excluded KERALAC UREA CREAM

3 KERALYT SALICYLIC ACID

3 KERALYT SCALP SALICYLIC ACID

3 KERLIX AMD POLYHEXAM BIGUAN/GAUZE BANDAGE

3 KERYDIN TAVABOROLE X

2 KETEK TELITHROMYCIN

1 KETOCONAZOLE 2 % CREAM KETOCONAZOLE

2 KETOCONAZOLE 2 % FOAM KETOCONAZOLE

1 KETOCONAZOLE 2 % SHAMPOO KETOCONAZOLE

1 KETOCONAZOLE TABLET KETOCONAZOLE

2 KETOCONAZOLE TOPICAL FOAM KETOCONAZOLE

2 KETOPROFEN ER CAPSULE KETOPROFEN

1 KETOROLAC TROMETHAMINE OPTHALMIC DROPS KETOROLAC TROMETHAMINE


Authorization

Quantity

Limit

Step

TherapyExcluded KEVZARA SARILUMAB

Excluded KHEDEZLA DESVENLAFAXINE

3 KINERET ANAKINRA X

2 KLARON SULFACETAMIDE SODIUM

2 KLONOPIN CLONAZEPAM

2 KLOR‐CON POTASSIUM CHLORIDE

2 KLOR‐CON 8, 10 POTASSIUM CHLORIDE

2 KLOR‐CON‐EF POTASSIUM BICARBONATE/CIT AC

Excluded KOMBIGLYZE XR

3 K‐PHOS NEUTRAL SOD PHOS DI, MONO/K PHOS MONO

3 K‐PHOS NO.2 SOD PHOS,M‐B/K PHOS,MONOB

3 K‐PHOS ORIGINAL POTASSIUM PHOSPHATE,MONOBASIC

2 KRISTALOSE LACTULOSE

3 KRYSTEXXA PEGLOTICASE X X

2 K‐TAB ER POTASSIUM CHLORIDE

3 KYLEENA LEVONORGESTREL

Excluded KYMRIAH TISAGENLECLEUCEL

2 KYNAMRO X

1 LABETALOL HCL LABETALOL HCL

3 LACRISERT HYDROXYPROPYL CELLULOSE

3 LACTATED RINGERS RINGERS SOLUTION,LACTATED

1 LACTIC ACID LACTIC ACID

1 LACTULOSE LACTULOSE

2 LAMICTAL LAMOTRIGINE

2 LAMICTAL (BLUE) LAMOTRIGINE

2 LAMICTAL (GREEN) LAMOTRIGINE

2 LAMICTAL (ORANGE) LAMOTRIGINE

3 LAMICTAL ODT (100 MG) TAB RAPDIS LAMOTRIGINE X X




3 LAMICTAL ODT (BLUE) LAMOTRIGINE X

3 LAMICTAL ODT (GREEN) LAMOTRIGINE X

3 LAMICTAL ODT (ORANGE) LAMOTRIGINE X

3 LAMICTAL XR (100 MG) TAB ER 24 LAMOTRIGINE X X






3 LAMICTAL XR (BLUE) LAMOTRIGINE X

3 LAMICTAL XR (GREEN) LAMOTRIGINE X

3 LAMICTAL XR (ORANGE) LAMOTRIGINE X

3 LAMIOFLUR HOMEOPATHIC DRUGS

2 LAMISIL TERBINAFINE HCL

1 LAMIVUDINE LAMIVUDINE X

1 LAMIVUDINE (10 MG/ML) SOLUTION LAMIVUDINE X

1 LAMIVUDINE (150 MG) TABLET LAMIVUDINE X

1 LAMIVUDINE (300 MG) TABLET LAMIVUDINE X

1 LAMIVUDINE/ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE X

2 LAMOTRIGINE (100 MG) TAB ER 24 LAMOTRIGINE X X

1 LAMOTRIGINE (100 MG) TAB RAPDIS LAMOTRIGINE X X

1 LAMOTRIGINE (100 MG) TABLET LAMOTRIGINE








1 LAMOTRIGINE (25 MG) TB CHW DSP LAMOTRIGINE

1 LAMOTRIGINE (25(21)‐50) TB RD DSPK LAMOTRIGINE X


Authorization

Quantity

Limit

Step

Therapy2 LAMOTRIGINE (250 MG) TAB ER 24 LAMOTRIGINE X X

1 LAMOTRIGINE (25‐50‐100) TB RD DSPK LAMOTRIGINE X


1 LAMOTRIGINE (5 MG) TB CHW DSP LAMOTRIGINE



1 LAMOTRIGINE (50(42)‐100) TB RD DSPK LAMOTRIGINE X

2 LANOXIN (125 MCG) TABLET DIGOXIN

3 LANOXIN (187.5 MCG) TABLET DIGOXIN

2 LANOXIN (250 MCG) TABLET DIGOXIN

3 LANOXIN (62.5 MCG) TABLET DIGOXIN

3 LANOXIN PEDIATRIC DIGOXIN

1 LANSOPRAZOLE LANSOPRAZOLE

1 LANSOPRAZOLE/AMOXICILN/CLARITH LANSOPRAZOLE/AMOXICILN/CLARITH X

2 LANTUS INSULIN GLARGINE,HUM.REC.ANLOG X

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

2 LASIX FUROSEMIDE

Excluded LASTACAFT

1 LATANOPROST LATANOPROST

2 LATUDA LURASIDONE HCL X X

Excluded LAZANDA

3 LC D NEBULIZER SET NEBULIZER

3 LC PLUS NEBULIZER

3 LC SPRINT NEBULIZER NEBULIZER

3 LC STAR NEBULIZER

1 LEFLUNOMIDE LEFLUNOMIDE

3 LEMTRADA ALEMTUZUMAB X X X

3 LESCOL XL FLUVASTATIN SODIUM

1 LETROZOLE LETROZOLE

1 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM

3 LEVA SET LIDOCAINE/PRILOCAINE

2 LEVALBUTEROL INHALATION SOLUTION LEVALBUTEROL

2 LEVAQUIN LEVOFLOXACIN

3 LEVATOL PENBUTOLOL SULFATE

2 LEVBID HYOSCYAMINE SULFATE

Excluded LEVEMIR

3 LEVER LOCK CANNULA SYRINGE ACCESSORY

1 LEVETIRACETAM LEVETIRACETAM

Excluded LEVITRA

1 LEVOBUNOLOL HCL LEVOBUNOLOL HCL

1 LEVOCETIRIZINE SOLUTION LEVOCETIRIZINE X X

1 LEVOCETIRIZINE TABS LEVOCETIRIZINE

1 LEVOFLOXACIN LEVOFLOXACIN

1 LEVORA‐28

2 LEVO‐T LEVOTHYROXINE SODIUM

1 LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM

2 LEVOXYL LEVOTHYROXINE SODIUM

2 LEVSIN HYOSCYAMINE SULFATE

2 LEVSIN‐SL HYOSCYAMINE SULFATE

3 LEVULAN AMINOLEVULINIC ACID HCL

2 LEXAPRO ESCITALOPRAM OXALATE

2 LEXIVA (50 MG/ML) ORAL SUSP FOSAMPRENAVIR CALCIUM X

2 LEXIVA (700 MG) TABLET FOSAMPRENAVIR CALCIUM X

2 LIALDA MESALAMINE

2 LIBRAX CHLORDIAZEPOXIDE/CLIDINIUM BR

2 LIDOCAINE CREAM 3% LIDOCAINE

2 LIDOCAINE OINTMENT 5% LIDOCAINE

3 LIDODERM LIDOCAINE

3 LIDO‐K LIDOCAINE HCL

3 LIDOPIN LIDOCAINE HCL

3 LIDOPRIL LIDOCAINE/PRILOCAINE

3 LIDOPRIL XR LIDOCAINE/PRILOCAINE


Authorization

Quantity

Limit

Step

Therapy3 LIDO‐PRILO CAINE PACK LIDOCAINE/PRILOCAINE

3 LIDOVEX LIDOCAINE

3 LILETTA LEVONORGESTREL

1 LINDANE LOTION LINDANE

1 LINEZOLID (100 MG/5ML) SUSP RECON LINEZOLID

1 LINEZOLID (600 MG) TABLET LINEZOLID X

2 LINZESS LINACLOTIDE X

3 LIORESAL INTRATHECAL BACLOFEN

1 LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM

2 LIPITOR ATORVASTATIN CALCIUM

3 LIPOCHOL PLUS METHIONINE/INOSI/CHOL/FOLIC AC

3 LIPOFEN FENOFIBRATE X

3 LIPROZONEPAK LIDOCAINE/PRILOCAINE

3 LIPTRUZET X X

1 LISINOPRIL TABLET LISINOPRIL

1 LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE

3 LITEAIRE INHALER, ASSIST DEVICES

3 LITETOUCH INHALER,ASSIST DEVICE,ACCESORY

1 LITHIUM CARBONATE LITHIUM CARBONATE

1 LITHIUM CITRATE LITHIUM CITRATE

2 LITHOBID LITHIUM CARBONATE

3 LITHOSTAT ACETOHYDROXAMIC ACID

2 LIVALO PITAVASTATIN CALCIUM X

3 LIVIXIL PAK LIDOCAINE/PRILOCAINE

2 LO LOESTRIN FE NORETHINDRONE‐E.ESTRADIOL‐IRON X

2 LOCOID (0.1 %) CREAM, OINTMENT, SOLUTION HYDROCORTISONE BUTYRATE

3 LOCOID (0.1 %) LOTION HYDROCORTISONE BUTYRATE

2 LOCOID LIPOCREAM HYDROCORTISONE BUTYRATE/EMOLL

Excluded LOCORT

2 LODINE ETODOLAC

2 LODOSYN CARBIDOPA

2 LOESTRIN NORETHINDRONE AC‐ETH ESTRADIOL X

2 LOESTRIN FE NORETHINDRONE‐E.ESTRADIOL‐IRON X

2 LOMOTIL DIPHENOXYLATE HCL/ATROPINE

1 LOPERAMIDE HCL LOPERAMIDE HCL

2 LOPID GEMFIBROZIL

1 LOPINAVIR/RITONAVIR LOPINAVIR/RITONAVIR X

2 LOPRESSOR METOPROLOL TARTRATE

2 LOPRESSOR HCT METOPROLOL/HYDROCHLOROTHIAZIDE

2 LOPROX CICLOPIROX

3 LOPROX CICLOPIROX/SKIN CLEANSER NO.40

1 LORAZEPAM LORAZEPAM

3 LORTAB (10‐300/15) SOLUTION HYDROCODONE/ACETAMINOPHEN X

2 LORTAB (10MG‐325MG) TABLET HYDROCODONE/ACETAMINOPHEN X

2 LORTAB (5 MG‐325MG) TABLET HYDROCODONE/ACETAMINOPHEN X

2 LORTAB (7.5‐325 MG) TABLET HYDROCODONE/ACETAMINOPHEN X

3 LORZONE CHLORZOXAZONE

1 LOSARTAN TABLET LOSARTAN

1 LOSARTAN/HCTZ COMBO TABLET LOSARTAN/HCTZ

3 LOSEASONIQUE L‐NORGEST/E.ESTRADIOL‐E.ESTRAD X X

2 LOTEMAX LOTEPREDNOL ETABONATE

2 LOTENSIN BENAZEPRIL HCL

2 LOTENSIN HCT BENAZEPRIL/HYDROCHLOROTHIAZIDE

2 LOTREL AMLODIPINE BESYLATE/BENAZEPRIL

2 LOTRISONE CLOTRIMAZOLE/BETAMETHASONE DIP

3 LOTRONEX ALOSETRON HCL

1 LOVASTATIN LOVASTATIN

2 LOVAZA OMEGA‐3 ACID ETHYL ESTERS X

2 LOVENOX (100 MG/ML) SYRINGE ENOXAPARIN SODIUM X

2 LOVENOX (120MG/.8ML) SYRINGE ENOXAPARIN SODIUM X

2 LOVENOX (150 MG/ML) SYRINGE ENOXAPARIN SODIUM X

2 LOVENOX (300MG/3ML) VIAL ENOXAPARIN SODIUM X


Authorization

Quantity

Limit

Step

Therapy2 LOVENOX (30MG/0.3ML) SYRINGE ENOXAPARIN SODIUM X

2 LOVENOX (40MG/0.4ML) SYRINGE ENOXAPARIN SODIUM X



1 LOW‐OGESTREL

1 LOXAPINE SUCCINATE LOXAPINE SUCCINATE

3 LP LITE PAK LIDOCAINE/PRILOCAINE

2 LUDENT FLUORIDE SODIUM FLUORIDE

2 LUMIGAN 0.01% BIMATOPROST X

2 LUNESTA ESZOPICLONE X

3 LUPANETA PACK LEUPROLIDE/NORETHINDRONE ACET

3 LUPRON LUEPROLIDE X X X

3 LUXAMEND EMOLLIENT COMBINATION NO.10

3 LUXIQ BETAMETHASONE VALERATE

3 LUZU LULICONAZOLE X X

2 LYRICA PREGABALIN

3 LYSIPLEX PLUS LYSINE/E/FOLIC ACID/BCOMP,C/ZN

3 LYSTEDA TRANEXAMIC ACID

3 MACI AUTOL CHRONDROCY/COLLAGEN,PORC

2 MACROBID NITROFURANTOIN MONOHYD/M‐CRYST

2 MACRODANTIN NITROFURANTOIN MACROCRYSTAL

3 MACUVEX FA/VIT C/E/ZINC/COPPER/LUT/ZEA

3 MACUZIN FA/VIT C/E/ZINC/COPPER/LUT/ZEA

3 MAGELLAN TUBERCULIN SYRINGE SYRINGE,SAFETY WITH NEEDLE,1ML

3 MALARONE ATOVAQUONE/PROGUANIL HCL

2 MALATHION LOTION MALATHION

1 MANNITOL/SORBITOL SOLUTION MANNITOL/SORBITOL SOLUTION

1 MAPROTILINE HCL MAPROTILINE HCL

2 MARINOL DRONABINOL X X

3 MARPLAN ISOCARBOXAZID

3 MARVONA SUIK BUPIVACAINE/PF/NORFLU/HFC245FA

3 MASK SET WITH Y‐PIECE NEBULIZER ACCESSORIES

3 MATRISTEM EXTRACELL MATRIX,PORCINE,FENES

3 MATRISTEM MICROMATRIX EXTRACELLULAR MATRIX,PORCINE

2 MAVIK TRANDOLAPRIL

2 MAXALT RIZATRIPTAN BENZOATE X

2 MAXALT MLT RIZATRIPTAN BENZOATE X

3 MAXARON FORTE IRON GLY,FUM/C/B12/ME‐THFOLATE

3 MAXFE IRON/MFOLATE/B12/C/BIOT/ZN/DSS

3 MAXIDEX DEXAMETHASONE

3 MAXINATE PNV 3/IRON FUM,GLUC/FOLIC ACID

2 MAXITROL NEOMYCIN/POLYMYXIN B/DEXAMETHA

2 MAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZID

2 MAXZIDE‐25 MG TRIAMTERENE/HYDROCHLOROTHIAZID

3 M‐CLEAR WC CODEINE PHOSPHATE/GUAIFENESIN X

1 MECLIZINE HCL MECLIZINE HCL

2 MECLOFENAMATE SODIUM CAPSULE MECLOFENAMATE SODIUM

3 MEDOLOR PAK LIDOCAINE/PRILOCAINE

2 MEDROL METHYLPREDNISOLONE

3 MEDROLOAN II SUIK ME‐PREDNIS/NORFLURAN/HFC 245FA

3 MEDROLOAN SUIK ME‐PREDNIS/NORFLURAN/HFC 245FA

1 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE X

2 MEFENAMIC ACID CAPSULE MEFENAMIC ACID

1 MEFLOQUINE HCL MEFLOQUINE HCL

2 MEGACE MEGESTROL ACETATE

2 MEGACE ES MEGESTROL ACETATE

1 MEGESTROL SOLUTION MEGESTROL

1 MEGESTROL TABLET MEGESTROL

1 MELOXICAM TABLET MELOXICAM

1 MEMANTINE HCL (10 MG) TABLET MEMANTINE HCL X

1 MEMANTINE HCL (2 MG/ML) SOLUTION MEMANTINE HCL X

1 MEMANTINE HCL (5 MG) TABLET MEMANTINE HCL X


Authorization

Quantity

Limit

Step

Therapy1 MEMANTINE HCL (5 MG‐10 MG) TAB DS PK MEMANTINE HCL X

3 M‐END MAX D DEXBROMPHENIRAMINE/PSE/CODEINE X

3 M‐END PE BROMPHENIRAMINE/PE/CODEINE X

2 MENEST ESTROGENS, ESTERIFIED

3 MENOSTAR ESTRADIOL X

3 MENTAX BUTENAFINE HCL

1 MEPERIDINE HCL (10 MG/ML) CARTRIDGE MEPERIDINE HCL

1 MEPERIDINE HCL (100 MG) TABLET MEPERIDINE HCL X

1 MEPERIDINE HCL (50 MG) TABLET MEPERIDINE HCL X

1 MEPERIDINE HCL (50 MG/5 ML) SOLUTION MEPERIDINE HCL X

1 MEPERIDINE HCL/PF MEPERIDINE HCL/PF

2 MEPHYTON PHYTONADIONE (VIT K1)

2 MEPROBAMATE TABLET MEPROBAMATE

3 MEPRON ATOVAQUONE

1 MERCAPTOPURINE MERCAPTOPURINE

1 MESALAMINE 4 G/60 MI ENEMA MESALAMINE

2 MESALAMINE DR TABLET 800MG (ASACOL HD) MESALAMINE

2 MESALAMINE KIT W/CLEANSING WIPES MESALAMINE W/CLEANSING WIPES

3 MESNEX MESNA

2 MESTINON PYRIDOSTIGMINE BROMIDE

2 METADATE CD (10 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X






1 METAPROTERENOL SULFATE METAPROTERENOL SULFATE

2 METAXALONE TABLET METAXALONE

1 ME‐TESTOSTERONE TESTOSTERONE

1 METFORMIN METFORMIN

2 METFORMIN ER METFORMIN

1 METFORMIN IR METFORMIN

1 METH/MEBLUE/SOD PHOS/PSAL/HYOS METH/MEBLUE/SOD PHOS/PSAL/HYOS

1 METHADONE HCL (10 MG) TABLET METHADONE HCL X X

1 METHADONE HCL (10 MG/5 ML) SOLUTION METHADONE HCL X X

1 METHADONE HCL (10 MG/ML) ORAL CONC METHADONE HCL X X

1 METHADONE HCL (10 MG/ML) VIAL METHADONE HCL X X

1 METHADONE HCL (40 MG) TABLET SOL METHADONE HCL X X

1 METHADONE HCL (5 MG) TABLET METHADONE HCL X X

1 METHADONE HCL (5 MG/5 ML) SOLUTION METHADONE HCL X X

3 METHADOSE METHADONE HCL X X

2 METHAMPHETAMINE TABLET METHAMPHETAMINE

Excluded METHAVER

2 METHAZOLAMIDE TABLET METHAZOLAMIDE

1 METHEN/MBLUE/SAL/SOD PHOS/HYOS METHEN/MBLUE/SAL/SOD PHOS/HYOS

1 METHENAM/M.BLUE/SALICYL/HYOSCY METHENAM/M.BLUE/SALICYL/HYOSCY

1 METHENAM/SOD PHOS/MBLUE/HYOSCY METHENAM/SOD PHOS/MBLUE/HYOSCY

1 METHENAMINE HIPPURATE METHENAMINE HIPPURATE

1 METHENAMINE MANDELATE METHENAMINE MANDELATE

1

METHENAMINE/HYOSCYAMINE 120‐0.12 MG

COMBINATION TABLET (USTELL) METHENAMINE/HYSCYAMINE

2

METHENAMINE/HYOSCYAMINE 120‐40.8MG COMBINATION

TABLET (INDIOMIN MB) METHENAMINE/HYSCYAMINE

1

METHENAMINE/HYOSCYAMINE 81.6‐10.8 MG

COMBINATION TABLET (UTIRA‐C) METHENAMINE/HYSCYAMINE

2


TABLET (HYOPHEN) METHENAMINE/HYSCYAMINE

2


TABLET (URELLE) METHENAMINE/HYSCYAMINE

2


TABLET (UROGESIC‐BLUE) METHENAMINE/HYSCYAMINE

2 METHERGINE METHYLERGONOVINE MALEATE


Authorization

Quantity

Limit

Step

Therapy1 METHIMAZOLE METHIMAZOLE

2 METHITEST METHYLTESTOSTERONE X

1 METHOCARBAMOL TABLET METHOCARBAMOL

1 METHOTREXATE METHOTREXATE

1 METHOTREXATE SODIUM/PF METHOTREXATE SODIUM/PF

1 METHOXSALEN METHOXSALEN

1 METHSCOPOLAMINE BROMIDE METHSCOPOLAMINE BROMIDE

1 METHYCLOTHIAZIDE METHYCLOTHIAZIDE

1 METHYLDOPA METHYLDOPA

1 METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE

2 METHYLIN (10 MG) TAB CHEW METHYLPHENIDATE HCL X

2 METHYLIN (10 MG/5 ML) SOLUTION METHYLPHENIDATE HCL

2 METHYLIN (2.5, 5 MG) TAB CHEW METHYLPHENIDATE HCL X

2 METHYLIN (5 MG/5 ML) SOLUTION METHYLPHENIDATE HCL

2 METHYLPHENIDATE ER CAPSULE (METADATE CD) METHYLPHENIDATE

2 METHYLPHENIDATE ER CAPSULE (RITALIN LA) METHYLPHENIDATE

2 METHYLPHENIDATE ER TABLET (CONCERTA) METHYLPHENIDATE

2 METHYLPHENIDATE HCL TABLET ER (METADATE ER) METHYLPHENIDATE HCL

1 METHYLPHENIDATE IR TABLET METHYLPHENIDATE

1 METHYLPREDNISOLONE TABLET METHYLPREDNISOLONE

1 METHYLTESTOSTERONE METHYLTESTOSTERONE X

1 METIPRANOLOL METIPRANOLOL

2 METOCLOPRAMIDE ODT METOCLOPRAMIDE

1 METOCLOPRAMIDE TABLET METOCLOPRAMIDE HCL

1 METOLAZONE METOLAZONE

1 METOPROLOL SUCCINATE 24 HR TABLET METOPROLOL SUCCINATE

1

METOPROLOL SUCCINATE 24 HR TABLET & HCTZ TABLET &

HCTZ METOPROLOL SUCCINATE & HCTZ

2

METOPROLOL SUCCINATE/HCTZ COMBO TABLET

(DUTOPROLOL) METOPROLOL SUCCINATE/HCTZ X

1 METOPROLOL TARTRATE 100 MG TABLET METOPROLOL TARTRATE

2 METOPROLOL TARTRATE 37.5 MG, 75 MG TABLET METOPROLOL TARTRATE

1 METOPROLOL TARTRATE 50 MG TABLET METOPROLOL TARTRATE

1 METOPROLOL TARTRATE/HCTZ COMBO TABLET METOPROLOL TARTRATE/HCTZ

2 METROCREAM METRONIDAZOLE

3 METROGEL METRONIDAZOLE

2 METROGEL‐VAGINAL METRONIDAZOLE

2 METROLOTION METRONIDAZOLE

1 METRONIDAZOLE 0.75 % CREAM METRONIDAZOLE

1 METRONIDAZOLE 0.75 % GEL METRONIDAZOLE

2 METRONIDAZOLE 1 % GEL METRONIDAZOLE

1 METRONIDAZOLE TABLET/CAPSULE METRONIDAZOLE

1 MEXILETINE HCL MEXILETINE HCL

3 MIACALCIN CALCITONIN,SALMON,SYNTHETIC

1 MIBELAS 24 FE

3 MICARDIS TELMISARTAN

3 MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZID

1 MICONAZOLE NITRATE MICONAZOLE NITRATE

3 MICORT‐HC HYDROCORTISONE ACETATE

3 MICROBORE EXTENSION SET INTRAVENOUS EXTENSION SET

3 MICROCHAMBER INHALER, ASSIST DEVICES

3 MICROCRYSTALLINE CELLULOSE CELLULOSE

3 MICROCYN HYPOC ACID/SOD HYPO/NACL/WATER

3 MICROCYN HYDROGEL HOCL/NA HY/NAMGF/NA PH/NACL/WA

1 MICROGESTIN 24 FE NORETHINDRONE‐E.ESTRADIOL‐IRON

3 MICROSPACER INHALER, ASSIST DEVICES

2 MICROZIDE HYDROCHLOROTHIAZIDE

1 MIDAZOLAM HCL MIDAZOLAM HCL

1 MIDODRINE HCL MIDODRINE HCL

3 MIFEPREX MIFEPRISTONE

2 MIGERGOT ERGOTAMINE TARTRATE/CAFFEINE X

2 MIGLITOL TABLET MIGLITOL


Authorization

Quantity

Limit

Step

Therapy3 MIGRANAL DIHYDROERGOTAMINE MESYLATE X

2 MILLIPRED PREDNISOLONE

3 MILLIPRED PREDNISOLONE SOD PHOSPHATE

2 MILLIPRED DP PREDNISOLONE

2 MINASTRIN 24 FE NORETHINDRONE‐E.ESTRADIOL‐IRON

3 MINI PLUS NEBULIZER NEBULIZER

3 MINILINK REAL‐TIME TRANSMITTER BLOOD‐GLUCOSE TRANSMITTER

3 MINIMED INFUSION SET FOR INSULIN PUMP

3 MINIMED 530G SUBCUTANEOUS INSULIN PUMP

3 MINIMED 630G SUBCUTANEOUS INSULIN PUMP

3 MINIMED 630G GUARDIAN START KT BLOOD‐GLUCOSE TRANSMITTER

3 MINIMED PRO‐SET INFUSION SET FOR INSULIN PUMP

2 MINIPRESS PRAZOSIN HCL

2 MINIVELLE ESTRADIOL X

3 MINI‐WRIGHT PEAK FLOW METER PEAK FLOW METER

2 MINOCIN MINOCYCLINE HCL

1 MINOCYCLINE CAPSULE MINOCYCLINE

2 MINOCYCLINE ER TABLET MINOCYCLINE

2 MINOCYCLINE IR TABLET MINOCYCLINE

1 MINOXIDIL MINOXIDIL

3 MIO INFUSION SET INFUSION SET FOR INSULIN PUMP

2 MIRAPEX (0.125 MG) TABLET PRAMIPEXOLE DI‐HCL





3 MIRAPEX ER PRAMIPEXOLE DI‐HCL X X

3 MIRCERA X

2 MIRCETTE DESOG‐E.ESTRADIOL/E.ESTRADIOL X

1 MIRTAZAPINE/SOLTAB MIRTAZAPINE/SOLTAB

3 MIRVASO BRIMONIDINE TARTRATE

1 MISOPROSTOL MISOPROSTOL

3 MISTASSIST SPIROMETERS AND ACCESSORIES

3 MISTASSIST KIT SPIROMETER/DRUG DELIVERY ADAPT

3 MITIGARE COLCHICINE X

3 MITOSOL MITOMYCIN

2 MOBIC MELOXICAM

2 MODAFINIL MODAFINIL X

3 MODERIBA DOSEPACK RIBAVIRIN X

1 MOEXIPRIL HCL MOEXIPRIL HCL

1 MOEXIPRIL/HYDROCHLOROTHIAZIDE MOEXIPRIL/HYDROCHLOROTHIAZIDE

1 MOLINDONE HCL (10 MG) TABLET MOLINDONE HCL X

1 MOLINDONE HCL (25 MG) TABLET MOLINDONE HCL X

1 MOLINDONE HCL (5 MG) TABLET MOLINDONE HCL

1 MOMETASONE FUROATE 0.1% CREAM (MEDIUM) MOMETASONE FUROATE

1 MOMETASONE FUROATE 0.1% OINTMENT (HIGH) MOMETASONE FUROATE

1 MOMETASONE FUROATE 0.1% SOLUTION (MEDIUM) MOMETASONE FUROATE

2 MOMETASONE NASAL SPRAY MOMETASONE

3 MONAGHAN Z STAT INHALER, ASSIST DEVICES

2 MONDOXYNE NL (100 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X

2 MONDOXYNE NL (50 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X

3 MONDOXYNE NL (75 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X X

2 MONODOX (100 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X

2 MONODOX (50 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X

3 MONODOX (75 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X X

3 MONO‐FLO DRAINAGE BAG

3 MONOJECT SYRINGE W‐NEEDLE,DISPOSAB,6 ML

3 MONOJECT SYRINGE W‐NEEDLE,DISPOSABLE

3 MONOJECT 0.9% SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE

3 MONOJECT BLOOD COLLECTION NEEDLES, BLOOD COLLECTION

3 MONOJECT CONTROL SYRINGE SYRINGE, DISPOSABLE, 12 ML

3 MONOJECT LUER ADAPTER INTRAVENOUS EQUIPMENT


Authorization

Quantity

Limit

Step

Therapy3 MONOJECT LUER LOCK TB SYRINGE SYRINGE, DISPOSABLE, 1 ML

3 MONOJECT MAGELLAN SYRINGE,SAFETY WITH NEEDLE,1ML

3 MONOJECT MAGELLAN SYRINGE,SAFETY WITH NEEDLE,3ML

3 MONOJECT MEGELLAN TB SYRINGE SYRINGE, DISPOSABLE, 1 ML

3 MONOJECT PHARMACY TRAY SYRINGE, DISPOSABLE, 1 ML

3 MONOJECT PREFILL 0.9 % SODIUM CHLORIDE

3 MONOJECT PREFILL ADVANCED 0.9 % SODIUM CHLORIDE

3 MONOJECT SAFETY SYRINGE SYRINGE,SAFETY NEEDLE,12 ML

3 MONOJECT SMARTIP CANNULA SYRINGE W‐CANNULA,DISP, 3 ML

3 MONOJECT SMARTIP CANNULA SYRINGE W‐CANNULA,DISP, 6 ML

3 MONOJECT SMARTIP CANNULA SYRINGE WITH CANNULA,DISP.12ML

3 MONOJECT SYRINGE SYRINGE W‐NEEDLE,DISPOSAB,6 ML

3 MONOJECT SYRINGE SYRINGE, DISPOSABLE, 12 ML



1 MONTELUKAST CHEWABLE TABLET MONTELUKAST

1 MONTELUKAST TABLET MONTELUKAST

3 MONUROL FOSFOMYCIN TROMETHAMINE

2 MORGIDOX DOXYCYCLINE HYCLATE X

1 MORPHINE SULFATE SOLUTION MORPHINE SULFATE

Excluded MOTOFEN DIFENOXIN HCL/ATROPINE SULFATE

3 MOUTHPIECE NEBULIZER ACCESSORIES

2 MOVANTIK NALOXEGOL OXALATE X

3 MOVIPREP PEG3350/SOD SUL/NACL/ASB/C/KCL

3 MOXATAG AMOXICILLIN

2 MOXEZA MOXIFLOXACIN HCL

1 MOXIFLOXACIN HCL MOXIFLOXACIN HCL

2 MS CONTIN MORPHINE SULFATE X

3 MUGARD GLY/CARB H.POLYMR A/POT HYDROX

2 MULTAQ DRONEDARONE HCL

1 MULTIVIT,IRON,MIN 5/FOLIC ACID MULTIVIT,IRON,MIN 5/FOLIC ACID

1 MULTIVIT34/FOLIC AC/NADH/COQ10 MULTIVIT34/FOLIC AC/NADH/COQ10

1 MULTIVIT‐MINS NO.20/IRON/FOLIC MULTIVIT‐MINS NO.20/IRON/FOLIC

1 MULTIVIT‐MINS NO.7/FOLIC ACID MULTIVIT‐MINS NO.7/FOLIC ACID

2 MUPIROCIN CALCIUM CREAM MUPIROCIN CALCIUM

1 MUPIROCIN OINTMENT MUPIROCIN

3 MURI‐LUBE MINERAL OIL MINERAL OIL

3 MUSE ALPROSTADIL X

3 M‐VIT PV W‐O CAL/FERROUS FUM/FOLIC

3 MY MDI PORTABLE NEBULISER NEBULIZER AND COMPRESSOR

2 MYAMBUTOL ETHAMBUTOL HCL

3 MYCOBUTIN RIFABUTIN

1 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL

1 MYCOPHENOLATE SODIUM MYCOPHENOLATE SODIUM

3 MYDRIACYL TROPICAMIDE

3 MYELOGRAM TRAY MYELOGRAM TRAY

3 MYFORTIC MYCOPHENOLATE SODIUM

3 MYOBLOC RIMABOTULINUMTOXIN B X X X

2 MYRBETRIQ MIRABEGRON X

2 MYSOLINE PRIMIDONE

3 MYTESI CROFELEMER X X

1 NABUMETONE TABLET NABUMETONE

2 NADOLOL TABLET NADOLOL

1 NADOLOL/BENDROFLUMETHIAZIDE NADOLOL/BENDROFLUMETHIAZIDE

2 NAFTIFINE CREAM NAFTIFINE

2 NAFTIN NAFTIFINE HCL

1 NALBUPHINE HCL NALBUPHINE HCL

2 NALFON FENOPROFEN CALCIUM

1 NALOXONE HCL NALOXONE HCL

1 NALTREXONE HCL NALTREXONE HCL

2 NAMENDA (10 MG) TABLET MEMANTINE HCL X

2 NAMENDA (2 MG/ML) SOLUTION MEMANTINE HCL X


Authorization

Quantity

Limit

Step

Therapy2 NAMENDA (5 MG) TABLET MEMANTINE HCL X

2 NAMENDA (5 MG‐10 MG) TAB DS PK MEMANTINE HCL X

2 NAMENDA XR (14 MG) CAP SPR 24 MEMANTINE HCL X




2 NAMENDA XR (7‐14‐21‐28) CAP24 DSPK MEMANTINE HCL X

2 NAMZARIC (14MG‐10MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X

2 NAMZARIC (21 MG‐10MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X

2 NAMZARIC (28 MG‐10MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X

2 NAMZARIC (7 MG‐10 MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X

2 NAMZARIC (7‐10/14‐10) CAP24 DSPK MEMANTINE HCL/DONEPEZIL HCL X X

Excluded NAPRELAN

2 NAPROSYN NAPROXEN

1 NAPROXEN NAPROXEN

1 NARATRIPTAN NARATRIPTAN X

2 NARCAN NALOXONE HCL X

2 NARDIL PHENELZINE SULFATE

3 NASCOBAL CYANOCOBALAMIN (VITAMIN B‐12)

3 NASONEB NASAL NEBULIZER NEBULIZER

2 NASONEX MOMETASONE FUROATE X

3 NATACHEW PNV 55/IRON FUM,B‐G/FOLIC ACID

3 NATACYN NATAMYCIN

3 NATAZIA ESTRADIOL VALERATE/DIENOGEST X

1 NATEGLINIDE NATEGLINIDE

3 NATELLE ONE PNV WITH CA,NO.70/IRON/FA/DHA

Excluded NATESTO

3 NATROBA SPINOSAD

2 NEBUPENT PENTAMIDINE ISETHIONATE

3 NEBUSAL SODIUM CHLORIDE FOR INHALATION

3 NEEDLE NEEDLES, SAFETY

3 NEEVODHA PRENATAL64/IRON/LMFOLATE/ALGAL

2 NEFAZODONE TABLET NEFAZODONE

1 NEOMYCIN SU/BACITRA/POLYMYXIN NEOMYCIN SU/BACITRA/POLYMYXIN

1 NEOMYCIN SULF/POLYMYXIN B SULF/HC DROPS NEOMYCIN SULF/POLYMYXIN B SULF

1 NEOMYCIN SULFATE NEOMYCIN SULFATE

1 NEOMYCIN/BACIT/P‐MYX/HYDROCORT NEOMYCIN/BACIT/P‐MYX/HYDROCORT

1 NEOMYCIN/POLYMYXIN B/DEXAMETHA NEOMYCIN/POLYMYXIN B/DEXAMETHA

1 NEOMYCIN/POLYMYXIN B/HYDROCORT NEOMYCIN/POLYMYXIN B/HYDROCORT

1 NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN/POLYMYXN B/GRAMICIDIN

2 NEORAL CYCLOSPORINE, MODIFIED

3 NEOSALUS EMOLLIENT COMBINATION NO.38

3 NEOSALUS EMOLLIENT COMBINATION NO.47

3 NEOSALUS CP EMOLLIENT COMBINATION NO.47

2 NEOSPORIN NEOMYCIN/POLYMYXN B/GRAMICIDIN

3 NEOSPORIN G.U. IRRIGANT NEOMYCIN SULF/POLYMYXIN B SULF

3 NEO‐SYNALAR NEOMYCIN SULFATE/FLUOCINOLONE X

3 NEPHROCAPS B COMPLEX W‐C NO.20/FOLIC ACID

3 NEPHROCAPS QT VIT B CPLX C NO.13/FOLIC AC/D3

2 NEPTAZANE METHAZOLAMIDE

Excluded NESINA

3 NESTABS PRENATAL VIT#86/IRON BISGLY/FA

3 NESTABS ABC PNV #86/IRON POLY/FA/DHA/EPA

3 NESTABS DHA PNV #87/IRON BISGLY/FA/DHA

2 NEUPRO ROTIGOTINE X X

2 NEURONTIN GABAPENTIN

3 NEUTRASAL SALIVA SUBSTITUTE COMB NO.10

3 NEUTRASAL SALIVA SUBSTITUTE COMBO NO.5

2 NEVANAC NEPAFENAC

1 NEVIRAPINE (100 MG) TAB ER 24H NEVIRAPINE X

1 NEVIRAPINE (200 MG) TABLET NEVIRAPINE X

1 NEVIRAPINE (400 MG) TAB ER 24H NEVIRAPINE X


Authorization

Quantity

Limit

Step

Therapy1 NEVIRAPINE (50 MG/5 ML) ORAL SUSP NEVIRAPINE X

3 NEXA PLUS PNV53/IRON FUM/FA/DOCUSATE/DHA

3 NEXAVIR LIVER EXTRACT (BEEF‐PORK)

2 NEXIUM ESOMEPRAZOLE MAGNESIUM X X

3 NEXIVA INTRAVENOUS CATHETER

1 NIACIN ER NIACIN X

2 NIASPAN NIACIN X

1 NICARDIPINE HCL NICARDIPINE HCL

3 NICOMIDE LMEFOLATE/B3/COPP/ZN/SEL/CHROM

3 NICOMIDE M‐TETRAHYROFOLATE/NIACIN/CU/ZN

1 NIFEDIPINE TABLET (ADALAT CC) NIFEDIPINE

1 NIFEDIPINE TABLET (PROCARDIA XL) NIFEDIPINE

1 NIFEDIPINE TABLET (PROCARDIA) NIFEDIPINE

1 NIMODIPINE NIMODIPINE

2 NISOLDIPINE ER TABLET NISOLDIPINE

2 NITRO‐BID NITROGLYCERIN

2 NITRO‐DUR NITROGLYCERIN

1 NITROFURANTOIN MACROCRYSTAL CAPSULE NITROFURANTOIN MACROCRYSTAL

2 NITROFURANTOIN ORAL SUSPENSION NITROFURANTOIN

1 NITROGLYCERIN SUBLINGUAL TABLET NITROGLYCERIN

2 NITROGLYCERIN TRANSLINGUAL SPRAY NITROGLYCERIN

2 NITROLINGUAL NITROGLYCERIN

3 NITROMIST NITROGLYCERIN

2 NITROSTAT NITROGLYCERIN

3 NIVATOPIC PLUS EMOLLIENT COMBINATION NO.53

2 NIZORAL KETOCONAZOLE

2 NORCO HYDROCODONE/ACETAMINOPHEN X

2 NORDIFLEX X

2 NORDITROPIN FLEXPEN X

1 NORETH‐ETHINYL ESTRADIOL/IRON (0.8‐25(24)) TAB CHEW NORETH‐ETHINYL ESTRADIOL/IRON

1

NORETHINDRONE AC‐ETH ESTRADIOL (HORMONAL

DEFICIENCY) NORETHINDRONE AC‐ETH ESTRADIOL

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

Excluded NORITATE

3 NORM‐JECT SYRINGE W‐NEEDLE,DISPOSABLE

3 NORMLGEL AG SILVER CARBONATE

2 NORPACE DISOPYRAMIDE PHOSPHATE

2 NORPACE CR DISOPYRAMIDE PHOSPHATE

2 NORPRAMIN DESIPRAMINE HCL

1 NORTEL

1 NORTRIPTYLINE NORTRIPTYLINE

2 NORVASC AMLODIPINE BESYLATE

2 NORVIR (100 MG) CAPSULE, TABLET RITONAVIR X

2 NORVIR (80 MG/ML) SOLUTION RITONAVIR X

3 NOSE CLIP NEBULIZER ACCESSORIES

3 NOVACORT HYDROCORTISONE/PRAMOXINE/ALOE

Excluded NOVOLIN

Excluded NOVOLOG

Excluded NOVOLOG FLEXPEN

3 NOXAFIL POSACONAZOLE

3 NUCALA MEPOLIZUMAB X

3 NUCORT HYDROCORTISONE ACETATE/ALOE V

2 NUCYNTA TAPENTADOL HCL X

2 NUCYNTA ER TAPENTADOL HCL X

3 NUEDEXTA DEXTROMETHORPHAN HBR/QUINIDINE X

2 NULEV HYOSCYAMINE SULFATE

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

3 NUMBONEX LIDOCAINE HCL

3 NUMOISYN SORBITOL/SAL ST#1/MAL AC/CA PH

3 NUOX BENZOYL PEROXIDE/SULFUR

Excluded NUPLAZID PIMAVANSERIN


Authorization

Quantity

Limit

Step

Therapy3 NUTRESTORE GLUTAMINE

3 NUTRICAP FOLIC ACID/MV,IRON,MIN

Excluded NUTROPIN

3 NUVAIL POLY‐UREAURETHANE

2 NUVARING ETONOGESTREL/ETHINYL ESTRADIOL X

3 NUVESSA METRONIDAZOLE

Excluded NYATA

1 NYSTATIN NYSTATIN

2 NYSTATIN/TRIAMCIN CREAM, OINTMENT NYSTATIN/TRIAMCIN

3 OASIS ULTRA PORCINE ACELL SUBMUCOSA,MESHED

3 OASIS ULTRA PORCINE SUBMUCOSA, FENESTRATED

3 OB COMPLETE IRON,CARBONYL/FOLIC ACID/MV‐MN

3 OB COMPLETE GOLD PNV NO.106/IRON/FOLATE #6/DHA

3 OB COMPLETE ONE PNV 85/IRON/FOLIC/DHA/FISH OIL

3 OB COMPLETE PETITE PRENATAL56/IRON/FOLIC ACID/DHA

3 OB COMPLETE PREMIER PNV83/IRON,CARB/IRON ASP GL/FA

3 OB COMPLETE WITH DHA PNV 30/IRON CARB,AG/FOLIC/OM3

3 OBREDON GUAIFENESIN/HYDROCODONE X X

3 OBSTETRIX EC PV W‐O CAL/IRON/DOCUSATE/FOLIC

3 OBSTETRIX ONE PNV NO.80/IRON/MFOLATE/DSS/DHA

3 OBTREX DHA PNV NO.12/IRON/FOLIC/DSS/OM‐3

1 OCELLA, SYEDA, ZARAH X

Excluded OCREVUS OCRELIZUMAB

2 OCUFEN FLURBIPROFEN SODIUM

2 OCUFLOX OFLOXACIN

2 ODEFSEY EMTRICITAB/RILPIVIRI/TENOF ALA X

1 OFLOXACIN OFLOXACIN

1 OLANZAPINE OLANZAPINE X

2 OLANZAPINE ODT OLANZAPINE

1 OLANZAPINE TABLET OLANZAPINE

1 OLANZAPINE TABLET & FLUOXETINE CAPSULE OLANZAPINE & FLUOXETINE

2 OLANZAPINE/FLUOXETINE OLANZAPINE/FLUOXETINE

3 OLEPTRO X X

1 OLMESARTAN/AMLODIPIN OLMESARTAN/AMLODIPIN

1 OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/AMLODIPIN/HCTHIAZID

1 OLMESARTAN/HYDROCHLOROTHIAZIDE OLMESARTAN/HYDROCHLOROTHIAZIDE

2 OLOPATADINE NASAL SPRAY OLOPATADINE X X

2 OLUX CLOBETASOL PROPIONATE

3 OLUX‐E CLOBETASOL PROPIONATE/EMOLL

3 OLYSIO X

1 OM‐3/DHA/EPA/B12/FA/B6/PHYTOST OM‐3/DHA/EPA/B12/FA/B6/PHYTOST

3 OMECLAMOX‐PAK OMEPRAZOLE/CLARITH/AMOXICILLIN

1 OMEG3/CALCIUM/D3/FOLIC/MVIT 13 OMEG3/CALCIUM/D3/FOLIC/MVIT 13

2 OMEGA‐3 ACID ETHYL ESTERS CAPSULE OMEGA‐3 ACID ETHYL ESTERS X

1 OMEPRAZOLE CAPSULE OMEPRAZOLE

Excluded OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE/SODIUM BICARBONATE

Excluded OMNARIS

3 OMNIPOD SUBCUTANEOUS INSULIN PUMP

2 OMNIPRED PREDNISOLONE ACETATE

2 OMNITROPE X

1 ONDANSETRON HCL (24 MG) TABLET ONDANSETRON HCL


1 ONDANSETRON HCL (4 MG/5 ML) SOLUTION ONDANSETRON HCL X


1 ONDANSETRON TABLET ONDANSETRON

3 ONETOUCH PING SUBCUTANEOUS INSULIN PUMP

2 ONEXTON CLINDAMYCIN PHOS/BENZOYL PEROX X

3 ONFI (10 MG) TABLET CLOBAZAM X X

3 ONFI (2.5 MG/ML) ORAL SUSP CLOBAZAM X X

3 ONFI (20 MG) TABLET CLOBAZAM X X

Excluded ONGLYZA

3 ONMEL ITRACONAZOLE


Authorization

Quantity

Limit

Step

TherapyExcluded ONSOLIS

Excluded ONZETRA

3 OPANA OXYMORPHONE HCL X

3 OPANA ER (5, 7.5, 10, 15, 20, 30, 40 MG) TAB ER 12H OXYMORPHONE HCL X

2 OPIUM TINCTURE OPIUM TINCTURE

1 OPIUM/BELLADONNA ALKALOIDS OPIUM/BELLADONNA ALKALOIDS

3 OPTICHAMBER INHALER,ASSIST DEVICE,ACCESORY

3 OPTICHAMBER DIAMOND INHALER, ASSIST DEVICES

3 ORAFATE SUCRALFATE MALATE, POLYMERIZED

2 ORALAIR (100 IR) TAB SUBL GR POL‐ORC/SW VER/RYE/KENT/TIM X

3 ORALAIR (100‐300 IR) TAB SUBL GR POL‐ORC/SW VER/RYE/KENT/TIM X

2 ORALAIR (300 IR) TAB SUBL GR POL‐ORC/SW VER/RYE/KENT/TIM X

3 ORAMAGICRX POT SORBATE/MALTO/ALOE/MANN PS

3 ORAP PIMOZIDE

3 ORAPRED ODT PREDNISOLONE SOD PHOSPHATE

3 ORAVIG MICONAZOLE

3 ORENCIA ABATACEPT X

1 ORPHENADRINE CITRATE ORPHENADRINE CITRATE

2 ORTHO MICRONOR NORETHINDRONE X

2 ORTHO TRI‐CYCLEN NORGESTIMATE‐ETHINYL ESTRADIOL X

2 ORTHO TRI‐CYCLEN LO NORGESTIMATE‐ETHINYL ESTRADIOL X

2 ORTHO‐CYCLEN NORGESTIMATE‐ETHINYL ESTRADIOL X

2 ORTHO‐NOVUM NORETHINDRONE‐ETHINYL ESTRAD X

1 OSELTAMIVIR PHOSPHATE (30, 45, 75 MG) CAPSULE OSELTAMIVIR PHOSPHATE X

Excluded OSENI

3 OSMOPREP SOD PHOSPHATE MBAS/NA PHOS,DI‐

3 OSPHENA OSPEMIFENE X

2 OTEZLA APREMILAST X

3 OTIPRIO CIPROFLOXACIN

3 OTOVEL CIPROFLOXACIN HCL/FLUOCINOLONE

2 OTREXUP METHOTREXATE X X

3 OVACE SULFACETAMIDE SODIUM

3 OVACE PLUS (10 %) CLEANSR ER, CREAM SULFACETAMIDE SODIUM

2 OVACE PLUS (10 %) SHAMPOO SULFACETAMIDE SODIUM

3 OVACE PLUS (9.8 %) FOAM, LOTION SULFACETAMIDE SODIUM

3 OVACE PLUS WASH SULFACETAMIDE SODIUM

3 OVCON‐35 NORETHINDRONE‐ETHINYL ESTRAD X

2 OVIDE MALATHION

3 OXANDRIN OXANDROLONE X

1 OXANDROLONE OXANDROLONE X

2 OXAPROZIN TABLET OXAPROZIN

3 OXAYDO OXYCODONE HCL X

1 OXAZEPAM OXAZEPAM

1 OXCARBAZEPINE OXCARBAZEPINE

2 OXICONAZOLE NITRATE 1% CREAM OXICONAZOLE NITRATE

3 OXISTAT OXICONAZOLE NITRATE

2 OXSORALEN‐ULTRA METHOXSALEN

3 OXTELLAR XR (150, 300, 600 MG) TAB ER 24H OXCARBAZEPINE X X

1 OXYBUTYNIN ER TABLET OXYBUTYNIN

1 OXYBUTYNIN IR TABLET OXYBUTYNIN

1 OXYCODONE CAPSULE OXYCODONE X

2 OXYCODONE HCL ORAL SOLUTIION 25MG/ML OXYCODONE HCL X

2 OXYCONTIN (10, 15, 20, 30, 40, 60, 80 MG) TAB ER 12H OXYCODONE HCL X

2 OXYMORPHONE HCL (10 MG) TAB ER 12H OXYMORPHONE HCL X

1 OXYMORPHONE HCL (10 MG) TABLET OXYMORPHONE HCL

1 OXYMORPHONE HCL (15, 20, 30 MG) TAB ER 12H OXYMORPHONE HCL X

2 OXYMORPHONE HCL (5 MG) TABLET OXYMORPHONE HCL

2 OXYMORPHONE HCL (5, 40 MG) TAB ER 12H OXYMORPHONE HCL X

1 OXYMORPHONE HCL (7.5 MG) TAB ER 12H OXYMORPHONE HCL X

3 OXYTROL OXYBUTYNIN X

3 PACNEX BENZOYL PEROXIDE

3 PACNEX HP BENZOYL PEROXIDE


Authorization

Quantity

Limit

Step

Therapy3 PACNEX LP BENZOYL PEROXIDE

3 PAIN EASE NORFLURANE/PENTAFLUOROPROPANE

1 PALIPERIDONE (1.5, 9 MG) TAB ER 24 PALIPERIDONE X X

2 PALIPERIDONE (6 MG) TAB ER 24 PALIPERIDONE X X

2 PALIPERIDONE ER TABLET PALIPERIDONE

2 PAMELOR NORTRIPTYLINE HCL

Excluded PANCREAZE

2 PANDEL HYDROCORTISONE PROBUTATE

1 PANTOPRAZOLE PANTOPRAZOLE

1 PAPAV/PHENTOLAM/ALPROST/WATER PAPAV/PHENTOLAM/ALPROST/WATER X

1 PAPAVERINE HCL PAPAVERINE HCL

1 PAPAVERINE HCL/ALPROSTAD/WATER PAPAVERINE HCL/ALPROSTAD/WATER X

1 PAPAVERINE/PHENTOLAMINE/WATER PAPAVERINE/PHENTOLAMINE/WATER X

3 PARADIGM INFUSION SUB‐Q INFUSION PUMP ACCESSORY

3 PARADIGM REAL‐TIME BLOOD‐GLUC TRANSMITTER/SENSOR

3 PARADIGM SILHOUETTE SUB‐Q INFUSION PUMP ACCESSORY

2 PARAFON FORTE DSC CHLORZOXAZONE

3 PARAGARD T 380‐A COPPER

1 PAREGORIC PAREGORIC

3 PAREMYD HYDROXYAMPHETAMINE/TROPICAMIDE

3 PARI LC PLUS NEBULIZER NEBULIZER ACCESSORIES

3 PARI LC SPRINT SINUS NEBULIZER

3 PARI SINUS AEROSOL SYSTEM NEBULIZER AND COMPRESSOR

2 PARICALCITOL CAPSULE PARICALCITOL

2 PARLODEL BROMOCRIPTINE MESYLATE

2 PARNATE TRANYLCYPROMINE SULFATE

1 PAROMOMYCIN SULFATE PAROMOMYCIN SULFATE

2 PAROXETINE CR/ER PAROXETINE

1 PAROXETINE IR PAROXETINE

3 PASER AMINOSALICYLIC ACID

2 PATADAY OLOPATADINE HCL X

3 PATANASE OLOPATADINE HCL X X

2 PATANOL OLOPATADINE HCL

2 PAXIL PAROXETINE HCL

3 PAXIL CR PAROXETINE HCL

Excluded PAZEO

3 PCCA ACCUPEN‐15 TOPICAL CREAM METERED‐DOSE DEV

2 PCE ERYTHROMYCIN BASE

1 PED MULTIVIT 142/IRON/FLUORIDE PED MULTIVIT 142/IRON/FLUORIDE

1 PED MVIT A,C,D3 NO.21/FLUORIDE PED MVIT A,C,D3 NO.21/FLUORIDE

1 PEDI MULTIVIT 45/FLUORIDE/IRON PEDI MULTIVIT 45/FLUORIDE/IRON

1 PEDI MULTIVIT 75/FLUORIDE/IRON PEDI MULTIVIT 75/FLUORIDE/IRON

1 PEDI MULTIVIT 84 WITH FLUORIDE PEDI MULTIVIT 84 WITH FLUORIDE

1 PEDI MULTIVIT NO.12 W‐FLUORIDE PEDI MULTIVIT NO.12 W‐FLUORIDE







2 PEDIAPRED PREDNISOLONE SOD PHOSPHATE

3 PEDIATRIC DINOSAUR NEBULIZER NEBULIZER AND COMPRESSOR

3 PEDIATRIC DOG NEBULIZER NEBULIZER AND COMPRESSOR

3 PEDIATRIC FROG NEBULIZER NEBULIZER AND COMPRESSOR

Excluded PEDIPAK

1 PEG3350/SOD SULF,BICARB,CL/KCL PEG3350/SOD SULF,BICARB,CL/KCL

3 PEGANONE ETHOTOIN

2 PEGASYS PEGINTERFERON ALFA 2A X

3 PEG‐PREP BISAC/NACL/NAHCO3/KCL/PEG 3350

1 PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM

2 PENLAC CICLOPIROX

Excluded PENNSAID


Authorization

Quantity

Limit

Step

Therapy2 PENTASA MESALAMINE

1 PENTAZOCINE HCL/NALOXONE HCL PENTAZOCINE HCL/NALOXONE HCL

1 PENTOXIFYLLINE PENTOXIFYLLINE

2 PEPCID FAMOTIDINE

2 PERCOCET OXYCODONE HCL/ACETAMINOPHEN X

2 PERFOROMIST FORMOTEROL FUMARATE X

2 PERIDEX CHLORHEXIDINE GLUCONATE

1 PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE

1 PERMETHRIN 5% CREAM PERMETHRIN

1 PERPHENAZINE PERPHENAZINE

1 PERPHENAZINE/AMITRIPTYLINE HCL PERPHENAZINE/AMITRIPTYLINE HCL

Excluded PERTZYE

Excluded PEXEVA

3 PFLEX TRAINER SPIROMETERS AND ACCESSORIES

3 PHASEAL ADAPTER INFUSION ADAPTER, CLOSED SYSTM

3 PHASEAL ASSEMBLY FIXTURE ASSEMBLY SYS,VIAL TO TRNSF,CLS

3 PHASEAL CONNECTOR LUER CONNECTOR LUER LOCK,CLOSD SYST

3 PHASEAL INFUSION CLAMP, IV TUBING

3 PHASEAL INJECTOR LUER NEEDLE INJECTOR,LUER,CLOSD SYS

3 PHASEAL INJECTOR LUER NEEDLE INJECTR,LUER LOCK,CLOSD

3 PHASEAL PROTECTOR TRANSFER DEVICE, CLOSED SYSTEM

3 PHASEAL SECONDARY SET INTRAVENOUS PIGGYBACK SET

3 PHASEAL Y‐SITE Y‐SITE CONNECTOR, CLOSED SYSTM

1 PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL

1 PHENELZINE TABLET PHENELZINE

3 PHENERGAN (ALLERGY) PROMETHAZINE HCL

2 PHENERGAN (ANTIEMESIS/ANTIVERTIGO) PROMETHAZINE HCL

1 PHENOBARBITAL PHENOBARBITAL

2 PHENOHYTRO PHENOBARB/HYOSCY/ATROPINE/SCOP

1 PHENTOLAMINE/ALPROSTADIL/WATER PHENTOLAMINE/ALPROSTADIL/WATER X

1 PHENYLEPHRINE HCL PHENYLEPHRINE HCL

1 PHENYLEPHRINE HCL/PROMETH HCL PHENYLEPHRINE HCL/PROMETH HCL

2 PHENYTEK PHENYTOIN SODIUM EXTENDED

1 PHENYTOIN PHENYTOIN

1 PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED

3 PHLAG SPRAY PALM OIL/EUCALYPTUS OIL

3 PHOSLYRA CALCIUM ACETATE

2 PHOSPHASAL METH/MEBLUE/SOD PHOS/PSAL/HYOS

3 PHOSPHOLINE IODIDE ECHOTHIOPHATE IODIDE

3 PHOTREXA RIBOFLAVIN 5‐PHOSPHATE SODIUM

3 PHOTREXA VISCOUS RIBOFLAVIN 5‐PHOS/20 % DEXTRAN

3 PHYSIOLYTE PHYSIOLOGICAL IRRIG SOLN NO.1

3 PHYSIOSOL PHYSIOLOGICAL IRRIG SOLN NO.1

1 PHYTONADIONE (VIT K1) PHYTONADIONE (VIT K1)

2 PICATO (0.015 %) GEL INGENOL MEBUTATE X

2 PICATO (0.05 %) GEL INGENOL MEBUTATE X

3 PILLOW MASK FOR CHILDREN NEBULIZER ACCESSORIES

1 PILOCARPINE TABLET PILOCARPINE

1 PIMOZIDE PIMOZIDE

1 PINDOLOL PINDOLOL

1 PIOGLITAZONE PIOGLITAZONE

1 PIOGLITAZONE TABLET & GLIMEPIRIDE TABLET PIOGLITAZONE & METFORMIN

1 PIOGLITAZONE TABLET & METFORMIN TABLET PIOGLITAZONE & METFORMIN

2 PIOGLITAZONE/GLIMEPIRIDE COMBINATION TABLET PIOGLITAZONE/GLIMEPIRIDE X

2 PIOGLITAZONE/METFORMIN COMBINATION TABLET PIOGLITAZONE/METFORMIN X

2 PIROXICAM PIROXICAM

2 PLAN B ONE‐STEP LEVONORGESTREL

3 PLANTAGO‐HOMACCORD HOMEOPATHIC DRUGS

2 PLAQUENIL HYDROXYCHLOROQUINE SULFATE

2 PLAVIX (300 MG) TABLET CLOPIDOGREL BISULFATE X

2 PLAVIX (75 MG) TABLET CLOPIDOGREL BISULFATE

3 PLEGISOL CARDIOPLEGIC SOLUTION NO.1


Authorization

Quantity

Limit

Step

Therapy2 PLEGRIDY X

3 PLEXION SULFACETAMIDE SODIUM/SULFUR

3 PLIAGLIS LIDOCAINE/TETRACAINE

1 PODOFILOX PODOFILOX

1 PODOPHYLLUM RESIN PODOPHYLLUM RESIN

1 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350

3 POLYFIN QR SUB‐Q INFUSION PUMP ACCESSORY

1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SULF/TRIMETHOPRIM

2 POLYTRIM POLYMYXIN B SULF/TRIMETHOPRIM

3 POLY‐TUSSIN AC BROMPHENIRAMINE/PE/CODEINE X

3 POLY‐VI‐FLOR PEDI MULTIVIT NO.33/FLUORIDE

3 POLY‐VI‐FLOR PEDI MULTIVIT NO.37 W‐FLUORIDE

3 POLY‐VI‐FLOR FS PEDI MULTIVIT NO.90 W‐FLUORIDE

3 POLY‐VI‐FLOR WITH IRON PEDI MULTIVIT 33/FLUORIDE/IRON

3 POLY‐VI‐FLOR WITH IRON PEDI MULTIVIT 37/FLUORIDE/IRON

3 PONSTEL MEFENAMIC ACID

3 PONTOCAINE TETRACAINE HCL

3 POPULUS COMPOSITUM HOMEOPATHIC DRUGS

3 PORTABLE NEBULIZER SYSTEM NEBULIZER AND COMPRESSOR

1 POT CHLORIDE/POT BICARB/CIT AC POT CHLORIDE/POT BICARB/CIT AC

3 POTABA POTASSIUM AMINOBENZOATE

1 POTASSIUM BICARBONATE/CIT AC POTASSIUM BICARBONATE/CIT AC

1 POTASSIUM CHLORIDE POTASSIUM CHLORIDE

1 POTASSIUM CITRATE POTASSIUM CITRATE

1 POTASSIUM HYDROXIDE POTASSIUM HYDROXIDE

1 POTASSIUM IODIDE POTASSIUM IODIDE

1 POTASSIUM IODIDE/IODINE POTASSIUM IODIDE/IODINE

2 POTIGA (50, 200, 300, 400 MG) TABLET EZOGABINE X X

3 PRADAXA DABIGATRAN ETEXILATE MESYLATE X X

3 PRALIDOXIME CHLORIDE PRALIDOXIME CHLORIDE

2 PRAMCORT HYDROCORTISONE/PRAMOXINE

1 PRAMIPEXOLE DI‐HCL (0.125 MG) TABLET PRAMIPEXOLE DI‐HCL


1 PRAMIPEXOLE DI‐HCL (0.375 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X







1 PRAMIPEXOLE DI‐HCL (3 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X



2 PRAMOSONE HYDROCORTISONE/PRAMOXINE

3 PRAMOSONE E HYDROCORTISONE/PRAMOXINE/EMOLL

2 PRANDIN REPAGLINIDE

2 PRAVACHOL PRAVASTATIN SODIUM

1 PRAVASTATIN TABLET PRAVASTATIN SODIUM

1 PRAZOSIN HCL PRAZOSIN HCL

3 PRE‐ATTACHED LTA KIT LIDOCAINE HCL

2 PRECOSE ACARBOSE

2 PRED FORTE PREDNISOLONE ACETATE

2 PRED MILD PREDNISOLONE ACETATE

3 PRED‐G GENTAMICIN SULF/PREDNISOLONE

1 PREDNICARBATE PREDNICARBATE

2

PREDNISOLONE SODIUM PHOSPHATE ODT TABLET

(ORAPRED ODT) PREDNISOLONE SOD PHOSPHATE

1 PREDNISOLONE SODIUM PHOSPHATE SOLUTION (ORAPRED) PREDNISOLONE SOD PHOSPHATE

1 PREDNISONE SOLUTION (PRELONE) PREDNISONE

1 PREDNISONE TABLET PREDNISONE

3 PREFERA OB PNV 21/IRON PS,HEME PPEP/FOLIC


Authorization

Quantity

Limit

Step

Therapy3 PREFERA‐OB ONE PNV 19/IRON PS,HEME/FOLIC/DHA

3 PREFERA‐OB PLUS DHA PNV NO.88/IRON PS,HEME/FA/DHA

3 PREFEST ESTRADIOL/NORGESTIMATE

2 PREMARIN ESTROGENS, CONJUGATED

2 PREMPHASE ESTROGEN,CON/M‐PROGEST ACET

2 PREMPRO ESTROGEN,CON/M‐PROGEST ACET

1 PRENAT VIT 17/IRON/FOLIC/OM3,6 PRENAT VIT 17/IRON/FOLIC/OM3,6

1 PRENAT VIT COMB.10/IRON/FA/DHA PRENAT VIT COMB.10/IRON/FA/DHA

3 PRENATA PRENATAL VIT37/IRON/FOLIC ACID

1 PRENATAL #108/IRON,CARBONYL/FA PRENATAL #108/IRON,CARBONYL/FA

1 PRENATAL #57/IRON/FA/DSS/DHA PRENATAL #57/IRON/FA/DSS/DHA

1 PRENATAL 105/IRON/FOLIC AC/DHA PRENATAL 105/IRON/FOLIC AC/DHA

1 PRENATAL 68/IRON/FOLIC NO1/DHA PRENATAL 68/IRON/FOLIC NO1/DHA

1 PRENATAL COMB NO.42/FOLIC ACID PRENATAL COMB NO.42/FOLIC ACID

1 PRENATAL NO.13/IRON PS/FA CB#1 PRENATAL NO.13/IRON PS/FA CB#1

1 PRENATAL NO.52/IRON/FA/DHA PRENATAL NO.52/IRON/FA/DHA

1 PRENATAL NO.75/IRON/FOLATE #1 PRENATAL NO.75/IRON/FOLATE #1

3 PRENATAL PLUS‐DHA PRENATAL72/IRON FUM/FA/OM3/DHA

1 PRENATAL VIT #76/IRON,CARB/FA PRENATAL VIT #76/IRON,CARB/FA

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



1 PRENATAL VIT 55/IRON/FOLIC/OM3 PRENATAL VIT 55/IRON/FOLIC/OM3

1 PRENATAL VIT 7‐IRON‐FOLIC‐DHA PRENATAL VIT 7‐IRON‐FOLIC‐DHA

1 PRENATAL VIT NO.109/IRON/FA PRENATAL VIT NO.109/IRON/FA




1 PRENATAL VIT#4/IRON FUM,PS/FA PRENATAL VIT#4/IRON FUM,PS/FA

1 PRENATAL VIT#86/IRON BISGLY/FA PRENATAL VIT#86/IRON BISGLY/FA

1 PRENATAL VIT/IRON BISGLYCIN/FA PRENATAL VIT/IRON BISGLYCIN/FA

1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL VIT/IRON FUMARATE/FA

1 PRENATAL VIT100/IRON/FOLIC/OM3 PRENATAL VIT100/IRON/FOLIC/OM3

1 PRENATAL VIT27,CALCIUM/IRON/FA PRENATAL VIT27,CALCIUM/IRON/FA

1 PRENATAL VITS#4/IRON FUM/FA PRENATAL VITS#4/IRON FUM/FA

1 PRENATAL,CALC NO.65/IRON/FOLIC PRENATAL,CALC NO.65/IRON/FOLIC

1 PRENATAL,CALC.40/IRON/FOLATE 1 PRENATAL,CALC.40/IRON/FOLATE 1

1 PRENATAL64/IRON/LMFOLATE/ALGAL PRENATAL64/IRON/LMFOLATE/ALGAL

1 PRENATAL71/IRON/FOLIC ACID/DHA PRENATAL71/IRON/FOLIC ACID/DHA

3 PRENATE AM PRENATAL VIT NO.114/FA/GINGER

3 PRENATE CHEWABLE PRENATAL VIT NO.112/FOLIC ACID

3 PRENATE DHA PNV #38/IRON FUM/FOLATE/DHA

3 PRENATE ELITE PRENATAL 114/IRON ASP GLY/FA 1

3 PRENATE ENHANCE PRENATAL VIT #68/IRON/FA#6/DHA

3 PRENATE ESSENTIAL PRENATAL NO35/IRON/FOLATE6/DHA

3 PRENATE MINI PRENATAL VIT NO.87/IRON/FA/DHA

3 PRENATE PIXIE PRENATAL VIT#85/IRON/FA#1/DHA

3 PRENATE RESTORE PRENATAL VIT #69/IRON/FA#6/DHA

3 PRENATE STAR PRENATAL NO.77/IRON ASP GLY/FA

3 PREPIDIL DINOPROSTONE

2 PREPOPIK SOD PICOSULF/MAG OX/CITRIC AC

3 PREQUE 10 PRENATAL 18/IRON/FOLIC/DSS/DHA

3 PRESERA EMOLLIENT COMBINATION NO.80

Excluded PRESTALIA

2 PREVACID (15, 30 MG) CAPSULE DR LANSOPRAZOLE

2 PREVACID (15, 30 MG) TAB RAP DR LANSOPRAZOLE X

3 PREVIDENT SODIUM FLUORIDE

3 PREVIDENT 5000 SODIUM FLUORIDE

3 PREVIDENT 5000 ENAMEL PROTECT SODIUM FLUORIDE/POTASSIUM NIT

3 PREVIDENT 5000 PLUS SODIUM FLUORIDE

3 PREVIDENT 5000 SENSITIVE SODIUM FLUORIDE/POTASSIUM NIT

2 PREVPAC LANSOPRAZOLE/AMOXICILN/CLARITH X


Authorization

Quantity

Limit

Step

Therapy2 PREZCOBIX DARUNAVIR/COBICISTAT X

2 PREZISTA (100 MG/ML) ORAL SUSP DARUNAVIR ETHANOLATE X

2 PREZISTA (75, 150, 600, 800 MG) TABLET DARUNAVIR ETHANOLATE X

3 PRIALT ZICONOTIDE ACETATE

3 PRIFTIN RIFAPENTINE

3 PRILOLID LIDOCAINE/PRILOCAINE

3 PRILOSEC OMEPRAZOLE MAGNESIUM

3 PRIMACARE PRENATAL VIT#118/IRON/FA#6/DHA

2 PRIMAQUINE PRIMAQUINE PHOSPHATE

3 PRIMEAIRE INHALER, ASSIST DEVICES

1 PRIMIDONE PRIMIDONE

3 PRIMLEV OXYCODONE HCL/ACETAMINOPHEN X

2 PRIMSOL TRIMETHOPRIM

2 PRINIVIL LISINOPRIL

2 PRISTIQ DESVENLAFAXINE SUCCINATE X X

2 PROAIR HFA ALBUTEROL SULFATE

2 PROAIR RESPICLICK ALBUTEROL SULFATE

1 PROBENECID PROBENECID

1 PROBENECID/COLCHICINE PROBENECID/COLCHICINE

3 PROBUPHINE BUPRENORPHINE HCL

2 PROCARDIA NIFEDIPINE

2 PROCARDIA XL NIFEDIPINE

3 PROCENTRA DEXTROAMPHETAMINE SULFATE X

3 PRO‐CEPTION FERTILITY PAK MEDICAL SUPPLY, MISCELLANEOUS

3 PROCHAMBER INHALER, ASSIST DEVICES

1 PROCHLORPERAZINE PROCHLORPERAZINE

1 PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE

3 PROCORT HYDROCORTISONE/PRAMOXINE

2 PROCRIT EPOETIN X

2 PROCTOCORT HYDROCORTISONE

2 PROCTOFOAM‐HC HYDROCORTISONE/PRAMOXINE

3 PRODIGY MINI‐MIST NEBULIZER

3 PROFERRIN‐FORTE IRON HEME POLYPEPTIDE/FOLIC AC

1 PROGESTERONE PROGESTERONE

1 PROGESTERONE, MICRONIZED PROGESTERONE, MICRONIZED

3 PROGLYCEM DIAZOXIDE

2 PROGRAF TACROLIMUS

3 PROLENSA BROMFENAC SODIUM

3 PROLIA DENOSUMAB X X X

1 PROMETHAZINE HCL PROMETHAZINE HCL

1 PROMETHAZINE HCL/CODEINE PROMETHAZINE HCL/CODEINE X

1 PROMETHAZINE/DEXTROMETHORPHAN PROMETHAZINE/DEXTROMETHORPHAN

1 PROMETHAZINE/PHENYLEPH/CODEINE PROMETHAZINE/PHENYLEPH/CODEINE X

2 PROMETRIUM PROGESTERONE, MICRONIZED

3 PROMISEB EMOLLIENT COMBINATION NO.43

3 PROMISEB COMPLETE EMOLLIENT #43/SKIN CLEANSER#27

3 PRONEB ULTRA II NEBULIZER AND COMPRESSOR

1 PROPAFENONE HCL PROPAFENONE HCL

1 PROPANTHELINE BROMIDE PROPANTHELINE BROMIDE

1 PROPARACAINE HCL PROPARACAINE HCL

1 PROPARACAINE/FLUORESCEIN SOD PROPARACAINE/FLUORESCEIN SOD

1 PROPRANOLOL HCL PROPRANOLOL HCL

1 PROPRANOLOL LA PROPRANOLOL

1 PROPRANOLOL/HCTZ COMBO TABLET PROPRANOLOL/HCTZ

3 PROPYLENE GLYCOL PROPYLENE GLYCOL

1 PROPYLTHIOURACIL PROPYLTHIOURACIL

3 PRO‐RED AC DEXCHLORPHEN/PHENYLEPH/CODEINE X

2 PROSCAR FINASTERIDE

3 PROSTIN E2 VAGINAL SUPPOSITORY DINOPROSTONE

1 PROTECT CMB2/CERAMIDE 1,3,6‐11 PROTECT CMB2/CERAMIDE 1,3,6‐11

3 PROTECT IRON MV‐MINS NO.24/IRON/FOLIC ACID

3 PROTHELIAL SUCRALFATE MALATE, POLYMERIZED


Authorization

Quantity

Limit

Step

Therapy3 PROTONIX (40 MG) GRANPKT DR PANTOPRAZOLE SODIUM X

2 PROTONIX (40 MG) TABLET DR PANTOPRAZOLE SODIUM

2 PROTONIX SUSP PANTOPRAZOLE SODIUM

2 PROTOPIC TACROLIMUS

2 PROTRIPTYLINE TABLET PROTRIPTYLINE

3 PROVENT NASAL EXHALATION RESISTANC.DEV

Excluded PROVENTIL HFA

2 PROVERA MEDROXYPROGESTERONE ACETATE

3 PROVIDA DHA PRENATAL#90/IRON FUM,PS/FA/DHA

3 PROVIDA OB PRENATAL VIT#65/IRON FUM,PS/FA

2 PROVIGIL MODAFINIL X

2 PROZAC FLUOXETINE HCL

2 PROZAC WEEKLY FLUOXETINE HCL

3 PRUDOXIN DOXEPIN HCL

1 PSEUDOEPHED/CHLOR‐MAL/BELL ALK PSEUDOEPHED/CHLOR‐MAL/BELL ALK

1 PSEUDOEPHED/COD/CHLORPHENIR PSEUDOEPHED/COD/CHLORPHENIR

1 PSEUDOEPHED/CODEINE/GUAIFEN PSEUDOEPHED/CODEINE/GUAIFEN X

2 PSORCON DIFLORASONE DIACETATE

3 PSORINOHEEL HOMEOPATHIC DRUGS

2 PULMICORT FLEXHALER BUDESONIDE X

2 PULMICORT RESPULES BUDESONIDE X

3 PULMO‐AIDE COMPRESSOR, FOR NEBULIZER

2 PULMOSAL SODIUM CHLORIDE FOR INHALATION

3 PURALOR CI FA7/PC,PE DHA/NAC/PAP/IF/MV46

3 PUREVIT DUALFE PLUS IRON FM,PS NO.1/FOLIC/MV NO.18

1 PV W‐O CAL/IRON PS CPLX/FOLIC PV W‐O CAL/IRON PS CPLX/FOLIC

3 PYLERA BISMUTH/METRONID/TETRACYCLINE

1 PYRAZINAMIDE PYRAZINAMIDE

2 PYRIDIUM PHENAZOPYRIDINE HCL

1 PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE

1 PYRIDOXINE HCL (VITAMIN B6) PYRIDOXINE HCL (VITAMIN B6)

3 PYROGALLIC ACID PYROGALLOL

3 QBRELIS LISINOPRIL X X

3 Q‐CARE RX DENTL SUCTION DEV/CHLORHX/SWB1

2 QNASL BECLOMETHASONE DIPROPIONATE X X

2 QNASL CHILDREN BECLOMETHASONE DIPROPIONATE X X

Excluded QSYMIA

3 QUAKE MUCUS CLEARING DEVICE

2 QUALAQUIN QUININE SULFATE

3 QUARTETTE L‐NORGEST/E.ESTRADIOL‐E.ESTRAD

1 QUAZEPAM QUAZEPAM

3 QUDEXY XR (25, 50, 100, 150, 200 MG) CAP SPR 24 TOPIRAMATE X X

2 QUESTRAN CHOLESTYRAMINE (WITH SUGAR)

2 QUESTRAN LIGHT CHOLESTYRAMINE/ASPARTAME

1 QUETIAPINE IR/XR QUETIAPINE X

3 QUICK RELEASE SOFT TEFLON INTRAVENOUS ADMINISTRATION SET

3 QUICK‐SET PARADIGM INFUSION SET FOR INSULIN PUMP

3 QUILLICHEW ER (20 MG) TAB CBP24H METHYLPHENIDATE HCL X X



2 QUILLIVANT XR (5 MG/ML) SU ER RC24 METHYLPHENIDATE HCL X X

1 QUINAPRIL QUINAPRIL

1 QUINAPRIL/HYDROCHLOROTHIAZIDE QUINAPRIL/HYDROCHLOROTHIAZIDE

1 QUINIDINE GLUCONATE QUINIDINE GLUCONATE

1 QUINIDINE SULFATE QUINIDINE SULFATE

1 QUININE SULFATE QUININE SULFATE

3 QUTENZA CAPSAICIN/SKIN CLEANSER X

2 QVAR BECLOMETHASONE DIPROPIONATE X

1 RABEPRAZOLE SODIUM RABEPRAZOLE X

3 RADIAGEL EMOLLIENT BASE

3 RADIAPLEXRX HYALURONATE/ALLANTOIN/ALOE EXT

Excluded RADICAVA EDARAVONE


Authorization

Quantity

Limit

Step

Therapy3 RADIGEL ACEMANNAN/ALLANTOIN

3 RADIOGARDASE PRUSSIAN BLUE (INSOLUBLE)

2 RAGWITEK WEED POLLEN‐SHORT RAGWEED X

1 RALOXIFENE HCL RALOXIFENE HCL X

1 RAMIPRIL TABLET RAMIPRIL

2 RANEXA (500, 1000 MG) TAB ER 12H RANOLAZINE X

1 RANITIDINE CAPSULE/TABLET RANITIDINE

1 RANITIDINE SYRUP RANITIDINE HCL

3 RAPAFLO SILODOSIN X

2 RAPAMUNE SIROLIMUS

3 RAPLIXA FIBRINOGEN/THROMBIN(HUMAN DER)

3 RAPLIXA DELIVERY KIT GAS PRESS.HEMOSTATIC SPRAY DEV

3 RAPPORT VACUUM THERAPY VACUUM ERECTION DEVICE SYSTEM

1 RASAGILINE MESYLATE RASAGILINE MESYLATE X

3 RASUVO METHOTREXATE X X X

3 RATE FLOW REGULATOR IV SET INTRAVENOUS ADMINISTRATION SET

2 RAYALDEE CALCIFEDIOL X

Excluded RAYOS

2 RAZADYNE GALANTAMINE HBR X

2 RAZADYNE ER GALANTAMINE HBR X

3 REA LO 39, 40 UREA

2 REBETOL SOLUTION RIBAVIRIN

2 REBIF X

2 REBIF REBIDOSE X

3 RECEDO POLYDIMETHYLSILOXANES/SILICON

3 RECLAST ZOLEDRONIC ACID X X X

3 RECONSTITUBE MEDICAL SUPPLY, MISCELLANEOUS

3 RECOTHROM THROMBIN (RECOMBINANT)

3 RECTIV NITROGLYCERIN

3 REGENECARE LIDOCAINE HCL/COLLAGEN

2 REGLAN METOCLOPRAMIDE HCL

2 REGRANEX BECAPLERMIN

3 RELADOR PAK LIDOCAINE/PRILOCAINE

3 RELADOR PAK PLUS LIDOCAINE/PRILOCAINE

3 RELAGARD ACETIC ACID/OXYQUINOLINE

3 RELENZA ZANAMIVIR X

3 RELISTOR METHYLNALTREXONE BROMIDE X X

3 RELIZORB ENTERAL PUMP ACCESS.HYDROLYSIS

3 RELPAX ELETRIPTAN HBR X X

2 REMERON MIRTAZAPINE

3 REMICADE INFLIXIMAB X

3 RENACIDIN CITRIC AC/GLUCONOLACT/MAG CARB

2 RENAGEL SEVELAMER HCL

3 RENEEL HOMEOPATHIC DRUGS

2 RENVELA SEVELAMER CARBONATE

1 REPAGLINIDE REPAGLINIDE

1 REPAGLINIDE/METFORMIN HCL REPAGLINIDE/METFORMIN HCL

3 REPLICARE HYDROCOLLOID DRESSING

3 REPLICARE THIN HYDROCOLLOID DRESSING

3 REPLICARE ULTRA HYDROCOLLOID DRESSING

3 REPLICARE ULTRA SACRUM HYDROCOLLOID DRESSING

3 REQ49+ MV‐MIN 16/FOLIC ACID/LUT/LYCOP

2 REQUIP ROPINIROLE HCL

2 REQUIP XL ROPINIROLE HCL X X

2 RESCRIPTOR DELAVIRDINE MESYLATE

3 RESECTISOL MANNITOL

1 RESERPINE RESERPINE

2 RESTASIS CYCLOSPORINE X

2 RESTASIS MULTIDOSE CYCLOSPORINE X

3 RESTIZAN EMOLLIENT COMBINATION NO.60

3 RESTORA RX LACTOBACILLUS CASEI/FOLIC ACID

3 RESTORA SPRINKLES LACTOBACILLUS CASEI/FOLIC ACID


Authorization

Quantity

Limit

Step

Therapy3 RESTORE SILVER SULFATE/FOAM BANDAGE

3 RESTORE CALCIUM ALGINATE SILVER/CALCIUM ALGINATE

3 RESTORE CONTACT LAYER SILVER SILVER SULFATE/NON‐ADH BANDAGE

2 RESTORIL TEMAZEPAM

3 RETIN‐A TRETINOIN

3 RETIN‐A MICRO TRETINOIN MICROSPHERES

3 RETIN‐A MICRO PUMP (0.04 %) GEL W/PUMP TRETINOIN MICROSPHERES

3 RETIN‐A MICRO PUMP (0.08 %) GEL W/PUMP TRETINOIN MICROSPHERES X

3 RETIN‐A MICRO PUMP (0.1 %) GEL W/PUMP TRETINOIN MICROSPHERES

2 RETROVIR (10 MG/ML) SYRUP ZIDOVUDINE X

2 RETROVIR (100 MG) CAPSULE ZIDOVUDINE X

3 REUSABLE NEBULIZER KIT NEBULIZER ACCESSORIES

3 REVEL PROGRAMMABLE PUMP SUBCUTANEOUS INSULIN PUMP

2 REVIA NALTREXONE HCL

2 REXULTI BREXPIPRAZOLE X X

2 REYATAZ (150, 200, 300 MG) CAPSULE ATAZANAVIR SULFATE X

2 REYATAZ (50 MG) POWD PACK ATAZANAVIR SULFATE X

3 REZIRA PSEUDOEPHED/HYDROCODONE X

3 RHOFADE OXYMETAZOLINE HCL

3 RIBAPAK X

1 RIBASPHERE 200MG

3 RIBASPHERE 400MG, 600MG X

1 RIBAVIRIN 200MG RIBAVIRIN

1 RIFABUTIN RIFABUTIN

2 RIFADIN RIFAMPIN

2 RIFAMATE RIFAMPIN/ISONIAZID

1 RIFAMPIN RIFAMPIN

3 RIFATER RIFAMP/ISONIAZID/PYRAZINAMIDE

1 RIMANTADINE HCL RIMANTADINE HCL

3 RIMSO‐50 DIMETHYL SULFOXIDE

1 RINGERS SOLUTION RINGERS SOLUTION

2 RIOMET METFORMIN HCL

2 RISEDRONATE TABLET RISEDRONATE

2 RISPERDAL (0.25 MG) TABLET RISPERIDONE X

2 RISPERDAL (0.5 MG) TABLET RISPERIDONE X

2 RISPERDAL (1 MG) TABLET RISPERIDONE X

2 RISPERDAL (1 MG/ML) SOLUTION RISPERIDONE X

2 RISPERDAL (2, 3, 4 MG) TABLET RISPERIDONE X

2 RISPERDAL M‐TAB RISPERIDONE X

2 RISPERIDONE ODT RISPERIDONE

1 RISPERIDONE TABLET RISPERIDONE

2 RITALIN METHYLPHENIDATE HCL X

2 RITALIN LA (10, 20, 30, 40 MG) (CPBP 50‐50) METHYLPHENIDATE HCL X

3 RITEFLO INHALER, ASSIST DEVICES

3 RITUXAN RITUXIMAB X

1 RIVASTIGMINE RIVASTIGMINE X

1 RIVASTIGMINE TARTRATE RIVASTIGMINE TARTRATE

1 RIVELSA

1 RIZATRIPTAN RIZATRIPTAN

1 RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE X

2 ROBAXIN METHOCARBAMOL

2 ROBAXIN‐750 METHOCARBAMOL

3 ROBINSON CLEAR VINYL CATHETER CATHETER

3 ROBINUL GLYCOPYRROLATE

3 ROBINUL FORTE GLYCOPYRROLATE

2 ROCALTROL CALCITRIOL

1 ROPINIROLE HCL (0.25 MG) TABLET ROPINIROLE HCL

1 ROPINIROLE HCL (0.5 MG) TABLET ROPINIROLE HCL

1 ROPINIROLE HCL (1 MG) TABLET ROPINIROLE HCL

1 ROPINIROLE HCL (12 MG) TAB ER 24H ROPINIROLE HCL X X




Authorization

Quantity

Limit

Step

Therapy1 ROPINIROLE HCL (3 MG) TABLET ROPINIROLE HCL






1 ROPIVACAINE HCL IN 0.9% NACL/PF ROPIVACAINE HCL IN 0.9%NACL/PF

3 ROSADAN METRONIDAZOLE

3 ROSANIL SULFACETAMIDE SODIUM/SULFUR

3 ROSULA SULFACETAMIDE SODIUM/SULFUR

1 ROSUVASTATIN ROSUVASTATIN

3 ROTARIX ROTAVIRUS VAC,LIVE ATT, 89‐12

3 ROTATEQ ROTAVIRUS VACCINE,LIVE ORAL PV

2 ROWASA MESALAMINE W/CLEANSING WIPES

2 ROWEEPRA LEVETIRACETAM

2 ROXICODONE OXYCODONE HCL X

Excluded ROZEREM

3 RUBBER MOUTHPIECE NEBULIZER ACCESSORIES

3 RYTARY CARBIDOPA/LEVODOPA X X

2 RYTHMOL SR PROPAFENONE HCL

3 RYVENT CARBINOXAMINE MALEATE

3 SABAL‐HOMACCORD HOMEOPATHIC DRUGS

3 SACCHARIN SACCHARIN

3 SAFETY SYRINGE WITH SHIELD SYRINGE,SAFETY WITH NEEDLE,3ML

3 SAFETY SYRINGE‐NEEDLE SYRINGE,SAFETY WITH NEEDLE,3ML

3 SAFETYGLIDE ALLERGY SYRINGE SYRINGE W‐NEEDLE,DISPOSAB,1 ML

3 SAF‐T‐INTIMA IV CATHETER INTRAVENOUS CATHETER KIT

3 SAFYRAL DROSPIR/ETH ESTRA/LEVOMEFOL CA X

Excluded SAIZEN

3 SALACYN SALICYLIC ACID

2 SALAGEN PILOCARPINE HCL

3 SALEX SALICYLIC ACID

1 SALICYLIC ACID GEL SALICYLIC ACID

2 SALICYLIC ACID/CERAMIDES KIT CLEANSER & CREAM SALICYLIC ACID/CERAMIDE

3 SALIVAMAX SALIVA SUBSTITUTE COMB NO.11

3 SALIVATERX SALIVA SUBSTITUTE COMB NO.11

3 SALKERA SALICYLIC ACID/AMMON LACT/ALOE

3 SALVAX DUO PLUS SALICYLIC ACID/UREA

3 SAMI THE SEAL NEBULIZER AND COMPRESSOR

3 SAMI THE SEAL MASK NEBULIZER ACCESSORIES

3 SAMSCA (15, 30 MG) TABLET TOLVAPTAN X

3 SANCUSO GRANISETRON X X

2 SANDIMMUNE CYCLOSPORINE

3 SANTYL COLLAGENASE CLOSTRIDIUM HIST.

2 SAPHRIS ASENAPINE MALEATE X X

3 SARAFEM FLUOXETINE HCL

Excluded SARILUMAB SARILUMAB

3 SAVAYSA EDOXABAN TOSYLATE X X

2 SAVELLA MILNACIPRAN HCL

2 SCALACORT HYDROCORTISONE

2 SCALACORT DK HYDROCORT/SAL ACID/SULF/SHAMP1

3 SCLEROSOL TALC

2 SEASONALE X X

3 SEASONIQUE L‐NORGEST/E.ESTRADIOL‐E.ESTRAD X X

3 SEBUDERM EMOLLIENT COMBINATION NO.60

3 SECONAL SODIUM SECOBARBITAL SODIUM

Excluded SEEBRI NEOHALER

3 SELECT‐OB + DHA PRENATAL VITS #33/IRON/FA/DHA

1 SELEGILINE HCL SELEGILINE HCL

2 SELENIUM SULFIDE 2.25 % SHAMPOO SELENIUM SULFIDE

3 SELRX SELENIUM SULFIDE

2 SELZENTRY (25, 75, 150, 300 MG) TABLET MARAVIROC X


Authorization

Quantity

Limit

Step

Therapy3 SEMPREX‐D PSEUDOEPHEDRINE HCL/ACRIVAS

2 SEREVENT DISKUS SALMETEROL XINAFOATE X

3 SERNIVO BETAMETHASONE DIPROPIONATE X

2 SEROQUEL QUETIAPINE FUMARATE X

3 SEROSTIM X

1 SERTRALINE TABLET SERTRALINE

1 SEVOFLURANE SEVOFLURANE

2 SFROWASA MESALAMINE

3 SIDESTREAM NEBULIZER

3 SIDESTREAM MASK NEBULIZER ACCESSORIES

3 SIDESTREAM NEBULIZER NEBULIZER

3 SIDESTREAM PLUS NEBULIZER

1 SILDENAFIL CITRATE SILDENAFIL CITRATE X

3 SILENOR DOXEPIN HCL X X

3 SILHOUETTE SUB‐Q INFUSION PUMP ACCESSORY

3 SILICONE MASK NEBULIZER ACCESSORIES

Excluded SILIQ BRODALUMAB

2 SILVADENE SILVER SULFADIAZINE

1 SILVER NITRATE SILVER NITRATE

1 SILVER NITRATE APPLICATOR SILVER NITRATE APPLICATOR

1 SILVER SULFADIAZINE SILVER SULFADIAZINE

3 SILVERSEAL HYDROGEL SILVER/HYDROCOLLOID DRESSING

3 SILVRSTAT SILVER

2 SIMBRINZA BRINZOLAMIDE/BRIMONIDINE TART

2 SIMCOR X X

Excluded SIMPONI ARIA GOLIMUMAB

1 SIMVASTATIN TABLET SIMVASTATIN X

1 SIMVASTATIN/EZETIMIBE SIMVASTATIN/EZETIMIBE X X

2 SINEMET 10‐100 CARBIDOPA/LEVODOPA



2 SINEMET CR CARBIDOPA/LEVODOPA

2 SINGULAIR MONTELUKAST SODIUM

3 SINUSTAR NEBULIZER

3 SINUSTAR NEBULIZER AND COMPRESSOR

1 SIROLIMUS SIROLIMUS

3 SITAVIG ACYCLOVIR X X

2 SIVEXTRO TEDIZOLID PHOSPHATE X

2 SKELAXIN METAXALONE

3 SKLICE IVERMECTIN

3 SKYLA LEVONORGESTREL

3 SMARTMASK KIDS NEBULIZER ACCESSORIES

Excluded SMARTRX GABA KIT

Excluded SMARTRX GABA ‐V KIT

3 SNAP INSULIN PUMP CONTROLLER INSULIN PUMP CONTROLLER

3 SNAP INSULIN PUMP‐INFUSION SET INFUSION SET‐INSULIN PUMP BODY

1 SOD PHOS DI, MONO/K PHOS MONO SOD PHOS DI, MONO/K PHOS MONO

3 SODIUM CHLORIDE BACTERIOSTATIC SODIUM CHLORIDE

1 SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE 0.45 %

1 SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE FOR INHALATION

1 SODIUM CHLORIDE IRRIG SOLUTION SODIUM CHLORIDE IRRIG SOLUTION

1 SODIUM CHLORIDE/NAHCO3/KCL/PEG SODIUM CHLORIDE/NAHCO3/KCL/PEG

1 SODIUM CITRATE SODIUM CITRATE

1 SODIUM FLUORIDE SODIUM FLUORIDE

1 SODIUM FLUORIDE/POTASSIUM NIT SODIUM FLUORIDE/POTASSIUM NIT

1 SODIUM POLYSTYRENE SULFON/SORB SODIUM POLYSTYRENE SULFON/SORB

1 SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE

3 SODIUM SUCCINATE SODIUM SUCCINATE

1 SODIUM THIOSULFATE/SAL ACID SODIUM THIOSULFATE/SAL ACID

3 SOF‐SENSOR BLOOD‐GLUCOSE SENSOR

3 SOF‐SET INTRAVENOUS ADMINISTRATION SET

3 SOF‐SET MICRO INTRAVENOUS ADMINISTRATION SET


Authorization

Quantity

Limit

Step

Therapy3 SOLARAZE DICLOFENAC SODIUM X X

3 SOLESTA DEXTRANOMER/HYALURONATE/NACL

Excluded SOLIQUA

3 SOLIRIS ECULIZUMAB X X X

3 SOLODYN MINOCYCLINE HCL X X

2 SOLTAMOX TAMOXIFEN CITRATE

3 SOLU‐CORTEF HYDROCORTISONE SODIUM SUCC/PF

2 SOMA CARISOPRODOL

2 SONATA ZALEPLON X

3 SOOLANTRA IVERMECTIN

3 SORBITOL SORBITOL SOLUTION

1 SORBITOL SOLUTION SORBITOL SOLUTION

3 SORILUX CALCIPOTRIENE X

1 SOTALOL HCL SOTALOL HCL

3 SOTYLIZE (5 MG/ML) SOLUTION SOTALOL HCL X X

3 SOVALDI X

3 SP ANTIPRURITIC NA MG FL/NA PHO/NACL/HA/NA HYP

3 SP SCAR MANAGEMENT EMOLLIENT COMBINATION NO.60

3 SPACE CHAMBER PLUS INHALER, ASSIST DEVICES

3 SPECTRACEF CEFDITOREN PIVOXIL

3 SPECTRAGEL GEL DRESSING

3 SPEEDICATH CATHETER

2 SPINOSAD SUSPENSION SPINOSAD

Excluded SPINRAZA

2 SPIRIVA TIOTROPIUM BROMIDE X

2 SPIRIVA RESPIMAT TIOTROPIUM BROMIDE X

1 SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACT/HYDROCHLOROTHIAZID

1 SPIRONOLACTONE TABLET SPIRONOLACTONE

2 SPORANOX ITRACONAZOLE

3 SPRAY AND STRETCH NORFLURANE/PENTAFLUOROPROPANE

1 SPRINTEC

3 SPRITAM (1000 MG) TAB SUSP LEVETIRACETAM X X

3 SPRITAM (250, 500, 750 MG) TAB SUSP LEVETIRACETAM X X

3 SPRIX KETOROLAC TROMETHAMINE X

3 SPS SODIUM POLYSTYRENE SULFON/SORB

3 SS 10‐2 SULFACETAMIDE SODIUM/SULFUR

2 STALEVO 100 CARBIDOPA/LEVODOPA/ENTACAPONE

2 STALEVO 50, 75, 125, 150, 200 CARBIDOPA/LEVODOPA/ENTACAPONE

2 STARLIX NATEGLINIDE

1 STAVUDINE (1 MG/ML) SOLN RECON STAVUDINE X

1 STAVUDINE (15, 20, 30, 40 MG) CAPSULE STAVUDINE X

Excluded STAXYN

STELARA USTEKINUMAB X

Excluded STENDRA

3 STIMATE DESMOPRESSIN ACETATE

2 STIOLTO RESPIMAT TIOTROPIUM BR/OLODATEROL HCL X

2 STRATTERA (10, 18, 25, 40, 60, 80, 100 MG) CAPSULE ATOMOXETINE HCL X

3 STRAVIX HUMAN REGENERATIVE TISSUE MTRX

3 STRIANT TESTOSTERONE X

2 STRIBILD ELVITEG/COBI/EMTRIC/TENOFO DIS X

2 STRIVERDI RESPIMAT OLODATEROL HCL X

3 STROMECTOL IVERMECTIN

3 STROVITE ONE MV,MIN10/FOLIC ACID/D3/ALA/LUT

2 SUBOXONE (2 MG‐0.5MG) FILM BUPRENORPHINE HCL/NALOXONE HCL X X

2 SUBOXONE (4MG‐1MG) FILM BUPRENORPHINE HCL/NALOXONE HCL X X

2 SUBOXONE (8 MG‐2 MG) FILM BUPRENORPHINE HCL/NALOXONE HCL X X

2 SUBOXONE FILM BUPRENORPHINE HCL/NALOXONE HCL X

Excluded SUBSYS

1 SUCRALFATE SUCRALFATE

3 SULAR NISOLDIPINE

2 SULFACETAMIDE SODIU,/SULFER MEDICATED PADS SULFACETAMIDE SODIUM/SULFUR

2 SULFACETAMIDE SODIUM 10% SHAMPOO SULFACETAMIDE SODIUM


Authorization

Quantity

Limit

Step

Therapy1 SULFACETAMIDE SODIUM 10% SOLUTION SULFACETAMIDE SODIUM

1 SULFACETAMIDE SODIUM/SULFUR 10 %‐5 % FOAM SULFACETAMIDE SODIUM/SULFUR

2 SULFACETAMIDE SODIUM/SULFUR LOTION SULFACETAMIDE SODIUM/SULFUR

2 SULFACETAMIDE SODIUM/SULFUR SUSPENSION SULFACETAMIDE SODIUM/SULFUR

1 SULFACT SOD/SULUR/AVOB/OTN/OCT SULFACT SOD/SULUR/AVOB/OTN/OCT

1 SULFADIAZINE SULFADIAZINE

1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM

3 SULFAMYLON MAFENIDE ACETATE

1 SULFASALAZINE 500 MG DR TABLET SULFASALAZINE

1 SULFASALAZINE 500 MG TABLET SULFASALAZINE

1 SULINDAC TABLET SULINDAC

3 SUMADAN SULFACETAMIDE SODIUM/SULFUR

3 SUMADAN XLT SULFACT SOD/SULUR/AVOB/OTN/OCT

1 SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE X

3 SUMAVEL DOSEPRO SUMATRIPTAN SUCCINATE X X

3 SUMAXIN SULFACETAMIDE SODIUM/SULFUR

3 SUMAXIN TS SULFACETAMIDE SODIUM/SULFUR

3 SUNRISE COMPRESSOR‐NEBULIZER COMPRESSOR, FOR NEBULIZER

3 SUPERVITE LYSINE/B COMP/FOLIC ACID/ZINC

3 SUPRANE DESFLURANE

2 SUPRAX CEFIXIME

2 SUPREP SODIUM, POTASSIUM,MAG SULFATES

3 SURE‐T SUB‐Q INFUSION PUMP ACCESSORY

3 SURE‐T PARADIGM INFUSION SET FOR INSULIN PUMP

3 SURFAXIN LUCINACTANT

Excluded SURILIMAB

3 SURMONTIL TRIMIPRAMINE MALEATE

3 SURVANTA BERACTANT

2 SUSTIVA EFAVIRENZ

2 SYMAX HYOSCYAMINE SULFATE

3 SYMAX DUOTAB HYOSCYAMINE SULFATE

2 SYMAX‐SL HYOSCYAMINE SULFATE

2 SYMAX‐SR HYOSCYAMINE SULFATE

2 SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE X

2 SYMBYAX OLANZAPINE/FLUOXETINE HCL X

2 SYMLIN PRAMLINTIDE ACETATE

2 SYMLINPEN 60 PRAMLINTIDE ACETATE

2 SYNALAR FLUOCINOLONE ACETONIDE

3 SYNALAR FLUOCINOLONE/EMOL CMB#65

3 SYNALAR TS FLUOCINOLONE/SKIN CLNSR28

3 SYNALGOS‐DC ASPIRIN/CAFFEIN/DIHYDROCODEINE X

3 SYNERA LIDOCAINE/TETRACAINE

Excluded SYNERDERM

2 SYNJARDY EMPAGLIFLOZIN/METFORMIN HCL X X

2 SYNJARDY XR EMPAGLIFLOZIN/METFORMIN HCL X X

2 SYNTHROID LEVOTHYROXINE SODIUM

3 SYNVEXIA TC LIDOCAINE HCL/MENTHOL

3 SYPRINE TRIENTINE HCL X

3 SYRINGE SYRINGE, DISPOSABLE, 5 ML

3 SYRINGE SYRINGE, DISPOSABLE, 60 ML

3 SYRINGE AVITENE MICROFIBRILLAR COLLAGEN

3 SYRINGE‐NEEDLE SYRINGE,SAFETY WITH NEEDLE,1ML

3 SYZYGIUM COMPOSITUM HOMEOPATHIC DRUGS

3 TACHOSIL FIBRINOGEN/THROMBIN(HUMAN DER)

3 TACLONEX CALCIPOTRIENE/BETAMETHASONE X

1 TACROLIMUS TACROLIMUS

3 TALWIN PENTAZOCINE LACTATE

2 TAMIFLU (30, 45, 75 MG) CAPSULE OSELTAMIVIR PHOSPHATE X

2 TAMIFLU (6 MG/ML) SUSP RECON OSELTAMIVIR PHOSPHATE X

1 TAMOXIFEN CITRATE TAMOXIFEN CITRATE

1 TAMSULOSIN TAMSULOSIN

3 TANDEM PLUS IRON FM,PS NO.1/FOLIC/MV NO.18


Authorization

Quantity

Limit

Step

TherapyExcluded TANZEUM

2 TAPAZOLE METHIMAZOLE

3 TARGADOX DOXYCYCLINE HYCLATE X X

1 TARINA FE

3 TARKA TRANDOLAPRIL/VERAPAMIL HCL

3 TASMAR TOLCAPONE X X

3 TAYTULLA NORETHINDRONE‐E.ESTRADIOL‐IRON

2 TAZORAC TAZAROTENE

2 TECFIDERA X

3 TECHNIVIE X

2 TEGRETOL CARBAMAZEPINE

2 TEGRETOL XR CARBAMAZEPINE

3 TEKAMLO ALISKIREN/AMLODIPINE BESYLATE X

3 TEKTURNA ALISKIREN HEMIFUMARATE X

3 TEKTURNA HCT ALISKIREN/HYDROCHLOROTHIAZIDE X

1 TELMISARTAN TELMISARTAN

1 TELMISARTAN & AMLODIPINE TABLETS TELMISARTAN & AMLODIPINE

2 TELMISARTAN/AMLODIPINE COMBO TABLET TELMISARTAN/AMLODIPINE

2 TELMISARTAN/HCTZ COMBO TABLET TELMISARTAN/HCTZ

2 TEMOVATE CLOBETASOL PROPIONATE

2 TENORETIC 50, 100 ATENOLOL/CHLORTHALIDONE

2 TENORMIN ATENOLOL

3 TENS 502, 504 TENS UNIT

3 TERAZOL 7 TERCONAZOLE

1 TERAZOSIN TERAZOSIN

1 TERBINAFINE TABLET TERBINAFINE

1 TERBUTALINE SULFATE TERBUTALINE SULFATE

1 TERCONAZOLE TERCONAZOLE

3 TERSI FOAM SELENIUM SULFIDE

3 TERUMO SURGUARD2 SYRINGE,SAFETY NEEDLE,10 ML

3 TERUMO SURGUARD2 SYRINGE,SAFETY WITH NEEDLE,1ML



3 TERUMO SURGUARD2 NEEDLES, SAFETY

3 TESSALON PERLE BENZONATATE

Excluded TESTIM

3 TESTOPEL TESTOSTERONE

1 TESTOSTERONE 1% GEL TESTOSTERONE X

1 TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE X

1 TESTOSTERONE ENANTHATE TESTOSTERONE ENANTHATE X

2 TESTOSTERONE GEL PUMP TESTOSTERONE

2 TESTOSTERONE GEL/GEL PACKET TESTOSTERONE

3 TESTRED METHYLTESTOSTERONE X

3 TETCAINE TETRACAINE HCL

1 TETRACAINE HCL TETRACAINE HCL

1 TETRACAINE HCL/PF TETRACAINE HCL/PF

1 TETRACYCLINE HCL TETRACYCLINE HCL

3 TETRAVISC TETRACAINE HCL

3 TETRAVISC FORTE TETRACAINE HCL

3 TETRIX PROTECTIVES COMBINATION NO.2

2 TEXACORT HYDROCORTISONE

3 TEXAVITE LQ PED MULTIVIT 108/IRON/FLUORIDE

2 THEO‐24 THEOPHYLLINE ANHYDROUS

1 THEOPHYLLINE THEOPHYLLINE

2 THERMAZENE SILVER SULFADIAZINE

1 THIAMINE HCL THIAMINE HCL

1 THIORIDAZINE HCL THIORIDAZINE HCL

1 THIOTHIXENE THIOTHIXENE

3 THRESHOLD IMT SPIROMETERS AND ACCESSORIES

3 THRESHOLD PEP SPIROMETERS AND ACCESSORIES

3 THRIVITE RX PRENATAL VIT #76/IRON,CARB/FA

1 THROMB‐CA‐CELL‐DRESSING, HEMOS THROMB‐CA‐CELL‐DRESSING, HEMOS


Authorization

Quantity

Limit

Step

Therapy1 THROMBIN (BOVINE) THROMBIN (BOVINE)

1 THROMBIN/CA/CMC/GEL/DRESS, HEM THROMBIN/CA/CMC/GEL/DRESS, HEM

1 THYROID,PORK THYROID,PORK

3 THYROLAR‐1 LIOTRIX

3 THYROLAR‐1/2 LIOTRIX

3 THYROLAR‐1/4 LIOTRIX



1 TIAGABINE HCL TIAGABINE HCL X X

2 TIAZAC DILTIAZEM HCL

Excluded TICALAST

Excluded TICANASE

1 TICLOPIDINE HCL TICLOPIDINE HCL

3 TIGAN TRIMETHOBENZAMIDE HCL

2 TIKOSYN DOFETILIDE X

1 TILIA FE, TRI‐LEGEST FE

1 TIMOLOL TIMOLOL

1 TIMOLOL OPHTHALMIC DROPS TIMOLOL

2 TIMOLOL OPHTHALMIC GEL SOLUTION TIMOLOL

1 TIMOLOL/DORZOLAMIDE TIMOLOL/DORZOLAMIDE

2 TIMOPTIC TIMOLOL MALEATE

3 TIMOPTIC OCUDOSE TIMOLOL MALEATE/PF X X

3 TINDAMAX TINIDAZOLE

2 TINIDAZOLE TABLET TINIDAZOLE

Excluded TIROSINT

3 TISSEEL VHSD THROMBIN(HUM PLAS)/FIB/APRO/CA

3 TIS‐U‐SOL PENTALYTE SOD,POT CHLOR/MAG/SOD,POT PHOS

2 TIVICAY DOLUTEGRAVIR SODIUM X

Excluded TIVORBEX

2 TIZANIDINE CAPSULE TIZANIDINE

1 TIZANIDINE TABLET TIZANIDINE

2 TOBRADEX TOBRAMYCIN/DEXAMETHASONE

3 TOBRADEX ST TOBRAMYCIN/DEXAMETHASONE

1 TOBRAMYCIN TOBRAMYCIN

1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE

2 TOBREX TOBRAMYCIN

2 TOFRANIL IMIPRAMINE HCL

3 TOLAK FLUOROURACIL

2 TOLAZAMIDE TABLET TOLAZAMIDE

1 TOLBUTAMIDE TOLBUTAMIDE

1 TOLCAPONE TOLCAPONE X X

2 TOLMETIN SODIUM TABLET TOLMETIN SODIUM

2 TOLTERODINE ER CAPSULE TOLTERODINE

2 TOLTERODINE TABLET TOLTERODINE

1 TOLTERODINE TARTRATE TOLTERODINE X

3 TOOMEY SYRINGE SYRINGE DISPOSABLE IRRIG,70 ML

2 TOPAMAX TOPIRAMATE

2 TOPICORT (0.05 %) CREAM DESOXIMETASONE

2 TOPICORT (0.05 %) GEL DESOXIMETASONE

2 TOPICORT (0.05 %) OINTMENT DESOXIMETASONE

2 TOPICORT (0.25 %) CREAM DESOXIMETASONE

2 TOPICORT (0.25 %) OINTMENT DESOXIMETASONE

3 TOPICORT (0.25 %) SPRAY DESOXIMETASONE X

1 TOPIRAMATE (100 MG) CAP SPR 24 TOPIRAMATE X X

1 TOPIRAMATE (100 MG) TABLET TOPIRAMATE

1 TOPIRAMATE (15 MG) CAP SPRINK TOPIRAMATE





1 TOPIRAMATE (25 MG) CAP SPRINK TOPIRAMATE



Authorization

Quantity

Limit

Step

Therapy1 TOPIRAMATE (50 MG) CAP SPR 24 TOPIRAMATE X X


2 TOPROL XL METOPROLOL SUCCINATE

3 TORONOVA II SUIK KETOROLAC/NORFLURANE/HFC 245FA

3 TORONOVA SUIK KETOROLAC/NORFLURANE/HFC 245FA

1 TORSEMIDE TORSEMIDE

3 TOUCH‐TROL CATHETER

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

2 TOVIAZ FESOTERODINE FUMARATE X

2 TRADJENTA LINAGLIPTIN X

1 TRAMADOL HCL (100 MG) (CPBP 25‐75) TRAMADOL HCL X X

1 TRAMADOL HCL (100 MG) (TBMP 24HR) TRAMADOL HCL X

2 TRAMADOL HCL (100 MG) TAB ER 24H TRAMADOL HCL X








1 TRAMADOL HCL (50 MG) TABLET TRAMADOL HCL X

1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN X

1 TRANDOLAPRIL TRANDOLAPRIL

1 TRANDOLAPRIL TABLET & VERAPAMIL TABLET TRANDOLAPRIL & VERAPAMIL HCL

2 TRANDOLAPRIL/VERAPAMIL HCL TABLET TRANDOLAPRIL/VERAPAMIL HCL

1 TRANEXAMIC ACID TRANEXAMIC ACID

3 TRANSDERM‐SCOP SCOPOLAMINE

Excluded TRANSLARNA ATALUREN

2 TRANXENE T‐TAB CLORAZEPATE DIPOTASSIUM

2 TRANYLCYPROMINE SULFATE TABLET TRANYLCYPROMINE SULFATE

2 TRAVAPROST DROPS TRAVOPROST

2 TRAVATAN Z TRAVOPROST X

1 TRAVOPROST TRAVOPROST X

1 TRAZODONE HCL TRAZODONE HCL

3 TRECATOR ETHIONAMIDE

3 TREK S COMBO PACK NEBULIZER AND COMPRESSOR

3 TREK S COMPACT COMPRESSOR NEBULIZER AND COMPRESSOR

3 TREK S PORTABLE PWR KIT NEBULIZER ACCESSORIES

Excluded TRESIBA

2 TRETINOIN (0.01 %) GEL TRETINOIN

2 TRETINOIN (0.025 %) CREAM TRETINOIN





2 TRETINOIN MICROSPHERES TRETINOIN MICROSPHERES

3 TRETIN‐X TRETINOIN

3 TRETIN‐X TRETINOIN/EMOL CMB9/SKIN CLN1

2 TREXALL METHOTREXATE SODIUM

Excluded TREXIMET

3 TREZIX ACETAMINOPHEN/CAFF/DIHYDROCOD X

2 TRIAMCINOLONE ABSORBASE 0.05% OINTMENT (MEDIUM) TRIAMCINOLONE

1 TRIAMCINOLONE ACETONIDE 0.025 % CREAM (LOW) TRIAMCINOLONE ACETONIDE X

1

TRIAMCINOLONE ACETONIDE 0.025 % LOTION

(LOWER‐MID) TRIAMCINOLONE ACETONIDE X

1

TRIAMCINOLONE ACETONIDE 0.025 % OINTMENT

(LOWER‐MID) TRIAMCINOLONE ACETONIDE X

1 TRIAMCINOLONE ACETONIDE 0.05 % CREAM (HIGH) TRIAMCINOLONE ACETONIDE X

1 TRIAMCINOLONE ACETONIDE 0.1 % LOTION (LOWER‐MID) TRIAMCINOLONE ACETONIDE X


Authorization

Quantity

Limit

Step

Therapy

1 TRIAMCINOLONE ACETONIDE 0.1 % OINTMENT (MEDIUM) TRIAMCINOLONE ACETONIDE X

1 TRIAMCINOLONE ACETONIDE 0.1% CREAM (MEDIUM) TRIAMCINOLONE ACETONIDE X

1 TRIAMCINOLONE ACETONIDE 0.5 % OINTMENT (HIGH) TRIAMCINOLONE ACETONIDE X

2 TRIAMCINOLONE TOPICAL SPRAY (MEDIUM) TRIAMCINOLONE ACETONIDE X

2 TRIAMCINOLONE/DIMETHICONE 0.1%‐5% (MEDIUM) TRIAMCINOLONE ACETONIDE X

1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID

1 TRIAZOLAM TRIAZOLAM

2 TRIBENZOR OLMESARTAN/AMLODIPIN/HCTHIAZID X

3 TRICARE PRENATAL #103/IRON FUMARATE/FA

3 TRICARE PRENATAL PRENATAL VIT #113/IRON/FOLATE

3 TRICARE PRENATAL DHA ONE PNV20/IRON/FOLIC/DOCUSATE/OM3S

3 TRICARE PRENATAL WITH DHA PRENATAL 113/IRON/LMFOL/OMEG3S

2 TRICOR FENOFIBRATE NANOCRYSTALLIZED

1 TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL

1 TRIFLURIDINE TRIFLURIDINE

2 TRIGLIDE FENOFIBRATE NANOCRYSTALLIZED X

1 TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL

2 TRILEPTAL OXCARBAZEPINE

3 TRILIPIX FENOFIBRIC ACID (CHOLINE)

3 TRILOAN II SUIK TRIAMCIN/NORFLURANE/HFC 245FA

3 TRILOAN SUIK TRIAMCIN/NORFLURANE/HFC 245FA

2 TRIMETHOBENZAMIDE HCL TRIMETHOBENZAMIDE HCL

1 TRIMETHOPRIM TRIMETHOPRIM

1 TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE

3 TRINATAL RX 1 PRENATAL VIT27,CALCIUM/IRON/FA

1 TRINESSA

2 TRI‐NORINYL NORETHINDRONE‐ETHINYL ESTRAD X

2 TRINTELLIX VORTIOXETINE HYDROBROMIDE X X

1 TRI‐SPRINTEC

3 TRISTART DHA PRENATAL NO.93/IRON/FA #9/DHA

2 TRIUMEQ ABACAVIR/DOLUTEGRAVIR/LAMIVUDI X

3 TRI‐VI‐FLOR PED MVIT A,C,D3 NO.38/FLUORIDE

1 TRIVORA‐28

2 TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE X

2 TROKENDI XR (100 MG) CAP ER 24H TOPIRAMATE X X




1 TROPICAMIDE TROPICAMIDE

1 TROSPIUM CHLORIDE TROSPIUM CHLORIDE X

1 TROSPIUM CHLORIDE ER TROSPIUM CHLORIDE X

3 TRULANCE PLECANATIDE X X

2 TRULICITY DULAGLUTIDE X

3 TRUNEB NEBULIZER NEBULIZER

3 TRUSKIN HUMAN REGENERATIVE TISSUE MTRX

2 TRUSOPT DORZOLAMIDE HCL

3 TRUST NATAL DHA PRENATAL 2/IRON/FOLIC ACID/OM3

2 TRUVADA EMTRICITABINE/TENOFOVIR (TDF) X

3 TRUZONE PEAK FLOW METER PEAK FLOW METER

Excluded TUDORZA PRESSAIR

2 TUSNEL C PSEUDOEPHED/CODEINE/GUAIFEN X

3 TUSNEL PEDIATRIC GUAIFENESIN/DM/PSEUDOEPHEDRINE

3 TUSSICAPS HYDROCODONE/CHLORPHEN P‐STIREX X

2 TUSSIGON HYDROCODONE BIT/HOMATROP ME‐BR X

2 TUSSIONEX HYDROCODONE/CHLORPHEN P‐STIREX X

3 TUZISTRA XR CODEINE POLI/CHLORPHENIR POLIS X X

1 TWO DULOXETINE 20MG CAPSULE DULOXETINE

3 TWYNSTA TELMISARTAN/AMLODIPINE

2 TYBOST COBICISTAT X

2 TYLENOL‐CODEINE NO.3, NO. 4 ACETAMINOPHEN WITH CODEINE X

3 TYMLOS X


Authorization

Quantity

Limit

Step

TherapyExcluded TYSABRI

3 TYZINE TETRAHYDROZOLINE HCL

3 UCERIS BUDESONIDE X

3 UDAMIN SP MV‐MINS NO.9/FOLIC/SAW PALMETT

3 ULESFIA BENZYL ALCOHOL

2 ULORIC FEBUXOSTAT X X

3 ULTANE SEVOFLURANE

3 ULTICARE SYRINGE W‐NEEDLE,DISPOSAB,1 ML

3 ULTICARE SYRINGE SYRINGE,NDLE,SAFE DISP 1.5 ML

2 ULTRACET TRAMADOL HCL/ACETAMINOPHEN X

3 ULTRAFOAM MICROFIBRILLAR COLLAGEN

2 ULTRAM TRAMADOL HCL X

3 ULTRASAL‐ER SALICYLIC ACID

2 ULTRAVATE (0.05 %) CREAM HALOBETASOL PROPIONATE

3 ULTRAVATE (0.05 %) LOTION HALOBETASOL PROPIONATE

2 ULTRAVATE (0.05 %) OINTMENT HALOBETASOL PROPIONATE

3 UMECTA UREA

3 UMECTA PD UREA

3 UNISTIK 2 NORMAL LANCING DEVICE/LANCETS

2 UNITHROID LEVOTHYROXINE SODIUM

3 URAMAXIN UREA

3 URAMAXIN GT UREA

2 UREA 39%, 40%, 50% CREAM UREA

2 URECHOLINE BETHANECHOL CHLORIDE

Excluded URE‐K

3 URELLE METH/MEBLUE/SOD PHOS/PSAL/HYOS

2 URETRON D‐S METH/MEBLUE/SOD PHOS/PSAL/HYOS

Excluded UREVAZ

3 URIBEL METH/MEBLUE/SOD PHOS/PSAL/HYOS

2 URIN D.S. METH/MEBLUE/SOD PHOS/PSAL/HYOS

3 UROCIT‐K POTASSIUM CITRATE

3 UROQID‐ACID NO.2 METHENAMINE/SOD PHOSPHATE MBAS

2 UROXATRAL ALFUZOSIN HCL

2 URSO URSODIOL

2 URSO FORTE URSODIOL

1 URSODIOL URSODIOL

3 URYL METHENAM/SOD PHOS/MBLUE/HYOSCY

3 UTA METHENAM/SOD PHOS/MBLUE/HYOSCY

Excluded UTIBRON

3 UTIRA‐C METH/MEBLUE/SOD PHOS/PSAL/HYOS

Excluded UTOPIC

3 VACUSTIM BLACK FOAM/GAUZE/LIDOCA/CHLHX/ISOPRO

3 VACUSTIM SILVER SILV/BANDG/LIDOCA/CHLORHEX/ALC

2 VAGIFEM ESTRADIOL

1 VALACYCLOVIR HCL VALACYCLOVIR HCL

3 VALCYTE VALGANCICLOVIR HCL

2 VALGANCICLOVIR HCL (450 MG) TABLET VALGANCICLOVIR HCL

1 VALGANCICLOVIR HCL (50 MG/ML) SOLN RECON VALGANCICLOVIR HCL

2 VALIUM DIAZEPAM

1 VALPROIC ACID VALPROIC ACID

1 VALPROIC ACID (AS SODIUM SALT) VALPROIC ACID (AS SODIUM SALT)

1 VALSARTAN TABLET VALSARTAN

1 VALSARTAN TABLET & AMLODIPINE TABLET VALSARTAN & AMLODIPINE

1 VALSARTAN/HCTZ COMBO T ABLET VALSARTAN/HCTZ

2 VALTREX VALACYCLOVIR HCL

3 VANATOL LQ BUTALB/ACETAMINOPHEN/CAFFEINE

2 VANCOCIN HCL (125 MG) CAPSULE VANCOMYCIN HCL X

2 VANCOCIN HCL (250 MG) CAPSULE VANCOMYCIN HCL X

1 VANCOMYCIN HCL (125 MG) CAPSULE VANCOMYCIN HCL X

1 VANCOMYCIN HCL (125MG/2.5) SYRINGE VANCOMYCIN HCL

1 VANCOMYCIN HCL (250 MG) CAPSULE VANCOMYCIN HCL X

2 VANDAZOLE METRONIDAZOLE


Authorization

Quantity

Limit

Step

Therapy2 VANOS FLUOCINONIDE

2 VANOXIDE‐HC BENZOYL PEROXIDE/HYDROCORTISON

3 VAPRO PLUS INTERMITT CATHETER URINARY BAG/CATHETER

3 VARITHENA ADMINISTRATION PACK TRANSFER SET/SYRINGE/BAND/TUBE

3 VARUBI ROLAPITANT HCL X

2 VASCEPA ICOSAPENT ETHYL X

2 VASCEPA (1 G) CAPSULE ICOSAPENT ETHYL X

3 VASCUDERM HYDROGEL WOUND GEL DRESSING

2 VASERETIC ENALAPRIL/HYDROCHLOROTHIAZIDE

3 VASHE WOUND THERAPY SODIUM CHLOR/HYPOCHLOROUS ACID

2 VASOTEC ENALAPRIL MALEATE

3 VAXCHORA ACTIVE COMPONENT CHOLERA VACCINE, LIVE

3 VAXCHORA BUFFER COMPONENT CHOLERA VAC BUFFER COMP 1 OF 2

3 VAXCHORA VACCINE CHOLERA VACCINE, LIVE

3 VECAMYL MECAMYLAMINE HCL X

2 VECTICAL CALCITRIOL X

3 VELPHORO SUCROFERRIC OXYHYDROXIDE

3 VELTASSA PATIROMER CALCIUM SORBITEX X X

Excluded VELTIN

3 VENELEX BALSAM PERU/CASTOR OIL

1 VENLAFAXINE ER CAPSULE VENLAFAXINE

2 VENLAFAXINE ER TABLET VENLAFAXINE

2 VENTOLIN HFA ALBUTEROL SULFATE

1 VERAPAM CAPSULE (VERELAN) VERAPAMIL

1 VERAPAM CAPSULEIL (VERELAN PM) VERAPAMIL

1 VERAPAMIL TABLET (CALAN SR) VERAPAMIL

1 VERAPAMIL TABLET (CALAN) VERAPAMIL

3 VERDESO DESONIDE

3 VERDROCET HYDROCODONE/ACETAMINOPHEN X

3 VEREGEN SINECATECHINS

2 VERELAN VERAPAMIL HCL

2 VERELAN PM VERAPAMIL HCL

3 VERIPRED 20 PREDNISOLONE SOD PHOSPHATE

3 VERSACLOZ CLOZAPINE X X

3 VERTIGOHEEL HOMEOPATHIC DRUGS

2 VESICARE SOLIFENACIN SUCCINATE X

2 VFEND VORICONAZOLE

3 VGO 20 SUB‐Q INSULIN DEVICE, 20 UNIT



2 VIAGRA SILDENAFIL CITRATE X

3 VIASPAN BELZER‐UW ORGAN PRESERVATION SOLN‐BELZER

3 VIBERZI ELUXADOLINE X

2 VIBRAMYCIN DOXYCYCLINE CALCIUM

2 VIBRAMYCIN DOXYCYCLINE HYCLATE X

2 VIBRAMYCIN DOXYCYCLINE MONOHYDRATE

2 VICTOZA LIRAGLUTIDE X X

2 VIDEX DIDANOSINE X

2 VIDEX EC (125, 200, 250, 400 MG) CAPSULE DR DIDANOSINE X

Excluded VIEKIRA PAK

2 VIGAMOX MOXIFLOXACIN HCL

2 VIIBRYD VILAZODONE HCL X X

Excluded VIMOVO

2 VIMPAT (10 MG/ML) SOLUTION LACOSAMIDE X X

3 VIMPAT (200MG/20ML) VIAL LACOSAMIDE

2 VIMPAT (50, 100, 150, 200 MG) TABLET LACOSAMIDE X X

3 VIOKACE LIPASE/PROTEASE/AMYLASE

3 VIOS AEROSOL DELIVERY SYSTEM NEBULIZER AND COMPRESSOR

2 VIRACEPT NELFINAVIR MESYLATE

2 VIRAMUNE (200 MG) TABLET NEVIRAPINE X

2 VIRAMUNE (50 MG/5 ML) ORAL SUSP NEVIRAPINE X

2 VIRAMUNE XR (100, 400 MG) TAB ER 24H NEVIRAPINE X


Authorization

Quantity

Limit

Step

Therapy3 VIRASAL SALICYLIC ACID

2 VIRAZOLE RIBAVIRIN

2 VIREAD (150, 200, 250, 300 MG) TABLET TENOFOVIR DISOPROXIL FUMARATE X

2 VIREAD (40MG/SCOOP) POWDER TENOFOVIR DISOPROXIL FUMARATE X

2 VIROPTIC TRIFLURIDINE

2 VISTARIL HYDROXYZINE PAMOATE

1 VIT B CMPLX 3/FOLIC AC/C/BIOT VIT B CMPLX 3/FOLIC AC/C/BIOT

1 VIT B CMPLX NO3/FA/C/BIOT/ZINC VIT B CMPLX NO3/FA/C/BIOT/ZINC

1 VIT B CPLX #11/FA/C/BIOT/ZN OX VIT B CPLX #11/FA/C/BIOT/ZN OX

3 VITAFOL FE+ PNV#102/IRON/FOLATE #1/DSS/DHA

3 VITAFOL ULTRA PNV#67/IRON PS/FA CMB#1/DHA

3 VITAFOL‐OB PRENATAL VIT COMB.10/IRON/FA

3 VITAFOL‐ONE PNV#26/IRON POLY/FA/DHA

3 VITAMEDMD ONE RX PRENATAL NO.25/IRON/FA #6/DHA

3 VITAMEDMD REDICHEW RX PRENATAL COMB NO.42/FOLIC ACID

1 VITAMINS B1,B2,B3,B5,AND B6 VITAMINS B1,B2,B3,B5,AND B6

3 VITAPEARL PRENATAL71/IRON/FOLIC ACID/DHA

3 VITA‐RESPA CYANOCOBALAMIN/FOLIC AC/VIT B6

3 VITATRUE PRENATAL 105/IRON/FOLIC AC/DHA

1 VITE AC/GRAPE/HYALURONIC ACID VITE AC/GRAPE/HYALURONIC ACID

3 VITUZ HYDROCODONE/CHLORPHENIRAMINE X

2 VIVELLE‐DOT ESTRADIOL X

1 VIVITROL NALTREXONE X X X

Excluded VIVLODEX

3 VIVOTIF TYPHOID VACC,LIVE,ATTENUATED

3 VIVOTIF BERNA TYPHOID VACC,LIVE,ATTENUATED

3 VIXONE NEBULIZER NEBULIZER

Excluded VOGELXO

2 VOLTAREN GEL DICLOFENAC SODIUM

2 VOLTAREN‐XR DICLOFENAC SODIUM

2 VORICONAZOLE TABLET VORICONAZOLE

3 VORTEX INHALER, ASSIST DEVICES

3 VORTEX VHC FROG MASK INHALER, ASSIST DEVICES

3 VORTEX VHC LADYBUG MASK INHALER, ASSIST DEVICES

2 VRAYLAR CARIPRAZINE HCL X X

3 VUSION MICONAZOLE NITRATE/ZINC OX/PET

3 VYTONE HYDROCORTISONE/IODOQUINOL/ALOE

2 VYTORIN (10 MG‐10MG) TABLET EZETIMIBE/SIMVASTATIN X



2 VYTORIN (10 MG‐80MG) TABLET EZETIMIBE/SIMVASTATIN X X

2 VYVANSE LISDEXAMFETAMINE DIMESYLATE X X

1 WARFARIN SODIUM WARFARIN SODIUM

1 WATER FOR IRRIGATION,STERILE WATER FOR IRRIGATION,STERILE

2 WELCHOL COLESEVELAM HCL

2 WELLBUTRIN SR BUPROPION HCL

2 WELLBUTRIN XL BUPROPION HCL

3 WIDE SEAL DIAPHRAGM DIAPHRAGMS, WIDE SEAL

3 WOUND MATRIX PORCINE SUBMUCOSA, FENESTRATED

2 XALATAN LATANOPROST

2 XANAX ALPRAZOLAM

3 XANAX XR ALPRAZOLAM

2 XARELTO (10 MG) TABLET RIVAROXABAN X


2 XARELTO (15 MG‐20MG) TAB DS PK RIVAROXABAN X


3 XARTEMIS XR OXYCODONE HCL/ACETAMINOPHEN X

3 XCLAIR HYALURONT/E/EMOL 12/ALLAN/SHEA

2 XELJANZ X

2 XELJANZ XR X

2 XEOMIN INCOBOTULINUMTOXIN A X X X

3 XERESE ACYCLOVIR/HYDROCORTISONE X X


Authorization

Quantity

Limit

Step

Therapy3 XEROFORM BISMUTH TRIBROMOPH/PETROLATUM

2 XGEVA DENOSUMAB X X X

3 XIFAXAN (200 MG) TABLET RIFAXIMIN X

2 XIFAXAN (550 MG) TABLET RIFAXIMIN X

Excluded XIGDUO XR

2 XIIDRA LIFITEGRAST X

2 XODOL 10‐300 HYDROCODONE/ACETAMINOPHEN X

3 XODOL 5‐300 HYDROCODONE/ACETAMINOPHEN X

3 XODOL 7.5‐300 HYDROCODONE/ACETAMINOPHEN X

2 XOLAIR OMALIZUMAB X X X

3 XOLEGEL KETOCONAZOLE

3 XOPENEX LEVALBUTEROL HCL

3 XOPENEX CONCENTRATE LEVALBUTEROL HCL

3 XTAMPZA ER (13.5 MG) CAP SPR 12 OXYCODONE MYRISTATE X

3 XTAMPZA ER (18 MG) CAP SPR 12 OXYCODONE MYRISTATE X




1 XULANE PATCH X

Excluded XULTOPHY

3 XYZAL (2.5 MG/5ML) SOLUTION LEVOCETIRIZINE DIHYDROCHLORIDE X X

2 XYZAL (5 MG) TABLET LEVOCETIRIZINE DIHYDROCHLORIDE

2 YASMIN ETHINYL ESTRADIOL/DROSPIRENONE X

2 YAZ ETHINYL ESTRADIOL/DROSPIRENONE X

Excluded YERVOY IPILIMUMAB

Excluded YESCARTA AXICABTAGENE CILOLEUCEL

Excluded YOSPRALA

2 ZAFIRLUKAST TABLET ZAFIRLUKAST

1 ZALEPLON ZALEPLON X

3 ZAMICET HYDROCODONE/ACETAMINOPHEN X

3 ZANABIN EMOLLIENT COMBINATION NO.60

2 ZANAFLEX TIZANIDINE HCL

2 ZANTAC RANITIDINE HCL

2 ZARONTIN ETHOSUXIMIDE

2 ZEBETA BISOPROLOL FUMARATE

3 ZEGERID OMEPRAZOLE/SODIUM BICARBONATE X X

3 ZELAPAR SELEGILINE HCL X

Excluded ZEMBRACE SYMTOUCH

2 ZEMPLAR PARICALCITOL

3 ZENCIA SULFACETAMIDE SODIUM/SULFUR

2 ZENPEP LIPASE/PROTEASE/AMYLASE

2 ZENZEDI (15 MG) TABLET DEXTROAMPHETAMINE SULFATE X

2 ZENZEDI (2.5 MG) TABLET DEXTROAMPHETAMINE SULFATE X X



2 ZENZEDI (7.5 MG) TABLET DEXTROAMPHETAMINE SULFATE X X

1 ZEOSA, ZENCHENT FE, WYMZYA FE

3 ZEPATIER X

2 ZERIT (1 MG/ML) SOLN RECON STAVUDINE X

2 ZERIT (15, 20, 30, 40 MG) CAPSULE STAVUDINE X

2 ZESTORETIC LISINOPRIL/HYDROCHLOROTHIAZIDE

2 ZESTRIL LISINOPRIL

2 ZETIA EZETIMIBE X

Excluded ZETONNA

2 ZIAC BISOPROL/HYDROCHLOROTHIAZIDE

2 ZIAGEN (20 MG/ML) SOLUTION ABACAVIR SULFATE X

2 ZIAGEN (300 MG) TABLET ABACAVIR SULFATE X

2 ZIANA CLINDAMYCIN/TRETINOIN

1 ZIDOVUDINE (10 MG/ML) SYRUP ZIDOVUDINE X

1 ZIDOVUDINE (100 MG) CAPSULE ZIDOVUDINE X

1 ZIDOVUDINE (300 MG) TABLET ZIDOVUDINE X

3 ZINBRYTA DACLIZUMAB X X X


Authorization

Quantity

Limit

Step

TherapyExcluded ZIOPTAN

1 ZIPRASIDONE ZIPRASIDONE X

Excluded ZIPSOR

2 ZIRGAN GANCICLOVIR

3 ZITHRANOL ANTHRALIN MICRONIZED X

3 ZITHRANOL‐RR ANTHRALIN X

2 ZITHROMAX AZITHROMYCIN

2 ZITHROMAX TRI‐PAK AZITHROMYCIN

2 ZMAX AZITHROMYCIN

2 ZOCOR (10 MG) TABLET SIMVASTATIN




2 ZOCOR (80 MG) TABLET SIMVASTATIN X

2 ZOFRAN (4 MG) TABLET ONDANSETRON HCL

2 ZOFRAN (4 MG/5 ML) SOLUTION ONDANSETRON HCL X

2 ZOFRAN (8 MG) TABLET ONDANSETRON HCL

2 ZOFRAN ODT ONDANSETRON

3 ZOHYDRO ER HYDROCODONE BITARTRATE X

2 ZOLMITRIPTAN ODT ZOLMITRIPTAN X X

2 ZOLMITRIPTAN TABLET ZOLMITRIPTAN

2 ZOLOFT SERTRALINE HCL

1 ZOLPIDEM TARTRATE (10 MG) TABLET ZOLPIDEM TARTRATE X

1 ZOLPIDEM TARTRATE (10MG) TABLET ZOLPIDEM TARTRATE X

2 ZOLPIDEM TARTRATE (12.5 MG) TAB MPHASE ZOLPIDEM TARTRATE X

1 ZOLPIDEM TARTRATE (5 MG) TABLET ZOLPIDEM TARTRATE X

1 ZOLPIDEM TARTRATE (5MG) TABLET ZOLPIDEM TARTRATE X

2 ZOLPIDEM TARTRATE (6.25 MG) TAB MPHASE ZOLPIDEM TARTRATE X

Excluded ZOLPIMIST

Excluded ZOMACTON

ZOMETA ZOLEDRONIC ACID X

2 ZOMIG (2.5 MG) SPRAY ZOLMITRIPTAN X X

2 ZOMIG (2.5 MG) TABLET ZOLMITRIPTAN X X

2 ZOMIG (5 MG) SPRAY ZOLMITRIPTAN X X

2 ZOMIG (5 MG) TABLET ZOLMITRIPTAN X X

2 ZOMIG ZMT ZOLMITRIPTAN X X

Excluded ZONACORT

3 ZONALON DOXEPIN HCL

3 ZONATUSS BENZONATATE

2 ZONEGRAN ZONISAMIDE

1 ZONISAMIDE ZONISAMIDE

3 ZONTIVITY VORAPAXAR SULFATE X

3 ZORBTIVE X

2 ZORTRESS EVEROLIMUS

Excluded ZORVOLEX

2 ZOVIRAX ACYCLOVIR

3 Z‐TUSS AC CHLORPHENIRAMINE/CODEINE PHOS X

2 ZUBSOLV BUPRENORPHINE HCL/NALOXONE HCL X

Excluded ZUPLENZ

2 ZURAMPIC LESINURAD X X

3 ZUTRIPRO HYDROCODONE/CPM/PSEUDOEPHED X

3 ZYCLARA (2.5 %) CRM MD PMP IMIQUIMOD X X

3 ZYCLARA (3.75 %) CREAM PACK IMIQUIMOD X X

3 ZYCLARA (3.75 %) CRM MD PMP IMIQUIMOD X X

3 ZYFLO ZILEUTON

2 ZYLET TOBRAMYCIN/LOTEPRED ETAB

2 ZYLOPRIM ALLOPURINOL

2 ZYMAXID GATIFLOXACIN

3 ZYMOGENETICS SPRAY APPLICATOR SPRAY APPLICATOR KIT, STERILE

3 ZYPRAM HYDROCORT/PRAMOXN/SKN CLNSR#16

2 ZYPREXA OLANZAPINE X

2 ZYPREXA ZYDIS OLANZAPINE X


Authorization

Quantity

Limit

Step

Therapy2 ZYVOX (100 MG/5ML) SUSP RECON LINEZOLID

2 ZYVOX (600 MG) TABLET LINEZOLID X

prior quantity step name generic name authorization limit

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