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Highlighted drugs denote new changes to the PDL since previous update Column Header Explanations: B, G or O: B = Brand G = Generic O = OTC B or G Drug Name Department of Human Services Approved PDL for IOWA Medicaid Program ALPHA DRUG LIST Effective Date 01/01/2016 trusted, reliable, innovative P, N, R or NR: P = Preferred N = Non-Preferred R = Recommended NR = Non-Recommended Drug Category P, N, Comment R or NR A G Abacavir Sulfate Antiretrovirals - Rti-Nucleoside Analogues-Purines NR G Abacavir Sulfate-Lamivudine-Zidovudine Antiretrovirals - Combinations NR B ABILIFY Antipsychotics - Atypicals P B ABILIFY DISCMELT Antipsychotics - Atypicals NP PA Required B ABILIFY MAINTENA Antipsychotics - Atypicals NP PA Required B ABRAXANE Antineoplastics - Mitotic Inhibitors B ABSORICA Acne Products: Isotretinoin B ABSTRAL Narcotics - Misc. G Acamprosate Calcium Alcohol Deterrents B ACANYA Topical - Acne Preparations NP G Acarbose Diabetic - Alphaglucosidase NP B ACCOLATE Antiasthmatic - Leukotriene Receptor Antagonists NP B ACCUPRIL ACE Inhibitors NP NP R N PA Required NP PA Required P B ACCURETIC ACE and Thiazide Combo's G Acebutolol HCl Beta Blockers - Cardio Selective P O Acetaminophen Analgesics - Misc. P G Acetaminophen w/ Codeine Narcotics - Misc. P G Acetazolamide Diuretics P G Acetic Acid Urological - Misc. P G Acetic Acid (Otic) Ear P G Acetic Acid-Aluminum Acetate Ear NP 12/15/2015 9:09:11 AM PA Required > 15 units / 30 days. Initial fill limited to 14 day supply. PA Required Page 1 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A G Acetylcysteine Antiasthmatic - Mucolytics P B ACIPHEX Gi - Proton Pump Inhibitor NP G Acitretin Anti-Psoriatics - Non-Biologicals NP B ACTEMRA Anti-Inflammatories, Non-Nsaid NP B ACTIGALL Gi - Misc. NP B ACTIMMUNE Interferon Gamma NP B ACTIQ Narcotics - Misc. NP B ACTIVASE Tissue Plasminogen Activator B ACTIVELLA Estrogen Combos NP B ACTONEL Osteoporosis NP B ACTOPLUS MET Diabetic - Thiazol / Biguanide Combo NP B ACTOPLUS MET XR Diabetic - Thiazol / Biguanide Combo NP B ACTOS Diabetic - Thiazol NP B ACULAR Op. Nsaid'S NP B ACUVAIL Op. Nsaid'S NP G Acyclovir Herpes Agents P G Acyclovir Sodium Herpes Agents P G Acyclovir SUSP Herpes Agents NP G Acyclovir Topical Topical - Antivirals NP B ADALAT CC Calcium Channel Blockers--Nifedipines NP G Adapalene cream Topical - Acne Preparations NP PA Required G Adapalene gel 0.1% Topical - Acne Preparations P PA Required G Adapalene gel 0.3% Topical - Acne Preparations P PA Required G Adapalene lotion Topical - Acne Preparations NP PA Required B ADCIRCA Pulmonary Anti-Hypertensives NP Grandfather Existing Users B ADDERALL Stimulants - Amphetamines - Short Acting NP PA Required B ADDERALL XR Stimulants - Amphetamines - Long Acting NP Grandfather Existing Users G Adefovir Dipivoxil Hepatitis B Only NP B ADEMPAS Pulmonary Anti-Hypertensives NP PA Required B ADOXA Tetracyclines NP PA Required B ADRENACLICK Anaphylaxis Therapy NP B ADRENALIN Anaphylaxis Therapy NP B ADVAIR Antiasthmatic - Adrenergic Combos P B ADVAIR HFA Antiasthmatic - Adrenergic Combos P 12/15/2015 9:09:11 AM PA Required PA Required PA Required P Page 2 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A B ADVATE Antihemophilic Agents NR B ADVICOR Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B AEROSPAN Antiasthmatic - Steroid Inhalants P B AFINITOR Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B AFLURIA Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B AFREZZA Diabetic - Insulin NP B AGGRENOX Platelet Aggr. Inhibitors / Combo's - Misc. P B AGRYLIN Platelet Aggr. Inhibitors / Combo's - Misc. NP B A-HYDROCORT Glucocorticoids - Mineralocorticoids B AKNE-MYCIN Topical - Acne Preparations NP PA Required B AKYNZEO Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALBENZA Anthelmintics G Albumin, Human Electrolytes/ Nutritionals G Albuterol Sulfate NEBU 0.63MG/3 Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Syrup 2 MG/5ML Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Tab 2 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab 4 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab SR 12HR 4 MG Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Tab SR 12HR 8 MG Antiasthmatic - Beta - Adrenergics P INJ PF 2015-16 P P NP B ALCAINE Op. Misc G Alclometasone Dipropionate Topical - Corticosteroids - Low Potency B ALDACTAZIDE TAB 25/25 Diuretics NP B ALDACTAZIDE TABS 50/50 Diuretics P B ALDACTONE Diuretics NP B ALDARA Topical - Genital Warts NP NP N B ALDURAZYME Mucopolysaccharidosis P G Alendronate Sodium Osteoporosis P G Alendronate Sodium SOLN Osteoporosis NP G Alfuzosin HCl BPH 12/15/2015 9:09:11 AM Preferred < 2 years of age PA Required Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). P Page 3 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A B ALIMTA Antineoplastics - Antimetabolites R B ALINIA Antiprotozoal Agents P B ALKERAN Antineoplastics - Nitrogen Mustards R G Allopurinol Gout P G Almotriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs NP B ALOCRIL Op. Antiallergics - Mast Cell Stabilizers NP B ALOMIDE Op. Antiallergics - Mast Cell Stabilizers NP B ALORA Estrogens - Patches G Alosetron Gi - Irritable Bowel Syndrome Agents NP B ALOXI Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP B ALPHAGAN P SOL 0.1% Op. Selective Alpha Adrenergic Agonists NP B ALPHAGAN P SOLN 0.15% Op. Selective Alpha Adrenergic Agonists P B ALPHANATE Antihemophilic Agents R B ALPHANINE SD Antihemophilic Agents R G Alprazolam Anxiolytics - Benzodiazepines P PA Required P PA Required B ALPRAZOLAM INTENSOL Anxiolytics - Benzodiazepines G Alprazolam Tab SR 24HR 0.5 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 1 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 2 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 3 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tablet Disperse Anxiolytics - Benzodiazepines NP PA Required B ALPROLIX Antihemophilic Agents NR B ALREX Op. Antiinflammatory / Steroids Ophth. B ALTABAX Topical - Antibiotic NP B ALTACE ACE Inhibitors NP B ALTOPREV Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B ALVESCO Antiasthmatic - Steroid Inhalants NP G Amantadine HCl Cap 100 MG Anti-Parkinsonian Drugs P G Amantadine HCl Syrup 50 MG/5ML Anti-Parkinsonian Drugs P G Amantadine HCl Tab 100 MG Anti-Parkinsonian Drugs NP B AMARYL Diabetic - Oral Sulfonylureas NP B AMBIEN Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBIEN CR Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBISOME Antifungals - Assorted 12/15/2015 9:09:11 AM P P P PA Required > 90 days Page 4 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A G Amcinonide Cream 0.1% Topical - Corticosteroids - High Potency N PA Required G Amcinonide LOTN Topical - Corticosteroids - High Potency N PA Required G Amcinonide OINT Topical - Corticosteroids - High Potency N PA Required B AMERGE Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required G Amifostine Crystalline Antineoplastics - Urinary Tract Protective Agents NR G Amikacin Sulfate Amino Glycosides P G Amiloride & Hydrochlorothiazide Diuretics P G Amiloride HCl Diuretics P G Amino Acid Electrolyte Infusion Electrolytes/ Nutritionals P G Amino Acid Infusion Electrolytes/ Nutritionals NP G Amino Acid Infusion SOLN 6% Electrolytes/ Nutritionals P G Aminocaproic Acid Hemostatic P G Aminophylline Antiasthmatic - Xanthines P B AMINOSYN Electrolytes/ Nutritionals P B AMINOSYN II Electrolytes/ Nutritionals P B AMINOSYN-HBC Electrolytes/ Nutritionals NP B AMINOSYN-PF Electrolytes/ Nutritionals NP G Amiodarone HCl Tab 200 MG Antiarrhythmics P G Amiodarone HCl TABS 400MG Antiarrhythmics NP B AMITIZA GI, Constipation - IBS-OIC NP G Amitriptyline HCl Antidepressants - Tri-Cyclics P G Amlodipine Besylate Calcium Channel Blockers--Amlodipines P G Amlodipine Besylate-Atorvastatin Calcium CCB / Lipid G Amlodipine Besylate-Benazepril HCl ACE Inhibitors And Calcium Channel Blockers G Amlodipine Besylate-Valsartan Arb/Ccb NP PA Required G Amlodipine-Valsartan-Hydrochlorothiazide ARB/CCB Plus Diuretics NP PA Required B AMMONUL Urea Cycle Disorder - Agents NP G Amoxapine Antidepressants - Tri-Cyclics G Amoxicillin & K Clavulanate Chew Tab 200-28.5 MG Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin & K Clavulanate Chew Tab 400-57 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate For Susp 200-28.5 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate For Susp 250-62.5 MG/5ML Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML Beta-Lactams / Clavulanate Combo'S P 12/15/2015 9:09:11 AM PA Required NP P P Page 5 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A G Amoxicillin & K Clavulanate Tab 250-125 MG Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin & K Clavulanate Tab 500-125 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & K Clavulanate Tab 875-125 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin & Pot Clavulanate Tablet ER 12HR Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin (Trihydrate) Cap 250 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Chew Tab 125 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Chew Tab 250 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 125 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 200 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 250 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) For Susp 400 MG/5ML Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Tab 500 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Tab 875 MG Beta-Lactams / Clavulanate Combo'S P G Amoxicillin (Trihydrate) Tab SR 24HR 775 MG Beta-Lactams / Clavulanate Combo'S NP G Amoxicillin-Clarithromycin w/ Lansoprazole Gi - Ulcer Anti-Infective NP G Amphetamine-Dextroamphetamine Stimulants - Amphetamines - Short Acting P G Amphetamine-Dextroamphetamine ER Stimulants - Amphetamines - Long Acting NP G Ampicillin Beta-Lactams / Clavulanate Combo'S P G Ampicillin & Sulbactam Sodium Beta-Lactams / Clavulanate Combo'S P B AMPYRA Multiple Sclerosis Agents – Non-Interferons NP PA Required B AMRIX Muscle Relaxants NP PA Required B AMTURNIDE Antihypertensive Combos NP NP B ANAFRANIL Antidepressants - Tri-Cyclics G Anagrelide HCl Platelet Aggr. Inhibitors / Combo's - Misc. B ANAPROX NSAIDS PA Required PA Required >= 21 yo. PA Required P NP PA Required B ANASPAZ Gi - Antidiarrheal / Antacid - Misc. P G Anastrozole Antineoplastics - Aromatase Inhibitors R B ANCOBON Antifungals - Assorted P PA Required > 90 days B ANDRODERM Androgens -Topical P PA Required B ANDROGEL Androgens -Topical NP PA Required B ANDROID Androgens - Anabolics P PA Required B ANDROXY Androgens - Anabolics P B ANGELIQ Estrogen Combos NP B ANORO ELLIPTA Antiasthmatic - Adrenergic Combos NP 12/15/2015 9:09:11 AM Page 6 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A B ANTABUSE Alcohol Deterrents NP B ANTARA Cholesterol - Fibric Acid Derivatives NP G Antipyrine-Benzocaine Ear B ANUSOL-HC Anorectal - Misc. NP B ANZEMET Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP B APIDRA Diabetic - Insulin NP B APIDRA Diabetic - Insulin Penfills NP PA Required B APLENZIN Antidepressants - Selected SSRI's NP PA Required B APLISOL Diagnostic Biologicals P B APOKYN Parkinsons - Selected Dopamin Agonists P G Apraclonidine HCl Op. Selective Alpha Adrenergic Agonists NP B APRISO Gi - Inflammatory Bowel Agents B Aptensio XR Stimulants - Methylphenidate - Long Acting NP B APTIOM Anticonvulsants NP B APTIVUS Antiretrovirals - Protease Inhibitors CAP 0.375GM ND AQUADEKS Vitamins - Misc. P PA Required P PA Required R P PA Required B ARALAST Alpha-Proteinase Inhibitor NP PA Required B ARANESP ALBUMIN FREE Erythropoeisis Stimulating Agents NP PA Required B ARAVA Rheumatoid Arthritis - Non-Biologicals NP B ARCAPTA NEOHALER Antiasthmatic - Beta - Adrenergics NP B ARICEPT Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B ARICEPT ODT Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B ARIMIDEX Antineoplastics - Aromatase Inhibitors NR G ARIPIPRAZOLE ANTIPSYCHOTICS - ATYPICALS NP B ARIXTRA Anticoagulants NP B ARMOUR THYROID Thyroid Hormones NP B ARNUITY ELLIPTA Antiasthmatic - Steroid Inhalants NP B AROMASIN Antineoplastics - Aromatase Inhibitors NP B ARRANON Antineoplastics - Antimetabolites R B ARTHROTEC NSAIDS NP O Artificial Tear Ointment Op. Misc P O Artificial Tear Solution Op. Misc P G Asa/dipyridamole Platelet Aggr. Inhibitors / Combo's - Misc. 12/15/2015 9:09:11 AM Grandfather Existing Users PA Required NP Page 7 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A B ASACOL HD Gi - Inflammatory Bowel Agents NP B ASMANEX 120 AER 220MCG TAB 800MG Antiasthmatic - Steroid Inhalants P B ASMANEX 14 AER 220MCG Antiasthmatic - Steroid Inhalants P B ASMANEX 30 AER 110MCG Antiasthmatic - Steroid Inhalants P B ASMANEX 30 AER 220MCG Antiasthmatic - Steroid Inhalants P B ASMANEX 60 AER 220MCG Antiasthmatic - Steroid Inhalants P B ASMANEX 7 Antiasthmatic - Steroid Inhalants NP NP AER 110MCG PA Required > 12 years of age B ASMANEX HFA ANTIASTHMATIC - STEROID INHALANTS O Aspirin Analgesics - Misc. P O Aspirin Buffered Analgesics - Misc. P B ASTAGRAF XL Immunosuppressants NP B ASTEPRO Antihistamines - Non-Sedating NP B ATACAND ARB'S NP PA Required B ATACAND HCT ARB'S And Diuretics NP PA Required B ATELVIA Osteoporosis NP G Atenolol Beta Blockers - Cardio Selective P G Atenolol & Chlorthalidone Beta Blockers And Diuretic Combo'S P B ATIVAN Anxiolytics - Benzodiazepines G Atorvastatin Calcium Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP G Atovaquone Antiprotozoal Agents NP G Atracurium Besylate Anti-Parkinsonian Drugs NP B ATRALIN Topical - Tretinoids N PA Required P B ATRIPLA Antiretrovirals R G Atropine Sulfate Gi - Antidiarrheal / Antacid - Misc. P G Atropine Sulfate (Ophthalmic) Op. Cycloplegics N B ATROVENT Antiasthmatic - Nasal Misc. B ATROVENT HFA Antiasthmatic - Anti-Cholinergics B ATROVENT NAS SOL 0.06% Antiasthmatic - Nasal Misc. NP B AUBAGIO Multiple Sclerosis Agents – Non-Interferons NP B AUGMENTIN SUS 125/5ML Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN SUS 250/5ML Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN SUS ES-600 Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN TAB 500MG Beta-Lactams / Clavulanate Combo'S NP B AUGMENTIN TAB 875MG Beta-Lactams / Clavulanate Combo'S NP 12/15/2015 9:09:11 AM PA Required PA Required NP P PA Required Page 8 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A B AUGMENTIN XR Beta-Lactams / Clavulanate Combo'S NP B AURYXIA PHOSPHATE BINDERS NP B AUVI-Q Anaphylaxis Therapy NP B AVALIDE ARB'S And Diuretics NP PA Required B AVANDAMET Diabetic - Thiazol / Biguanide Combo NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B AVANDARYL Diabetic - Sulfonylurea / Biguanide NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B AVANDIA Diabetic - Thiazol NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B AVAPRO ARB'S NP PA Required B AVASTIN Antineoplastics - Antimetabolites B AVEED Androgens - Anabolics NP PA Required B AVODART BPH NP Grandfather Existing Users B AVONEX Multiple Sclerosis Agents – Interferons P B AVONEX PEN Multiple Sclerosis Agents – Interferons P B AXERT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP B AXID Gi - H2-Antagonists NP B AXIRON Androgens -Topical NP B AYGESTIN Progestins NP B AZACTAM Antibiotics - Misc. P B AZACTAM IN DEXTROSE Antibiotics - Misc. NP B AZASAN Purine Analog P B AZASITE Op. Antibiotics NP G Azathioprine Purine Analog G AZELASTINE DRO 0.05% Op. Antiallergics - Antihistamines G AZELASTINE SPR 0.1% Antihistamines - Non-Sedating P G AZELASTINE SPR 0.15% Antihistamines - Non-Sedating NP G Azelastine HCl (Ophth) Op. Antiallergics - Antihistamines B AZELEX Topical - Acne Preparations B AZILECT Anti-Parkinsonian Drugs G Azithromycin For Susp 100 MG/5ML Macrolides / Erythromycin'S / Ketolides G Azithromycin For Susp 200 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Azithromycin IV For Soln 500 MG Macrolides / Erythromycin'S / Ketolides NP G Azithromycin Powd Pack for Susp 1 GM Macrolides / Erythromycin'S / Ketolides P 12/15/2015 9:09:11 AM PA Required R PA Required PA Required P NP N P PA Required NP P Page 9 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR A G Azithromycin Tab 250 MG Macrolides / Erythromycin'S / Ketolides P G Azithromycin Tab 500 MG Macrolides / Erythromycin'S / Ketolides P G Azithromycin Tab 600 MG Macrolides / Erythromycin'S / Ketolides P B AZOPT Op. Carbonic Anhydrase Inhibitors/Combo P B AZOR Arb/Ccb NP G Aztreonam Antibiotics - Misc. NP B AZULFIDINE Gi - Inflammatory Bowel Agents NP PA Required B ND *B-Complex w/ C & Folic Acid Tab 1 MG*** Vitamins - Misc. P G Bacitracin (Ophthalmic) Op. Antibiotics O Bacitracin (Topical) Topical - Antibiotic P G Bacitracin-Polymyxin B (Ophth) Op. Antibiotics P G Bacitracin-Poly-Neomycin-HC Op. Antiinflammatory / Steroids Ophth. G Baclofen Muscle Relaxants B BACTOCILL IN DEXTROSE Beta-Lactams / Clavulanate Combo'S B BACTRIM Anti Infective Combo's - Misc. NP B BACTROBAN Topical - Antibiotic NP B BACTROBAN NASAL Topical - Nasal Antibiotics B BACTROBAN OINT Topical - Antibiotic G Balsalazide Disodium Gi - Inflammatory Bowel Agents B BANZEL Anticonvulsants NP B BARACLUDE Hepatitis B Only P CRE 2% ND B-Complex w/ C & Folic Acid PA Required NP NP P P P NP P Vitamins - Misc. P B BEBULIN Antihemophilic Agents R B BECONASE AQ Nasal Steroids NP B BELSOMRA Sedative/Hypnotics - Non-Benzodiazepines NP G Benazepril & Hydrochlorothiazide ACE and Thiazide Combo's G Benazepril HCl ACE Inhibitors P B BENEFIX Antihemophilic Agents R B BENICAR ARB'S NP PA Required B BENICAR HCT ARB'S And Diuretics NP PA Required B BENTYL CAP 10MG Gi - Antidiarrheal / Antacid - Misc. NP B BENTYL INJ 10MG/ML Gi - Antidiarrheal / Antacid - Misc. NP B BENTYL TAB 20MG Gi - Antidiarrheal / Antacid - Misc. NP 12/15/2015 9:09:11 AM PA Required PA Required P Page 10 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR B B BENZACLIN Topical - Acne Preparations P PA Required B BENZACLIN GEL 1-5% GEL 1-5%PUMP Topical - Acne Preparations NP PA Required B BENZAMYCIN Topical - Acne Preparations NP PA Required B BENZAMYCIN GEL PAK Topical - Acne Preparations NP PA Required O Benzoyl Peroxide Topical - Acne Preparations P B Benzoyl peroxide 7% cleanser Topical - Acne Preparations P PA Required G Benzoyl Peroxide-Erythromycin Topical - Acne Preparations P PA Required G Benztropine Mesylate Inj 1 MG/ML Parkinsons - Anticholinergics NP G Benztropine Mesylate Tab 0.5 MG Parkinsons - Anticholinergics P G Benztropine Mesylate Tab 1 MG Parkinsons - Anticholinergics P G Benztropine Mesylate Tab 2 MG Parkinsons - Anticholinergics B BEPREVE Op. Antiallergics - Antihistamines B BESIVANCE Op. Quinolones B BETAGAN Op. Beta - Blockers G Betamethasone Dipropionate (Topical) LOTN Topical - Corticosteroids - Medium Potency N G Betamethasone Dipropionate (Topical) OINT Topical - Corticosteroids - High Potency P G Betamethasone Dipropionate Augmented Cream 0.05% Topical - Corticosteroids - High Potency P G Betamethasone Dipropionate Augmented Gel 0.05% Topical - Corticosteroids - High Potency N PA Required G Betamethasone Dipropionate Augmented Lotion 0.05% Topical - Corticosteroids - High Potency N PA Required G Betamethasone Dipropionate Augmented Oint 0.05% Topical - Corticosteroids - High Potency N PA Required G Betamethasone Dipropionate Cream 0.05% Topical - Corticosteroids - High Potency P G Betamethasone Valerate Topical - Corticosteroids - Medium Potency P G Betamethasone Valerate FOAM Topical - Corticosteroids - Medium Potency B BETAPACE Beta Blockers - Non Selective NP B BETAPACE AF Beta Blockers - Non Selective NP P NP P NP N B BETASERON Multiple Sclerosis Agents – Interferons G Betaxolol HCl Beta Blockers - Cardio Selective NP G Betaxolol HCl (Ophth) Op. Beta - Blockers NP G Bethanechol Chloride Cholinergic P B BETHKIS Amino Glycosides P B BETIMOL Op. Beta - Blockers NP B BETOPTIC-S Op. Beta - Blockers P G Bexarotene Antineoplastics - Selective Retinoid X Receptor Agonists NP B BEYAZ Contraceptives - Monophasic Combination O/C'S NP 12/15/2015 9:09:11 AM PA Required PA Required P Page 11 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR B B BIAXIN SUS 250/5ML Macrolides / Erythromycin'S / Ketolides NP B BIAXIN TAB 250MG Macrolides / Erythromycin'S / Ketolides NP TAB 500MG Macrolides / Erythromycin'S / Ketolides NP B BIAXIN G Bicalutamide Antineoplastics - Antiandrogens R B BICILLIN Beta-Lactams / Clavulanate Combo'S P B BIDIL Antianginals--Isosorbide Nitrate B BILTRICIDE Anthelmintics G BIMATOPROST OP. PROSTAGLANDINS NP B BINOSTO Osteoporosis NP G Bisoprolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S P G Bisoprolol Fumarate Beta Blockers - Cardio Selective P B BIVIGAM Immune Serums P G Bleomycin Sulfate Antineoplastics - Antibiotics B BLEPH-10 Op. Antibiotics B BLEPHAMIDE Op. Antiinflammatory / Steroids Ophth. B BLEPHAMIDE S.O.P. Op. Antiinflammatory / Steroids Ophth. B BONIVA Osteoporosis NP B BOSULIF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B BOTOX Neuromuscular Blocking Agents NP B BREO ELLIPTA Antiasthmatic - Adrenergic Combos NP B BREVICON-28 Contraceptives - Monophasic Combination O/C'S B BRILINTA Platelet Aggregation Inhibitors G Brimonidine Tartrate Ophth Soln 0.2% Op. Selective Alpha Adrenergic Agonists P G Brimonidine Tartrate SOLN 0.15% Op. Selective Alpha Adrenergic Agonists NP B BRINTELLIX Antidepressants - Selected SSRI's NP NP P R NP P P PA Required N NP B BRISDELLE Antidepressants - Selected SSRI's NP G Bromfenac Sodium (Ophth) Op. Nsaid'S NP G Bromocriptine Mesylate 2.5mg tabs Anti-Parkinsonian Drugs P G Bromocriptine Mesylate 5 MG Cap Anti-Parkinsonian Drugs N B BROVANA Antiasthmatic - Beta - Adrenergics G Budesonide Glucocorticoids - Mineralocorticoids G Budesonide (Inhalation) Antiasthmatic - Steroid Inhalants NP G Budesonide (Nasal) Nasal Steroids NP G Bumetanide Diuretics 12/15/2015 9:09:11 AM PA Required PA Required NP P P Page 12 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR B B BUNAVAIL Narcotics - Misc. NP B BUPHENYL Urea Cycle Disorder - Agents NP G Bupivacaine in Dextrose Topical - Local Anesthetics NP B BUPRENEX Narcotics - Selected NP PA Required G Buprenorphine HCl Narcotics - Misc. NP PA Required G Buprenorphine HCl Narcotics - Selected NP PA Required G Buprenorphine HCl-Naloxone HCl Dihydrate Narcotics - Misc. NP PA Required G Bupropion HCl (Smoking Deterrent) Smoking Cessation (Oral) P PA Required G Bupropion HCl Tab 100 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab 75 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 12HR 100 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 12HR 150 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 12HR 200 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 24HR 150 MG Antidepressants - Selected SSRI's P G Bupropion HCl Tab SR 24HR 300 MG Antidepressants - Selected SSRI's P G Buspirone HCl Tab 10 MG Anxiolytics - Misc. P G Buspirone HCl Tab 15 MG Anxiolytics - Misc. P G Buspirone HCl Tab 5 MG Anxiolytics - Misc. P G Buspirone HCl Tab 7.5 MG Anxiolytics - Misc. P G Buspirone HCl TABS 30MG Anxiolytics - Misc. NP B BUSULFEX Antineoplastics - Alkylating Agents R G Butalbital-Acetaminophen Tab 50-325 MG Analgesics - Misc. P G Butalbital-Acetaminophen-Caff w/ COD Cap 50-300-40-30 MG Narcotics - Misc. NP G Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG Narcotics - Misc. P G Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG Analgesics - Misc. P G Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG Analgesics - Misc. P G Butalbital-Aspirin-Caffeine Analgesics - Misc. P G Butalbital-Aspirin-Caffeine w/Cod Narcotics - Misc. NP B BUTISOL SODIUM Sedative/Hypnotics - Barbiturate NP G Butorphanol Tartrate Narcotics - Selected P PA Required B BUTRANS Narcotics - Misc. NP PA Required B BYDUREON Diabetic - Non-Insulin Injectables NP PA Required B BYETTA Diabetic - Non-Insulin Injectables P PA Required 12/15/2015 9:09:11 AM PA Required BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets PA Required PA Required Page 13 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR B B BYSTOLIC Beta Blockers - Cardio Selective NP PA Required C G Cabergoline Dopamine Receptor Agonists B CADUET CCB / Lipid NP B CAFERGOT Migraine - Ergot Combinations NP B CALAN Calcium Channel Blockers--Verapamils NP G Calcipotriene Anti-Psoriatics - Non-Biologicals P G Calcipotriene-Betamethasone Dipropionate Topical - Steroid Combinations NP G Calcitonin (Salmon) Osteoporosis G Calcitriol Hyperparathyroid Treatment - Vitamin D Analogs ND Calcium & Phosphorus w/ Vitamin D Tab 105 MG-81 MG-120 Unit G Calcium Acetate (Phosphate Binder) Minerals P P P NP Phosphate Binders P ND Calcium Carbonate Minerals P PA Required ND Calcium Carbonate (Antacid) Minerals P PA Required ND Calcium Carbonate Tab 600 MG Minerals P PA Required ND Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit Minerals P PA Required B CALDOLOR NSAIDS NP PA Required B CAMBIA NSAIDS NP PA Required B CAMPTOSAR Antineoplastics - Topoisomerase I Inhibitors NP B CANASA Gi - Inflammatory Bowel Agents NP B CANCIDAS Antifungals - Assorted G Candesartan Cilexetil ARB'S NP PA Required G Candesartan Cilexetil-Hydrochlorothiazide ARB'S And Diuretics NP PA Required G Capecitabine Antineoplastics - Antimetabolites NP PA Required B CAPEX Topical - Corticosteroids - Medium Potency B CAPITAL/CODEINE Narcotics - Misc. B CAPRELSA Antineoplastics - Protein-Tyrosine Kinase Inhibitors R G Captopril ACE Inhibitors P G Captopril & Hydrochlorothiazide ACE and Thiazide Combo's P B CARAC Topical - Antineoplastics NP B CARAFATE SUS 1GM/10ML Gi - Misc. Anti-Ulcer NP B CARAFATE TAB 1GM Gi - Misc. Anti-Ulcer NP G Carbamazepine Anticonvulsants P G Carbamazepine Capsule ER 12HR Anticonvulsants P SUP 1000MG 12/15/2015 9:09:11 AM P PA Required > 90 days P NP PA Required Initial fill limited to 15 day supply. Page 14 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C G Carbamazepine SUSP Anticonvulsants NP G Carbamazepine Tablet ER 12HR Anticonvulsants NP NP B CARBATROL Anticonvulsants G Carbidopa-Levodopa Anti-Parkinsonian Drugs P G Carbidopa-Levodopa-Entacapone Anti-Parkinsonian Drugs P G Carbinoxamine Maleate Antihistamines - Other NP B CARBOCAINE Topical - Local Anesthetics NP B CARDIZEM Calcium Channel Blockers--Diltiazems NP B CARDIZEM CD Calcium Channel Blockers--Diltiazems NP B CARDIZEM LA Calcium Channel Blockers--Diltiazems NP B CARDURA BPH NP B CARDURA XL BPH NP Grandfather for seizure disorder. Grandfather for seizure disorder. PA Required PA Required B CARIMUNE NANOFILTERED Immune Serums P G Carisoprodol Muscle Relaxants NP PA Required G Carisoprodol w/ Aspirin Muscle Relaxant -Combinations NP PA Required G Carisoprodol w/ Aspirin & Codeine Muscle Relaxant -Combinations NP PA Required B CARNITOR INJ 1GM/5ML Carnitine Replenisher - Agents NP B CARNITOR SOL 1GM/10ML Carnitine Replenisher - Agents P B CARNITOR TAB 330MG Carnitine Replenisher - Agents P B CARNITOR SF SOL 1GM/10ML Carnitine Replenisher - Agents P G Carteolol HCl (Ophth) Op. Beta - Blockers P G Carvedilol Beta Blockers - Alpha / Beta P B CASODEX Antineoplastics - Antiandrogens NR B CATAPRES Antihypertensives - Central NP B CATAPRES-TTS Antihypertensives - Central P B CATHFLO ACTIVASE Tissue Plasminogen Activator P B CAYSTON Antibiotics - Misc. P B CEDAX Cephalosporins NP G Cefaclor Cap 250 MG Cephalosporins NP G Cefaclor Cap 500 MG Cephalosporins NP G Cefaclor For Susp 125 MG/5ML Cephalosporins NP G Cefaclor For Susp 250 MG/5ML Cephalosporins NP G Cefaclor For Susp 375 MG/5ML Cephalosporins NP G Cefaclor Monohydrate Tab SR 12HR 500 MG Cephalosporins NP 12/15/2015 9:09:11 AM Requires a Selected Brand Name Drug PA PA Required < 7 years of age Page 15 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C G Cefadroxil Cap 500 MG Cephalosporins P G Cefadroxil For Susp 250 MG/5ML Cephalosporins P G Cefadroxil For Susp 500 MG/5ML Cephalosporins P G Cefadroxil Tab 1 GM Cephalosporins NP G Cefazolin in D5W Cephalosporins P G Cefazolin Sodium Cephalosporins P G Cefdinir Cephalosporins P G Cefditoren Pivoxil Cephalosporins NP G Cefepime HCl Cephalosporins P G Cefepime HCl and Dextrose Cephalosporins NP G Cefixime oral suspension CEPHALOSPORINS NP G Cefotaxime Sodium Cephalosporins NP G Cefpodoxime Proxetil Cephalosporins NP G Cefprozil Cephalosporins P G Ceftazidime Cephalosporins P G Ceftibuten Cephalosporins NP B CEFTIN Cephalosporins NP G Ceftriaxone Sodium Cephalosporins P G Ceftriaxone Sodium in Dextrose Cephalosporins P G Cefuroxime Axetil Tab 250 MG Cephalosporins P G Cefuroxime Axetil Tab 500 MG Cephalosporins P G Cefuroxime Sodium Cephalosporins P B CELEBREX Cox 2 Inhibitors - Selective NP PA Required G Celecoxib Cox 2 Inhibitors - Selective NP PA Required B CELESTONE-SOLUSPAN Glucocorticoids - Mineralocorticoids NP B CELEXA Antidepressants - Selected SSRI's NP B CELLCEPT Immunosuppressants NP B CELLCEPT SUSR Immunosuppressants P B CENESTIN Estrogens - Tabs P B CENTANY AT Topical - Antibiotic NP G Cephalexin Cephalosporins P G Cephalexin CAPS 750MG Cephalosporins P G Cephalexin TABS Cephalosporins NP B CERDELGA Agents For Gaucher Disease NP 12/15/2015 9:09:11 AM Page 16 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C B CEREZYME Agents For Gaucher Disease NP B CESAMET Antiemetic - Tetrahydrocannabinol (THC) Derivatives NP O Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) Antihistamines - Non-Sedating P O Cetirizine HCl Tab 10 MG Antihistamines - Non-Sedating P O Cetirizine HCl Tab 5 MG Antihistamines - Non-Sedating P G Cevimeline HCl Artificial Saliva/Stimulants NP B CHANTIX Smoking Cessation (Oral) P PA Required B CHANTIX CONTINUING MONTHPAK Smoking Cessation (Oral) P PA Required B CHANTIX STARTING MONTH PAK Smoking Cessation (Oral) P PA Required B CHEMET Antidotes - Chelating Agents P G Chloramphenicol Sodium Succinate Lincosamides / Oxazolidinones / Leprostatics G Chlordiazepoxide HCl Anxiolytics - Benzodiazepines P G Chlordiazepoxide-Amitriptyline Psychotherapeutic Combination P G Chlorhexidine Gluconate Soln 0.12% Mouth Antiseptics P G Chloroquine Phosphate Antimalarial Agents P G Chlorothiazide Sodium Diuretics NP G Chlorothiazide Tab Diuretics P O Chlorpheniramine Maleate Antihistamines - Other P G Chlorpromazine HCl Antipsychotics - Typical NP G Chlorpropamide Diabetic - Oral Sulfonylureas P G Chlorthalidone Diuretics P G Chlorzoxazone Muscle Relaxants P NP B CHOLBAM GI - MISC. G Cholestyramine Cholesterol - Bile Sequestrants P G Cholestyramine Light Cholesterol - Bile Sequestrants P G Ciclopirox Gel 0.77% Topical - Antifungals NP G Ciclopirox Olamine Topical - Antifungals P G Ciclopirox Shampoo 1% Topical - Antifungals NP G Ciclopirox Solution 8% Topical - Antifungals P G Cidofovir Cyto-Megalovirus Agents N G Cilostazol Platelet Aggr. Inhibitors / Combo's - Misc. P B CILOXAN OIN 0.3% OP Op. Quinolones P B CILOXAN SOL 0.3% OP Op. Quinolones NP G Cimetidine 12/15/2015 9:09:11 AM Gi - H2-Antagonists Grandfather Existing Users NP P Page 17 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C B CIMZIA Anti-Inflammatories, Non-Nsaid NP B CIPRO (10%) SUS 500MG/5 Fluoroquinolones NP B CIPRO (5%) SUS 250MG/5 Fluoroquinolones NP B CIPRO HC Ear B CIPRO TABS Fluoroquinolones PA Required P NP B CIPRODEX Ear P G Ciprofloxacin HCl (Ophth) Op. Quinolones P G Ciprofloxacin HCl Tab 100 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin HCl Tab 250 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin HCl Tab 500 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin HCl Tab 750 MG (Base Equiv) Fluoroquinolones P G Ciprofloxacin IV Soln 200 MG/20ML (1%) Fluoroquinolones P G Ciprofloxacin IV Soln 400 MG/40ML (1%) Fluoroquinolones P G Ciprofloxacin-Ciprofloxacin HCl Fluoroquinolones P G Cisplatin Antineoplastics - Alkylating Agents R G Citalopram Hydrobromide Antidepressants - Selected SSRI's P B CLAFORAN Cephalosporins P B CLARINEX Antihistamines - Non-Sedating NP PA Required B CLARINEX-D Antihistamines - Non-Sedating / Decongestants NP PA Required G Clarithromycin For Susp 125 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Clarithromycin For Susp 250 MG/5ML Macrolides / Erythromycin'S / Ketolides P G Clarithromycin Tab 250 MG Macrolides / Erythromycin'S / Ketolides P G Clarithromycin Tab 500 MG Macrolides / Erythromycin'S / Ketolides P G Clarithromycin Tab SR 24HR 500 MG Macrolides / Erythromycin'S / Ketolides NP G Clemastine Fumarate Antihistamines - Other NP B CLEOCIN CAP 150MG Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN CAP 300MG Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN CAP 75MG Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN CRE 2% VAG Vaginal - Antibacterials NP B CLEOCIN SUP 100MG Vaginal - Antibacterials P B CLEOCIN IN D5W Lincosamides / Oxazolidinones / Leprostatics P B CLEOCIN PED SOL 75MG/5ML Lincosamides / Oxazolidinones / Leprostatics NP B CLEOCIN-T Topical - Acne Preparations NP B CLIMARA Estrogens - Patches NP 12/15/2015 9:09:11 AM Preferred < 8yo PA Required PA Required Page 18 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C B CLIMARA PRO Estrogen Combos NP B CLINDAGEL Topical - Acne Preparations NP G Clindamycin HCl Cap 150 MG Lincosamides / Oxazolidinones / Leprostatics P G Clindamycin HCl Cap 300 MG Lincosamides / Oxazolidinones / Leprostatics NP G Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv) Lincosamides / Oxazolidinones / Leprostatics P G Clindamycin Phosphate (Topical) Topical - Acne Preparations P G Clindamycin Phosphate Vaginal Vaginal - Antibacterials P G Clindamycin Phosphate-Benzoyl Peroxide Topical - Acne Preparations NP B CLINDESSE Vaginal - Anti Fungals NP G Clobetasol Propionate Topical - Corticosteroids - High Potency G Clobetasol Propionate Emollient Base Topical - Corticosteroids - High Potency P G Clobetasol Propionate Emulsion FOAM Topical - Corticosteroids - High Potency N G Clobetasol Propionate SOLN Topical - Corticosteroids - High Potency P B CLOBEX Topical - Corticosteroids - High Potency P B CLOBEX LIQD Topical - Corticosteroids - High Potency N PA Required N PA Required PA Required PA Required PA Required PA Required B CLODERM Topical - Corticosteroids - Medium Potency N PA Required G Clomipramine HCl Antidepressants - Tri-Cyclics P Initial fill limited to 15 day supply. G Clonazepam Anticonvulsants P G Clonazepam Tablet Disperse Anticonvulsants NP PA Required G Clonidine HCl (ADHD) Stimulants - Other Stimulants / Like Stimulants NP PA Required G Clonidine HCl Patch Weekly Antihypertensives - Central NP G Clonidine HCl Tab 0.1 MG Antihypertensives - Central P G Clonidine HCl Tab 0.2 MG Antihypertensives - Central P G Clonidine HCl Tab 0.3 MG Antihypertensives - Central P G Clopidogrel Bisulfate Platelet Aggregation Inhibitors P G Clopidogrel Bisulfate TABS 300MG Platelet Aggregation Inhibitors NP G Clorazepate Dipotassium Anxiolytics - Benzodiazepines P B CLORPRES Antihypertensive Combos G Clotrimazole (Topical) Topical - Antifungals P G Clotrimazole Troche Antifungals - Assorted P G Clotrimazole w/ Betamethasone Topical - Antifungals P G Clozapine Antipsychotics - Special Atypicals P G CLOZAPINE ODT Antipsychotics - Special Atypicals NP B CLOZARIL Antipsychotics - Special Atypicals NP 12/15/2015 9:09:11 AM PA Required < 9 years of age NP PA Required > 90 days PA Required Page 19 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C G Codeine Sulfate Narcotics - Misc. B COLAZAL Gi - Inflammatory Bowel Agents P G Colchicine Gout P G Colchicine w/ Probenecid Gout P B COLCRYS Gout NP B COLESTID Cholesterol - Bile Sequestrants NP G Colestipol HCl Cholesterol - Bile Sequestrants P G Colistimethate Sodium Antibiotics - Misc. B COLY-MYCIN S Ear NP B COLY-MYCIN-M Antibiotics - Misc. NP B COLYTE Gi - Anti - Flatulents / GI Stimulants P B COMBIGAN Op. Carbonic Anhydrase Inhibitors/Combo P B COMBIPATCH Estrogen Combos B COMBIVENT RESPIMAT Antiasthmatic - Adrenergic Combos B COMBIVIR Antiretrovirals - Combinations NP B COMETRIQ Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B COMPLERA Antiretrovirals - Combinations NP B COMTAN Parkinsons - Comt Inhibitors NP B CONCERTA Stimulants - Methylphenidate - Long Acting NP B CONDYLOX Topical - Genital Warts NP B CONZIP Narcotics - Selected NP B COPAXONE INJ 40MG/ML Multiple Sclerosis Agents – Non-Interferons NP B COPAXONE SOSY 20MG/ML Multiple Sclerosis Agents – Non-Interferons B COPEGUS Hepatitis C Agents NP B CORDARONE Antiarrhythmics NP B CORDRAN Topical - Corticosteroids - Medium Potency B COREG CR B B NP 3 tablets per 60 days allowed. PA required for quantities exceeding this limit P NP P Grandfather Existing Users PA Required PA Required P N PA Required Beta Blockers - Alpha / Beta NP PA Required COREG TABS Beta Blockers - Alpha / Beta NP CORGARD Beta Blockers - Non Selective NP B CORLANOR Sinus Node Inhibitors NP B CORTEF Glucocorticoids - Mineralocorticoids B CORTENEMA Anorectal - Misc. NP B CORTIFOAM Anorectal - Misc. NP 12/15/2015 9:09:11 AM P Page 20 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C G Cortisone Acetate Glucocorticoids - Mineralocorticoids B CORTISPORIN Topical - Antibiotic NP P B CORTISPORIN-TC Ear NP B CORTROSYN Diagnostic Drugs NP B CORZIDE Beta Blockers And Diuretic Combo'S NP B COSENTYX Anti-Inflammatories, Non-NSAID B COSOPT Op. Carbonic Anhydrase Inhibitors/Combo NP P B COSOPT PF Op. Carbonic Anhydrase Inhibitors/Combo NP G Cosyntropin Diagnostic Drugs NP B COUMADIN Anticoagulants P B COUMADIN SOLR Anticoagulants NP B COZAAR ARB'S NP B CREON Gi - Digestive Enzymes P B CRESTOR Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P B CRIXIVAN Antiretrovirals - Protease Inhibitors R G Cromolyn Sodium Antiasthmatic - Antiinflammatory Agents P G Cromolyn Sodium (Mastocytosis) Gi - Anti - Flatulents / GI Stimulants P G Cromolyn Sodium (Ophth) Op. Antiallergics - Mast Cell Stabilizers B CUBICIN Lincosamides / Oxazolidinones / Leprostatics NP B CUPRIMINE Chelating Agents NP B CUTIVATE Topical - Corticosteroids - Medium Potency B CUVPOSA Gi - Antidiarrheal / Antacid - Misc. G Cyanocobalamin Inj 1000 MCG/ML PA Required PA Required P N PA Required NP Vitamins P ND Cyanocobalamin Tab 1000 MCG Vitamins NP PA Required ND Cyanocobalamin Tab CR 1000 MCG Vitamins NP PA Required NP B CYCLESSA Contraceptives - Tri-Phasic Combinations G Cyclobenzaprine HCl Muscle Relaxants P B CYCLOGYL Op. Cycloplegics NP B CYCLOMYDRIL Op. Cycloplegics NP G Cyclopentolate HCl Op. Cycloplegics P G Cyclophosphamide Antineoplastics - Nitrogen Mustards NR G Cycloserine Antimycobacterials / Antituberculosis NP G Cyclosporine Immunosuppressants P G Cyclosporine Modified (For Microemulsion) Immunosuppressants P 12/15/2015 9:09:11 AM Page 21 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR C B CYMBALTA Antidepressants - Selected SSRI's NP PA Required G Cyproheptadine HCl Antihistamines - Other NP PA Required B CYSTAGON Urological - Misc. NP B CYSTARAN Op. Misc NP G Cytarabine Antineoplastics - Antimetabolites NR B CYTOGAM Immune Serums NP B CYTOMEL Thyroid Hormones P B CYTOTEC Gi - Prostaglandins NP B CYTOVENE Cyto-Megalovirus Agents NP B D.H.E. 45 Migraine - Ergotamine Derivatives NP B Daklinza Hepatitis C Agents NP D B DALIRESP Phosphodiesterase Inhibitors NP G Danazol Androgens - Anabolics NP PA Required B DANTRIUM Muscle Relaxants NP PA Required G Dantrolene Sodium Muscle Relaxants NP PA Required G Dapsone Lincosamides / Oxazolidinones / Leprostatics B DARAPRIM Antimalarial Agents NP B DAYPRO NSAIDS NP B DAYTRANA B DDAVP INJ 4MCG/ML Vasopressins NP PA Required B DDAVP SOL 0.01% Vasopressins NP PA Required B DDAVP SPR 0.01% Vasopressins NP PA Required B DDAVP TABS Vasopressins NP PA Required G Deferoxamine Mesylate Antidotes B DELESTROGEN Estrogens - Tabs NP B DELZICOL Gi - Inflammatory Bowel Agents NP Stimulants - Methylphenidate - Long Acting CAP 400MG P P PA Required >= 21 yo. P B DEMADEX Diuretics NP G Demeclocycline HCl Tetracyclines NP B DEMEROL Narcotics - Misc. NP B DEMSER Agents For Pheochromocytoma NP B DENAVIR Topical - Antivirals NP B DEPACON Anticonvulsants NP B DEPAKENE Anticonvulsants NP 12/15/2015 9:09:11 AM PA Required PA Required Page 22 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR D B DEPAKOTE Anticonvulsants NP B DEPAKOTE ER Anticonvulsants NP B DEPAKOTE SPRINKLES Anticonvulsants P B DEPEN TITRATABS Chelating Agents P B DEPOCYT Antineoplastics - Antimetabolites B DEPO-ESTRADIOL Estrogens - Tabs P B DEPO-MEDROL Glucocorticoids - Mineralocorticoids N B DEPO-PROVERA Contraceptives - Injectable NP B DEPO-PROVERA Antineoplastics - Progestins R B DEPO-TESTOSTERONE Androgens - Anabolics B DERMA-SMOOTHE/FS BODY B DERMA-SMOOTHE/FS SCALP B DERMATOP Topical - Corticosteroids - Medium Potency B DERMOTIC Ear NP B DESFERAL Antidotes NP G Desipramine HCl Antidepressants - Tri-Cyclics NP Grandfather Existing Users G Desloratadine Antihistamines - Non-Sedating NP PA Required G Desmopressin Acetate Vasopressins P PA Required G Desmopressin Acetate Refrigerated Vasopressins P PA Required G Desmopressin Acetate Spray Vasopressins P PA Required G Desmopressin Acetate Spray Refrigerated Vasopressins P PA Required B DESOGEN Contraceptives - Monophasic Combination O/C'S P G Desogest-Ethin Est Tab 0.1-0.025/0.125-0.025/0.15-0.025MG-MG Contraceptives - Tri-Phasic Combinations P G Desogestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P G Desogestrel-Ethinyl Estradiol (Biphasic) Contraceptives - Monophasic Combination O/C'S P Grandfather for seizure disorder. NR NP PA Required Topical - Corticosteroids - Medium Potency N PA Required Topical - Corticosteroids - Medium Potency N PA Required N PA Required B DESONATE Topical - Corticosteroids - Low Potency N PA Required G Desonide Topical - Corticosteroids - Low Potency N PA Required B DESOWEN Topical - Corticosteroids - Low Potency N PA Required G Desoximetasone Topical - Corticosteroids - High Potency N PA Required B DESOXYN Stimulants NP PA Required G Desvenlafaxine Antidepressants - Selected SSRI's NP PA Required B DETROL Antispasmodics NP Initial fill limited to 15 day supply. B DETROL LA Antispasmodics - Long Acting NP Initial fill limited to 15 day supply. G Dexamethasone Glucocorticoids - Mineralocorticoids 12/15/2015 9:09:11 AM P Page 23 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR D B DEXAMETHASONE INTENSOL Glucocorticoids - Mineralocorticoids P G Dexamethasone Sodium Phosphate Glucocorticoids - Mineralocorticoids P G Dexamethasone Sodium Phosphate (Ophth) Op. Antiinflammatory / Steroids Ophth. B DEXEDRINE Stimulants - Amphetamines - Long Acting B DEXILANT Gi - Proton Pump Inhibitor G Dexmethylphenidate HCl Stimulants - Methylphenidate G Dexmethylphenidate HCl Stimulants - Methylphenidate - Long Acting NP NP P NP PA Required P P PA Required >= 21 yo. PA Required B DEXPAK Glucocorticoids - Mineralocorticoids G Dexrazoxane Antineoplastics - Cardiac Protective Agents G Dextroamphetamine Sulfate Stimulants - Amphetamines - Long Acting NP PA Required G Dextroamphetamine Sulfate Stimulants - Amphetamines - Short Acting NP PA Required O Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML Cough/Cold - Antitussive-Expectorant P G Dextrose Electrolytes/ Nutritionals P G Dextrose in Lactated Ringers Electrolytes/ Nutritionals P G Dextrose w/ Sodium Chloride Electrolytes/ Nutritionals P B DIABETA Diabetic - Oral Sulfonylureas P B DIALYVITE/ TAB ZINC Vitamins - Misc. P B DIAMOX Diuretics P B DIASTAT Anticonvulsants P G Diazepam Anxiolytics - Benzodiazepines P G Diazepam (Anticonvulsant) Gel Anticonvulsants NP B DICLEGIS Antiemetic - Anticholinergic / Dopaminergic NP G Diclofenac Potassium NSAIDS P G Diclofenac Sodium NSAIDS P G Diclofenac Sodium (Actinic Keratoses) Topical - Antineoplastics G Diclofenac Sodium (Ophth) Op. Nsaid'S G Diclofenac Sodium (Topical) NSAIDS NP PA Required G Diclofenac Sodium Tablet ER 24HR NSAIDS NP PA Required G Diclofenac w/ Misoprostol NSAIDS NP PA Required G Dicloxacillin Sodium Beta-Lactams / Clavulanate Combo'S G Dicyclomine HCl Gi - Antidiarrheal / Antacid - Misc. P G Didanosine Antiretrovirals - Rti-Nucleoside Analogues-Purines R B DIFFERIN CRE 0.1% Topical - Acne Preparations P PA Required B DIFFERIN GEL 0.1% Topical - Acne Preparations P PA Required 12/15/2015 9:09:11 AM R PA Required Initial fill limited to 15 day supply. NP P P Page 24 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR D B DIFFERIN Topical - Acne Preparations P PA Required B DIFFERIN LOTN GEL 0.3% Topical - Acne Preparations NP PA Required B DIFICID Macrolides / Erythromycin'S / Ketolides NP G Diflorasone Diacetate Cream 0.05% Topical - Corticosteroids - High Potency N PA Required G Diflorasone Diacetate Oint 0.05% Topical - Corticosteroids - High Potency N PA Required NP PA Required B DIFLUCAN Antifungals - Assorted G Diflunisal Analgesics - Misc. G Digoxin Cardiac Glycosides P G Digoxin IJ Cardiac Glycosides NP G Dihydroergotamine Mesylate Migraine - Ergotamine Derivatives NP B DILANTIN Anticonvulsants NP B DILANTIN CAPS 30MG Anticonvulsants P B DILANTIN INFATABS Anticonvulsants N Grandfather for seizure disorder. B DILANTIN SUSP Anticonvulsants NP Grandfather for seizure disorder. B DILATRATE SR Antianginals--Isosorbide Nitrate NP NP P Grandfather for seizure disorder. B DILAUDID Narcotics - Misc. G Diltiazem HCl Calcium Channel Blockers--Diltiazems P G Diltiazem HCl Coated Beads Calcium Channel Blockers--Diltiazems NP G Diltiazem HCl Extended Release Beads Calcium Channel Blockers--Diltiazems P B DIOVAN ARB'S NP PA Required B DIOVAN HCT ARB'S And Diuretics NP PA Required B DIPENTUM Gi - Inflammatory Bowel Agents P G Diphenhydramine HCl Antihistamines - Other P G Diphenoxylate w/ Atropine Gi - Antiperistaltic Agents P B DIPROLENE Topical - Corticosteroids - Medium Potency N PA Required B DIPROLENE AF CRE 0.05% Topical - Corticosteroids - High Potency N PA Required B DIPROLENE OINT Topical - Corticosteroids - High Potency N PA Required G Dipyridamole Platelet Aggregation Inhibitors P G Disopyramide Phosphate Antiarrhythmics P G Disulfiram Alcohol Deterrents P B DITROPAN XL Antispasmodics - Long Acting NP B DIURIL Diuretics NP G Divalproex Sodium Anticonvulsants P G Divalproex Sodium Cap Sprinkle Anticonvulsants NP LOT 0.05% 12/15/2015 9:09:11 AM PA Required Page 25 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR D G Divalproex Sodium Tablet ER 24HR Anticonvulsants B DIVIGEL Estrogens - Patches NP P NP B DOLOPHINE Narcotics -Long Acting G Donepezil Hydrochloride Alzheimer - Cholinomimetics P PA Required Restricted to persons 40 years of age and older. G Donepezil Hydrochloride TABS HCL 23MG Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B DORAL Sedative/Hypnotics - Benzodiazepines NP PA Required B DORYX Tetracyclines NP PA Required G Dorzolamide HCl Op. Carbonic Anhydrase Inhibitors/Combo P G Dorzolamide HCl-Timolol Maleate Op. Carbonic Anhydrase Inhibitors/Combo P B DOVONEX Anti-Psoriatics - Non-Biologicals G Doxazosin Mesylate BPH NP P G Doxepin HCl Antidepressants - Tri-Cyclics P G Doxercalciferol Hyperparathyroid Treatment - Vitamin D Analogs B DOXIL Antineoplastics - Antibiotics G Doxorubicin HCl Antineoplastics - Antibiotics G Doxycycline (Monohydrate) Tetracyclines NP G Doxycycline (Monohydrate) CAPS 100MG Tetracyclines P G Doxycycline (Monohydrate) CAPS 50MG Tetracyclines P G Doxycycline Hyclate Tetracyclines NP G Doxycycline Hyclate TBEC Tetracyclines NP G Dronabinol Antiemetic - Tetrahydrocannabinol (THC) Derivatives NP G Droperidol Anxiolytics - Misc. P G Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG Contraceptives - Monophasic Combination O/C'S N G Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG Contraceptives - Monophasic Combination O/C'S P B DROXIA Antineoplastics - Misc. B DUAC Topical - Acne Preparations B DUAVEE Estrogens - Tabs NP B DUETACT Diabetic - Thiazol NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B DUEXIS NSAIDS NP PA Required NP R R NR N B DULERA Antiasthmatic - Adrenergic Combos P G Duloxetine HCl Antidepressants - Selected SSRI's P B DUOPA ANTI-PARKINSONIAN DRUGS 12/15/2015 9:09:11 AM PA Required PA Required NP Page 26 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR D B DURAGESIC Narcotics -Long Acting B DUREZOL Op. Antiinflammatory / Steroids Ophth. NP B DUTOPROL Beta Blockers And Diuretic Combo'S NP B DYAZIDE Diuretics NP B DYMISTA Nasal Steroid/Antihistamine Combos NP B DYSPORT Neuromuscular Blocking Agents NP PA Required N E B E.E.S. GRANULES Macrolides / Erythromycin'S / Ketolides NP B EC-NAPROSYN NSAIDS NP G Econazole Nitrate Topical - Antifungals NP B EDARBI ARB'S NP PA Required B EDARBYCLOR ARB'S And Diuretics NP PA Required B EDECRIN Diuretics B EDLUAR Sedative/Hypnotics - Non-Benzodiazepines B EDURANT Antiretrovirals - Rti-Non-Nucleoside Analogues B EFFEXOR XR Antidepressants - Selected SSRI's NP B EFFIENT Platelet Aggregation Inhibitors NP B EFUDEX Topical - Antineoplastics P B ELDEPRYL Anti-Parkinsonian Drugs NP B ELELYSO Agents For Gaucher Disease NP B ELESTAT Op. Antiallergics - Antihistamines NP B ELESTRIN Estrogens - Patches NP B ELIDEL Topical - Immunomodulators NP B ELIGARD Antineoplastics - Lhrh Analogs B ELIMITE Topical - Scabicides And Pediculicides B ELIPHOS Phosphate Binders B ELIQUIS Anticoagulants B ELIXOPHYLLIN Antiasthmatic - Xanthines P B ELLA Contraceptives - Emergency Contraceptive P B ELMIRON B ELOCON CRE 0.1% Topical - Corticosteroids - Medium Potency N PA Required B ELOCON LOT 0.1% Topical - Corticosteroids - Medium Potency N PA Required B ELOCON OIN 0.1% Topical - Corticosteroids - Medium Potency N PA Required B ELOCTATE Urological - Misc. 12/15/2015 9:09:11 AM Antihemophilic Agents PA Required P NP P R PA Required PA Required < 18 years of age PA Required PA Required < 18 years of age NP P NP PA Required NP NR Page 27 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR E B EMADINE Op. Antiallergics - Antihistamines NP B Embeda Narcotics -Long Acting NP B EMCYT Antineoplastics - Estrogens B EMEND Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B EMSAM Antidepressants - Mao Inhibitors NP Grandfather Existing Users B EMTRIVA Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines B ENABLEX Antispasmodics - Long Acting G Enalapril Maleate ACE Inhibitors P G Enalapril Maleate & Hydrochlorothiazide ACE and Thiazide Combo's P G Enalaprilat ACE Inhibitors B ENBREL Anti-Inflammatories, Non-Nsaid B ENJUVIA Estrogens - Tabs G ENOXAPARIN SODIUM SYRINGES Anticoagulants P G ENOXAPARIN SODIUM VIALS Anticoagulants P G Entacapone Parkinsons - Comt Inhibitors P G Entecavir Hepatitis B Only NP B ENTOCORT EC Glucocorticoids - Mineralocorticoids NP B Entresto ARB Combinations NP B EPANED ACE Inhibitors G Ephedrine Sulfate (Pressors) Pressors B EPIDUO Topical - Acne Preparations B EPIFOAM Topical - Steroid Local Anesthetics NP G Epinastine HCl (Ophth) Op. Antiallergics - Antihistamines NP G Epinephrine Anaphylaxis Therapy NP G Epinephrine HCl Antiasthmatic - Mixed Adrenergics B EPIPEN Anaphylaxis Therapy P B EPIVIR Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines R G Eplerenone Diuretics B EPOGEN Erythropoeisis Stimulating Agents G Epoprostenol Sodium Pulmonary Anti-Hypertensives G Eprosartan Mesylate ARB'S B EPZICOM Antiretrovirals B EQUETRO Anticonvulsants B ERBITUX Antineoplastics - Antimetabolites 12/15/2015 9:09:11 AM PA Required R R NP Initial fill limited to 15 day supply. NP P PA Required NP P PA Required Preferred < 8yo NP P PA Required P P PA Required NP PA Required P PA Required NP PA Required P NP R PA Required Page 28 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR E ND Ergocalciferol Soln 8000 Unit/ML Vitamins NP G Ergoloid Mesylates Neurologics - Misc. B ERIVEDGE Antineoplastics - Antimetabolites NR B ERTACZO Topical - Antifungals NP B ERYPED Macrolides / Erythromycin'S / Ketolides NP NP B ERY-TAB Macrolides / Erythromycin'S / Ketolides G Erythromycin (Acne Aid) Topical - Acne Preparations G Erythromycin (Ophth) Op. Antibiotics G Erythromycin Base Macrolides / Erythromycin'S / Ketolides NP G Erythromycin Ethylsuccinate Macrolides / Erythromycin'S / Ketolides NP NP P PA Required PA Required P B ESBRIET Idiopathic Pulmonary Fibrosis G Escitalopram Oxalate Antidepressants - Selected SSRI's G Esomeprazole Strontium Gi - Proton Pump Inhibitor G Estazolam Sedative/Hypnotics - Benzodiazepines B ESTRACE Estrogens - Tabs NP NP PA Required P NP PA Required P B ESTRACE Vaginal - Estrogens G Estradiol Estrogens - Tabs P G Estradiol & Norethindrone Acetate Estrogen Combos NP B Estradiol Bi-Weekly Estrogens - Patches NP G Estradiol Valerate Estrogens - Tabs NP G Estradiol Weekly Estrogens - Patches P B ESTRING Vaginal - Estrogens NP G Estropipate Estrogens - Tabs P B ESTROSTEP FE Contraceptives - Tri-Phasic Combinations P G Eszopiclone Sedative/Hypnotics - Non-Benzodiazepines P G Ethambutol HCl Antimycobacterials / Antituberculosis G Ethosuximide CAPS Anticonvulsants NP G Ethosuximide Soln 250 MG/5ML Anticonvulsants P G Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G Etidronate Disodium Osteoporosis NP G Etodolac CAPS NSAIDS NP G Etodolac Tab 400 MG NSAIDS P G Etodolac Tab 500 MG NSAIDS P G Etodolac Tab SR 24HR 400 MG NSAIDS NP 12/15/2015 9:09:11 AM PA Required P P PA Required PA Required Page 29 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR E G Etodolac Tab SR 24HR 500 MG NSAIDS NP PA Required G Etodolac Tab SR 24HR 600 MG NSAIDS NP PA Required G Etoposide Antineoplastics - Mitotic Inhibitors NR B EURAX Topical - Scabicides And Pediculicides NP B EVAMIST Estrogens - Patches NP B EVEKEO STIMULANTS NP B EVISTA Osteoporosis NP B EVOCLIN Topical - Acne Preparations NP B EVOTAZ Antiretrovirals - Combinations B EVOXAC Artificial Saliva/Stimulants NP B EXALGO Narcotics -Long Acting NP B EXELDERM Topical - Antifungals NP B EXELON CAP Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B EXELON DIS Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. G Exemestane Antineoplastics - Aromatase Inhibitors P B EXFORGE Arb/Ccb P PA required if ACE-I not previously filled. B EXFORGE HCT ARB/CCB Plus Diuretics P PA required if ACE-I not previously filled. B EXJADE Antidotes - Chelating Agents P PA Required B EXTAVIA Multiple Sclerosis Agents – Interferons NP B EXTINA Topical - Antifungals NP PA Required PA Required P PA Required F B FABIOR Topical - Tretinoids B FABRAZYME Agents For Fabrys Disease G Famciclovir Herpes Agents NP G Famotidine For Susp 40 MG/5ML Gi - H2-Antagonists NP G Famotidine Tab 20 MG Gi - H2-Antagonists P G Famotidine Tab 40 MG Gi - H2-Antagonists B FAMVIR Herpes Agents B FARESTON Antineoplastics - Antiestrogens B FARXIGA Diabetic - Other NP B Farydak Antineoplastics - Misc. NR B FASLODEX Antineoplastics - Estrogen Receptor Antagonist R B FAZACLO Antipsychotics - Special Atypicals N 12/15/2015 9:09:11 AM NP PA Required P P NP R PA Required Page 30 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR F B FEIBA Antihemophilic Agents NR G Felbamate Anticonvulsants NP Grandfather for seizure disorder. B FELBATOL Anticonvulsants NP Grandfather for seizure disorder. B FELDENE NSAIDS NP PA Required G Felodipine Calcium Channel Blockers--Felodipines NP B FEMARA Antineoplastics - Aromatase Inhibitors NP B FEMCON FE Contraceptives - Monophasic Combination O/C'S B FEMHRT Estrogen Combos NP B FEMRING Vaginal - Estrogens NP G Fenofibrate CAPS Cholesterol - Fibric Acid Derivatives NP G Fenofibrate Micronized Cholesterol - Fibric Acid Derivatives NP G FENOFIBRATE TABS Cholesterol - Fibric Acid Derivatives P G Fenoprofen Calcium NSAIDS NP PA Required G Fentanyl Narcotics -Long Acting NP PA Required G Fentanyl Citrate Narcotics - Misc. NP PA Required G Fentanyl Citrate SOLN Narcotics - Misc. P B FENTORA Narcotics - Misc. NP B FERRIPROX Antidotes NP Minerals P Vitamins - Misc. P ND Ferrous Gluconate Tab 324 MG (38 MG Elemental Iron) Minerals P ND Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe) Minerals P ND Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe) Minerals P ND Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) Minerals P ND Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe) G Ferrous Fumarate w/ B12-Vit C-FA-IFC P PA Required PA Required B FETZIMA Antidepressants - Selected SSRI's NP PA Required B FEXMID Muscle Relaxants NP PA Required B FINACEA Topical - Acne Preparations NP PA Required G finasteride BPH B FIORICET/CODEINE Narcotics - Misc. NP PA Required B FIORINAL/CODEINE #3 Narcotics - Misc. NP PA Required B FIRAZYR Hereditary Angioedema Agents NP B FLAGYL Antibiotics - Misc. NP B FLAGYL ER Antibiotics - Misc. NP B FLAREX Op. Antiinflammatory / Steroids Ophth. 12/15/2015 9:09:11 AM P PA Required P Page 31 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR F G Flavoxate HCl Antispasmodics P B FLEBOGAMMA Immune Serums P G Flecainide Acetate Antiarrhythmics B FLECTOR NSAIDS NP PA Required B FLOLAN Pulmonary Anti-Hypertensives NP PA Required B FLOMAX BPH NP B FLONASE Nasal Steroids NP B FLOVENT Antiasthmatic - Steroid Inhalants P B FLUARIX PF INJ 2015-16 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FLUARIX QUAD INJ 2015-16 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. G Fluconazole Antifungals - Assorted P PA Required > 90 days G Fluconazole in Dextrose Antifungals - Assorted P PA Required > 90 days G Fluconazole in NaCl Antifungals - Assorted P PA Required > 90 days G Flucytosine Antifungals - Assorted NP G Fludrocortisone Acetate Glucocorticoids - Mineralocorticoids P B FLULAVAL Influenza Agents P INJ 2015-16 Initial fill limited to 15 day supply. P PA Required Those 0-18 should be referred to the Vaccines for Children Program. B FLUMADINE Influenza Agents NP G Flunisolide (Nasal) Nasal Steroids NP G Fluocinolone Acetonide Topical - Corticosteroids - Medium Potency G Fluocinolone Acetonide (Otic) Ear P G Fluocinolone Acetonide Oil 0.01% (Body Oil) Topical - Corticosteroids - Medium Potency N PA Required G Fluocinolone Acetonide Oil 0.01% (Scalp Oil) Topical - Corticosteroids - Medium Potency N PA Required G Fluocinonide Cream 0.05% Topical - Corticosteroids - High Potency P G Fluocinonide Cream 0.1% Topical - Corticosteroids - High Potency N G Fluocinonide Emulsified Base Topical - Corticosteroids - High Potency P G Fluocinonide Gel 0.05% Topical - Corticosteroids - High Potency P G Fluocinonide Oint 0.05% Topical - Corticosteroids - High Potency P G Fluocinonide Soln 0.05% Topical - Corticosteroids - High Potency P G Fluorometholone (Ophth) Op. Antiinflammatory / Steroids Ophth. P G Fluorouracil Antineoplastics - Antimetabolites G Fluorouracil Cream 5% Topical - Antineoplastics NP G Fluorouracil Soln 2% Topical - Antineoplastics P 12/15/2015 9:09:11 AM N PA Required PA Required R Page 32 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR F G Fluorouracil Soln 5% Topical - Antineoplastics P G Fluoxetine HCl Antidepressants - Selected SSRI's P G Fluoxetine HCl (PMDD) Antidepressants - Selected SSRI's NP Initial fill limited to 15 day supply. G Fluoxetine HCl CAPS 40MG Antidepressants - Selected SSRI's NP PROZAC,FLUOXETINE HCL 40mg CAPS Use two FLUOXETINE HCL 20mg CAPS instead G Fluoxetine HCl CAPSULE DELAYED RELEASE Antidepressants - Selected SSRI's NP PA Required G Fluoxetine HCl TABS 20MG Antidepressants - Selected SSRI's NP FLUOXETINE HCL 20mg TABS - Use FLUOXETINE HCL 20mg CAPS instead G Fluphenazine Decanoate Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Fluphenazine HCl Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Flurazepam HCl Sedative/Hypnotics - Benzodiazepines P PA Required < 15 years of age G Flurbiprofen NSAIDS P G Flurbiprofen Sodium Op. Nsaid'S P G Flutamide Antineoplastics - Antiandrogens G Fluticasone Propionate Topical - Corticosteroids - Medium Potency P G Fluticasone Propionate (Nasal) Nasal Steroids P G Fluticasone Propionate LOTN Topical - Corticosteroids - Medium Potency G Fluvastatin Sodium Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations B FLUVIRIN Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FLUVIRIN PF INJ 2015-16 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. G Fluvoxamine Maleate Antidepressants - Selected SSRI's P B FLUZONE INJ PF 2015-16 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FLUZONE SPLT INJ 2015-16 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FML Op. Antiinflammatory / Steroids Ophth. P B FML Forte Op. Antiinflammatory / Steroids Ophth. N B FML LIQUIFILM Op. Antiinflammatory / Steroids Ophth. NP B FOCALIN Stimulants - Methylphenidate NP B FOCALIN XR Stimulants - Methylphenidate - Long Acting P G Folic Acid Tab 1 MG Vitamins P INJ 2015-16 12/15/2015 9:09:11 AM NR N PA Required NP PA Required PA Required >= 21 yo. Page 33 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR F B FOLOTYN Antineoplastics - Antimetabolites G Fondaparinux Sodium Anticoagulants NP R B FORFIVO XL Antidepressants - Selected SSRI's NP B FORTAMET Diabetic - Oral Biguanides NP B FORTAZ Cephalosporins NP B FORTEO Osteoporosis NP B FORTESTA Androgens -Topical NP B FORTICAL SPR 200/ACT Osteoporosis NP B FOSAMAX TAB 70MG Osteoporosis NP G Fosinopril Sodium ACE Inhibitors P G Fosinopril Sodium & Hydrochlorothiazide ACE and Thiazide Combo's NP G Fosphenytoin Sodium Anticonvulsants NP B FOSRENOL Phosphate Binders NP B FRAGMIN Anticoagulants B FREAMINE III Electrolytes/ Nutritionals NP B FROVA Migraine - Selective Serotonin Agonists (5HT)--Tabs NP B FULYZAQ Gi - Antidiarrheal / Antacid - Misc. NP NP Initial fill limited to 15 day supply. PA Required P B FURADANTIN Urological - Misc. G Furosemide Diuretics P B FUZEON Antiretrovirals - Fusion Inhibitors R B FYCOMPA Anticonvulsants PA Required NP G G Gabapentin Cap 100 MG Anticonvulsants P G Gabapentin Cap 300 MG Anticonvulsants P G Gabapentin Cap 400 MG Anticonvulsants P G Gabapentin Oral Soln 250 MG/5ML Anticonvulsants P G Gabapentin Tab 600 MG Anticonvulsants P G Gabapentin Tab 800 MG Anticonvulsants P B GABITRIL Anticonvulsants P B GABLOFEN Muscle Relaxants G Galantamine Hydrobromide Alzheimer - Cholinomimetics NP B GAMASTAN S/D Immune Serums NP B GAMMAGARD Immune Serums P 12/15/2015 9:09:11 AM P Restricted to persons 40 years of age and older. Page 34 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR G B GAMMAKED Immune Serums NP B GAMMAPLEX Immune Serums NP B GAMUNEX-C Immune Serums G Ganciclovir Sodium Cyto-Megalovirus Agents P B GASTROCROM Gi - Anti - Flatulents / GI Stimulants P G Gatifloxacin (Ophth) Op. Quinolones Fourth Generation NP B GATTEX Gi - Antiperistaltic Agents NP NP NP B GELNIQUE Antispasmodics - Long Acting G Gemcitabine HCl Antineoplastics - Antimetabolites P G Gemfibrozil Cholesterol - Fibric Acid Derivatives P B GEMZAR Antineoplastics - Antimetabolites G GENGRAF Immunosuppressants Initial fill limited to 15 day supply. NP P B GENOTROPIN Growth Hormone NP G Gentamicin in Saline Amino Glycosides P G Gentamicin Sulfate Amino Glycosides P G Gentamicin Sulfate (Ophth) Op. Antibiotics P G Gentamicin Sulfate (Topical) Topical - Antibiotic P PA Required B GEODON Antipsychotics - Atypicals G Gianvi Contraceptives - Monophasic Combination O/C'S B GIAZO Gi - Inflammatory Bowel Agents B GILENYA Multiple Sclerosis Agents – Non-Interferons B GILOTRIF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B GLASSIA Alpha-Proteinase Inhibitor NP PA Required G Glatopa MULTIPLE SCLEROSIS AGENTS NP B GLEEVEC Antineoplastics - Protein-Tyrosine Kinase Inhibitors B Gleostine ANTINEOPLASTICS - NITROSOUREAS B GLIADEL WAFER Antineoplastics - Nitrosoureas R G Glimepiride Diabetic - Oral Sulfonylureas P G Glipizide Diabetic - Oral Sulfonylureas P G Glipizide-Metformin HCl Diabetic - Sulfonylurea / Biguanide P B GLUCAGEN Diabetic - Other P B GLUCAGON EMERGENCY KIT Diabetic - Other NP B GLUCOPHAGE Diabetic - Oral Biguanides NP 12/15/2015 9:09:11 AM NP P NP P R No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months PA Required NP Page 35 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR G B GLUCOTROL Diabetic - Oral Sulfonylureas NP B GLUCOTROL XL Diabetic - Oral Sulfonylureas NP NP B GLUCOVANCE Diabetic - Sulfonylurea / Biguanide G Glyburide Diabetic - Oral Sulfonylureas P G Glyburide Micronized Diabetic - Oral Sulfonylureas P G Glyburide-Metformin Diabetic - Sulfonylurea / Biguanide P G Glycopyrrolate Injection Gi - Antidiarrheal / Antacid - Misc. NP G Glycopyrrolate TABS Gi - Antidiarrheal / Antacid - Misc. B GLYNASE Diabetic - Oral Sulfonylureas NP B GLYSET Diabetic - Alphaglucosidase P B GLYXAMBI DIABETIC - OTHER B GOLYTELY Gi - Anti - Flatulents / GI Stimulants PA Required P NP PA Required P B GRALISE Anticonvulsants NP PA Required G Granisetron HCl Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B GRANIX Granulocyte Csf NP PA Required B GRASTEK Allergenic Extracts NP PA Required G Griseofulvin Microsize TABS Antifungals - Assorted NP PA Required G GRISEOFULVIN SUS Antifungals - Assorted P G Griseofulvin Ultramicrosize Antifungals - Assorted NP B GRIS-PEG Antifungals - Assorted P PA Required > 90 days G Guanfacine er Stimulants - Other Stimulants / Like Stimulants P PA Required G Guanfacine HCl Antihypertensives - Central P B H.P. ACTHAR Glucocorticoids - Corticotropin NP PA Required B HALCION Sedative/Hypnotics - Benzodiazepines NP PA Required B HALDOL Antipsychotics - Typical NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B HALDOL DECANOATE 100 Antipsychotics - Typical NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B HALDOL DECANOATE 50 Antipsychotics - Typical NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. PA Required > 90 days PA Required H 12/15/2015 9:09:11 AM Page 36 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR H G Halobetasol Propionate Topical - Corticosteroids - High Potency N PA Required B HALOG Topical - Corticosteroids - High Potency N PA Required G Haloperidol Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Haloperidol Decanoate Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. G Haloperidol Lactate Antipsychotics - Typical P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B HARVONI Hepatitis C Agents P PA Required B HECTOROL Hyperparathyroid Treatment - Vitamin D Analogs B HELIXATE FS Antihemophilic Agents B HEMANGEOL Beta Blockers - Non Selective B HEMOFIL M Antihemophilic Agents NP Grandfather Existing Users R NP R B HEPAGAM B Immune Serums G Heparin (Porcine) in Sodium Chloride Anticoagulants P G Heparin Sodium (Porcine) Anticoagulants P B HEPSERA Hepatitis B Only P B HERCEPTIN Antineoplastics - Antimetabolites R PA Required B HETLIOZ Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B HIPREX Urological - Misc. NP B HIZENTRA Immune Serums NP B HORIZANT Restless Leg Syndrome Agents NP B HUMALOG Diabetic - Insulin B HUMALOG Diabetic - Insulin Penfills B HUMALOG MIX 50/50 Diabetic - Insulin B HUMALOG MIX 50/50 Diabetic - Insulin Penfills B HUMALOG MIX 75/25 Diabetic - Insulin B HUMALOG MIX 75/25 Diabetic - Insulin Penfills B HUMATE-P Antihemophilic Agents B HUMATROPE Growth Hormone B HUMIRA B HUMIRA PEN 12/15/2015 9:09:11 AM NP PA Required P NP PA Required P NP PA Required P NP PA Required R NP PA Required Anti-Inflammatories, Non-Nsaid P PA Required Anti-Inflammatories, Non-Nsaid P PA Required Page 37 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR H B HUMIRA PEN-CROHNS DISEASESTARTER Anti-Inflammatories, Non-Nsaid P Preferred with Conditions and allow a one time fill. B HUMIRA PEN-PSORIASIS STARTER Anti-Inflammatories, Non-Nsaid P Preferred with Conditions and allow a one time fill. O HUMULIN 70/30 Diabetic - Insulin O HUMULIN 70/30 PEN Diabetic - Insulin Penfills O HUMULIN N Diabetic - Insulin O HUMULIN N U-100 PEN Diabetic - Insulin Penfills B HUMULIN R Diabetic - Insulin B HYCAMTIN Antineoplastics - Topoisomerase I Inhibitors B HYCET Narcotics - Misc. G Hydralazine HCl Antihypertensives - Central B HYDREA Antineoplastics - Misc. G Hydrochlorothiazide Diuretics G Hydrocodone-Acetaminophen Narcotics - Misc. P G Hydrocodone-Acetaminophen TABS 10-300MG Narcotics - Misc. NP PA Required G Hydrocodone-Acetaminophen TABS 5-300MG Narcotics - Misc. NP PA Required G Hydrocodone-Acetaminophen TABS 7.5-300 Narcotics - Misc. NP PA Required G Hydrocodone-Ibuprofen Narcotics - Misc. NP PA Required G Hydrocortisone Glucocorticoids - Mineralocorticoids P G Hydrocortisone (Intrarectal) Anorectal - Misc. P G Hydrocortisone (Rectal) Anorectal - Misc. P G Hydrocortisone Acetate w/ Pramoxine Anorectal - Misc. NP G Hydrocortisone Butyrate Topical - Corticosteroids - Medium Potency N G Hydrocortisone Cream 1% Topical - Corticosteroids - Low Potency P G Hydrocortisone Cream 2.5% Topical - Corticosteroids - Low Potency P G Hydrocortisone Lotion 2.5% Topical - Corticosteroids - Low Potency P G Hydrocortisone Oint 1% Topical - Corticosteroids - Low Potency P G Hydrocortisone Oint 2.5% Topical - Corticosteroids - Low Potency P G Hydrocortisone Valerate Topical - Corticosteroids - Low Potency G Hydrocortisone w/Acetic Acid Ear NP G HYDROMORPHONE HCL INJ Narcotics - Misc. NP G Hydromorphone HCl Tab 2 MG Narcotics - Misc. P G Hydromorphone HCl Tab 4 MG Narcotics - Misc. P G Hydromorphone HCl Tab 8 MG Narcotics - Misc. P 12/15/2015 9:09:11 AM P NP PA Required P NP PA Required P R PA Required NP PA Required P NP P N PA Required PA Required PA Required Page 38 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR H G Hydroxychloroquine Sulfate Antimalarial Agents P G Hydroxyurea Antineoplastics - Misc. P G Hydroxyzine HCl SOLN Antihistamines - Other P G Hydroxyzine HCl SYRP Antihistamines - Other P G Hydroxyzine HCl Tab 25 MG Antihistamines - Other P G Hydroxyzine HCl Tab 50 MG Antihistamines - Other P G Hydroxyzine HCl TABS 10MG Antihistamines - Other P G Hydroxyzine Pamoate Antihistamines - Other P G Hydroxyzine Pamoate CAPS 100MG Antihistamines - Other NP G Hyoscyamine Sulfate Gi - Antidiarrheal / Antacid - Misc. B HYPERHEP B S/D Immune Serums NP B HYPERHEP B S/D SOLN Immune Serums P B HYPERRHO S/D Immune Serums P B HYPERTET S/D Immune Serums P B HYQVIA Immune Serums P B HYSINGLA ER Narcotics -Long Acting NP PA Required B HYZAAR ARB'S And Diuretics NP PA Required G Ibandronate Sodium Osteoporosis B IBRANCE Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B IBUDONE Narcotics - Misc. NP PA Required G Ibuprofen Susp 100 MG/5ML NSAIDS NP O Ibuprofen Susp 100 MG/5ML NSAIDS P O Ibuprofen Tab 200 MG NSAIDS P G Ibuprofen Tab 400 MG NSAIDS P G Ibuprofen Tab 600 MG NSAIDS P G Ibuprofen Tab 800 MG NSAIDS P PA Required P I NP B ICLUSIG Antineoplastics - Misc. G Ifosfamide & Mesna Antineoplastics - Combinations B ILEVRO Op. Nsaid'S NP B IMBRUVICA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR G Imipenem-Cilastatin Carbapenems NP G Imipramine HCl Antidepressants - Tri-Cyclics P G Imipramine Pamoate Antidepressants - Tri-Cyclics NP 12/15/2015 9:09:11 AM NR R PA Required Imipramine Pamoate - Use Imipramine HCL Page 39 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR I G Imiquimod Topical - Genital Warts B IMITREX Migraine - Selective Serotonin Agonists (5HT)--Injectables B IMITREX Migraine - Selective Serotonin Agonists (5HT)--Tabs B IMITREX STATDOSE REFILL Migraine - Selective Serotonin Agonists (5HT)--Injectables P PA Required> 12 Units/30 Days supply B IMITREX STATDOSE SYSTEM Migraine - Selective Serotonin Agonists (5HT)--Injectables P PA Required> 12 Units/30 Days supply B IMURAN Purine Analog NP B INCRELEX Growth Hormone NP B INCRUSE ELLIPTA Antiasthmatic - Anti-Cholinergics NP G Indapamide Diuretics B INDERAL LA Beta Blockers - Non Selective NP B INDOCIN NSAIDS NP G Indomethacin NSAIDS P G Indomethacin CPCR NSAIDS NP PA Required B INLYTA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B INNOPRAN XL Beta Blockers - Non Selective NP B INSPRA Diuretics NP B INTELENCE Antiretrovirals - Rti-Non-Nucleoside Analogues NR B INTERMEZZO Sedative/Hypnotics - Non-Benzodiazepines NP B INTRALIPID Electrolytes/ Nutritionals NP B INTRON-A Antineoplastics - Misc. NR B INTUNIV Stimulants - Other Stimulants / Like Stimulants NP B INVANZ Carbapenems B INVEGA Antipsychotics - Atypicals NP B INVEGA SUSTENNA Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B Invega Trinza Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B INVIRASE Antiretrovirals - Protease Inhibitors B INVOKAMET Diabetic - Other NP PA Required B INVOKANA Diabetic - Other NP PA Required B IOPIDINE Op. Selective Alpha Adrenergic Agonists NP 12/15/2015 9:09:11 AM P Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). P PA Required> 12 Units/30 Days supply NP PA Required PA Required P PA Required PA Required PA Required PA Required P PA Required R Page 40 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR I G Ipratropium Bromide Antiasthmatic - Anti-Cholinergics P G Ipratropium Bromide (Nasal) SOLN 0.03% Antiasthmatic - Nasal Misc. P G Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) Antiasthmatic - Nasal Misc. NP G Ipratropium-Albuterol Antiasthmatic - Adrenergic Combos P G Irbesartan ARB'S P PA required if ACE-I not previously filled. G Irbesartan-Hydrochlorothiazide ARB'S And Diuretics P PA required if ACE-I not previously filled. G Irinotecan HCl Antineoplastics - Topoisomerase I Inhibitors P G Iron Dextran Minerals P B ISENTRESS CHW 100MG Antiretrovirals P B ISENTRESS CHW 25MG Antiretrovirals P B ISENTRESS TABS Antiretrovirals P G Isoniazid Antimycobacterials / Antituberculosis P B ISOPTO ATROPINE Op. Cycloplegics B ISOPTO CARPINE Op. Miotics - Direct Acting NP B ISORDIL TITRADOSE Antianginals--Isosorbide Nitrate NP G Isosorbide Dinitrate Antianginals--Isosorbide Nitrate P G Isosorbide Mononitrate Antianginals--Isosorbide Nitrate P G Isotretinoin Acne Products: Isotretinoin G Isradipine Calcium Channel Blockers--Isradipines NP B ISTALOL Op. Beta - Blockers NP G ISTODAX Antineoplastics - Misc. NR PA Required G Itraconazole Antifungals - Assorted NP PA Required G Ivermectin Anthelmintics B Ixinity Antihemophilic Agents B JADENU Antidotes - Chelating Agents B JAKAFI Antineoplastics - Protein-Tyrosine Kinase Inhibitors B JALYN BPH B JANUMET Diabetic - Other P PA Required B JANUMET XR Diabetic - Other P PA Required B JANUVIA Diabetic - Other P PA Required B JARDIANCE Diabetic - Other NP PA Required B JENTADUETO Diabetic - Other P PA Required B JINTELI Estrogen Combos P P PA Required P NR J 12/15/2015 9:09:11 AM NP R PA Required PA Required < 18 years of age NP NP Page 41 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR J B JUBLIA Topical - Antifungals N B JUXTAPID Antihyperlipidemics NP PA Required B KADIAN Narcotics -Long Acting B KALETRA Antiretrovirals - Combinations B KALYDECO Cystic Fibrosis Agents NP PA Required B KAPVAY Stimulants - Other Stimulants / Like Stimulants NP PA Required B KAZANO Diabetic - Other NP PA Required B KEFLEX Cephalosporins NP B KENALOG Glucocorticoids - Mineralocorticoids P B KENALOG Topical - Corticosteroids - Medium Potency N B KEPPRA Anticonvulsants NP Grandfather for seizure disorder. B KEPPRA XR Anticonvulsants NP Grandfather for seizure disorder. B KERYDIN Topical - Antifungals K P R N PA Required PA Required B KETEK Macrolides / Erythromycin'S / Ketolides NP G Ketoconazole Antifungals - Assorted NP G Ketoconazole (Topical) Topical - Antifungals P G Ketoconazole (Topical) FOAM Topical - Antifungals NP G Ketoprofen NSAIDS P G Ketoprofen Capsule ER 24HR NSAIDS NP PA Required G Ketorolac Tromethamine Cox 2 Inhibitors - Selective NP PA Required G Ketorolac Tromethamine (Ophth) Op. Nsaid'S G Ketorolac Tromethamine SOLN 60MG/2ML Cox 2 Inhibitors - Selective NP PA Required B KHEDEZLA Antidepressants - Selected SSRI's NP PA Required B KINERET Anti-Inflammatories, Non-Nsaid NP PA Required B KITABIS PAK AMINO GLYCOSIDES B KLARON Topical - Acne Preparations NP PA Required B KLONOPIN Anticonvulsants NP PA Required B KOATE-DVI Antihemophilic Agents R B KOGENATE FS Antihemophilic Agents NR B KOGENATE FS BIO-SET Antihemophilic Agents NR B KOMBIGLYZE XR Diabetic - Other N B KORLYM Diabetic - Other NP B K-PHOS TAB NO 2 12/15/2015 9:09:11 AM Urological - Misc. PA Required P P PA Required P Page 42 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR K B KRISTALOSE Gi - Anti - Flatulents / GI Stimulants NP B KUVAN Phenylketonuria NP B KYNAMRO Antihyperlipidemics NP L G Labetalol HCl Beta Blockers - Alpha / Beta P G Lactated Ringer's Electrolytes/ Nutritionals P G Lactic Acid (Ammonium Lactate) Cream 12% Topical - Emollients NP ND Lactic Acid (Ammonium Lactate) Lotion 12% Topical - Emollients P G Lactulose Gi - Anti - Flatulents / GI Stimulants P G Lactulose (Encephalopathy) Gi - Anti - Flatulents / GI Stimulants B LAMICTAL Anticonvulsants NP Grandfather for seizure disorder. B LAMICTAL XR Anticonvulsants NP PA Required PA Required P B LAMISIL Antifungals - Assorted NP G Lamivudine Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines NR G Lamivudine-Zidovudine Antiretrovirals - Combinations P G Lamotrigine Anticonvulsants P G Lamotrigine Tablet Disperse Anticonvulsants NP PA Required G Lamotrigine Tablet ER 24HR Anticonvulsants NP PA Required B LANOXIN Cardiac Glycosides NP Grandfather Existing Users G Lansoprazole Gi - Proton Pump Inhibitor NP PA Required B LANTUS Diabetic - Insulin P B LANTUS SOLOSTAR Diabetic - Insulin Penfills P B LASIX Diuretics NP B LASTACAFT Op. Antiallergics - Antihistamines NP G Latanoprost Op. Prostaglandins P B LATUDA Antipsychotics - Atypicals P G Leflunomide Rheumatoid Arthritis - Non-Biologicals P B Lenvima Antineoplastics - Protein-Tyrosine Kinase Inhibitors B LESCOL Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P B LESCOL XL Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P B LETAIRIS Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist P PA Required G Letrozole Antineoplastics - Aromatase Inhibitors P Payable for members 50 years of age and older without prior authorization G Leucovorin Calcium Antineoplastics - Folic Acid Antagonists Rescue Agents R INJ 100/ML 12/15/2015 9:09:11 AM PA Required NR Page 43 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR L B LEUKERAN Antineoplastics - Nitrogen Mustards B LEUKINE Granulocyte Csf NP R G Leuprolide Acetate Antineoplastics - Lhrh Analogs NR B LEVAQUIN Fluoroquinolones NP B LEVAQUIN SOLN Fluoroquinolones P B LEVATOL Beta Blockers - Non Selective P B LEVEMIR Diabetic - Insulin P B LEVEMIR Diabetic - Insulin Penfills P G Levetiracetam Anticonvulsants P G Levetiracetam Tablet ER 24HR Anticonvulsants NP G Levobunolol HCl Op. Beta - Blockers P G Levocarnitine Inj 200 MG/ML Carnitine Replenisher - Agents P G Levocarnitine Oral Soln 1 GM/10ML (10%) Carnitine Replenisher - Agents NP G Levocarnitine Tab 330 MG Carnitine Replenisher - Agents NP G Levocetirizine Dihydrochloride Antihistamines - Non-Sedating NP G Levofloxacin Fluoroquinolones P G Levofloxacin in D5W Fluoroquinolones P G Levofloxacin Ophth Soln 0.5% Op. Quinolones NP G Levofloxacin SOLN 25MG/ML Fluoroquinolones NP G Levonorgestrel & Ethinyl Estradiol Tab 0.1 MG-20 MCG Contraceptives - Monophasic Combination O/C'S P G Levonorgestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P G Levonorgestrel (Emergency OC) Contraceptives - Emergency Contraceptive P G Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-30MG-MCG Contraceptives - Tri-Phasic Combinations P G Levonorgestrel-Ethinyl Estradiol (91-Day) TABS Contraceptives - Monophasic Combination O/C'S P G Levonorgestrel-Ethinyl Estradiol (Continuous) Contraceptives - Monophasic Combination O/C'S NP G Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab 0.01MG(7) Contraceptives - Monophasic Combination O/C'S NP G Levothyroxine Sodium For IV Inj 500 MCG Thyroid Hormones NP G Levothyroxine Sodium Tab 100 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 112 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 125 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 137 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 150 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 175 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 200 MCG Thyroid Hormones P 12/15/2015 9:09:11 AM PA Required PA Required PA Required PA Required Page 44 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR L G Levothyroxine Sodium Tab 25 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 300 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 50 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 75 MCG Thyroid Hormones P G Levothyroxine Sodium Tab 88 MCG Thyroid Hormones P B LEVSIN Gi - Antidiarrheal / Antacid - Misc. NP B LEXAPRO Antidepressants - Selected SSRI's NP B LEXIVA B LIALDA G Antiretrovirals - Protease Inhibitors TAB 1.2GM R Gi - Inflammatory Bowel Agents NP Lidocaine HCl (Cardiac) Antiarrhythmics NP G Lidocaine HCl Cream 3% Topical - Local Anesthetics P G Lidocaine HCl Gel 2% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 1% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 1.5% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 2% Topical - Local Anesthetics P G Lidocaine HCl Local Inj 4% Topical - Local Anesthetics P G Lidocaine HCl Local Preservative Free (PF) Inj 0.5% Topical - Local Anesthetics P G Lidocaine HCl Local Preservative Free (PF) Inj 1% Topical - Local Anesthetics P G Lidocaine HCl Local Preservative Free (PF) Inj 2% Topical - Local Anesthetics P G Lidocaine HCl Lotion 3% Topical - Local Anesthetics P G Lidocaine HCl Soln 4% Topical - Local Anesthetics P G Lidocaine HCl Viscous Soln 2% Mouth - Anesthetics Topical Oral P G Lidocaine Oint 5% Topical - Local Anesthetics P G Lidocaine w/ Epinephrine Topical - Local Anesthetics P G Lidocaine-Hydrocortisone Acetate (Rectal) Anorectal - Misc. G Lidocaine-Hydrocortisone Acetate (Rectal) Topical - Steroid Local Anesthetics P G Lidocaine-Prilocaine Topical - Local Anesthetics P B LIDODERM Topical - Local Anesthetics NP B LINCOCIN Lincosamides / Oxazolidinones / Leprostatics NP G Lindane Topical - Scabicides And Pediculicides NP G Linezolid Lincosamides / Oxazolidinones / Leprostatics B LINZESS GI, Constipation - IBS-OIC B LIORESAL INTRATHECAL Muscle Relaxants 12/15/2015 9:09:11 AM NP P NP PA Required Authorized Generic Distributed by Teva Pharmaceuticals is Preferred with Prior Authorization PA Required P Page 45 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR L G Liothyronine Sodium Thyroid Hormones NP B LIPITOR Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP B LIPOFEN Cholesterol - Fibric Acid Derivatives NP B LIPOSYN Electrolytes/ Nutritionals P G Lisinopril ACE Inhibitors P G Lisinopril & Hydrochlorothiazide ACE and Thiazide Combo's P G Lithium Carbonate Cap 150 MG Lithium P G Lithium Carbonate Cap 300 MG Lithium P G Lithium Carbonate Cap 600 MG Lithium NP G Lithium Carbonate Tab 300 MG Lithium P G Lithium Carbonate Tab CR 300 MG Lithium P G Lithium Carbonate Tab CR 450 MG Lithium P B LITHOBID Lithium NP B LITHOSTAT Urological - Misc. NP B LIVALO Cholesterol - Hmg COA + Absorb Inhibitors NP B LO LOESTRIN FE Contraceptives - Monophasic Combination O/C'S NP B LODOSYN Anti-Parkinsonian Drugs NP B LOESTRIN Contraceptives - Monophasic Combination O/C'S NP B LOESTRIN FE 1.5/30 Contraceptives - Monophasic Combination O/C'S NP B LOESTRIN FE 1/20 Contraceptives - Monophasic Combination O/C'S NP B LOFIBRA Cholesterol - Fibric Acid Derivatives NP B LOMOTIL Gi - Antiperistaltic Agents NP G Lomustine Antineoplastics - Nitrosoureas P G Loperamide HCl Cap 2 MG Gi - Antiperistaltic Agents P O Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) Gi - Antiperistaltic Agents P O Loperamide HCl Tab 2 MG Gi - Antiperistaltic Agents B LOPID Cholesterol - Fibric Acid Derivatives NP B LOPRESSOR Beta Blockers - Cardio Selective NP B LOPRESSOR HCT Beta Blockers And Diuretic Combo'S NP B LOPROX SHAMPOO Topical - Antifungals NP O Loratadine Syrup 5 MG/5ML Antihistamines - Non-Sedating P O Loratadine Tab 10 MG Antihistamines - Non-Sedating P G Lorazepam Anxiolytics - Benzodiazepines P B LORAZEPAM INTENSOL Anxiolytics - Benzodiazepines NP 12/15/2015 9:09:11 AM Grandfather Existing Users P PA Required Page 46 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR L G Losartan Potassium ARB'S P PA required if ACE-I not previously filled. G Losartan Potassium & Hydrochlorothiazide ARB'S And Diuretics P PA required if ACE-I not previously filled. B LOSEASONIQUE Contraceptives - Monophasic Combination O/C'S B LOTEMAX Op. Antiinflammatory / Steroids Ophth. B LOTENSIN ACE Inhibitors NP B LOTENSIN HCT ACE and Thiazide Combo's NP B LOTREL ACE Inhibitors And Calcium Channel Blockers NP B LOTRISONE Topical - Antifungals NP B LOTRONEX Gi - Irritable Bowel Syndrome Agents NP G Lovastatin Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P B LOVAZA Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B LOVENOX SYRINGES Anticoagulants NP NP NP P B LOVENOX VIALS Anticoagulants G Loxapine Succinate Antipsychotics - Typical P B LOXITANE Antipsychotics - Typical NP B LUMIGAN Op. Prostaglandins NP B LUNESTA Sedative/Hypnotics - Non-Benzodiazepines NP B LUPANETA PACK Lhrh/Gnrh Agonist Analog Pituitary Suppressants NP B LUPR DEP-PED INJ 11.25MG Central Precocious Puberty Agents P B LUPR DEP-PED INJ 15MG Central Precocious Puberty Agents P B LUPR DEP-PED INJ 7.5MG Central Precocious Puberty Agents P B LUPRON DEPOT Antineoplastics - Lhrh Analogs R B LUPRON DEPOT-PED KIT 11.25MG Central Precocious Puberty Agents P B LUPRON DEPOT-PED KIT 30MG Central Precocious Puberty Agents P B LUXIQ Topical - Corticosteroids - Medium Potency N PA Required B LYNPARZA Antineoplastics - Parp Inhibitors NR PA Required B LYRICA Anticonvulsants NP PA Required B LYSODREN Antineoplastics - Antiadrenals B LYSTEDA Hemostatic B MACROBID Urological - Misc. NP B MACRODANTIN Urological - Misc. NP B MAGNEBIND 400 Minerals P O Magnesium Hydroxide Susp 400 MG/5ML Gi - Misc. P PA Required R NP M 12/15/2015 9:09:11 AM PA Required Page 47 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR M ND Magnesium Oxide Tab 400 mg Gi - Antidiarrheal / Antacid - Misc. P G Magnesium Sulfate Inj 4% Minerals P G Magnesium Sulfate Inj 50% Minerals P G Magnesium Sulfate Inj 8% Minerals P B MALARONE Antimalarial Agents P G Malathion Topical - Scabicides And Pediculicides G Maprotiline HCl Antidepressants - Selected SSRI's P B MARCAINE Topical - Local Anesthetics P B MARCAINE W/O EPI Topical - Local Anesthetics P B MARINOL Antiemetic - Tetrahydrocannabinol (THC) Derivatives B MATULANE Antineoplastics - Misc. B MAVIK ACE Inhibitors NP B MAXALT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B MAXALT-MLT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B MAXIDEX Op. Antiinflammatory / Steroids Ophth. P B MAXITROL Op. Antiinflammatory / Steroids Ophth. NP B MAXZIDE Diuretics NP O Meclizine HCl Antiemetic - Anticholinergic / Dopaminergic G Meclofenamate Sodium NSAIDS B MEDROL PAK 4MG Glucocorticoids - Mineralocorticoids P B MEDROL TAB 16MG Glucocorticoids - Mineralocorticoids NP B MEDROL TAB 2MG Glucocorticoids - Mineralocorticoids NP B MEDROL TAB 32MG Glucocorticoids - Mineralocorticoids NP B MEDROL TAB 4MG Glucocorticoids - Mineralocorticoids P B MEDROL TAB 8MG Glucocorticoids - Mineralocorticoids NP G Medroxyprogesterone Acetate Progestins P G Medroxyprogesterone Acetate (Contraceptive) Contraceptives - Injectable P G Mefenamic Acid NSAIDS G Mefloquine HCl Antimalarial Agents B MEGACE ES Progestins NP NP Initial fill limited to 15 day supply. NP R P NP NP PA Required PA Required P B MEGACE ORAL Antineoplastics - Progestins NR G Megestrol Acetate Antineoplastics - Progestins R B MEKINIST Antineoplastics - Protein-Tyrosine Kinase Inhibitors G Meloxicam Cox 2 Inhibitors - Selective 12/15/2015 9:09:11 AM PA Required NR Requires a Selected Brand Name Drug PA PA Required P Page 48 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR M G Melphalan HCl Antineoplastics - Nitrogen Mustards G Memantine Alzheimer - Cholinomimetics NR B MENEST Estrogens - Tabs B MENOSTAR Estrogens - Patches NP P P B MENTAX Topical - Antifungals NP G Meperidine HCl SOLN Narcotics - Misc. NP G Meperidine HCl Tab 100 MG Narcotics - Misc. P G Meperidine HCl Tab 50 MG Narcotics - Misc. P B MEPHYTON Vitamins P G Mepivacaine HCl Topical - Local Anesthetics G Meprobamate Anxiolytics - Misc. P B MEPRON Antiprotozoal Agents P G Mercaptopurine Antineoplastics - Antimetabolites P G Meropenem Carbapenems P NP B MERREM Carbapenems Mesalamine Gi - Inflammatory Bowel Agents G Mesna Antineoplastics - Urinary Tract Protective Agents NR B MESNEX Antineoplastics - Urinary Tract Protective Agents R B MESTINON Neurologics - Misc. P B MESTINON TABS Neurologics - Misc. NP B MESTINON TIMESPAN Neurologics - Misc. P B METADATE Stimulants - Methylphenidate - Long Acting P G Metaproterenol Sulfate Antiasthmatic - Beta - Adrenergics NP G Metaxalone Muscle Relaxants NP G Metformin HCl Diabetic - Oral Biguanides P G Metformin HCl Tablet ER 24HR 500MG ER Diabetic - Oral Biguanides NP G Methadone HCl CONC Narcotics -Long Acting P G Methadone HCl SOLN Narcotics -Long Acting P G Methadone HCl Tab 10 MG Narcotics -Long Acting P G Methadone HCl Tab 5 MG Narcotics -Long Acting P G Methadone HCl Tab For Oral Susp 40 MG Narcotics -Long Acting P B METHADOSE Narcotics -Long Acting P B METHADOSE SF CON 10MG/ML Narcotics -Long Acting P CON 10MG/ML 12/15/2015 9:09:11 AM PA Required NP G SYP 60MG/5ML Restricted to persons 40 years of age and older. P PA Required >= 21 yo. PA Required PA Required Page 49 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR M G Methamphetamine HCl Stimulants NP G Methazolamide Diuretics NP G Methenamine Hippurate Urological - Misc. NP G Methenamine Mandelate Urological - Misc. P G Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal Urological - Misc. NP G Methimazole Antithyroid Therapies B METHITEST Androgens - Anabolics G Methocarbamol Muscle Relaxants P G Methotrexate Sodium Antineoplastics - Antimetabolites P G Methoxsalen Rapid Anti-Psoriatics - Non-Biologicals NP G Methscopolamine Bromide Gi - Antidiarrheal / Antacid - Misc. P G Methyclothiazide Diuretics P G Methyldopa Antihypertensives - Central P G Methyldopa & Hydrochlorothiazide Antihypertensive Combos P G Methylergonovine Maleate Oxytocics P PA Required P NP PA Required B Methylin oral solution Stimulants - Methylphenidate P PA Required >= 21 yo. G Methylphenidate HCl Stimulants - Methylphenidate P PA Required >= 21 yo. G Methylphenidate HCl Capsule ER 24HR Stimulants - Methylphenidate - Long Acting NP G Methylphenidate HCl Tab SA OSM 18 MG Stimulants - Methylphenidate - Long Acting P Preferred product is authorized generic distributed by Watson/Actavis. PA Required >= 21 yo. G Methylphenidate HCl Tab SA OSM 27 MG Stimulants - Methylphenidate - Long Acting P Preferred product is authorized generic distributed by Watson/Actavis. PA Required >= 21 yo. G Methylphenidate HCl Tab SA OSM 36 MG Stimulants - Methylphenidate - Long Acting P Preferred product is authorized generic distributed by Watson/Actavis. PA Required >= 21 yo. G Methylphenidate HCl Tab SA OSM 54 MG Stimulants - Methylphenidate - Long Acting P Preferred product is authorized generic distributed by Watson/Actavis. PA Required >= 21 yo. G Methylphenidate HCl Tablet ER 10MG ER Stimulants - Methylphenidate - Long Acting NP PA Required G METHYLPHENIDATE TAB 20MG CR Stimulants - Methylphenidate - Long Acting NP PA Required G Methylprednisolone Acetate Glucocorticoids - Mineralocorticoids P G Methylprednisolone Sod Succ Glucocorticoids - Mineralocorticoids P G Methylprednisolone Tab 16 MG Glucocorticoids - Mineralocorticoids NP G Methylprednisolone Tab 32 MG Glucocorticoids - Mineralocorticoids NP G Methylprednisolone Tab 4 MG Glucocorticoids - Mineralocorticoids P 12/15/2015 9:09:11 AM PA Required Page 50 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR M G Methylprednisolone Tab 8 MG Glucocorticoids - Mineralocorticoids G Metipranolol Op. Beta - Blockers NP P G Metoclopramide HCl Gi - Anti - Flatulents / GI Stimulants P G Metolazone Diuretics P G Metoprolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S G Metoprolol Succinate Beta Blockers - Cardio Selective P G Metoprolol Tartrate Beta Blockers - Cardio Selective P B METOZOLV ODT Gi - Anti - Flatulents / GI Stimulants B METRO IV Antibiotics - Misc. P B METROCREAM Topical - Acne Preparations N PA Required B METROGEL Topical - Acne Preparations P PA Required B METROGEL-VAGINAL Vaginal - Antibacterials P NP NP PA Required B METROLOTION Topical - Acne Preparations P PA Required G Metronidazole (Topical) LOTN Topical - Acne Preparations NP PA Required G Metronidazole CAPS Antibiotics - Misc. NP G Metronidazole Cream 0.75% Topical - Acne Preparations P PA Required G Metronidazole Gel 0.75% Topical - Acne Preparations NP PA Required G Metronidazole in NaCl Antibiotics - Misc. P Powders P ND Metronidazole Powder G Metronidazole Tab 250 MG Antibiotics - Misc. P G Metronidazole Tab 500 MG Antibiotics - Misc. P G Metronidazole Vaginal Vaginal - Antibacterials P G Mexiletine HCl Antiarrhythmics B MIACALCIN INJ 200/ML Osteoporosis NP B MIACALCIN SPR 200/ACT Osteoporosis NP B MICARDIS ARB'S P PA required if ACE-I not previously filled. B MICARDIS HCT ARB'S And Diuretics P PA required if ACE-I not previously filled. O Miconazole Nitrate Cream 2% Topical - Antifungals P O Miconazole Nitrate Vaginal Cream 2% Vaginal - Anti Fungals P O Miconazole Nitrate Vaginal Suppos 100 MG Vaginal - Anti Fungals P B MICRHOGAM ULTRA-FILTEREDPLUS Immune Serums P B MICRO-K Minerals P B MICROZIDE Diuretics NP G Midazolam HCl Sedative/Hypnotics - Benzodiazepines NP 12/15/2015 9:09:11 AM P PA Required Page 51 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR M G Midazolam HCl SYRP Sedative/Hypnotics - Benzodiazepines P G Midodrine HCl Pressors P B MIGERGOT Migraine - Ergot Combinations P B MIGRANAL Migraine - Ergotamine Derivatives P B MILLIPRED SOL 10MG/5ML Glucocorticoids - Mineralocorticoids NP B MILLIPRED TABS Glucocorticoids - Mineralocorticoids NP G Milrinone in Dextrose Phosphodiesterase Inhibitors NP G Milrinone Lactate Phosphodiesterase Inhibitors NP B MINIPRESS Antihypertensives - Central NP B MINIVELLE Estrogens - Patches NP G Minocycline HCl Cap 100 MG Tetracyclines P G Minocycline HCl Cap 50 MG Tetracyclines P G Minocycline HCl Cap 75 MG Tetracyclines P G Minocycline HCl Tab 100 MG Tetracyclines NP G Minocycline HCl Tab 50 MG Tetracyclines NP G Minocycline HCl Tab 75 MG Tetracyclines NP G Minocycline HCl Tablet ER 24HR Tetracyclines NP G Minoxidil Antihypertensives - Central B MIRAPEX Parkinsons - Selected Dopamin Agonists NP B MIRAPEX ER Parkinsons - Selected Dopamin Agonists NP NP P B MIRCETTE Contraceptives - Monophasic Combination O/C'S G Mirtazapine Antidepressants - Selected SSRI's P G Mirtazapine Tablet Disperse Antidepressants - Selected SSRI's NP G Misoprostol Gi - Prostaglandins B MOBIC Cox 2 Inhibitors - Selective G Modafinil Stimulants - Other Stimulants / Like Stimulants B MODICON Contraceptives - Monophasic Combination O/C'S NP G Moexipril HCl ACE Inhibitors NP G Moexipril-Hydrochlorothiazide ACE and Thiazide Combo's NP G Mometasone Furoate Topical - Corticosteroids - Medium Potency P B MONOCLATE-P Antihemophilic Agents R B MONONINE Antihemophilic Agents R G Montelukast granules Antiasthmatic - Leukotriene Receptor Antagonists P G Montelukast Sodium Chew Tab 4 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P 12/15/2015 9:09:11 AM PA Required PA Required PA Required P NP PA Required N PA Required Preferred < 2 years of age Page 52 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR M G Montelukast Sodium Chew Tab 5 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P G Montelukast Sodium Tab 10 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P B MONUROL Urological - Misc. G MORPHINE SUL CAP ER Narcotics -Long Acting NP P G MORPHINE SUL TAB ER Narcotics -Long Acting P G Morphine Sulfate Narcotics -Long Acting P G Morphine Sulfate Narcotics - Misc. P B Movantik GI, Constipation - IBS-OIC NP B MOVIPREP Gi - Misc. NP B MOXATAG Beta-Lactams / Clavulanate Combo'S NP PA Required PA Required PA Required B MOXEZA Op. Quinolones Fourth Generation NP G Moxifloxacin HCl Fluoroquinolones NP B MS CONTIN Narcotics -Long Acting P B MULTAQ Antiarrhythmics P G Mupirocin Calcium Cream 2% Topical - Antibiotic G Mupirocin Oint Topical - Antibiotic B MYALEPT Lipodystrophy Agents B MYAMBUTOL Antimycobacterials / Antituberculosis P B MYCAMINE Antifungals - Assorted P B MYCOBUTIN Antimycobacterials / Antituberculosis G Mycophenolate Mofetil Immunosuppressants P G Mycophenolate Sodium Immunosuppressants NP B MYDFRIN Op. Misc B MYDRIACYL Op. Cycloplegics B MYFORTIC Immunosuppressants B MYLERAN Antineoplastics - Alkylating Agents B MYOBLOC Neuromuscular Blocking Agents NP B MYRBETRIQ Antispasmodics - Long Acting NP Initial fill limited to 15 day supply. B MYSOLINE Anticonvulsants NP Grandfather Existing Users B NABI-HB Immune Serums P G Nabumetone Cox 2 Inhibitors - Selective P G Nadolol Beta Blockers - Non Selective G Nadolol & Bendroflumethiazide Beta Blockers And Diuretic Combo'S NP P NP NP P NP P R N 12/15/2015 9:09:11 AM P NP Page 53 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR N G Nafcillin Sodium Beta-Lactams / Clavulanate Combo'S B NAFTIN Topical - Antifungals NP P NP B NAGLAZYME Metabolic Modifiers - Lysosomal Storage Disorder Treatments G Nalbuphine HCl Narcotics - Selected B NALFON NSAIDS G Naloxone HCl Narcotic - Antagonists P G Naltrexone HCl Narcotic - Antagonists P B NAMENDA Alzheimer - Cholinomimetics N Restricted to persons 40 years of age and older. B NAMENDA XR Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B NAMZARIC ALZHEIMER - Cholinomimetics NP Restricted to persons 40 years of age and older. G Naphazoline HCl Op. Misc P B NAPRELAN NSAIDS NP PA Required B NAPROSYN NSAIDS NP PA Required B NAPROSYN SUSP NSAIDS P G Naproxen NSAIDS P G Naproxen Sodium Tab 550 MG NSAIDS P G Naproxen Sodium TABS 275MG NSAIDS NP G Naratriptan HCl Migraine - Selective Serotonin Agonists (5HT)--Tabs B NARDIL Antidepressants - Mao Inhibitors B NASONEX Nasal Steroids B NATAZIA Contraceptives - Multi-Phasic Combinations G Nateglinide Diabetic - Meglitinides P B NATESTO Androgens - Anabolics NP B NATPARA PTH NP B NATROBA Topical - Scabicides And Pediculicides B NAVELBINE Antineoplastics - Mitotic Inhibitors B NEBUPENT Antibiotics - Misc. B NECON 1/50-28 Contraceptives - Monophasic Combination O/C'S B NECON 10/11-28 Contraceptives - Bi-Phasic Combinations 12/15/2015 9:09:11 AM P NP P PA Required PA Required PA Required> 12 Units/30 Days supply NP P NP P PA Required No manual PA required if one course of treatment of a preferred permethrin or pyrethrins-piperonyl butoxide product is in the member's pharmacy claims history in past 30 days. Trial of Natroba or Ulesfia is required prior to consideration of any nonpreferred agent. NP P P NP Page 54 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR N G Nefazodone HCl Antidepressants - Selected SSRI's P G Neomycin Sulfate Amino Glycosides P Initial fill limited to 15 day supply. G Neomycin/Polymyxin B GU Urological - Misc. G Neomycin-Bacitracin Zn-Polymyxin Op. Antibiotics O Neomycin-Bacitracin-Polymyxin Topical - Antibiotic G Neomycin-Polymy-Dexameth Op. Antiinflammatory / Steroids Ophth. G Neomycin-Polymyxin-Gramicidin Op. Antibiotics NP G Neomycin-Polymyxin-HC (Ophth) Op. Antiinflammatory / Steroids Ophth. NP G Neomycin-Polymyxin-HC (Otic) Ear B NEORAL Immunosuppressants NP B NEOSPORIN Op. Antibiotics NP B NEOSPORIN GU IRRIGANT Urological - Misc. B NEPHPLEX RX Vitamins - Misc. B NEPTAZANE Diuretics NP B NESINA Diabetic - Other NP PA Required B NEULASTA Granulocyte Csf NP PA Required B NEUMEGA Granulocyte Csf NP PA Required B NEUPOGEN Granulocyte Csf P PA Required B NEUPRO Parkinsons - Selected Dopamin Agonists NP B NEURONTIN Anticonvulsants NP B NEURONTIN SOLN Anticonvulsants NP B NEVANAC Op. Nsaid'S G Nevirapine Antiretrovirals - Rti-Non-Nucleoside Analogues R G Nevirapine SUSP Antiretrovirals - Rti-Non-Nucleoside Analogues NR B NEXAVAR Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B NEXIUM Gi - Proton Pump Inhibitor NP PA Required G Niacin (Antihyperlipidemic) Cholesterol - Fibric Acid Derivatives NP ND Niacin Tab 100 MG Vitamins NP PA Required ND Niacin Tab 250 MG Vitamins NP PA Required ND Niacin Tab 50 MG Vitamins NP PA Required ND Niacin Tab 500 MG P NP P P P P P PA Required Grandfather for seizure disorder. P Vitamins NP PA Required B NIASPAN Cholesterol - Fibric Acid Derivatives NP Grandfather Existing Users G Nicardipine HCl Nicardipines NP 12/15/2015 9:09:11 AM Page 55 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR N O NICODERM CQ Nicotine Replacement Therapy NP PA required limited to package size of #14 for initial fill O NICORETTE Nicotine Replacement Therapy NP PA required limited to package size of #110 for initial fill O NICORETTE LOZG Nicotine Replacement Therapy NP PA required, Limit of 144 for initial fill O NICORETTE LOZG Nicotine Replacement Therapy P PA required, Limit of 144 for initial fill O NICORETTE MINI Nicotine Replacement Therapy NP PA required, Limit of 144 for initial fill O NICORETTE MINI Nicotine Replacement Therapy P PA required, Limit of 144 for initial fill O NICORETTE STARTER KIT Nicotine Replacement Therapy NP PA required limited to package size of #110 for initial fill O Nicotine Polacrilex Nicotine Replacement Therapy P PA required limited to package size of #110 for initial fill O Nicotine Polacrilex LOZG Nicotine Replacement Therapy P PA required, Limit of 144 for initial fill O Nicotine TD Patch 24HR 14 MG/24HR Nicotine Replacement Therapy P PA required limited to package size of #14 for initial fill O Nicotine TD Patch 24HR 21 MG/24HR Nicotine Replacement Therapy P PA required limited to package size of #14 for initial fill O Nicotine TD Patch 24HR 7 MG/24HR Nicotine Replacement Therapy P PA required limited to package size of #14 for initial fill B NICOTROL Nicotine Replacement Therapy NP PA required limited to package size 168 for intial fill B NICOTROL SOLN Nicotine Replacement Therapy NP PA required limited to package size 40ml for initial fill G Nifedipine Calcium Channel Blockers--Nifedipines P G Nifedipine Tab SR 24HR 30 MG Calcium Channel Blockers--Nifedipines P G Nifedipine Tab SR 24HR 60 MG Calcium Channel Blockers--Nifedipines P G Nifedipine Tab SR 24HR 90 MG Calcium Channel Blockers--Nifedipines P B NILANDRON Antineoplastics - Antiandrogens R G Nisoldipine Calcium Channel Blockers--Nisoldipine B NITRO-BID B NITRO-DUR DIS 0.1MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.2MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.3MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.4MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.6MG/HR Nitro - Patches NP B NITRO-DUR DIS 0.8MG/HR Nitro - Patches P G Nitrofurantoin Macrocrystal Urological - Misc. P G Nitrofurantoin Monohyd Macro Urological - Misc. NP Nitro - Ointment/Cap/Cr 12/15/2015 9:09:11 AM NP P Page 56 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR N G Nitrofurantoin Suspension Urological - Misc. P G Nitroglycerin Nitro - Ointment/Cap/Cr P G Nitroglycerin Nitro - Patches P G Nitroglycerin Nitro - Sublingual/ Spray P G Nitroglycerin in D5W Nitro - Ointment/Cap/Cr NP G Nitroglycerin SOLN Nitro - Sublingual/ Spray NP B NITROLINGUAL Nitro - Sublingual/ Spray NP B NITROMIST Nitro - Sublingual/ Spray NP B NITROSTAT Nitro - Sublingual/ Spray P G Nizatidine Gi - H2-Antagonists NP B NIZORAL SHAMPOO Topical - Antifungals NP B NORCO Narcotics - Misc. NP PA Required PA Required B NORDITROPIN Growth Hormone P G Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone & Ethinyl Estradiol-Fe Contraceptives - Monophasic Combination O/C'S NP G Norethindrone (Contraceptive) Contraceptives - Progestin Only P G Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P G Norethindrone Acet & Eth Estra Contraceptives - Monophasic Combination O/C'S NP G Norethindrone Acetate Tab 5 MG Progestins G Norethindrone Ac-Ethinyl Estrad-Fe Tab 1-20/1-30/1-35 MG-MCG Contraceptives - Tri-Phasic Combinations NP G Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG-MCG Contraceptives - Tri-Phasic Combinations P G Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG Contraceptives - Tri-Phasic Combinations P G Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35 MG-MCG Contraceptives - Tri-Phasic Combinations P G Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG Contraceptives - Monophasic Combination O/C'S P B NORINYL TAB 1/35 Contraceptives - Monophasic Combination O/C'S NP B NORINYL TAB 1+50-28 Contraceptives - Monophasic Combination O/C'S P B NORITATE Topical - Acne Preparations NP B NORPACE Antiarrhythmics NP B NORPRAMIN Antidepressants - Tri-Cyclics NP B NOR-QD Contraceptives - Progestin Only NP G Nortriptyline HCl Antidepressants - Tri-Cyclics 12/15/2015 9:09:11 AM P PA Required P Page 57 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR N B NORVASC B NORVIR CAP 100MG Calcium Channel Blockers--Amlodipines Antiretrovirals - Protease Inhibitors NP R B NORVIR SOL 80MG/ML Antiretrovirals - Protease Inhibitors R B NORVIR TABS Antiretrovirals - Protease Inhibitors R B NOVOEIGHT Antihemophilic Agents NR O NOVOLIN 70/30 Diabetic - Insulin NP O NOVOLIN N Diabetic - Insulin NP O NOVOLIN R Diabetic - Insulin NP B NOVOLOG Diabetic - Insulin NP B NOVOLOG Diabetic - Insulin Penfills B NOVOLOG MIX 70/30 Diabetic - Insulin B NOVOSEVEN Antihemophilic Agents R B NOXAFIL Antifungals - Assorted NP PA Required B NPLATE Thrombopoeitin Receptor Agonists NP PA Required B NUCYNTA Narcotics - Misc. NP PA Required B NUCYNTA ER Narcotics -Long Acting NP PA Required B NUEDEXTA Neurologics - Misc. NP B NULYTELY Gi - Anti - Flatulents / GI Stimulants P B NUTROPIN AQ Growth Hormone P B NUVARING Contraceptives - Patches/ Vaginal Products P B NUVESSA VAGINAL - ANTIBACTERIALS NP B NUVIGIL Stimulants - Other Stimulants / Like Stimulants NP NP P PA Required NP B NYMALIZE Calcium Channel Blockers--Nifedipines G Nystatin Antifungals - Assorted G Nystatin Cream 100000 Unit/GM Topical - Antifungals NP G Nystatin Oint 100000 Unit/GM Topical - Antifungals P G Nystatin Susp 100000 Unit/ML Mouth Anti-Infectives P G Nystatin-Triamcinolone Topical - Antifungals NP PA Required PA Required P O ND *Oral Electrolyte Solution*** Electrolytes/ Nutritionals P B OBIZUR Antihemophilic Agents NR B OCTAGAM Immune Serums NP G Octreotide Acetate Somatostatic Agents B OCUFEN Op. Nsaid'S 12/15/2015 9:09:11 AM N NP Page 58 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR O B OCUFLOX Op. Quinolones NP B OFEV Idiopathic Pulmonary Fibrosis NP G Ofloxacin Fluoroquinolones NP G Ofloxacin (Ophth) Op. Quinolones G Ofloxacin (Otic) Ear NP NP PA Required P B OGESTREL Contraceptives - Monophasic Combination O/C'S G Olanzapine Antipsychotics - Atypicals P G Olanzapine Tablet Disperse Antipsychotics - Atypicals NP PA Required G Olanzapine-Fluoxetine HCl Psychotherapeutic Combination NP Grandfather Existing Users B OLEPTRO Antidepressants - Selected SSRI's NP PA Required G Olopatadine HCl (Nasal) Antihistamines - Non-Sedating NP B OLUX Topical - Corticosteroids - High Potency B OLUX-E Topical - Corticosteroids - High Potency B OLYSIO Hepatitis C Agents NP G Omega-3-acid Ethyl Esters Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP G Omeprazole Gi - Proton Pump Inhibitor P G Omeprazole-Sodium Bicarbonate Gi - Proton Pump Inhibitor NP B OMNARIS Nasal Steroids NP B OMNIPRED Op. Antiinflammatory / Steroids Ophth. NP B OMNITROPE Growth Hormone NP G Ondansetron HCl Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin P G Ondansetron HCl Oral Soln 4 MG/5ML Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP G Ondansetron ODT Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin P B Onexton Topical - Acne Preparations NP PA Required B ONFI Anticonvulsants NP PA Required B ONGLYZA Diabetic - Other N PA Required B ONMEL Antifungals - Assorted NP PA Required B OPANA Narcotics - Misc. NP PA Required B OPANA ER (CRUSH RESISTANT) Narcotics -Long Acting NP PA Required G Opium Tincture Gi - Antiperistaltic Agents NP B OPSUMIT Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist NP B OPTIVAR Op. Antiallergics - Antihistamines NP 12/15/2015 9:09:11 AM P P PA Required PA Required PA Required PA required for quantities exceeding 604mg tabs, 60-8mg tabs, 4-20ml vials, and 82ml vials. PA Required PA required for quantities exceeding 604mg tabs, 60-8mg tabs. PA Required Page 59 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR O B ORACEA Tetracyclines B ORACIT Urological - Misc. B ORALAIR Allergenic Extracts NP B ORAP Neurologics - Misc. P B ORAPRED Glucocorticoids - Mineralocorticoids NP B ORBACTIV Antibiotics - Misc. NP B ORENCIA Anti-Inflammatories, Non-Nsaid NP PA Required B ORENITRAM Pulmonary Anti-Hypertensives NP PA Required B ORFADIN Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents B Orkambi Cystic Fibrosis Agents G Orphenadrine Citrate Muscle Relaxants P B ORTHO EVRA Contraceptives - Patches/ Vaginal Products P B ORTHO MICRONOR Contraceptives - Progestin Only P B ORTHO TRI-CYCLEN Contraceptives - Tri-Phasic Combinations P B ORTHO TRI-CYCLEN LO Contraceptives - Tri-Phasic Combinations NP B ORTHO-CEPT Contraceptives - Monophasic Combination O/C'S NP B ORTHO-NOVUM TAB 1/35 Contraceptives - Monophasic Combination O/C'S NP B ORTHO-NOVUM 7/7/7 Contraceptives - Tri-Phasic Combinations NP B OSENI Diabetic - Other NP B OSMOPREP Gi - Anti - Flatulents / GI Stimulants NP B OTEZLA Anti-Inflammatories, Non-Nsaid NP PA Required B OTREXUP Arthritis - Misc. NP PA Required B OVCON-35 Contraceptives - Monophasic Combination O/C'S NP B OVIDE Topical - Scabicides And Pediculicides NP G Oxacillin Sodium Beta-Lactams / Clavulanate Combo'S P G Oxandrolone Androgens - Anabolics NP G Oxaprozin NSAIDS NP G Oxazepam Anxiolytics - Benzodiazepines P G Oxcarbazepine SUSP Anticonvulsants P G Oxcarbazepine Tab 150 MG Anticonvulsants P G Oxcarbazepine Tab 300 MG Anticonvulsants P G Oxcarbazepine Tab 600 MG Anticonvulsants P B OXISTAT Topical - Antifungals B OXSORALEN ULTRA Anti-Psoriatics - Non-Biologicals 12/15/2015 9:09:11 AM NP P PA Required P NP PA Required PA Required PA Required PA Required < 6 years of age NP P Page 60 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR O B OXTELLAR XR Anticonvulsants NP G OXYBUTYNIN SYP 5MG/5ML Antispasmodics P PA Required G OXYBUTYNIN TAB 5MG Antispasmodics P G Oxybutynin Chloride ER Antispasmodics - Long Acting P G Oxycodone HCl Narcotics - Misc. P G Oxycodone HCl ER Narcotics -Long Acting NP PA Required G Oxycodone w/ Acetaminophen Tab 10-325 MG Narcotics - Misc. NP PA Required G Oxycodone w/ Acetaminophen Tab 5-325 MG Narcotics - Misc. P G Oxycodone w/ Acetaminophen TABS 2.5-325 Narcotics - Misc. P G Oxycodone w/ Acetaminophen TABS 7.5-325 Narcotics - Misc. NP G Oxycodone-Aspirin Narcotics - Misc. P G Oxycodone-Ibuprofen Narcotics - Misc. NP B OXYCONTIN Narcotics -Long Acting NP PA Required G Oxymorphone HCl Narcotics -Long Acting NP PA Required G Oxymorphone HCl Narcotics - Misc. NP B Oxytrol Antispasmodics - Long Acting NP P G Paclitaxel Antineoplastics - Mitotic Inhibitors NR B PAMELOR Antidepressants - Tri-Cyclics NP G Pamidronate Disodium Osteoporosis NP B PANCREAZE Gi - Digestive Enzymes NP G Pancrelipase (Lipase-Protease-Amylase) Gi - Digestive Enzymes P G Pantoprazole Sodium Gi - Proton Pump Inhibitor P G Papaverine HCl Peripheral Vasodilators P B PARAFON FORTE DSC Muscle Relaxants NP G Paregoric Gi - Antiperistaltic Agents NP G Parenteral Electrolytes Electrolytes/ Nutritionals NP G Paricalcitol Hyperparathyroid Treatment - Vitamin D Analogs And Calcimimetics NP B PARLODEL Anti-Parkinsonian Drugs P B PARNATE Antidepressants - Mao Inhibitors G Paromomycin Sulfate Amino Glycosides P G Paroxetine HCl Antidepressants - Selected SSRI's P G PAROXETINE HCL ER Antidepressants - Selected SSRI's P B PATADAY Op. Antiallergics - Antihistamines P 12/15/2015 9:09:11 AM PA Required NP Page 61 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR P B PATANASE Antihistamines - Non-Sedating P B PATANOL Op. Antiallergics - Antihistamines P B PAXIL Antidepressants - Selected SSRI's NP B PAXIL CR Antidepressants - Selected SSRI's NP B PAXIL SUSP Antidepressants - Selected SSRI's P B PAZEO Op. Antiallergics - Antihistamines NP B PCE Macrolides / Erythromycin'S / Ketolides NP B PEDIAPRED Glucocorticoids - Mineralocorticoids NP ND Pediatric Multiple Vitamin w/ Minerals & C Vitamins - Misc. P P G PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate Gi - Anti - Flatulents / GI Stimulants G PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride Gi - Anti - Flatulents / GI Stimulants B PEGANONE Anticonvulsants B PEGASYS Hepatitis C Agents P B PEGASYS PROCLICK Hepatitis C Agents P B PEG-INTRON Hepatitis C Agents P G Penicillin G Pot in Dextrose Beta-Lactams / Clavulanate Combo'S P G Penicillin G Potassium Beta-Lactams / Clavulanate Combo'S P G Penicillin V Potassium Beta-Lactams / Clavulanate Combo'S B PENLAC NAIL LACQUER Topical - Antifungals NP B PENNSAID NSAIDS NP B PENTAM 300 Antibiotics - Misc. P B PENTASA CAP 250MG CR Gi - Inflammatory Bowel Agents P CAP 500MG CR PA Required P NP P B PENTASA Gi - Inflammatory Bowel Agents NP G Pentazocine w/ Naloxone Narcotics - Misc. NP G Pentoxifylline Platelet Aggr. Inhibitors / Combo's - Misc. B PEPCID Gi - H2-Antagonists B PERCODAN Narcotics - Misc. PA Required PA Required P NP P B PERFOROMIST Antiasthmatic - Beta - Adrenergics NP G Perindopril Erbumine ACE Inhibitors NP G Permethrin Cream 5% Topical - Scabicides And Pediculicides P O Permethrin Lotion 1% Topical - Scabicides And Pediculicides P G Perphenazine Antipsychotics - Typical P G Perphenazine-Amitriptyline Psychotherapeutic Combination B PERSANTINE Platelet Aggregation Inhibitors 12/15/2015 9:09:11 AM Grandfather Existing Users P NP Page 62 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR P B PERTZYE Gi - Digestive Enzymes B PEXEVA Antidepressants - Selected SSRI's N NP B PFIZERPEN-G Beta-Lactams / Clavulanate Combo'S P G Phenazopyridine HCl Urological - Misc. P G Phenelzine Sulfate Antidepressants - Mao Inhibitors P Initial fill limited to 15 day supply. B PHENERGAN Antiemetic - Anticholinergic / Dopaminergic G Phenobarbital Sedative/Hypnotics - Barbiturate NP P G Phenobarbital Sodium Sedative/Hypnotics - Barbiturate NP B Phenoxybenzamine Agents For Pheochromocytoma NP G Phentolamine Mesylate Agents For Pheochromocytoma P G Phenylephrine HCl (Ophth) Op. Misc B PHENYTEK Anticonvulsants NP G Phenytoin Infatab Anticonvulsants P G Phenytoin Sodium Anticonvulsants P G Phenytoin Sodium Extended Cap 100 MG Anticonvulsants P G Phenytoin Sodium Extended CAPS 200MG Anticonvulsants NP Use Multiples of Phenytoin Sodium 100mg Capsules. G Phenytoin Sodium Extended CAPS 300MG Anticonvulsants NP Use Multiples of Phenytoin Sodium 100mg Capsules. G Phenytoin susp Anticonvulsants B PHOSLO Phosphate Binders NP B PHOSLYRA Phosphate Binders P B PHOSPHOLINE IODIDE Op. Miotics - Direct Acting P G Phytonadione Vitamins P P P B PICATO Topical - Antineoplastics G Pilocarpine HCl Op. Miotics - Direct Acting P G Pilocarpine HCl (Oral) Artificial Saliva/Stimulants P B PILOPINE HS Op. Miotics - Direct Acting P G Pindolol Beta Blockers - Non Selective P NP B PINNACAINE OTIC Ear G Pioglitazone HCl Diabetic - Thiazol P G Pioglitazone HCl-Glimepiride Diabetic - Thiazol NP G Pioglitazone HCl-Metformin HCl Diabetic - Thiazol / Biguanide Combo NP G Piperacillin Sodium-Tazobactam Sodium Beta-Lactams / Clavulanate Combo'S P G Piroxicam NSAIDS 12/15/2015 9:09:11 AM Grandfather Existing Users NP NP PA Required Page 63 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR P B PITRESSIN SYNTHETIC Vasopressins NP B PLAQUENIL Antimalarial Agents NP B PLAVIX Platelet Aggregation Inhibitors NP B PLEGRIDY Multiple Sclerosis Agents – Interferons NP B PLEGRIDY STARTER PACK Multiple Sclerosis Agents – Interferons NP B PLETAL Platelet Aggr. Inhibitors / Combo's - Misc. NP B PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID Vitamins - Misc. B PNV FOLIC AC TAB + IRON Vitamins - Misc. B PODOCON 25 Topical - Enzymes / Keratolytics / Urea NP G Podofilox Topical - Genital Warts NP O polyethylene glycol 3350 Gi - Anti - Flatulents / GI Stimulants P G polyethylene glycol 3350 PACK 3350 NF Gi - Anti - Flatulents / GI Stimulants P G Polymyxin B Sulfate Antibiotics - Misc. G Polymyxin B-Trimethoprim Op. Antibiotics B POLYTRIM Op. Antibiotics NP B POMALYST Antineoplastics - Misc. NR PA Required B PONSTEL NSAIDS NP PA Required G Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic Minerals P G Potassium Acetate Inj 2 mEq/ML Minerals P G Potassium Bicarbonate Effer Tab 25 mEq Minerals P G Potassium Chloride in Dextrose Electrolytes/ Nutritionals P G Potassium Chloride in Dextrose & Sodium Chloride Electrolytes/ Nutritionals P G Potassium Chloride in NaCl Electrolytes/ Nutritionals P G Potassium Chloride Inj 10 mEq/100 ML Minerals P G Potassium Chloride Inj 10 mEq/50 ML Minerals P G Potassium Chloride Inj 2 mEq/ML Minerals P G Potassium Chloride Oral Liq 10% (20 MEQ/15ML) Minerals P G Potassium Chloride Oral Liq 20% (40 MEQ/15ML) Minerals P G Potassium Chloride Tab CR 10 mEq Minerals P G Potassium Chloride Tab CR 8 mEq (600 MG) Minerals P G Potassium Chloride Tablet ER 20MEQ ER Minerals P G Potassium Citrate (Alkalinizer) Urological - Misc. P B POTIGA Anticonvulsants 12/15/2015 9:09:11 AM P P Preferred for ages 0-12, PA Required ages 13-18, Not covered ages 19 and above. NP P NP Page 64 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR P B PRADAXA Anticoagulants NP B Praluent ANTIHYPERLIPIDEMICS NP G Pramipexole Dihydrochloride Parkinsons - Selected Dopamin Agonists P G Pramipexole Dihydrochloride Tablet ER 24HR Parkinsons - Selected Dopamin Agonists NP B PRANDIMET Diabetic - Other NP B PRANDIN Diabetic - Meglitinides NP B PRAVACHOL Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP G Pravastatin Sodium Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations P G Prazosin HCl Antihypertensives - Central P B PRECOSE Diabetic - Alphaglucosidase NP B PRED FORTE Op. Antiinflammatory / Steroids Ophth. NP B PRED MILD Op. Antiinflammatory / Steroids Ophth. P PA Required PA Required B PRED-G Op. Antiinflammatory / Steroids Ophth. P G Prednicarbate Topical - Corticosteroids - Medium Potency N G Prednisolone Glucocorticoids - Mineralocorticoids P G Prednisolone Acetate (Ophth) Op. Antiinflammatory / Steroids Ophth. P G Prednisolone Sodium Phosphate Glucocorticoids - Mineralocorticoids P G Prednisolone Sodium Phosphate (Ophth) Op. Antiinflammatory / Steroids Ophth. P G Prednisone Glucocorticoids - Mineralocorticoids P B PREDNISONE INTENSOL Glucocorticoids - Mineralocorticoids NP B PREFEST Estrogen Combos NP B PREMARIN Estrogens - Tabs P B PREMARIN Vaginal - Estrogens P B PREMASOL Electrolytes/ Nutritionals P B PREMPHASE Estrogen Combos P B PREMPRO Estrogen Combos P B PRENATAL VIT TAB PLUS Vitamins - Misc. P B PREVACID Gi - Proton Pump Inhibitor NP PA Required B PREVACID SOLUTAB Gi - Proton Pump Inhibitor NP PA Required B PREVPAC Gi - Ulcer Anti-Infective NP B PREZCOBIX Antiretrovirals - Combinations NP B PREZISTA Antiretrovirals B PRILOSEC Gi - Proton Pump Inhibitor NP B PRIMAXIN Carbapenems NP 12/15/2015 9:09:11 AM PA Required R PA Required Page 65 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR P G Primidone Anticonvulsants B PRIMLEV NARCOTICS - MISC. NP P B PRINIVIL ACE Inhibitors NP B PRISTIQ Antidepressants - Selected SSRI's NP B PRIVIGEN Immune Serums NP B PROAIR HFA Antiasthmatic - Beta - Adrenergics B PROAIR RESPICLICK ANTIASTHMATIC - BETA - ADRENERGICS G Probenecid Gout P G Procainamide HCl Antiarrhythmics P B PROCALAMINE Electrolytes/ Nutritionals NP B PROCARDIA Calcium Channel Blockers--Nifedipines NP B PROCARDIA XL Calcium Channel Blockers--Nifedipines NP NP PA Required P NP B PROCENTRA Stimulants G Prochlorperazine Edisylate Antihistamines - Other P G Prochlorperazine Maleate Antihistamines - Other P G Prochlorperazine Supp Antihistamines - Other P B PROCRIT Erythropoeisis Stimulating Agents P B PROCTOFOAM HC Anorectal - Misc. NP B PROCYSBI Urological - Misc. NP B PROFILNINE SD Antihemophilic Agents G Progesterone IM in Oil 50 MG/ML Progestins NP G Progesterone Micronized Progestins NP PA Required PA Required R ND Progesterone Micronized Powder Powders P ND Progesterone Powder Powders P P B PROGLYCEM Diabetic - Other B PROGRAF Immunosuppressants B PROLASTIN C Alpha-Proteinase Inhibitor B PROLENSA Op. Nsaid'S B PROLEUKIN Antineoplastics - Interleukins R B PROMACTA Thrombopoeitin Receptor Agonists P G Promethazine HCl Inj 25 MG/ML Antiemetic - Anticholinergic / Dopaminergic NP G Promethazine HCl Inj 50 MG/ML Antiemetic - Anticholinergic / Dopaminergic NP G Promethazine HCl Suppos 12.5 MG Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Suppos 25 MG Antiemetic - Anticholinergic / Dopaminergic P 12/15/2015 9:09:11 AM PA Required NP P PA Required NP PA Required Page 66 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR P G Promethazine HCl Syrup 6.25 MG/5ML Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Tab 12.5 MG Antiemetic - Anticholinergic / Dopaminergic NP G Promethazine HCl Tab 25 MG Antiemetic - Anticholinergic / Dopaminergic P G Promethazine HCl Tab 50 MG Antiemetic - Anticholinergic / Dopaminergic P B PROMETRIUM Progestins G Propafenone HCl Antiarrhythmics P G Propantheline Bromide Gi - Antidiarrheal / Antacid - Misc. P G Proparacaine HCl Op. Misc P G Propranolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S P G Propranolol HCl Beta Blockers - Non Selective P G Propylthiouracil Antithyroid Therapies B PROSCAR BPH NP B PROTONIX Gi - Proton Pump Inhibitor NP PA Required B PROTOPIC Topical - Immunomodulators NP PA Required G Protriptyline HCl Antidepressants - Tri-Cyclics NP B PROVENTIL HFA Antiasthmatic - Beta - Adrenergics B PROVERA Progestins B PROVIGIL Stimulants - Other Stimulants / Like Stimulants B PROZAC Antidepressants - Selected SSRI's NP B PROZAC WEEKLY Antidepressants - Selected SSRI's NP NP NP P P NP P B PRUDOXIN Topical - Antipruritics O Pseudoephedrine HCl Tab 30 MG Cough/Cold - Systemic Decongestants P O Pseudoephedrine HCl Tab 60 MG Cough/Cold - Systemic Decongestants P B PULMICORT INHALER Antiasthmatic - Steroid Inhalants P B PULMICORT SUS Antiasthmatic - Steroid Inhalants P B PULMICORT SUS SUSP 1MG/2ML Antiasthmatic - Steroid Inhalants NP B PULMOZYME Cystic Fibrosis Agents P B PYLERA Gi - Ulcer Anti-Infective P G Pyrazinamide Antimycobacterials / Antituberculosis P O Pyrethrins-Piperonyl Butoxide Topical - Scabicides And Pediculicides P G Pyridostigmine Bromide Neurologics - Misc. P G Pyridostigmine er Neurologics - Misc. NP B QNASL Nasal Steroids PA Required >= 21 yo. PA Required Preferred < 8yo PA Required Q 12/15/2015 9:09:11 AM NP Page 67 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR Q B QUARTETTE Contraceptives - Monophasic Combination O/C'S NP B QUDEXY XR Anticonvulsants NP NP B QUESTRAN Cholesterol - Bile Sequestrants G Quetiapine Fumarate Antipsychotics - Atypicals P B QUILLIVANT XR Stimulants - Methylphenidate - Long Acting P G Quinapril HCl ACE Inhibitors G Quinapril-Hydrochlorothiazide ACE and Thiazide Combo's G Quinidine Gluconate Antiarrhythmics P G Quinidine Sulfate Antiarrhythmics P G Quinidine Sulfate Tablet ER Antiarrhythmics NP B QVAR Antiasthmatic - Steroid Inhalants PA Required PA Required >= 21 yo. P NP P R G Rabeprazole Sodium Gi - Proton Pump Inhibitor NP PA Required B RAGWITEK Allergenic Extracts NP PA Required G Raloxifene HCl Osteoporosis NP G Ramipril ACE Inhibitors P B RANEXA Antianginals NP G Ranitidine HCl Cap 150 MG Gi - H2-Antagonists NP G Ranitidine HCl Cap 300 MG Gi - H2-Antagonists NP G Ranitidine HCl Inj 150 MG/6ML (25 MG/ML) Gi - H2-Antagonists P G Ranitidine HCl Inj 50 MG/2ML (25 MG/ML) Gi - H2-Antagonists P G Ranitidine HCl Syrup 15 MG/ML (75 MG/5ML) Gi - H2-Antagonists P G Ranitidine HCl Tab 150 MG Gi - H2-Antagonists P G Ranitidine HCl Tab 300 MG Gi - H2-Antagonists P B RAPAFLO BPH B RAPAMUNE Immunosuppressants B RASUVO Arthritis - Misc. NP B RAVICTI Urea Cycle Disorder - Agents NP B RAYOS Glucocorticoids - Mineralocorticoids NP PA Required B RAZADYNE Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B REBETOL Hepatitis C Agents NP B REBIF Multiple Sclerosis Agents – Interferons P B REBIF REBIDOSE Multiple Sclerosis Agents – Interferons P 12/15/2015 9:09:11 AM NP P PA Required Page 68 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR R B REBIF REBIDOSE TITRATIONPACK Multiple Sclerosis Agents – Interferons P B RECOMBINATE Antihemophilic Agents R B RECTIV Anorectal - Misc. NP B REGLAN Gi - Anti - Flatulents / GI Stimulants NP B REGONOL Neurologics - Misc. B REGRANEX Topical - Wound / Decubitus Care B RELENZA DISKHALER Influenza Agents B RELISTOR Gi - Misc. B RELPAX Migraine - Selective Serotonin Agonists (5HT)--Tabs B REMERON Antidepressants - Selected SSRI's NP B REMERON SOLTAB Antidepressants - Selected SSRI's NP PA Required B REMICADE Anti-Inflammatories, Non-Nsaid NP PA Required B REMODULIN Pulmonary Anti-Hypertensives NP PA Required B RENACIDIN Urological - Misc. P B RENAGEL TAB 400MG Phosphate Binders P B RENAGEL TAB 800MG Phosphate Binders P B RENVELA Phosphate Binders NP G Repaglinide Diabetic - Meglitinides NP B Repatha ANTIHYPERLIPIDEMICS NP B REQUIP Parkinsons - Selected Dopamin Agonists NP B REQUIP XL Parkinsons - Selected Dopamin Agonists NP B RESCRIPTOR Antiretrovirals - Rti-Non-Nucleoside Analogues P NP PA Required P NP N PA Required PA Required R B RESCULA Op. Prostaglandins G Reserpine Antihypertensives - Central B RESTASIS Op. Misc NP B RESTORIL Sedative/Hypnotics - Benzodiazepines NP PA Required B RETIN-A Topical - Tretinoids P PA Required B RETIN-A MICRO Topical - Tretinoids NP PA Required B RETIN-A MICRO PUMP Topical - Tretinoids NP PA Required B RETROVIR Antiretrovirals - Rti-Nucleoside Analogues-Thymidines NR Requires a Selected Brand Name Drug PA B Revatio Pulmonary Anti-Hypertensives NP PA Required B REVATIO SUSR Pulmonary Anti-Hypertensives NP PA Required B REVIA Narcotic - Antagonists NP B REVLIMID Antineoplastics - Misc. R 12/15/2015 9:09:11 AM NP P PA Required Page 69 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR R B Rexulti ANTIPSYCHOTICS - ATYPICALS NP B REYATAZ Antiretrovirals - Protease Inhibitors R B RHEUMATREX Arthritis - Misc. NP B RHINOCORT AQUA Nasal Steroids NP B RHOGAM ULTRA-FILTERED PLUS Immune Serums P B RHOPHYLAC Immune Serums P B RIBASPHERE Hepatitis C Agents NP PA Required RHEUMATREX - Write METHOTREXATE instead B RIBASPHERE RIBAPAK Hepatitis C Agents NP G Ribavirin Cap 200 MG Hepatitis C Agents P G Ribavirin Tab 200 MG Hepatitis C Agents P B RIDAURA Arthritis - Misc. P B RIFADIN Antimycobacterials / Antituberculosis G Rifampin Antimycobacterials / Antituberculosis B RILUTEK ALS Drug NP PA Required G Riluzole ALS Drug P PA Required G Rimantadine Hydrochloride Influenza Agents P B RIOMET Diabetic - Oral Biguanides NP G Risedronate OSTEOPOROSIS NP B RISPERDAL Antipsychotics - Atypicals NP PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B RISPERDAL CONSTA Antipsychotics - Atypicals P PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. B RISPERDAL M-TAB Antipsychotics - Atypicals NP G Risperidone Antipsychotics - Atypicals P G Risperidone Tablet Disperse Antipsychotics - Atypicals NP PA Required B RITALIN Stimulants - Methylphenidate NP PA Required B RITALIN LA Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. G RIVASTIGMINE CAP Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. G RIVASTIGMINE DIS Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. 12/15/2015 9:09:11 AM NP P PA Required PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. Page 70 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR R B RIXUBIS Antihemophilic Agents G Rizatriptan Benzoate Migraine - Selective Serotonin Agonists (5HT)--Tabs NR G Rizatriptan Benzoate Tablet Disperse Migraine - Selective Serotonin Agonists (5HT)--Tabs B ROBAXIN Muscle Relaxants NP B ROBINUL Gi - Antidiarrheal / Antacid - Misc. NP G Ropinirole Hydrochloride Parkinsons - Selected Dopamin Agonists P G Ropinirole Hydrochloride Tablet ER 24HR Parkinsons - Selected Dopamin Agonists NP PA Required B ROXICODONE Narcotics - Misc. NP PA Required B ROZEREM Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B RYBIX ODT Narcotics - Selected NP B RYTARY Anti-Parkinsonian Drugs NP PA Required B RYTHMOL SR Antiarrhythmics NP PA Required B RYTHMOL TABS Antiarrhythmics NP P PA Required> 12 Units/30 Days supply P PA Required> 12 Units/30 Days supply PA Required S B SABRIL ANTICONVULSANTS NP B SAIZEN Growth Hormone NP B SALAGEN Artificial Saliva/Stimulants NP B SALEX Topical - Enzymes / Keratolytics / Urea NP G Salicylic Acid Cream 6% Topical - Enzymes / Keratolytics / Urea P G Salicylic Acid Lotion 6% Topical - Enzymes / Keratolytics / Urea P G Salicylic Acid Shampoo 6% Topical - Enzymes / Keratolytics / Urea P G Salicylic Acid Soln 26% Topical - Enzymes / Keratolytics / Urea P ND Saline w/ Benzyl Alcohol Minerals P ND Saline, Bacteriostatic Compounding Materials P PA Required G Salsalate Analgesics - Misc. B SAMSCA Vasopressins NP B SANCUSO Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP B SANDIMMUNE Immunosuppressants P B SANDOSTATIN Somatostatic Agents P B SANTYL Topical - Enzymes / Keratolytics / Urea B Saphris Antipsychotics - Atypicals NP Grandfather Existing Users B SARAFEM Antidepressants - Selected SSRI's NP Initial fill limited to 15 day supply. B SAVAYSA Anticoagulants NP PA Required B SAVELLA Antidepressants - Selected SSRI's NP PA Required 12/15/2015 9:09:11 AM P PA Required P Page 71 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR S B SEASONIQUE Contraceptives - Monophasic Combination O/C'S B SECONAL Sedative/Hypnotics - Barbiturate NP P NP B SECTRAL Beta Blockers - Cardio Selective G Selegiline HCl Anti-Parkinsonian Drugs P G Selenium Sulfide Topical - Antiseborrheics P G Selenium Sulfide-Pyrithione Zinc in Urea Vehicle Topical - Antiseborrheics B SELZENTRY Antiretrovirals NR B SEMPREX-D Antihistamines/Decongestants NP B SE-NATAL 19 CHEW TABLET Vitamins - Misc. P O Sennosides Syrup 8.8 MG/5ML Gi - Misc. P O Sennosides Tab 8.6 MG Gi - Anti - Flatulents / GI Stimulants P O Sennosides-Docusate Sodium Tab 8.6-50 MG Gi - Misc. P B SENSIPAR Hyperparathyroid Treatment - Vitamin D Analogs And Calcimimetics B SEREVENT DISKUS Antiasthmatic - Beta - Adrenergics B SEROQUEL Antipsychotics - Atypicals NP B SEROQUEL XR Antipsychotics - Atypicals NP PA Required B SEROSTIM Growth Hormone NP PA Required G Sertraline HCl Antidepressants - Selected SSRI's G Sevelamer Carbonate Phosphate Binders NP B SFROWASA Gi - Inflammatory Bowel Agents NP NP ENE 4GM P NP P PA Required < 4 years of age P B SIGNIFOR Somatostatic Agents G Sildenafil Citrate (Pulmonary Hypertension) Pulmonary Anti-Hypertensives B SILENOR Antidepressants - Tri-Cyclics NP B SILVADENE Topical - Burn Products NP G Silver Nitrate Topical - Cauterizing Agents P G Silver Sulfadiazine Topical - Burn Products P B SIMBRINZA Op. Selective Alpha Adrenergic Agonists P B SIMCOR Cholesterol - Hmg COA + Absorb Inhibitors NP Grandfather Existing Users B SIMPONI Anti-Inflammatories, Non-Nsaid NP PA Required G Simvastatin Tab 10 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin Tab 20 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin Tab 40 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin Tab 5 MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P G Simvastatin TABS 80MG Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP 12/15/2015 9:09:11 AM P PA Required Grandfather Existing Users Page 72 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR S B SINEMET Anti-Parkinsonian Drugs NP B SINGULAIR CHW 4MG Antiasthmatic - Leukotriene Receptor Antagonists NP B SINGULAIR CHW 5MG Antiasthmatic - Leukotriene Receptor Antagonists NP B SINGULAIR TAB 10MG Antiasthmatic - Leukotriene Receptor Antagonists NP B SINGULAIR PACK Antiasthmatic - Leukotriene Receptor Antagonists NP G Sirolimus Immunosuppressants B SIRTURO Antimycobacterials / Antituberculosis NP B SITAVIG Herpes Agents NP B SIVEXTRO Lincosamides / Oxazolidinones / Leprostatics NP B SKELAXIN Muscle Relaxants NP B SKLICE Topical - Scabicides And Pediculicides NP G Sodium Acetate Inj 2 mEq/ML Minerals P ND Sodium Bicarbonate (Antacid) Tabs P Gi - Antidiarrheal / Antacid - Misc. P G Sodium Bicarbonate Inj 4.2% Minerals P G Sodium Bicarbonate Inj 7.5% Minerals P G Sodium Bicarbonate Inj 8.4% Minerals P G Sodium Chloride (GU Irrigant) Urological - Misc. P O Sodium Chloride Hypertonic Ophth Oint 5% Op. Misc P O Sodium Chloride Hypertonic Ophth Soln 5% Op. Misc P G Sodium Chloride Inj 0.45% Minerals P Minerals P Minerals P ND Sodium Chloride IV Soln 0.9% Minerals P ND Sodium Chloride Soln Nebu 0.9% Antiasthmatic - Misc. Respiratory Inhalants P ND Sodium Chloride Inj 0.9% G Sodium Chloride Inj 3% G Sodium Citrate & Citric Acid Urological - Misc. P G Sodium Fluoride (Dental) Dental Products P G Sodium Fluoride Chew Tab 0.25 MG F (from 0.55 MG NaF) Minerals P G Sodium Fluoride Chew Tab 0.5 MG F (from 1.1 MG NaF) Minerals P G Sodium Fluoride Chew Tab 1 MG F (from 2.2 MG NaF) Minerals P G Sodium Fluoride Soln 0.125 MG/DROP F (0.275 MG/DROP NaF) Minerals P G Sodium Fluoride Soln 0.5 MG/ML F (from 1.1 MG/ML NaF) Minerals P G Sodium Phosphate Inj 3 MMole/ML Minerals P G Sodium Polystyrene Sulfonate K Removing Resins B SOLARAZE Topical - Antineoplastics 12/15/2015 9:09:11 AM PA Required PA Required PA Required P NP Page 73 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR S B SOLODYN Tetracyclines NP B SOLTAMOX Antineoplastics - Antiestrogens NR PA Required B SOLU-CORTEF Glucocorticoids - Mineralocorticoids P B SOLU-MEDROL Glucocorticoids - Mineralocorticoids P B SOMA Muscle Relaxants NP B SOMAVERT Somatostatic Agents NP B SONATA Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B SOOLANTRA Topical - Acne Preparations NP PA Required B SORIATANE Anti-Psoriatics - Non-Biologicals NP B SORILUX Anti-Psoriatics - Non-Biologicals NP G Sotalol HCl Beta Blockers - Non Selective P G Sotalol HCl (AFIB/AFL) Beta Blockers - Non Selective P B SOTYLIZE BETA BLOCKERS - NON SELECTIVE B SOVALDI Hepatitis C Agents B SPECTRACEF Cephalosporins NP G Spinosad Topical - Scabicides And Pediculicides NP B SPIRIVA HANDIHALER Antiasthmatic - Anti-Cholinergics PA Required NP P PA Required P B SPIRIVA RESPIMAT ANTIASTHMATIC - ANTI-CHOLINERGICS G Spironolactone Diuretics P G Spironolactone & Hydrochlorothiazide Diuretics P B SPORANOX Antifungals - Assorted NP PA Required B SPRIX Cox 2 Inhibitors - Selective NP PA Required B SPRYCEL Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B SPS K Removing Resins NP B SSKI Minerals B STALEVO Anti-Parkinsonian Drugs G Stannous Fluoride Dental Products NP P NP P B STARLIX Diabetic - Meglitinides G Stavudine Antiretrovirals - Rti-Nucleoside Analogues-Thymidines B STELARA Anti-Inflammatories, Non-Nsaid NP PA Required B Step 3 - Fanapt Antipsychotics - Atypicals NP Grandfather Existing Users ND STERILE DILU SOL FLOLAN Compounding Materials B STIMATE Vasopressins B Stiolto respimat Antiasthmatic - Adrenergic Combos 12/15/2015 9:09:11 AM NP R P P PA Required NP Page 74 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR S B STIVARGA Antineoplastics - Protein-Tyrosine Kinase Inhibitors B STRATTERA Stimulants - Other Stimulants / Like Stimulants NR G Streptomycin Sulfate Amino Glycosides B STRIANT Androgens -Topical NP PA Required B STRIBILD Antiretrovirals - Combinations NP Grandfather Existing Users B STRIVERDI RESPIMAT Antiasthmatic - Beta - Adrenergics NP B STROMECTOL Anthelmintics NP B SUBLIMAZE Narcotics - Misc. NP PA Required B SUBOXONE Narcotics - Misc. P PA Required B SUBSYS Narcotics - Misc. NP PA Required G Sucralfate Susp 1 GM/10ML Gi - Misc. Anti-Ulcer NP G Sucralfate Tab 1 GM Gi - Misc. Anti-Ulcer P P PA Required PA Required >= 21 yo. P B SULAR Calcium Channel Blockers--Nisoldipine NP G Sulfacetamide Sodium (Acne) Topical - Acne Preparations NP G Sulfacetamide Sodium (Ophth) Op. Antibiotics G Sulfacetamide Sodium Liquid 10% Topical - Antiseborrheics G Sulfacetamide Sodium w/ Sulfur Topical - Acne Preparations NP G Sulfacetamide Sod-Prednisolone Op. Antiinflammatory / Steroids Ophth. NP G Sulfadiazine Antibiotics - Misc. P G Sulfamethoxazole-Trimethoprim Anti Infective Combo's - Misc. P PA Required P P PA Required B SULFAMYLON Topical - Burn Products G Sulfasalazine Gi - Inflammatory Bowel Agents G Sulindac NSAIDS G Sumatriptan Spray Migraine - Selective Serotonin Agonists (5HT)--Injectables NP PA Required G Sumatriptan Succinate Migraine - Selective Serotonin Agonists (5HT)--Injectables NP PA Required G Sumatriptan Succinate Migraine - Selective Serotonin Agonists (5HT)--Tabs B SUMAVEL DOSEPRO Migraine - Selective Serotonin Agonists (5HT)--Injectables NP PA Required B SUMAXIN Topical - Acne Preparations NP PA Required B SUMAXIN TS Topical - Acne Preparations NP PA Required B SUPRAX Cephalosporins NP B SUPRAX SUSR 100/5ML Cephalosporins NP B SUPRAX SUSR 200/5ML Cephalosporins NP B SURMONTIL Antidepressants - Tri-Cyclics P B SUSTIVA Antiretrovirals - Rti-Non-Nucleoside Analogues R 12/15/2015 9:09:11 AM NP P P P PA Required> 12 Units/30 Days supply Page 75 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR S B SUTENT Antineoplastics - Protein-Tyrosine Kinase Inhibitors B SYLATRON Antineoplastics - Misc. R PA Required B SYMBICORT Antiasthmatic - Adrenergic Combos B SYMBYAX Psychotherapeutic Combination NP Grandfather Existing Users B SYMLINPEN 120 Diabetic - Other NP PA Required B SYMLINPEN 60 Diabetic - Other NP PA Required B SYNAGIS RSV Prophylaxis P PA Required B SYNALGOS-DC Narcotics - Misc. NP PA Required B SYNERA Topical - Local Anesthetics NP B Synjardy Diabetic - Other NP B SYNTHROID Thyroid Hormones NP B SYPRINE Chelating Agents B TABLOID Antineoplastics - Antimetabolites NR P PA Required P T R B TACLONEX Topical - Steroid Combinations G Tacrolimus Immunosuppressants NP G Tacrolimus (Topical) Topical - Immunomodulators NP PA Required B TAFINLAR Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B TAMIFLU Influenza Agents P G Tamoxifen Citrate Antineoplastics - Antiestrogens R G Tamsulosin HCl BPH P B TANZEUM Diabetic - Non-Insulin Injectables P B TAPAZOLE Antithyroid Therapies B TARCEVA Antineoplastics - Protein-Tyrosine Kinase Inhibitors B TARGRETIN Antineoplastics - Selective Retinoid X Receptor Agonists B TARKA ACE Inhibitors And Calcium Channel Blockers B TASIGNA Antineoplastics - Protein-Tyrosine Kinase Inhibitors B TASMAR Parkinsons - Comt Inhibitors B TAXOTERE Antineoplastics - Mitotic Inhibitors B TAZORAC Anti-Psoriatics - Non-Biologicals B TECFIDERA Multiple Sclerosis Agents B Technivie B B P PA Required: > 14 Units/30Days Supply PA Required NP R PA Required P Initial fill limited to 15 day supply. NP R PA Required NP R P PA Required NP PA Required Hepatitis C Agents P PA Required TEGRETOL Anticonvulsants P TEGRETOL SUSP Anticonvulsants P 12/15/2015 9:09:11 AM Page 76 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR T B TEGRETOL XR Anticonvulsants B TEKAMLO Direct Renin Inhibitors NP P B TEKTURNA Direct Renin Inhibitors NP B TEKTURNA HCT Direct Renin Inhibitors NP G Telmisartan ARB'S NP PA Required G Telmisartan-Amlodipine Arb/Ccb NP PA Required G Telmisartan-Hydrochlorothiazide ARB'S And Diuretics NP PA Required G Temazepam Cap 15 MG Sedative/Hypnotics - Benzodiazepines P G Temazepam Cap 30 MG Sedative/Hypnotics - Benzodiazepines P G Temazepam CAPS 22.5MG Sedative/Hypnotics - Benzodiazepines NP PA Required G Temazepam CAPS 7.5MG Sedative/Hypnotics - Benzodiazepines NP PA Required B TEMODAR Antineoplastics - Imidazotetrazines R PA Required B TEMOVATE Topical - Corticosteroids - High Potency G Temozolomide Antineoplastics - Imidazotetrazines NR P B TENEX Antihypertensives - Central NP B TENORETIC Beta Blockers And Diuretic Combo'S NP B TENORMIN Beta Blockers - Cardio Selective NP NP PA Required B TERAZOL Vaginal - Anti Fungals G Terazosin HCl BPH P G Terbinafine HCl Antifungals - Assorted P G Terbutaline Sulfate Inj 1 MG/ML Antiasthmatic - Beta - Adrenergics NP G Terbutaline Sulfate Tab 2.5 MG Antiasthmatic - Beta - Adrenergics P G Terbutaline Sulfate Tab 5 MG Antiasthmatic - Beta - Adrenergics P G Terconazole Vaginal Cream 0.4% Vaginal - Anti Fungals P G Terconazole Vaginal Cream 0.8% Vaginal - Anti Fungals P G Terconazole Vaginal Suppos 80 MG Vaginal - Anti Fungals NP B TESTIM Androgens -Topical P PA Required G Testosterone Cypionate Androgens - Anabolics P PA Required G Testosterone Enanthate Androgens - Anabolics P PA Required G TESTOSTERONE GEL Androgens -Topical NP PA Required P PA Required B TESTRED Androgens - Anabolics G Tetrabenazine Neurologics - Misc. G Tetracaine HCl (Ophth) Op. Misc G Tetracycline HCl Tetracyclines 12/15/2015 9:09:11 AM PA Required > 90 days NP P NP Page 77 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR T B TEVETEN ARB'S NP PA Required B TEVETEN HCT ARB'S And Diuretics NP PA Required B TEV-TROPIN Growth Hormone NP PA Required B TEXACORT Topical - Corticosteroids - Low Potency N PA Required B THALOMID Antileprotic P B THEO-24 Antiasthmatic - Xanthines P G Theophylline Antiasthmatic - Xanthines P G Thiamine HCl Vitamins B THIOLA Urological - Misc. G Thioridazine HCl Antipsychotics - Typical G Thiothixene Antipsychotics - Typical B THYROGEN Diagnostic Drugs B THYROLAR Thyroid Hormones B TIAZAC Calcium Channel Blockers--Diltiazems NP G Ticlopidine HCl Platelet Aggregation Inhibitors NP B TIGAN Antiemetic - Anticholinergic / Dopaminergic NP B TIKOSYN Antiarrhythmics P P NP P P NP P B TIMENTIN Beta-Lactams / Clavulanate Combo'S P G Timolol Maleate Beta Blockers - Non Selective P G Timolol Maleate Ophth Gel Forming Soln 0.25% Op. Beta - Blockers P G Timolol Maleate Ophth Gel Forming Soln 0.5% Op. Beta - Blockers P G Timolol Maleate Ophth Soln 0.25% Op. Beta - Blockers P G Timolol Maleate Ophth Soln 0.5% Op. Beta - Blockers P B TIMOPTIC Op. Beta - Blockers NP B TIMOPTIC-XE Op. Beta - Blockers NP B TINDAMAX Antiprotozoal Agents NP G Tinidazole Antiprotozoal Agents NP B TIROSINT Thyroid Hormones NP B TIVICAY Antiretrovirals B TIVORBEX NSAIDS G Tizanidine HCl Muscle Relaxants P B TOBI Amino Glycosides NP B TOBI PODHALER Amino Glycosides NP B TOBRADEX Op. Antiinflammatory / Steroids Ophth. 12/15/2015 9:09:11 AM P NP PA Required P Page 78 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR T B TOBRADEX ST Op. Antiinflammatory / Steroids Ophth. G Tobramycin (Ophth) Op. Antibiotics NP G Tobramycin Neb Solution Amino Glycosides NP G Tobramycin Sulfate Amino Glycosides P G Tobramycin-Dexamethasone Op. Antiinflammatory / Steroids Ophth. NP B TOBREX Op. Antibiotics NP B TOFRANIL Antidepressants - Tri-Cyclics NP P B TOFRANIL-PM Antidepressants - Tri-Cyclics NP G Tolazamide Diabetic - Oral Sulfonylureas P G Tolbutamide Diabetic - Oral Sulfonylureas NP G TOLCAPONE PARKINSONS - COMT INHIBITORS NP G Tolmetin Sodium NSAIDS NP O Tolnaftate Topical - Antifungals G Tolterodine Tartrate Antispasmodics NP G Tolterodine Tartrate Antispasmodics - Long Acting NP B TOPAMAX Anticonvulsants NP B TOPICORT Topical - Corticosteroids - High Potency G Topiramate Anticonvulsants P G Topiramate CS24 Anticonvulsants NP B TOPROL XL Beta Blockers - Cardio Selective NP G Torsemide Diuretics B Toujeo Diabetic - Insulin Penfills NP NP Imipramine Pamoate - Use Imipramine HCL PA Required P N Initial fill limited to 15 day supply. PA Required PA Required P PA Required B TOVIAZ Antispasmodics - Long Acting G Trace Minerals (Cr-Cu-Mn-Se-Zn) Minerals P B TRACLEER Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist P PA Required PA Required B TRADJENTA Diabetic - Other P G Tramadol HCl Narcotics - Selected P G Tramadol HCl Tab SR 24HR Biphasic Release 100 MG Narcotics - Selected NP G Tramadol HCl Tab SR 24HR Biphasic Release 200 MG Narcotics - Selected NP G Tramadol HCl Tab SR 24HR Biphasic Release 300 MG Narcotics - Selected NP G Tramadol HCl Tablet ER 24HR Narcotics - Selected NP PA Required G Tramadol-Acetaminophen Narcotics - Selected NP ULTRACET - Use Tramadol & Acetaminophen separately B TRANDATE Beta Blockers - Alpha / Beta NP 12/15/2015 9:09:11 AM Page 79 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR T G Trandolapril ACE Inhibitors P G Trandolapril-Verapamil HCl ACE Inhibitors And Calcium Channel Blockers P B TRANSDERM-SCOP Antiemetic - Anticholinergic / Dopaminergic B TRANXENE Anxiolytics - Benzodiazepines G Tranylcypromine Sulfate Antidepressants - Mao Inhibitors P B TRAVASOL Electrolytes/ Nutritionals P B TRAVATAN Z Op. Prostaglandins P G Travoprost Op. Prostaglandins NP G Trazodone HCl Antidepressants - Selected SSRI's P G Trazodone HCl TABS 300MG Antidepressants - Selected SSRI's NP B TRECATOR Antimycobacterials / Antituberculosis P B TRELSTAR Antineoplastics - Lhrh Analogs R G Tretinoin Topical - Tretinoids N PA Required G Tretinoin (chemotherapy) antineoplastics - retinoids R PA Required G Tretinoin Microsphere Topical - Tretinoids NP PA Required B TREXALL Antineoplastics - Antimetabolites NP B TREXIMET Migraine - Selective Serotonin Agonists-5HT Combinations NP G Triamcinolone Acetonide (Nasal) Nasal Steroids NP G Triamcinolone Acetonide (Topical) Topical - Corticosteroids - Medium Potency P G Triamcinolone Acetonide (Topical) LOTN Topical - Corticosteroids - Medium Potency P G Triamcinolone Acetonide Dental Paste 0.1% Mouth - Steroids P G Triamterene & Hydrochlorothiazide Diuretics P P NP PA Required PA Required B Trianex Topical - Corticosteroids - Medium Potency N PA Required G Triazolam Sedative/Hypnotics - Benzodiazepines NP PA Required B TRIBENZOR ARB/CCB Plus Diuretics NP PA Required NP B TRICOR Cholesterol - Fibric Acid Derivatives G Trifluoperazine HCl Antipsychotics - Typical G Trifluridine Op. Antibiotics B TRIGLIDE Cholesterol - Fibric Acid Derivatives G Trihexyphenidyl HCl Parkinsons - Anticholinergics B TRILEPTAL Anticonvulsants NP B TRILEPTAL SUSP Anticonvulsants NP Grandfather for seizure disorder. B TRILIPIX Cholesterol - Fibric Acid Derivatives NP PA Required G Trimethobenzamide HCl Antiemetic - Anticholinergic / Dopaminergic 12/15/2015 9:09:11 AM P P NP P P Page 80 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR T G Trimethoprim Antibiotics - Misc. P B TRINATAL GT Vitamins - Misc. P B TRINATAL RX 1 Vitamins - Misc. B TRI-NORINYL 28 Contraceptives - Tri-Phasic Combinations B TRIOSTAT Thyroid Hormones B TRIUMEQ Antiretrovirals - Combinations NP B TRIZIVIR Antiretrovirals - Combinations R B TROKENDI XR Anticonvulsants NP B TROPHAMINE Electrolytes/ Nutritionals NP G Tropicamide Op. Cycloplegics P G Trospium Chloride Antispasmodics NP Initial fill limited to 15 day supply. B TRULICITY Diabetic - Non-Insulin Injectables NP PA Required B TRUSOPT Op. Carbonic Anhydrase Inhibitors/Combo NP B TRUVADA Antiretrovirals B TUDORZA PRESSAIR Antiasthmatic - Anti-Cholinergics B TWYNSTA Arb/Ccb NP B TYBOST Antiretrovirals NR B TYGACIL Antibiotics - Misc. B TYKERB Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B TYLENOL/CODEINE Narcotics - Misc. NP PA Required B TYVASO Pulmonary Anti-Hypertensives NP PA Required B TYZEKA Hepatitis B Only NP B UCERIS Glucocorticoids - Mineralocorticoids NP B U-CORT Topical - Steroid Combinations NP B ULESFIA Topical - Scabicides And Pediculicides B ULORIC Gout NP PA Required B ULTRACET Narcotics - Selected NP ULTRACET - Use Tramadol & Acetaminophen separately B ULTRAM Narcotics - Selected NP PA Required P NP P Grandfather Existing Users PA Required P NP PA Required P U 12/15/2015 9:09:11 AM P No manual PA required if one course of treatment of a preferred permethrin or pyrethrins-piperonyl butoxide product is in the member's pharmacy claims history in past 30 days. Trial of Natroba or Ulesfia is required prior to consideration of any nonpreferred agent. Page 81 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR U B ULTRAVATE Topical - Corticosteroids - High Potency B ULTRESA Gi - Digestive Enzymes NP N B UMECTA Topical - Emollients NP B UMECTA NAIL FILM Topical - Emollients NP B UNASYN Beta-Lactams / Clavulanate Combo'S NP B UNIRETIC ACE and Thiazide Combo's B UNIVASC ACE Inhibitors NP PA Required P B URAMAXIN Topical - Emollients NP G Urea Cream 50% Topical - Emollients NP G Urea Foam 40% Topical - Emollients NP G Urea Gel 40% Topical - Emollients NP G Urea Gel 45% Topical - Emollients NP G Urea Lotion 40% Topical - Emollients P G Urea Lotion 45% Topical - Emollients NP B URECHOLINE Cholinergic NP B UROCIT Urological - Misc. B UROXATRAL BPH NP P B URSO Gi - Misc. NP G Ursodiol Gi - Misc. P B VAGIFEM Vaginal - Estrogens G Valacyclovir HCl Herpes Agents V NP P B VALCYTE Cyto-Megalovirus Agents P G Valganciclovir HCl Cyto-Megalovirus Agents NP G Valproate Sodium Anticonvulsants P G Valproic Acid Anticonvulsants P G Valsartan ARB'S P PA required if ACE-I not previously filled. G Valsartan-Hydrochlorothiazide ARB'S And Diuretics P PA required if ACE-I not previously filled. B VALTREX Herpes Agents NP B VANCOCIN HCL Antibiotics - Misc. P G Vancomycin HCl Antibiotics - Misc. P G Vancomycin HCl CAPS Antibiotics - Misc. NP G Vancomycin HCl in Dextrose Antibiotics - Misc. P B VANOS Topical - Corticosteroids - High Potency N 12/15/2015 9:09:11 AM PA Required Page 82 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR V B VASCEPA Cholesterol - Hmg COA + Absorb Inhibitors NP B VASERETIC ACE and Thiazide Combo's NP G Vasopressin Inj 20 Unit/ML Vasopressins NP B VASOTEC ACE Inhibitors NP B VECTICAL Anti-Psoriatics - Non-Biologicals NP B VELCADE Antineoplastics - Protein-Tyrosine Kinase Inhibitors B VELETRI Pulmonary Anti-Hypertensives NP B VELPHORO Phosphate Binders NP B VELTIN Topical - Acne Preparations NP G Venlafaxine HCl Antidepressants - Selected SSRI's P G Venlafaxine HCl Cap SR 24HR 150 MG (Base Equivalent) Antidepressants - Selected SSRI's P G Venlafaxine HCl Cap SR 24HR 37.5 MG (Base Equivalent) Antidepressants - Selected SSRI's P G Venlafaxine HCl Cap SR 24HR 75 MG (Base Equivalent) Antidepressants - Selected SSRI's P G Venlafaxine HCl Tablet ER 24HR Antidepressants - Selected SSRI's NP B VENTAVIS Pulmonary Anti-Hypertensives B VENTOLIN HFA Antiasthmatic - Beta - Adrenergics B VERAMYST Nasal Steroids G Verapamil HCl Calcium Channel Blockers--Verapamils P G Verapamil HCl SOLN Calcium Channel Blockers--Verapamils NP B VEREGEN Topical - Genital Warts B VERELAN Calcium Channel Blockers--Verapamils NP B VERIPRED 20 Glucocorticoids - Mineralocorticoids NP B VERSACLOZ Antipsychotics - Special Atypicals NP B VESICARE Antispasmodics - Long Acting P B VEXOL Op. Antiinflammatory / Steroids Ophth. P B VFEND Antifungals - Assorted NP B VFEND IV Antifungals - Assorted P PA Required > 90 days B VFEND SUSR Antifungals - Assorted P PA Required > 90 days B VIBATIV Antibiotics - Misc. NP B VIBRAMYCIN CAP 100MG Tetracyclines NP B VIBRAMYCIN SUSR Tetracyclines NP B VIBRAMYCIN SYRP Tetracyclines P 12/15/2015 9:09:11 AM R P PA Required PA Required PA Required P NP P Payable for members who are 18 years of age and older. Quantity limitations of 15 grams/4 weeks (28 days) or a total of 60 grams/16 weeks (112 days) PA Required Initial fill limited to 15 day supply. PA Required Page 83 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR V B VICOPROFEN Narcotics - Misc. NP PA Required B VICTOZA Diabetic - Non-Insulin Injectables NP PA Required B VICTRELIS Hepatitis C Agents P PA Required B VIDAZA Antineoplastics - Antimetabolites R B VIDEX Antiretrovirals - Rti-Nucleoside Analogues-Purines R B VIEKIRA PAK Hepatitis C Agents B VIGAMOX Op. Quinolones Fourth Generation NP B VIIBRYD Antidepressants - Selected SSRI's NP PA Required B VIMOVO Gi - Proton Pump Inhibitor/Nsaid Combo NP PA Required B VIMPAT Anticonvulsants P G Vinblastine Sulfate Antineoplastics - Mitotic Inhibitors R G Vincristine Sulfate Antineoplastics - Mitotic Inhibitors R G Vinorelbine Tartrate Antineoplastics - Mitotic Inhibitors P B VIOKACE Gi - Digestive Enzymes B VIRACEPT Antiretrovirals - Protease Inhibitors B VIRAMUNE Antiretrovirals - Rti-Non-Nucleoside Analogues NR B VIRAMUNE SUSP Antiretrovirals - Rti-Non-Nucleoside Analogues R B VIRAMUNE XR Antiretrovirals - Rti-Non-Nucleoside Analogues R B VIREAD Antiretrovirals - Rti-Nucleotide Analogues B VIROPTIC Op. Antibiotics NP B VISTARIL Antihistamines - Other NP B VITEKTA Antiretrovirals NR B VIVELLE Estrogens - Patches B VIVITROL Narcotic - Antagonists NP B VOGELXO Androgens -Topical NP B VOL-NATE Vitamins - Misc. B VOL-PLUS B VOLTAREN GEL NSAIDS NP PA Required NP PA Required TAB Vitamins - Misc. P No manual PA required if a preferred agent of a different chemical entity is found in member’s pharmacy claims history in past 12 months NP R Requires a Selected Brand Name Drug PA R PA Required P PA Required P P B VOLTAREN-XR NSAIDS G Voriconazole Antifungals - Assorted P G Voriconazole SOLR Antifungals - Assorted NP B VOSPIRE ER Antiasthmatic - Beta - Adrenergics NP 12/15/2015 9:09:11 AM PA Required PA Required > 90 days PA Required Page 84 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR V B VOTRIENT Antineoplastics - Protein-Tyrosine Kinase Inhibitors B VPRIV Agents For Gaucher Disease NP R B VUSION Topical - Antifungals NP B VYTORIN Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P B VYVANSE Stimulants - Amphetamines - Long Acting P PA Required PA Required PA Required >= 21 yo. W G Warfarin Sodium ND Water For Inject, Bacteriostatic Parabens Anticoagulants P Compounding Materials P B WELCHOL Cholesterol - Bile Sequestrants NP B WELLBUTRIN Antidepressants - Selected SSRI's P B WELLBUTRIN XL Antidepressants - Selected SSRI's NP B WILATE Antihemophilic Agents R B WINRHO SDF Immune Serums P X B XALATAN Op. Prostaglandins NP B XALKORI Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B XANAX Anxiolytics - Benzodiazepines NP PA Required B XANAX XR Anxiolytics - Long Acting NP PA Required B XARELTO Anticoagulants B XARTEMIS XR Narcotics -Long Acting NP PA Required B XELJANZ Anti-Inflammatories, Non-Nsaid NP PA Required B XELODA Antineoplastics - Antimetabolites P PA Required B Xenazine Neurologics - Misc. NP B XEOMIN Neuromuscular Blocking Agents NP O XERAC AC Topical - Astringents / Protectants B XERESE Topical - Antivirals NP B XIFAXAN Antibiotics - Misc. NP B XIGDUO XR Diabetic - Other NP PA Required B XODOL Narcotics - Misc. NP PA Required B XOLAIR Antiasthmatic - Antiinflammatory Agents NP PA Required B XOPENEX Antiasthmatic - Beta - Adrenergics NP PA Required B XTANDI Antineoplastics - Antiandrogens NR Initial fill limited to 15 day supply. G XULANE Contraceptives - Patches/ Vaginal Products 12/15/2015 9:09:11 AM P PA required. Preferred for post surgery DVT prophylaxis only. P P Page 85 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR X B XYLOCAINE Antiarrhythmics B XYLOCAINE/EPINEPHRINE Topical - Local Anesthetics NP P B XYLOCAINE-MPF Topical - Local Anesthetics NP B Xyntha Antihemophilic Agents R B XYREM Anti-Cataplectic Agents NP PA Required B XYZAL Antihistamines - Non-Sedating NP PA Required Y B YASMIN 28 Contraceptives - Monophasic Combination O/C'S NP B YAZ Contraceptives - Monophasic Combination O/C'S NP G Zafirlukast Antiasthmatic - Leukotriene Receptor Antagonists G Zaleplon Sedative/Hypnotics - Non-Benzodiazepines B ZANAFLEX Muscle Relaxants NP B ZANTAC Gi - H2-Antagonists NP B ZARONTIN Anticonvulsants P B ZARONTIN SOLN Anticonvulsants NP B ZAROXOLYN Diuretics B Zarxio Granulocyte Csf NP B ZAVESCA Agents For Gaucher Disease NP B ZEBETA Beta Blockers - Cardio Selective NP B Zecuity Migraine - Selective Serotonin Agonists (5HT)--Injectables NP B ZELAPAR Anti-Parkinsonian Drugs NP B ZELBORAF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ZEMAIRA Alpha-Proteinase Inhibitor NP PA Required B ZEMPLAR Hyperparathyroid Treatment - Vitamin D Analogs And Calcimimetics NP Grandfather Existing Users B ZENPEP Gi - Digestive Enzymes B ZERIT Antiretrovirals - Rti-Nucleoside Analogues-Thymidines NR B ZESTORETIC ACE and Thiazide Combo's NP B ZESTRIL ACE Inhibitors NP B ZETIA Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations B ZETONNA Nasal Steroids NP B ZIAC Beta Blockers And Diuretic Combo'S NP Z 12/15/2015 9:09:11 AM NP P PA Required P PA Required PA Required P P Requires a Selected Brand Name Drug PA No manual PA required if HMG-CoA reductase inhibitor found in member’s pharmacy claims history in past 12 months. Page 86 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR Z B ZIAGEN Antiretrovirals - Rti-Nucleoside Analogues-Purines B ZIANA Topical - Acne Preparations G Zidovudine Antiretrovirals - Rti-Nucleoside Analogues-Thymidines B ZINACEF Cephalosporins B ZINECARD Antineoplastics - Cardiac Protective Agents R NP PA Required R NP R B ZIOPTAN Op. Prostaglandins G Ziprasidone HCl Antipsychotics - Atypicals B ZIPSOR NSAIDS NP B ZIRGAN Op. Antibiotics NP B ZITHROMAX INJ 500MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX POW 1GM PAK Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX SUS 100/5ML Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX SUS 200/5ML Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB 250MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB 500MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB 600MG Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB TRI-PAK Macrolides / Erythromycin'S / Ketolides NP B ZITHROMAX TAB Z-PAK Macrolides / Erythromycin'S / Ketolides NP B ZMAX Macrolides / Erythromycin'S / Ketolides NP B ZOCOR Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations NP B ZOFRAN Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ZOFRAN ODT Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ZOHYDRO ER Narcotics -Long Acting NP PA Required B ZOLADEX Antineoplastics - Lhrh Analogs B ZOLINZA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR Initial fill limited to 15 day supply. G Zolmitriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ZOLOFT Antidepressants - Selected SSRI's NP G Zolpidem Tartrate Sedative/Hypnotics - Non-Benzodiazepines P G Zolpidem Tartrate Tablet ER Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B ZOLPIMIST Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B ZOMETA Osteoporosis NP B ZOMIG Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ZOMIG NASAL SPRAY Migraine - Selective Serotonin Agonists (5HT)--Injectables NP PA Required B ZOMIG ZMT Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required SUS 2GM 12/15/2015 9:09:11 AM NP P PA Required R Page 87 Of 89 B or G Drug Name Drug Category P, N, Comment R or NR Z B ZONALON Topical - Antipruritics B ZONEGRAN Anticonvulsants G Zonisamide Anticonvulsants B ZONTIVITY Platelet Aggr. Inhibitors / Combo's - Misc. NP PA Required B ZORBTIVE Growth Hormone NP PA Required B ZORTRESS Immunosuppressants NP B ZORVOLEX NSAIDS NP B ZOSTAVAX Vaccines P B ZOSYN Beta-Lactams / Clavulanate Combo'S P B ZOVIA 1/50E B ZOVIRAX CAP 200MG Herpes Agents NP B ZOVIRAX CRE 5% Topical - Antivirals NP B ZOVIRAX OIN 5% Topical - Antivirals NP B ZOVIRAX SUS 200/5ML Herpes Agents P B ZOVIRAX TAB 400MG Herpes Agents NP B ZOVIRAX TAB 800MG Herpes Agents NP B ZUBSOLV Narcotics - Misc. NP B ZYCLARA Topical - Genital Warts NP B ZYCLARA PUMP Topical - Genital Warts NP B ZYDELIG Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B ZYFLO Antiasthmatic - 5-Lipoxygenase Inhibitors NP B ZYKADIA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B ZYLET Op. Antiinflammatory / Steroids Ophth. B ZYLOPRIM Gout NP B ZYMAXID Op. Quinolones Fourth Generation NP B ZYPREXA Antipsychotics - Atypicals NP B ZYPREXA ZYDIS Antipsychotics - Atypicals NP PA Required B ZYTIGA Antineoplastics - Androgen Biosynthesis Inhibitor. NR PA Required < 18 years of age B ZYVOX Lincosamides / Oxazolidinones / Leprostatics INJ Contraceptives - Monophasic Combination O/C'S 12/15/2015 9:09:11 AM P NP Grandfather for seizure disorder. P PA Required Payable for members 50 years of age and older without prior authorization P PA Required PA Required PA Required P N PA Required Page 88 Of 89 12/15/2015 9:09:11 AM Page 89 Of 89
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