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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 01/01/2015 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 P PA Required B ABSTRAL Narcotics - Misc. NP PA Required G Acamprosate Calcium Alcohol Deterrents NP 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 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 12/3/2014 3:05:12 PM PA Required > 15 units / 30 days. Initial fill limited to 14 day supply. PA Required Page 1 Of 88 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 Biologic Immunomodulators NP B ACTIGALL Gi - Misc. NP B ACTIMMUNE Antineoplastics - Misc. NR 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 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 B ADVAIR HFA Antiasthmatic - Adrenergic Combos P B ADVATE Antihemophilic Agents R B ADVICOR Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations B AEROSPAN Antiasthmatic - Steroid Inhalants 12/3/2014 3:05:12 PM PA Required PA Required PA Required P P NP P Page 2 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A B AFINITOR B AFLURIA 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 B ALBENZA Anthelmintics G Albumin, Human Electrolytes/ Nutritionals G Albuterol Sulfate NEBU 0.63MG/3 Antiasthmatic - Beta - Adrenergics P Preferred < 2 years of age 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 14-15 Antineoplastics - Protein-Tyrosine Kinase Inhibitors R Initial fill limited to 15 day supply. Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. P NP P NP B ALCAINE Op. Misc NP G Alclometasone Dipropionate Topical - Corticosteroids NP B ALDACTAZIDE TAB 25/25 Diuretics NP B ALDACTAZIDE TABS 50/50 Diuretics P B ALDACTONE Diuretics NP B ALDARA Topical - Genital Warts NP B ALDURAZYME Mucopolysaccharidosis P G Alendronate Sodium Osteoporosis P G Alendronate Sodium SOLN Osteoporosis NP G Alfuzosin HCl BPH P B ALIMTA Antineoplastics - Antimetabolites R B ALINIA Antiprotozoal Agents P B ALKERAN Antineoplastics - Nitrogen Mustards R B ALKERAN Antineoplastics - Nitrogen Mustards R G Allopurinol Gout P 12/3/2014 3:05:12 PM 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). Page 3 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A B ALOCRIL Op. Antiallergics - Mast Cell Stabilizers NP B ALOMIDE Op. Antiallergics - Mast Cell Stabilizers NP B ALORA Estrogens - Patches 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 P PA Required B ALPHANINE SD Antihemophilic Agents R G Alprazolam Anxiolytics - Benzodiazepines P B ALPRAZOLAM INTENSOL Anxiolytics - Benzodiazepines P 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 NP B ALVESCO Antiasthmatic - Steroid Inhalants G Amantadine HCl Cap 100 MG Anti-Parkinsonian Drugs G Amantadine HCl Syrup 50 MG/5ML G Amantadine HCl Tab 100 MG B P P . Anti-Parkinsonian Drugs P . Anti-Parkinsonian Drugs NP . 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 G Amcinonide Cream 0.1% Topical - Corticosteroids NP G Amcinonide LOTN Topical - Corticosteroids NP G Amcinonide OINT Topical - Corticosteroids NP B AMERGE Migraine - Selective Serotonin Agonists (5HT)--Tabs NP B AMETHYST Contraceptives - Monophasic Combination O/C'S NP G Amifostine Crystalline Antineoplastics - Urinary Tract Protective Agents NR 12/3/2014 3:05:12 PM P PA Required > 90 days . PA Required Page 4 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A 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 - Anti - Flatulents / GI Stimulants NP G Amitriptyline HCl Antidepressants - Tri-Cyclics P G Amlodipine Besylate Calcium Channel Blockers--Amlodipines P G Amlodipine Besylate-Atorvastatin Calcium CCB / Lipid NP G Amlodipine Besylate-Benazepril HCl ACE Inhibitors And Calcium Channel Blockers NP 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 . 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 . 12/3/2014 3:05:12 PM . PA Required P PA Required Page 5 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A 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 NP B AMPYRA Multiple Sclerosis Agents – Non-Interferons NP PA Required B AMRIX Muscle Relaxants NP PA Required B AMTURNIDE Antihypertensive Combos NP PA Required >= 21 yo. PA Required B ANAFRANIL Antidepressants - Tri-Cyclics P G Anagrelide HCl Platelet Aggr. Inhibitors / Combo's - Misc. P B ANAPROX NSAIDS 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 B ANTABUSE Alcohol Deterrents B ANTARA Cholesterol - Fibric Acid Derivatives 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 12/3/2014 3:05:12 PM NP Initial fill limited to 15 day supply. PA Required P NP P PA Required PA Required Page 6 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A B APLENZIN Antidepressants - Selected SSRI's B APLISOL Diagnostic Biologicals NP B APOKYN Parkinsons - Selected Dopamin Agonists P G Apraclonidine HCl Op. Selective Alpha Adrenergic Agonists NP B APRISO Gi - Inflammatory Bowel Agents B APTIOM Anticonvulsants B APTIVUS Antiretrovirals - Protease Inhibitors CAP 0.375GM ND AQUADEKS Vitamins - Misc. PA Required P P . NP 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 B ARIXTRA Anticoagulants NP B ARMOUR THYROID Thyroid Hormones NP B AROMASIN Antineoplastics - Aromatase Inhibitors R B ARRANON Antineoplastics - Antimetabolites R Grandfather Existing Users B ARTHROTEC NSAIDS NP O Artificial Tear Ointment Op. Misc P O Artificial Tear Solution Op. Misc P B ASACOL HD Gi - Inflammatory Bowel Agents NP . B ASMANEX 120 AER 220MCG 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 . O Aspirin Analgesics - Misc. P O Aspirin Buffered Analgesics - Misc. P B ASTAGRAF XL Immunosuppressants NP PA Required B ASTEPRO Antihistamines - Non-Sedating NP PA Required TAB 800MG AER 110MCG 12/3/2014 3:05:12 PM PA Required Page 7 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A B ATACAND ARB'S NP PA Required B ATACAND HCT ARB'S And Diuretics NP PA Required NP B ATELVIA Osteoporosis 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 P PA Required P PA Required B ATRIPLA Antiretrovirals R G Atropine Sulfate Gi - Antidiarrheal / Antacid - Misc. P G Atropine Sulfate (Ophthalmic) Op. Cycloplegics 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 PA Required 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 . B AUGMENTIN XR Beta-Lactams / Clavulanate Combo'S NP PA Required 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 AVINZA Narcotics -Long Acting NP PA Required 12/3/2014 3:05:12 PM P NP P R Page 8 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR A B AVINZA Narcotics -Long Acting 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 HCl Antihistamines - Non-Sedating NP G Azelastine HCl (Ophth) Op. Antiallergics - Antihistamines NP B AZELEX Topical - Acne Preparations B AZILECT Anti-Parkinsonian Drugs G Azithromycin For Susp 100 MG/5ML Macrolides / Erythromycin'S / Ketolides P . 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 . 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 PA Required PA Required P P PA Required PA Required NP 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. G Bacitracin (Ophthalmic) Op. Antibiotics O Bacitracin (Topical) Topical - Antibiotic G Bacitracin-Polymyxin B (Ophth) Op. Antibiotics G Bacitracin-Poly-Neomycin-HC Op. Antiinflammatory / Steroids Ophth. 12/3/2014 3:05:12 PM P PA Required NP P P NP Page 9 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR B G Baclofen Muscle Relaxants P B BACTOCILL IN DEXTROSE Beta-Lactams / Clavulanate Combo'S P B BACTRIM Anti Infective Combo's - Misc. NP B BACTROBAN Topical - Antibiotic NP B BACTROBAN NASAL Topical - Nasal Antibiotics CRE 2% P B BACTROBAN OINT Topical - Antibiotic G Balsalazide Disodium Gi - Inflammatory Bowel Agents B BANZEL Anticonvulsants NP B BARACLUDE Hepatitis B Only P Vitamins - Misc. P ND B-Complex w/ C & Folic Acid . NP P PA Required B BEBULIN Antihemophilic Agents B BECONASE AQ Nasal Steroids G Benazepril & Hydrochlorothiazide ACE and Thiazide Combo's P 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 . B BENZACLIN Topical - Acne Preparations P PA Required B BENZACLIN GEL 1-5% 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 G Benzoyl Peroxide Liq 7% Topical - Acne Preparations NP 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 P . B BEPREVE Op. Antiallergics - Antihistamines NP B BESIVANCE Op. Quinolones NP B BETAGAN Op. Beta - Blockers NP GEL 1-5%PUMP 12/3/2014 3:05:12 PM R NP Page 10 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR B G Betamethasone Dipropionate (Topical) LOTN Topical - Corticosteroids P G Betamethasone Dipropionate (Topical) OINT Topical - Corticosteroids P G Betamethasone Dipropionate Augmented Cream 0.05% Topical - Corticosteroids P . G Betamethasone Dipropionate Augmented Gel 0.05% Topical - Corticosteroids NP . G Betamethasone Dipropionate Augmented Lotion 0.05% Topical - Corticosteroids NP . G Betamethasone Dipropionate Augmented Oint 0.05% Topical - Corticosteroids NP . G Betamethasone Dipropionate Cream 0.05% Topical - Corticosteroids P . G Betamethasone Valerate Topical - Corticosteroids P G Betamethasone Valerate FOAM Topical - Corticosteroids NP B BETAPACE Beta Blockers - Non Selective NP B BETAPACE AF Beta Blockers - Non Selective NP B BETASERON Multiple Sclerosis Agents – Interferons NP G Betaxolol HCl Beta Blockers - Cardio Selective NP G Betaxolol HCl (Ophth) Op. Beta - Blockers NP G Bethanechol Chloride Cholinergic B BETHKIS Amino Glycosides B BETIMOL Op. Beta - Blockers B BETOPTIC-S Op. Beta - Blockers B BEYAZ Contraceptives - Monophasic Combination O/C'S NP B BIAXIN SUS 250/5ML Macrolides / Erythromycin'S / Ketolides NP . B BIAXIN TAB 250MG Macrolides / Erythromycin'S / Ketolides NP . B BIAXIN TAB 500MG Macrolides / Erythromycin'S / Ketolides NP . B BIAXIN XL TAB 500MG Macrolides / Erythromycin'S / Ketolides NP . B BIAXIN XL TAB PAC 500 Macrolides / Erythromycin'S / Ketolides NP . G Bicalutamide Antineoplastics - Antiandrogens R B BICILLIN Beta-Lactams / Clavulanate Combo'S P B BICILLIN Beta-Lactams / Clavulanate Combo'S P B BIDIL Antianginals--Isosorbide Nitrate B BILTRICIDE Anthelmintics P 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 R 12/3/2014 3:05:12 PM P P NP P NP PA Required Page 11 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR B 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 BPO Topical - Acne Preparations B BREO ELLIPTA Antiasthmatic - Adrenergic Combos NP B BREVICON-28 Contraceptives - Monophasic Combination O/C'S NP B BRILINTA Platelet Aggregation Inhibitors NP 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 B BRISDELLE Antidepressants - Selected SSRI's NP G Bromfenac Sodium (Ophth) Op. Nsaid'S NP G Bromocriptine Mesylate Anti-Parkinsonian Drugs NP B BROVANA Antiasthmatic - Beta - Adrenergics NP G Budesonide Glucocorticoids - Mineralocorticoids G Budesonide (Inhalation) Antiasthmatic - Steroid Inhalants NP G Budesonide (Nasal) Nasal Steroids NP G Bumetanide Diuretics 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 . 12/3/2014 3:05:12 PM NP P P P Initial fill limited to 15 day supply. PA Required . PA Required P P Page 12 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR B 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 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. G Butalbital-Aspirin-Caffeine w/Cod Narcotics - Misc. NP NP BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets R P B BUTISOL SODIUM Sedative/Hypnotics - Barbiturate G Butorphanol Tartrate Narcotics - Selected B BUTRANS B B B PA Required P PA Required Narcotics - Misc. NP PA Required BYDUREON Diabetic - Non-Insulin Injectables NP PA Required BYETTA Diabetic - Non-Insulin Injectables P PA Required BYSTOLIC Beta Blockers - Cardio Selective NP PA Required C G Cabergoline Dopamine Receptor Agonists P B CADUET CCB / Lipid NP B CAFERGOT Migraine - Ergot Combinations NP NP B CALAN Calcium Channel Blockers--Verapamils G Calcipotriene Anti-Psoriatics - Non-Biologicals P G Calcipotriene-Betamethasone Dipropionate Topical - Steroid Combinations NP G Calcitonin (Salmon) Osteoporosis NP 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 NP Phosphate Binders P ND Calcium Carbonate Minerals P PA Required ND Calcium Carbonate (Antacid) Minerals P PA Required 12/3/2014 3:05:12 PM Page 13 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C ND Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca) 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 CAMPRAL Alcohol Deterrents B CAMPTOSAR Antineoplastics - Topoisomerase I Inhibitors B CANASA Gi - Inflammatory Bowel Agents SUP 1000MG P R 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 NR B CAPEX Topical - Corticosteroids 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 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 NP G Carbamazepine SUSP Anticonvulsants NP G Carbamazepine Tablet ER 12HR Anticonvulsants NP B CARBATROL Anticonvulsants P G Carbidopa-Levodopa Anti-Parkinsonian Drugs P G Carbidopa-Levodopa-Entacapone Anti-Parkinsonian Drugs 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 B CARIMUNE NANOFILTERED Immune Serums 12/3/2014 3:05:12 PM P . PA Required > 90 days P NP PA Required Initial fill limited to 15 day supply. P Grandfather for seizure disorder. P PA Required PA Required P Page 14 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C 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 Requires a Selected Brand Name Drug PA B CATAFLAM NSAIDS NP PA Required B CATAPRES Antihypertensives - Central NP B CATAPRES-TTS Antihypertensives - Central P B CATHFLO ACTIVASE Tissue Plasminogen Activator P B CAYSTON Antibiotics - Misc. P PA Required < 7 years of age 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 . 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 Cefotaxime Sodium Cephalosporins NP G Cefpodoxime Proxetil Cephalosporins NP 12/3/2014 3:05:12 PM Page 15 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C G Cefprozil Cephalosporins P G Ceftazidime Cephalosporins P 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 B CELEBREX Cox 2 Inhibitors - Selective NP 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 B CEREZYME Agents For Gaucher Disease NP NP P PA Required B CESAMET Antiemetic - Tetrahydrocannabinol (THC) Derivatives 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 12/3/2014 3:05:12 PM NP . Page 16 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C G Chlorothiazide Sodium Diuretics NP G Chlorothiazide Tab Diuretics P O Chlorpheniramine Maleate Antihistamines - Other P G Chlorpromazine HCl Antipsychotics - Typical P G Chlorpropamide Diabetic - Oral Sulfonylureas P G Chlorthalidone Diuretics P G Chlorzoxazone Muscle Relaxants P G Cholestyramine Cholesterol - Bile Sequestrants P G Cholestyramine Light Cholesterol - Bile Sequestrants P G Choline & Mag Salicylate Analgesics - Misc. 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 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 Gi - H2-Antagonists B CIMZIA Biologic Immunomodulators NP PA Required B CIPRO (10%) SUS 500MG/5 Fluoroquinolones NP . B CIPRO (5%) SUS 250MG/5 Fluoroquinolones NP . B CIPRO HC Ear B CIPRO TABS Fluoroquinolones 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 12/3/2014 3:05:12 PM . P P NP Preferred < 8yo Page 17 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C B CLAFORAN Cephalosporins 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 PA Required 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 P B CLEOCIN-T Topical - Acne Preparations B CLIMARA Estrogens - Patches B CLIMARA PRO Estrogen Combos NP NP NP . PA Required P B CLINDAGEL Topical - Acne Preparations 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 NP . G Clindamycin Phosphate (Topical) Topical - Acne Preparations G Clindamycin Phosphate Vaginal Vaginal - Antibacterials G Clindamycin Phosphate-Benzoyl Peroxide Topical - Acne Preparations NP P PA Required P B CLINDESSE Vaginal - Anti Fungals NP G Clobetasol Propionate Topical - Corticosteroids NP G Clobetasol Propionate Emollient Base Topical - Corticosteroids P G Clobetasol Propionate Emulsion FOAM Topical - Corticosteroids NP G Clobetasol Propionate SOLN Topical - Corticosteroids P B CLOBEX Topical - Corticosteroids P B CLOBEX LIQD Topical - Corticosteroids NP 12/3/2014 3:05:12 PM PA Required PA Required Page 18 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C B CLODERM Topical - Corticosteroids NP G Clomipramine HCl Antidepressants - Tri-Cyclics NP 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 NP NP B CLOZARIL Antipsychotics - Special Atypicals G Codeine Sulfate Narcotics - Misc. B COLAZAL Gi - Inflammatory Bowel Agents G Colchicine w/ Probenecid Gout P B COLCRYS Gout NP PA Required > 90 days P NP B COLESTID Cholesterol - Bile Sequestrants NP G Colestipol HCl Cholesterol - Bile Sequestrants P G Colistimethate Sodium Antibiotics - Misc. NP B COLY-MYCIN S Ear NP B COLY-MYCIN-M Antibiotics - Misc. P 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 P B COMBIVIR Antiretrovirals - Combinations R B COMETRIQ Antineoplastics - Protein-Tyrosine Kinase Inhibitors 12/3/2014 3:05:12 PM PA Required < 9 years of age 3 tablets per 60 days allowed. PA required for quantities exceeding this limit NP NR Page 19 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C B COMPLERA Antiretrovirals - Combinations NR B COMTAN Parkinsons - Comt Inhibitors P B CONCERTA Stimulants - Methylphenidate - Long Acting NP B CONDYLOX Topical - Genital Warts NP B CONZIP Narcotics - Selected NP B COPAXONE B COPAXONE B B Multiple Sclerosis Agents – Non-Interferons P Multiple Sclerosis Agents – Non-Interferons NP COPEGUS Hepatitis C Agents NP CORDARONE Antiarrhythmics NP B CORDRAN Topical - Corticosteroids NP B COREG CR Beta Blockers - Alpha / Beta NP B COREG TABS Beta Blockers - Alpha / Beta NP B CORGARD Beta Blockers - Non Selective NP B CORTEF Glucocorticoids - Mineralocorticoids B CORTENEMA Anorectal - Misc. NP NP INJ 40MG/ML PA Required PA Required PA Required P B CORTIFOAM Anorectal - Misc. G Cortisone Acetate Glucocorticoids - Mineralocorticoids B CORTISPORIN Topical - Antibiotic NP B CORTISPORIN Topical - Antibiotic NP B CORTISPORIN Ear NP B CORTISPORIN-TC Ear NP B CORTROSYN Diagnostic Drugs NP B CORZIDE Beta Blockers And Diuretic Combo'S NP B COSOPT Op. Carbonic Anhydrase Inhibitors/Combo NP 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 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 12/3/2014 3:05:12 PM PA Required < 18 years of age P PA Required P Page 20 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR C G Cromolyn Sodium (Ophth) Op. Antiallergics - Mast Cell Stabilizers B CUBICIN Lincosamides / Oxazolidinones / Leprostatics NP P B CUPRIMINE Chelating Agents NP B CUTIVATE Topical - Corticosteroids NP B CUVPOSA Gi - Antidiarrheal / Antacid - Misc. NP G Cyanocobalamin Inj 1000 MCG/ML Vitamins P ND Cyanocobalamin Tab 1000 MCG Vitamins NP ND Cyanocobalamin Tab CR 1000 MCG Vitamins NP B CYCLESSA Contraceptives - Tri-Phasic Combinations P G Cyclobenzaprine HCl Muscle Relaxants P B CYCLOGYL Op. Cycloplegics NP B CYCLOMYDRIL Op. Cycloplegics NP G Cyclopentolate HCl Op. Cycloplegics G Cyclophosphamide Antineoplastics - Nitrogen Mustards NR G Cycloserine Antimycobacterials / Antituberculosis NP G Cyclosporine Immunosuppressants P G Cyclosporine Modified (For Microemulsion) Immunosuppressants P . PA Required P B CYMBALTA Antidepressants - Selected SSRI's P 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 CYTRA-3 Urological - Misc. B D.H.E. 45 Migraine - Ergotamine Derivatives NP P D B DALIRESP Phosphodiesterase Inhibitors NP G Danazol Androgens - Anabolics NP B DANTRIUM Muscle Relaxants NP PA Required G Dantrolene Sodium Muscle Relaxants NP PA Required G Dapsone Lincosamides / Oxazolidinones / Leprostatics 12/3/2014 3:05:12 PM P Page 21 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR D 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 DELATESTRYL Androgens - Anabolics NP B DELESTROGEN Estrogens - Tabs NP B DELZICOL Gi - Inflammatory Bowel Agents NP 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 B DEPAKENE Anticonvulsants NP B DEPAKOTE Anticonvulsants NP B DEPAKOTE ER Anticonvulsants P B DEPAKOTE SPRINKLES Anticonvulsants P B DEPEN TITRATABS Chelating Agents B DEPOCYT Antineoplastics - Antimetabolites B DEPO-ESTRADIOL Estrogens - Tabs B DEPO-MEDROL Glucocorticoids - Mineralocorticoids B DEPO-PROVERA Contraceptives - Injectable B DEPO-PROVERA Antineoplastics - Progestins B DEPO-TESTOSTERONE Androgens - Anabolics NP B DERMA-SMOOTHE/FS BODY Topical - Corticosteroids NP B DERMA-SMOOTHE/FS SCALP Topical - Corticosteroids NP B DERMATOP Topical - Corticosteroids NP B DERMOTIC Ear NP B DESFERAL Antidotes NP Stimulants - Methylphenidate - Long Acting CAP 400MG 12/3/2014 3:05:12 PM P PA Required PA Required >= 21 yo. P PA Required . PA Required P NR P P NP R PA Required Page 22 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR D 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 NP . 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 NP B DESONATE Topical - Corticosteroids NP G Desonide Topical - Corticosteroids NP B DESOWEN Topical - Corticosteroids NP G Desoximetasone Topical - Corticosteroids NP 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. NP Initial fill limited to 15 day supply. B DETROL LA Antispasmodics - Long Acting G Dexamethasone Glucocorticoids - Mineralocorticoids P B DEXAMETHASONE INTENSOL Glucocorticoids - Mineralocorticoids P G Dexamethasone Sodium Phosphate Glucocorticoids - Mineralocorticoids P G Dexamethasone Sodium Phosphate (Ophth) Op. Antiinflammatory / Steroids Ophth. P B DEXEDRINE Stimulants - Amphetamines - Long Acting B DEXILANT Gi - Proton Pump Inhibitor G Dexmethylphenidate HCl Stimulants - Methylphenidate NP G Dexmethylphenidate HCl Stimulants - Methylphenidate - Long Acting NP B DEXPAK Glucocorticoids - Mineralocorticoids NP 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 12/3/2014 3:05:12 PM NP PA Required P PA Required R . Page 23 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR D B DIABETA Diabetic - Oral Sulfonylureas P B DIALYVITE/ TAB ZINC Vitamins - Misc. P B DIAMOX Diuretics B DIASTAT Anticonvulsants P G Diazepam Anxiolytics - Benzodiazepines P G Diazepam (Anticonvulsant) Gel Anticonvulsants B DIAZEPAM INTENSOL Anxiolytics - Benzodiazepines PA Required NP NP P B DICLEGIS Antiemetic - Anticholinergic / Dopaminergic G Diclofenac Potassium NSAIDS NP P Initial fill limited to 15 day supply. 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 P 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 B DIFFERIN GEL 0.3% Topical - Acne Preparations P PA Required B DIFFERIN LOTN Topical - Acne Preparations NP PA Required NP P B DIFICID Macrolides / Erythromycin'S / Ketolides NP G Diflorasone Diacetate Cream 0.05% Topical - Corticosteroids NP . G Diflorasone Diacetate Oint 0.05% Topical - Corticosteroids NP . 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 DILACOR XR Calcium Channel Blockers--Diltiazems NP B DILANTIN Anticonvulsants NP B DILANTIN CAPS 30MG Anticonvulsants P B DILANTIN INFATABS Anticonvulsants P 12/3/2014 3:05:12 PM P Grandfather for seizure disorder. Page 24 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR D B DILANTIN SUSP Anticonvulsants B DILATRATE SR Antianginals--Isosorbide Nitrate NP P NP 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 NP B DIOVAN ARB'S B DIOVAN HCT ARB'S And Diuretics B DIPENTUM Gi - Inflammatory Bowel Agents P G Diphenhydramine HCl Antihistamines - Other P O Diphenhydramine HCl Antihistamines - Other P G Diphenoxylate w/ Atropine Gi - Antiperistaltic Agents P B DIPROLENE Topical - Corticosteroids P . B DIPROLENE AF CRE 0.05% Topical - Corticosteroids NP . B DIPROLENE OINT Topical - Corticosteroids NP G Dipyridamole Platelet Aggregation Inhibitors P G Disopyramide Phosphate Antiarrhythmics P B DITROPAN XL Antispasmodics - Long Acting NP B DIURIL Diuretics NP G Divalproex Sodium Anticonvulsants P G Divalproex Sodium Cap Sprinkle Anticonvulsants NP G Divalproex Sodium Tablet ER 24HR Anticonvulsants NP B DIVIGEL Estrogens - Patches NP B DOLOPHINE Narcotics -Long Acting NP G Donepezil Hydrochloride Alzheimer - Cholinomimetics P B DORAL Sedative/Hypnotics - Benzodiazepines P B DORYX Tetracyclines G Dorzolamide HCl Op. Carbonic Anhydrase Inhibitors/Combo P G Dorzolamide HCl-Timolol Maleate Op. Carbonic Anhydrase Inhibitors/Combo P LOT 0.05% P NP NP B DOVONEX Anti-Psoriatics - Non-Biologicals G Doxazosin Mesylate BPH P G Doxepin HCl Antidepressants - Tri-Cyclics P G Doxercalciferol Hyperparathyroid Treatment - Vitamin D Analogs 12/3/2014 3:05:12 PM PA Required PA required if ACE-I not previously filled. PA Required Grandfather for seizure disorder. PA Required Restricted to persons 40 years of age and older. PA Required NP NP Page 25 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR D B DOXIL Antineoplastics - Antibiotics R G Doxorubicin HCl Antineoplastics - Antibiotics R 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. G Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG Contraceptives - Monophasic Combination O/C'S G Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG B DROXIA B DUAC Topical - Acne Preparations B DUETACT Diabetic - Thiazol NP Grandfathered for Existing Users with previous Actos use or CHF diagnosis B DUEXIS NSAIDS NP PA Required B DULERA Antiasthmatic - Adrenergic Combos P G Duloxetine HCl Antidepressants - Selected SSRI's NP PA Required B DURAGESIC Narcotics -Long Acting NP PA Required B DUREZOL Op. Antiinflammatory / Steroids Ophth. 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 P NP . Contraceptives - Monophasic Combination O/C'S NP . Antineoplastics - Misc. NR P PA Required P 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 NP PA Required B EDURANT Antiretrovirals - Rti-Non-Nucleoside Analogues NR PA Required < 18 years of age B EFFEXOR XR Antidepressants - Selected SSRI's NP 12/3/2014 3:05:12 PM PA Required P Page 26 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR E B EFFIENT Platelet Aggregation Inhibitors 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 B ELLA Contraceptives - Emergency Contraceptive B ELMIRON Urological - Misc. NP B ELOCON CRE 0.1% Topical - Corticosteroids NP . B ELOCON LOT 0.1% Topical - Corticosteroids NP . B ELOCON OIN 0.1% Topical - Corticosteroids NP . B ELOCTATE Antihemophilic Agents NR B EMADINE Op. Antiallergics - Antihistamines 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 G Enalapril Maleate & Hydrochlorothiazide ACE and Thiazide Combo's G Enalaprilat ACE Inhibitors B ENBREL Biologic Immunomodulators B ENJUVIA Estrogens - Tabs G ENOXAPARIN SODIUM SYRINGES Anticoagulants P G ENOXAPARIN SODIUM VIALS Anticoagulants NP G Entacapone Parkinsons - Comt Inhibitors NP G Entecavir Hepatitis B Only NP B ENTOCORT EC Glucocorticoids - Mineralocorticoids NP 12/3/2014 3:05:12 PM NP R PA Required PA Required < 18 years of age NP P NP PA Required P P R R NP Initial fill limited to 15 day supply. P P NP P PA Required NP Page 27 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR E B EPANED ACE Inhibitors G Ephedrine Sulfate (Pressors) Pressors NP B EPIDUO Topical - Acne Preparations NP 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 P PA Required NP PA Required P PA Required NP PA Required 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 ND Ergocalciferol Soln 8000 Unit/ML Vitamins P PA Required P R NP R NP G Ergoloid Mesylates Neurologics - Misc. B ERIVEDGE Antineoplastics - Antimetabolites NR B ERTACZO Topical - Antifungals NP B ERYPED Macrolides / Erythromycin'S / Ketolides NP B ERY-TAB Macrolides / Erythromycin'S / Ketolides NP G Erythromycin (Acne Aid) Topical - Acne Preparations P G Erythromycin (Ophth) Op. Antibiotics P G Erythromycin Base Macrolides / Erythromycin'S / Ketolides NP G Erythromycin Ethylsuccinate Macrolides / Erythromycin'S / Ketolides NP G Escitalopram Oxalate Antidepressants - Selected SSRI's G Esomeprazole Strontium Gi - Proton Pump Inhibitor G Estazolam Sedative/Hypnotics - Benzodiazepines B ESTRACE Estrogens - Tabs NP P PA Required < 18 years of age PA Required P NP PA Required P B ESTRACE Vaginal - Estrogens NP G Estradiol Estrogens - Patches NP G Estradiol Estrogens - Tabs P G Estradiol & Norethindrone Acetate Estrogen Combos NP 12/3/2014 3:05:12 PM Preferred < 8yo Page 28 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR E G Estradiol Valerate Estrogens - Tabs NP B ESTRING Vaginal - Estrogens NP G Estropipate Estrogens - Tabs P B ESTROSTEP FE Contraceptives - Tri-Phasic Combinations P G Eszopiclone Sedative/Hypnotics - Non-Benzodiazepines 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 PA Required 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 B EVAMIST Estrogens - Patches NP B EVISTA Osteoporosis NP B EVOCLIN Topical - Acne Preparations NP B EVOXAC Artificial Saliva/Stimulants NP B EXALGO Narcotics -Long Acting NP B EXELDERM Topical - Antifungals NP B EXELON Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. B EXELON Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. G Exemestane Antineoplastics - Aromatase Inhibitors 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 B EXTAVIA Multiple Sclerosis Agents – Interferons B EXTINA Topical - Antifungals 12/3/2014 3:05:12 PM NP PA Required P PA Required P PA Required PA Required NR NP P Grandfather Existing Users NP Page 29 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR F B FABIOR Topical - Tretinoids B FABRAZYME Agents For Fabrys Disease NP PA Required P B FACTIVE Fluoroquinolones NP 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 P . B FAMVIR Herpes Agents B FANAPT Antipsychotics - Atypicals P B FANAPT TITRATION PACK Antipsychotics - Atypicals NP B FARESTON Antineoplastics - Antiestrogens B FARXIGA Diabetic - Other B FASLODEX Antineoplastics - Estrogen Receptor Antagonist B FAZACLO Antipsychotics - Special Atypicals NP B FEIBA Antihemophilic Agents NR G Felbamate Anticonvulsants NP B FELBATOL Anticonvulsants P NP R NP PA Required R Grandfather Existing Users Grandfather for seizure disorder. B FELDENE NSAIDS NP G Felodipine Calcium Channel Blockers--Felodipines NP B FEM PH Vaginal - Other NP B FEMARA Antineoplastics - Aromatase Inhibitors NR 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 12/3/2014 3:05:12 PM PA Required Payable for members 50 years of age and older without prior authorization P PA Required Page 30 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR F ND Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe) Minerals P . Vitamins - Misc. P PA Required 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 Soln 75 MG/ML (15 MG/ML Elemental Fe) Minerals P . ND Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) Minerals P . G Ferrous Fumarate w/ B12-Vit C-FA-IFC 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 P G Finasteride (Alopecia) BPH P 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 PA Required B FLAREX Op. Antiinflammatory / Steroids Ophth. P 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 FLOVENT Antiasthmatic - Steroid Inhalants P B FLUARIX PF INJ 2014-15 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FLUARIX QUAD INJ 2014-15 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 12/3/2014 3:05:12 PM Initial fill limited to 15 day supply. P PA Required Page 31 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR F G Fludrocortisone Acetate Glucocorticoids - Mineralocorticoids P B FLULAVAL Influenza Agents P INJ 2014-15 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 P G Fluocinolone Acetonide (Otic) Ear P G Fluocinolone Acetonide Oil 0.01% (Body Oil) Topical - Corticosteroids NP . G Fluocinolone Acetonide Oil 0.01% (Scalp Oil) Topical - Corticosteroids NP . G Fluocinonide Cream 0.05% Topical - Corticosteroids P . G Fluocinonide Cream 0.1% Topical - Corticosteroids NP . G Fluocinonide Emulsified Base Topical - Corticosteroids P G Fluocinonide Gel 0.05% Topical - Corticosteroids P . G Fluocinonide Oint 0.05% Topical - Corticosteroids P . G Fluocinonide Soln 0.05% Topical - Corticosteroids P . G Fluorometholone (Ophth) Op. Antiinflammatory / Steroids Ophth. G Fluorouracil Antineoplastics - Antimetabolites G Fluorouracil Cream 5% Topical - Antineoplastics NP . G Fluorouracil Soln 2% Topical - Antineoplastics P . 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 12/3/2014 3:05:12 PM NP R Page 32 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR F G Flurbiprofen Sodium Op. Nsaid'S G Flutamide Antineoplastics - Antiandrogens NR G Fluticasone Propionate Topical - Corticosteroids NP G Fluticasone Propionate (Nasal) Nasal Steroids P G Fluticasone Propionate LOTN Topical - Corticosteroids P 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 2014-15 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 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FLUZONE SPLT INJ 2014-15 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B FML Op. Antiinflammatory / Steroids Ophth. P B FML LIQUIFILM Op. Antiinflammatory / Steroids Ophth. NP B FOCALIN Stimulants - Methylphenidate P PA Required >= 21 yo. INJ 2014-15 INJ PF 14-15 P NP B FOCALIN XR Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. G Folic Acid Tab 1 MG Vitamins P . B FOLOTYN Antineoplastics - Antimetabolites G Fondaparinux Sodium Anticoagulants R B FORADIL AEROLIZER Antiasthmatic - Beta - Adrenergics P B FORFIVO XL Antidepressants - Selected SSRI's NP B FORTAMET Diabetic - Oral Biguanides NP B FORTAZ Cephalosporins NP B FORTAZ Cephalosporins NP B FORTEO Osteoporosis NP B FORTESTA Androgens -Topical NP PA Required B FORTICAL SPR 200/ACT Osteoporosis NP . TAB 70MG . NP B FOSAMAX 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 12/3/2014 3:05:12 PM PA Required < 5 years of age Initial fill limited to 15 day supply. P Page 33 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR F B FREAMINE III Electrolytes/ Nutritionals NP B FROVA Migraine - Selective Serotonin Agonists (5HT)--Tabs NP B FULYZAQ Gi - Antidiarrheal / Antacid - Misc. NP B FURADANTIN Urological - Misc. NP G Furosemide Diuretics B FUZEON Antiretrovirals - Fusion Inhibitors B FYCOMPA Anticonvulsants 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 P G Galantamine Hydrobromide Alzheimer - Cholinomimetics NP B GAMASTAN S/D Immune Serums NP B GAMMAGARD Immune Serums P B GAMMAKED Immune Serums NP B GAMMAPLEX Immune Serums NP B GAMUNEX-C Immune Serums P G Ganciclovir Sodium Cyto-Megalovirus Agents B GASTROCROM Gi - Anti - Flatulents / GI Stimulants P G Gatifloxacin (Ophth) Op. Quinolones Fourth Generation NP B GATTEX Gi - Antiperistaltic Agents NP B GELNIQUE Antispasmodics - Long Acting NP G Gemcitabine HCl Antineoplastics - Antimetabolites NR G Gemfibrozil Cholesterol - Fibric Acid Derivatives P PA Required P R NP G NP B GEMZAR Antineoplastics - Antimetabolites R G GENGRAF Immunosuppressants P B GENOTROPIN Growth Hormone NP G Gentamicin in Saline Amino Glycosides P 12/3/2014 3:05:12 PM Restricted to persons 40 years of age and older. Initial fill limited to 15 day supply. PA Required Page 34 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR G G Gentamicin Sulfate Amino Glycosides P G Gentamicin Sulfate (Ophth) Op. Antibiotics P G Gentamicin Sulfate (Topical) Topical - Antibiotic B GEODON Antipsychotics - Atypicals NP B GIAZO Gi - Inflammatory Bowel Agents NP B GILENYA Multiple Sclerosis Agents – Non-Interferons B GILOTRIF Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B GLASSIA Alpha-Proteinase Inhibitor NP B GLEEVEC Antineoplastics - Protein-Tyrosine Kinase Inhibitors R 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 B GLUCOTROL Diabetic - Oral Sulfonylureas NP B GLUCOTROL XL Diabetic - Oral Sulfonylureas NP NP P P No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months PA Required Initial fill limited to 15 day supply. PA Required 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 GOLYTELY Gi - Anti - Flatulents / GI Stimulants 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 P B GRASTEK Allergenic Extracts NP PA Required G Griseofulvin Microsize TABS Antifungals - Assorted NP PA Required G GRISEOFULVIN SUS Antifungals - Assorted P 12/3/2014 3:05:12 PM PA Required > 90 days Page 35 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR G G Griseofulvin Ultramicrosize Antifungals - Assorted NP B GRIS-PEG Antifungals - Assorted P G Guanfacine HCl Antihypertensives - Central P PA Required PA Required > 90 days H 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. G Halobetasol Propionate Topical - Corticosteroids NP B HALOG Topical - Corticosteroids NP 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 NP PA Required B HECTOROL Hyperparathyroid Treatment - Vitamin D Analogs NP Grandfather Existing Users B HELIDAC Gi - Ulcer Anti-Infective NP B HELIXATE FS Antihemophilic Agents R B HEMANGEOL Beta Blockers - Non Selective B HEMOFIL M Antihemophilic Agents NP R B HEPAGAM B Immune Serums G Heparin (Porcine) in Sodium Chloride Anticoagulants P G Heparin Sodium (Porcine) Anticoagulants P 12/3/2014 3:05:12 PM NP Page 36 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR H B HEPSERA Hepatitis B Only P B HERCEPTIN Antineoplastics - Antimetabolites R B HETLIOZ Sedative/Hypnotics - Non-Benzodiazepines NP 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 B PA Required PA Required P NP PA Required P NP PA Required P NP PA Required R NP PA Required Biologic Immunomodulators P PA Required HUMIRA PEN Biologic Immunomodulators P PA Required HUMIRA PEN-CROHNS DISEASESTARTER Biologic Immunomodulators P Preferred with Conditions and allow a one time fill. B HUMIRA PEN-PSORIASIS STARTER Biologic Immunomodulators P Preferred with Conditions and allow a one time fill. O HUMULIN 70/30 Diabetic - Insulin P O HUMULIN 70/30 PEN Diabetic - Insulin Penfills O HUMULIN N Diabetic - Insulin O HUMULIN N U-100 PEN Diabetic - Insulin Penfills NP PA Required P NP B HUMULIN R Diabetic - Insulin P O HUMULIN R Diabetic - Insulin P B HYCAMTIN Antineoplastics - Topoisomerase I Inhibitors B HYCET Narcotics - Misc. G Hydralazine HCl Antihypertensives - Central PA Required R NP PA Required P 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 12/3/2014 3:05:12 PM NR P Page 37 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR H G Hydrocodone-Ibuprofen Narcotics - Misc. 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 NP G Hydrocortisone Cream 1% Topical - Corticosteroids P . G Hydrocortisone Cream 2.5% Topical - Corticosteroids P . G Hydrocortisone Lotion 2.5% Topical - Corticosteroids P . G Hydrocortisone Oint 1% Topical - Corticosteroids P . G Hydrocortisone Oint 2.5% Topical - Corticosteroids P . G Hydrocortisone Valerate Topical - Corticosteroids NP 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 . G Hydroxychloroquine Sulfate Antimalarial Agents P G Hydroxyurea Antineoplastics - Misc. R G Hydroxyzine HCl SOLN Antihistamines - Other P G Hydroxyzine HCl SYRP Antihistamines - Other P G Hydroxyzine HCl Tab 25 MG Antihistamines - Other NP . G Hydroxyzine HCl Tab 50 MG Antihistamines - Other NP . 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. G HYPERCARE Topical - Astringents / Protectants 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 HYZAAR ARB'S And Diuretics 12/3/2014 3:05:12 PM SOL 20% NP PA Required PA Required PA Required P P NP PA Required Page 38 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR I G Ibandronate Sodium Osteoporosis NP 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 . B ICLUSIG Antineoplastics - Misc. G Ifosfamide & Mesna Antineoplastics - Combinations B ILEVRO Op. Nsaid'S B IMBRUVICA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR NR R P B IMDUR Antianginals--Isosorbide Nitrate NP G Imipenem-Cilastatin Carbapenems NP G Imipramine HCl Antidepressants - Tri-Cyclics P G Imipramine Pamoate Antidepressants - Tri-Cyclics NP G Imiquimod Topical - Genital Warts 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). B IMITREX Migraine - Selective Serotonin Agonists (5HT)--Injectables P PA Required> 12 Units/30 Days supply 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 G Indapamide Diuretics B INDERAL LA Beta Blockers - Non Selective NP B INDOCIN NSAIDS NP G Indomethacin NSAIDS P G Indomethacin CPCR NSAIDS NP B INFERGEN Hepatitis C Agents NP B INLYTA Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B INNOPRAN XL Beta Blockers - Non Selective NP B INSPRA Diuretics NP 12/3/2014 3:05:12 PM NP Imipramine Pamoate - Use Imipramine HCL PA Required PA Required P PA Required PA Required PA Required < 18 years of age PA Required Page 39 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR I 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 B INVIRASE Antiretrovirals - Protease Inhibitors B INVOKAMET Diabetic - Other NP PA Required B INVOKANA Diabetic - Other NP PA Required NP PA Required PA Required 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. R B IOPIDINE Op. Selective Alpha Adrenergic Agonists G Ipratropium Bromide Antiasthmatic - Anti-Cholinergics 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 R G Iron Dextran Minerals P B ISENTRESS CHW 100MG Antiretrovirals R dummy B ISENTRESS CHW 25MG Antiretrovirals R dummy B ISENTRESS TABS Antiretrovirals R G Isoniazid Antimycobacterials / Antituberculosis B ISOPTO ATROPINE Op. Cycloplegics NP B ISOPTO CARPINE Op. Miotics - Direct Acting NP B ISOPTO HYOSCINE Op. Cycloplegics 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 P G Isradipine Calcium Channel Blockers--Isradipines 12/3/2014 3:05:12 PM P . P P PA Required NP Page 40 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR I B ISTALOL Op. Beta - Blockers NP G Itraconazole Antifungals - Assorted NP B JAKAFI Antineoplastics - Protein-Tyrosine Kinase Inhibitors B JALYN BPH B JANUMET Diabetic - Other P PA Required B JANUMET XR Diabetic - Other NP PA Required B JANUVIA Diabetic - Other P PA Required B JARDIANCE Diabetic - Other NP PA Required B JENTADUETO Diabetic - Other NP PA Required B JINTELI Estrogen Combos NP B JUBLIA Topical - Antifungals NP B JUXTAPID Antihyperlipidemics NP PA Required J R PA Required < 18 years of age NP K B KADIAN Narcotics -Long Acting P B KALETRA Antiretrovirals - Combinations R 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 B KENALOG Topical - Corticosteroids NP B KEPPRA Anticonvulsants NP Grandfather for seizure disorder. B KEPPRA XR Anticonvulsants NP Grandfather for seizure disorder. P 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 12/3/2014 3:05:12 PM PA Required P NP PA Required Page 41 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR K B KHEDEZLA Antidepressants - Selected SSRI's NP PA Required B KINERET Biologic Immunomodulators NP PA Required 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 P B KORLYM Diabetic - Other NP B K-PHOS B KRISTALOSE Gi - Anti - Flatulents / GI Stimulants NP B KUVAN Phenylketonuria NP B KYNAMRO Antihyperlipidemics NP TAB NO 2 Urological - Misc. P PA Required . 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 NR G Lamotrigine Anticonvulsants P 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 PA Required B LASIX Diuretics NP B LASTACAFT Op. Antiallergics - Antihistamines NP G Latanoprost Op. Prostaglandins INJ 100/ML 12/3/2014 3:05:12 PM P Page 42 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR L B LATUDA Antipsychotics - Atypicals P G Leflunomide Rheumatoid Arthritis - Non-Biologicals P 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 R Payable for members 50 years of age and older without prior authorization G Leucovorin Calcium Antineoplastics - Folic Acid Antagonists Rescue Agents R B LEUKERAN Antineoplastics - Nitrogen Mustards B LEUKINE Granulocyte Csf NP 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 R PA Required 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 PA Required 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 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 . 12/3/2014 3:05:12 PM PA Required PA Required . . Page 43 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR L 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 . 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 Antiretrovirals - Protease Inhibitors R B LIALDA Gi - Inflammatory Bowel Agents NP G Lidocaine HCl (Cardiac) TAB 1.2GM 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 G Lidocaine-Hydrocortisone Acetate (Rectal) Anorectal - Misc. G Lidocaine-Hydrocortisone Acetate (Rectal) Topical - Steroid Local Anesthetics P G Lidocaine-Prilocaine Topical - Local Anesthetics P 12/3/2014 3:05:12 PM . P NP Page 44 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR L B LIDODERM Topical - Local Anesthetics NP B LINCOCIN Lincosamides / Oxazolidinones / Leprostatics NP G Lindane Topical - Scabicides And Pediculicides NP B LINZESS Gi - Irritable Bowel Syndrome Agents NP B LIORESAL INTRATHECAL Muscle Relaxants P 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 B LIPTRUZET Cholesterol - Hmg COA + Absorb Inhibitors 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 24 FE 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 NR 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 P . B LOPID Cholesterol - Fibric Acid Derivatives 12/3/2014 3:05:12 PM PA Required PA Required P NP Grandfather Existing Users NP Page 45 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR L B LOPRESSOR Beta Blockers - Cardio Selective NP B LOPRESSOR HCT Beta Blockers And Diuretic Combo'S NP NP B LOPROX SHAMPOO Topical - Antifungals 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 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 NP B LOTEMAX Op. Antiinflammatory / Steroids Ophth. NP B LOTENSIN ACE Inhibitors NP B LOTENSIN HCT ACE and Thiazide Combo's NP B LOTREL ACE Inhibitors And Calcium Channel Blockers O LOTRIMIN ULTRA Topical - Antifungals 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 PA Required P B LOVENOX VIALS Anticoagulants P 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 LUVOX CR Antidepressants - Selected SSRI's NP B LUXIQ Topical - Corticosteroids NP 12/3/2014 3:05:12 PM PA Required PA Required Page 46 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR L B LYRICA Anticonvulsants B LYSODREN Antineoplastics - Antiadrenals NP B LYSTEDA Hemostatic PA Required R NP M B MACROBID Urological - Misc. NP B MACRODANTIN Urological - Misc. NP B MAGNACET Narcotics - Selected NP PA Required B MAGNEBIND 400 Minerals P PA Required O Magnesium Hydroxide Susp 400 MG/5ML Gi - Misc. P . ND Magnesium Oxide Tab 400 mg Gi - Antidiarrheal / Antacid - Misc. P PA Required 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 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. B MAXITROL Op. Antiinflammatory / Steroids Ophth. B MAXZIDE Diuretics 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 . 12/3/2014 3:05:12 PM NP Initial fill limited to 15 day supply. P NP R P P NP P NP PA Required Page 47 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR M 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 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 NR G Melphalan HCl Antineoplastics - Nitrogen Mustards B MENEST Estrogens - Tabs B MENOSTAR Estrogens - Patches NP Requires a Selected Brand Name Drug PA PA Required P NR 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 R G Meropenem Carbapenems P NP NP B MERREM Carbapenems G 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 SYP 60MG/5ML 12/3/2014 3:05:12 PM PA Required P . PA Required >= 21 yo. PA Required PA Required Page 48 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR M 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 . G Methamphetamine HCl Stimulants G Methazolamide Diuretics G Methenamine Hippurate Urological - Misc. 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 G Methotrexate Sodium Antineoplastics - Antimetabolites R 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 G Methyldopate HCl Antihypertensives - Central G Methylergonovine Maleate Oxytocics P G Methylphenidate HCl Stimulants - Methylphenidate P 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. 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. 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. 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. PA Required >= 21 yo. 12/3/2014 3:05:12 PM CON 10MG/ML NP PA Required P NP P NP PA Required P P NP PA Required >= 21 yo. PA Required Page 49 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR M G Methylphenidate HCl Tablet ER 10MG ER Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. G METHYLPHENIDATE TAB 20MG CR Stimulants - Methylphenidate - Long Acting P PA Required >= 21 yo. G Methylprednisolone Acetate Glucocorticoids - Mineralocorticoids NP G Methylprednisolone Sod Succ Glucocorticoids - Mineralocorticoids NP G Methylprednisolone Tab 16 MG Glucocorticoids - Mineralocorticoids NP . G Methylprednisolone Tab 32 MG Glucocorticoids - Mineralocorticoids NP . G Methylprednisolone Tab 4 MG Glucocorticoids - Mineralocorticoids P . G Methylprednisolone Tab 8 MG Glucocorticoids - Mineralocorticoids NP . G Metipranolol Op. Beta - Blockers P G Metoclopramide HCl Gi - Anti - Flatulents / GI Stimulants P G Metolazone Diuretics G Metoprolol & Hydrochlorothiazide Beta Blockers And Diuretic Combo'S NP G Metoprolol Succinate Beta Blockers - Cardio Selective NP 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 P PA Required B METROGEL Topical - Acne Preparations P PA Required B METROGEL-VAGINAL Vaginal - Antibacterials P 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 NP PA Required G Metronidazole Gel 0.75% Topical - Acne Preparations NP PA Required G Metronidazole in NaCl Antibiotics - Misc. P ND Metronidazole Powder P NP PA Required Powders P G Metronidazole Tab 250 MG Antibiotics - Misc. P . G Metronidazole Tab 500 MG Antibiotics - Misc. P . G Metronidazole Vaginal Vaginal - Antibacterials G Mexiletine HCl Antiarrhythmics B MIACALCIN INJ 200/ML Osteoporosis NP . B MIACALCIN SPR 200/ACT Osteoporosis P . 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. 12/3/2014 3:05:12 PM NP P Page 50 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR M 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 G Midazolam HCl SYRP Sedative/Hypnotics - Benzodiazepines P G Midodrine HCl Pressors P B MIGERGOT Migraine - Ergot Combinations P B MIGRANAL B MILLIPRED Migraine - Ergotamine Derivatives SOL 10MG/5ML PA Required P 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 PA Required G Minoxidil Antihypertensives - Central B MIRAPEX Parkinsons - Selected Dopamin Agonists NP B MIRAPEX ER Parkinsons - Selected Dopamin Agonists NP B MIRAPEX ER Tablet ER 24HR 2.25MG Parkinsons - Selected Dopamin Agonists NP B MIRAPEX ER Tablet ER 24HR 3.75MG Parkinsons - Selected Dopamin Agonists NP 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 12/3/2014 3:05:12 PM P PA Required P PA Required P NP PA Required Page 51 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR M 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 P B MONOCLATE-P Antihemophilic Agents R B MONONINE Antihemophilic Agents R G Montelukast Sodium Chew Tab 4 MG (Base Equiv) Antiasthmatic - Leukotriene Receptor Antagonists P . 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 G MORPHINE SUL TAB ER Narcotics -Long Acting P G Morphine Sulfate Narcotics -Long Acting P G Morphine Sulfate Narcotics - Misc. P B MOTOFEN Gi - Antiperistaltic Agents NP B MOVIPREP Gi - Misc. NP B MOXATAG Beta-Lactams / Clavulanate Combo'S NP B MOXEZA Op. Quinolones Fourth Generation G Moxifloxacin HCl Fluoroquinolones B MS CONTIN Narcotics -Long Acting P B MULTAQ Antiarrhythmics P G Mupirocin Calcium Cream 2% Topical - Antibiotic NP G Mupirocin Oint Topical - Antibiotic P B MYALEPT Lipodystrophy Agents B MYAMBUTOL Antimycobacterials / Antituberculosis P B MYCAMINE Antifungals - Assorted P P PA Required PA Required P NP . NP 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 P B MYLERAN Antineoplastics - Alkylating Agents R 12/3/2014 3:05:12 PM PA Required P NP P NP Page 52 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR M 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 N B NABI-HB Immune Serums P G Nabumetone Cox 2 Inhibitors - Selective P G Nadolol Beta Blockers - Non Selective P G Nadolol & Bendroflumethiazide Beta Blockers And Diuretic Combo'S NP G Nafcillin Sodium Beta-Lactams / Clavulanate Combo'S P B NAFTIN Topical - Antifungals NP B NAGLAZYME Metabolic Modifiers - Lysosomal Storage Disorder Treatments NP G Nalbuphine HCl Narcotics - Selected P B NALFON NSAIDS G Naloxone HCl Narcotic - Antagonists NP P PA Required G Naltrexone HCl Narcotic - Antagonists P B NAMENDA Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. B NAMENDA XR Alzheimer - Cholinomimetics P Restricted to persons 40 years of age and older. B NAMENDA XR TITRATION PACK 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 PA Required G Naratriptan HCl Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B NARDIL Antidepressants - Mao Inhibitors NP B NASACORT AQ Nasal Steroids NP B NASONEX Nasal Steroids P B NATAZIA Contraceptives - Multi-Phasic Combinations G Nateglinide Diabetic - Meglitinides 12/3/2014 3:05:12 PM . NP P Page 53 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR N B NATROBA Topical - Scabicides And Pediculicides P B NAVELBINE Antineoplastics - Mitotic Inhibitors R B NEBUPENT Antibiotics - Misc. P B NECON 1/50-28 Contraceptives - Monophasic Combination O/C'S B NECON 10/11-28 Contraceptives - Bi-Phasic Combinations G Nefazodone HCl Antidepressants - Selected SSRI's P G Neomycin Sulfate Amino Glycosides P G Neomycin/Polymyxin B GU Urological - Misc. P 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. P B NEPHPLEX RX Vitamins - Misc. P B NEPTAZANE Diuretics 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 P 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 12/3/2014 3:05:12 PM No manual PA required if one course of treatment of a preferred permethrin 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. P NP Initial fill limited to 15 day supply. NP P P P PA Required P Grandfather for seizure disorder. Initial fill limited to 15 day supply. Page 54 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR N B NEXIUM Gi - Proton Pump Inhibitor NP G Niacin (Antihyperlipidemic) Cholesterol - Fibric Acid Derivatives NP ND Niacin Tab 100 MG Vitamins NP ND Niacin Tab 250 MG Vitamins NP ND Niacin Tab 50 MG Vitamins NP ND Niacin Tab 500 MG PA Required Vitamins NP B NIASPAN Cholesterol - Fibric Acid Derivatives NP G Nicardipine HCl Nicardipines NP 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 B NIRAVAM Anxiolytics - Benzodiazepines NP G Nisoldipine Calcium Channel Blockers--Nisoldipine NP 12/3/2014 3:05:12 PM Grandfather Existing Users PA Required Page 55 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR N B NITRO-BID B NITRO-DUR DIS 0.1MG/HR Nitro - Ointment/Cap/Cr Nitro - Patches NP P . 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 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 G Nizatidine Gi - H2-Antagonists NP B NIZORAL SHAMPOO Topical - Antifungals NP B NORCO Narcotics - Misc. NP PA Required B NORDITROPIN Growth Hormone P PA Required 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 G Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG-MCG G Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG 12/3/2014 3:05:12 PM P P . NP . Contraceptives - Tri-Phasic Combinations P . Contraceptives - Tri-Phasic Combinations NP . Page 56 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR N 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 NP PA Required B NOR-QD Contraceptives - Progestin Only G Nortriptyline HCl Antidepressants - Tri-Cyclics B NORVASC Calcium Channel Blockers--Amlodipines B NORVIR CAP 100MG Antiretrovirals - Protease Inhibitors R . B NORVIR SOL 80MG/ML Antiretrovirals - Protease Inhibitors R . NR P NP B NORVIR TABS Antiretrovirals - Protease Inhibitors O NOVOLIN 70/30 Diabetic - Insulin P O NOVOLIN 70/30 RELION Diabetic - Insulin P O NOVOLIN N Diabetic - Insulin P O NOVOLIN N RELION Diabetic - Insulin P O NOVOLIN R Diabetic - Insulin P O NOVOLIN R RELION Diabetic - Insulin P B NOVOLOG Diabetic - Insulin P B NOVOLOG Diabetic - Insulin Penfills P B NOVOLOG MIX 70/30 Diabetic - Insulin P 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 B NUVIGIL Stimulants - Other Stimulants / Like Stimulants NP B NYMALIZE Calcium Channel Blockers--Nifedipines NP G Nystatin Antifungals - Assorted 12/3/2014 3:05:12 PM Norvir tablets - Use Norvir capsules instead PA Required PA Required P PA Required P Page 57 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR N 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 O ND *Oral Electrolyte Solution*** Electrolytes/ Nutritionals P B OCTAGAM Immune Serums NP G Octreotide Acetate Somatostatic Agents NP B OCUFEN Op. Nsaid'S NP B OCUFLOX Op. Quinolones NP G Ofloxacin Fluoroquinolones NP G Ofloxacin (Ophth) Op. Quinolones G Ofloxacin (Otic) Ear 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 B OLUX Topical - Corticosteroids B OLUX-E Topical - Corticosteroids B OLYSIO Hepatitis C Agents NP B OMECLAMOX-PAK Gi - Ulcer Anti-Infective 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 NP P P NP P P B OMNITROPE Growth Hormone 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 ONFI Anticonvulsants 12/3/2014 3:05:12 PM NP PA Required PA Required PA Required PA required for quantities exceeding 124mg tabs, 12-8mg tabs, 4-24mg tabs, 420ml vials, and 8-2ml vials. PA Required PA required for quantities exceeding 124mg tabs, 12-8mg tabs. PA Required Page 58 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR O B ONGLYZA Diabetic - Other P PA Required B ONMEL Antifungals - Assorted NP PA Required B OPANA Narcotics - Misc. NP PA Required B OPANA ER Narcotics -Long Acting NP PA Required G Opium Tincture Gi - Antiperistaltic Agents NP B OPSUMIT Pulmonary Anti-Hypertensives NP B OPTIVAR Op. Antiallergics - Antihistamines NP B ORACEA Tetracyclines NP B ORACIT Urological - Misc. P B ORAP Neurologics - Misc. P B ORAPRED Glucocorticoids - Mineralocorticoids NP B ORENCIA Biologic Immunomodulators NP PA Required B ORENITRAM Pulmonary Anti-Hypertensives NP PA Required B ORFADIN Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents P 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 Biologic Immunomodulators 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 B OXANDRIN Androgens - Anabolics NP G Oxandrolone Androgens - Anabolics NP G Oxaprozin NSAIDS NP G Oxazepam Anxiolytics - Benzodiazepines G Oxcarbazepine SUSP Anticonvulsants 12/3/2014 3:05:12 PM P NP PA Required . PA Required PA Required PA Required < 6 years of age Grandfather for seizure disorder. Page 59 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR O G Oxcarbazepine Tab 150 MG Anticonvulsants P . G Oxcarbazepine Tab 300 MG Anticonvulsants P . G Oxcarbazepine Tab 600 MG Anticonvulsants P . B OXECTA Narcotics - Misc. NP B OXISTAT Topical - Antifungals NP B OXSORALEN ULTRA Anti-Psoriatics - Non-Biologicals B OXTELLAR XR Anticonvulsants NP G OXYBUTYNIN SYP 5MG/5ML Antispasmodics P G OXYBUTYNIN TAB 5MG Antispasmodics P G Oxybutynin Chloride ER Antispasmodics - Long Acting P G Oxycodone HCl Narcotics - Misc. P G Oxycodone w/ Acetaminophen Tab 10-325 MG Narcotics - Misc. NP 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 PA Required PA Required P PA Required PA Required . PA Required B OXYCONTIN Narcotics -Long Acting NP PA Required G Oxymorphone HCl Narcotics -Long Acting NP PA Required G Oxymorphone HCl Narcotics - Misc. NP P G Paclitaxel Antineoplastics - Mitotic Inhibitors NR B PAMELOR Antidepressants - Tri-Cyclics NP G Pamidronate Disodium Osteoporosis NP B PAMINE Gi - Antidiarrheal / Antacid - Misc. NP B PANCREAZE Gi - Digestive Enzymes NP G Pancrelipase (Lipase-Protease-Amylase) Gi - Digestive Enzymes P NP B PANDEL Topical - Corticosteroids G Pantoprazole Sodium Gi - Proton Pump Inhibitor G Papaverine HCl Peripheral Vasodilators 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 12/3/2014 3:05:12 PM P P PA Required Page 60 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P B PARLODEL Anti-Parkinsonian Drugs P B PARNATE Antidepressants - Mao Inhibitors P 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 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 B PCE Macrolides / Erythromycin'S / Ketolides NP B PEDIAPRED Glucocorticoids - Mineralocorticoids NP ND Pediatric Multiple Vitamin w/ Minerals & C Grandfather Existing Users P Vitamins - Misc. P P PA Required 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 P NP P PA Required B PENTASA Gi - Inflammatory Bowel Agents NP . G Pentazocine w/ Naloxone Narcotics - Misc. NP PA Required G Pentoxifylline Platelet Aggr. Inhibitors / Combo's - Misc. B PEPCID Gi - H2-Antagonists B PERCODAN Narcotics - Misc. B PERFOROMIST Antiasthmatic - Beta - Adrenergics NP G Perindopril Erbumine ACE Inhibitors NP 12/3/2014 3:05:12 PM P NP P Page 61 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P G Permethrin Cream 5% Topical - Scabicides And Pediculicides NP . O Permethrin Lotion 1% Topical - Scabicides And Pediculicides P . G Perphenazine Antipsychotics - Typical P G Perphenazine-Amitriptyline Psychotherapeutic Combination P B PERSANTINE Platelet Aggregation Inhibitors NP B PERTZYE Gi - Digestive Enzymes NP B PEXEVA Antidepressants - Selected SSRI's NP B PFIZERPEN-G Beta-Lactams / Clavulanate Combo'S P G Phenazopyridine HCl Urological - Misc. P G Phenelzine Sulfate Antidepressants - Mao Inhibitors P B PHENERGAN Antiemetic - Anticholinergic / Dopaminergic G Phenobarbital Sedative/Hypnotics - Barbiturate P G Phenobarbital Sodium Sedative/Hypnotics - Barbiturate NP G Phentolamine Mesylate Agents For Pheochromocytoma P G Phenylephrine HCl (Ophth) Op. Misc P Initial fill limited to 15 day supply. NP B PHENYTEK Anticonvulsants NP G Phenytoin Anticonvulsants NP 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. B PHOSLO Phosphate Binders NP B PHOSLYRA Phosphate Binders P B PHOSPHOLINE IODIDE Op. Miotics - Direct Acting P G Phytonadione Vitamins 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 B PINNACAINE OTIC Ear G Pioglitazone HCl Diabetic - Thiazol P G Pioglitazone HCl-Glimepiride Diabetic - Thiazol NP 12/3/2014 3:05:12 PM Grandfather Existing Users . P NP P NP Page 62 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P G Pioglitazone HCl-Metformin HCl Diabetic - Thiazol / Biguanide Combo NP G Piperacillin Sodium-Tazobactam Sodium Beta-Lactams / Clavulanate Combo'S NP G Piroxicam NSAIDS NP B PITRESSIN SYNTHETIC Vasopressins NP B PLAQUENIL Antimalarial Agents NP B PLAVIX Platelet Aggregation Inhibitors NP B PLETAL Platelet Aggr. Inhibitors / Combo's - Misc. NP B PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID Vitamins - Misc. P B PNV FOLIC AC TAB + IRON Vitamins - Misc. P B PODOCON 25 Topical - Enzymes / Keratolytics / Urea NP G Podofilox Topical - Genital Warts NP O polyethylene glycol 3350 Gi - Anti - Flatulents / GI Stimulants G polyethylene glycol 3350 PACK 3350 NF Gi - Anti - Flatulents / GI Stimulants G Polymyxin B Sulfate Antibiotics - Misc. G Polymyxin B-Trimethoprim Op. Antibiotics P B POLYTRIM Op. Antibiotics NP B POMALYST Antineoplastics - Misc. NR NP P PA Required . Preferred for ages 0-12, PA Required ages 13-18, Not covered ages 19 and above. P NP B PONSTEL NSAIDS G Pot & Sod Citrates w/ Cit Ac Soln 550-500-334 MG/5ML Urological - Misc. G Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic Minerals P G Potassium Acetate Inj 2 mEq/ML Minerals P . G Potassium Acetate Inj 4 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 . 12/3/2014 3:05:12 PM P PA Required . Page 63 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P G Potassium Chloride Tablet ER 20MEQ ER Minerals G Potassium Citrate & Citric Acid Powder Pack 3300-1002 MG Urological - Misc. NP P . G Potassium Citrate & Citric Acid Soln 1100-334 MG/5ML Urological - Misc. P . G Potassium Citrate (Alkalinizer) Urological - Misc. P G Potassium Phosphate Dibasic Inj 3 MMole/ML Minerals P B POTIGA Anticonvulsants NP B PRADAXA Anticoagulants NP G Pramipexole Dihydrochloride Parkinsons - Selected Dopamin Agonists B PRANDIMET Diabetic - Other NP B PRANDIN Diabetic - Meglitinides NP . PA Required P 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 B PRED-G Op. Antiinflammatory / Steroids Ophth. P G Prednicarbate Topical - Corticosteroids G Prednisolone Glucocorticoids - Mineralocorticoids G Prednisolone Acetate (Ophth) Op. Antiinflammatory / Steroids Ophth. 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. 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 12/3/2014 3:05:12 PM NP P NP P . Page 64 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P B PREZISTA Antiretrovirals B PRILOSEC Gi - Proton Pump Inhibitor NP R NP B PRIMAXIN Carbapenems G Primidone Anticonvulsants B PRINIVIL ACE Inhibitors NP B PRISTIQ Antidepressants - Selected SSRI's NP B PRIVIGEN Immune Serums NP PA Required P B PROAIR HFA Antiasthmatic - Beta - Adrenergics P 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 B PROCENTRA Stimulants NP G Prochlorperazine Edisylate Antihistamines - Other P G Prochlorperazine Maleate Antihistamines - Other P G Prochlorperazine Supp Antihistamines - Other P B PROCRIT Erythropoeisis Stimulating Agents B PROCTOFOAM HC Anorectal - Misc. NP B PROCYSBI Urological - Misc. NP P B PROFILNINE SD Antihemophilic Agents G Progesterone IM in Oil 50 MG/ML Progestins NP G Progesterone Micronized Progestins NP PA Required PA Required PA Required R ND Progesterone Micronized Powder Powders P ND Progesterone Powder Powders P . B PROGLYCEM Diabetic - Other B PROGRAF Immunosuppressants NP B PROLASTIN Alpha-Proteinase Inhibitor NP PA Required B PROLASTIN SOLR 1000MG Alpha-Proteinase Inhibitor P PA Required 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 . 12/3/2014 3:05:12 PM P NP PA Required Page 65 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P G Promethazine HCl Suppos 12.5 MG Antiemetic - Anticholinergic / Dopaminergic P . G Promethazine HCl Suppos 25 MG Antiemetic - Anticholinergic / Dopaminergic 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 B PROSTIGMIN Neurologics - Misc. 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 B PRUDOXIN Topical - Antipruritics NP 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 B PURINETHOL Antineoplastics - Antimetabolites B PYLERA Gi - Ulcer Anti-Infective P G Pyrazinamide Antimycobacterials / Antituberculosis P O Pyrethrins-Piperonyl Butoxide Topical - Scabicides And Pediculicides P 12/3/2014 3:05:12 PM NP P NP P P NP P P PA Required >= 21 yo. PA Required Preferred < 8yo PA Required NR Page 66 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR P G Pyridostigmine Bromide Neurologics - Misc. P Q B QNASL Nasal Steroids NP B QUARTETTE Contraceptives - Monophasic Combination O/C'S NP B QUDEXY XR Anticonvulsants NP B QUESTRAN Cholesterol - Bile Sequestrants NP G Quetiapine Fumarate Antipsychotics - Atypicals P PA Required B QUILLIVANT XR Stimulants - Methylphenidate - Long Acting P G Quinapril HCl ACE Inhibitors P PA Required >= 21 yo. 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 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 NP P R 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 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 12/3/2014 3:05:12 PM NP P Page 67 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR R B REBIF Multiple Sclerosis Agents – Interferons NP Grandfather Existing Users B REBIF REBIDOSE Multiple Sclerosis Agents – Interferons NP Grandfather Existing Users B REBIF REBIDOSE TITRATIONPACK Multiple Sclerosis Agents – Interferons NP Grandfather Existing Users B RECOMBINATE Antihemophilic Agents 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 Biologic Immunomodulators 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 REQUIP Parkinsons - Selected Dopamin Agonists NP B REQUIP XL Parkinsons - Selected Dopamin Agonists NP B RESCRIPTOR Antiretrovirals - Rti-Non-Nucleoside Analogues 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 Grandfather Existing Users B REVATIO SUSR Pulmonary Anti-Hypertensives NP PA Required B REVIA Narcotic - Antagonists NP 12/3/2014 3:05:12 PM R P NP PA Required P NP P PA Required> 12 Units/30 Days supply PA Required R NP P Page 68 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR R B REVLIMID Antineoplastics - Misc. B REYATAZ Antiretrovirals - Protease Inhibitors NR 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 < 18 years of age R 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 NP G Rifampin Antimycobacterials / Antituberculosis P B RILUTEK ALS Drug P PA Required G Riluzole ALS Drug NP PA Required G Rimantadine Hydrochloride Influenza Agents B RIOMET Diabetic - Oral Biguanides 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. P 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 NP PA Required B RITALIN SR Stimulants - Methylphenidate - Long Acting NP PA Required G Rivastigmine Tartrate Alzheimer - Cholinomimetics NP Restricted to persons 40 years of age and older. B RIXUBIS Antihemophilic Agents NR G Rizatriptan Benzoate Migraine - Selective Serotonin Agonists (5HT)--Tabs 12/3/2014 3:05:12 PM 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. PA Required> 12 Units/30 Days supply Page 69 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR R G Rizatriptan Benzoate Tablet Disperse Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ROBAXIN Muscle Relaxants NP PA Required B ROBINUL Gi - Antidiarrheal / Antacid - Misc. NP B ROCEPHIN Cephalosporins 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 RYTHMOL SR Antiarrhythmics NP B RYTHMOL TABS Antiarrhythmics NP INJ 1GM . PA Required S B SAIZEN Growth Hormone NP B SALAGEN Artificial Saliva/Stimulants NP PA Required B SALEX Topical - Enzymes / Keratolytics / Urea NP G Salicylic Acid Cream 6% Topical - Enzymes / Keratolytics / Urea P . G Salicylic Acid Foam 6% Topical - Enzymes / Keratolytics / Urea NP . 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 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 P B SAPHRIS Antipsychotics - Atypicals P B SARAFEM Antidepressants - Selected SSRI's NP Initial fill limited to 15 day supply. B SAVELLA Antidepressants - Selected SSRI's NP PA Required B SEASONIQUE Contraceptives - Monophasic Combination O/C'S B SECONAL Sedative/Hypnotics - Barbiturate 12/3/2014 3:05:12 PM P PA Required Duplicate therapy with other antipsychotics will be allowed for a maximum of 30 days. P NP Page 70 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR S B SECTRAL Beta Blockers - Cardio Selective G Selegiline HCl Anti-Parkinsonian Drugs NP P G Selenium Sulfide Topical - Antiseborrheics P G Selenium Sulfide-Pyrithione Zinc in Urea Vehicle Topical - Antiseborrheics P B SELZENTRY Antiretrovirals NR B SEMPREX-D Antihistamines/Decongestants NP B SE-NATAL 19 CHEW TABLET Vitamins - Misc. P O Senna Tab 187 MG Gi - Anti - Flatulents / GI Stimulants 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 NP PA Required NP P B SEROSTIM Growth Hormone G Sertraline HCl Antidepressants - Selected SSRI's G Sevelamer Carbonate Phosphate Binders NP B SFROWASA Gi - Inflammatory Bowel Agents NP B SIGNIFOR Somatostatic Agents NP G Sildenafil Citrate (Pulmonary Hypertension) Pulmonary Anti-Hypertensives B SILENOR Antidepressants - Tri-Cyclics NP NP ENE 4GM PA Required < 4 years of age P P . PA Required B SILVADENE Topical - Burn Products G Silver Nitrate Topical - Cauterizing Agents P G Silver Sulfadiazine Topical - Burn Products P B SIMBRINZA Op. Selective Alpha Adrenergic Agonists B SIMCOR Cholesterol - Hmg COA + Absorb Inhibitors NP Grandfather Existing Users NP PA Required P B SIMPONI Biologic Immunomodulators 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 B SINEMET Anti-Parkinsonian Drugs NP 12/3/2014 3:05:12 PM Grandfather Existing Users Page 71 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR S 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 P G Sirolimus Immunosuppressants P 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 . Gi - Antidiarrheal / Antacid - Misc. P PA Required ND Sodium Bicarbonate (Antacid) Tabs Preferred < 2 years of age PA Required PA Required 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 . ND Sodium Chloride Inj 0.9% Minerals P . ND Sodium Chloride IV Soln 0.9% G Sodium Chloride Inj 3% Minerals P . ND Sodium Chloride Soln Nebu 0.9% Antiasthmatic - Misc. Respiratory Inhalants P . G Sodium Chloride Soln Nebu 10% Antiasthmatic - Misc. Respiratory Inhalants P . G Sodium Chloride Soln Nebu 3% Antiasthmatic - Misc. Respiratory Inhalants P . 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 P 12/3/2014 3:05:12 PM Page 72 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR S B SOLARAZE Topical - Antineoplastics NP B SOLODYN Tetracyclines NP B SOLTAMOX Antineoplastics - Antiestrogens NR 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 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 SOVALDI Hepatitis C Agents B SPECTRACEF Cephalosporins NP G Spinosad Topical - Scabicides And Pediculicides NP P PA Required PA Required PA Required PA Required B SPIRIVA HANDIHALER Antiasthmatic - Anti-Cholinergics P G Spironolactone Diuretics P G Spironolactone & Hydrochlorothiazide Diuretics B SPORANOX Antifungals - Assorted NP PA Required B SPRIX Cox 2 Inhibitors - Selective NP PA Required B SPRYCEL Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR Initial fill limited to 15 day supply. B SPS K Removing Resins NP B SSKI Minerals B STALEVO Anti-Parkinsonian Drugs G Stannous Fluoride Dental Products P P NP P B STARLIX Diabetic - Meglitinides G Stavudine Antiretrovirals - Rti-Nucleoside Analogues-Thymidines B STAVZOR Anticonvulsants NP B STELARA Biologic Immunomodulators NP ND STERILE DILU SOL FLOLAN Compounding Materials NP R P . P PA Required B STIMATE Vasopressins B STIVARGA Antineoplastics - Protein-Tyrosine Kinase Inhibitors B STRATTERA Stimulants - Other Stimulants / Like Stimulants P G Streptomycin Sulfate Amino Glycosides P 12/3/2014 3:05:12 PM PA Required NR PA Required >= 21 yo. Page 73 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR S B STRIANT Androgens -Topical NP PA Required B STRIBILD Antiretrovirals - Combinations NR PA Required < 18 years of age B STRIVERDI RESPIMAT Antiasthmatic - Beta - Adrenergics NP B STROMECTOL Anthelmintics B SUBLIMAZE Narcotics - Misc. B SUBOXONE B SUBSYS G G P NP PA Required Narcotics - Misc. P PA Required Narcotics - Misc. NP PA Required Sucralfate Susp 1 GM/10ML Gi - Misc. Anti-Ulcer NP . Sucralfate Tab 1 GM Gi - Misc. Anti-Ulcer 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 P G Sulindac NSAIDS P 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 P B SUPRAX SUSR 200/5ML Cephalosporins P B SURMONTIL Antidepressants - Tri-Cyclics P B SUSTIVA Antiretrovirals - Rti-Non-Nucleoside Analogues R B SUTENT Antineoplastics - Protein-Tyrosine Kinase Inhibitors R B SYLATRON Antineoplastics - Misc. B SYMBICORT Antiasthmatic - Adrenergic Combos 12/3/2014 3:05:12 PM NP P PA Required> 12 Units/30 Days supply Initial fill limited to 15 day supply. NR P Page 74 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR S 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 SYNTHROID Thyroid Hormones NP B SYPRINE Chelating Agents P T B TABLOID Antineoplastics - Antimetabolites B TACLONEX Topical - Steroid Combinations G Tacrolimus Immunosuppressants B TAFINLAR Antineoplastics - Protein-Tyrosine Kinase Inhibitors B TAMIFLU Influenza Agents P G Tamoxifen Citrate Antineoplastics - Antiestrogens R G Tamsulosin HCl BPH P B TANZEUM Diabetic - Non-Insulin Injectables NP B TAPAZOLE Antithyroid Therapies NP B TARCEVA Antineoplastics - Protein-Tyrosine Kinase Inhibitors R Initial fill limited to 15 day supply. B TARGRETIN Antineoplastics - Selective Retinoid X Receptor Agonists R Initial fill limited to 15 day supply. B TARGRETIN Antineoplastics - Selective Retinoid X Receptor Agonists R Initial fill limited to 15 day supply. B TARKA ACE Inhibitors And Calcium Channel Blockers P B TASMAR Parkinsons - Comt Inhibitors B TAXOTERE Antineoplastics - Mitotic Inhibitors B TAZORAC Anti-Psoriatics - Non-Biologicals B TECFIDERA Multiple Sclerosis Agents B TEGRETOL Anticonvulsants P B TEGRETOL SUSP Anticonvulsants P B TEGRETOL XR Anticonvulsants P B TEKAMLO Direct Renin Inhibitors NP 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 12/3/2014 3:05:12 PM R NP P NR PA Required PA Required: > 14 Units/30Days Supply PA Required NP R P PA Required NP PA Required Page 75 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR T G Telmisartan-Hydrochlorothiazide ARB'S And Diuretics G Temazepam Cap 15 MG Sedative/Hypnotics - Benzodiazepines G Temazepam Cap 30 MG G Temazepam CAPS 22.5MG G NP PA Required P . Sedative/Hypnotics - Benzodiazepines P . Sedative/Hypnotics - Benzodiazepines NP PA Required Temazepam CAPS 7.5MG Sedative/Hypnotics - Benzodiazepines NP PA Required B TEMODAR Antineoplastics - Imidazotetrazines R B TEMOVATE Topical - Corticosteroids P G Temozolomide Antineoplastics - Imidazotetrazines NR B TENEX Antihypertensives - Central NP B TENORETIC Beta Blockers And Diuretic Combo'S NP B TENORMIN Beta Blockers - Cardio Selective NP B TERAZOL Vaginal - Anti Fungals NP 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 . PA Required > 90 days B TESTIM Androgens -Topical P PA Required G Testosterone Cypionate Androgens - Anabolics P PA Required G Testosterone Enanthate Androgens - Anabolics G TESTOSTERONE GEL Androgens -Topical B TESTRED Androgens - Anabolics G Tetracaine HCl (Ophth) Op. Misc G Tetracycline HCl Tetracyclines NP 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 NP B THALOMID Antileprotic P B THEO-24 Antiasthmatic - Xanthines P G Theophylline Antiasthmatic - Xanthines P 12/3/2014 3:05:12 PM P PA Required NP PA Required P PA Required P Page 76 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR T G Thiamine HCl Vitamins B THIOLA Urological - Misc. P G Thioridazine HCl Antipsychotics - Typical P G Thiothixene Antipsychotics - Typical P B THYROGEN Diagnostic Drugs B THYROLAR Thyroid Hormones P B TIAZAC Calcium Channel Blockers--Diltiazems P G Ticlopidine HCl Platelet Aggregation Inhibitors NP B TIGAN Antiemetic - Anticholinergic / Dopaminergic NP B TIKOSYN Antiarrhythmics P NP NP 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 NR G Tizanidine HCl Muscle Relaxants P B TOBI Amino Glycosides P B TOBI PODHALER Amino Glycosides NP B TOBRADEX Op. Antiinflammatory / Steroids Ophth. P B TOBRADEX ST Op. Antiinflammatory / Steroids Ophth. NP G Tobramycin (Ophth) Op. Antibiotics 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 B TOFRANIL-PM Antidepressants - Tri-Cyclics NP 12/3/2014 3:05:12 PM P Imipramine Pamoate - Use Imipramine HCL Page 77 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR T G Tolazamide Diabetic - Oral Sulfonylureas P G Tolbutamide Diabetic - Oral Sulfonylureas 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 NP PA Required P B TOPICORT Topical - Corticosteroids G Topiramate Anticonvulsants P G Topiramate CS24 Anticonvulsants NP B TOPROL XL Beta Blockers - Cardio Selective P G Torsemide Diuretics P Initial fill limited to 15 day supply. PA Required B TOVIAZ Antispasmodics - Long Acting P G Trace Minerals (Cr-Cu-Mn-Se-Zn) Minerals P B TRACLEER Pulmonary Anti-Hypertensives-Endothelin Receptor Antagonist P PA Required NP PA Required B TRADJENTA Diabetic - Other 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 NP B TRANDATE Beta Blockers - Alpha / Beta G Trandolapril ACE Inhibitors 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 12/3/2014 3:05:12 PM P P NP PA Required P Page 78 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR T B TRELSTAR Antineoplastics - Lhrh Analogs R G Tretinoin Topical - Tretinoids P PA Required G Tretinoin Microsphere Topical - Tretinoids NP PA Required B TREXALL Antineoplastics - Antimetabolites B TREXIMET Migraine - Selective Serotonin Agonists-5HT Combinations NP G Triamcinolone Acetonide (Nasal) Nasal Steroids NP G Triamcinolone Acetonide (Topical) Topical - Corticosteroids P G Triamcinolone Acetonide (Topical) LOTN Topical - Corticosteroids NP G Triamcinolone Acetonide Dental Paste 0.1% Mouth - Steroids P G Triamterene & Hydrochlorothiazide Diuretics P G Triazolam Sedative/Hypnotics - Benzodiazepines NP PA Required B TRIBENZOR ARB/CCB Plus Diuretics NP PA Required NP R B TRICOR Cholesterol - Fibric Acid Derivatives G Trifluoperazine HCl Antipsychotics - Typical P G Trifluridine Op. Antibiotics P B TRIGLIDE Cholesterol - Fibric Acid Derivatives G Trihexyphenidyl HCl Parkinsons - Anticholinergics B TRILEPTAL Anticonvulsants NP B TRILEPTAL SUSP Anticonvulsants P B TRILIPIX Cholesterol - Fibric Acid Derivatives G Trimethobenzamide HCl Antiemetic - Anticholinergic / Dopaminergic P G Trimethoprim Antibiotics - Misc. P B TRINATAL GT Vitamins - Misc. P B TRINATAL RX 1 Vitamins - Misc. P B TRI-NORINYL 28 Contraceptives - Tri-Phasic Combinations P B TRIOSTAT Thyroid Hormones B TRIUMEQ Antiretrovirals - Combinations B TRIZIVIR Antiretrovirals - Combinations B TROKENDI XR Anticonvulsants NP B TROPHAMINE Electrolytes/ Nutritionals NP G Tropicamide Op. Cycloplegics P G Trospium Chloride Antispasmodics NP B TRUSOPT Op. Carbonic Anhydrase Inhibitors/Combo NP B TRUVADA Antiretrovirals 12/3/2014 3:05:12 PM PA Required . NP P NP PA Required P NR R PA Required Initial fill limited to 15 day supply. R Page 79 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR T B TUDORZA PRESSAIR Antiasthmatic - Anti-Cholinergics NP B TWYNSTA Arb/Ccb NP B TYGACIL Antibiotics - Misc. B TYKERB Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR B TYLENOL/CODEINE Narcotics - Misc. NP PA Required B TYVASO Pulmonary Anti-Hypertensives NP PA Required B TYZEKA Hepatitis B Only NP B U-CORT Topical - Steroid Combinations 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 B ULTRAVATE Topical - Corticosteroids P B ULTRESA Gi - Digestive Enzymes NP B UMECTA Topical - Emollients NP B UMECTA NAIL FILM Topical - Emollients NP B UNASYN Beta-Lactams / Clavulanate Combo'S P B UNIRETIC ACE and Thiazide Combo's P B UNIVASC ACE Inhibitors NP PA Required P U NP P No manual PA required if one course of treatment of a preferred permethrin 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. 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 . G Urea Suspension 40% Topical - Emollients NP . B URECHOLINE Cholinergic NP 12/3/2014 3:05:12 PM Page 80 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR U B URELLE Urological - Misc. NP B UROCIT Urological - Misc. P B UROXATRAL BPH NP B URSO Gi - Misc. NP G Ursodiol Gi - Misc. P V B VAGIFEM Vaginal - Estrogens NP G Valacyclovir HCl Herpes Agents P B VALCYTE Cyto-Megalovirus Agents P G Valproate Sodium Anticonvulsants P G Valproic Acid Anticonvulsants P G Valsartan ARB'S G Valsartan-Hydrochlorothiazide ARB'S And Diuretics B VALTREX Herpes Agents NP P PA Required PA required if ACE-I not previously filled. 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. B VANOS Topical - Corticosteroids NP 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 NP P . R PA Required B VELTIN Topical - Acne Preparations 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 12/3/2014 3:05:12 PM P PA Required PA Required Page 81 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR V 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 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 VIGAMOX Op. Quinolones Fourth Generation P 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 R B VIOKACE Gi - Digestive Enzymes 12/3/2014 3:05:12 PM 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 . 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 Page 82 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR V 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 R B VIROPTIC Op. Antibiotics NP B VISTARIL Antihistamines - Other NP B VISTIDE Cyto-Megalovirus Agents B VIVACTIL Antidepressants - Tri-Cyclics B VIVELLE Estrogens - Patches B VIVITROL Narcotic - Antagonists NP B VOGELXO Androgens -Topical NP B VOL-NATE B VOL-PLUS B VOLTAREN GEL NSAIDS NP PA Required NP PA Required TAB R Requires a Selected Brand Name Drug PA PA Required P NP P Vitamins - Misc. P Vitamins - Misc. P B VOLTAREN-XR NSAIDS G Voriconazole Antifungals - Assorted P G Voriconazole SOLR Antifungals - Assorted NP B VOSOL HC Ear NP B VOSPIRE ER Antiasthmatic - Beta - Adrenergics NP B VOTRIENT Antineoplastics - Protein-Tyrosine Kinase Inhibitors B VPRIV Agents For Gaucher Disease NP B VUSION Topical - Antifungals NP B VYTORIN Cholesterol - Hmg COA + Absorb Inhibitors: High Potency Drugs/Combinations P B VYVANSE Stimulants - Amphetamines - Long Acting P R PA Required . PA Required > 90 days PA Required Initial fill limited to 15 day supply. PA Required PA Required >= 21 yo. W G Warfarin Sodium ND Water For Inject, Bacteriostatic Parabens Anticoagulants Compounding Materials P P B WELCHOL Cholesterol - Bile Sequestrants 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 12/3/2014 3:05:12 PM NP Page 83 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR 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 Biologic Immunomodulators NP PA Required B XELODA Antineoplastics - Antimetabolites R B XEOMIN Neuromuscular Blocking Agents NP B XERAC AC Topical - Astringents / Protectants B XERESE Topical - Antivirals NP B XIFAXAN Antibiotics - Misc. NP B XODOL Narcotics - Misc. NP PA Required B XOLAIR Antiasthmatic - Antiinflammatory Agents NP PA Required B XOPENEX Antiasthmatic - Beta - Adrenergics 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 NP G X-VIATE CRE 40% Topical - Emollients B XYLOCAINE Antiarrhythmics B XYLOCAINE/EPINEPHRINE Topical - Local Anesthetics P B XYLOCAINE-MPF Topical - Local Anesthetics NP B XYREM Anti-Cataplectic Agents NP PA Required B XYZAL Antihistamines - Non-Sedating NP PA Required B YASMIN 28 Contraceptives - Monophasic Combination O/C'S P B YAZ Contraceptives - Monophasic Combination O/C'S P P PA required. Preferred for post surgery DVT prophylaxis only. P P . NP Y Z G Zafirlukast Antiasthmatic - Leukotriene Receptor Antagonists NP G Zaleplon Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B ZANAFLEX Muscle Relaxants NP PA Required B ZANTAC Gi - H2-Antagonists NP B ZARONTIN Anticonvulsants 12/3/2014 3:05:12 PM P Page 84 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR Z B ZARONTIN SOLN Anticonvulsants B ZAROXOLYN Diuretics NP B ZAVESCA Agents For Gaucher Disease NP B ZEBETA Beta Blockers - Cardio Selective 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 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 P 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. 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 . 12/3/2014 3:05:12 PM NP P PA Required Page 85 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR Z B ZMAX Macrolides / Erythromycin'S / Ketolides NP B ZOCOR SUS 2GM 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 ZOLVIT Narcotics - Misc. 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 B ZONALON Topical - Antipruritics B ZONEGRAN Anticonvulsants NP G Zonisamide Anticonvulsants P 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 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 P . B ZOVIRAX SUS 200/5ML Herpes Agents P . B ZOVIRAX TAB 400MG Herpes Agents NP . INJ Contraceptives - Monophasic Combination O/C'S 12/3/2014 3:05:12 PM . R P Grandfather for seizure disorder. PA Required Payable for members 50 years of age and older without prior authorization P Page 86 Of 88 B or G Drug Name Drug Category P, N, Comment R or NR Z B ZOVIRAX Herpes Agents NP . B ZUBSOLV TAB 800MG Narcotics - Misc. NP PA Required 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 12/3/2014 3:05:12 PM Initial fill limited to 15 day supply. P P PA Required Page 87 Of 88 12/3/2014 3:05:12 PM Page 88 Of 88
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