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ADENOSINE RECEPTOR ANTAGONIST.............................................................................................................................. 18
ADENOSINE RECEPTOR ANTAGONIS................................................................................................................................................18
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS.............................................................................................18
ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS........................................................................................................18ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR...........................................................................................18AMPHETAMINE MIXTURES.................................................................................................................................................................18AMPHETAMINES.................................................................................................................................................................................18ANALEPTICS...................................................................................................................................................................................... 18ANOREXIANTS NON-AMPHETAMINE..................................................................................................................................................18STIMULANTS - MISC..........................................................................................................................................................................18
ALS AGENTS - MISCELLANEOUS........................................................................................................................................ 18
ALS AGENTS - MISCELLANEOUS.....................................................................................................................................................18
AMINOGLYCOSIDES............................................................................................................................................................... 18
AMINOGLYCOSIDES...........................................................................................................................................................................18
ANALGESICS - ANTI-INFLAMMATORY................................................................................................................................ 19
ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS.....................................................................................................................19ANTIRHEUMATIC ANTIMETABOLITES.................................................................................................................................................19ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES..............................................................................................................................19ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES...........................................................................................................................19CYCLOOXYGENASE 2 (COX-2) INHIBITORS.....................................................................................................................................19GOLD COMPOUNDS...........................................................................................................................................................................19INTERLEUKIN-1 BLOCKERS...............................................................................................................................................................19INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA).........................................................................................................................19INTERLEUKIN-1BETA BLOCKERS......................................................................................................................................................19INTERLEUKIN-6 RECEPTOR INHIBITORS...........................................................................................................................................19NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS.......................................................................................................19NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS).............................................................................................................19PYRIMIDINE SYNTHESIS INHIBITORS.................................................................................................................................................19SELECTIVE COSTIMULATION MODULATORS.....................................................................................................................................19SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS............................................................................................................19
ANALGESICS - NONNARCOTIC............................................................................................................................................ 19
ANALGESICS OTHER.........................................................................................................................................................................19ANALGESICS-SEDATIVES..................................................................................................................................................................19SALICYLATE COMBINATIONS............................................................................................................................................................20SALICYLATES.................................................................................................................................................................................... 20SELECTIVE N-TYPE NEURONAL CALCIUM CHANNEL BLOCKERS...................................................................................................20
ANALGESICS - OPIOID........................................................................................................................................................... 20
CODEINE COMBINATIONS..................................................................................................................................................................20DIHYDROCODEINE COMBINATIONS...................................................................................................................................................20HYDROCODONE COMBINATIONS.......................................................................................................................................................20OPIOID AGONISTS.............................................................................................................................................................................20OPIOID COMBINATIONS.....................................................................................................................................................................20OPIOID PARTIAL AGONISTS..............................................................................................................................................................20TRAMADOL COMBINATIONS..............................................................................................................................................................20
ANDROGENS-ANABOLIC....................................................................................................................................................... 20
ANDROGENS......................................................................................................................................................................................20
Updated July 1, 2020 Page
ANORECTAL AGENTS............................................................................................................................................................ 21
INTRARECTAL STEROIDS...................................................................................................................................................................21NITRATE VASODILATING AGENTS.....................................................................................................................................................21RECTAL ANESTHETIC/STEROIDS......................................................................................................................................................21
ANTHELMINTICS..................................................................................................................................................................... 21
ANTHELMINTICS.................................................................................................................................................................................21
ANTIANGINAL AGENTS.......................................................................................................................................................... 21
ANTIANGINALS-OTHER......................................................................................................................................................................21NITRATES...........................................................................................................................................................................................21
ANTIANXIETY AGENTS.......................................................................................................................................................... 21
ANTIANXIETY AGENTS - MISC..........................................................................................................................................................21BENZODIAZEPINES............................................................................................................................................................................ 21
ANTIARRHYTHMICS................................................................................................................................................................ 21
ANTIARRHYTHMICS - MISC................................................................................................................................................................21ANTIARRHYTHMICS TYPE I-A............................................................................................................................................................21ANTIARRHYTHMICS TYPE I-B............................................................................................................................................................21ANTIARRHYTHMICS TYPE I-C............................................................................................................................................................21ANTIARRHYTHMICS TYPE III..............................................................................................................................................................22
ANTIASTHMATIC AND BRONCHODILATOR AGENTS....................................................................................................... 22
ADRENERGIC COMBINATIONS...........................................................................................................................................................22ANTI-IGE MONOCLONAL ANTIBODIES..............................................................................................................................................22ANTI-INFLAMMATORY AGENTS.........................................................................................................................................................22BETA ADRENERGICS.........................................................................................................................................................................22BRONCHODILATORS - ANTICHOLINERGICS.......................................................................................................................................22LEUKOTRIENE RECEPTOR ANTAGONISTS........................................................................................................................................22SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS...............................................................................................................22STEROID INHALANTS.........................................................................................................................................................................22XANTHINES........................................................................................................................................................................................ 22
ANTICOAGULANTS................................................................................................................................................................. 22
COUMARIN ANTICOAGULANTS..........................................................................................................................................................22DIRECT FACTOR XA INHIBITORS......................................................................................................................................................23HEPARINS AND HEPARINOID-LIKE AGENTS.....................................................................................................................................23LOW MOLECULAR WEIGHT HEPARINS.............................................................................................................................................23SYNTHETIC HEPARINOID-LIKE AGENTS...........................................................................................................................................23THROMBIN INHIBITORS - HIRUDIN TYPE...........................................................................................................................................23THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE..........................................................................................................23
ANTICONVULSANTS............................................................................................................................................................... 23
AMPA GLUTAMATE RECEPTOR ANTAGONISTS..............................................................................................................................23ANTICONVULSANTS - BENZODIAZEPINES.........................................................................................................................................23ANTICONVULSANTS - MISC...............................................................................................................................................................23CARBAMATES....................................................................................................................................................................................23GABA MODULATORS.......................................................................................................................................................................23HYDANTOINS..................................................................................................................................................................................... 23SUCCINIMIDES................................................................................................................................................................................... 23VALPROIC ACID.................................................................................................................................................................................23
ANTIDEPRESSANTS............................................................................................................................................................... 24
Updated July 1, 2020 Page
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)....................................................................................................................24ANTIDEPRESSANTS - MISC...............................................................................................................................................................24MODIFIED CYCLICS........................................................................................................................................................................... 24MONOAMINE OXIDASE INHIBITORS (MAOIS)...................................................................................................................................24SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)...............................................................................................................24SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)....................................................................................................24TRICYCLIC AGENTS...........................................................................................................................................................................24
ANTIDIABETICS....................................................................................................................................................................... 24
ALPHA-GLUCOSIDASE INHIBITORS...................................................................................................................................................24ANTIDIABETIC - AMYLIN ANALOGS...................................................................................................................................................24BIGUANIDES.......................................................................................................................................................................................24DIABETIC OTHER...............................................................................................................................................................................24DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS..............................................................................................................................24DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS..................................................................................................24HUMAN INSULIN.................................................................................................................................................................................24INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)..........................................................................................................25INSULIN-INCRETIN MIMETIC COMBINATIONS....................................................................................................................................25MEGLITINIDE ANALOGUES................................................................................................................................................................25MEGLITINIDE-BIGUANIDE COMBINATIONS........................................................................................................................................25SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB............................................................................................................25SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS..................................................................................................................25SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS.....................................................................................................25SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB.........................................................................................25SULFONYLUREA-BIGUANIDE COMBINATIONS...................................................................................................................................25SULFONYLUREAS.............................................................................................................................................................................. 25SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS.....................................................................................................................25THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS.............................................................................................................................25THIAZOLIDINEDIONES........................................................................................................................................................................25
ANTIDIARRHEALS................................................................................................................................................................... 25
ANTIPERISTALTIC AGENTS................................................................................................................................................................25
ANTIDOTES.............................................................................................................................................................................. 26
ANTIDOTES........................................................................................................................................................................................ 26ANTIDOTES - CHELATING AGENTS...................................................................................................................................................26BENZODIAZEPINE ANTAGONISTS......................................................................................................................................................26OPIOID ANTAGONISTS.......................................................................................................................................................................26
ANTIDOTES AND SPECIFIC ANTAGONISTS....................................................................................................................... 26
ANTIDOTES AND SPECIFIC ANTAGONISTS........................................................................................................................................26
ANTIEMETICS.......................................................................................................................................................................... 26
5-HT3 RECEPTOR ANTAGONISTS....................................................................................................................................................26ANTIEMETIC COMBINATIONS.............................................................................................................................................................26ANTIEMETICS - ANTICHOLINERGIC....................................................................................................................................................26ANTIEMETICS - MISCELLANEOUS......................................................................................................................................................26SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS...................................................................................................26
ANTIFUNGALS......................................................................................................................................................................... 26
ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)...............................................................................................26ANTIFUNGALS....................................................................................................................................................................................26IMIDAZOLES....................................................................................................................................................................................... 27TRIAZOLES.........................................................................................................................................................................................27
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ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES........................................................................................27
ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES............................................................................................................27
ANTIHISTAMINES.................................................................................................................................................................... 27
ANTIHISTAMINES - ALKYLAMINES.....................................................................................................................................................27ANTIHISTAMINES - ETHANOLAMINES................................................................................................................................................27ANTIHISTAMINES - NON-SEDATING..................................................................................................................................................27ANTIHISTAMINES - PHENOTHIAZINES................................................................................................................................................27ANTIHISTAMINES - PIPERIDINES........................................................................................................................................................27
ANTIHYPERLIPIDEMICS......................................................................................................................................................... 27
ANTIHYPERLIPIDEMICS - MISC..........................................................................................................................................................27BILE ACID SEQUESTRANTS..............................................................................................................................................................27FIBRIC ACID DERIVATIVES................................................................................................................................................................27HMG COA REDUCTASE INHIBITORS................................................................................................................................................27INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB........................................................................................28INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS.....................................................................................................................28MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS......................................................................................................28NICOTINIC ACID DERIVATIVES..........................................................................................................................................................28
ANTIHYPERTENSIVES............................................................................................................................................................ 28
ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS.................................................................................................28ACE INHIBITORS...............................................................................................................................................................................28ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE..................................................................................................................................28ADRENOLYTICS-CENTRAL & THIAZIDE/THIAZIDE-LIKE COMB........................................................................................................28AGENTS FOR PHEOCHROMOCYTOMA...............................................................................................................................................28ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB..........................................................................................28ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE....................................................................................................28ANGIOTENSIN II RECEPTOR ANTAGONISTS......................................................................................................................................28ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER-THIAZIDES...........................................................................................28ANTIADRENERGICS - CENTRALLY ACTING.......................................................................................................................................28ANTIADRENERGICS - PERIPHERALLY ACTING..................................................................................................................................29BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB.............................................................................................29BETA BLOCKER & DIURETIC COMBINATIONS..................................................................................................................................29DIRECT RENIN INHIBITORS................................................................................................................................................................29DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB........................................................................................................29RESERPINE........................................................................................................................................................................................ 29SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)...................................................................................................29VASODILATORS................................................................................................................................................................................. 29
ANTI-INFECTIVE AGENTS - MISC......................................................................................................................................... 29
ANTI-INFECTIVE AGENTS - MISC......................................................................................................................................................29ANTI-INFECTIVE MISC. - COMBINATIONS..........................................................................................................................................29ANTIPROTOZOAL AGENTS................................................................................................................................................................29CARBAPENEM COMBINATIONS.........................................................................................................................................................29CARBAPENEMS..................................................................................................................................................................................29CYCLIC LIPOPEPTIDES......................................................................................................................................................................29GLYCYLCYCLINES..............................................................................................................................................................................29LEPROSTATICS..................................................................................................................................................................................29LINCOSAMIDES.................................................................................................................................................................................. 29OXAZOLIDINONES..............................................................................................................................................................................30POLYMYXINS......................................................................................................................................................................................30STREPTOGRAMIN COMBINATIONS....................................................................................................................................................30
Updated July 1, 2020 Page
ANTIMALARIALS..................................................................................................................................................................... 30
ANTIMALARIAL COMBINATIONS........................................................................................................................................................30ANTIMALARIALS................................................................................................................................................................................ 30
ANTIMYASTHENIC AGENTS.................................................................................................................................................. 30
ANTIMYASTHENIC AGENTS...............................................................................................................................................................30ANTIMYASTHENIC/CHOLINERGIC AGENTS........................................................................................................................................30
ANTIMYCOBACTERIAL AGENTS.......................................................................................................................................... 30
ANTIMYCOBACTERIAL AGENTS.........................................................................................................................................................30
ANTINEOPLASTIC - BCL-2 INHIBITORS.............................................................................................................................. 30
ANTINEOPLASTIC - BCL-2 INHIBITORS............................................................................................................................................30
ANTINEOPLASTIC - FGFR KINASE INHIBITORS................................................................................................................ 30
ANTINEOPLASTIC - FGFR KINASE INHIBITORS................................................................................................................................30
ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS.........................................................................30
ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS...............................................................................................30
ANTINEOPLASTIC - XPO1 INHIBITORS............................................................................................................................... 30
ANTINEOPLASTIC - XPO1 INHIBITORS.............................................................................................................................................30
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES......................................................................................................... 30
ALKYLATING AGENTS.......................................................................................................................................................................30ANDROGEN BIOSYNTHESIS INHIBITORS...........................................................................................................................................31ANTIADRENALS................................................................................................................................................................................. 31ANTIANDROGENS.............................................................................................................................................................................. 31ANTIESTROGENS...............................................................................................................................................................................31ANTIMETABOLITES............................................................................................................................................................................ 31ANTINEOPLASTIC - AUTOLOGOUS CELLULAR IMMUNOTHERAPY....................................................................................................31ANTINEOPLASTIC - BISPECIFIC T-CELL ENGAGERS........................................................................................................................31ANTINEOPLASTIC - BRAF KINASE INHIBITORS...............................................................................................................................31ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS...................................................................................................................31ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS................................................................................................................31ANTINEOPLASTIC - IMMUNOMODULATORS.......................................................................................................................................31ANTINEOPLASTIC - MEK INHIBITORS...............................................................................................................................................31ANTINEOPLASTIC - MONOCLONAL ANTIBODIES...............................................................................................................................31ANTINEOPLASTIC - MTOR KINASE INHIBITORS...............................................................................................................................32ANTINEOPLASTIC - MULTIKINASE INHIBITORS..................................................................................................................................32ANTINEOPLASTIC - PROTEASOME INHIBITORS.................................................................................................................................32ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS..........................................................................................................................32ANTINEOPLASTIC ANTIBIOTICS.........................................................................................................................................................32ANTINEOPLASTIC -ANTIBODY FOR RADIOPHARMACEUTICAL THERAPY..........................................................................................32ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES............................................................................................................................32ANTINEOPLASTIC COMBINATIONS....................................................................................................................................................32ANTINEOPLASTIC ENZYMES..............................................................................................................................................................32ANTINEOPLASTIC RADIOPHARMACEUTICALS...................................................................................................................................32ANTINEOPLASTICS - INTERLEUKINS..................................................................................................................................................32ANTINEOPLASTICS - PHOTOACTIVATED AGENTS.............................................................................................................................32ANTINEOPLASTICS MISC...................................................................................................................................................................32AROMATASE INHIBITORS...................................................................................................................................................................33CARBOXYPEPTIDASE ENZYME AGENTS...........................................................................................................................................33CARDIAC PROTECTIVE AGENTS.......................................................................................................................................................33
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CHEMOTHERAPY ADJUNCTS - HYPERURICEMIA AGENTS................................................................................................................33CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH FACTORS...............................................................................................33CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS..........................................................................................................................33ESTROGEN RECEPTOR ANTAGONIST...............................................................................................................................................33ESTROGENS-ANTINEOPLASTIC.........................................................................................................................................................33FOLIC ACID ANTAGONISTS RESCUE AGENTS..................................................................................................................................33GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS...................................................................................................33IMIDAZOTETRAZINES..........................................................................................................................................................................33ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS.....................................................................................................................33JANUS ASSOCIATED KINASE (JAK) INHIBITORS.............................................................................................................................33LHRH ANALOGS...............................................................................................................................................................................33MITOTIC INHIBITORS..........................................................................................................................................................................33NITROGEN MUSTARDS......................................................................................................................................................................33NITROSOUREAS.................................................................................................................................................................................33PROGESTINS-ANTINEOPLASTIC........................................................................................................................................................34RETINOIDS......................................................................................................................................................................................... 34SELECTIVE RETINOID X RECEPTOR AGONISTS...............................................................................................................................34TOPOISOMERASE I INHIBITORS.........................................................................................................................................................34URINARY TRACT PROTECTIVE AGENTS...........................................................................................................................................34VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS................................................................................................34
ANTIPARKINSON AGENTS.................................................................................................................................................... 34
ANTIPARKINSON ANTICHOLINERGICS...............................................................................................................................................34ANTIPARKINSON DOPAMINERGICS....................................................................................................................................................34ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS.......................................................................................................................34LEVODOPA COMBINATIONS..............................................................................................................................................................34NONERGOLINE DOPAMINE RECEPTOR AGONISTS...........................................................................................................................34PERIPHERAL COMT INHIBITORS......................................................................................................................................................34
ANTIPSYCHOTICS/ANTIMANIC AGENTS............................................................................................................................. 34
ANTIMANIC AGENTS..........................................................................................................................................................................34ANTIPSYCHOTICS - MISC..................................................................................................................................................................34BENZISOXAZOLES............................................................................................................................................................................. 34BUTYROPHENONES........................................................................................................................................................................... 34DIBENZODIAZEPINES.........................................................................................................................................................................35DIBENZOTHIAZEPINES.......................................................................................................................................................................35DIBENZOXAZEPINES.......................................................................................................................................................................... 35PHENOTHIAZINES...............................................................................................................................................................................35QUINOLINONE DERIVATIVES.............................................................................................................................................................35THIENBENZODIAZEPINES...................................................................................................................................................................35THIOXANTHENES............................................................................................................................................................................... 35
ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR.......................................................................35
ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR............................................................................................35
ANTISEPTICS & DISINFECTANTS......................................................................................................................................... 35
CHLORINE ANTISEPTICS...................................................................................................................................................................35
ANTIVIRALS............................................................................................................................................................................. 35
ANTIRETROVIRAL COMBINATIONS....................................................................................................................................................35ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)......................................................................................................35ANTIRETROVIRALS - FUSION INHIBITORS.........................................................................................................................................35ANTIRETROVIRALS - INTEGRASE INHIBITORS...................................................................................................................................35ANTIRETROVIRALS - PROTEASE INHIBITORS....................................................................................................................................35
Updated July 1, 2020 Page
ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES..............................................................................................................36ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES.......................................................................................................36ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES................................................................................................36ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES.................................................................................................36ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES.......................................................................................................................36CMV AGENTS................................................................................................................................................................................... 36HEPATITIS B AGENTS.......................................................................................................................................................................36HEPATITIS C AGENTS.......................................................................................................................................................................36HERPES AGENTS - PURINE ANALOGUES.........................................................................................................................................36HERPES AGENTS - THYMIDINE ANALOGUES....................................................................................................................................36INFLUENZA AGENTS..........................................................................................................................................................................36NEURAMINIDASE INHIBITORS............................................................................................................................................................36RSV AGENTS - NUCLEOSIDE ANALOGUES......................................................................................................................................36
ASSORTED CLASSES............................................................................................................................................................ 36
ANTILEPROTICS.................................................................................................................................................................................36ASSORTED CLASSES.................................................................................................................................................................36B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS.........................................................................................................36CHELATING AGENTS.........................................................................................................................................................................36CYCLOSPORINE ANALOGS................................................................................................................................................................37ENZYMES........................................................................................................................................................................................... 37IMMUNE GLOBULIN IMMUNOSUPPRESSANTS....................................................................................................................................37IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES.........................................................................................................37INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS.............................................................................................................37MACROLIDE IMMUNOSUPPRESSANTS...............................................................................................................................................37MONOCLONAL ANTIBODIES..............................................................................................................................................................37POTASSIUM REMOVING RESINS........................................................................................................................................................37PROSTAGLANDINS.............................................................................................................................................................................37PURINE ANALOGS.............................................................................................................................................................................37SCLEROSING AGENTS.......................................................................................................................................................................37SELECTIVE T-CELL COSTIMULATION BLOCKERS............................................................................................................................37
ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES........................................................................................................ 37
ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES..........................................................................................................................37
BETA BLOCKERS.................................................................................................................................................................... 37
ALPHA-BETA BLOCKERS..................................................................................................................................................................37BETA BLOCKERS CARDIO-SELECTIVE.............................................................................................................................................37BETA BLOCKERS NON-SELECTIVE...................................................................................................................................................38
BILE ACID SYNTHESIS DISORDER AGENTS...................................................................................................................... 38
BILE ACID SYNTHESIS DISORDER AGENTS.....................................................................................................................................38
BIOLOGICALS MISC................................................................................................................................................................ 38
ALLERGENIC EXTRACTS...................................................................................................................................................................38BIOLOGICALS MISC...........................................................................................................................................................................38
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG............................................................................38
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG..............................................................................................38
CALCIUM CHANNEL BLOCKERS.......................................................................................................................................... 38
CALCIUM CHANNEL BLOCKERS........................................................................................................................................................38
CARDIOTONICS....................................................................................................................................................................... 38
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CARDIAC GLYCOSIDES..................................................................................................................................................................... 38PHOSPHODIESTERASE INHIBITORS...................................................................................................................................................38
CARDIOVASCULAR AGENTS - MISC................................................................................................................................... 38
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS........................................................................................38
CARDIOVASCULAR AGENTS - MISC................................................................................................................................... 38
CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB.....................................................................................38PERIPHERAL VASODILATORS............................................................................................................................................................38PROSTAGLANDIN - IMPOTENCE AGENTS..........................................................................................................................................38PROSTAGLANDIN VASODILATORS....................................................................................................................................................38PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)......................................................................................39PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS........................................................................................39PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS................................................................................................39SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS.......................................................................................................39VASOACTIVE NATRIURETIC PEPTIDES..............................................................................................................................................39
CARDIOVASCULAR, HYPERTENSION & LIPIDS................................................................................................................ 39
MISC. CARDIOVASCULAR AGENTS........................................................................................................................................39MISC. COAGULATION AGENTS................................................................................................................................................39
CEPHALOSPORIN COMBINATIONS..................................................................................................................................... 39
CEPHALOSPORIN COMBINATIONS.....................................................................................................................................................39
CEPHALOSPORINS................................................................................................................................................................. 39
CEPHALOSPORINS - 1ST GENERATION............................................................................................................................................39CEPHALOSPORINS - 2ND GENERATION............................................................................................................................................39CEPHALOSPORINS - 3RD GENERATION............................................................................................................................................39CEPHALOSPORINS - 4TH GENERATION............................................................................................................................................39CEPHALOSPORINS - 5TH GENERATION............................................................................................................................................39
CONTRACEPTIVES................................................................................................................................................................. 39
BIPHASIC CONTRACEPTIVES - ORAL................................................................................................................................................39COMBINATION CONTRACEPTIVES - ORAL........................................................................................................................................39COMBINATION CONTRACEPTIVES - VAGINAL...................................................................................................................................40CONTINUOUS CONTRACEPTIVES - ORAL..........................................................................................................................................40EMERGENCY CONTRACEPTIVES.......................................................................................................................................................40EXTENDED-CYCLE CONTRACEPTIVES - ORAL.................................................................................................................................40FOUR PHASE CONTRACEPTIVES - ORAL.........................................................................................................................................40PROGESTIN CONTRACEPTIVES - IMPLANTS.....................................................................................................................................40PROGESTIN CONTRACEPTIVES - INJECTABLE..................................................................................................................................40PROGESTIN CONTRACEPTIVES - IUD...............................................................................................................................................40PROGESTIN CONTRACEPTIVES - ORAL............................................................................................................................................40TRIPHASIC CONTRACEPTIVES - ORAL..............................................................................................................................................40
CORTICOSTEROIDS................................................................................................................................................................ 41
GLUCOCORTICOSTEROIDS................................................................................................................................................................41MINERALOCORTICOIDS......................................................................................................................................................................41
COUGH/COLD/ALLERGY........................................................................................................................................................ 41
ANTITUSSIVE - NONNARCOTIC..........................................................................................................................................................41ANTITUSSIVE - OPIOID...................................................................................................................................................................... 41DECONGESTANT................................................................................................................................................................................41DECONGESTANT-ANTIHISTAMINE.....................................................................................................................................................41
Updated July 1, 2020 Page
DECONGESTANT-ANTIHISTAMINE W/ EXPECTORANT.......................................................................................................................41MUCOLYTICS..................................................................................................................................................................................... 41NON-NARC ANTITUSSIVE-ANTIHISTAMINE......................................................................................................................................41NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE...........................................................................................................41OPIOID ANTITUSSIVE-ANTIHISTAMINE..............................................................................................................................................41OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE..................................................................................................................41
CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS.......................................................................................................... 41
CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS..........................................................................................................................41
CYSTIC FIBROSIS AGENT - COMBINATION........................................................................................................................ 41
CYSTIC FIBROSIS AGENT - COMBINATIONS.....................................................................................................................................41
CYSTIC FIBROSIS AGENT - COMBINATIONS..................................................................................................................... 41
CYSTIC FIBROSIS AGENT - COMBINATIONS.....................................................................................................................................41
DERMATOLOGICALS.............................................................................................................................................................. 42
ACNE ANTIBIOTICS............................................................................................................................................................................42ACNE COMBINATIONS.......................................................................................................................................................................42ACNE PRODUCTS..............................................................................................................................................................................42ANTIBIOTICS - TOPICAL.................................................................................................................................................................... 42ANTIFUNGALS - TOPICAL..................................................................................................................................................................42ANTIFUNGALS - TOPICAL COMBINATIONS........................................................................................................................................42ANTI-INFLAMMATORY AGENTS - TOPICAL........................................................................................................................................42ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL........................................................................................................................42ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL.............................................................................................................................42ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL MISC...................................................................................................42ANTIPSORIATICS................................................................................................................................................................................42ANTIPSORIATICS - SYSTEMIC............................................................................................................................................................42ANTISEBORRHEIC PRODUCTS...........................................................................................................................................................42ANTIVIRALS - TOPICAL......................................................................................................................................................................43BURN PRODUCTS..............................................................................................................................................................................43CORTICOSTEROIDS - TOPICAL..........................................................................................................................................................43DEPIGMENTING AGENTS...................................................................................................................................................................43EMOLLIENT/KERATOLYTIC AGENTS.................................................................................................................................................43EMOLLIENTS......................................................................................................................................................................................43ENZYMES - TOPICAL......................................................................................................................................................................... 43IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL...............................................................................................................................43IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL...........................................................................................................43KERATOLYTIC/ANTIMITOTIC AGENTS...............................................................................................................................................43LOCAL ANESTHETICS - TOPICAL......................................................................................................................................................43MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL.............................................................................................................................43MISC. DERMATOLOGICAL PRODUCTS..............................................................................................................................................43PIGMENTING AGENTS........................................................................................................................................................................44ROSACEA AGENTS............................................................................................................................................................................44SCABICIDES & PEDICULICIDES.........................................................................................................................................................44TOPICAL ANESTHETIC COMBINATIONS.............................................................................................................................................44TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS................................................................................................................44TOPICAL STEROID COMBINATIONS...................................................................................................................................................44WOUND DRESSINGS..........................................................................................................................................................................44
DIAGNOSTIC PRODUCTS....................................................................................................................................................... 44
DIAGNOSTIC BIOLOGICALS...............................................................................................................................................................44DIAGNOSTIC DRUGS..........................................................................................................................................................................44
Updated July 1, 2020 Page
DIAGNOSTIC RADIOPHARMACEUTICALS - CARDIAC.........................................................................................................................44MISCELLANEOUS CONTRAST MEDIA................................................................................................................................................44RADIOGRAPHIC CONTRAST MEDIA - IODINATED..............................................................................................................................44
DIAGNOSTICS & MISCELLANEOUS AGENTS..................................................................................................................... 44
IRRIGATING SOLUTIONS............................................................................................................................................................44MISCELLANEOUS AGENTS.......................................................................................................................................................44NEUTRACEUTICALS....................................................................................................................................................................44
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS..........................................................................................44
DIETARY MANAGEMENT PRODUCT COMBINATIONS.........................................................................................................................44
DIGESTIVE AIDS...................................................................................................................................................................... 45
DIGESTIVE ENZYMES.........................................................................................................................................................................45
DIURETICS................................................................................................................................................................................ 45
CARBONIC ANHYDRASE INHIBITORS................................................................................................................................................45DIURETIC COMBINATIONS.................................................................................................................................................................45LOOP DIURETICS...............................................................................................................................................................................45OSMOTIC DIURETICS.........................................................................................................................................................................45POTASSIUM SPARING DIURETICS.....................................................................................................................................................45THIAZIDES AND THIAZIDE-LIKE DIURETICS......................................................................................................................................45
DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS).........................................................................45
DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)..............................................................................................45
ENDOCRINE AND METABOLIC AGENTS - MISC................................................................................................................ 45
BISPHOSPHONATES...........................................................................................................................................................................45CALCIMIMETIC AGENTS.....................................................................................................................................................................45CALCITONINS.....................................................................................................................................................................................45CARNITINE REPLENISHER - AGENTS................................................................................................................................................45DOPAMINE RECEPTOR AGONISTS....................................................................................................................................................45FABRY DISEASE - AGENTS...............................................................................................................................................................45GAA DEFICIENCY TREATMENT - AGENTS.......................................................................................................................................45GROWTH HORMONE RECEPTOR ANTAGONISTS..............................................................................................................................46GROWTH HORMONE RELEASING HORMONES (GHRH)..................................................................................................................46GROWTH HORMONES........................................................................................................................................................................46HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS.................................................................................................................46HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS...............................................................................................46HOMOCYSTINURIA TREATMENT - AGENTS.......................................................................................................................................46HYPERAMMONEMIA TREATMENT - AGENTS.....................................................................................................................................46HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS.............................................................................................................46HYPOPHOSPHATASIA (HPP) AGENTS..............................................................................................................................................46INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)......................................................................................................................46LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS.......................................................................................................46LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS...............................................................................................................46MUCOPOLYSACCHARIDOSIS I (MPS I) - AGENTS............................................................................................................................46MUCOPOLYSACCHARIDOSIS II (MPS II) - AGENTS..........................................................................................................................46MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS.......................................................................................................................46OVULATION STIMULANTS-GONADOTROPINS....................................................................................................................................46OVULATION STIMULANTS-SYNTHETIC..............................................................................................................................................46PARATHYROID HORMONE AND DERIVATIVES..................................................................................................................................46PHENYLKETONURIA TREATMENT - AGENTS.....................................................................................................................................46RANK LIGAND (RANKL) INHIBITORS.............................................................................................................................................46
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SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS).........................................................................................................47SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS...............................................................................................................47SOMATOSTATIC AGENTS..................................................................................................................................................................47UREA CYCLE DISORDER - AGENTS..................................................................................................................................................47VASOPRESSIN....................................................................................................................................................................................47
ESTROGENS............................................................................................................................................................................ 47
ESTROGEN & ANDROGEN.................................................................................................................................................................47ESTROGEN & PROGESTIN.................................................................................................................................................................47ESTROGENS.......................................................................................................................................................................................47
ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB........................................................................47
ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB..............................................................................................47
FLUOROQUINOLONES........................................................................................................................................................... 47
FLUOROQUINOLONES........................................................................................................................................................................47
GASTROINTESTINAL AGENTS - MISC................................................................................................................................. 47
FARNESOID X RECEPTOR (FXR) AGONISTS...................................................................................................................................47GALLSTONE SOLUBILIZING AGENTS................................................................................................................................................47GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS.................................................................................................................47GASTROINTESTINAL STIMULANTS....................................................................................................................................................47IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS...........................................................................................................48IBS AGENT - MU-OPIOID RECEPTOR AGONISTS.............................................................................................................................48IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS...........................................................................................................48INFLAMMATORY BOWEL AGENTS.....................................................................................................................................................48PERIPHERAL OPIOID RECEPTOR ANTAGONISTS..............................................................................................................................48PHOSPHATE BINDER AGENTS..........................................................................................................................................................48TUMOR NECROSIS FACTOR ALPHA BLOCKERS..............................................................................................................................48
GENERAL ANESTHETICS...................................................................................................................................................... 48
ANESTHETICS - MISC........................................................................................................................................................................48BARBITURATE ANESTHETICS............................................................................................................................................................48
GENITOURINARY AGENTS - MISCELLANEOUS................................................................................................................. 48
5-ALPHA REDUCTASE INHIBITORS...................................................................................................................................................48ALPHA 1-ADRENOCEPTOR ANTAGONISTS.......................................................................................................................................48CITRATES...........................................................................................................................................................................................48CYSTINOSIS AGENTS........................................................................................................................................................................ 48GENITOURINARY IRRIGANTS.............................................................................................................................................................48INTERSTITIAL CYSTITIS AGENTS.......................................................................................................................................................48URINARY ANALGESICS......................................................................................................................................................................48
GLYCOPEPTIDES.................................................................................................................................................................... 49
GLYCOPEPTIDES................................................................................................................................................................................49
GOUT AGENTS........................................................................................................................................................................ 49
GOUT AGENTS.................................................................................................................................................................................. 49URICOSURICS.................................................................................................................................................................................... 49
HEMATOLOGICAL AGENTS - MISC...................................................................................................................................... 49
ANTIHEMOPHILIC PRODUCTS............................................................................................................................................................49BRADYKININ B2 RECEPTOR ANTAGONISTS.....................................................................................................................................49C1 INHIBITORS.................................................................................................................................................................................. 49
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COMPLEMENT INHIBITORS................................................................................................................................................................49CYCLOPENTYLTRIAZOLOPYRIMIDINE (CPTP) DERIVATIVES............................................................................................................49GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS..............................................................................................................................49HEMATORHEOLOGIC AGENTS...........................................................................................................................................................49HEMIN................................................................................................................................................................................................ 49HUMAN PROTEIN C...........................................................................................................................................................................49PHOSPHODIESTERASE III INHIBITORS...............................................................................................................................................49PLASMA EXPANDERS........................................................................................................................................................................49PLASMA KALLIKREIN INHIBITORS.....................................................................................................................................................50PLASMA PROTEINS........................................................................................................................................................................... 50PLATELET AGGREGATION INHIBITOR COMBINATIONS.....................................................................................................................50PLATELET AGGREGATION INHIBITORS.............................................................................................................................................50PROTAMINE....................................................................................................................................................................................... 50QUINAZOLINE AGENTS......................................................................................................................................................................50THIENOPYRIDINE DERIVATIVES.........................................................................................................................................................50TISSUE PLASMINOGEN ACTIVATORS................................................................................................................................................50
HEMATOPOIETIC AGENTS.................................................................................................................................................... 50
AGENTS FOR GAUCHER DISEASE....................................................................................................................................................50COBALAMINS.....................................................................................................................................................................................50CXCR4 RECEPTOR ANTAGONIST....................................................................................................................................................50CYTOTOXIC AGENTS.........................................................................................................................................................................50ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)...........................................................................................................................50ERYTHROPOIETINS............................................................................................................................................................................ 50FOLIC ACID/FOLATE COMBINATIONS...............................................................................................................................................50FOLIC ACID/FOLATES.......................................................................................................................................................................50GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)...........................................................................................................50GRANULOCYTE/MACROPHAGE COLONY-STIMULATING FACTOR(GM-CSF)..................................................................................50IRON...................................................................................................................................................................................................50IRON COMBINATIONS........................................................................................................................................................................ 50IRON W/ FOLIC ACID.........................................................................................................................................................................51IRON-B12-FOLATE............................................................................................................................................................................51THROMBOPOIETIN (TPO) RECEPTOR AGONISTS.............................................................................................................................51
HEMOSTATICS......................................................................................................................................................................... 51
HEMOSTATICS - SYSTEMIC...............................................................................................................................................................51
HEPATITIS C AGENT - COMBINATIONS.............................................................................................................................. 51
HEPATITIS C AGENT - COMBINATIONS.............................................................................................................................................51
HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS....................................................................................51
HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS........................................................................................................51
HYPNOTICS.............................................................................................................................................................................. 51
BARBITURATE HYPNOTICS................................................................................................................................................................51BENZODIAZEPINE HYPNOTICS...........................................................................................................................................................51NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS...........................................................................................................51SELECTIVE MELATONIN RECEPTOR AGONISTS...............................................................................................................................51
IBS AGENT - 5-HT4 RECEPTOR PARTIAL AGONISTS....................................................................................................... 51
IBS AGENT - 5-HT4 RECEPTOR PARTIAL AGONISTS.....................................................................................................................51
INSULIN-LIKE GROWTH FACTOR-1 RECEPTOR INHIBITORS(IGF-1R)...........................................................................51
INSULIN-LIKE GROWTH FACTOR-1 RECEPTOR INHIBITORS(IGF-1R).............................................................................................51Updated July 1, 2020 Page
INTEGRIN RECEPTOR ANTAGONISTS................................................................................................................................ 52
INTEGRIN RECEPTOR ANTAGONISTS................................................................................................................................................52
INTERLEUKIN-4 ALPHA ANTAGONISTS.............................................................................................................................. 52
INTERLEUKIN-4 ALPHA ANTAGONISTS.............................................................................................................................................52
INTERLEUKIN-6 (IL-6) ANTAGONISTS................................................................................................................................. 52
INTERLEUKIN-6 (IL-6) ANTAGONISTS...............................................................................................................................................52
LAXATIVES............................................................................................................................................................................... 52
BOWEL EVACUANT COMBINATIONS.................................................................................................................................................52LAXATIVES - MISCELLANEOUS.........................................................................................................................................................52
LEPTIN ANALOGUES.............................................................................................................................................................. 52
LEPTIN ANALOGUES......................................................................................................................................................................... 52
LOCAL ANESTHETICS-PARENTERAL................................................................................................................................. 52
LOCAL ANESTHETIC & SYMPATHOMIMETIC.....................................................................................................................................52LOCAL ANESTHETICS - AMIDES.......................................................................................................................................................52LOCAL ANESTHETICS - ESTERS.......................................................................................................................................................52
MACROLIDES........................................................................................................................................................................... 52
AZITHROMYCIN.................................................................................................................................................................................. 52CLARITHROMYCIN..............................................................................................................................................................................52ERYTHROMYCINS...............................................................................................................................................................................52
MEDICAL DEVICES................................................................................................................................................................. 52
CERVICAL CAPS................................................................................................................................................................................52GLUCOSE MONITORING TEST SUPPLIES..........................................................................................................................................53NEEDLES & SYRINGES......................................................................................................................................................................53
MIGRAINE PRODUCTS........................................................................................................................................................... 53
ERGOT COMBINATIONS.....................................................................................................................................................................53MIGRAINE PRODUCTS.......................................................................................................................................................................53SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS.............................................................................................................53SELECTIVE SEROTONIN AGONISTS 5-HT(1)....................................................................................................................................53
MINERALS & ELECTROLYTES.............................................................................................................................................. 53
BICARBONATES.................................................................................................................................................................................53CALCIUM............................................................................................................................................................................................53ELECTROLYTES & DEXTROSE..........................................................................................................................................................53ELECTROLYTES PARENTERAL..........................................................................................................................................................53IODINE PRODUCTS.............................................................................................................................................................................54MAGNESIUM.......................................................................................................................................................................................54MANGANESE......................................................................................................................................................................................54PHOSPHATE.......................................................................................................................................................................................54PHOSPHATES.....................................................................................................................................................................................54POTASSIUM........................................................................................................................................................................................54TRACE MINERAL COMBINATIONS.....................................................................................................................................................54TRACE MINERALS............................................................................................................................................................................. 54
MIXED ALLERGENIC EXTRACTS.......................................................................................................................................... 54
MIXED ALLERGENIC EXTRACTS........................................................................................................................................................54
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MONOBACTAMS...................................................................................................................................................................... 54
MONOBACTAMS.................................................................................................................................................................................54
MOUTH/THROAT/DENTAL AGENTS..................................................................................................................................... 54
ANTI-INFECTIVE COMBINATIONS - THROAT......................................................................................................................................54FLUORIDE DENTAL PRODUCTS.........................................................................................................................................................54SALIVA STIMULANTS.........................................................................................................................................................................54
MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS........................................................................................................ 54
MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS.......................................................................................................................54
MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS...................................................................................................... 55
MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS.....................................................................................................................55
MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES....................................................................................................55
MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES......................................................................................................................55
MULTIVITAMINS....................................................................................................................................................................... 55
B-COMPLEX VITAMINS......................................................................................................................................................................55B-COMPLEX W/ C & FOLIC ACID.....................................................................................................................................................55MULTIPLE VITAMINS W/ CALCIUM.....................................................................................................................................................55MULTIPLE VITAMINS W/ MINERALS...................................................................................................................................................55MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID..........................................................................................................55MULTIPLE VITAMINS W/ MINERALS & FOLIC ACID..........................................................................................................................55MULTIVITAMINS..................................................................................................................................................................................55PED MULTI VITAMINS W/FL & FE....................................................................................................................................................55PED MV W/ FLUORIDE......................................................................................................................................................................55PEDIATRIC MULTIPLE VITAMINS.......................................................................................................................................................55PRENATAL MV & MIN W/FE-FA......................................................................................................................................................55PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL..............................................................................................................56PRENATAL MV & MIN W/FE-FA-DHA............................................................................................................................................56PRENATAL VITAMINS.........................................................................................................................................................................56
MUSCULOSKELETAL THERAPY AGENTS.......................................................................................................................... 56
CENTRAL MUSCLE RELAXANTS.......................................................................................................................................................56DIRECT MUSCLE RELAXANTS...........................................................................................................................................................56VISCOSUPPLEMENTS.........................................................................................................................................................................56
NASAL AGENTS - SYSTEMIC AND TOPICAL...................................................................................................................... 56
ANTIHISTAMINE-STEROID..................................................................................................................................................................56NASAL ANTICHOLINERGICS..............................................................................................................................................................56NASAL ANTIHISTAMINES...................................................................................................................................................................56NASAL STEROIDS..............................................................................................................................................................................56
NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB.............................................................................56
NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB...............................................................................................56
NEUROMUSCULAR AGENTS................................................................................................................................................. 57
BENZATHIAZOLES..............................................................................................................................................................................57DEPOLARIZING MUSCLE RELAXANTS...............................................................................................................................................57NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS...................................................................................................................57
NUTRIENTS.............................................................................................................................................................................. 57
AMINO ACID MIXTURES.................................................................................................................................................................... 57Updated July 1, 2020 Page
CARBOHYDRATES............................................................................................................................................................................. 57LIPIDS................................................................................................................................................................................................ 57
OPHTHALMIC AGENTS.......................................................................................................................................................... 57
BETA-BLOCKERS - OPHTHALMIC......................................................................................................................................................57BETA-BLOCKERS - OPHTHALMIC COMBINATIONS............................................................................................................................57CYCLOPLEGIC MYDRIATICS..............................................................................................................................................................57LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG.............................................................................................57MIOTICS - CHOLINESTERASE INHIBITORS.........................................................................................................................................57MIOTICS - DIRECT ACTING................................................................................................................................................................57OPHTHALMIC ANTIALLERGIC............................................................................................................................................................57OPHTHALMIC ANTIBIOTICS................................................................................................................................................................57OPHTHALMIC ANTIFUNGAL...............................................................................................................................................................58OPHTHALMIC ANTI-INFECTIVE COMBINATIONS................................................................................................................................58OPHTHALMIC ANTIVIRALS.................................................................................................................................................................58OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS..........................................................................................................................58OPHTHALMIC ENZYMES.................................................................................................................................................................... 58OPHTHALMIC IMMUNOMODULATORS................................................................................................................................................58OPHTHALMIC IRRIGATION SOLUTIONS..............................................................................................................................................58OPHTHALMIC LOCAL ANESTHETICS.................................................................................................................................................58OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS........................................................................................................58OPHTHALMIC PHOTODYNAMIC THERAPY AGENTS...........................................................................................................................58OPHTHALMIC RHO KINASE INHIBITORS............................................................................................................................................58OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS.............................................................................................................58OPHTHALMIC STEROID COMBINATIONS...........................................................................................................................................58OPHTHALMIC STEROIDS....................................................................................................................................................................58OPHTHALMIC SULFONAMIDES...........................................................................................................................................................58OPHTHALMICS - CYSTINOSIS AGENTS.............................................................................................................................................59PROSTAGLANDINS - OPHTHALMIC....................................................................................................................................................59VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS...........................................................................................59
OPHTHALMIC GENE THERAPY............................................................................................................................................. 59
OPHTHALMIC GENE THERAPY..........................................................................................................................................................59
OPHTHALMIC KINASE INHIBITORS - COMBINATIONS..................................................................................................... 59
OPHTHALMIC KINASE INHIBITORS - COMBINATIONS........................................................................................................................59
OREXIN RECEPTOR ANTAGONISTS.................................................................................................................................... 59
OREXIN RECEPTOR ANTAGONISTS...................................................................................................................................................59
OTIC AGENTS.......................................................................................................................................................................... 59
OTIC AGENTS - MISCELLANEOUS.....................................................................................................................................................59OTIC ANALGESIC COMBINATIONS....................................................................................................................................................59OTIC ANTI-INFECTIVES......................................................................................................................................................................59OTIC STEROID-ANTI-INFECTIVE COMBINATIONS..............................................................................................................................59OTIC STEROIDS.................................................................................................................................................................................59
OXYTOCICS.............................................................................................................................................................................. 59
ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS...........................................................................................................59OXYTOCICS........................................................................................................................................................................................59
PASSIVE IMMUNIZING AGENTS............................................................................................................................................ 59
ANTITOXINS-ANTIVENINS..................................................................................................................................................................59ANTIVIRAL MONOCLONAL ANTIBODIES............................................................................................................................................59
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IMMUNE SERUMS...............................................................................................................................................................................59
PCSK9 INHIBITORS................................................................................................................................................................. 60
PCSK9 INHIBITORS..........................................................................................................................................................................60
PENICILLINS............................................................................................................................................................................. 60
AMINOPENICILLINS............................................................................................................................................................................60NATURAL PENICILLINS......................................................................................................................................................................60PENICILLIN COMBINATIONS...............................................................................................................................................................60PENICILLINASE-RESISTANT PENICILLINS..........................................................................................................................................60
PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS.................................................................................................60
PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS..................................................................................................................60
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL...............................................................................................60
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL................................................................................................................60
POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS................................................................................................60
POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS...............................................................................................................60
POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS..............................................................................60
POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS.................................................................................................60
PROGESTINS........................................................................................................................................................................... 60
PROGESTINS......................................................................................................................................................................................60
PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS.....................................................................................60
PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS.......................................................................................................60
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC....................................................................................60
AGENTS FOR NARCOTIC WITHDRAWAL...........................................................................................................................................60ALCOHOL DETERRENTS....................................................................................................................................................................60ANTI-CATAPLECTIC AGENTS............................................................................................................................................................61ANTIDEMENTIA AGENT COMBINATIONS............................................................................................................................................61BENZODIAZEPINES & TRICYCLIC AGENTS.......................................................................................................................................61CHOLINOMIMETICS - ACHE INHIBITORS..........................................................................................................................................61FIBROMYALGIA AGENT - SNRIS......................................................................................................................................................61MOVEMENT DISORDER DRUG THERAPY..........................................................................................................................................61MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS.........................................................................................................................61MULTIPLE SCLEROSIS AGENTS........................................................................................................................................................61MULTIPLE SCLEROSIS AGENTS - INTERFERONS..............................................................................................................................61MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES........................................................................................................61MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS....................................................................................................61MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS.............................................................................................61N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS.....................................................................................................61PHENOTHIAZINES & TRICYCLIC AGENTS..........................................................................................................................................61PSEUDOBULBAR AFFECT AGENT COMBINATIONS...........................................................................................................................61SMOKING DETERRENTS....................................................................................................................................................................61SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS.....................................................................................................61THIENBENZODIAZEPINES & SSRIS...................................................................................................................................................61VASOMOTOR SYMPTOM AGENTS - SSRIS.......................................................................................................................................61
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST.....................................................................61
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST............................................................................................61
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RESPIRATORY AGENTS - MISC............................................................................................................................................ 62
ALPHA-PROTEINASE INHIBITOR (HUMAN)........................................................................................................................................62CFTR POTENTIATORS......................................................................................................................................................................62HYDROLYTIC ENZYMES.....................................................................................................................................................................62INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA).................................................................................................................................62PULMONARY FIBROSIS AGENTS.......................................................................................................................................................62
SCLEROSTIN INHIBITORS..................................................................................................................................................... 62
SCLEROSTIN INHIBITORS...................................................................................................................................................................62
SINUS NODE INHIBITORS...................................................................................................................................................... 62
SINUS NODE INHIBITORS...................................................................................................................................................................62
SPINAL MUSCULAR ATROPHY AGENTS (SMA)................................................................................................................ 62
SPINAL MUSCULAR ATROPHY AGENTS (SMA)...............................................................................................................................62
TETRACYCLINES.................................................................................................................................................................... 62
TETRACYCLINES................................................................................................................................................................................62
TETRAHYDROISOQUINOLINES............................................................................................................................................ 62
TETRAHYDROISOQUINOLINES............................................................................................................................................................62
THYROID AGENTS.................................................................................................................................................................. 62
ANTITHYROID AGENTS......................................................................................................................................................................62THYROID HORMONES........................................................................................................................................................................62
TOXOIDS................................................................................................................................................................................... 62
TOXOID COMBINATIONS....................................................................................................................................................................62
TRIPEPTIDYL PEPTIDASE 1 DEFICIENCY TREATMENT - AGENTS................................................................................62
TRIPEPTIDYL PEPTIDASE 1 DEFICIENCY TREATMENT - AGENTS.....................................................................................................62
TRYPTOPHAN HYDROXYLASE INHIBITORS...................................................................................................................... 63
TRYPTOPHAN HYDROXYLASE INHIBITORS........................................................................................................................................63
ULCER DRUGS........................................................................................................................................................................ 63
ANTISPASMODICS..............................................................................................................................................................................63BELLADONNA ALKALOIDS................................................................................................................................................................63H-2 ANTAGONISTS............................................................................................................................................................................63MISC. ANTI-ULCER............................................................................................................................................................................63PROTON PUMP INHIBITOR-ANTACID COMBINATIONS.......................................................................................................................63PROTON PUMP INHIBITORS...............................................................................................................................................................63QUATERNARY ANTICHOLINERGICS...................................................................................................................................................63ULCER ANTI-INFECTIVE W/ PROTON PUMP INHIBITORS..................................................................................................................63ULCER DRUGS - PROSTAGLANDINS.................................................................................................................................................63
URINARY ANTI-INFECTIVES.................................................................................................................................................. 63
URINARY ANTI-INFECTIVES...............................................................................................................................................................63URINARY ANTISEPTIC-ANTISPASMODIC &/OR ANALGESICS...........................................................................................................63
URINARY ANTISPASMODICS................................................................................................................................................ 63
BETA-3 ADRENERGIC AGONISTS.....................................................................................................................................................63URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)...............................................................................................63URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS (NEW).......................................................................................................64
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URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS..........................................................................................................64
VACCINES................................................................................................................................................................................ 64
BACTERIAL VACCINES......................................................................................................................................................................64VIRAL VACCINE COMBINATIONS.......................................................................................................................................................64VIRAL VACCINES...............................................................................................................................................................................64
VAGINAL PRODUCTS............................................................................................................................................................. 64
IMIDAZOLE-RELATED ANTIFUNGALS................................................................................................................................................64VAGINAL ANTI-INFECTIVES...............................................................................................................................................................64VAGINAL ESTROGENS.......................................................................................................................................................................64VAGINAL PROGESTINS......................................................................................................................................................................64
VASOPRESSORS.................................................................................................................................................................... 64
ANAPHYLAXIS THERAPY AGENTS....................................................................................................................................................64VASOPRESSORS................................................................................................................................................................................64
VITAMINS.................................................................................................................................................................................. 65
VITAMIN A......................................................................................................................................................................................... 65VITAMIN B-1......................................................................................................................................................................................65VITAMIN B-6......................................................................................................................................................................................65VITAMIN C......................................................................................................................................................................................... 65VITAMIN K......................................................................................................................................................................................... 65
VITAMINS, HEMATINICS & ELECTROLYTES...................................................................................................................... 65
VITAMINS & HEMATINICS...........................................................................................................................................................65
X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS...................................................................................65
X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS.....................................................................................................65
Updated July 1, 2020 Page
Adenosine Receptor Antagonist
Adenosine Receptor AntagonisNON PREFERRED NOURIANZ
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
ADHD Agent - Selective Alpha Adrenergic AgonistsGENERIC clonidine hcl er guanfacine er
ADHD Agent - Selective Norepinephrine Reuptake Inhibitor
GENERIC atomoxetine hcl
NON PREFERRED STRATTERA
Amphetamine MixturesGENERIC amphetamine salt combo er
PREFERRED MYDAYIS
NON PREFERRED ADDERALL ADDERALL XR
AmphetaminesGENERIC dextroamphetamine sulfate dextroamphetamine sulfate er methamphetamine hcl
PREFERRED VYVANSE
NON PREFERRED EVEKEO
AnalepticsGENERIC caffeine citrated caffeine/sodium benzoate
Anorexiants Non-AmphetamineGENERIC benzphetamine hcl diethylpropion hcl phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl
Stimulants - Misc.GENERIC armodafinil dexmethylphenidate er dexmethylphenidate hcl dexmethylphenidate hcl er methylphenidate cd methylphenidate er methylphenidate hcl methylphenidate hcl er (cd) methylphenidate la modafinil
NON PREFERRED ADHANSIA XR CONCERTA DAYTRANA FOCALIN FOCALIN XR JORNAY PM METADATE CD QUILLICHEW ER QUILLIVANT XR RITALIN RITALIN LA
ALS Agents - Miscellaneous
ALS Agents - MiscellaneousNON PREFERRED RADICAVA
AMINOGLYCOSIDES
AminoglycosidesGENERIC gentamicin sulfate gentamicin sulfate in ns neomycin sulfate paromomycin sulfate tobramycin sulfate tobramycin sulfate in ns
PREFERRED AMIKACIN BETHKIS KITABIS PAK
NON PREFERRED GENTAMICIN SULFATE 60MG/ML VIAL GENTAMICIN SULFATE IN NS 100MG/50ML GENTAMICIN SULFATE IN NS 120MG/0.1L STREPTOMYCIN SULFATE TOBI PODHALER
Updated July 1, 2020 Page
ANALGESICS - ANTI-INFLAMMATORY
Antirheumatic - Janus Kinase (JAK) InhibitorsPREFERRED XELJANZ XELJANZ XR
NON PREFERRED RINVOQ
Antirheumatic AntimetabolitesNON PREFERRED OTREXUP RASUVO
Anti-TNF-alpha - Monoclonal AntibodiesPREFERRED HUMIRA
NON PREFERRED SIMPONI ARIA
Anti-TNF-alpha - Monoclonoal AntibodiesNON PREFERRED SIMPONI
Cyclooxygenase 2 (COX-2) InhibitorsGENERIC celecoxib
NON PREFERRED CELEBREX
Gold CompoundsNON PREFERRED RIDAURA
Interleukin-1 BlockersNON PREFERRED ARCALYST
Interleukin-1 Receptor Antagonist (IL-1Ra)NON PREFERRED KINERET
Interleukin-1beta BlockersNON PREFERRED ILARIS
Interleukin-6 Receptor InhibitorsNON PREFERRED ACTEMRA ACTEMRA ACTPEN KEVZARA
Nonsteroidal Anti-inflammatory Agent CombinationsGENERIC diclofenac sodium/misoprostol del rel
Nonsteroidal Anti-inflammatory Agents (NSAIDs)GENERIC diclofenac potassium diclofenac sodium etodolac etodolac er fenoprofen calcium flurbiprofen ibuprofen ibuprofen lysine indomethacin indomethacin er ketoprofen er ketorolac tromethamine meclofenamate sodium mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium
NON PREFERRED CALDOLOR FENOPROFEN CALCIUM NEOPROFEN QMIIZ ODT TIVORBEX ZORVOLEX
Pyrimidine Synthesis InhibitorsGENERIC leflunomide
Selective Costimulation ModulatorsNON PREFERRED ORENCIA ORENCIA CLICKJECT
Soluble Tumor Necrosis Factor Receptor AgentsPREFERRED ENBREL
ANALGESICS - NonNarcotic
Analgesics OtherGENERIC acetaminophen-diphenhydramine clonidine
NON PREFERRED OFIRMEV
Analgesics-SedativesGENERIC butalbital compound butalbital/apap/caffeine butalbital/aspirin/caffeine
Updated July 1, 2020 Page
Salicylate CombinationsGENERIC choline mag trisalicylate
SalicylatesGENERIC diflunisal salicylamide salsalate
NON PREFERRED DISALCID
Selective N-Type Neuronal Calcium Channel BlockersNON PREFERRED PRIALT
ANALGESICS - OPIOID
Codeine CombinationsGENERIC acetaminophen/codeine butalbital compound/codeine butalbital/caff/apap/codeine
Dihydrocodeine CombinationsGENERIC dihydrocodeine/aspirin/caffeine
Hydrocodone CombinationsGENERIC hydrocodone/acetaminophen hydrocodone/ibuprofen
Opioid AgonistsGENERIC alfentanil hcl codeine sulfate fentanyl citrate hydrocodone bitartrate er hydromorphone hcl levorphanol tartrate meperidine hcl methadone hcl morphine sulfate morphine sulfate cr morphine sulfate er oxycodone hcl oxycodone hcl/ibuprofen oxymorphone hcl oxymorphone hcl er remifentanil hcl sufentil 50mcg/ml ampul tramadol hcl tramadol hcl er
PREFERRED OXYCONTIN ROXYBOND XTAMPZA ER
NON PREFERRED ABSTRAL CODEINE SULFATE SOLUTION DSUVIA FENTANYL CITRATE 100MCG/2ML FENTORA HYDROMORPHONE HCL 0.5MG/0.5ML SYRINGE HYSINGLA ER INFUMORPH MORPHINE SULFATE NUCYNTA NUCYNTA ER SUBSYS SUFENTIL 50MCG/ML VIAL TRAMADOL HCL ER ULTIVA ZOHYDRO ER
Opioid CombinationsGENERIC oxycodone w/aspirin oxycodone/acetaminophen
Opioid Partial AgonistsGENERIC buprenorphine buprenorphine/naloxone butorphanol nalbuphine hcl
PREFERRED BELBUCA SUBOXONE ZUBSOLV
NON PREFERRED BUTRANS SUBLOCADE SUBOXONE (FILM)
Tramadol CombinationsGENERIC tramadol/acetaminophen
ANDROGENS-ANABOLIC
AndrogensGENERIC danazol oxandrolone testosterone cypionate testosterone enanthate testosterone gel
NON PREFERRED ANDRODERM AXIRON METHITEST TESTOSTERONE GEL
Updated July 1, 2020 Page
ANORECTAL AGENTS
Intrarectal SteroidsPREFERRED CORTIFOAM
NON PREFERRED UCERIS FOAM
Nitrate Vasodilating AgentsNON PREFERRED RECTIV
Rectal Anesthetic/SteroidsGENERIC hydrocortisone hydrocortisone/pramoxine lidocaine-hc pramcort
NON PREFERRED LIDOCAINE-HC PROCTOFOAM-HC
ANTHELMINTICS
AnthelminticsGENERIC praziquantel
PREFERRED ALBENZA
NON PREFERRED BENZNIDAZOLE BILTRICIDE EMVERM STROMECTOL
ANTIANGINAL AGENTS
Antianginals-OtherGENERIC ranolazine er
NON PREFERRED RANEXA
NitratesGENERIC isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er minitran nitroglycerin nitroglycerin er nitroglycerin spray nitroglycerin tablets
PREFERRED DILATRATE-SR
NON PREFERRED NITRO-DUR NITROGLYCERIN IN D5W NITROSTAT
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.GENERIC buspirone hcl droperidol hydroxyzine hcl hydroxyzine pamoate
NON PREFERRED VISTARIL
BenzodiazepinesGENERIC alprazolam alprazolam er alprazolam odt chlordiazepoxide hcl clorazepate dipotassium diazepam lorazepam oxazepam
NON PREFERRED XANAX XANAX XR
ANTIARRHYTHMICS
Antiarrhythmics - Misc.GENERIC adenosine
Antiarrhythmics Type I-AGENERIC procainamide hcl quinidine gluconate quinidine gluconate er quinidine sulfate
PREFERRED QUINIDINE SULFATE
Antiarrhythmics Type I-BGENERIC lidocaine hcl in 7.5% dextrose mexiletine hcl
Updated July 1, 2020 Page
Antiarrhythmics Type I-CGENERIC flecainide acetate propafenone hcl propafenone hcl er
Antiarrhythmics Type IIIGENERIC amiodarone hcl dofetilide ibutilide fumarate
NON PREFERRED NEXTERONE
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Adrenergic CombinationsGENERIC fluticasone-salmeterol ipratropium-albuterol wixela inhub
PREFERRED ADVAIR HFA ANORO ELLIPTA BREO ELLIPTA COMBIVENT RESPIMAT STIOLTO RESPIMAT SYMBICORT TRELEGY ELLIPTA
NON PREFERRED ADVAIR DISKUS BEVESPI AEROSPHERE DULERA UTIBRON NEOHALER
Anti-IgE Monoclonal AntibodiesNON PREFERRED XOLAIR
Anti-Inflammatory AgentsGENERIC cromolyn sodium
Beta AdrenergicsGENERIC albuterol sulfate albuterol sulfate hfa levalbuterol hcl metaproterenol sulfate terbutaline sulfate
PREFERRED ALBUTEROL ARCAPTA NEOHALER PERFOROMIST PROAIR RESPICLICK SEREVENT DISKUS
NON PREFERRED PROAIR HFA STRIVERDI RESPIMAT VENTOLIN HFA VOSPIRE ER
Bronchodilators - AnticholinergicsGENERIC ipratropium bromide ipratropium/albuterol nebulization
PREFERRED INCRUSE ELLIPTA SPIRIVA RESPIMAT
NON PREFERRED SEEBRI NEOHALER TUDORZA PRESSAIR YUPELRI
Leukotriene Receptor AntagonistsGENERIC montelukast sodium zafirlukast
NON PREFERRED ACCOLATE
Selective Phosphodiesterase 4 (PDE4) InhibitorsPREFERRED DALIRESP
Steroid InhalantsGENERIC budesonide
PREFERRED ARNUITY ELLIPTA ASMANEX, HFA FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR QVAR REDIHALER
NON PREFERRED ALVESCO ARMONAIR RESPICLICK
XanthinesGENERIC aminophylline theophylline anhydrous drops er 12 hr theophylline anhydrous er
NON PREFERRED AMINOPHYLLINE 500MG/20ML AMPUL
Updated July 1, 2020 Page
ANTICOAGULANTS
Coumarin AnticoagulantsGENERIC warfarin sodium
NON PREFERRED COUMADIN
Direct Factor Xa InhibitorsPREFERRED ELIQUIS XARELTO
Heparins And Heparinoid-Like AgentsGENERIC heparin lock flush heparin sodium in 0.45% nacl heparin sodium in 5% dextrose heparin sodium syringe
NON PREFERRED HEPARIN SODIUM IN 0.45% NACL 12500/500
Low Molecular Weight HeparinsGENERIC enoxaparin sodium
NON PREFERRED FRAGMIN
Synthetic Heparinoid-Like AgentsGENERIC fondaparinux sodium
Thrombin Inhibitors - Hirudin TypeGENERIC bivalirudin
NON PREFERRED ANGIOMAX
Thrombin Inhibitors - Selective Direct & ReversibleNON PREFERRED ARGATROBAN
ANTICONVULSANTS
AMPA Glutamate Receptor AntagonistsNON PREFERRED FYCOMPA
Anticonvulsants - BenzodiazepinesGENERIC clobazam clonazepam clonazepam odt diazepam rectal gel
NON PREFERRED NAYZILAM ONFI SYMPAZAN VALTOCO
Anticonvulsants - Misc.GENERIC carbamazepine carbamazepine er gabapentin lamotrigine lamotrigine er levetiracetam levetiracetam er oxcarbazepine pregabalin primidone roweepra topiramate zonisamide
PREFERRED ROWEEPRA XR
NON PREFERRED BANZEL DIACOMIT LAMICTAL XR LYRICA OXTELLAR XR POTIGA QUDEXY XR VIMPAT ZONISAMIDE
CarbamatesGENERIC felbamate
NON PREFERRED XCOPRI
GABA ModulatorsGENERIC tiagabine hcl vigabatrin
NON PREFERRED GABITRIL SABRIL
HydantoinsGENERIC fosphenytoin sodium phenytoin phenytoin sodium
NON PREFERRED DILANTIN DILANTIN 30MG PEGANONE
Updated July 1, 2020 Page
SuccinimidesGENERIC ethosuximide
NON PREFERRED CELONTIN
Valproic AcidGENERIC divalproex sodium divalproex sodium er valproate sodium valproic acid
PREFERRED VALPROIC ACID
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)GENERIC mirtazapine mirtazapine disintegrating
NON PREFERRED REMERON REMERON ODT
Antidepressants - Misc.GENERIC bupropion hcl bupropion hcl er bupropion hcl xl er bupropion sr
Modified CyclicsGENERIC trazodone hcl
NON PREFERRED VIIBRYD
Monoamine Oxidase Inhibitors (MAOIs)GENERIC phenelzine sulfate tranylcypromine sulfate
Selective Serotonin Reuptake Inhibitors (SSRIs)GENERIC citalopram hbr escitalopram oxalate fluoxetine fluvoxamine maleate er paroxetine hcl paroxetine hcl er
NON PREFERRED CELEXA PROZAC
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)GENERIC desvenlafaxine succinate er duloxetine venlafaxine hcl venlafaxine hcl er
PREFERRED FETZIMA
NON PREFERRED EFFEXOR XR PRISTIQ
Tricyclic AgentsGENERIC amitriptyline hcl amoxapine 150mg amoxapine 25mg clomipramine hcl desipramine hcl doxepin hcl imipramine hcl imipramine pamoate nortriptyline hcl trimipramine maleate
ANTIDIABETICS
Alpha-Glucosidase InhibitorsGENERIC acarbose
Antidiabetic - Amylin AnalogsNON PREFERRED SYMLINPEN 120 SYMLINPEN 60
BiguanidesGENERIC metformin hcl metformin hcl er
NON PREFERRED RIOMET
Diabetic OtherPREFERRED BAQSIMI GLUCAGON
NON PREFERRED GLUCAGEN PROGLYCEM
Dipeptidyl Peptidase-4 (DPP-4) InhibitorsPREFERRED JANUVIA ONGLYZA TRADJENTA
Updated July 1, 2020 Page
Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations
PREFERRED JANUMET JANUMET XR JENTADUETO JENTADUETO XR
NON PREFERRED KOMBIGLYZE XR
Human InsulinGENERIC insulin lispro
PREFERRED HUMULIN R 500 UNITS HUMULIN R U-500 KWIKPEN LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR, FLEXTOUCH NOVOLIN 70-30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRESIBA TRESIBA FLEXTOUCH
NON PREFERRED BASAGLAR KWIKPEN U-100 HUMALOG HUMALOG JUNIOR KWIKPEN HUMALOG KWIKPEN HUMULIN 70/30 KWIKPEN HUMULIN 70-30 HUMULIN N HUMULIN N KWIKPEN
Incretin Mimetic Agents (GLP-1 Receptor Agonists)PREFERRED BYETTA OZEMPIC TRULICITY VICTOZA
NON PREFERRED BYDUREON BYDUREON BCISE BYDUREON PEN
Insulin-Incretin Mimetic CombinationsPREFERRED SOLIQUA 100-33 XULTOPHY 100-3.6
Meglitinide AnaloguesGENERIC nateglinide repaglinide
Meglitinide-Biguanide CombinationsGENERIC repaglinide/metformin
SGLT2 Inhibitor - DPP-4 Inhibitor - Biguanide CombNON PREFERRED TRIJARDY XR
SGLT2 Inhibitor - DPP-4 Inhibitor CombinationsNON PREFERRED GLYXAMBI STEGLUJAN
Sodium-Glucose Co-Transporter 2 (SGLT2) InhibitorsPREFERRED FARXIGA INVOKANA
NON PREFERRED JARDIANCE STEGLATRO
Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb
PREFERRED INVOKAMET INVOKAMET XR XIGDUO XR
NON PREFERRED SEGLUROMET SYNJARDY SYNJARDY XR
Sulfonylurea-Biguanide CombinationsGENERIC glyburide/metformin hcl
SulfonylureasGENERIC glimepiride glipizide glipizide er glyburide glyburide micronized tolazamide tolbutamide
Sulfonylurea-Thiazolidinedione CombinationsGENERIC pioglitazone/glimepiride
Thiazolidinedione-Biguanide CombinationsGENERIC pioglitazone/metformin
NON PREFERRED ACTOPLUS MET ACTOPLUS MET XR
Updated July 1, 2020 Page
ThiazolidinedionesGENERIC pioglitazone hcl
NON PREFERRED ACTOS
ANTIDIARRHEALS
Antiperistaltic AgentsGENERIC diphenoxylate/atropine opium paregoric
NON PREFERRED LOMOTIL TABLET
ANTIDOTES
AntidotesGENERIC deferoxamine fomepizole physostigmine salicylate
PREFERRED PHYSOSTIGMINE SALICYLATE VISTOGARD
NON PREFERRED SODIUM THIOSULFATE
Antidotes - Chelating AgentsGENERIC deferasirox
NON PREFERRED CHEMET EXJADE FERRIPROX JADENU JADENU SPRINKLE
Benzodiazepine AntagonistsGENERIC flumazenil
Opioid AntagonistsGENERIC naloxone hcl naltrexone hydrochloride
PREFERRED NARCAN
NON PREFERRED VIVITROL
ANTIDOTES AND SPECIFIC ANTAGONISTS
Antidotes and Specific AntagonistsGENERIC methylene blue
NON PREFERRED BAL IN OIL PROTOPAM CHLORIDE
ANTIEMETICS
5-HT3 Receptor AntagonistsGENERIC granisetron hcl ondansetron hcl ondansetron odt palonosetron hcl
PREFERRED SANCUSO
NON PREFERRED ALOXI
Antiemetic CombinationsNON PREFERRED AKYNZEO
Antiemetics - AnticholinergicGENERIC dimenhydrinate meclizine hcl scopolamine patch trimethobenzamide hcl
NON PREFERRED SCOPOLAMINE HYDROBROMIDE TRANSDERM SCOP
Antiemetics - MiscellaneousGENERIC dronabinol
Substance P/Neurokinin 1 (NK1) Receptor AntagonistsGENERIC aprepitant fosaprepitant
PREFERRED VARUBI
NON PREFERRED EMEND
Updated July 1, 2020 Page
ANTIFUNGALS
Antifungal - Glucan Synthesis Inhibitors (Echinocandins)
GENERIC caspofungin acetate micafungin sodium
NON PREFERRED CANCIDAS MYCAMINE
AntifungalsGENERIC amphotericin flucytosine griseofulvin griseofulvin ultramicrosize nystatin terbinafine
PREFERRED NYSTATIN TERBINAFINE
NON PREFERRED AMBISOME LAMISIL LAMISIL 250MG TABLET
ImidazolesGENERIC ketoconazole
NON PREFERRED KETOCONAZOLE CRYSTALS
TriazolesGENERIC fluconazole fluconazole in dextrose fluconazole in saline itraconazole posaconazole voriconazole
PREFERRED CRESEMBA
NON PREFERRED FLUCONAZOLE 100MG/50ML PIGGYBACK NOXAFIL SPORANOX CAPSULE SPORANOX SOLUTION
Antihemophilic Products - Monoclonal Antibodies
Antihemophilic Products - Monoclonal AntibodiesNON PREFERRED HEMLIBRA
ANTIHISTAMINES
Antihistamines - AlkylaminesGENERIC dexchlorpheniramine maleate er
Antihistamines - EthanolaminesGENERIC arbinoxa carbinoxamine clemastine fumarate diphenhydramine diphenhydramine hcl
Antihistamines - Non-SedatingGENERIC cetirizine syrup desloratadine desloratadine disintegrating tablets levocetirizine dihydrochloride
Antihistamines - PhenothiazinesGENERIC promethazine hcl promethegan
Antihistamines - PiperidinesGENERIC cyproheptadine hcl
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Misc.GENERIC omega-3-acid ethyl esters
PREFERRED VASCEPA
Bile Acid SequestrantsGENERIC cholestyramine cholestyramine light colesevelam hcl colestipol hcl
NON PREFERRED WELCHOL
Fibric Acid DerivativesGENERIC fenofibric acid fenofibric acid dr gemfibrozil
PREFERRED FENOFIBRATE LIPOFEN
Updated July 1, 2020 Page
HMG CoA Reductase InhibitorsGENERIC atorvastatin calcium fluvastatin sodium lovastatin pravastatin sodium rosuvastatin simvastatin
PREFERRED LIVALO
NON PREFERRED EZALLOR SPRINKLE
Intest Cholest Absorp Inhib-HMG CoA Reductase Inhib Comb
GENERIC ezetimibe/simvastatin
NON PREFERRED VYTORIN
Intestinal Cholesterol Absorption InhibitorsGENERIC ezetimibe
NON PREFERRED ZETIA
Microsomal Triglyceride Transfer Protein InhibitorsNON PREFERRED JUXTAPID
Nicotinic Acid DerivativesGENERIC niacin er
ANTIHYPERTENSIVES
ACE Inhibitor & Calcium Channel Blocker Combinations
GENERIC trandolapril/verapamil er
NON PREFERRED PRESTALIA TARKA
ACE InhibitorsGENERIC benazepril hcl captopril enalapril maleate enalaprilat fosinopril sodium lisinopril moexipril hcl perindopril erbumine quinapril ramipril
trandolapril
NON PREFERRED MAVIK VASOTEC
ACE Inhibitors & Thiazide/Thiazide-LikeGENERIC benazepril/hctz captopril/hydrochlorothiazide enalapril maleate/hctz fosinopril/hydrochlorothiazide lisinopril/hctz moexipril/hydrochlorothiazide quinapril/hydrochlorothiazide
Adrenolytics-Central & Thiazide/Thiazide-Like CombGENERIC methyldopa/hydrochlorothiazide
Agents for PheochromocytomaGENERIC phentolamine mesylate
NON PREFERRED DEMSER PHENTOLAMINE MESYLATE VIAL
Angiotensin II Receptor Antag & Ca Channel Blocker Comb
GENERIC amlodipine/olmesartan amlodipine/valsartan
NON PREFERRED AZOR
Angiotensin II Receptor Antag & Thiazide/Thiazide-LikeGENERIC candesartan/hydrochlorothiazide irbesartan/hydrochlorothiazide losartan/hydrochlorothiazide olmesartan medoxomil/hctz valsartan/hydrochlorothiazide
NON PREFERRED BENICAR HCT EDARBYCLOR
Angiotensin II Receptor AntagonistsGENERIC candesartan cilexetil irbesartan losartan potassium olmesartan medoxomil valsartan
NON PREFERRED BENICAR EDARBI
Updated July 1, 2020 Page
Angiotensin II Receptor Ant-Ca Channel Blocker-Thiazides
GENERIC amlodipine/valsartan/hctz olmesartan/amlodipine/hctz
NON PREFERRED TRIBENZOR
Antiadrenergics - Centrally ActingGENERIC clonidine hcl guanfacine hcl methyldopa methyldopate hcl
Antiadrenergics - Peripherally ActingGENERIC doxazosin mesylate prazosin hcl terazosin hcl
Beta Blocker & Angiotensin II Receptor Antagonist Comb
NON PREFERRED BYVALSON
Beta Blocker & Diuretic CombinationsGENERIC atenolol/chlorthalidone bisoprolol fumarate/hctz metoprolol/hydrochlorothiazide nadolol-bendroflumethiazide propranolol/hctz
Direct Renin InhibitorsGENERIC aliskiren fumarate
NON PREFERRED TEKTURNA
Direct Renin Inhibitors & Thiazide/Thiazide-Like CombNON PREFERRED TEKTURNA HCT
ReserpineGENERIC reserpine
Selective Aldosterone Receptor Antagonists (SARAs)GENERIC eplerenone
VasodilatorsGENERIC hydralazine hcl minoxidil
ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.GENERIC bacitracin colistimethate metronidazole pentamidine isethionate tinidazole trimethoprim
PREFERRED XIFAXAN
NON PREFERRED FLAGYL IMPAVIDO NEBUPENT TINDAMAX VANCOMYCIN-D5W VANCOMYCIN-NS
Anti-infective Misc. - CombinationsGENERIC sulfamethoxazole/trimethoprim
NON PREFERRED BACTRIM BACTRIM DS
Antiprotozoal AgentsGENERIC atovaquone
NON PREFERRED ALINIA MEPRON
Carbapenem CombinationsGENERIC imipenem-cilastatin
CarbapenemsNON PREFERRED DORIBAX INVANZ MEROPENEM - 0.9% NACL
Cyclic LipopeptidesGENERIC daptomycin
PREFERRED CUBICIN RF
NON PREFERRED CUBICIN
GlycylcyclinesGENERIC tigecycline
Updated July 1, 2020 Page
NON PREFERRED TYGACIL
LeprostaticsGENERIC dapsone
LincosamidesGENERIC clindamycin hcl clindamycin palmitate hcl clindamycin phosphate clindamycin phosphate/dextrose
PREFERRED CLINDAMYCIN PHOSPHATE
OxazolidinonesGENERIC linezolid
NON PREFERRED SIVEXTRO TABLET SIVEXTRO VIAL
PolymyxinsGENERIC polymyxin b sulfate
Streptogramin CombinationsNON PREFERRED SYNERCID
ANTIMALARIALS
Antimalarial CombinationsGENERIC atovaquone/proguanil hcl
NON PREFERRED COARTEM MALARONE
AntimalarialsGENERIC chloroquine phosphate hydroxychloroquine sulfate mefloquine hcl primaquine pyrimethamine quinine sulfate
NON PREFERRED DARAPRIM
ANTIMYASTHENIC AGENTS
Antimyasthenic AgentsGENERIC neostigmine methylsulfate pyridostigmine bromide
NON PREFERRED NEOSTIGMINE METHYLSULFATE
Antimyasthenic/Cholinergic AgentsGENERIC guanidine hcl
NON PREFERRED MESTINON MESTINON ER
ANTIMYCOBACTERIAL AGENTS
Antimycobacterial AgentsGENERIC ethambutol hcl isoniazid pyrazinamide rifabutin
NON PREFERRED CAPASTAT SULFATE PRETOMANID PRIFTIN RIFADIN SIRTURO
Antineoplastic - BCL-2 Inhibitors
Antineoplastic - BCL-2 InhibitorsNON PREFERRED VENCLEXTA VENCLEXTA STARTER PACK
Antineoplastic - FGFR Kinase Inhibitors
Antineoplastic - FGFR Kinase InhibitorsNON PREFERRED PEMAZYRE
Antineoplastic - Tropomyosin Receptor Kinase Inhibitors
Antineoplastic - Tropomyosin Receptor Kinase Inhibitors
NON PREFERRED ROZLYTREK
Updated July 1, 2020 Page
Antineoplastic - XPO1 Inhibitors
Antineoplastic - XPO1 InhibitorsNON PREFERRED XPOVIO
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating AgentsGENERIC carboplatin cisplatin
PREFERRED CISPLATIN POWDER HEXALEN MYLERAN
NON PREFERRED BENDAMUSTINE HCL BENDEKA BUSUFLEX OXALIPLATIN THIOTEPA TREANDA
Androgen Biosynthesis InhibitorsGENERIC abiraterone acetate
NON PREFERRED YONSA ZYTIGA
AntiadrenalsPREFERRED LYSODREN
AntiandrogensGENERIC bicalutamide flutamide nilutamide
PREFERRED XTANDI
NON PREFERRED ERLEADA NILANDRON NUBEQA
AntiestrogensGENERIC tamoxifen citrate toremifene citrate
NON PREFERRED FARESTON
AntimetabolitesGENERIC azacitidine capecitabine cladribine cytarabine decitabine floxuridine fludarabine phosphate mercaptopurine methotrexate
PREFERRED ARRANON TABLOID
NON PREFERRED ALIMTA CLOLAR DEPOCYT FOLOTYN GEMCITABINE HCL INFUGEM PURIXAN TREXALL
Antineoplastic - Autologous Cellular ImmunotherapyNON PREFERRED KYMRIAH PROVENGE YESCARTA
Antineoplastic - Bispecific T-cell EngagersNON PREFERRED BLINCYTO
Antineoplastic - BRAF Kinase InhibitorsNON PREFERRED BRAFTOVI TAFINLAR ZELBORAF
Antineoplastic - Hedgehog Pathway InhibitorsNON PREFERRED ERIVEDGE
Antineoplastic - Histone Deacetylase InhibitorsNON PREFERRED ISTODAX ZOLINZA
Antineoplastic - ImmunomodulatorsNON PREFERRED POMALYST
Antineoplastic - MEK InhibitorsNON PREFERRED COTELLIC KOSELUGO MEKINIST MEKTOVI
Updated July 1, 2020 Page
Antineoplastic - Monoclonal AntibodiesPREFERRED ONTAK
NON PREFERRED ARZERRA BAVENCIO DARZALEX ERBITUX GAZYVA HERCEPTIN HERZUMA IMFINZI KEYTRUDA LARTRUVO OGIVRI OPDIVO ONTRUZANT PERJETA RITUXAN TECENTRIQ TRAZIMERA TRUXIMA UNITUXIN VECTIBIX YERVOY
Antineoplastic - mTOR Kinase InhibitorsGENERIC everolimus
NON PREFERRED AFINITOR AFINITOR DISPERZ TORISEL
Antineoplastic - Multikinase InhibitorsPREFERRED NEXAVAR SUTENT
NON PREFERRED RYDAPT STIVARGA
Antineoplastic - Proteasome InhibitorsNON PREFERRED KYPROLIS NINLARO VELCADE
Antineoplastic - Tyrosine Kinase InhibitorsGENERIC erlotinib hcl imatinib mesylate
PREFERRED SPRYCEL TASIGNA XALKORI
NON PREFERRED ALECENSA BOSULIF BRUKINSA
CAPRELSA GILOTRIF ICLUSIG IMBRUVICA INLYTA IRESSA LENVIMA NERLYNX TAGRISSO TARCEVA TUKYSA TYKERB VOTRIENT ZYKADIA
Antineoplastic AntibioticsGENERIC bleomycin dactinomycin daunorubicin doxorubicin hcl doxorubicin hcl liposomal epirubicin hcl
NON PREFERRED DAUNOXOME IDARUBICIN HCL MITOMYCIN MITOXANTRONE VALSTAR
Antineoplastic -Antibody for Radiopharmaceutical Therapy
NON PREFERRED ZEVALIN
Antineoplastic Antibody-Drug ComplexesNON PREFERRED ADCETRIS BESPONSA KADCYLA MYLOTARG
Antineoplastic CombinationsNON PREFERRED LONSURF RITUXAN HYCELA VYXEOS LIPOSOME
Antineoplastic EnzymesNON PREFERRED ONCASPAR
Antineoplastic RadiopharmaceuticalsNON PREFERRED LUTATHERA QUADRAMET XOFIGO
Antineoplastics - InterleukinsNON PREFERRED PROLEUKIN
Updated July 1, 2020 Page
Antineoplastics - Photoactivated AgentsNON PREFERRED PHOTOFRIN
Antineoplastics Misc.GENERIC arsenic trioxide dacarbazine hydroxyurea
PREFERRED INTRON A MATULANE
NON PREFERRED ACTIMMUNE ALFERON N SYLATRON SYNRIBO THERACYS TICE BCG TRISENOX
Aromatase InhibitorsGENERIC anastrozole exemestane letrozole
NON PREFERRED ARIMIDEX AROMASIN FEMARA
Carboxypeptidase Enzyme AgentsPREFERRED VORAXAZE
Cardiac Protective AgentsGENERIC dexrazoxane
Chemotherapy Adjuncts - Hyperuricemia AgentsNON PREFERRED ELITEK
Chemotherapy Adjuncts - Keratinocyte Growth FactorsNON PREFERRED KEPIVANCE
Cyclin-Dependent Kinases (CDK) InhibitorsPREFERRED IBRANCE
Estrogen Receptor AntagonistGENERIC fulvestrant
NON PREFERRED FASLODEX
Estrogens-AntineoplasticPREFERRED EMCYT
Folic Acid Antagonists Rescue AgentsGENERIC leucovorin calcium levoleucovorin calcium
NON PREFERRED FUSILEV
Gonadotropin Releasing Hormone (GnRH) AntagonistsNON PREFERRED FIRMAGON
ImidazotetrazinesNON PREFERRED TEMODAR 100MG VIAL TEMODAR CAPSULES TEMOZOLOMIDE
Isocitrate Dehydrogenase-2 (IDH2) InhibitorsNON PREFERRED IDHIFA
Janus Associated Kinase (JAK) InhibitorsNON PREFERRED INREBIC JAKAFI
LHRH AnalogsPREFERRED ELIGARD LUPRON DEPOT 11.25MG LUPRON DEPOT 3.75MG
NON PREFERRED LEUPROLIDE ACETATE LUPRON DEPOT (FOR PROSTATE CANCER) TRELSTAR MIXJECT (LA) TRELSTAR VIAL VANTAS ZOLADEX
Mitotic InhibitorsGENERIC docetaxel etoposide
NON PREFERRED ABRAXANE DOCEFREZ ETOPOPHOS HALAVEN IXEMPRA JEVTANA MARQIBO PACLITAXEL TENIPOSIDE VINBLASTINE SULFATE
Updated July 1, 2020 Page
Nitrogen MustardsGENERIC cyclophosphamide ifosfamide-mesna melphalan hcl
PREFERRED LEUKERAN
NON PREFERRED ALKERAN 2MG ALKERAN 50MG IFOSFAMIDE MUSTARGEN
NitrosoureasNON PREFERRED BICNU GLEOSTINE LOMUSTINE ZANOSAR
Progestins-AntineoplasticGENERIC hydroxyprogesterone caproate megestrol acetate
PREFERRED DEPO-PROVERA 400 MG/ML
RetinoidsNON PREFERRED TRETINOIN CAP
Selective Retinoid X Receptor AgonistsNON PREFERRED TARGRETIN 75 CAPSULE
Topoisomerase I InhibitorsNON PREFERRED HYCAMTIN 4MG VIAL HYCAMTIN CAPSULES IRINOTECAN HCL ONIVYDE TOPOTECAN HCL
Urinary Tract Protective AgentsGENERIC amifostine
PREFERRED MESNEX 400MG TABLET
NON PREFERRED MESNA MESNEX 100MG/ML VIAL
Vascular Endothelial Growth Factor (VEGF) InhibitorsNON PREFERRED AVASTIN CYRAMZA
ZALTRAP ZIRABEV
ANTIPARKINSON AGENTS
Antiparkinson AnticholinergicsGENERIC benztropine benztropine mesylate trihexyphenidyl hcl
Antiparkinson DopaminergicsGENERIC amantadine hcl
Antiparkinson Monoamine Oxidase InhibitorsGENERIC rasagiline mesylate selegiline hcl
NON PREFERRED AZILECT
Levodopa CombinationsGENERIC carbidopa/levodopa carbidopa/levodopa er carbidopa/levodopa odt carbidopa/levodopa/entacapone
Nonergoline Dopamine Receptor AgonistsGENERIC pramipexole er ropinirole hcl ropinirole hcl er
NON PREFERRED APOKYN
Peripheral COMT InhibitorsGENERIC entacapone
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic AgentsGENERIC lithium carbonate lithium carbonate er
Antipsychotics - Misc.GENERIC ziprasidone hcl
NON PREFERRED CAPLYTA LATUDA
Updated July 1, 2020 Page
BenzisoxazolesGENERIC risperidone
PREFERRED PERSERIS
NON PREFERRED RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB DISINTEGRATING
ButyrophenonesGENERIC haloperidol haloperidol decanoate haloperidol lactate
NON PREFERRED HALDOL
DibenzodiazepinesGENERIC clozapine clozapine odt
NON PREFERRED CLOZAPINE ODT
DibenzothiazepinesGENERIC quetiapine fumarate quetiapine fumarate er
DibenzoxazepinesGENERIC loxapine succinate
PhenothiazinesGENERIC chlorpromazine fluphenazine decanoate fluphenazine hcl prochlorperazine edisylate prochlorperazine maleate thioridazine hcl trifluoperazine hcl
Quinolinone DerivativesGENERIC aripiprazole odt aripiprazole tablets
PREFERRED ABILIFY MAINTENA, ER
NON PREFERRED ARISTADA
ThienbenzodiazepinesGENERIC olanzapine olanzapine odt
ThioxanthenesGENERIC thiothixene
Antiretrovirals - CD4-Directed Post-Attachment Inhibitor
Antiretrovirals - CD4-Directed Post-Attachment Inhibitor
NON PREFERRED TROGARZO
ANTISEPTICS & DISINFECTANTS
Chlorine AntisepticsGENERIC chlorhexidine gluconate
NON PREFERRED CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE 0.2 SOLUTION
ANTIVIRALS
Antiretroviral CombinationsGENERIC abacavir sulfate/lamivudine abacavir/lamivudine/zidovudine lamivudine/zidovudine lopinavir-ritonavir oral soln
PREFERRED SYMFI SYMFI LO TRUVADA
NON PREFERRED ATRIPLA BIKTARVY COMPLERA DESCOVY DOVATO EPZICOM GENVOYA KALETRA ODEFSEY STRIBILD TRIUMEQ
Antiretrovirals - CCR5 Antagonists (Entry Inhibitor)NON PREFERRED SELZENTRY
Updated July 1, 2020 Page
Antiretrovirals - Fusion InhibitorsNON PREFERRED FUZEON
Antiretrovirals - Integrase InhibitorsNON PREFERRED ISENTRESS ISENTRESS HD TIVICAY
Antiretrovirals - Protease InhibitorsGENERIC atazanavir sulfate capsule fosamprenavir calcium ritonavir
NON PREFERRED APTIVUS CRIXIVAN INVIRASE LEXIVA NORVIR PREZISTA REYATAZ CAPSULE REYATAZ ORAL POWDER VIRACEPT
Antiretrovirals - RTI-Non-Nucleoside AnaloguesGENERIC efavirenz
PREFERRED SUSTIVA
NON PREFERRED EDURANT INTELENCE RESCRIPTOR RETROVIR VIAL VIRAMUNE
Antiretrovirals - RTI-Nucleoside Analogues-PurinesGENERIC abacavir didanosine
NON PREFERRED VIDEX VIDEX EC ZIAGEN
Antiretrovirals - RTI-Nucleoside Analogues-PyrimidinesNON PREFERRED EMTRIVA LAMIVUDINE
Antiretrovirals - RTI-Nucleoside Analogues-ThymidinesGENERIC stavudine zidovudine
NON PREFERRED RETROVIR
Antiretrovirals - RTI-Nucleotide AnaloguesGENERIC tenofovir disoproxil 300mg tablet
NON PREFERRED VIREAD
CMV AgentsGENERIC cidofovir valganciclovir hcl
NON PREFERRED GANCICLOVIR PREVYMIS VALCYTE
Hepatitis B AgentsGENERIC adefovir dipivoxil entecavir lamivudine hbv
NON PREFERRED TYZEKA VEMLIDY
Hepatitis C AgentsPREFERRED PEGASYS PEGASYS PROCLICK
NON PREFERRED DAKLINZA RIBAVIRIN SOVALDI
Herpes Agents - Purine AnaloguesGENERIC acyclovir valacyclovir
Herpes Agents - Thymidine AnaloguesGENERIC famciclovir
Influenza AgentsGENERIC rimantadine hcl
Neuraminidase InhibitorsGENERIC oseltamivir phosphate
NON PREFERRED RAPIVAB RELENZA TAMIFLU
Updated July 1, 2020 Page
RSV Agents - Nucleoside AnaloguesGENERIC ribavirin inh
ASSORTED CLASSES
AntileproticsPREFERRED THALOMID
ASSORTED CLASSESNON PREFERRED PROGRAF
B-Lymphocyte Stimulator (BLyS)-Specific InhibitorsNON PREFERRED BENLYSTA
Chelating AgentsGENERIC penicillamine
PREFERRED DEPEN
NON PREFERRED CUPRIMINE
Cyclosporine AnalogsGENERIC cyclosporine
NON PREFERRED SANDIMMUNE SOLUTION SANDIMMUNE SOLUTION 100MG/ML SOLUTION
EnzymesNON PREFERRED XIAFLEX
Immune Globulin ImmunosuppressantsNON PREFERRED ATGAM THYMOGLOBULIN
Immunomodulators for Myelodysplastic SyndromesPREFERRED REVLIMID
Inosine Monophosphate Dehydrogenase InhibitorsGENERIC mycophenolate acid del rel mycophenolic acid del rel
PREFERRED CELLCEPT 500MG VIAL
NON PREFERRED CELLCEPT ORAL SUSP MYCOPHENOLATE MOFETIL
Macrolide ImmunosuppressantsGENERIC everolimus sirolimus tacrolimus
NON PREFERRED RAPAMUNE ZORTRESS
Monoclonal AntibodiesNON PREFERRED SIMULECT
Potassium Removing ResinsGENERIC sodium polystyrene sulfonate
NON PREFERRED LOKELMA VELTASSA
ProstaglandinsGENERIC alprostadil
Purine AnalogsGENERIC azathioprine azathioprine sodium
NON PREFERRED AZASAN
Sclerosing AgentsPREFERRED ETHAMOLIN
NON PREFERRED SOTRADECOL
Selective T-Cell Costimulation BlockersNON PREFERRED NULOJIX
Atopic Dermatitis - Monoclonal Antibodies
Atopic Dermatitis - Monoclonal AntibodiesNON PREFERRED DUPIXENT
Updated July 1, 2020 Page
BETA BLOCKERS
Alpha-Beta BlockersGENERIC carvedilol er labetalol hcl
NON PREFERRED COREG CR
Beta Blockers Cardio-SelectiveGENERIC acebutolol hcl atenolol betaxolol hcl bisoprolol fumarate metoprolol succinate er metoprolol tartrate
PREFERRED BYSTOLIC
NON PREFERRED SECTRAL TENORMIN
Beta Blockers Non-SelectiveGENERIC nadolol pindolol propranolol hcl propranolol hcl er sotalol timolol maleate
NON PREFERRED BETAPACE BETAPACE AF SOTALOL HCL SOTYLIZE
Bile Acid Synthesis Disorder Agents
Bile Acid Synthesis Disorder AgentsNON PREFERRED CHOLBAM
BIOLOGICALS MISC
Allergenic ExtractsPREFERRED GRASTEK
NON PREFERRED RAGWITEK
Biologicals MiscNON PREFERRED ADAGEN
Calcitonin Gene-Related Peptide (CGRP) Receptor Antag
Calcitonin Gene-Related Peptide (CGRP) Receptor Antag
PREFERRED AIMOVIG EMGALITY UBRELVY
NON PREFERRED AJOVY NURTEC VYEPTI
CALCIUM CHANNEL BLOCKERS
Calcium Channel BlockersGENERIC amlodipine besylate diltiazem diltiazem 24hr cd diltiazem er diltiazem er 24 hour diltiazem hcl felodipine er isradipine nicardipine hcl nimodipine verapamil er verapamil er pm verapamil hcl
NON PREFERRED CLEVIPREX KATERZIA
CARDIOTONICS
Cardiac GlycosidesGENERIC digoxin
NON PREFERRED LANOXIN LANOXIN PEDIATRIC
Phosphodiesterase InhibitorsGENERIC milrinone in 5% dextrose milrinone lactate
CARDIOVASCULAR AGENTS - MISC
Pulmonary Hypertension - Endothelin Receptor Antagonists
NON PREFERRED LETAIRIS
Updated July 1, 2020 Page
CARDIOVASCULAR AGENTS - MISC.
Calcium Channel Blocker & HMG CoA Reductase Inhibit Comb
GENERIC amlodipine-atorvastatin
Peripheral VasodilatorsGENERIC isoxsuprine hcl papaverine hcl papaverine hcl er
Prostaglandin - Impotence AgentsNON PREFERRED CAVERJECT MUSE
Prostaglandin VasodilatorsGENERIC epoprostenol treprostinil sodium
NON PREFERRED FLOLAN REMODULIN TYVASO VENTAVIS
Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (sGC)
PREFERRED ADEMPAS
Pulmonary Hypertension - Endothelin Receptor Antagonists
GENERIC ambrisentan bosentan
PREFERRED OPSUMIT
NON PREFERRED TRACLEER
Pulmonary Hypertension - Phosphodiesterase Inhibitors
GENERIC sildenafil citrate (pah) tadalafil
NON PREFERRED ADCIRCA REVATIO
Selective cGMP Phosphodiesterase Type 5 InhibitorsGENERIC sildenafil citrate tablet
NON PREFERRED CIALIS VIAGRA
Vasoactive Natriuretic PeptidesNON PREFERRED NATRECOR
Cardiovascular, Hypertension & Lipids
MISC. CARDIOVASCULAR AGENTSNON PREFERRED RETAVASE
MISC. COAGULATION AGENTSNON PREFERRED ATRYN
Cephalosporin Combinations
Cephalosporin CombinationsPREFERRED AVYCAZ
NON PREFERRED ZERBAXA
CEPHALOSPORINS
Cephalosporins - 1st GenerationGENERIC cefazolin cephalexin
NON PREFERRED CEFAZOLIN/DEXTROSE KEFLEX
Cephalosporins - 2nd GenerationGENERIC cefaclor cefoxitin cefoxitin/dextrose cefprozil cefuroxime axetil cefuroxime sodium
Cephalosporins - 3rd GenerationGENERIC cefdinir cefotetan cefpodoxime proxetil ceftazidime ceftibuten ceftriaxone
Updated July 1, 2020 Page
NON PREFERRED CEFTAZIDIME IV PIGGYBACK CEFTRIAXONE 100G BULK BAG
Cephalosporins - 4th GenerationGENERIC cefepime cefotaxime
NON PREFERRED CEFEPIME/DEXTROSE
Cephalosporins - 5th GenerationNON PREFERRED TEFLARO
CONTRACEPTIVES
Biphasic Contraceptives - OralGENERIC azurette kariva viorele
Combination Contraceptives - OralGENERIC altavera alyacen apri aubra aviane balziva briellyn caziant chateal cryselle cyclafem dasetta drospirenone/eth estra/levomef elinest emoquette enskyce estarylla falmina gianvi gildagia gildess gildess fe junel junel fe kelnor 1-35 kurvelo lessina levora loryna low-ogestrel lutera marlissa microgestin microgestin fe mono-linyah mononessa necon norethindrone/eth estradiol/iron norethindrone/ethinyl estradiol norethin-eth estra ferrous fum
nortrel ocella ogestrel orsythia philith pirmella portia reclipsen sprintec sronyx syeda vestura wera wymzya fe zarah zenchent zenchent fe zeosa zovia
PREFERRED LO LOESTRIN FE MINASTRIN 24 FE
NON PREFERRED BEYAZ SAFYRAL TAYTULLA
Combination Contraceptives - VaginalGENERIC eluryng ring etonogestrel-ethinyl estradiol ring
NON PREFERRED NUVARING
Continuous Contraceptives - OralGENERIC amethyst
Emergency ContraceptivesGENERIC levonorgestrel
Extended-Cycle Contraceptives - OralGENERIC amethia amethia lo camrese camrese lo daysee introvale jolessa quasense
Four Phase Contraceptives - OralPREFERRED NATAZIA
Updated July 1, 2020 Page
Progestin Contraceptives - ImplantsNON PREFERRED IMPLANON NEXPLANON
Progestin Contraceptives - InjectableNON PREFERRED DEPO-PROVERA
Progestin Contraceptives - IUDNON PREFERRED KYLEENA MIRENA SKYLA
Progestin Contraceptives - OralGENERIC errin heather jencycla jolivette lyza nora-be
Triphasic Contraceptives - OralGENERIC aranelle enpresse leena myzilra tilia fe tri-estarylla tri-legest fe tri-linyah trinessa trivora velivet
CORTICOSTEROIDS
GlucocorticosteroidsGENERIC a-hydrocort budesonide budesonide ec budesonide er cortisone acetate dexamethasone dexamethasone sodium phosphate methylprednisolone methylprednisolone acetate methylprednisolone sod succ prednisolone prednisolone sodium phosphate prednisone triamcinolone veripred 20
PREFERRED BETAMETHASONE BETAMETHASONE ACETATE BETAMETHASONE SODIUM PHOSPHATE
NON PREFERRED ARISTOSPAN DEPO-MEDROL KENALOG MEDROL SOLU-CORTEF SOLU-MEDROL VIAL UCERIS ER
MineralocorticoidsGENERIC fludrocortisone acetate
COUGH/COLD/ALLERGY
Antitussive - NonnarcoticGENERIC benzonatate
Antitussive - OpioidGENERIC hydrocodone/homatropine
DecongestantGENERIC pseudoephedrine hcl er
NON PREFERRED PSEUDOEPHEDRINE SULFATE ER
Decongestant-AntihistamineGENERIC brompheniramine/pseudoephedrine phenylephrine/chlorpheniramine 10peh-4cpm
Decongestant-Antihistamine w/ ExpectorantNON PREFERRED PSEUDOEPH/CHLOPHEDIANOL/GG 12.5CPD-100GFN-30PSE
MucolyticsGENERIC acetylcysteine
Non-Narc Antitussive-AntihistamineGENERIC promethazine/dextromethorphan
Non-Narc Antitussive-Decongestant-AntihistamineGENERIC chlorphen/pse/dm tannate d-chlorphenira/pse/chlophedian 12.5cpd-1dcpm-30pse dm/phenyleph/chlorpheniramine 10peh-4cpm-20dm
Opioid Antitussive-AntihistamineGENERIC promethazine w/codeine
Updated July 1, 2020 Page
NON PREFERRED TUSSICAPS TUSSIONEX TUXARIN ER
Opioid Antitussive-Decongestant-AntihistamineGENERIC dihydrocodeine/bpm/pe promethazine vc/codeine
Cyclin-Dependent Kinases (CDK) Inhibitors
Cyclin-Dependent Kinases (CDK) InhibitorsNON PREFERRED VERZENIO
Cystic Fibrosis Agent - Combination
Cystic Fibrosis Agent - CombinationsNON PREFERRED ORKAMBI
Cystic Fibrosis Agent - Combinations
Cystic Fibrosis Agent - CombinationsNON PREFERRED TRIKAFTA
DERMATOLOGICALS
Acne AntibioticsGENERIC clindamycin phosphate topical dapsone gel erythromycin solution sulfacetamide sodium
NON PREFERRED ACZONE CLINDAMYCIN PHOSPHATE GEL (ONCE DAILY) SULFACETAMIDE SODIUM
Acne CombinationsGENERIC clindamycin phos-tretinoin erythromycin-benzoyl peroxide sodium sulfacetamide/sulfur
PREFERRED EPIDUO EPIDUO FORTE ONEXTON
NON PREFERRED SODIUM SULFACETAMIDE/SULFUR GEL ZIANA
Acne ProductsGENERIC adapalene cream, gel adapalene-benzoyl peroxide gel benzoyl peroxide clindamycin/benzoyl peroxide isotretinoin tretinoin tretinoin microsphere
NON PREFERRED ABSORICA ADAPALENE LOTION ARAZLO AZELEX DIFFERIN TRETIN-X
Antibiotics - TopicalGENERIC gentamicin sulfate mupirocin
Antifungals - TopicalGENERIC ciclopirox nystatin
PREFERRED NYSTATIN
NON PREFERRED LOPROX GEL & SHAMPOO PENLAC
Antifungals - Topical CombinationsGENERIC clotrimazole/betamethasone nystatin w/triamcinolone
Anti-inflammatory Agents - TopicalGENERIC diclofenac epolamine diclofenac sodium gel
NON PREFERRED FLECTOR VOLTAREN GEL
Antineoplastic Alkylating Agents - TopicalNON PREFERRED VALCHLOR
Antineoplastic Antimetabolites - TopicalGENERIC fluorouracil
NON PREFERRED CARAC FLUOROURACIL 0.5% CREAM
Updated July 1, 2020 Page
Antineoplastic or Premalignant Lesions - Topical Misc.NON PREFERRED PICATO
AntipsoriaticsGENERIC calcipotriene tazarotene cream
PREFERRED TAZORAC GEL
NON PREFERRED CALCITRIOL TAZORAC CREAM
Antipsoriatics - SystemicGENERIC acitretin
PREFERRED COSENTYX SKYRIZI STELARA
NON PREFERRED TREMFYA
Antiseborrheic ProductsGENERIC selenium sulfide
Antivirals - TopicalGENERIC acyclovir
NON PREFERRED DENAVIR ZOVIRAX
Burn ProductsGENERIC mafenide acetate silver sulfadiazine
NON PREFERRED SILVADENE SULFAMYLON CREAM SULFAMYLON PACKET
Corticosteroids - TopicalGENERIC alclometasone dipropionate amcinonide betamethasone dipropionate augment betamethasone valerate betamethasone valerate foam clobetasol e clobetasol propionate desonide
desoximetasone diflorasone diacetate cream diflorasone diacetate oint fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyrate/emoll hydrocortisone valerate mometasone furoate
NON PREFERRED DESONATE DESOWEN DIPROLENE AF CREAM DIPROLENE LOTION DIPROLENE OINT FLUTICASONE PROPIONATE 50MCG SPRAY LUXIQ PSORCON CREAM VERDESO
Depigmenting AgentsGENERIC alphaquin hp hydroquinone cream hydroquinone er cream
Emollient/Keratolytic AgentsGENERIC urea
EmollientsGENERIC ammonium lactate lactic acid
Enzymes - TopicalNON PREFERRED SANTYL
Imidazole-Related Antifungals - TopicalGENERIC clotrimazole econazole nitrate
Immunomodulators Imidazoquinolinamines - TopicalGENERIC imiquimod
Keratolytic/Antimitotic AgentsGENERIC podofilox salicylic acid
PREFERRED SALICYLIC ACID
Updated July 1, 2020 Page
NON PREFERRED CONDYLOX GEL
Local Anesthetics - TopicalGENERIC cocaine hcl
PREFERRED COCAINE HCL
Macrolide Immunosuppressants - TopicalGENERIC primecrolimus
NON PREFERRED ELIDEL
Misc. Dermatological ProductsGENERIC eletone emulsion sb hpr hpr plus mb hydrogel pruclair prumyx tl-cermide
PREFERRED ETHYL ALCOHOL LACTIC ACID 88 TO 92 % UREAM POWDER, BEADS
NON PREFERRED ETHYL ALCOHOL 1 LIQUID
Pigmenting AgentsPREFERRED OXSORALEN 1% LOTION
Rosacea AgentsGENERIC ivermectin
NON PREFERRED FINACEA MIRVASO ORACEA SOOLANTRA
Scabicides & PediculicidesGENERIC lindane malathion permethrin
NON PREFERRED ELIMITE SPINOSAD
Topical Anesthetic CombinationsGENERIC lidocaine/prilocaine
Topical Selective Retinoid X Receptor AgonistsPREFERRED TARGRETIN GEL
Topical Steroid CombinationsGENERIC calcipotriene-betameth diprop
NON PREFERRED ENSTILAR TACLONEX OINTMENT TACLONEX SUSPENSION
Wound DressingsGENERIC avo cream prutect sonafine
DIAGNOSTIC PRODUCTS
Diagnostic BiologicalsGENERIC candin
PREFERRED TUBERSOL
NON PREFERRED APLISOL
Diagnostic DrugsGENERIC cosyntropin
NON PREFERRED ACTHREL KINEVAC LEXISCAN THYROGEN
Diagnostic Radiopharmaceuticals - CardiacNON PREFERRED THALLOUS CHLORIDE TL-201
Miscellaneous Contrast MediaNON PREFERRED EOVIST MAGNEVIST PROHANCE
Radiographic Contrast Media - IodinatedGENERIC md-gastroview
Updated July 1, 2020 Page
NON PREFERRED ISOVUE ISOVUE-M OMNIPAQUE VISIPAQUE
DIAGNOSTICS & MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONSGENERIC neomycin-polymyxin b
MISCELLANEOUS AGENTSNON PREFERRED PROSTAMEN
NEUTRACEUTICALSPREFERRED UVA URSI LEAF FLUID EXTRACT
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
Dietary Management Product CombinationsGENERIC folbic foltanx metafolbic metafolbic plus
NON PREFERRED FOLBIC RF FOLIC ACID-VIT B12 METHYLFOLATE MECOBALAMIN-NAC 6-600-2MG
DIGESTIVE AIDS
Digestive EnzymesGENERIC pancrelipase
PREFERRED CREON SUCRAID VIOKACE ZENPEP DEL-REL
NON PREFERRED PANCREAZE
DIURETICS
Carbonic Anhydrase InhibitorsGENERIC acetazolamide acetazolamide er methazolamide
NON PREFERRED DIAMOX SEQUELS
Diuretic CombinationsGENERIC amiloride hcl w/hctz spironolactone/hctz
Loop DiureticsGENERIC bumetanide ethacrynate sodium furosemide torsemide
NON PREFERRED EDECRIN TABLET EDECRIN VIAL FUROSEMIDE 40MG/4ML SOLUTION TORSEMIDE
Osmotic DiureticsGENERIC mannitol
Potassium Sparing DiureticsGENERIC amiloride hcl spironolactone
Thiazides and Thiazide-Like DiureticsGENERIC chlorothiazide chlorothiazide sodium chlorthalidone hydrochlorothiazide indapamide methyclothiazide metolazone
Dopamine and Norepinephrine Reuptake Inhibitors (DNRIs)
Dopamine and Norepinephrine Reuptake Inhibitors (DNRIs)
NON PREFERRED SUNOSI
ENDOCRINE AND METABOLIC AGENTS - MISC.
BisphosphonatesGENERIC alendronate sodium etidronate disodium ibandronate risedronate dr risedronate sodium zoledronic acid
Updated July 1, 2020 Page
NON PREFERRED ACTONEL BONIVA FOSAMAX PAMIDRONATE DISODIUM ZOMETA
Calcimimetic AgentsGENERIC cinacalcet hcl
NON PREFERRED SENSIPAR
CalcitoninsGENERIC calcitonin salmon nasal
NON PREFERRED MIACALCIN VIAL
Carnitine Replenisher - AgentsGENERIC levocarnitine
Dopamine Receptor AgonistsGENERIC cabergoline
Fabry Disease - AgentsNON PREFERRED FABRAZYME
GAA Deficiency Treatment - AgentsNON PREFERRED LUMIZYME
Growth Hormone Receptor AntagonistsNON PREFERRED SOMAVERT
Growth Hormone Releasing Hormones (GHRH)NON PREFERRED EGRIFTA
Growth HormonesPREFERRED GENOTROPIN NORDITROPIN OMNITROPE
NON PREFERRED HUMATROPE SEROSTIM
Hereditary Orotic Aciduria Treatment - AgentsNON PREFERRED XURIDEN
Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents
GENERIC nitisinone
NON PREFERRED NITYR ORFADIN
Homocystinuria Treatment - AgentsNON PREFERRED CYSTADANE
Hyperammonemia Treatment - AgentsNON PREFERRED CARBAGLU
Hyperparathyroid Treatment - Vitamin D AnalogsGENERIC calcitriol doxercalciferol paricalcitol
NON PREFERRED HECTOROL ZEMPLAR
Hypophosphatasia (HPP) AgentsNON PREFERRED STRENSIQ
Insulin-Like Growth Factors (Somatomedins)NON PREFERRED INCRELEX
LHRH/GnRH Agonist Analog Pituitary SuppressantsPREFERRED LUPRON DEPOT-PED
NON PREFERRED SYNAREL
Lysosomal Acid Lipase (LAL) Deficiency - AgentsNON PREFERRED KANUMA
Mucopolysaccharidosis I (MPS I) - AgentsNON PREFERRED ALDURAZYME
Mucopolysaccharidosis II (MPS II) - AgentsNON PREFERRED ELAPRASE
Updated July 1, 2020 Page
Mucopolysaccharidosis VI (MPS VI) - AgentsNON PREFERRED NAGLAZYME
Ovulation Stimulants-GonadotropinsPREFERRED FOLLISTIM AQ
NON PREFERRED BRAVELLE CHORIONIC GONADOTROPIN GONAL-F GONAL-F RFF GONAL-F RFF REDI-JECT MENOPUR NOVAREL PREGNYL
Ovulation Stimulants-SyntheticGENERIC clomiphene citrate
Parathyroid Hormone And DerivativesPREFERRED FORTEO TYMLOS
NON PREFERRED NATPARA
Phenylketonuria Treatment - AgentsNON PREFERRED KUVAN
RANK Ligand (RANKL) InhibitorsPREFERRED PROLIA
NON PREFERRED XGEVA
Selective Estrogen Receptor Modulators (SERMs)NON PREFERRED OSPHENA
Selective Vasopressin V2-Receptor AntagonistsNON PREFERRED SAMSCA
Somatostatic AgentsGENERIC octreotide acetate
NON PREFERRED SANDOSTATIN SANDOSTATIN LAR DEPOT SIGNIFOR SOMATULINE DEPOT
Urea Cycle Disorder - AgentsGENERIC sodium phenylbutyrate
NON PREFERRED AMMONUL BUPHENYL RAVICTI
VasopressinGENERIC desmopressin acetate vasopressin vasopressin-ns
NON PREFERRED STIMATE SPRAY
ESTROGENS
Estrogen & AndrogenGENERIC estrogen/methyltestosterone
Estrogen & ProgestinGENERIC estradiol/norethindrone acetate
PREFERRED PREMPHASE PREMPRO
NON PREFERRED COMBIPATCH
EstrogensGENERIC estradiol patch estradiol tablet/cream estradiol valerate estropipate
PREFERRED PREMARIN
NON PREFERRED DEPO-ESTRADIOL DIVIGEL ENJUVIA ESTRACE TABLET MINIVELLE
Estrogen-Selective Estrogen Receptor Modulator Comb
Estrogen-Selective Estrogen Receptor Modulator CombPREFERRED DUAVEE
Updated July 1, 2020 Page
FLUOROQUINOLONES
FluoroquinolonesGENERIC ciprofloxacin ciprofloxacin er ciprofloxacin suspension ciprofloxacin/dextrose levofloxacin/d5w moxifloxacin hcl ofloxacin ofloxacin tablets
NON PREFERRED AVELOX IV LEVOFLOXACIN HEMIHYDRATE SOLUTION MOXIFLOXACIN HCL IV PIGGYBACK
GASTROINTESTINAL AGENTS - MISC.
Farnesoid X Receptor (FXR) AgonistsNON PREFERRED OCALIVA
Gallstone Solubilizing AgentsGENERIC ursodiol
NON PREFERRED ACTIGALL CHENODAL URSO URSO FORTE
Gastrointestinal Chloride Channel ActivatorsPREFERRED AMITIZA
Gastrointestinal StimulantsGENERIC metoclopramide hcl
IBS Agent - Guanylate Cyclase-C (GC-C) AgonistsPREFERRED LINZESS
IBS Agent - Mu-Opioid Receptor AgonistsNON PREFERRED VIBERZI
IBS Agent - Selective 5-HT3 Receptor AntagonistsNON PREFERRED LOTRONEX
Inflammatory Bowel AgentsGENERIC balsalazide disodium mesalamine sulfasalazine
sulfasalazine dr
NON PREFERRED ASACOL HD CANASA DELZICOL LIALDA PENTASA
Peripheral Opioid Receptor AntagonistsPREFERRED MOVANTIK
NON PREFERRED RELISTOR
Phosphate Binder AgentsGENERIC calcium acetate lanthanum carbonate sevelamer carbonate
PREFERRED VELPHORO
NON PREFERRED CALCIUM ACETATE FOSRENOL CHEW TABLET PHOSLYRA RENVELA
Tumor Necrosis Factor Alpha BlockersNON PREFERRED CIMZIA INFLECTRA REMICADE RENFLEXIS
GENERAL ANESTHETICS
Anesthetics - Misc.GENERIC etomidate ketamine hcl propofol
NON PREFERRED KETAMINE HCL 50MG/ML SYRINGE
Barbiturate AnestheticsNON PREFERRED BREVITAL
GENITOURINARY AGENTS - MISCELLANEOUS
5-Alpha Reductase InhibitorsGENERIC finasteride
Updated July 1, 2020 Page
NON PREFERRED PROSCAR
Alpha 1-Adrenoceptor AntagonistsGENERIC alfuzosin hcl er tamsulosin hcl er 24 hr
PREFERRED RAPAFLO
NON PREFERRED FLOMAX
CitratesGENERIC potassium citrate er
Cystinosis AgentsNON PREFERRED CYSTAGON
Genitourinary IrrigantsGENERIC acetic acid irrigation glycine
PREFERRED AMINOACETIC ACID
NON PREFERRED RENACIDIN RESECTISOL
Interstitial Cystitis AgentsNON PREFERRED ELMIRON
Urinary AnalgesicsGENERIC phenazopyridine hcl
Glycopeptides
GlycopeptidesGENERIC vancomycin hcl
PREFERRED VANCOMYCIN HCL
NON PREFERRED DALVANCE ORBACTIV VIBATIV
GOUT AGENTS
Gout AgentsGENERIC allopurinol allopurinol sodium febuxostat
NON PREFERRED COLCHICINE COLCRYS KRYSTEXXA MITIGARE ULORIC
UricosuricsGENERIC probenecid
HEMATOLOGICAL AGENTS - MISC.
Antihemophilic ProductsNON PREFERRED ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX BEBULIN BENEFIX COAGADEX CORIFACT ELOCTATE ESPEROCT FEIBA NF HELIXATE FS HEMOFIL HUMATE-P IXINITY KOATE-DVI KOGENATE FS KOVALTRY MONOCLATE-P MONONINE NOVOEIGHT NOVOSEVEN RT NUWIQ OBIZUR PROFILNINE PROFILNINE SD RECOMBINATE RIASTAP TRETTEN VONVENDI WILATE XYNTHA XYNTHA SOLOFUSE
Bradykinin B2 Receptor AntagonistsGENERIC icatibant acetate
NON PREFERRED FIRAZYR
Updated July 1, 2020 Page
C1 InhibitorsNON PREFERRED BERINERT CINRYZE
Complement InhibitorsNON PREFERRED SOLIRIS
Cyclopentyltriazolopyrimidine (CPTP) DerivativesPREFERRED BRILINTA
Glycoprotein IIb/IIIa Receptor InhibitorsGENERIC eptifibatide
NON PREFERRED AGGRASTAT INTEGRILIN REOPRO
Hematorheologic AgentsGENERIC pentoxifylline
HeminNON PREFERRED PANHEMATIN
Human Protein CNON PREFERRED CEPROTIN
Phosphodiesterase III InhibitorsGENERIC cilostazol
Plasma ExpandersGENERIC hetastarch w/sodium chloride
NON PREFERRED HEXTEND LACTATED ELECTROLYTE
Plasma Kallikrein InhibitorsNON PREFERRED KALBITOR
Plasma ProteinsGENERIC albumin
NON PREFERRED THROMBATE III
Platelet Aggregation Inhibitor CombinationsGENERIC aspirin / dipyridamole er
Platelet Aggregation InhibitorsGENERIC dipyridamole
ProtamineGENERIC protamine sulfate
Quinazoline AgentsGENERIC anagrelide hydrochloride
Thienopyridine DerivativesGENERIC clopidogrel prasugrel hcl
NON PREFERRED EFFIENT
Tissue Plasminogen ActivatorsNON PREFERRED ACTIVASE CATHFLO ACTIVASE
HEMATOPOIETIC AGENTS
Agents for Gaucher DiseaseNON PREFERRED CERDELGA CEREZYME ELELYSO VPRIV ZAVESCA
CobalaminsGENERIC hydroxocobalamin
NON PREFERRED NASCOBAL
CXCR4 Receptor AntagonistNON PREFERRED MOZOBIL
Cytotoxic AgentsPREFERRED DROXIA
Updated July 1, 2020 Page
Erythropoiesis-Stimulating Agents (ESAs)PREFERRED EPOGEN PROCRIT
NON PREFERRED ARANESP
ErythropoietinsPREFERRED EPOGEN MIRCERA
Folic Acid/Folate CombinationsGENERIC fabb folbee folplex 2.2 tl gard rx
Folic Acid/FolatesGENERIC folic acid
NON PREFERRED FOLIC ACID 20MG CAP
Granulocyte Colony-Stimulating Factors (G-CSF)PREFERRED NEULASTA NEUPOGEN ZARXIO
NON PREFERRED GRANIX UDENYCA
Granulocyte/Macrophage Colony-Stimulating Factor(GM-CSF)
NON PREFERRED LEUKINE
IronNON PREFERRED FERAHEME INFED VENOFER
Iron CombinationsGENERIC centratex ferocon ferrocite plus ferrogels forte hematinic plus hematogen hematogen fa hematogen forte iferex 150 forte multigen multigen folic multigen plus poly-iron 150 forte
polysaccharide iron forte se-tan plus taron forte tl icon tl-hem 150 er 24 hr tricon trigels-f forte
Iron w/ Folic AcidGENERIC hematinic with folic acid therapeutic hematinic
Iron-B12-FolateGENERIC ferraplus 90 hemetab
NON PREFERRED FE 90 PLUS
Thrombopoietin (TPO) Receptor AgonistsNON PREFERRED NPLATE PROMACTA
HEMOSTATICS
Hemostatics - SystemicGENERIC tranexamic acid
NON PREFERRED AMICAR CYKLOKAPRON LYSTEDA
Hepatitis C Agent - Combinations
Hepatitis C Agent - CombinationsPREFERRED EPCLUSA HARVONI MAVYRET VOSEVI
NON PREFERRED TECHNIVIE VIEKIRA PAK VIEKIRA XR ZEPATIER
Histamine H3-Receptor Antagonist/Inverse Agonists
Histamine H3-Receptor Antagonist/Inverse AgonistsNON PREFERRED WAKIX
Updated July 1, 2020 Page
HYPNOTICS
Barbiturate HypnoticsGENERIC phenobarbital
NON PREFERRED AMYTAL NEMBUTAL SODIUM PHENOBARBITAL SODIUM SECONAL SODIUM
Benzodiazepine HypnoticsGENERIC flurazepam hcl midazolam hcl temazepam triazolam
NON PREFERRED MIDAZOLAM HCL/SODIUM CHLORIDE
Non-Benzodiazepine - GABA-Receptor ModulatorsGENERIC zaleplon zolpidem tartrate zolpidem tartrate er
NON PREFERRED AMBIEN AMBIEN CR SONATA
Selective Melatonin Receptor AgonistsGENERIC ramelteon
NON PREFERRED ROZEREM
IBS Agent - 5-HT4 Receptor Partial Agonists
IBS Agent - 5-HT4 Receptor Partial AgonistsNON PREFERRED ZELNORM
Insulin-Like Growth Factor-1 Receptor Inhibitors(IGF-
1R)
Insulin-Like Growth Factor-1 Receptor Inhibitors(IGF-1R)
NON PREFERRED TEPEZZA
Integrin Receptor Antagonists
Integrin Receptor AntagonistsNON PREFERRED ENTYVIO
Interleukin-4 Alpha Antagonists
Interleukin-4 Alpha AntagonistsNON PREFERRED DUPIXENT
Interleukin-6 (IL-6) Antagonists
Interleukin-6 (IL-6) AntagonistsNON PREFERRED SYLVANT
LAXATIVES
Bowel Evacuant CombinationsGENERIC peg 3350-electrolyte polyethylene glycol
PREFERRED CLENPIQ POLYETHYLENE GLYCOL SUPREP
NON PREFERRED POLYETHYLENE GLYCOL PREPOPIK SUCLEAR
Laxatives - MiscellaneousGENERIC lactulose
Leptin Analogues
Leptin AnaloguesNON PREFERRED MYALEPT
LOCAL ANESTHETICS-Parenteral
Local Anesthetic & SympathomimeticGENERIC bupivacaine/epinephrine lidocaine hcl w/epinephrine
NON PREFERRED BUPIVACAINE/EPINEPHRINE CARTRIDGE LIDOCAINE HCL W/EPINEPHRINE
Updated July 1, 2020 Page
Local Anesthetics - AmidesGENERIC bupivacaine hcl bupivacaine/dextrose lidocaine lidocaine hcl ropivacaine sensorcaine 2.5mg/ml vial sensorcaine 5mg/ml vial
NON PREFERRED CARBOCAINE LIDOCAINE LIDOCAINE HCL
Local Anesthetics - EstersGENERIC chloroprocaine
NON PREFERRED NESACAINE
MACROLIDES
AzithromycinGENERIC azithromycin
NON PREFERRED ZITHROMAX
ClarithromycinGENERIC clarithromycin clarithromycin er
ErythromycinsGENERIC erythromycin erythromycin del rel erythromycin ethylsuccinate erythromycin stearate erythromycin/sulfisoxazole
NON PREFERRED E.E.S.200MG/5ML ORAL RECON SUSP ERYTHROCIN LACTOBIONATE
MEDICAL DEVICES
Cervical CapsNON PREFERRED FEMCAP
Glucose Monitoring Test SuppliesPREFERRED ACCU-CHEK SOFTCLIX LANCETS DEVICE FORA LANCING DEVICE FREESTYLE CONTROL SOLUTION
FREESTYLE FREEDOM KIT FREESTYLE FREEDOM LITE FREESTYLE FREEDOM LITE METER FREESTYLE INSULINX FREESTYLE INSULINX GLUCOSE SYSTEM FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE METER FREESTYLE LITE TEST STRIPS FREESTYLE TEST STRIPS ONE TOUCH ULTRA 2 ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO ONE TOUCH VERIO FLEX ONE TOUCH VERIO IQ ONE TOUCH VERIO SYNC PRECISION XTRA B-KETONE STRIPS PRECISION XTRA MONITOR PRECISION XTRA TEST STRIPS
NON PREFERRED ACCU-CHEK FASTCLIX, MULTICLIX, SOFTCLIX LANCETS DEXCOM G4 METER DEXCOM G4 SENSOR DEXCOM G4 TRANSMITTER DEXCOM G5 METER DEXCOM G5 TRANSMITTER OPTIUM EZ
Needles & SyringesPREFERRED MINIMED MINIMED RESERVOIR NOVOFINE NOVOFINE AUTOCOVER PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE SOFT TOUCH
MIGRAINE PRODUCTS
Ergot CombinationsGENERIC ergotamine-caffeine
Migraine ProductsGENERIC dihydroergotamine mesylate ergoloid mesylates
NON PREFERRED MIGRANAL
Selective Serotonin Agonist-NSAID CombinationsNON PREFERRED TREXIMET
Updated July 1, 2020 Page
Selective Serotonin Agonists 5-HT(1)GENERIC eletriptan hbr naratriptan hcl rizatriptan rizatriptan disintegrating tablets sumatriptan succinate zolmitriptan zolmitriptan odt
PREFERRED REYVOW TOSYMRA
NON PREFERRED ONZETRA XSAIL RELPAX SUMAVEL DOSEPRO ZOLMITRIPTAN ZOMIG SPRAY ZOMIG TABLET
MINERALS & ELECTROLYTES
BicarbonatesGENERIC sodium acetate sodium lactate
NON PREFERRED NEUT
CalciumGENERIC calcium chloride calcium gluconate
PREFERRED CALCIUM CHLORIDE CALCIUM GLUCONATE 61MG
NON PREFERRED CALCIUM GLUCONATE 50MG
Electrolytes & DextroseGENERIC dextrose in lactated ringers dextrose with sodium chloride potassium chloride/dextrose
Electrolytes ParenteralGENERIC nutrilyte nutrilyte ii potassium chloride ringers ringers irrigation
PREFERRED POTASSIUM CHLORIDE
NON PREFERRED ISOLYTE S NORMOSOL-M AND DEXTROSE NORMOSOL-R AND DEXTROSE NORMOSOL-R PH 7.4 PLASMA-LYTE 148
Iodine ProductsNON PREFERRED IODOPEN
MagnesiumGENERIC magnesium sulfate
PREFERRED MAGNESIUM SULFATE MAGNESIUM SULFATE IN DEXTROSE
NON PREFERRED MAGNESIUM SULFATE 100MG CAPSULE
ManganeseGENERIC manganese manganese sulfate
PhosphateGENERIC sodium phosphate 3mmol/ml vial
PREFERRED SODIUM PHOSPHATE
NON PREFERRED GLYCOPHOS K-PHOS
PhosphatesNON PREFERRED K-PHOS NEUTRAL
PotassiumGENERIC klor-con pot chloride/dextrose/ns potassium acetate potassium bicarbonate potassium chl-normal saline
PREFERRED POTASSIUM ACETATE POTASSIUM BICARBONATE
NON PREFERRED K-TAB potassium chloride er
Trace Mineral CombinationsPREFERRED MULTITRACE-5
Updated July 1, 2020 Page
NON PREFERRED ADDAMEL N MULTITRACE-4 PEDITRACE TRACE ELEMENTS
Trace MineralsGENERIC copper chloride selenium
NON PREFERRED SELENIUM
Mixed Allergenic Extracts
Mixed Allergenic ExtractsNON PREFERRED ODACTRA
Monobactams
MonobactamsGENERIC aztreonam
PREFERRED AZACTAM-ISO-OSMOTIC DEXTROSE
NON PREFERRED CAYSTON
MOUTH/THROAT/DENTAL AGENTS
Anti-infective Combinations - ThroatNON PREFERRED FIRST-MOUTHWASH BLM
Fluoride Dental ProductsGENERIC sodium fluoride
PREFERRED SODIUM FLUORIDE
Saliva StimulantsGENERIC cevimeline hcl pilocarpine hcl
Mucopolysaccharidosis IV (MPS IV) - Agents
Mucopolysaccharidosis IV (MPS IV) - AgentsNON PREFERRED VIMIZIM
Mucopolysaccharidosis VII (MPS VII) - Agents
Mucopolysaccharidosis VII (MPS VII) - AgentsNON PREFERRED MEPSEVII
Multiple Sclerosis Agents - Antimetabolites
Multiple Sclerosis Agents - AntimetabolitesNON PREFERRED MAVENCLAD
MULTIVITAMINS
B-Complex VitaminsGENERIC b-complex
NON PREFERRED B-COMPLEX
B-Complex w/ C & Folic AcidGENERIC dailyvite folbee plus mynephrocaps renal caps rena-vite rx reno caps triphrocaps
Multiple Vitamins w/ CalciumGENERIC advanced am/pm
Multiple Vitamins w/ MineralsGENERIC folivane-plus strovite v-c forte vp-zel
Multiple Vitamins w/ Minerals & Calcium-Folic AcidGENERIC tl g-fol os
Multiple Vitamins w/ Minerals & Folic AcidGENERIC corvita
MultivitaminsGENERIC m.v.i. adult
PREFERRED M.V.I.-12
NON PREFERRED INFUVITE
Updated July 1, 2020 Page
Ped Multi Vitamins w/Fl & FEGENERIC multivitamin w/fluoride & iron
Ped MV w/ FluorideGENERIC multivitamin with fluoride
Pediatric Multiple VitaminsNON PREFERRED M.V.I. PEDIATRIC
Prenatal MV & Min w/FE-FAGENERIC bal-care dha elite ob elite-ob folcaps folivane-ob hemenatal ob inatal advance inatal ultra mynatal mynatal advance mynatal caps mynatal plus mynatal-z mynate 90 plus er obstetrix dha pnv-omega pnv-select pnv-total prenaplus prenatabs fa prenatabs rx prenatal low iron prenatal plus prenatal-u relnate dha se-natal 19 taron-bc tl-care dha tl-fol 500 er triadvance trinatal gt trinatal rx 1 trinate ultimatecare one ultimatecare one nf vena-bal dha vinacal vinate ic vinate ii vinate one vinate-m virt-pn virt-pn plus vol-care rx vol-nate vol-plus vol-tab rx vp-ch plus zatean-pn plus
NON PREFERRED STUART ONE VITAFOL-OB
Prenatal MV & Min w/FE-FA-CA-Omega 3 Fish OilGENERIC complete natal dha pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec triveen-duo dha
Prenatal MV & Min w/FE-FA-DHAGENERIC folivane-prx dha nf hemenatal ob + dha macnatal cn dha pnv ob+dha pnv-dha prena1 prenaissance prenaissance 90 dha prenaissance dha prenaissance harmony dha prenaissance plus taron-c dha tl-select triveen-prx rnf vemavite-prx 2 venatal-fa vinate dha virt-pn dha virt-select vp-ch-pnv vp-heme one zatean-ch zatean-pn dha
PREFERRED LEVOMEFOLATE DHA
Prenatal VitaminsGENERIC prena1 chew prenaissance next
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle RelaxantsGENERIC baclofen chlorzoxazone cyclobenzaprine hcl cyclobenzaprine hcl er methocarbamol orphenadrine citrate orphenadrine compound tizanidine hcl
PREFERRED CYCLOBENZAPRINE HCL
NON PREFERRED GABLOFEN LIORESAL OZOBAX ROBAXIN
Updated July 1, 2020 Page
Direct Muscle RelaxantsGENERIC dantrolene sodium
ViscosupplementsPREFERRED HYALGAN SYNVISC-ONE
NON PREFERRED MONOVISC ORTHOVISC SYNVISC
NASAL AGENTS - SYSTEMIC AND TOPICAL
Antihistamine-SteroidGENERIC azelastine-fluticasone
NON PREFERRED DYMISTA
Nasal AnticholinergicsGENERIC ipratropium bromide spray
NON PREFERRED ATROVENT SPRAY
Nasal AntihistaminesGENERIC azelastine hcl
Nasal SteroidsGENERIC flunisolide nasal spray fluticasone nasal spray mometasone furoate nasal triamcinolone acetonide
PREFERRED QNASL
NON PREFERRED BECONASE AQ NASONEX
Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb
Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb
PREFERRED ENTRESTO
NEUROMUSCULAR AGENTS
BenzathiazolesGENERIC riluzole
Depolarizing Muscle RelaxantsGENERIC anectine
Neuromuscular Blocking Agent - NeurotoxinsNON PREFERRED BOTOX MYOBLOC
NUTRIENTS
Amino Acid MixturesNON PREFERRED AMINO ACID 700MG TABLETS AMINOSYN CLINIMIX CLINIMIX E FREAMINE HBC FREAMINE III HEPATAMINE NEPHRAMINE PREMASOL PROCALAMINE PROSOL TRAVASOL TROPHAMINE
CarbohydratesGENERIC dextrose in water
LipidsGENERIC intralipid
NON PREFERRED INTRALIPID
OPHTHALMIC AGENTS
Beta-blockers - OphthalmicGENERIC betaxolol ophth solution carteolol hcl levobunolol hcl drops metipranolol drops
PREFERRED BETOPTIC S
NON PREFERRED BETAGAN
Updated July 1, 2020 Page
Beta-blockers - Ophthalmic CombinationsGENERIC dorzolamide/timolol
PREFERRED COMBIGAN
Cycloplegic MydriaticsGENERIC atropine sulfate cyclopentolate ophth solution homatropine hydrobromide tropicamide
PREFERRED HOMATROPINE HYDROBROMIDE
NON PREFERRED CYCLOGYL MYDRIACYL
Lymphocyte Function-Associated Antigen-1 (LFA-1) Antag
PREFERRED XIIDRA
Miotics - Cholinesterase InhibitorsNON PREFERRED PHOSPHOLINE IODIDE DROPS
Miotics - Direct ActingGENERIC pilocarpine hcl
NON PREFERRED ISOPTO CARPINE
Ophthalmic AntiallergicGENERIC azelastine hcl ophth solution cromolyn sodium epinastine hcl olopatadine hcl (ophthalmic)
PREFERRED PAZEO
NON PREFERRED BEPREVE ELESTAT PATADAY PATANOL ZERVIATE
Ophthalmic AntibioticsGENERIC bacitracin ciprofloxacin ophth solution erythromycin ointment gatifloxacin levofloxacin hemihydrate moxifloxacin hcl
tobramycin sulfate drops
PREFERRED BESIVANCE
NON PREFERRED AZASITE MOXEZA OCUFLOX TOBREX VIGAMOX
Ophthalmic AntifungalNON PREFERRED NATACYN
Ophthalmic Anti-infective CombinationsGENERIC bacitracin/polymyxin ophth oint neomycin/polymyxin/gramicidin
Ophthalmic AntiviralsGENERIC trifluridine
NON PREFERRED VIROPTIC
Ophthalmic Carbonic Anhydrase InhibitorsGENERIC dorzolamide hcl
Ophthalmic EnzymesNON PREFERRED JETREA
Ophthalmic ImmunomodulatorsPREFERRED RESTASIS RESTASIS MULTIDOSE
Ophthalmic Irrigation SolutionsGENERIC balanced salt ophth irrigation
Ophthalmic Local AnestheticsGENERIC proparacaine hcl tetcaine drops
Ophthalmic Nonsteroidal Anti-inflammatory AgentsGENERIC bromfenac ophth flurbiprofen sodium ketorolac tromethamine drops
PREFERRED ILEVRO
Updated July 1, 2020 Page
NON PREFERRED NEVANAC PROLENSA
Ophthalmic Photodynamic Therapy AgentsNON PREFERRED VISUDYNE
Ophthalmic Rho Kinase InhibitorsPREFERRED RHOPRESSA
Ophthalmic Selective Alpha Adrenergic AgonistsGENERIC apraclonidine ophth solution brimonidine ophth solution
PREFERRED ALPHAGAN P 0.001%
NON PREFERRED ALPHAGAN P 0.0015%
Ophthalmic Steroid CombinationsGENERIC neomycin/bacitracin/poly/hc sulfacetamide w/prednisolone tobramycin/dexamethasone
PREFERRED TOBRADEX OINTMENT TOBRADEX ST
NON PREFERRED BLEPHAMIDE S.O.P. TOBRADEX SUSPENSION ZYLET
Ophthalmic SteroidsGENERIC dexamethasone sod phos ophth fluorometholone loteprednol etabonate susp prednisolone acetate prednisolone sodium phosphate drops
PREFERRED DUREZOL FML S.O.P.
NON PREFERRED ALREX LOTEMAX PRED MILD
Ophthalmic SulfonamidesGENERIC sulfacetamide sodium
NON PREFERRED BLEPH-10
Ophthalmics - Cystinosis AgentsNON PREFERRED CYSTARAN
Prostaglandins - OphthalmicGENERIC bimatoprost latanoprost drops travoprost
PREFERRED LUMIGAN
NON PREFERRED TRAVATAN Z XALATAN
Vascular Endothelial Growth Factor (VEGF) Antagonists
NON PREFERRED EYLEA LUCENTIS
Ophthalmic Gene Therapy
Ophthalmic Gene TherapyNON PREFERRED LUXTURNA
Ophthalmic Kinase Inhibitors - Combinations
Ophthalmic Kinase Inhibitors - CombinationsPREFERRED ROCKLATAN
Orexin Receptor Antagonists
Orexin Receptor AntagonistsPREFERRED BELSOMRA
OTIC AGENTS
Otic Agents - MiscellaneousGENERIC acetic acid otic solution acetic acid/aluminum otic sol
PREFERRED ACETIC ACID
Otic Analgesic CombinationsGENERIC antipyrine/benzocaine otic sol antipyrine/benzocaine/poly otic sol chloroxylenol/benzocaine/hc acetate otic susp
Updated July 1, 2020 Page
Otic Anti-infectivesGENERIC ciprofloxacin hcl ofloxacin otic drops
PREFERRED CIPROFLOXACIN HCL
Otic Steroid-Anti-infective CombinationsGENERIC neomycin/polymyxin/hc otic susp & soln
PREFERRED CIPRODEX
NON PREFERRED CIPRO HC COLY-MYCIN S OTOVEL
Otic SteroidsGENERIC acetic acid/hydrocortisone otic sol
NON PREFERRED DERMOTIC
OXYTOCICS
Abortifacients/Cervical Ripening - ProstaglandinsGENERIC carboprost
NON PREFERRED HEMABATE
OxytocicsGENERIC methylergonovine maleate oxytocin
PASSIVE IMMUNIZING AGENTS
Antitoxins-AntiveninsNON PREFERRED CROFAB
Antiviral Monoclonal AntibodiesNON PREFERRED SYNAGIS
Immune SerumsPREFERRED GAMUNEX
NON PREFERRED CYTOGAM GAMASTAN S-D GAMMAGARD LIQUID GAMMAGARD S-D
GAMUNEX-C HEPAGAM B HIZENTRA HYPERHEP B S-D HYPERRAB S-D HYPERRHO S-D HYPERTET S-D IMOGAM RABIES-HT PRIVIGEN VARIZIG
PCSK9 Inhibitors
PCSK9 InhibitorsPREFERRED PRALUENT PEN PRALUENT SYRINGE REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE
PENICILLINS
AminopenicillinsGENERIC amoxicillin ampicillin
Natural PenicillinsGENERIC penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium
NON PREFERRED BICILLIN L-A PENICILLIN GK-ISO-OSM DEXTROSE
Penicillin CombinationsGENERIC amoxicillin/clavulanate er ampicillin/sulbactam piperacillin-tazobactam
NON PREFERRED AUGMENTIN BICILLIN C-R ZOSYN IV SOLUTION ZOSYN VIAL
Penicillinase-Resistant PenicillinsGENERIC dicloxacillin sodium nafcillin dextrose nafcillin sodium oxacillin sodium
Updated July 1, 2020 Page
Phosphatidylinositol 3-Kinase (PI3K) Inhibitors
Phosphatidylinositol 3-Kinase (PI3K) InhibitorsNON PREFERRED ALIQOPA ZYDELIG
Phosphodiesterase 4 (PDE4) Inhibitors - Topical
Phosphodiesterase 4 (PDE4) Inhibitors - TopicalPREFERRED EUCRISA
Poly (ADP-ribose) Polymerase (PARP) Inhibitors
Poly (ADP-ribose) Polymerase (PARP) InhibitorsNON PREFERRED LYNPARZA RUBRACA TALZENNA ZEJULA
Postherpetic Neuralgia (PHN)/Neuropathic Pain Agents
Postherpetic Neuralgia (PHN)/Neuropathic Pain AgentsNON PREFERRED GRALISE LYRICA CR
PROGESTINS
ProgestinsGENERIC medroxyprogesterone acetate norethindrone acetate progesterone in oil progesterone micronized
NON PREFERRED MAKENA
Protease-Activated Receptor-1 (PAR-1) Antagonists
Protease-Activated Receptor-1 (PAR-1) AntagonistsNON PREFERRED ZONTIVITY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Narcotic WithdrawalNON PREFERRED LUCEMYRA
Alcohol DeterrentsGENERIC acamprosate calcium disulfiram
Anti-Cataplectic AgentsPREFERRED XYREM
Antidementia Agent CombinationsPREFERRED NAMZARIC THERAPY PACK
NON PREFERRED NAMZARIC
Benzodiazepines & Tricyclic AgentsGENERIC amitriptyline/chlordiazepoxide
Cholinomimetics - ACHE InhibitorsGENERIC donepezil hcl galantamine rivastigmine
Fibromyalgia Agent - SNRIsPREFERRED SAVELLA
Movement Disorder Drug TherapyGENERIC tetrabenazine
NON PREFERRED XENAZINE
MS Agents - Pyrimidine Synthesis InhibitorsPREFERRED AUBAGIO
Multiple Sclerosis AgentsNON PREFERRED COPAXONE GLATOPA
Multiple Sclerosis Agents - InterferonsPREFERRED AVONEX BETASERON PLEGRIDY
NON PREFERRED EXTAVIA REBIF REBIF REBIDOSE
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Multiple Sclerosis Agents - Monoclonal AntibodiesNON PREFERRED LEMTRADA OCREVUS TYSABRI
Multiple Sclerosis Agents - Nrf2 Pathway ActivatorsPREFERRED TECFIDERA
NON PREFERRED VUMERITY
Multiple Sclerosis Agents - Potassium Channel Blockers
NON PREFERRED AMPYRA
N-Methyl-D-Aspartate (NMDA) Receptor AntagonistsGENERIC memantine memantine dose pack
NON PREFERRED NAMENDA XR
Phenothiazines & Tricyclic AgentsGENERIC perphenazine/amitriptyline
Pseudobulbar Affect Agent CombinationsPREFERRED NUEDEXTA
Smoking DeterrentsGENERIC buproban bupropion er (12 hour)
NON PREFERRED CHANTIX ZYBAN
Sphingosine 1-Phosphate (S1P) Receptor ModulatorsPREFERRED GILENYA
Thienbenzodiazepines & SSRIsGENERIC olanzapine/fluoxetine hcl
Vasomotor Symptom Agents - SSRIsNON PREFERRED BRISDELLE
Pulmonary Hypertension - Prostacyclin Receptor Agonist
Pulmonary Hypertension - Prostacyclin Receptor Agonist
NON PREFERRED UPTRAVI
RESPIRATORY AGENTS - MISC.
Alpha-Proteinase Inhibitor (Human)NON PREFERRED ARALAST NP PROLASTIN C ZEMAIRA
CFTR PotentiatorsNON PREFERRED KALYDECO
Hydrolytic EnzymesNON PREFERRED PULMOZYME
Interleukin-5 Antagonists (IgG1 kappa)PREFERRED FASENRA
NON PREFERRED NUCALA
Pulmonary Fibrosis AgentsNON PREFERRED ESBRIET
Sclerostin Inhibitors
Sclerostin InhibitorsNON PREFERRED EVENITY
Sinus Node Inhibitors
Sinus Node InhibitorsPREFERRED CORLANOR
Spinal Muscular Atrophy Agents (SMA)
Spinal Muscular Atrophy Agents (SMA)NON PREFERRED SPINRAZA
Updated July 1, 2020 Page
TETRACYCLINES
TetracyclinesGENERIC coremino demeclocycline hcl doxycycline hyclate doxycycline monohydrate minocycline hcl minocycline hcl er
PREFERRED TETRACYCLINE XIMINO
NON PREFERRED MINOCIN MINOCIN 100MG VIAL SEYSARA SOLODYN ER
Tetrahydroisoquinolines
TetrahydroisoquinolinesNON PREFERRED YONDELIS
THYROID AGENTS
Antithyroid AgentsGENERIC methimazole propylthiouracil
NON PREFERRED TAPAZOLE
Thyroid HormonesGENERIC levothyroxine sodium liothyronine sodium
NON PREFERRED ARMOUR THYROID CYTOMEL SYNTHROID TIROSINT
TOXOIDS
Toxoid CombinationsPREFERRED INFANRIX PEDIARIX TETANUS DIPHTHERIA TOXOIDS - PED
NON PREFERRED ADACEL BOOSTRIX PENTACEL
QUADRACEL DTAP-IPV TETANUS DIPHTHERIA TOXOIDS
Tripeptidyl Peptidase 1 Deficiency Treatment - Agents
Tripeptidyl Peptidase 1 Deficiency Treatment - AgentsNON PREFERRED BRINEURA
Tryptophan Hydroxylase Inhibitors
Tryptophan Hydroxylase InhibitorsNON PREFERRED XERMELO
ULCER DRUGS
AntispasmodicsGENERIC dicyclomine hcl
Belladonna AlkaloidsGENERIC hyoscyamine sulfate hyoscyamine sulfate disinegrating tablets hyoscyamine sulfate er
NON PREFERRED ATROPEN LEVSIN 0.125MG TABLET LEVSIN 0.5MG/ML AMPUL
H-2 AntagonistsGENERIC cimetidine famotidine nizatidine ranitidine hcl
NON PREFERRED ZANTAC RX
Misc. Anti-UlcerGENERIC sucralfate
NON PREFERRED CARAFATE
Proton Pump Inhibitor-Antacid CombinationsGENERIC omeprazole sodium bicarbonate
NON PREFERRED OMEPRAZOLE SODIUM BICARBONATE
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Proton Pump InhibitorsGENERIC esomeprazole lansoprazole omeprazole pantoprazole sodium
NON PREFERRED NEXIUM NEXIUM (RX) VIAL
Quaternary AnticholinergicsGENERIC glycopyrrolate
Ulcer Anti-Infective w/ Proton Pump InhibitorsGENERIC lansoprazole/amoxicillin/clarithromycin
Ulcer Drugs - ProstaglandinsGENERIC misoprostol
NON PREFERRED CYTOTEC
URINARY ANTI-INFECTIVES
Urinary Anti-infectivesGENERIC methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal
NON PREFERRED MACROBID MACRODANTIN
Urinary Antiseptic-Antispasmodic &/or AnalgesicsGENERIC hyophen phosphasal uretron d-s urimar-t urin d.s. urogesic ustell
URINARY ANTISPASMODICS
Beta-3 Adrenergic AgonistsPREFERRED MYRBETRIQ ER 24 HR
Urinary Antispasmodic - Antimuscarinic (Anticholinergic)
GENERIC darifenacin er oxybutynin chloride oxybutynin chloride er solifenacin succinate tolterodine tartrate trospium chloride er
NON PREFERRED DITROPAN XL ENABLEX GELNIQUE TOVIAZ VESICARE
Urinary Antispasmodics - Cholinergic Agonists (new)GENERIC bethanechol chloride
Urinary Antispasmodics - Direct Muscle RelaxantsGENERIC flavoxate hcl
VACCINES
Bacterial VaccinesPREFERRED VIVOTIF BERNA DEL REL
NON PREFERRED ACTHIB BEXSERO BIOTHRAX MENACTRA MENOMUNE-A-C-Y-W-135 PEDVAXHIB PNEUMOVAX 23 PREVNAR 13 TRUMENBA TYPHIM VI VAXCHORA VACCINE
Viral Vaccine CombinationsPREFERRED TWINRIX
NON PREFERRED M-M-R II VACCINE W/DILUENT PROQUAD
Viral VaccinesPREFERRED AFLURIA AFLURIA QUAD FLUAD FLUBLOK FLUBLOK QUAD FLUCELVAX QUAD FLULAVAL QUAD FLUMIST FLUZONE HIGH-DOSE FLUZONE QUAD
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RABAVERT SHINGRIX VAQTA VIAL
NON PREFERRED ENGERIX-B GARDASIL 9 HAVRIX IMOVAX RABIES VACCINE IPOL IXIARO RECOMBIVAX HB ROTATEQ STAMARIL VAQTA SYRINGES VARIVAX VACCINE YF-VAX
VAGINAL PRODUCTS
Imidazole-Related AntifungalsGENERIC miconazole 1 terconazole
PREFERRED MICONAZOLE 1
Vaginal Anti-infectivesGENERIC clindamycin phosphate vaginal
Vaginal EstrogensGENERIC yuvafem
PREFERRED PREMARIN CREAM
NON PREFERRED ESTRACE CREAM ESTRING FEMRING
Vaginal ProgestinsPREFERRED CRINONE
NON PREFERRED ENDOMETRIN
VASOPRESSORS
Anaphylaxis Therapy AgentsGENERIC epinephrine auto-injector
PREFERRED SYMJEPI
NON PREFERRED EPIPEN EPIPEN JR.
VasopressorsGENERIC dobutamine dobutamine/dextrose dopamine hcl dopamine hcl in 5% dextrose ephedrine sulfate epinephrine ampule/vial midodrine hcl norepinephrine bitartrate phenylephrine hcl phenylephrine hcl-ns
PREFERRED PHENYLEPHRINE HCL-NS
NON PREFERRED EPINEPHRINE 1MG/ML AMPUL LEVOPHED AMPULE/VIAL PHENYLEPHRINE HCL-NS 200MCG/5ML SYRINGE PHENYLEPHRINE HCL-NS 40MG/5ML SYRINGE
VITAMINS
Vitamin AGENERIC vitamin a
PREFERRED VITAMIN A
NON PREFERRED AQUASOL A VITAMIN A
Vitamin B-1GENERIC thiamine hcl
NON PREFERRED THIAMINE HCL
Vitamin B-6GENERIC pyridoxine hcl
PREFERRED PYRIDOXINE HCL
NON PREFERRED PYRIDOXINE HCL 500MG TABLETS
Vitamin CGENERIC ascorbic acid
Updated July 1, 2020 Page
PREFERRED ASCORBIC ACID
Vitamin KGENERIC phytonadione
PREFERRED PHYTONADIONE
NON PREFERRED MEPHYTON
VITAMINS, HEMATINICS & ELECTROLYTES
VITAMINS & HEMATINICSGENERIC elite-ob 400 folivane-f
NON PREFERRED VYNATAL-FA
X-Linked Hypophosphatemia (XLH) Treatment - Agents
X-Linked Hypophosphatemia (XLH) Treatment - AgentsPREFERRED CRYSVITA
Updated July 1, 2020 Page