CMDP Preferred Drug List - AZ Preferred Drug List October 2019.pdfPreferred Drug Status PA Type Step Therapy Requirements Quantity Limit QL Days ADHD/ANTI-NARCOLEPSY AMPHETAMINES AMPHETAMINE

Drug Class/Drug Name Reference Brand NameBrand Only /

Generic NotesPreferred Drug

Status PA Type Step Therapy RequirementsQuantity

Limit QL Days ADHD/ANTI-NARCOLEPSYAMPHETAMINESAMPHETAMINE SUSPENSION EXTENDED RELEASE DYANAVEL XR Preferred Drug PA Required for Ages < 6 years 240.00 30.00AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand and Generic Preferred Drug PA Required for Ages < 6 years 60.00 30.00DEXTROAMPHETAMINE SULFATE TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 60.00 30.00LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00LISDEXAMFETAMINE DIMESYLATE CHEWABLE TABLETS VYVANSE CHEWABLES Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00STIMULANTSDEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR FOCALIN XR Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Preferred Drug PA Required for Ages < 6 years 60.00 30.00METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Brand Only Preferred Drug PA Required for Ages < 6 years 90.00 30.00METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA /APTENSIO XR Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE PATCH DAYTRANA Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for Ages < 6 years 300.00 30.00METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for Ages < 6 years 150.00 30.00METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 90.00 30.00METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE CONCERTA ONLY Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00MISCELLANEOUS AGENTSATOMOXETINE HCL CAPSULES VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00CENTRAL ALPHA-AGONISTSCLONIDINE HCL TABLETS CATAPRES PA Required for Ages < 6 yearsCLONIDINE HCL TD PATCH WEEKLY CATAPRES PATCHES PA Required for Ages < 6 years 4 28CLONIDINE HCL (ADHD) TABLET 12-HOUR CLONIDINE ER PA Required for Ages < 6 years 120.00 30.00GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30.00 30.00GUANFACINE HCL TABLETS TENEX PA Required for Ages < 6 yearsAMINOGLYCOSIDESAMINOGLYCOSIDESNEOMYCIN SULFATE TABLETS NEOMYCIN SULFATEPAROMOMYCIN SULFATE CAPSULES PAROMOMYCIN SULFATETOBRAMYCIN NEBULIZED KITABIS AND BETHKIS Preferred Drug PA Required ANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC ANTIMETABOLITESMETHOTREXATE SODIUM (ANTIRHEUMATIC) TABLETS RHEUMATREXANTIRHEUMATIC - ENZYME INHIBITORS

TOFACITINIB CITRATEXELJANZ IMMEDIATE

RELEASE ONLY Brand Only Preferred Drug PA Required ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIESADALIMUMAB HUMIRA Preferred Drug PA Required NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)CELECOXIB CAPSULES CELEBREXDICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XR 30.00 30.00DICLOFENAC SODIUM TABLET ENTERIC COATED DICLOFENAC SODIUM DRDICLOFENAC TABLET ENTERIC COATED DICLOFENAC SODIUM ECETODOLAC CAPSULES ETODOLACETODOLAC TABLETS ETODOLACETODOLAC TABLET 24-HOUR ETODOLAC ERFENOPROFEN CALCIUM CAPSULES NALFONFENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUMFLURBIPROFEN TABLETS FLURBIPROFEN

CMDP Preferred Drug List

• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019




Limit QL Days



IBUPROFEN CAPSULES ADVILIBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRINIBUPROFEN SUSPENSION CHILDRENS MOTRINIBUPROFEN TABLETS ADVIL JUNIOR STRENGTHINDOMETHACIN CAPSULES TIVORBEXINDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CRINDOMETHACIN SUPPOSITORY INDOCININDOMETHACIN SUSPENSION INDOCINKETOROLAC TROMETHAMINE TABLETS KETOROLAC TROMETHAMINE 20.00 30.00MEFENAMIC ACID CAPSULES PONSTELMELOXICAM SUSPENSION MOBICMELOXICAM TABLETS MOBICNABUMETONE TABLETS NABUMETONENAPROXEN SODIUM ALEVENAPROXEN SODIUM TABLETS ANAPROXNAPROXEN SUSPENSION NAPROSYNNAPROXEN TABLETS NAPROSYNNAPROXEN TABLET ENTERIC COATED EC-NAPROSYNOXAPROZIN TABLETS DAYPROPIROXICAM CAPSULES FELDENESULINDAC TABLETS SULINDACPHOSPHODIESTERASE 4 (PDE4) INHIBITORSAPREMILAST OTEZLA Brand Only Preferred Drug PA Required PYRIMIDINE SYNTHESIS INHIBITORSLEFLUNOMIDE TABLETS ARAVASOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTSETANERCEPT ENBREL Preferred Drug PA Required ANALGESICS - NONNARCOTICANALGESIC COMBINATIONSBUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS VARIOIUS 120.00 30.00BUTALBITAL-ASPIRIN-CAFFEINE TABLETS VARIOUS 120.00 30.00ANALGESICS OTHERACETAMINOPHEN CAPSULES ACETAMINOPHENACETAMINOPHEN CHEWABLE TABLETS CHILDRENS MEDI-TABLETSACETAMINOPHEN ELIXIR MEDI-TABLETS CHILDRENS

ACETAMINOPHEN LIQUIDLITTLE REMEDIES FOR FEVERS FEVER/PAIN RELIEVER

CHILDRENSACETAMINOPHEN SOLUTION ACETAMINOPHENACETAMINOPHEN SUPPOSITORY FEVERALL INFANTSACETAMINOPHEN SUSPENSION TYLENOL INFANTS

ACETAMINOPHEN SYRUPTRIAMINIC FEVER REDUCER PAIN RELIEVER

CHILDRENSACETAMINOPHEN TABLETS MEDI-TABLETSACETAMINOPHEN TABLET CONTROLLED RELEASE TYLENOL 8 HOURACETAMINOPHEN ORALLY DISPERSABLE TABLET MAPAP CHILDRENSSALICYLATESASPIRIN CHEWABLE TABLETS ST JOSEPH ADULTASPIRIN SUPPOSITORY ASPIRINASPIRIN TABLETS ASPIRINASPIRIN ORALLY DISPERSABLE TABLET ADULT ASPIRIN LOW STRENGTHASPIRIN TABLET ENTERIC COATED 1/2HALFPRINASPIRIN TABLET EFFERVESCENT MEDI-SELTZERDIFLUNISAL TABLETS DIFLUNISAL




Limit QL Days



SALSALATE TABLETS DISALCIDANALGESICS - OPIOIDLONG-ACTING OPIOID AGONISTS

FENTANYL PATCH 72-HOUR 12mcg, 25mcg, 50mcg, 75mcg & 100mcgDURAGESIC 12mcg, 25mcg, 50mcg, 75mcg &

100mcg Preferred Drug PA RequiredMORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE EMBEDA Preferred Drug PA RequiredMORPHINE SULFATE TABLET CONTROLLED RELEASE MS CONTIN Preferred Drug PA RequiredOXYCODONE CAPSULE ER 12-HOUR ABUSE-DETERRENT XTAMPZA ER Preferred Drug PA RequiredTRAMADOL HCL ER TABLET 24-HOUR TRAMADOL HCL ER Preferred Drug PA RequiredSHORT-ACTING OPIOID AGONISTS

HYDROMORPHONE HCL LIQUID DILAUDID

PA Required for > 2 Different Short Acting Opioid Medications in a 30-day

time period.

HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCL


time period.

HYDROMORPHONE HCL TABLETS DILAUDID


time period.

MEPERIDINE HCL TABLETS DEMEROL


time period.

MORPHINE SULFATE SOLUTION MORPHINE SULFATE


time period.

MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATE


time period.

MORPHINE SULFATE TABLETS MORPHINE SULFATE


time period.

OXYCODONE HCL CAPSULES OXYCODONE HCL


time period.

OXYCODONE HCL CONCENTRATE OXYCODONE HCL


time period.

OXYCODONE HCL SOLUTION OXYCODONE HCL


time period.

OXYCODONE HCL TABLETS ROXICODONE


time period.

TRAMADOL HCL TABLETS ULTRAM


time period. OPIOID COMBINATIONS

ACETAMINOPHEN W/ CODEINE SOLUTION ACETAMINOPHEN/CODEINE


time period.

ACETAMINOPHEN W/ CODEINE TABLETS ACETAMINOPHEN/CODEINE


time period.




Limit QL Days



BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES FIORICET/CODEINE


time period.

BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES ASCOMP/CODEINE


time period.

HYDROCODONE-ACETAMINOPHEN CAPSULES HYDROGESIC


time period.

HYDROCODONE-ACETAMINOPHEN SOLUTION HYCET


time period.

HYDROCODONE-ACETAMINOPHEN TABLETS VERDROCET


time period.

HYDROCODONE-IBUPROFEN TABLETS REPREXAIN


time period.

OXYCODONE W/ ACETAMINOPHEN CAPSULES OXYCODONE/ACETAMINOPHEN


time period.

OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICET


time period.

OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCET


time period.

OXYCODONE-IBUPROFEN TABLETS OXYCODONE/IBUPROFEN


time period. OPIOID PARTIAL AGONISTS

BUPRENORPHINE VARIOUS VARIOUS

PA Required unless the member is pregnant- the prescriber must note the following ICD-10 codes on the prescription:1. O09.91- Supervision of high risk pregnancy, 1st Trimester.2. O09.92- Supervision of high risk pregnancy, 2nd Trimester.3. O09.93- Supervision of high risk pregnancy, 3rd Trimester.4. O09.91- Supervision of high risk pregnancy- use for Postpartum Nursing Mothers. The first digit of the diagnosis code is the Letter - O and the second is a Zero - 0

BUPRENORPHINE PATCH WEEKLY BUTRANS Brand Only Preferred Drug PA RequiredBUPRENORPHINE SOLUTION PREFILLED SYRINGE SUBLOCADE Preferred Drug PA RequiredBUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM SUBOXONE FILM Brand Only Preferred Drug

BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE SUBLINGUAL BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE

GENERIC FORMULATIONS

ONLY Preferred Drug




Limit QL Days



METHADONE VARIOUSOnly avaliable at an Opioid Treatment

Program (OTP) provider.ANDROGENS-ANABOLICANDROGENS**DANAZOL CAPSULES DANAZOLFLUOXYMESTERONE TABLETS ANDROXYTESTOSTERONE CYPIONATE KIT TESTONE CIK PA RequiredTESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA RequiredTESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA RequiredTESTOSTERONE GEL ANDROGEL PA RequiredTESTOSTERONE PATCH 24-HOUR ANDRODERM PA RequiredTESTOSTERONE SOLUTION AXIRON PA RequiredANORECTAL AGENTSINTRARECTAL STEROIDSHYDROCORTISONE (INTRARECTAL) ENEMA COLOCORTHYDROCORTISONE ACETATE (INTRARECTAL) FOAM CORTIFOAMRECTAL STEROIDSHYDROCORTISONE (RECTAL) CREAM PROCTOCORTANTACIDSANTACIDS - CALCIUM SALTSCALCIUM CARBONATE (ANTACID) CHEWABLE TABLETS CHILDRENS MYLANTA UPSET STOMACH RELIEFCALCIUM CARBONATE (ANTACID) TABLETS CALCIUM CARBONATEANTACID COMBINATIONSALUM & MAG HYDROX-SIMETHICONE SUSPENSION ANTACID FAST ACTINGANTACIDS - MAGNESIUM SALTSMAGNESIUM OXIDE TABLETS MAGNESIUM OXIDE ANTHELMINTICSANTHELMINTICSALBENDAZOLE TABLETS ALBENZA PA RequiredIVERMECTIN TABLETS STROMECTOL PA RequiredPRAZIQUANTEL TABLETS BILTRICIDEANTIANGINAL AGENTSANTIANGINALS-OTHERRANOLAZINE TABLET 12-HOUR RANEXA PA RequiredNITRATESISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE DILATRATE SRISOSORBIDE DINITRATE SUBLINGUAL ISOSORBIDE DINITRATEISOSORBIDE DINITRATE TABLETS ISORDIL TITRADOSEISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE ISOSORBIDE DINITRATE ERISOSORBIDE MONONITRATE TABLETS ISOSORBIDE MONONITRATEISOSORBIDE MONONITRATE TABLET 24-HOUR IMDURNITROGLYCERIN CAPSULE CONTROLLED RELEASE NITRO-TIMENITROGLYCERIN OINTMENT NITRO-BIDNITROGLYCERIN PATCH 24-HOUR NITRO-DURNITROGLYCERIN SUBLINGUAL NITROSTATANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.HYDROXYZINE HCL SYRUP ATARAX SYRUP 300.00 30.00HYDROXYZINE HCL TABLETS ATARAX TABLETS 240.00 30.00HYDROXYZINE PAMOATE CAPSULES VISTARIL 120.00 30.00

BUSPIRONE HCL TAB 5 MG BUSPIRONE HCLPA Required for > 1 Anxiolytic

Medication in a 30-day time period. 120.00 30.00




Limit QL Days



BUSPIRONE HCL TAB 7.5 MG BUSPIRONE HCLPA Required for > 1 Anxiolytic







Medication in a 30-day time period. 60.00 30.00BENZODIAZEPINES

ALPRAZOLAM CONC 1 MG/ML ALPRAZOLAM INTENSOLPA Required for > 1 Anxiolytic


ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM TAB 0.25 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM TAB 0.5 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM TAB 1 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM TAB 2 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM TAB SR 24HR 0.5 MG VARIOUSPA Required for > 1 Anxiolytic


ALPRAZOLAM TAB SR 24HR 1 MG VARIOUSPA Required for > 1 Anxiolytic






CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUSPA Required for > 1 Anxiolytic






CLONAZEPAM 0.5 MG KlonopinPA Required for > 1 Anxiolytic


CLONAZEPAM 1.0 MG KlonopinPA Required for > 1 Anxiolytic


CLONAZEPAM 2 MG KlonopinPA Required for > 1 Anxiolytic


CLONAZEPAM ODT 0.125MG VARIOUSPA Required for > 1 Anxiolytic


CLONAZEPAM ODT 0.25MG VARIOUSPA Required for > 1 Anxiolytic


CLONAZEPAM ODT 0.5 MG VARIOUSPA Required for > 1 Anxiolytic





Limit QL Days



CLONAZEPAM ODT 1MG VARIOUSPA Required for > 1 Anxiolytic


CLONAZEPAM ODT 2MG VARIOUSPA Required for > 1 Anxiolytic


CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUSPA Required for > 1 Anxiolytic


CLORAZEPATE DIPOTASSIUM TAB 3.75 MG VARIOUSPA Required for > 1 Anxiolytic


CLORAZEPATE DIPOTASSIUM TAB 7.5 MG VARIOUSPA Required for > 1 Anxiolytic


DIAZEPAM CONC 5 MG/ML DIAZEPAM INTENSOLPA Required for > 1 Anxiolytic


DIAZEPAM SOLN 1 MG/ML VARIOUSPA Required for > 1 Anxiolytic


DIAZEPAM TAB 10 MG VARIOUSPA Required for > 1 Anxiolytic






LORAZEPAM CONC 2 MG/ML LORAZEPAM INTENSOLPA Required for > 1 Anxiolytic


LORAZEPAM TAB 0.5 MG VARIOUSPA Required for > 1 Anxiolytic


LORAZEPAM TAB 1 MG VARIOUSPA Required for > 1 Anxiolytic


LORAZEPAM TAB 2 MG VARIOUSPA Required for > 1 Anxiolytic


OXAZEPAM CAP 10 MG VARIOUSPA Required for > 1 Anxiolytic





Medication in a 30-day time period. 60.00 30.00ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-ADISOPYRAMIDE PHOSPHATE CAPSULES NORPACEDISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR NORPACE CRQUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CRQUINIDINE SULFATE TABLETS QUINIDINE SULFATEQUINIDINE SULFATE TABLET CONTROLLED RELEASE QUINIDINE SULFATE ERANTIARRHYTHMICS TYPE I-BMEXILETINE HCL CAPSULES MEXILETINE HCLANTIARRHYTHMICS TYPE I-CFLECAINIDE ACETATE TABLETS TAMBOCORPROPAFENONE HCL CAPSULE 12-HOUR RYTHMOL SRPROPAFENONE HCL TABLETS RYTHMOLANTIARRHYTHMICS TYPE IIIAMIODARONE HCL TABLETS 100MG & 200MG PACERONEDOFETILIDE CAPSULES TIKOSYN PA RequiredDRONEDARONE HCL TABLETS MULTAQ PA RequiredANTIASTHMATIC AND BRONCHODILATOR AGENTSANTI-INFLAMMATORY AGENTS




Limit QL Days



CROMOLYN SODIUM NEBULIZED CROMOLYN SODIUMBRONCHODILATORS - ANTICHOLINERGICSACLIDINIUM BROMIDE AEROSOL SOLUTION TUDORZA PRESSAIR Preferred DrugIPRATROPIUM BROMIDE HFA AEROSOL SOLUTION ATROVENT HFA Preferred DrugIPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDE Preferred DrugTIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALER Preferred DrugLEUKOTRIENE MODULATORSMONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR 30.00 30.00MONTELUKAST SODIUM GRANULES SINGULAIR PA Required for > 4 Years of AgeMONTELUKAST SODIUM TABLETS SINGULAIR 30.00 30.00STEROID INHALANTSBUDESONIDE (INHALATION) SUSPENSION 0.25MG/2ML, 0.5MG/2ML PULMICORT Brand Only Preferred Drug PA Required for > 4 Years of Age BUDESONIDE (INHALATION) SUSPENSION 1MG/2ML PULMICORT Preferred Drug PA Required for > 4 Years of Age BUDESONIDE (INHALATION) AEROSOL POWDER PULMICORT FLEXHALER Preferred DrugFLUTICASONE PROPIONATE HFA AERO FLOVENT HFA Preferred DrugMOMETASONE FUROATE (INHALATION) AEPB ASMANEX TWISTHALER Preferred DrugSYMPATHOMIMETICSALBUTEROL SULFATE TABLETS ALBUTEROL SULFATEALBUTEROL SULFATE TABLET 12-HOUR ALBUTEROL SULFATE ER

ALBUTEROL SULFATE INHALER ProAir Brand OnlyPreferred Drug Only

ProAirALBUTEROL SULFATE NEBULIZED ALBUTEROL SULFATEALBUTEROL SULFATE SYRUP ALBUTEROL SULFATE

BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE INHALER SYMBICORT Preferred Drug Step Therapy

Patient must have tried one steriod inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or Mometasone

FLUTICASONE-SALMETEROL INHALER ADVAIR HFA Preferred Drug Step Therapy


GLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL SOLUTION BEVESPI AEROSPHERE Preferred Drug PA Required 1.00 30.00IPRATROPIUM-ALBUTEROL INHALER COMBIVENT Preferred DrugIPRATROPIUM-ALBUTEROL AEROSOL SOLUTION COMBIVENT RESPIMAT Preferred DrugIPRATROPIUM-ALBUTEROL SOLUTION DUONEB Preferred DrugLEVALBUTEROL HCL NEBULIZED XOPENEX PA Required for > 4 Years of Age

MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE INHALER DULERA Preferred Drug Step Therapy


SALMETEROL XINAFOATE INHALER BREATH ACTIVATED SEREVENT DISKUS Preferred Drug PA RequiredTIOTROPIUM BROMIDE-OLODATEROL HCL AEROSOL SOLUTION STIOLTO RESPIMAT Preferred Drug PA Required 1.00 30.00XANTHINESTHEOPHYLLINE CAPSULE 24-HOUR THEO-24THEOPHYLLINE ELIXIR ELIXIROPHYLLINTHEOPHYLLINE SOLUTION THEOPHYLLINETHEOPHYLLINE TABLET 12-HOUR THEOCHRONTHEOPHYLLINE TABLET 24-HOUR THEOPHYLLINE ERANTICOAGULANTSCOUMARIN ANTICOAGULANTSWARFARIN SODIUM TABLETS COUMADINDIRECT FACTOR XA INHIBITORSAPIXABAN TABLETS ELIQUIS Brand Only Preferred Drug 60.00 30.00




Limit QL Days



APIXABAN TABLETS STARTER PACK ELIQUIS STARTER PACK Brand Only Preferred Drug 74.00 365.00RIVAROXABAN TABLETS XARELTO Brand Only Preferred Drug 60.00 30.00RIVAROXABAN TABLETS THERAPY PACK XARELTO STARTER PACK Brand Only Preferred Drug 51.00 30.00HEPARINS AND HEPARINOID-LIKE AGENTSENOXAPARIN SODIUM INJ 100 MG/ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 120 MG/0.8ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 150 MG/ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 30 MG/0.3ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 300 MG/3ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 40 MG/0.4ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 60 MG/0.6ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 80 MG/0.8ML VARIOUS Preferred Drug 60.00 30.00HEPARIN (PORCINE) IN SODIUM CHLORIDE SOLUTION HEPARIN SODIUM/NACL 0.9%HEPARIN SOD (PORCINE) IN D5W SOLUTION HEPARIN SODIUM/D5WHEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSH KIT HEPARIN SODIUM LOCK FLUSHHEPARIN SODIUM (PORCINE) LOCK FLUSH SOLUTION HEPARIN LOCK FLUSHTHROMBIN INHIBITORSDABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA Brand Only Preferred Drug 60.00 30.00ANTICONVULSANTSANTICONVULSANTS - BENZODIAZEPINESCLOBAZAM SUSPENSION ONFI PA RequiredCLOBAZAM TABLETS ONFI PA Required

CLONAZEPAM TAB 0.5 MG KLONOPINPA Required for > 1 Anxiolytic


CLONAZEPAM TAB 1 MG KLONOPINPA Required for > 1 Anxiolytic


CLONAZEPAM TAB 2 MG KLONOPINPA Required for > 1 Anxiolytic


CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG VARIOUSPA Required for > 1 Anxiolytic






CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG VARIOUSPA Required for > 1 Anxiolytic


CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG VARIOUSPA Required for > 1 Anxiolytic

Medication in a 30-day time period. 60.00 30.00DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIASTAT 2.00 30.00DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIASTAT 2.00 30.00DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG DIASTAT 2.00 30.00ANTICONVULSANTS - MISC.CARBAMAZEPINE (ANTIPSYCHOTIC) CAPSULE 12-HOUR EQUETROCARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINECARBAMAZEPINE CAPSULE 12-HOUR CARBATROLCARBAMAZEPINE SUSPENSION TEGRETOLCARBAMAZEPINE TABLETS EPITOLCARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XREZOGABINE TABLETS POTIGA PA RequiredGABAPENTIN CAPSULES NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN TABLETS NEURONTINGABAPENTIN (ONCE-DAILY) TABLETS GRALISE PA Required




Limit QL Days



GABAPENTIN ENACARBIL TABLET CONTROLLED RELEASE HORIZANT PA RequiredLACOSAMIDE SOLUTION VIMPAT PA RequiredLACOSAMIDE TABLETS VIMPAT PA RequiredLAMOTRIGINE CHEWABLE TABLETS LAMICTALLAMOTRIGINE KIT LAMICTAL STARTER/TAKING VALPROATELAMOTRIGINE TABLETS LAMICTALLAMOTRIGINE TABLET 24-HOUR LAMICTAL XRLAMOTRIGINE ORALLY DISPERSABLE TABLET LAMICTAL ODTLEVETIRACETAM SOLUTION KEPPRALEVETIRACETAM TABLETS KEPPRALEVETIRACETAM TABLET 24-HOUR KEPPRA XROXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTALOXCARBAZEPINE TABLET 24-HOUR OXTELLAR XRPREGABALIN CAPSULES (25MG, 50MG, 75MG, 100MG, 150MG, 200MG) LYRICA 90.00 30.00PREGABALIN CAPSULES (225MG, 300MG) LYRICA 60.00 30.00PREGABALIN SOLUTION LYRICA 900.00 30.00PRIMIDONE TABLETS MYSOLINERUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA RequiredTOPIRAMATE CAPSULE 24-HOUR TROKENDI XRTOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLETOPIRAMATE TABLETS TOPAMAXZONISAMIDE CAPSULES ZONEGRANCARBAMATESFELBAMATE SUSPENSION FELBATOLFELBAMATE TABLETS FELBATOLGABA MODULATORSTIAGABINE HCL TABLETS GABITRIL PA RequiredHYDANTOINSPHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETSPHENYTOIN SODIUM EXTENDED CAPSULES DILANTINPHENYTOIN SUSPENSION DILANTIN-125SUCCINIMIDESETHOSUXIMIDE CAPSULES ZARONTINETHOSUXIMIDE SOLUTION ZARONTINVALPROIC ACIDDIVALPROEX SODIUM SPRINKLE CAPSULES DEPAKOTE SPRINKLESDIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ERDIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTEVALPROATE SODIUM SYRUP DEPAKENEVALPROIC ACID CAPSULES DEPAKENEVALPROIC ACID CAPSULE DELAYED RELEASE STAVZORANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)MIRTAZAPINE TABLETS REMERON PA Required for Ages < 6 years 30.00 30.00MIRTAZAPINE ORALLY DISPERSABLE TABLET REMERON SOLTAB PA Required for Ages < 6 years 30.00 30.00NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)BUPROPION HCL TABLETS WELLBUTRIN PA Required for Ages < 6 years 120.00 30.00BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for Ages < 6 years 60.00 30.00BUPROPION HCL TABLET 24-HOUR WELLBUTRIN XL PA Required for Ages < 6 years 30.00 30.00SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)




Limit QL Days



CITALOPRAM HYDROBROMIDE SOLUTION CELEXAPA Required for Ages < 6 years and for >

the age of 12 years of age 600.00 30.00CITALOPRAM HYDROBROMIDE TABLETS 10MG CELEXA PA Required for Ages < 6 years 60.00 30.00CITALOPRAM HYDROBROMIDE TABLETS 20MG CELEXA PA Required for Ages < 6 years 30.00 30.00CITALOPRAM HYDROBROMIDE TABLETS 40MG CELEXA PA Required for Ages < 6 years 30.00 30.00ESCITALOPRAM OXALATE TABLETS 5MG LEXAPRO PA Required for Ages < 6 years 60.00 30.00ESCITALOPRAM OXALATE TABLETS 10MG LEXAPRO PA Required for Ages < 6 years 30.00 30.00ESCITALOPRAM OXALATE TABLETS 20MG LEXAPRO PA Required for Ages < 6 years 30.00 30.00FLUOXETINE HCL CAPSULES ONLY 10MG PROZAC PA Required for Ages < 6 years 60.00 30.00FLUOXETINE HCL CAPSULES ONLY 20MG PROZAC PA Required for Ages < 6 years 120.00 30.00FLUOXETINE HCL CAPSULES ONLY 40MG PROZAC PA Required for Ages < 6 years 60.00 30.00

FLUOXETINE HCL SOLUTION FLUOXETINE HCLPA Required for Ages < 6 years and for >

the age of 12 years of age 600.00 30.00FLUVOXAMINE MALEATE TABLETS 25MG LUVOX PA Required for Ages < 6 years 60.00 30.00FLUVOXAMINE MALEATE TABLETS 50MG LUVOX PA Required for Ages < 6 years 180.00 30.00FLUVOXAMINE MALEATE TABLETS 100MG LUVOX PA Required for Ages < 6 years 90.00 30.00PAROXETINE HCL TABLETS 10MG PAXIL PA Required for Ages < 6 years 30.00 30.00PAROXETINE HCL TABLETS 20MG PAXIL PA Required for Ages < 6 years 30.00 30.00PAROXETINE HCL TABLETS 30MG PAXIL PA Required for Ages < 6 years 30.00 30.00PAROXETINE HCL TABLETS 40MG PAXIL PA Required for Ages < 6 years 45.00 30.00

SERTRALINE HCL CONCENTRATE ZOLOFTPA Required for Ages < 6 years and for >

the age of 12 years of age 300.00 30.00SERTRALINE HCL TABLETS 25MG ZOLOFT PA Required for Ages < 6 years 90.00 30.00SERTRALINE HCL TABLETS 50MG ZOLOFT PA Required for Ages < 6 years 120.00 30.00SERTRALINE HCL TABLETS 100MG ZOLOFT PA Required for Ages < 6 years 60.00 30.00SEROTONIN MODULATORSTRAZODONE HCL TABLETS 50MG TRAZODONE HCL PA Required for Ages < 6 years 90.00 30.00TRAZODONE HCL TABLETS 100MG TRAZODONE HCL PA Required for Ages < 6 years 120.00 30.00TRAZODONE HCL TABLETS 150MG TRAZODONE HCL PA Required for Ages < 6 years 60.00 30.00TRAZODONE HCL TABLETS 300MG TRAZODONE HCL PA Required for Ages < 6 years 30.00 30.00SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)DULOXETINE HCL CAPSULE DELAYED RELEASE 20MG CYMBALTA PA Required for Ages < 6 years 120.00 30.00DULOXETINE HCL CAPSULE DELAYED RELEASE 30MG CYMBALTA PA Required for Ages < 6 years 120.00 30.00DULOXETINE HCL CAPSULE DELAYED RELEASE 60MG CYMBALTA PA Required for Ages < 6 years 60.00 30.00VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 37.5MG EFFEXOR XR PA Required for Ages < 6 years 90.00 30.00VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 75MG EFFEXOR XR PA Required for Ages < 6 years 90.00 30.00VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 150MG EFFEXOR XR PA Required for Ages < 6 years 30.00 30.00

VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 25MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 120.00 30.00

VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 37.5MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 90.00 30.00



VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 100MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 90.00 30.00TRICYCLIC AGENTSAMITRIPTYLINE HCL TABLETS AMITRIPTYLINE HCL PA Required for Ages < 6 yearsAMOXAPINE TABLETS VARIOUS PA Required for ages < 6 yearsCLOMIPRAMINE HCL CAPSULES ANAFRANIL PA Required for Ages < 6 yearsDESIPRAMINE HCL TABLETS NORPRAMIN PA Required for Ages < 6 yearsDOXEPIN HCL CAPSULES DOXEPIN HCL PA Required for Ages < 6 years 90.00 30.00




Limit QL Days



DOXEPIN HCL CONCENTRATE DOXEPIN HCL PA Required for Ages < 6 years 180.00 30.00IMIPRAMINE HCL TABLETS TOFRANIL PA Required for Ages < 6 yearsIMIPRAMINE PAMOATE CAPSULES TOFRANIL-PM PA Required for Ages < 6 years 30.00 30.00NORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for Ages < 6 yearsNORTRIPTYLINE HCL SOLUTION NORTRIPTYLINE HCL PA Required for Ages < 6 yearsPROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for Ages < 6 yearsTRIMIPRAMINE MALEATE SURMONTIL PA Required for Ages < 6 yearsANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORSACARBOSE TABLETS PRECOSEANTIDIABETIC - AMYLIN ANALOGSPRAMLINTIDE ACETATE SOLUTION PEN INJECTION SYMLINPEN 60 Preferred Drug PA RequiredANTIDIABETIC COMBINATIONSEMPAGLIFLOZIN-LINAGLIPTIN TABLETS GLYXAMBI Preferred Drug PA RequiredGLYBURIDE-METFORMIN HCL TABLETS GLYBURIDE/METFORMIN HCLPIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS METPIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XRSITAGLIPTIN-METFORMIN HCL TABLETS JANUMET Preferred Drug PA RequiredSITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR Preferred Drug PA RequiredBIGUANIDESMETFORMIN HCL TABLETS GLUCOPHAGE

METFORMIN HCL TABLET 24-HOUR (GENERIC OF GLUCOPHAGE XR ONLY- 500MG & 750MG)

Various GENERIC OF GLUCOPHAGE XR ONLY- 500MG &

750MGPA Required for Osmotic and Modified

Release Products DIABETIC OTHERGLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1.00 30.00GLUCAGON HCL (RDNA) SOLUTION GLUCAGEN HYPOKIT 1.00 30.00MIFEPRISTONE (HYPERGLYCEMIA) TABLETS KORLYM PA RequiredDIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSALOGLIPTIN BENZOATE TABLETS NESINALINAGLIPTIN TABLETS TRADJENTA Preferred Drug PA RequiredLINAGLIPTIN-METFORMIN HCL TABLETS JENTADUETO Preferred Drug PA RequiredLIRAGLUTIDE SOLUTION PEN INJECTION VICTOZA Preferred Drug PA RequiredSAXAGLIPTIN HCL TABLETS ONGLYZA Preferred Drug PA RequiredSAXAGLIPTIN-METFORMIN HCL TABLETS KOMBIGLYZE XR Preferred Drug PA RequiredSITAGLIPTIN PHOSPHATE TABLETS JANUVIA Preferred Drug PA RequiredINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)EXENATIDE SOLUTION PEN INJECTION BYETTA Preferred Drug PA RequiredEXENATIDE PEN BYDUREON Preferred Drug PA RequiredEXENATIDE SUSPENSION EXTENDED RELEASE BYDUREON Preferred Drug PA RequiredINSULIN SENSITIZING AGENTSPIOGLITAZONE HCL TABLETS ACTOSINSULININSULIN ASPART SOLUTION NOVOLOG Preferred DrugINSULIN ASPART SOCT NOVOLOG PENFILL Preferred DrugINSULIN ASPART SOLUTION PEN INJECTION NOVOLOG FLEXPEN Preferred DrugINSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION (70/30) NOVOLOG MIX 70/30INSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION PEN INJECTION (70/30) NOVOLOG MIX 70/30 PREFILLED FLEXPENINSULIN DETEMIR SOLUTION LEVEMIR Preferred DrugINSULIN DETEMIR SOLUTION PEN INJECTION LEVEMIR FLEXPEN Preferred DrugINSULIN GLARGINE SOLUTION LANTUS Preferred DrugINSULIN GLARGINE SOLUTION PEN INJECTION LANTUS SOLOSTAR Preferred Drug




Limit QL Days



INSULIN LISPRO (HUMAN) SOLUTION HUMALOG Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION (75-25) HUMALOG MIX 75/25 Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION (50-50) HUMALOG MIX 50/50 Preferred DrugINSULIN LISPRO (HUMAN) SOLUTION PEN INJECTION 100/ML HUMALOG KWIKPEN Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION PEN INJECTION (75-25) HUMALOG MIX 75/25 KWIKPEN Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION PEN INJECTION (50-50) HUMALOG MIX 50/50 KWIKPEN Preferred DrugINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N Preferred DrugINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION NOVOLIN N Preferred DrugINSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30 Preferred DrugINSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION NOVOLIN 70/30 Preferred DrugINSULIN REGULAR (HUMAN) SOLUTION HUMULIN R Preferred DrugINSULIN REGULAR (HUMAN) SOLUTION NOVOLIN R Preferred DrugINSULIN REGULAR (HUMAN) SOLUTION HUMULIN R U-500 (CONCENTRATED) Preferred Drug PA RequiredINSULIN REGULAR (HUMAN) SOLUTION PEN INJECTION HUMULIN R U-500 KWIKPEN Preferred Drug PA RequiredMEGLITINIDE ANALOGUESNATEGLINIDE TABLETS STARLIXREPAGLINIDE TABLETS PRANDINSGLT2SDAPAGLIFLOZIN PROPANEDIOL FARXIGA Preferred Drug PA RequiredCANAGLIFLOZIN INVOKANA Preferred Drug PA RequiredEMPAGLIFLOZIN JARDIANCE Preferred Drug PA RequiredSULFONYLUREASCHLORPROPAMIDE TABLETS CHLORPROPAMIDEGLIMEPIRIDE TABLETS AMARYLGLIPIZIDE TABLETS GLUCOTROLGLIPIZIDE TABLET 24-HOUR GLIPIZIDE XLGLYBURIDE MICRONIZED TABLETS GLYNASEGLYBURIDE TABLETS DIABETATOLAZAMIDE TABLETS TOLAZAMIDETOLBUTAMIDE TABLETS TOLBUTAMIDEANTIDIARRHEALSANTIPERISTALTIC AGENTSDIPHENOXYLATE W/ ATROPINE LIQUID DIPHENOXYLATE/ATROPINEDIPHENOXYLATE W/ ATROPINE TABLETS LOMOTILLOPERAMIDE HCL CAPSULES LOPERAMIDE HCLLOPERAMIDE HCL CHEWABLE TABLETS IMODIUM A-DLOPERAMIDE HCL LIQUID LOPERAMIDE HCLLOPERAMIDE HCL SUSPENSION IMODIUM A-DLOPERAMIDE HCL TABLETS IMODIUM A-DANTIDOTESOPIOID ANTAGONISTSNALOXONE HCL SOLUTION + SYRINGE NALOXONE HCL + SYRINGE Preferred DrugNALOXONE HCL NASAL SPRAY NARCAN NASAL SPRAY Preferred DrugNALTREXONE HCL TABLETS NALTREXONE HCL Preferred DrugNALTREXONE SUSPENSION VIVITROL Preferred DrugANTIEMETICS5-HT3 RECEPTOR ANTAGONISTSDOLASETRON MESYLATE TABLETS ANZEMET PA RequiredGRANISETRON HCL SOLUTION GRANISOL PA RequiredGRANISETRON HCL TABLETS GRANISETRON HCL PA RequiredONDANSETRON HCL SOLUTION ZOFRAN 150.00 30.00




Limit QL Days



ONDANSETRON HCL TABLETS ZOFRAN 30.00 30.00ONDANSETRON ORALLY DISPERSABLE TABLET ZOFRAN ODT 30.00 30.00ANTIEMETICS - ANTICHOLINERGICMECLIZINE HCL CHEWABLE TABLETS MECLIZINE HCLMECLIZINE HCL TABLETS MECLIZINE HCLTRIMETHOBENZAMIDE HCL CAPSULES TIGANTRIMETHOBENZAMIDE HCL SOLUTION TIGANANTIEMETICS - MISCELLANEOUSDRONABINOL CAPSULES MARINOL PA RequiredPROCHLORPERAZINE MALEATE TABLETS COMPAZINEPROCHLORPERAZINE SUPPOSITORY COMPAZINESUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTAPREPITANT CAPSULES EMEND 6.00 21.00ANTIFUNGALSANTIFUNGAL ORAL AGENTSCLOTRIMAZOLE TROCHE VARIOUSGRISEOFULVIN SUSPENSION VARIOUSGRISEOFULVIN MICROSIZE TABLETS GRIFULVIN VNYSTATIN SUSPENSION NYSTATINNYSTATIN TABLETS NYSTATINTERBINAFINE HCL TABLETS LAMISIL 90.00 365.00IMIDAZOLE-RELATED ANTIFUNGALSFLUCONAZOLE SUSPENSION DIFLUCAN 600.00 30.00FLUCONAZOLE TABLETS DIFLUCAN 60.00 30.00ANTIHISTAMINESANTIHISTAMINES - ALKYLAMINESBROMPHENIRAMINE MALEATE J-TAN PDCHLORPHENIRAMINE MALEATE TABLETS CHLORPHENIRAMINE MALEATEDEXCHLORPHENIRAMINE MALEATE SYRUP DEXCHLORPHENIRAMINE MALEATEANTIHISTAMINES - ETHANOLAMINESCLEMASTINE FUMARATE SYRUP CLEMASTINE FUMARATECLEMASTINE FUMARATE TABLETS CLEMASTINE FUMARATEDIPHENHYDRAMINE HCL CAPSULES BANOPHENDIPHENHYDRAMINE HCL CHEWABLE TABLETS BENADRYL ALLERGY CHILDRENSDIPHENHYDRAMINE HCL ELIXIR MEDI-PHEDRYLDIPHENHYDRAMINE HCL LIQUID BANOPHENDIPHENHYDRAMINE HCL SOLUTION DIPHENHYDRAMINE HCLDIPHENHYDRAMINE HCL STRP TRIAMINIC COUGH & RUNNY NOSEDIPHENHYDRAMINE HCL SUSPENSION DICOPANOL FUSEPAQDIPHENHYDRAMINE HCL SYRUP ALTARYL

DIPHENHYDRAMINE HCL TABLETS ALKA-SELTZER PLUS ALLERGY FAST RELIEF FORMULADIPHENHYDRAMINE HCL ORALLY DISPERSABLE TABLET WAL-DRYL ALLERGY RELIEF CHILDRENSANTIHISTAMINES - NON-SEDATINGCETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30.00 30.00CETIRIZINE HCL CHEWABLE TABLETS WAL-ZYR CHILDRENS 30.00 30.00CETIRIZINE HCL SYRUP ALL DAY ALLERGY CHILDRENS 150.00 30.00CETIRIZINE HCL TABLETS CETIRIZINE HCL 30.00 30.00CETIRIZINE HCL ORALLY DISPERSABLE TABLET ZYRTEC ALLERGY 30.00 30.00FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS 150.00 30.00FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS 30.00 30.00FEXOFENADINE HCL ORALLY DISPERSABLE TABLET ALLEGRA ALLERGY CHILDRENS 30.00 30.00LORATADINE CAPSULES CLARITIN 30.00 30.00




Limit QL Days



LORATADINE CHEWABLE TABLETS CLARITIN 30.00 30.00LORATADINE SYRUP CLARITIN 150.00 30.00LORATADINE TABLETS ALAVERT 30.00 30.00LORATADINE ORALLY DISPERSABLE TABLET CLARITIN REDITABLETS 30.00 30.00ANTIHISTAMINES - PHENOTHIAZINESPROMETHAZINE HCL SOLUTION PROMETHAZINE HCLPROMETHAZINE HCL SUPPOSITORY PHENADOZPROMETHAZINE HCL TABLETS PROMETHAZINE HCLANTIHISTAMINES - PIPERIDINESCYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCLCYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCLANTIHYPERLIPIDEMICSBILE ACID SEQUESTRANTSCHOLESTYRAMINE LIGHT PACK PREVALITECHOLESTYRAMINE LIGHT POWDER PREVALITECHOLESTYRAMINE PACK QUESTRANCHOLESTYRAMINE POWDER QUESTRANCOLESTIPOL HCL GRANULES COLESTIDCOLESTIPOL HCL PACK COLESTIDCOLESTIPOL HCL TABLETS COLESTIDFIBRIC ACID DERIVATIVESFENOFIBRATE MICRONIZED CAPSULES 67MG, 134MG & 200MG VARIOUSFENOFIBRATE TABLETS 48MG, 54MG, 145MG & 160MG VARIOUSFENOFIBRIC ACID TABLETS FIBRICORGEMFIBROZIL TABLETS LOPIDHMG COA REDUCTASE INHIBITORSATORVASTATIN CALCIUM TABLETS LIPITOR 30.00 30.00FLUVASTATIN SODIUM CAPSULES LESCOL 30.00 30.00FLUVASTATIN SODIUM TABLET 24-HOUR LESCOL XL 30.00 30.00LOVASTATIN TABLETS LOVASTATIN 30.00 30.00PRAVASTATIN SODIUM TABLETS PRAVASTATIN SODIUM 30.00 30.00ROSUVASTATIN CALCIUM TABLETS CRESTOR 30.00 30.00SIMVASTATIN TABLETS ZOCOR 30.00 30.00INTESTINAL CHOLESTEROL ABSORPTION INHIBITORSEZETIMIBE TABLETS ZETIA PA RequiredNICOTINIC ACID DERIVATIVESNIACIN (ANTIHYPERLIPIDEMIC) TABLETS (250MG, 500MG, & 750MG) NIACIN CRANTIHYPERTENSIVESACE INHIBITORSBENAZEPRIL HCL TABLETS BENAZEPRIL HCLCAPTOPRIL TABLETS CAPTOPRILENALAPRIL MALEATE SOLUTION EPANEDENALAPRIL MALEATE TABLETS VASOTECFOSINOPRIL SODIUM TABLETS FOSINOPRIL SODIUMLISINOPRIL TABLETS ZESTRILMOEXIPRIL HCL TABLETS UNIVASCPERINDOPRIL ERBUMINE TABLETS PERINDOPRIL ERBUMINEQUINAPRIL HCL TABLETS ACCUPRILRAMIPRIL CAPSULES ALTACETRANDOLAPRIL TABLETS MAVIKANGIOTENSIN II RECEPTOR ANTAGONISTS

CANDESARTAN CILEXETIL TABLETS ATACAND Step Therapy Patient must have tried Losaratan, Irbesartan




Limit QL Days



IRBESARTAN TABLETS AVAPROLOSARTAN POTASSIUM TABLETS COZAAR

OLMESARTAN MEDOXOMIL TABLETS BENICAR Step Therapy Patient must have tried Irbesartan & Losartan

VALSARTAN TABLETS DIOVANANTIADRENERGIC ANTIHYPERTENSIVESCLONIDINE HCL PATCH WEEKLY CATAPRES-TTS PA Required for Ages < 6 years 4.00 28.00CLONIDINE HCL TABLETS CATAPRES PA Required for Ages < 6 yearsDOXAZOSIN MESYLATE TABLETS CARDURAGUANFACINE HCL TABLETS TENEX PA Required for Ages < 6 yearsMETHYLDOPA TABLETS METHYLDOPAPRAZOSIN HCL CAPSULES MINIPRESSTERAZOSIN HCL CAPSULES TERAZOSIN HCLANTIHYPERTENSIVE COMBINATIONSATENOLOL & CHLORTHALIDONE TABLETS VARIOUSBISOPROLOL & HYDROCHLOROTHIAZIDE TABLETS ZIACCAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETS CAPTOPRIL/HYDROCHLOROTHIAZIDE

ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETS ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE

FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETS FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDELISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETICLOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS HYZAARMETOPROLOL & HYDROCHLOROTHIAZIDE TABLETS LOPRESSOR HCTMOEXIPRIL-HYDROCHLOROTHIAZIDE TABLETS UNIRETICNADOLOL & BENDROFLUMETHIAZIDE TABLETS CORZIDEOLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TABLETS BENICAR HCTPROPRANOLOL & HYDROCHLOROTHIAZIDE TABLETS PROPRANOLOL/HYDROCHLOROTHIAZIDEQUINAPRIL-HYDROCHLOROTHIAZIDE TABLETS ACCURETICVALSARTAN-HYDROCHLOROTHIAZIDE TABLETS DIOVAN HCTDIRECT RENIN INHIBITORSALISKIREN FUMARATE TABLETS TEKTURNA PA RequiredSELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)EPLERENONE TABLETS INSPRA PA RequiredVASODILATORSHYDRALAZINE HCL TABLETS HYDRALAZINE HCLMINOXIDIL TABLETS MINOXIDILANTI-INFECTIVE AGENTS - MISC.ANTI-INFECTIVE AGENTS - MISC.METRONIDAZOLE CAPSULES FLAGYLMETRONIDAZOLE TABLETS FLAGYLRIFAXIMIN TABLETS XIFAXAN PA RequiredTRIMETHOPRIM TABLETS TRIMETHOPRIMVANCOMYCIN HCL CAPSULES VANCOCIN HCL PA RequiredVANCOMYCIN HCL SOLUTION FIRST-VANCOMYCIN 25 PA RequiredANTI-INFECTIVE MISC. - COMBINATIONSERYTHROMYCIN-SULFISOXAZOLE SUSPENSION E.S.P.SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION SULFATRIM PEDIATRICSULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS BACTRIMLEPROSTATICSDAPSONE TABLETS DAPSONELINCOSAMIDESCLINDAMYCIN HCL CAPSULES CLEOCIN




Limit QL Days



CLINDAMYCIN PALMITATE HYDROCHLORIDE SOLUTION CLEOCIN PEDIATRIC GRANULESOXAZOLIDINONESLINEZOLID SUSPENSION ZYVOX PA RequiredLINEZOLID TABLETS ZYVOX PA RequiredANTIMALARIALSANTIMALARIAL COMBINATIONSARTEMETHER-LUMEFANTRINE TABLETS COARTEMATOVAQUONE-PROGUANIL HCL TABLETS MALARONEANTIMALARIALSCHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATEHYDROXYCHLOROQUINE SULFATE TABLETS PLAQUENILPRIMAQUINE PHOSPHATE TABLETS PRIMAQUINE PHOSPHATEPYRIMETHAMINE TABLETS DARAPRIMQUININE SULFATE CAPSULES QUALAQUINANTIMYASTHENIC/CHOLINERGIC AGENTSANTIMYASTHENIC/CHOLINERGIC AGENTSPYRIDOSTIGMINE BROMIDE SYRUP MESTINONPYRIDOSTIGMINE BROMIDE TABLETS MESTINONPYRIDOSTIGMINE BROMIDE TABLET CONTROLLED RELEASE MESTINON TIMESPANANTIMYCOBACTERIAL AGENTSANTI TB COMBINATIONSISONIAZID & RIFAMPIN CAPSULES RIFAMATEANTIMYCOBACTERIAL AGENTSETHAMBUTOL HCL TABLETS MYAMBUTOLISONIAZID SYRUP ISONIAZIDISONIAZID TABLETS ISONIAZIDPYRAZINAMIDE TABLETS PYRAZINAMIDERIFAMPIN CAPSULES RIFADIN

ONCOLOGY -FEDERALLY REIMBURSABLE ANTINEOPLASTIC AGENTS,NOT LISTED BELOW, ARE AVAILABLE THROUGH PRIOR AUTHORIZATION ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTSALTRETAMINE CAPSULES HEXALEN PA RequiredCHLORAMBUCIL TABLETS LEUKERANCYCLOPHOSPHAMIDE CAPSULES CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE TABLETS CYCLOPHOSPHAMIDELOMUSTINE CAPSULES CEENUTEMOZOLOMIDE CAPSULES TEMODAR PA RequiredANTIMETABOLITESMERCAPTOPURINE TABLETS VARIOUSMETHOTREXATE SODIUM TABLETS METHOTREXATETHIOGUANINE TABLETS TABLOIDANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORSVISMODEGIB CAPSULES ERIVEDGE PA RequiredANTINEOPLASTIC - HORMONAL AND RELATED AGENTSABIRATERONE ACETATE TABLETS ZYTIGA PA RequiredANASTROZOLE TABLETS ARIMIDEX PA RequiredBICALUTAMIDE TABLETS CASODEXDEGARELIXIR ACETATE SOLUTION FIRMAGON PA RequiredESTRAMUSTINE PHOSPHATE SODIUM CAPSULES EMCYT PA RequiredEXEMESTANE TABLETS AROMASIN PA Required




Limit QL Days



FLUTAMIDE CAPSULES FLUTAMIDELETROZOLE TABLETS FEMARA PA RequiredLEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (6 MONTH) KIT ELIGARD PA RequiredLEUPROLIDE ACETATE KIT LUPRON DEPOT PA RequiredMEGESTROL ACETATE SUSPENSION MEGACE ORALMEGESTROL ACETATE TABLETS MEGESTROL ACETATEMITOTANE TABLETS LYSODRENNILUTAMIDE TABLETS NILANDRON 60.00 30.00TAMOXIFEN CITRATE SOLUTION SOLTAMOXTAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETOREMIFENE CITRATE TABLETS FARESTON PA RequiredANTINEOPLASTIC ENZYME INHIBITORSALECTINIB HCL CAPSULES ALECENSA PA RequiredAXITINIB TABLETS INLYTA PA RequiredCOBIMETINIB FUMARATE TABLETS COTELLIC PA RequiredCRIZOTINIB CAPSULES XALKORI PA RequiredDASATINIB TABLETS SPRYCEL PA RequiredERLOTINIB HCL TABLETS TARCEVA PA RequiredEVEROLIMUS TABLETS AFINITOR PA RequiredEVEROLIMUS TBSO AFINITOR DISPERZ PA RequiredGEFITINIB TABLETS IRESSA PA RequiredIBRUTINIB CAPSULES IMBRUVICA PA RequiredIMATINIB MESYLATE TABLETS GLEEVEC BRAND PREFERRED BRAND PREFERRED PA RequiredIBRUTINIB TABLETS IMBRUVICA PA RequiredLAPATINIB DITOSYLATE TABLETS TYKERB PA RequiredIXAZOMIB CITRATE CAPSULES NINLARO PA RequiredNILOTINIB HCL CAPSULES TASIGNA PA RequiredPAZOPANIB HCL TABLETS VOTRIENT PA RequiredPONATINIB HCL TABLETS ICLUSIG PA RequiredRUXOLITINIB PHOSPHATE TABLETS JAKAFI PA RequiredSORAFENIB TOSYLATE TABLETS NEXAVAR PA RequiredSUNITINIB MALATE CAPSULES SUTENT PA RequiredVANDETANIB TABLETS CAPRELSA PA RequiredVEMURAFENIB TABLETS ZELBORAF PA RequiredVORINOSTAT CAPSULES ZOLINZA PA RequiredANTINEOPLASTICS MISC.BEXAROTENE CAPSULES TARGRETIN PA RequiredHYDROXYUREA CAPSULES HYDREAINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-N3 SOLUTION ALFERON N PA RequiredINTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA RequiredPEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA RequiredPROCARBAZINE HCL CAPSULES MATULANETRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of AgeCHEMOTHERAPY RESCUE/ANTIDOTE AGENTSLEUCOVORIN CALCIUM TABLETS LEUCOVORIN CALCIUMMITOTIC INHIBITORSETOPOSIDE CAPSULES ETOPOSIDEANTIPARKINSON AGENTSANTIPARKINSON ADJUVANTS




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CARBIDOPA TABLETS LODOSYNANTIPARKINSON ANTICHOLINERGICSBENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATEBENZTROPINE MESYLATE SOLUTION COGENTINTRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCLTRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCLANTIPARKINSON COMT INHIBITORSENTACAPONE TABLETS COMTANANTIPARKINSON DOPAMINERGICSAMANTADINE HCL CAPSULES AMANTADINE HCLAMANTADINE HCL SYRUP AMANTADINE HCLAMANTADINE HCL TABLETS AMANTADINE HCLBROMOCRIPTINE MESYLATE CAPSULES PARLODELBROMOCRIPTINE MESYLATE TABLETS PARLODELCARBIDOPA-LEVODOPA TABLETS SINEMETCARBIDOPA-LEVODOPA TABLET CONTROLLED RELEASE SINEMET CRCARBIDOPA-LEVODOPA ORALLY DISPERSABLE TABLET PARCOPACARBIDOPA-LEVODOPA-ENTACAPONE TABLETS STALEVO 50PRAMIPEXOLE DIHYDROCHLORIDE TABLETS MIRAPEXPRAMIPEXOLE DIHYDROCHLORIDE TABLET 24-HOUR MIRAPEX ERROPINIROLE HYDROCHLORIDE TABLETS REQUIPROPINIROLE HYDROCHLORIDE TABLET 24-HOUR REQUIP XLANTIPARKINSON MONOAMINE OXIDASE INHIBITORSSELEGILINE HCL CAPSULES ELDEPRYLSELEGILINE HCL TABLETS SELEGILINE HCLSELEGILINE HCL ORALLY DISPERSABLE TABLET ZELAPARANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS

LITHIUM CARBONATE CAPSULES LITHIUM CARBONATE

Prior Authorization is not required when prescribed by a psychiatric clinician, a

behavioral pediatrician or other prescribers as approved by the FFS

Administration

LITHIUM CARBONATE POWDER LITHIUM CARBONATE



Administration

LITHIUM CARBONATE TABLETS LITHIUM CARBONATE



Administration

LITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBID



Administration

LITHIUM SOLUTION LITHIUM



Administration




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ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS

ARIPIPRAZOLE TABLETS ABILIFY Preferred Drug

PA Required for < 6 years of age, Prior Authorization is not required when

prescribed by a psychiatric clinician, a behavioral pediatrician or other

prescribers as approved by the FFS Administration. 30.00 30.00

CLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO Preferred Drug

PA Required for Ages < 18 years Prior Authorization is not required when



CLOZAPINE TABLETS CLOZARIL Preferred Drug




LURASIDONE HCL TABS LATUDA Preferred Drug




OLANZAPINE ORALLY DISPERSABLE TABLET 5MG ZYPREXA ZYDIS Preferred Drug



















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OLANZAPINE TABLETS ZYPREXA Preferred Drug




QUETIAPINE FUMARATE TABLETS SEROQUEL Preferred Drug




RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT Preferred Drug




RISPERIDONE ORAL SOLUTION RISPERDAL Preferred Drug




RISPERIDONE TABLETS RISPERDAL Preferred Drug




ZIPRASIDONE HCL CAPSULES GEODON Preferred Drug




ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES

ARIPIPRAZOLE LAUROXIL ARISTADA Preferred Drug




ARIPIPRAZOLE LAUROXIL PREFILLED SYRINGE ARISTADA INITIO Preferred Drug







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ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Preferred Drug




PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Preferred Drug




PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Preferred Drug




RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Preferred Drug




ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS

CHLORPROMAZINE HCL SOLUTION VARIOUS



prescribers as approved by the FFS Administration.

CHLORPROMAZINE HCL TABLETS VARIOUS




FLUPHENAZINE HCL CONCENTRATE VARIOUS




FLUPHENAZINE HCL ELIXIR VARIOUS







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FLUPHENAZINE HCL TABLETS VARIOUS




HALOPERIDOL LACTATE CONCENTRATE VARIOUS




HALOPERIDOL TABLETS VARIOUS




LOXAPINE SUCCINATE CAPSULES LOXITANE




PERPHENAZINE TABLETS VARIOUS




PIMOZIDE ORAP




THIORIDAZINE HCL TABLETS VARIOUS

PA Required for < 6 years of age. Prior Authorization is not required when



THIOTHIXENE CAPSULES VARIOUS







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TRIFLUOPERAZINE HCL TABLETS VARIOUS




ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS

FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE




HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE 50




ANTIVIRALSANTIRETROVIRALSABACAVIR SULFATE SOLUTION ZIAGENABACAVIR SULFATE TABLETS ZIAGENABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOMABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIRABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQATAZANAVIR SULFATE CAPSULES REYATAZATAZANAVIR SULFATE PACK REYATAZATAZANAVIR SULFATE-COBICISTAT TABLETS EVOTAZ

BICTEGRAVIR-EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS BIKTARVY 30.00 30.00COBICISTAT TABLETS TYBOST 30.00 30.00DARUNAVIR ETHANOLATE SUSPENSION PREZISTADARUNAVIR ETHANOLATE TABLETS PREZISTADARUNAVIR-COBICISTAT TABLETS PREZCOBIXDELAVIRDINE MESYLATE TABLETS RESCRIPTORDIDANOSINE CAPSULE DELAYED RELEASE VIDEX ECDIDANOSINE SOLUTION VIDEX PEDIATRICDOLUTEGRAVIR SODIUM TABLETS TIVICAYDORAVIRINE TABLETS PIFELTROEFAVIRENZ CAPSULES SUSTIVAEFAVIRENZ TABLETS SUSTIVAEFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLAELVITEGRAVIR TABLETS VITEKTAELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILD

ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE TABLETS GENVOYA 30.00 30.00EMTRICITABINE CAPSULES EMTRIVAEMTRICITABINE SOLUTION EMTRIVA

EMTRICITABINE-RILPIVIRINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS ODEFSEY 30.00 30.00EMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS COMPLERAEMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS DESCOVY 30.00 30.00




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EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADAENFUVIRTIDE SOLUTION FUZEON PA Required 1.00 30.00ETRAVIRINE TABLETS INTELENCEFOSAMPRENAVIR CALCIUM SUSPENSION LEXIVAFOSAMPRENAVIR CALCIUM TABLETS LEXIVAINDINAVIR SULFATE CAPSULES CRIXIVANLAMIVUDINE SOLUTION EPIVIRLAMIVUDINE TABLETS EPIVIRLAMIVUDINE-ZIDOVUDINE TABLETS COMBIVIRLOPINAVIR-RITONAVIR SOLUTION KALETRALOPINAVIR-RITONAVIR TABLETS KALETRAMARAVIROC TABLETS SELZENTRY PA RequiredNELFINAVIR MESYLATE TABLETS VIRACEPTNEVIRAPINE SUSPENSION VIRAMUNENEVIRAPINE TABLETS VIRAMUNENEVIRAPINE TABLET 24-HOUR VIRAMUNE XRRALTEGRAVIR POTASSIUM CHEWABLE TABLETS ISENTRESSRALTEGRAVIR POTASSIUM PACK ISENTRESSRALTEGRAVIR POTASSIUM TABLETS ISENTRESSRILPIVIRINE HCL TABLETS EDURANTRITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIRSAQUINAVIR MESYLATE CAPSULES INVIRASESAQUINAVIR MESYLATE TABLETS INVIRASESTAVUDINE CAPSULES ZERITSTAVUDINE SOLUTION ZERITTENOFOVIR DISOPROXIL FUMARATE POWDER VIREADTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREADTIPRANAVIR CAPSULES APTIVUSTIPRANAVIR SOLUTION APTIVUSZIDOVUDINE CAPSULES RETROVIRZIDOVUDINE SYRUP RETROVIRZIDOVUDINE TABLETS ZIDOVUDINECMV AGENTSVALGANCICLOVIR HCL SOLUTION VALCYTE PA RequiredVALGANCICLOVIR HCL TABLETS VALCYTE PA RequiredHEPATITIS AGENTSADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredGLECAPREVIR-PIBRENTASVIR TABLETS MAVYRET Preferred Drug PA RequiredLAMIVUDINE (HBV) SOLUTION EPIVIR HBVLAMIVUDINE (HBV) TABLETS EPIVIR HBVPEGINTERFERON ALFA-2A SOLUTION PEGASYS Preferred Drug PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON Preferred Drug PA RequiredRIBAVIRIN (HEPATITIS C) CAPSULES VARIOUS Preferred Drug PA RequiredRIBAVIRIN (HEPATITIS C) TABLETS VARIOUS Preferred Drug PA Required

SOFOSBUVIR-VELPATASVIR TABLETS EPCLUSAAUTHORIZED GENERIC

ONLY Preferred Drug PA RequiredTELBIVUDINE TABLETS TYZEKA PA RequiredHERPES AGENTSACYCLOVIR SUSPENSION ZOVIRAX




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ACYCLOVIR TABLETS ZOVIRAXFAMCICLOVIR TABLETS FAMVIRVALACYCLOVIR HCL TABLETS VALTREX PA RequiredINFLUENZA AGENTSOSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20.00 270.00OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLURIMANTADINE HYDROCHLORIDE TABLETS FLUMADINEZANAMIVIR AEPB RELENZA DISKHALER 40.00 270.00ASSORTED CLASSESBLOOD PRODUCTS - IMMUNE GLOBULINSIMMUNE GLOBULIN BIVIGAM (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN CARIMUNE NF NANOFILTERED (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN FLEBOGFAMMA DIF (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMASTAN S/D (IM) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMMAGARD LIQUID (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMMAGARD S-D LIQUID (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMUNEX-C (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN HIZENTRAL (SUBQ) BRAND ONLY PREFERRED DRUG PA REQUIREDCHELATING AGENTSPENICILLAMINE CAPSULES CUPRIMINEIMMUNOMODULATORSLENALIDOMIDE CAPSULES REVLIMID PA RequiredTHALIDOMIDE CAPSULES THALOMID PA RequiredIMMUNOSUPRESSIVE AGENTSAZATHIOPRINE TABLETS IMURANCYCLOSPORINE CAPSULES SANDIMMUNECYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAFCYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAFCYCLOSPORINE SOLUTION SANDIMMUNEEVEROLIMUS (IMMUNOSUPPRESSANT) TABLETS ZORTRESS PA RequiredMYCOPHENOLATE MOFETIL CAPSULES CELLCEPTMYCOPHENOLATE MOFETIL SUSPENSION CELLCEPTMYCOPHENOLATE MOFETIL TABLETS CELLCEPTSIROLIMUS SOLUTION RAPAMUNESIROLIMUS TABLETS RAPAMUNETACROLIMUS CAPSULES HECORIATACROLIMUS CAPSULE 24-HOUR ASTAGRAF XLPOTASSIUM REMOVING RESINSSODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATESODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEXBETA BLOCKERSALPHA-BETA BLOCKERSCARVEDILOL TABLETS COREGLABETALOL HCL TABLETS TRANDATEBETA BLOCKERS CARDIO-SELECTIVEATENOLOL TABLETS TENORMINBISOPROLOL FUMARATE TABLETS ZEBETAMETOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XLMETOPROLOL TARTRATE TABLETS METOPROLOL TARTRATEBETA BLOCKERS NON-SELECTIVENADOLOL TABLETS CORGARDPROPRANOLOL HCL CAPSULE 24-HOUR INDERAL LAPROPRANOLOL HCL SOLUTION PROPRANOLOL HCL




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PROPRANOLOL HCL TABLETS PROPRANOLOL HCLSOTALOL AF TABLETS SOTALOL HCL (AF)SOTALOL HCL SOLUTION SOTALOL HYDROCHLORIDESOTALOL HCL TABLETS BETAPACECALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERSAMLODIPINE BESYLATE TABLETS NORVASC 30.00 30.00DILTIAZEM HCL COATED BEADS CAPSULE 24-HOUR CARDIZEM CDDILTIAZEM HCL CAPSULE 12-HOUR DILTIAZEM HCL ERDILTIAZEM HCL CAPSULE 24-HOUR DILTIAZEM HCL ERDILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULE 24-HOUR TAZTIA XTDILTIAZEM HCL TABLETS CARDIZEMFELODIPINE TABLET 24-HOUR FELODIPINE ERNIFEDIPINE CAPSULES PROCARDIANIFEDIPINE TABLET 24-HOUR ADALAT CC 30.00 30.00NIMODIPINE CAPSULES NIMODIPINEVERAPAMIL HCL CAPSULE 24-HOUR VERELAN PM 30.00 30.00VERAPAMIL HCL TABLETS VERAPAMIL HCLVERAPAMIL HCL TABLET CONTROLLED RELEASE CALAN SR 30.00 30.00CARDIOTONICSCARDIAC GLYCOSIDESDIGOXIN SOLUTION DIGOXINDIGOXIN TABLETS LANOXINCARDIOVASCULAR AGENTS - MISC.CARDIOVASCULAR AGENTS MISC. - COMBINATIONSSACUBITRIL-VALSARTAN TABS ENTRESTO PA RequiredPULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTAMBRISENTAN TABLETS LETAIRIS BRAND ONLY PREFERRED DRUG PA RequiredBOSENTAN TABLETS TRACLEER BRAND ONLY PREFERRED DRUG PA RequiredPULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITOR

SILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO SUSPENSION BRAND ONLY

PREFERRED FOR UNDER THE AGE OF

12 PA Required FOR > 12 YEARS OF AGESILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS VARIOIUS PREFERRED DRUG PA RequiredTADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA BRAND ONLY PREFERRED DRUG PA RequiredCEPHALOSPORINSCEPHALOSPORINS - 1ST GENERATIONCEFADROXIL CAPSULES CEFADROXILCEFADROXIL SUSPENSION CEFADROXILCEFADROXIL TABLETS CEFADROXILCEPHALEXIN CAPSULES KEFLEXCEPHALEXIN SUSPENSION CEPHALEXINCEPHALEXIN TABLETS CEPHALEXINCEPHALOSPORINS - 2ND GENERATIONCEFACLOR CAPSULES CEFACLORCEFACLOR SUSPENSION CEFACLORCEFPROZIL SUSPENSION CEFPROZILCEFPROZIL TABLETS CEFPROZILCEFUROXIME AXETIL SUSPENSION CEFTINCEFUROXIME AXETIL TABLETS CEFTINCEPHALOSPORINS - 3RD GENERATIONCEFDINIR CAPSULES CEFDINIRCEFDINIR SUSPENSION CEFDINIR




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CEFIXIME CAPSULES SUPRAX 1.00 30.00CEFIXIME CHEWABLE TABLETS SUPRAX 1.00 30.00CEFIXIME SUSPENSION SUPRAX 1.00 30.00CEFIXIME TABLETS SUPRAX 1.00 30.00CEFPODOXIME PROXETIL SUSPENSION CEFPODOXIME PROXETILCEFPODOXIME PROXETIL TABLETS CEFPODOXIME PROXETILCONTRACEPTIVESCOMBINATION CONTRACEPTIVES - ORALDESOGESTREL & ETHINYL ESTRADIOL TABLETS APRIDESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS AZURETTEDESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS CAZIANTDROSPIRENONE-ETHINYL ESTRADIOL TABLETS OCELLAETHYNODIOL DIACET & ETH ESTRAD TABLETS KELNOR 1/35LEVONORGESTREL & ETH ESTRADIOL TABLETS AUBRALEVONORGESTREL-ETH ESTRADIOL (TRIPHASIC) TABLETS ENPRESSE-28LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS AMETHIA LONORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TABLETS JUNEL FE NORETHINDRONE & ETH ESTRADIOL TABLETS BALZIVA NORETHINDRONE & MESTRANOL TABLETS NECON 1/50-28NORETHINDRONE ACET & ETH ESTRA TABLETS GILDESS 1/20NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS ESTROSTEP FENORETHINDRONE-ETH ESTRADIOL (BIPHASIC) TABLETS NECON 10/11-28NORETHINDRONE-ETH ESTRADIOL (TRIPHASIC) TABLETS CYCLAFEM 7/7/7NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ORTHO TRI-CYCLENNORGESTIMATE-ETHINYL ESTRADIOL TABLETS ESTARYLLANORGESTREL & ETHINYL ESTRADIOL TABLETS CRYSELLE-28COMBINATION CONTRACEPTIVES - VAGINALETONOGESTREL-ETHINYL ESTRADIOL RING NUVARINGEMERGENCY CONTRACEPTIVESLEVONORGESTREL (EMERGENCY OC) TABLETS PLAN BPROGESTIN CONTRACEPTIVES - INJECTIONECTABLEMEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) SUSPENSION DEPO-PROVERA CONTRACEPTIVEPROGESTIN CONTRACEPTIVES - ORALNORETHINDRONE (CONTRACEPTIVE) TABLETS CAMILACORTICOSTEROIDSGLUCOCORTICOSTEROIDSCORTISONE ACETATE TABLETS CORTISONE ACETATEDEXAMETHASONE CONCENTRATE DEXAMETHASONE INTENSOLDEXAMETHASONE ELIXIR BAYCADRONDEXAMETHASONE SOLUTION DEXAMETHASONEDEXAMETHASONE TABLETS DEXAMETHASONEHYDROCORTISONE SOD SUCCINATE SOLUTION A-HYDROCORT Prior Authorization RequiredMETHYLPREDNISOLONE ACETATE SUSPENSION DEPO-MEDROL Prior Authorization RequiredMETHYLPREDNISOLONE SOD SUCC SOLUTION A-METHAPRED Prior Authorization RequiredMETHYLPREDNISOLONE TABLETS MEDROLPREDNISOLONE ACETATE SUSPENSION FLO-PREDPREDNISOLONE SODIUM PHOSPHATE SOLUTION ORAPREDPREDNISOLONE SODIUM PHOSPHATE ORALLY DISPERSABLE TABLET ORAPRED ODTPREDNISOLONE SYRUP PRELONEPREDNISOLONE TABLETS MILLIPREDPREDNISONE CONCENTRATE PREDNISONE INTENSOLPREDNISONE SOLUTION PREDNISONEPREDNISONE TABLETS PREDNISONE




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PREDNISONE TABLET ENTERIC COATED RAYOSTRIAMCINOLONE ACETONIDE SUSPENSION KENALOG-10 Prior Authorization RequiredTRIAMCINOLONE DIACETATE SUSPENSION TRIAMCINOLONE Prior Authorization RequiredMINERALOCORTICOIDSFLUDROCORTISONE ACETATE TABLETS FLUDROCORTISONE ACETATECOUGH/COLD/ALLERGYANTITUSSIVESBENZONATATE CAPSULES TESSALON PERLES

HYDROCODONE W/ HOMATROPINE SYRUPHYDROCODONE BITARTRATE/HOMATROPINE

METHYLBROMIDE PA Required for < 18 years of age 240.00 12.00HYDROCODONE W/ HOMATROPINE TABLETS TUSSIGON PA Required for < 18 years of ageCOUGH/COLD/ALLERGY COMBINATIONSBROMPHENIRAMINE & PSEUDOEPH J-TAN D PDBROMPHENIRAMINE & PSEUDOEPH TABLET 12-HOUR BPM PSEUDOCETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR KLS ALLER-TEC D 30.00 30.00CHLORPHENIRAMINE & PSEUDOEPH CHEWABLE TABLETS DICELCHLORPHENIRAMINE & PSEUDOEPH LIQUID LOHIST-DCHLORPHENIRAMINE & PSEUDOEPH SOLUTION NEUTRAHISTCHLORPHENIRAMINE & PSEUDOEPH SYRUP EQ TRIACTING COLD/ALLERGYCHLORPHENIRAMINE & PSEUDOEPH TABLETS SUDOGEST SINUS & ALLERGYCHLORPHENIRAMINE W/ CODEINE LIQUID CODAR AR PA Required for < 18 years of age 240.00 12.00DEXTROMETHORPHAN-GUAIFENESIN BRONCOTRONDEXTROMETHORPHAN-GUAIFENESIN LIQUID NORTUSS-EXDEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DM

DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN LIQUID THERAFLU WARMING RELIEF FLU & SORE THROATDIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN PACK MUCINEX FAST-MAX NIGHT TIME COLD & FLUDIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN SUSPENSION TYLENOL CHILDRENS PLUS COLD & ALLERGYDIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN TABLETS BENADRYL ALLERGY & COLDFEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR ALLEGRA-D 12 HOUR ALLERGY & CONGESTION 30.00 30.00FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR ALLEGRA-D 24 HOUR ALLERGY & CONGESTION 30.00 30.00GUAIFENESIN-CODEINE M-CLEAR PA Required for < 18 years of age 240.00 12.00GUAIFENESIN-CODEINE LIQUID DEX-TUSS PA Required for < 18 years of age 240.00 12.00LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30.00 30.00LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30.00 30.00PHENYLEPHRINE W/ DM-GG CAPSULES GILTUSS TRPHENYLEPHRINE W/ DM-GG LIQUID ROBITUSSIN CHILDRENS COUGH & COLD CFPHENYLEPHRINE W/ DM-GG SUSPENSION BRONCOTRON-DPHENYLEPHRINE W/ DM-GG SYRUP DESPEC DM

PHENYLEPHRINE W/ DM-GG TABLETSMUCINEX FAST-MAX SEVERE CONGESTION &

COUGHPHENYLEPHRINE W/ DM-GG TABLET 12-HOUR GILTUSS TRPHENYLEPHRINE-BROMPHENIRAMINE W/ CODEINE POLY-TUSSIN AC PA Required for < 18 years of age 240.00 12.00PHENYLEPHRINE-BROMPHENIRAMINE-DM ELIXIR DIMAPHEN DM COLD & COUGH 480.00 30.00PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID DIMETAPP DM COLD & COUGH 480.00 30.00PHENYLEPHRINE-BROMPHENIRAMINE-DM SYRUP BPM-DM-PHEN 480.00 30.00PHENYLEPHRINE-CHLORPHEN-DM LIQUID GENCONTUSS PA RequiredPHENYLEPHRINE-CHLORPHEN-DM SOLUTION FATHER JOHNS MEDICINE PLUS PA RequiredPHENYLEPHRINE-CHLORPHEN-DM SYRUP BALAMINE DMPHENYLEPHRINE-CHLORPHEN-DM TABLETS PHENABID DM PA RequiredPHENYLEPHRINE-GUAIFENESIN CAPSULES DECONEXPHENYLEPHRINE-GUAIFENESIN LIQUID TRIAMINIC CHEST/NASAL CONGESTIONPHENYLEPHRINE-GUAIFENESIN SYRUP TRIAMINIC CHEST & NASAL CONGESTION




Limit QL Days



PHENYLEPHRINE-GUAIFENESIN TABLETS LIQUIBID PD-RPROMETHAZINE & PHENYLEPHRINE SYRUP PROMETHAZINE/PHENYLEPHRINEPROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE PA Required for < 18 years of age 240.00 12.00PROMETHAZINE-DM SYRUP PROMETHAZINE/DEXTROMETHORPHANPSEUDOEPHEDRINE W/ CODEINE-GG SUTTAR-2 240.00 12.00PSEUDOEPHEDRINE-BROMPHENIRAMINE-CODEINE LIQUID CPB WC PA Required for < 18 years of age 240.00 12.00PSEUDOEPHEDRINE-GUAIFENESIN CAPSULES RESPAIRE-30PSEUDOEPHEDRINE-GUAIFENESIN LIQUID TUSNEL PEDIATRICPSEUDOEPHEDRINE-GUAIFENESIN SYRUP ALTARUSSIN-PEPSEUDOEPHEDRINE-GUAIFENESIN TABLETS AMBI 40PSE/400GFNPSEUDOEPHEDRINE-GUAIFENESIN TABLET 12-HOUR MUCINEX DEXPECTORANTSGUAIFENESIN LIQUID HERBAL EXPECGUAIFENESIN PACK MUCINEX FOR KIDSGUAIFENESIN SOLUTION TRIACTIN CHEST CONGESTIONGUAIFENESIN SYRUP DIABETIC TUSSIN EXGUAIFENESIN TABLETS GUAIFENESINGUAIFENESIN TABLET 12-HOUR EQ MUCUS ERMISC. RESPIRATORY INHALANTSSODIUM CHLORIDE (INHALANT) NEBULIZED SODIUM CHLORIDEDERMATOLOGICALSACNE PRODUCTSADAPALENE CREAM DIFFERIN PA Required For > 26 Years of AgeADAPALENE GEL DIFFERIN PA Required For > 26 Years of AgeADAPALENE LOTION DIFFERIN PA Required For > 26 Years of AgeAZELAIC ACID (ACNE) CREAM AZELEX PA Required For > 26 Years of AgeBENZOYL PEROXIDE BAR PANOXYL

BENZOYL PEROXIDE CREAM NEUTROGENA ON-THE-SPOT ACNE TREATMENTBENZOYL PEROXIDE FOAM BENZEFOAMBENZOYL PEROXIDE GEL BENZOYL PEROXIDEBENZOYL PEROXIDE LIQUID PANOXYLBENZOYL PEROXIDE LOTION BP CLEANSING LOTIONBENZOYL PEROXIDE SOLUTION EFFACLAR DUOBENZOYL PEROXIDE-ERYTHROMYCIN GEL BENZAMYCINBENZOYL PEROXIDE-ERYTHROMYCIN PACK BENZAMYCINPAKCLINDAMYCIN PHOSPHATE (TOPICAL) FOAM EVOCLINCLINDAMYCIN PHOSPHATE (TOPICAL) GEL CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) LOTION CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) SOLUTION CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) SWAB CLEOCIN-TCLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL BENZACLINERYTHROMYCIN (ACNE AID) GEL ERYGELERYTHROMYCIN (ACNE AID) OINTMENT AKNE-MYCINERYTHROMYCIN (ACNE AID) PADS ERYTHROMYCINERYTHROMYCIN (ACNE AID) SOLUTION ERYTHROMYCINISOTRETINOIN CAPSULES ABSORICA PA RequiredSULFACETAMIDE SODIUM (ACNE) LOTION KLARONTRETINOIN CREAM VARIOUS PA Required For > 26 Years of AgeTRETINOIN GEL VARIOUS PA Required For > 26 Years of AgeANTIBIOTICS - TOPICALBACITRACIN (TOPICAL) OINTMENT BACIGUENTBACITRACIN ZINC OINTMENT BACITRACIN




Limit QL Days



BACITRACIN-POLYMYXIN B OINTMENT POLYSPORINBACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORINGENTAMICIN SULFATE (TOPICAL) CREAM GENTAMICIN SULFATEGENTAMICIN SULFATE (TOPICAL) OINTMENT GENTAMICIN SULFATEMUPIROCIN CALCIUM (TOPICAL) CREAM BACTROBANMUPIROCIN OINTMENT BACTROBANNEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT LANABIOTICANTIFUNGALS - TOPICALBUTENAFINE LOTRIMIN ULTRA PREFERRED BRANDCICLOPROX CREAM VARIOUSCICLOPROX SOLUTION VARIOUSCICLOPROX SUSPENSION VARIOUSCLOTRIMAZOLE CREAM (RX & OTC) LOTRIMINCLOTRIMAZOLE OINTMENT LOTRIMINCLOTRIMAZOLE SOLUTION ( RX & OTC) VARIOUSCLOTRIMAZOLE W/ BETAMETHASONE CREAM LOTRISONEKETOCONAZOLE CREAM VARIOUSKETOCONAZOLE SHAMPOO VARIOUSMICONAZOLE NITRATE CREAM VARIOUSMICONAZOLE NITRATE LIQUID/SPRAY VARIOUSMICONAZOLE NITRATE OINTMENT VARIOUSMICONAZOLE NITRATE POWDER VARIOUSNYSTATIN CREAM VARIOUSNYSTATIN OINTMENT VARIOUSNYSTATIN POWDER NYAMYCTOLNAFTATE AERO POWDER VARIOUSTOLNAFTATE CREAM VARIOUSTOLNAFTATE POWDER VARIOUSTOLNAFTATE SPRAY VARIOUSTERBINAFINE CREAM VARIOUSANTIHISTAMINES-TOPICALDIPHENHYDRAMINE HCL (TOPICAL) CREAM ANTI-ITCH MAXIMUM STRENGTHDIPHENHYDRAMINE HCL (TOPICAL) GEL BENADRYL ITCH STOPPINGDIPHENHYDRAMINE HCL (TOPICAL) SOLUTION BENADRYL MAXIMUM STRENGTHDICLOFENAC SODIUM (TOPICAL) GEL VOLTAREN BRAND ONLY 100 GM 300.00ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPBEXAROTENE (TOPICAL) GEL TARGRETINFLUOROURACIL (TOPICAL) CREAM CARACFLUOROURACIL (TOPICAL) SOLUTION FLUOROURACILANTIPSORIATICSACITRETIN CAPSULES SORIATANEANTHRALIN CREAM DRITHO-CREME HPCALCIPOTRIENE CREAM DOVONEXCALCIPOTRIENE FOAM SORILUXCALCIPOTRIENE OINTMENT CALCITRENECALCIPOTRIENE SOLUTION CALCIPOTRIENEMETHOXSALEN RAPID CAPSULES OXSORALEN ULTRATAZAROTENE CREAM TAZORAC PA RequiredTAZAROTENE GEL TAZORAC PA RequiredANTISEBORRHEIC PRODUCTSSELENIUM SULFIDE LOTION SELSUN SHAMPOOANTIVIRALS - TOPICALDOCOSANOL CREAM ABREVA




Limit QL Days



ACYCLOVIR OINTMENT ZOVIRAX 15GM 30.00BURN PRODUCTSSILVER SULFADIAZINE CREAM SILVADENECORTICOSTEROIDS - TOPICAL LOW POTENCYHYDROCORTISONE CREAM VARIOUSHYDROCORTISONE GEL VARIOUSHYDROCORTISONE KIT VARIOUSHYDROCORTISONE LOTION VARIOUSHYDROCORTISONE OINTMENT VARIOUSHYDROCORTISONE ACETATE CREAM 0.5% VARIOUSFLUOCINOLONE 0.01% OIL VARIOUSCORTICOSTEROIDS - TOPICAL MEDIUM POTENCYFLUTICASONE PROPIONATE CREAM VARIOUSFLUTICASONE PROPIONATE OINTMENT VARIOUSMOMETASONE FUROATE CREAM VARIOUSMOMETASONE FUROATE OINTMENT VARIOUSMOMETASONE FUROATE SOLUTION VARIOUSCORTICOSTEROIDS - TOPICAL HIGH POTENCYBETAMETHASONE DIPROPIONATE LOTION VARIOUSBETAMETHASONE DIPROPIONATE/PROPYLENE GLYC. CREAM VARIOUSBETAMETHASONE VALERATE CREAM VARIOUSBETAMETHASONE VALERATE LOTION VARIOUSBETAMETHASONE VALERATE OINTMENT VARIOUSFLUOCINONIDE CREAM VARIOUSFLUOCINONIDE OINTMENT VARIOUSFLUOCINONIDE SOLUTION VARIOUSTRIAMCINOLONE ACETONIDE CREAM VARIOUSTRIAMCINOLONE ACETONIDE LOTION VARIOUSTRIAMCINOLONE ACETONIDE OINTMENT VARIOUSCORTICOSTEROIDS - TOPICAL VERY HIGH POTENCYCLOBETASOL PROPIONATE CREAM VARIOUS 100 30CLOBETASOL PROPIONATE EMOLLIENT VARIOUS 100 30CLOBETASOL PROPIONATE GEL VARIOUS 118 30CLOBETASOL PROPIONATE OINTMENT VARIOUS 100 30CLOBETASOL PROPIONATE SOLUTION VARIOUS 100 30HALOBETASOL PROPIONATE CREAM VARIOUS 100 30HALOBETASOL PROPIONATE OINTMENT VARIOUS 100 30EMOLLIENTSLACTIC ACID (AMMONIUM LACTATE) CREAM NOBLE MYSTIQUE EMU-LACLACTIC ACID (AMMONIUM LACTATE) FOAM PRO:12 MOUSSE AL12LACTIC ACID (AMMONIUM LACTATE) LOTION GERI-HYDROLAC 5IMMUNOSUPPRESSIVE AGENTS - TOPICALPIMECROLIMUS CREAM ELIDELTACROLIMUS (TOPICAL) OINTMENT PROTOPIC PA RequiredVITAMINS A & D (TOPICAL) OINTMENT CURAD VITAMIN A & DKERATOLYTIC/ANTIMITOTIC AGENTSSALICYLIC ACID CREAM SALACYNSALICYLIC ACID FOAM SALVAXSALICYLIC ACID GEL KERALYTSALICYLIC ACID KIT KERALYT SCALPSALICYLIC ACID LIQUID VIRASALSALICYLIC ACID LOTION SALACYNSALICYLIC ACID SHAMPOO SALEX




Limit QL Days



SALICYLIC ACID SOLUTION SALICYLIC ACIDLOCAL ANESTHETICS - TOPICALLIDOCAINE CREAM 4% ASPERCREME W/LIDOCAINELIDOCAINE HCL GEL 2% GLYDOLIDOCAINE HCL LOTION LIDOCAINE HCLLIDOCAINE OINTMENT LIDOCAINE PA RequiredLIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE-PRILOCAINE CREAM EMLAMISC. TOPICALALUMINUM CHLORIDE SOLUTION DRYSOLZINC OXIDE (TOPICAL) OINTMENT ZINC OXIDEZINC OXIDE (TOPICAL) PASTE ZINC OXIDEPIGMENTING-DEPIGMENTING AGENTSMETHOXSALEN (TOPICAL) LOTION OXSORALENROSACEA AGENTSMETRONIDAZOLE (TOPICAL) CREAM 0.75% METROCREAMMETRONIDAZOLE (TOPICAL) GEL 0.75% ROSADANMETRONIDAZOLE (TOPICAL) LOTION METROLOTIONSCABICIDES & PEDICULICIDESCROTAMITON CREAM EURAXCROTAMITON LOTION EURAXIVERMECTIN (PEDICULICIDE) LOTION SKLICE PA RequiredLINDANE LOTION LINDANE PA RequiredLINDANE SHAMPOO LINDANE PA RequiredMALATHION LOTION OVIDEPERMETHRIN 1%, 5% NIX, ELIMITEPERMETHRIN CREAM ACTICINPERMETHRIN LIQUID NIX CREME RINSEPERMETHRIN LOTION LICE TREATMENTPYRETHRINS-PIPERONYL BUTOXIDE GEL A-200PYRETHRINS-PIPERONYL BUTOXIDE KIT PRONTOPYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARCPYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDESPINOSAD SUSPENSION NATROBA PA RequiredWOUND CARE PRODUCTSBECAPLERMIN GEL REGRANEX PA RequiredDIAGNOSTIC PRODUCTSDIAGNOSTIC TESTSGLUCOSE BLOOD STRIPS TRUETRACK AND ACCU-CHEK AVIVA 200.00 30.00DIGESTIVE AIDSDIGESTIVE ENZYMESLIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE CREON Brand Only Preferred Drug 300.00 30.00LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE ZENPEP Brand Only Preferred Drug 300.00 30.00LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 UNITS PANCRELIPASE 5000 UNITS Preferred Drug 300.00 30.00SACROSIDASE SOLUTION SUCRAID PA RequiredDIURETICSCARBONIC ANHYDRASE INHIBITORSACETAZOLAMIDE CAPSULE 12-HOUR DIAMOXACETAZOLAMIDE TABLETS ACETAZOLAMIDEMETHAZOLAMIDE TABLETS NEPTAZANEDIURETIC COMBINATIONSSPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDE




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TRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25LOOP DIURETICSBUMETANIDE TABLETS BUMETANIDEFUROSEMIDE SOLUTION FUROSEMIDEFUROSEMIDE TABLETS LASIXTORSEMIDE TABLETS DEMADEXPOTASSIUM SPARING DIURETICSAMILORIDE HCL TABLETS AMILORIDE HCLSPIRONOLACTONE TABLETS ALDACTONETRIAMTERENE CAPSULES DYRENIUMTHIAZIDES AND THIAZIDE-LIKE DIURETICSCHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDECHLORTHALIDONE TABLETS CHLORTHALIDONEHYDROCHLOROTHIAZIDE 12.5MG CAPSULES VARIOUSHYDROCHLOROTHIAZIDE TABLETS 25MG & 50MG HYDROCHLOROTHIAZIDEINDAPAMIDE TABLETS INDAPAMIDEMETHYCLOTHIAZIDE TABLETS METHYCLOTHIAZIDEMETOLAZONE TABLETS ZAROXOLYNENDOCRINE AND METABOLIC AGENTS - MISC.BONE DENSITY REGULATORSALENDRONATE SODIUM SOLUTION ALENDRONATE SODIUM PA RequiredALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM 30.00 30.00CALCITONIN (SALMON) SOLUTION FORTICALRALOXIFENE TABLETS VARIOUSGROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOLUTION SOMAVERT PA RequiredGROWTH HORMONESSOMATROPIN SOLUTION NORDITROPIN Brand Only Preferred Drug PA Required SOMATROPIN SOLUTION GENOTROPIN Brand Only Preferred Drug PA Required HORMONE RECEPTOR MODULATORSRALOXIFENE HCL TABLETS EVISTA 30.00 30.00INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)MECASERMIN SOLUTION INCRELEX PA RequiredLHRH/GNRH AGONIST ANALOG PITUITARY SUPPOSITORYRESSANTSLEUPROLIDE ACETATE (CPP) (3 MONTH) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE (CPP) KIT LUPRON DEPOT-PED PA RequiredNAFARELIN ACETATE SOLUTION SYNAREL PA RequiredMETABOLIC MODIFIERSCALCITRIOL CAPSULES ROCALTROLCALCITRIOL SOLUTION ROCALTROLCINACALCET HCL TABLETS SENSIPAR PA RequiredIDURSULFASE SOLUTION ELAPRASE PA RequiredLEVOCARNITINE (METABOLIC MODIFIERS) SOLUTION CARNITOR PA RequiredLEVOCARNITINE (METABOLIC MODIFIERS) TABLETS CARNITOR PA RequiredPOSTERIOR PITUITARY HORMONESDESMOPRESSIN ACETATE REFRIGERATED SOLUTION DDAVPDESMOPRESSIN ACETATE SOLUTION STIMATEDESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION DESMOPRESSIN ACETATEDESMOPRESSIN ACETATE SPRAY SOLUTION DDAVPDESMOPRESSIN ACETATE TABLETS DDAVPPROLACTIN INHIBITORSCABERGOLINE TABLETS CABERGOLINE PA Required




Limit QL Days



SOMATOSTATIC AGENTSLANREOTIDE ACETATE SOLUTION SOMATULINE DEPOT PA RequiredOCTREOTIDE ACETATE KIT SANDOSTATIN LAR DEPOT PA RequiredOCTREOTIDE ACETATE SOLUTION SANDOSTATIN PA RequiredESTROGENSESTROGEN COMBINATIONSCONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPROESTERIFIED ESTROGENS & METHYLTESTOSTERONE TABLETS COVARYX HSESTRADIOL & NORETHINDRONE ACETATE PATCH TWICE WEEKLY COMBIPATCHESTRADIOL & NORETHINDRONE ACETATE TABLETS ACTIVELLAESTRADIOL-LEVONORGESTREL PATCH WEEKLY CLIMARA PRONORETHINDRONE ACETATE-ETHINYL ESTRADIOL TABLETS FEMHRT LOW DOSEESTROGENSESTERIFIED ESTROGENS TABLETS MENESTESTRADIOL PATCH TWICE WEEKLY ALORAESTRADIOL PATCH WEEKLY MENOSTARESTRADIOL TABLETS ESTRACEESTROGENS, CONJUGATED SYNTHETIC A TABLETS CENESTINESTROGENS, CONJUGATED TABLETS PREMARINESTROPIPATE TABLETS ORTHO-ESTFLUOROQUINOLONESFLUOROQUINOLONESCIPROFLOXACIN HCL TABLETS CIPROFLOXACIN HCLLEVOFLOXACIN SOLUTION LEVAQUINLEVOFLOXACIN TABLETS LEVAQUINOFLOXACIN TABLETS OFLOXACINGASTROINTMENTESTINAL AGENTS - MISC.GALLSTONE SOLUBILIZING AGENTSURSODIOL CAPSULES ACTIGALLURSODIOL TABLETS URSO 250GASTROINTMENTESTINAL ANTIALLERGY AGENTSCROMOLYN SODIUM (MASTOCYTOSIS) CONCENTRATE GASTROCROMGASTROINTMENTESTINAL CHLORIDE CHANNEL ACTIVATORSLUBIPROSTONE CAPSULES AMITIZA PA RequiredGASTROINTMENTESTINAL STIMULANTSMETOCLOPRAMIDE HCL SOLUTION METOCLOPRAMIDE HCLMETOCLOPRAMIDE HCL TABLETS REGLANMETOCLOPRAMIDE HCL ORALLY DISPERSABLE TABLET METOZOLV ODTINFLAMMATORY BOWEL AGENTSBALSALAZIDE DISODIUM CAPSULES COLAZAL 270.00 30.00BALSALAZIDE DISODIUM TABLETS GIAZO 270.00 30.00MESALAMINE CAPSULE CONTROLLED RELEASE PENTASA 270.00 30.00MESALAMINE ENEMA MESALAMINE 240.00 30.00MESALAMINE TABLET ENTERIC COATED ASACOL HD 120.00 30.00OLSALAZINE SODIUM CAPSULES DIPENTUM 120.00 30.00SULFASALAZINE TABLETS AZULFIDINE 240.00 30.00SULFASALAZINE TABLET ENTERIC COATED AZULFIDINE EN-TABLETS 240.00 30.00INTESTINAL ACIDIFIERSLACTULOSE (ENCEPHALOPATHY) SOLUTION LACTULOSEIRRITABLE BOWEL SYNDROME (IBS) AGENTSALOSETRON HCL TABLETS LOTRONEX PA RequiredLINACLOTIDE CAPSULES LINZESS PA RequiredPHOSPHATE BINDER AGENTS




Limit QL Days



CALCIUM ACETATE (PHOSPHATE BINDER) CAPSULES CALCIUM ACETATECALCIUM ACETATE (PHOSPHATE BINDER) TABLETS CALCIUM ACETATESEVELAMER CARBONATE TABLETS RENVELA Brand OnlySEVELAMER HCL TABLETS RENAGEL Brand OnlyGENITOURINARY AGENTS - MISCELLANEOUSACIDIFIERSPOTASSIUM & SODIUM ACID PHOSPHATES TABLETS K-PHOS NO 2ALKALINIZERS

POT & SOD CITRATES W/CITRIC AC SOLUTION POTASSIUM CITRATE/SODIUM CITRATE/CITRIC ACIDPOT & SOD CITRATES W/CITRIC AC SYRUP CYTRA-3POTASSIUM CITRATE (ALKALINIZER) TABLET CONTROLLED RELEASE UROCIT-K 5POTASSIUM CITRATE-CITRIC ACID PACK TARON-CRYSTALSPOTASSIUM CITRATE-CITRIC ACID SOLUTION POTASSIUM CITRATE/CITRIC ACIDSODIUM CITRATE & CITRIC ACID SOLUTION SHOHLS SOLUTION MODIFIEDINTERSTITIAL CYSTITIS AGENTSPENTOSAN POLYSULFATE SODIUM CAPSULES ELMIRON PA RequiredPROSTATIC HYPERTROPHY AGENTSALFUZOSIN HCL TABLET 24-HOUR VARIOUSDOXAZOSIN MESYLATE TABLETS VARIOUSDUTASTERIDE CAPS VARIOUSFINASTERIDE TABLETS PROSCARTAMSULOSIN HCL CAPSULES FLOMAXTERAZOSIN HCL CAPSULES VARIOUSURINARY ANALGESICSPHENAZOPYRIDINE HCL BARIDIUMPHENAZOPYRIDINE HCL TABLETS PYRIDIUMGOUT AGENTSGOUT AGENT COMBINATIONSCOLCHICINE W/ PROBENECID TABLETS PROBENECID/COLCHICINEGOUT AGENTSALLOPURINOL TABLETS ZYLOPRIMCOLCHICINE TABLETS COLCRYS PA RequiredFEBUXOSTAT TABLETS ULORIC 30.00 30.00URICOSURICSPROBENECID TABLETS PROBENECIDHEMATOLOGICAL AGENTS - MISC.HEMATORHEOLOGIC AGENTSPENTOXIFYLLINE TABLET CONTROLLED RELEASE TRENTALPLATELET AGGREGATION INHIBITORSANAGRELIDE HCL CAPSULES AGRYLINCILOSTAZOL TABLETS PLETALCLOPIDOGREL BISULFATE TABLETS PLAVIXDIPYRIDAMOLE TABLETS PERSANTINETICAGRELOR TABLETS BRILINTATICLOPIDINE HCL TABLETS TICLOPIDINE HCLGASTROINTESTINAL AGENTS - MISCELLANEOUSANTIFLATULENTSSIMETHICONE SUSPENSION CVS INFANTS GAS RELIEFHEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASEELIGLUSTAT TARTRATE CARDELA (oral) PA RequiredIMIGLUCERASE SOLUTION CEREZYME 400 IU (IV) PA Required




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TALIGLUCERASE ALFA ELELYSO (IV) PA RequiredMIGLUSTAT MIGLUSTAT (AG) (oral) PA RequiredVELAGLUCERASE ALFA VPRIB 400 IU PA RequiredFOLIC ACID/FOLATESFOLIC ACID CAPSULES FA-8FOLIC ACID TABLETS FOLIC ACIDHEMATOPOIETIC GROWTH FACTORSELTROMBOPAG OLAMINE TABLETS PROMACTA BRAND ONLY PREFERRED DRUG PA RequiredEPOETIN ALFA-EPBX SOLUTION RETACRIT BRAND ONLY PREFERRED DRUG PA RequiredFILGRASTIM SOLUTION NEUPOGEN VIAL & DISPOSABLE SYRINGE BRAND ONLY PREFERRED DRUG PA RequiredPEGFILGRASTIM SOLUTION UDENYCA BRAND ONLY PREFERRED DRUG PA RequiredPEGFILGRASTIM- JMDB SOLUTION FULPHILIA BRAND ONLY PREFERRED DRUG PA RequiredROMIPLOSTIM NPLATE BRAND ONLY PREFERRED DRUG PA RequiredHEMATOPOIETIC MIXTURESFE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC ACID CAPSULES HEMATOGEN FAFERROUS FUMARATE W/ B12-VIT C-FA-IFC CAPSULES TRICONFERROUS FUMARATE W/ FA-DSS-B COMPLEX-VIT C TABLETS NEPHRON FAFOLATE-VITAMIN B12-INTRINSIC FACTOR TABLETS INTRINSI B12/FOLATEIRON COMBINATIONS CORVITE 150IRON COMBINATIONS CAPSULES HEMATOGENIRON COMBINATIONS ELIXIR HEMOCYTE-FIRONFERROUS FUMARATE CAPSULES HIGH POTENCY IRONFERROUS FUMARATE TABLETS FEMIRONFERROUS FUMARATE TABLET CONTROLLED RELEASE IRONFERROUS GLUCONATE TABLETS FERATEFERROUS SULFATE DRIED TABLETS FEOSOLFERROUS SULFATE DRIED TABLET CONTROLLED RELEASE EQ SLOW-RELEASE IRONFERROUS SULFATE ELIXIR FEROSULFERROUS SULFATE LIQUID SPATONE PUR-ABSORB IRONFERROUS SULFATE SOLUTION BPROTECTED PEDIA IRONFERROUS SULFATE SYRUP FERROUS SULFATEFERROUS SULFATE TABLETS FERROUS SULFATEFERROUS SULFATE TABLET CONTROLLED RELEASE FERROUS SULFATEFERROUS SULFATE TABLET ENTERIC COATED FERROUS SULFATEHEMOSTATICSHEMOSTATICS - SYSTEMICAMINOCAPROIC ACID SYRUP AMICARAMINOCAPROIC ACID TABLETS AMICARHYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTANTIHISTAMINE HYPNOTICSDIPHENHYDRAMINE HCL (SLEEP) CAPSULES CVS NIGHTTIME SLEEP AIDDIPHENHYDRAMINE HCL (SLEEP) TABLET NIGHTTIME SLEEP-AIDDIPHENHYDRAMINE HCL (SLEEP) LIQUID ZZZQUILDIPHENHYDRAMINE HCL (SLEEP) TABLET DISPERSIBLE WAL-SOMBARBITURATE HYPNOTICSPHENOBARBITAL SOLUTION PHENOBARBITALPHENOBARBITAL TABLETS PHENOBARBITALNON-BARBITURATE HYPNOTICSTEMAZEPAM CAPSULES 15MG & 30MG RESTORIL PA Required for > 1 Hypnotic 30.00 30.00ZOLPIDEM TARTRATE TABLETS 5MG AMBIEN PA Required for > 1 Hypnotic 60.00 30.00ZOLPIDEM TARTRATE TABLETS 10MG AMBIEN PA Required for > 1 Hypnotic 30.00 30.00SELECTIVE MELATONIN RECEPTOR AGONISTS




Limit QL Days



RAMELTEON TABLETS ROZEREMPatient must have tried Temazepam and

ZolpidemHYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTANTIHISTAMINE HYPNOTICSDOXYLAMINE SUCCINATE (SLEEP) TABLETS RA NIGHT SLEEP AIDLAXATIVESBULK LAXATIVESFIBER CAPSULES ADVANCED FIBER COMPLEX/ACIDOPHILUSFIBER TABLETS FIBER COMPLETEFIBER CHEWABLES EQ FIBER SUPPLEMENTFIBER LIQDID LIQUAFIBERFIBER POWDER SOLFIBERMETHYLCELLULOSE (LAXATIVE) TABLETS MIRAFIBERMETHYLCELLULOSE (LAXATIVE) POWDER CITRUCEL FIBER LAXATIVEMETHYLCELLULOSE (LAXATIVE) PACKETS CITRUCEL FIBER LAXATIVEPSYLLIUM CAPSULES NAT-RUL PSYLLIUM SEED HUSKSPSYLLIUM PACK METAMUCIL SMOOTH TEXTUREPSYLLIUM POWDER KONSYLPSYLLIUM SUBLINGUAL METAMUCILLAXATIVE COMBINATIONSPEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTE-FLAVOR PACKS

PEG 3350-POTASSIUM CHLORIDE-SOD BICARBONATE-SOD CHLORIDE SOLUTION GAVILYTE-N/FLAVOR PACKSENNOSIDES-DOCUSATE SODIUM TABLETS SENNA-SLAXATIVES - MISCELLANEOUSGLYCERIN (LAXATIVE) SUPPOSITORIES GLYCERIN CHILDRENLACTULOSE PACK KRISTALOSELACTULOSE SOLUTION LACTULOSEPOLYETHYLENE GLYCOL 3350 PACK CLEARLAXPOLYETHYLENE GLYCOL 3350 POWDER CLEARLAXSALINE LAXATIVESMAGNESIUM CITRATE SOLNTION CITROMAMAGNESIUM OXIDE (LAXATIVE) TABLETS PHILLIPSSODIUM PHOSPHATES ENEMA GNP ENEMASTIMULANT LAXATIVESBISACODYL ENEMA FLEET BISACODYLBISACODYL KIT DULCOLAX BOWEL PREP KITBISACODYL POWDER BISACODYLBISACODYL SUPPOSITORY BISAC-EVACBISACODYL TABLET ENTERIC COATED ALOPHENCASCARA SAGRADA CAPSULES CASCARA SAGRADACASCARA SAGRADA TABLETS CASCARA SAGRADACASCARA SAGRADA EXTRACT CASCARA SAGRADASENNA SYRP SENNASENNA MISC CORRECTOL HERBAL TEASENNA LEAV SENNA LEAVESSENNOSIDES CAPSULES RA SENNASENNOSIDES TABLETS SENNA-LAXSENNOSIDES CHEWABLES RA LAXATIVESENNOSIDES LIQUID AGORAL MAXIMUM STRENGTHSENNOSIDES SYRUP SENNA-GRXSURFACTANT LAXATIVESDOCUSATE SODIUM CAPSULES COLACE




Limit QL Days



DOCUSATE SODIUM ENEMA DOCUSOL KIDSDOCUSATE SODIUM LIQUID PEDIA-LAXDOCUSATE SODIUM SYRUP DIOCTODOCUSATE SODIUM TABLETS DOKMACROLIDESAZITHROMYCINAZITHROMYCIN PACK ZITHROMAXAZITHROMYCIN SUSPENSION ZITHROMAXAZITHROMYCIN TABLETS ZITHROMAXCLARITHROMYCINCLARITHROMYCIN SUSPENSION CLARITHROMYCINCLARITHROMYCIN TABLETS BIAXINCLARITHROMYCIN TABLET 24-HOUR BIAXIN XLERYTHROMYCIN PRODUCTS REQUIRE PRIOR AUTHORIZATIONFIDAXOMICINFIDAXOMICIN TABLETS DIFICID PA RequiredMEDICAL DEVICECESCONTRACEPTIVESCONDOMS - FEMALE MISC FC FEMALE CONDOM 30.00 30.00CONDOMS - MALE MISC LIFESTYLES ASSORTED COLORS 30.00 30.00CONDOMS LATEX LUBRICATED - MALE MISC ATLAS COLORED LUBRICATED CONDOM 30.00 30.00CONDOMS LATEX NON-LUBRICATED - MALE MISC ATLAS COLORED CONDOM/SPERMICIDE 30.00 30.00CONDOMS NON-LATEX NON-LUBRICATED - MALE MISC TROJAN NATURALAMB 30.00 30.00DIAPHRAGM ARC-SPRING DPRH CAYA 1.00 365.00DIAPHRAGM COIL SPRING KIT ORTHO DIAPHRAGM COIL SPRING KIT 50 1.00 365.00DIAPHRAGM FLAT SPRING KIT ORTHO DIAPHRAGM FLAT SPRING KIT 55 1.00 365.00DIAPHRAGM WIDE SEAL DPRH WIDE-SEAL SILICONE DIAPHRAGM KIT 60 1.00 365.00DIAPHRAGMS DPRH OMNIFLEX DIAPHRAGM 1.00 365.00DIABETIC SUPPLIES

BLOOD GLUCOSE CALIBRATION LIQUID ACCU-CHEK ACTIVE GLUCOSE CONTROL SOLUTIONBLOOD GLUCOSE MONITORING SUPPLIES DEVICE TRUETRACK MIS BLD GLCBLOOD GLUCOSE MONITORING SUPPLIES KIT TRUETRACK KIT SYSTEMLANCET DEVICES MISC ACCU-CHEK SOFTCLIX LANCETDEVICECELANCETS MISC 1ST CHOICE LANCETS SUPER THINLANCETS MISC. KIT ACCU-CHEK FASTCLIX LANCETDEVICECE KITLANCETS MISC. MISC AUTOLET PLATFORMSMISC. DEVICECESALCOHOL SWABS PADS ALCOH-GLOVE CONTOURED WIPEPARENTERAL THERAPY SUPPLIESINSULIN PEN NEEDLE MISC BD AUTOSHIELD 29G X 3/16"INSULIN SYRINGE/NEEDLE U-100 MISC RELION INSULIN SYRINGE/U-100/0.3ML/29GINSULIN SYRINGE/NEEDLE U-40 MISC BD INSULIN SYRINGE U-40/1ML/25G X 5/8"

INSULIN SYRINGES (DISPOSABLE) MISC KMART VALU PLUS INSULIN SYRINGE/0.3ML/30G

SYRINGE/NEEDLE (DISP) 1 ML MONOJECT MAGELLAN SYRINGE/SAFETY

NEEDLE/1ML/23G X 1"

SYRINGE/NEEDLE (DISP) 1 ML MISCMONOJECT LIFESHIELD BLUNTCANNULA/REG LUER

SYR/1ML/18G X 1"RESPIRATORY THERAPY SUPPLIESPEAK FLOW METER W/INHALER ASSIST DEVICE KIT AEROGEAR ASTHMA ACTION 2.00 365.00RESPIRATORY THERAPY DEVICE AEROBIKARESPIRATORY THERAPY KIT AIRS DISPOSABLE NEBULIZER




Limit QL Days



RESPIRATORY THERAPY MISC ACE AEROSOL CLOUD ENHANCER 2.00 365.00SPACER/AEROSOL-HOLDING CHAMBER - MASKS MISC MASK VORTEX/BABY WHIRL DUCKLINGSPACER/AEROSOL-HOLDING CHAMBERS DEVICE AEROCHAMBER MINI CHAMBER 2.00 365.00SPACER/AEROSOL-HOLDING CHAMBERS MISC AEROCHAMBER MINI CHAMBERMIGRAINE PRODUCTSMIGRAINE COMBINATIONSERGOTAMINE W/ CAFFEINE SUPPOSITORY MIGERGOT 12.00 30.00ERGOTAMINE W/ CAFFEINE TABLETS CAFERGOT 40.00 30.00MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIESERENUMAB-AOOE SOLUTION AUTOINJECTOR AIMOVIG Preferred Drug PA Required

GALCANEZUMAB-GNLM SOLUTION AUTOINJECTOR / PREFILLED SYRINGE / PEN EMGALITY Preferred Drug PA RequiredSEROTONIN AGONISTSNARATRIPTAN HCL TABLETS AMERGE 9.00 30.00RIZATRIPTAN BENZOATE TABLETS MAXALT 9.00 30.00RIZATRIPTAN BENZOATE ORALLY DISPERSABLE TABLET MAXALT-MLT 9.00 30.00SUMATRIPTAN SOLUTION NASAL SPRAY IMITREX SPRAY 6.00 30.00SUMATRIPTAN SUCCINATE SOLUTION INJECTION IMITREX 2.00 30.00SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTION IMITREX STATDOSE SYSTEM 2.00 30.00SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE IMITREX STATDOSE REFILL 2.00 30.00SUMATRIPTAN SUCCINATE TABLETS IMITREX 9.00 30.00ZOLMITRIPTAN TABLETS ZOMIG 9.00 30.00ZOLMITRIPTAN ORALLY DISPERSABLE TABLET ZOMIG ZMT 9.00 30.00MINERALS & ELECTROLYTESCALCIUMCALCIUM LACTATE CAPSULES CAL-LACCALCIUM LACTATE TABLETS CALCIUM LACTATEFLUORIDESODIUM FLUORIDE CHEWABLE TABLETS LUDENTSODIUM FLUORIDE LOZG LOZI-FLURSODIUM FLUORIDE SOLUTION FLUOR-A-DAYSODIUM FLUORIDE TABLETS SODIUM FLUORIDEMAGNESIUMMAGNESIUM OXIDE (MG SUPPLEMENT) CAPSULES MAGNESIUMMAGNESIUM OXIDE (MG SUPPLEMENT) TABLETS MAG-200POTASSIUMPOTASSIUM BICARB & CHLORIDE TABLET EFFERVESCENT EFFERVESCENT POTASSIUM/CHLORIDEPOTASSIUM BICARBONATE TABLET EFFERVESCENT EFFER-KPOTASSIUM BICARBONATE-CITRIC ACID TABLET EFFERVESCENT EFFER-KPOTASSIUM CHLORIDE CAPSULE CONTROLLED RELEASE KLOR-CON SPRINKLEPOTASSIUM CHLORIDE LIQUID K-SOL

POTASSIUM CHLORIDE MICRO ENCAPSULESULATED CRYSTALS CONTROLLED RELEASE KLOR-CON M10POTASSIUM CHLORIDE PACK KLOR-CONPOTASSIUM CHLORIDE TABLET CONTROLLED RELEASE KLOR-CON 8SODIUMSODIUM CHLORIDE FLUSH SOLUTION NORMAL SALINE FLUSHMOUTH/THROAT/DENTAL AGENTSANTISEPTICS - MOUTH/THROATCHLORHEXIDINE GLUCONATE (MOUTH-THROAT) SOLUTION PAROEXSTEROIDS - MOUTH/THROATTRIAMCINOLONE ACETONIDE (MOUTH) PASTE ORALONE 10.00 30.00ANESTHETICS TOPICAL ORAL




Limit QL Days



LIDOCAINE HCL (MOUTH-THROAT) SOLUTION LIDOCAINE VISCOUSTHROAT PRODUCTS - MISC.ARTIFICIAL SALIVA KIT ORAL RELIEF FOR DRY MOUTH& DISCOMFORTARTIFICIAL SALIVA LOZENGE ACT DRY MOUTHARTIFICIAL SALIVA SOLUTION BIOTENE MOISTURIZING MOUTH SPRAYMULTIVITAMINSB-COMPLEX VITAMINSB-COMPLEX VITAMINS B-COMPLEXB-COMPLEX W/ CB COMPLEX W/ C CAPSULES B COMPLEX/VITAMIN CB COMPLEX W/ C TABLETS B COMPLEX/CB COMPLEX W/ C TABLET CONTROLLED RELEASE B-COMPLEX +CB-COMPLEX W/ FOLIC ACIDB COMPLEX W/ C-BIOTIN-E-FOLIC ACID & IRON CARBONYL MISC RENATABLETS WITH IRONB-COMPLEX W/ C & FOLIC ACID MILCO-B-FORTEB-COMPLEX W/ C & FOLIC ACID CAPSULES NEPHROCAPSULESB-COMPLEX W/ C & FOLIC ACID TABLETS DIALYVITEB-COMPLEX W/ C-BIOTIN-D-ZINC & FOLIC ACID TABLETS VITAL-D RXB-COMPLEX W/ LYSINE-MIN-FE & FOLIC ACID LIQUID NUTRIVITB-COMPLEX W/ LYSINE-ZN & FOLIC ACID LIQUID SUPERVITEIRON W/ VITAMINSIRON W/ VITAMINS TABLETS GERITOL COMPLETE 30.00 30.00MULTIPLE VITAMINS W/ IRONMULTIPLE VITAMINS W/ IRON TABLETS MULTIPLE VITAMINS/IRONMULTIPLE VITAMINS W/ MINERALSMULTIPLE VITAMINS W/ MINERALS CAPSULES VARIOUS 30.00 30.00MULTIPLE VITAMINS W/ MINERALS CHEWABLE TABLETS VARIOUS 30.00 30.00MULTIPLE VITAMINS W/ MINERALS LIQUID VARIOUS 30.00 30.00MULTIPLE VITAMINS W/ MINERALS TABLETS VARIOUS 30.00 30.00PEDIATRIC MULTIPLE VITAMINSPEDIATRIC MULTIPLE VITAMIN W/ C SOLUTION POLY-VITE DROPSPED MULTIPLE VITAMINS W/ MINERALSPEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEWABLES CHILDRENS CHEWABLE GUMMIESPED MV W/ IRONPEDIATRIC MULTIPLE VITAMINS W/ IRON SOULTION POLY-VITE SOL /IRONPED MULTI VITAMINS W/FL & FEPEDIATRIC VITAMINS ACD FLUORIDE & IRON SOLUTION TRI-VIT/FLUORIDE/IRONPED MV W/ FLUORIDEPEDIATRIC MULTIVITAMINS W/FL CHEWABLE TABLETS MVC-FLUORIDE 30.00 30.00PEDIATRIC MULTIVITAMINS W/FL SOLUTION QUFLORA PEDIATRICPEDIATRIC MULTIVITAMINS W/FL SUSPENSION POLY-VI-FLORPEDIATRIC VITAMINS ACD W/ FLUORIDE SOLUTION TRIPLE-VITAMIN/FLUORIDEPRENATAL VITAMINSPRENATAL MULTIVIT-MIN W/FE-FA TABS PRE-NATAL FORMULA 30.00 30.00PRENATAL MV & MIN W/FE FUMARATE-FA-DHA MISC VITAFOL-OB+DHA 30.00 30.00PRENATAL MV & MIN W/FE POLYSACCHARIDE COMPLEX-FA-DHA CAPS VITAFOL-ONE 30.00 30.00PRENATAL MV & MIN W/FE POLYSACCHARIDE COMPLEX-FA-DHA MISC SELECT-OB+DHA 30.00 30.00

PRENATAL VIT W/ DOCUSATE-FE FUMARATE-FOLIC ACID TABS PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID 30.00 30.00PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FOLIC ACID TABS VINATE AZ EXTRA 30.00 30.00PRENATAL VIT W/ FE FUM-IRON POLYSACCH COMPLEX -FA-OMEGA 3 CAPS CONCEPT DHA 30.00 30.00PRENATAL VIT W/ FERROUS FUMARATE-FA-OMEGA 3 FATTY ACIDS CAPS VIVA DHA 30.00 30.00PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID CHEW COMPLETENATE 30.00 30.00




Limit QL Days



PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID TABS M-VIT 30.00 30.00PRENATAL VIT W/ FERROUS FUMARATE-L METHYLFOLATE-FOLIC ACID TABS ZATEAN-PN 30.00 30.00PRENATAL VIT W/ IRON CARBONYL-FE ASPART GLYC-FA-OMEGA 3 CAPS FOLCAPS OMEGA 3 30.00 30.00PRENATAL VIT W/ IRON CARBONYL-FOLIC ACID TABS PRENATABS RX 30.00 30.00PRENATAL VIT W/ SELENIUM-FE FUMARATE-FOLIC ACID TABS VINATE M 30.00 30.00PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA-DHA CAPS PRENEXA 30.00 30.00PRENATAL WITHOUT A VIT W/ FE FUMARATE-FOLIC ACID CHEW VINATE CARE 30.00 30.00PRENATAL WITHOUT A VIT W/ FE FUM-IRON POLYSACCH COMPLEX -FA CAPS CONCEPT OB 30.00 30.00PRENATAL WITHOUT VIT A W/ FE CARBONYL-FE GLUC-DOCUSATE-FA TABS CITRANATAL RX 30.00 30.00MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTSBACLOFEN TABLETS BACLOFENCYCLOBENZAPRINE HCL TABLETS 5MG & 10MG ONLY FLEXERILMETAXALONE TABLETS METAXALONEMETHOCARBAMOL TABLETS ROBAXINORPHENADRINE CITRATE TABLET 12-HOUR ORPHENADRINE CITRATE CRTIZANIDINE HCL - 2mg and 4mg TABLETS ONLY TIZANIDINE HCLDIRECT MUSCLE RELAXANTSDANTROLENE SODIUM CAPSULES DANTRIUMNASAL AGENTS - SYSTEMIC AND TOPICALNASAL AGENTS - MISCELLANEOUSSALINE NASAL SPRAY SALINE NASAL SPRAYNASAL ANTIALLERGYAZELASTINE HCL SOLUTION 0.10% ASTELINNASAL ANTICHOLINERGICSIPRATROPIUM BROMIDE (NASAL) SOLUTION ATROVENTNASAL STEROIDSFLUNISOLIDE (NASAL) SOLUTION FLUNISOLIDEFLUTICASONE PROPIONATE (NASAL) SUSPENSION FLONASEMOMETASONE FUROATE (NASAL) SUSPENSION NASONEXSYMPATHOMIMETIC DECONGESTANTSPSEUDOEPHEDRINE HCL GEL ELIXIRSURE CONGESTIONPSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENSPSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINE

PSEUDOEPHEDRINE HCL TABLETSSHOPKO NASAL DECONGESTANTMAXIMUM

STRENGTHPSEUDOEPHEDRINE HCL TABLET 12-HOUR SHOPKO NASAL DECONGESTANTPSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOUROPHTHALMIC AGENTSARTIFICIAL TEARS AND LUBRICANTSARTIFICIAL TEAR GEL GEL VARIOUSARTIFICIAL TEAR OINTMENT VARIOUSARTIFICIAL TEAR SOLUTION SOLUTION VARIOUSCARBOXYMETHYLCELLULOSE-GLYCERIN SOLUTION VARIOUSCARBOXYMETHYLCELLULOSE-HYPROMELLOSE GEL VARIOUSCARBOXYMETHYLCELLULOSE SODIUM (OPHTH) SOUTION VARIOUSCARBOXYMETHYLCELLULOSE SODIUM (OPHTH) GEL VARIOUSHYPROMELLOSE (GONIOSCOPIC) SOLUTION VARIOUSPOLYETHYLENE GLYCOL 400 (OPHTH) GEL VARIOUSPOLYETHYLENE GLYCOL 400 (OPHTH) SOLUTION VARIOUSPOLYETHYLENE GLYCOL-PROPYLENE GLYCOL (OPHTH) SOLUTION VARIOUSPOLYSORBATE 80 (OPHTH) SOLUTION VARIOUSPOLYVINYL ALCOHOL SOLUTION VARIOUS




Limit QL Days



BETA-BLOCKERS - OPHTHALMICBETAXOLOL HCL (OPHTH) SOLUTION BETAXOLOL HCLBETAXOLOL HCL (OPHTH) SUSPENSION BETOPTIC-SBRIMONIDINE TARTRATE-TIMOLOL MALEATE SOLUTION COMBIGANCARTEOLOL HCL (OPHTH) SOLUTION CARTEOLOL HCLDORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION COSOPTLEVOBUNOLOL HCL SOLUTION LEVOBUNOLOL HCLMETIPRANOLOL SOLUTION METIPRANOLOLTIMOLOL MALEATE (OPHTH) DROPS TIMOPTIC-XETIMOLOL MALEATE (OPHTH) SOLUTION TIMOPTICTIMOLOL SOLUTION BETIMOLCYCLOPLEGIC MYDRIATICSATROPINE SULFATE (OPHTHALMIC) OINTMENT ATROPINE SULFATEATROPINE SULFATE (OPHTHALMIC) SOLUTION ISOPTO ATROPINECYCLOPENTOLATE HCL SOLUTION CYCLOGYLHOMATROPINE HBR SOLUTION ISOPTO HOMATROPINETROPICAMIDE SOLUTION TROPICAMIDEMIOTICSPILOCARPINE HCL GEL PILOPINE HSPILOCARPINE HCL SOLUTION ISOPTO CARPINEOPHTHALMIC ADRENERGIC AGENTSAPRACLONIDINE HCL SOLUTION IOPIDINEBRIMONIDINE TARTRATE SOLUTION ALPHAGAN POPHTHALMIC ANTI-INFECTIVESBACITRACIN (OPHTHALMIC) OINTMENT BACITRACIN 3.50 7.00BACITRACIN-POLYMYXIN B (OPHTH) OINTMENT POLYCINCIPROFLOXACIN HCL (OPHTH) OINTMENT CILOXANCIPROFLOXACIN HCL (OPHTH) SOLUTION CILOXANERYTHROMYCIN (OPHTH) OINTMENT ILOTYCINGENTAMICIN SULFATE (OPHTH) OINTMENT GARAMYCINGENTAMICIN SULFATE (OPHTH) SOLUTION GARAMYCINMOXIFLOXACIN HCL (OPHTH) SOLUTION VIGAMOXNATAMYCIN SUSPENSION NATACYNNEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT NEO-POLYCINNEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION NEOSPORINOFLOXACIN (OPHTH) SOLUTION OCUFLOXPOLYMYXIN B-TRIMETHOPRIM SOLUTION POLYTRIMSULFACETAMIDE SODIUM (OPHTH) OINTMENT SULFACETAMIDE SODIUMSULFACETAMIDE SODIUM (OPHTH) SOLUTION BLEPH-10TOBRAMYCIN (OPHTH) OINTMENT TOBREX 3.50 7.00TOBRAMYCIN (OPHTH) SOLUTION TOBREXTRIFLURIDINE SOLUTION VIROPTICOPHTHALMIC DECONGESTANTS

HYPROMELLOSE-GLYCERIN-NAPHAZOLINE SOLUTION CLEAR EYES FOR DRY EYES PLUS REDNESS RELIEFHYPROMELLOSE-NAPHAZOLINE-POLYSORBATE 80-ZINC SULFATE SOLUTION CLEAR EYES COMPLETE 7 SYMPTOM RELIEFNAPHAZOLINE HCL SOLUTION VASOCLEARNAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-ANAPHAZOLINE W/ ZINC SULFATE SOLUTION VASOCLEAR ANAPHAZOLINE-GLYCERIN SOLUTION CLEAR EYES REDNESS RELIEFNAPHAZOLINE-GLYCERIN-ZINC SULFATE SOLUTION CLEAR EYES SEASONAL RELIEFNAPHAZOLINE-HYPROMELLOSE SOLUTION CVS MAXIMUM REDNESS RELIEFNAPHAZOLINE-POLYETHYLENE GLYCOL 300 SOLUTION CVS REDNESS RELIEF




Limit QL Days



OXYMETAZOLINE HCL (OPHTH) SOLUTION VISINE-LRPHENYLEPHRINE-POLYVINYL ALCOHOL SOLUTION REFRESH REDNESS RELIEFTETRAHYDROZOLINE HCL (OPHTH) SOLUTION ALTAZINETETRAHYDROZOLINE W/ POLYETHYLENE GLYCOL SOLUTION ADVANCED LUBRICANTTETRAHYDROZOLINE W/ ZINC SULFATE SOLUTION VISINE-AC

TETRAHYDROZOLINE-DEXTRAN-POLYETHYLENE GLYCOL-POVIDONE SOLUTION VISINE ADVANCED RELIEFTETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400 SOLUTION VISINE MAXIMUM REDNESS RELIEF

TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400-ZINC SULFATE SOLUTION VISINE TOTALITY MULTI-SYMPTOM/HYDROBLENDTETRAHYDROZOLINE-POLYVINYL ALCOHOL-POVIDONE SOLUTION CLEAR EYES TRIPLE ACTION RELIEFOPHTHALMIC IMMUNOMODULATORSCYCLOSPORINE (OPHTH) EMULSION RESTASIS PA RequiredOPHTHALMIC STEROIDSBACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HCDEXAMETHASONE (OPHTH) SUSPENSION MAXIDEXDEXAMETHASONE SODIUM PHOSPHATE (OPHTH) SOLUTION DEXAMETHASONE SODIUM PHOSPHATEFLUOROMETHOLONE (OPHTH) OINTMENT FMLFLUOROMETHOLONE (OPHTH) SUSPENSION FML LIQUIFILMGENTAMICIN-PREDNISOLONE ACETATE OINTMENT PRED-G S.O.P.GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION PRED-GNEOMYCIN-POLYMY-DEXAMETH OINTMENT MAXITROLNEOMYCIN-POLYMY-DEXAMETH SUSPENSION MAXITROLNEOMYCIN-POLYMYXIN-HC (OPHTH) SUSPENSION NEOMYCIN/POLYMYXIN/HYDROCORTISONEPREDNISOLONE ACETATE (OPHTH) SUSPENSION PRED MILDPREDNISOLONE SODIUM PHOSPHATE (OPHTH) SOLUTION PREDNISOLONE SODIUM PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE OINTMENT BLEPHAMIDE S.O.P.

SULFACETAMIDE SOD-PREDNISOLONE SOLUTIONSULFACETAMIDE SODIUM/PREDNISOLONE SODIUM

PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE SUSPENSION BLEPHAMIDETOBRAMYCIN-DEXAMETHASONE OINTMENT TOBRADEX 3.50 7.00TOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX STOPHTHALMICS - MISC.AZELASTINE HCL (OPHTH) SOLUTION OPTIVARBRINZOLAMIDE SUSPENSION AZOPT PA RequiredBROMFENAC SODIUM (OPHTH) SOLUTION PROLENSACROMOLYN SODIUM (OPHTH) SOLUTION CROMOLYN SODIUMDICLOFENAC SODIUM (OPHTH) SOLUTION DICLOFENAC SODIUMDORZOLAMIDE HCL SOLUTION TRUSOPTEPINASTINE HCL (OPHTH) SOLUTION ELESTATFLURBIPROFEN SODIUM SOLUTION OCUFENKETOROLAC TROMETHAMINE (OPHTH) SOLUTION ACULAR LSKETOTIFEN FUMARATE (OPHTH) SOLUTION ALAWAYLODOXAMIDE TROMETHAMINE SOLUTION ALOMIDEOLOPATADINE HCL SOLUTION PATANOLSODIUM CHLORIDE HYPERTONIC SOLUTION ALTACHLOREPROSTAGLANDINS - OPHTHALMICLATANOPROST SOLUTION XALATAN 2.50 30.00TAFLUPROST SOLUTION ZIOPTAN PA RequiredTRAVOPROST SOLUTION TRAVATAN Z PA RequiredOTIC AGENTSOTIC AGENTS - MISCELLANEOUSACETIC ACID (OTIC) SOLUTION ACETIC ACID




Limit QL Days



OTIC ANTI-INFECTIVESCIPROFLOXACIN HCL (OTIC) SOLUTION VARIOIUS PREFERRED DRUGOTIC COMBINATIONSCIPROFLOXACIN-DEXAMETHASONE CIPRODEX BRAND ONLY PREFERRED BRANDNEOMYCIN-POLYMYXIN-HC (OTIC) SOLUTION VARIOUS PREFERRED BRANDNEOMYCIN-POLYMYXIN-HC (OTIC) SUSPENSION VARIOUS PREFERRED BRANDOTIC STEROIDSFLUOCINOLONE ACETONIDE (OTIC) OIL DERMOTICHYDROCORTISONE W/ACETIC ACID SOLUTION ACETASOL HCOXYTOCICSOXYTOCICSMETHYLERGONOVINE MALEATE TABLETS METHERGINEPASSIVE IMMUNIZING AGENTSMONOCLONAL ANTIBODIES

PALIVIZUMAB SOLUTION SYNAGIS

PA Required - if approved the prescriber must buy and bill a medical claim for the

drugPENICILLINSAMINOPENICILLINSAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLINAMOXICILLIN TABLETS AMOXICILLINAMOXICILLIN TABLET 24-HOUR MOXATAGAMPICILLIN CAPSULES AMPICILLINAMPICILLIN SUSPENSION AMPICILLINNATURAL PENICILLINSPENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUMPENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUMPENICILLIN COMBINATIONSAMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTINAMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTINAMOXICILLIN & POT CLAVULANATE TABLETS AMOXICILLIN/CLAVULANATE POTASSIUMAMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRPENICILLINASE-RESISTANT PENICILLINSDICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUMPROGESTINSPROGESTINSHYDROXYPROGESTERONE CAPROATE OIL MAKENA 250 MG/ML BRAND ONLY PA RequiredHYDROXYPROGESTERONE CAPROATE SOLUTION AUTOINJECTOR MAKENA AUTO INJECTOR BRAND ONLY PA RequiredMEDROXYPROGESTERONE ACETATE TABLETS PROVERANORETHINDRONE ACETATE TABLETS AYGESTINPROGESTERONE MICRONIZED CAPSULES PROMETRIUMPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTAGENTS FOR CHEMICAL DEPENDENCYACAMPROSATE CALCIUM TABLET DELAYED RELEASE VARIOUSDISULFIRAM TABLETS VARIOUSANTIDEMENTIA AGENTSDONEPEZIL HYDROCHLORIDE TABLETS ARICEPTDONEPEZIL HYDROCHLORIDE ORALLY DISPERSABLE TABLET ARICEPT ODTGALANTAMINE HYDROBROMIDE CAPSULE 24-HOUR RAZADYNE ER PA RequiredGALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA Required




Limit QL Days



MEMANTINE HCL CAPSULE 24-HOUR NAMENDA XR PA RequiredMEMANTINE HCL SOLUTION NAMENDA PA RequiredMEMANTINE HCL TABLETS NAMENDA PA RequiredRIVASTIGMINE PATCH 24-HOUR EXELON PA RequiredRIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredMULTIPLE SCLEROSIS AGENTSFINGOLIMOD HCL CAPSULES GILENYA PA RequiredGLATIRAMER ACETATE 20MG COPAXONE 20mg BRAND ONLY Preferred Drug PA RequiredGLATIRAMER ACETATE 40MG GLATOPA 40MG BRAND ONLY Preferred Drug PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE TITRATION PACK PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.ERGOLOID MESYLATES TABLETS ERGOLOID MESYLATES

PIMOZIDE TABLETS ORAPPrior Authorization is required for < 12

years of age. SMOKING DETERRENTSBUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR BUPROBAN 168.00 180.00NICOTINE INHALER NICOTROL INHALER 1008.00 180.00NICOTINE KIT NICOTINE TRANSDERMAL SYSTEM 84.00 180.00NICOTINE POLACRILEX GUM KLS QUIT2 540.00 180.00NICOTINE POLACRILEX LOZENGE COMMIT 540.00 180.00NICOTINE PATCH 24-HOUR NICODERM CQ 84.00 180.00NICOTINE SOLUTION NICOTROL NS 120.00 180.00VARENICLINE TARTRATE TABLETS CHANTIX 168.00 180.00RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA RequiredCYSTIC FIBROSIS AGENTSDORNASE ALFA SOLUTION PULMOZYME PA RequiredIVACAFTOR PACK KALYDECO PA RequiredIVACAFTOR TABLETS KALYDECO PA RequiredSULFONAMIDESSULFONAMIDESSULFADIAZINE TABLETS SULFADIAZINETOXOIDSTOXOID COMBINATIONSDIPH-AC PERT-TET TOX AD-POLIO IPV-HAEMOPHIL B POLY VAC SUSPENSION PENTACEL

DIPH-TETANUS TOX AD-ACELL PERTUSSIS & POLIO VIRUS, IPV VAC SUSPENSION KINRIX

DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B RECOMB-POLIO IPV VA SUSPENSION PEDIARIXDIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS TOXOIDS SUSPENSION INFANRIX

DIPHTHERIA-TETANUS TOXOIDS (DT) SUSPENSIONDIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC

TETANUS TOXOID-DIPHTHERIA-ACELLULAR PERTUSSIS ADSORB (TDAP) SUSPENSION BOOSTRIX

TETANUS-DIPHTHERIA TOXOIDS (TD) INJECTIONTETANUS/DIPHTHERIA TOXOID-ADSORBED

PUROGENATED ADULT

TETANUS-DIPHTHERIA TOXOIDS (TD) SUSPENSION TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULTTETRACYCLINES




Limit QL Days



TETRACYCLINESDEMECLOCYCLINE HCL TABLETS DEMECLOCYCLINE HCL PA RequiredDOXYCYCLINE HYCLATE CAPSULES - 50MG AND 100MG CAPSULES ONLY VARIOUSDOXYCYCLINE HYCLATE TABLETS - 20MG AND 100MG TABLETS ONLY VARIOUSDOXYCYCLINE MONOHYDRATE - CAPSULES 50MG & 100MG ONLY VARIOUSMINOCYCLINE HCL - 50MG, 75MG & 100MG CAPSULES ONLY MINOCINTHYROID AGENTSANTITHYROID AGENTSMETHIMAZOLE TABLETS TAPAZOLEPROPYLTHIOURACIL TABLETS PROPYLTHIOURACILTHYROID HORMONESLEVOTHYROXINE SODIUM CAPSULES TIROSINT 30.00 30.00LEVOTHYROXINE SODIUM TABLETS LEVO-T 30.00 30.00LIOTHYRONINE SODIUM TABLETS CYTOMEL 30.00 30.00THYROID TABLETS ARMOUR THYROIDULCER DRUGSANTISPASMODICSDICYCLOMINE HCL CAPSULES BENTYLDICYCLOMINE HCL SOLUTION DICYCLOMINE HCLDICYCLOMINE HCL TABLETS BENTYLGLYCOPYRROLATE SOLUTION CUVPOSAGLYCOPYRROLATE TABLETS ROBINULHYOSCYAMINE SULFATE ELIXIR HYOSCYAMINE SULFATE 120.00 30.00HYOSCYAMINE SULFATE SOLUTION HYOSCYAMINE SULFATE 120.00 30.00HYOSCYAMINE SULFATE SUBLINGUAL HYOMAX-SL 120.00 30.00HYOSCYAMINE SULFATE TABLETS LEVSIN 120.00 30.00HYOSCYAMINE SULFATE TABLET 12-HOUR LEVBID 120.00 30.00HYOSCYAMINE SULFATE TABLET CONTROLLED RELEASE SYMAX DUOTAB 120.00 30.00HYOSCYAMINE SULFATE ORALLY DISPERSABLE TABLET ANASPAZ 120.00 30.00PROPANTHELINE BROMIDE TABLETS PROPANTHELINE BROMIDEH-2 ANTAGONISTSFAMOTIDINE CHEWABLE TABLETS PEPCID ACFAMOTIDINE SUSPENSION PEPCIDFAMOTIDINE TABLETS PEPCID ACNIZATIDINE CAPSULES NIZATIDINENIZATIDINE SOLUTION AXIDRANITIDINE HCL CAPSULES RANITIDINE HCLRANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQRANITIDINE HCL SYRUP ZANTACRANITIDINE HCL TABLETS WAL-ZAN 75MISC. ANTI-ULCERSUCRALFATE TABLETS CARAFATEPROTON PUMP INHIBITORSLANSOPRAZOLE CAPSULE DELAYED RELEASE HEARTBURN RELIEF 24 HOUR 30.00 30.00LANSOPRAZOLE ORALLY DISPERSABLE TABLET PREVACID SOLUTAB 60.00 30.00OMEPRAZOLE CAPSULE DELAYED RELEASE PRILOSEC 60.00 30.00OMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE OMEPRAZOLE MAGNESIUM 60.00 30.00OMEPRAZOLE MAGNESIUM TABLET ENTERIC COATED PRILOSEC OTC 60.00 30.00ULCER DRUGS - PROSTAGLANDINSMISOPROSTOL TABLETS CYTOTECURINARY ANTI-INFECTIVESURINARY ANTI-INFECTIVES




Limit QL Days



FOSFOMYCIN TROMETHAMINE PACK MONUROL Patient must have tried Cipro AND Macrobid NITROFURANTOIN MACROCRYSTAL CAPSULES MACRODANTINNITROFURANTOIN MONOHYD MACRO CAPSULES MACROBIDNITROFURANTOIN SUSPENSION FURADANTINURINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLIOXYBUTYNIN CHLORIDE GEL GELNIQUEOXYBUTYNIN CHLORIDE SYRUP OXYBUTYNIN CHLORIDEOXYBUTYNIN CHLORIDE TABLETS OXYBUTYNIN CHLORIDEOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XLTOLTERODINE TARTRATE CAPSULE 24-HOUR DETROL LATOLTERODINE TARTRATE TABLETS DETROLTROSPIUM CHLORIDE CAPSULE 24-HOUR SANCTURA XRTROSPIUM CHLORIDE TABLETS SANCTURAURINARY ANTISPASMODICS - CHOLINERGIC AGONISTSBETHANECHOL CHLORIDE TABLETS URECHOLINEURINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTSFLAVOXATE HCL TABLETS FLAVOXATE HCLVAGINAL PRODUCTSSPERMICIDESNONOXYNOL-9 FILM VCF VAGINAL CONTRACEPTIVE FILMNONOXYNOL-9 FOAM VCF VAGINAL CONTRACEPTIVE FOAMNONOXYNOL-9 GEL SHUR-SEALNONOXYNOL-9 MISC TODAY SPONGENONOXYNOL-9 SUPPOSITORY ENCAREVAGINAL ANTI-INFECTIVESCLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCINCLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCINCLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMINMETRONIDAZOLE VAGINAL GEL METROGEL-VAGINALMICONAZOLE NITRATE VAGINAL KIT MONISTAT 3 COMBINATION PACKMICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3SULFANILAMIDE VAGINAL CREAM AVCTERCONAZOLE VAGINAL CREAM TERAZOL 7TERCONAZOLE VAGINAL SUPPOSITORY TERAZOL 3TIOCONAZOLE VAGINAL MONISTAT 1-DAYVAGINAL ESTROGENSESTRADIOL ACETATE VAGINAL RING FEMRING PA Required 1.00 30.00ESTRADIOL VAGINAL CREAM ESTRADIOLESTRADIOL VAGINAL RING ESTRING 1.00 90.00ESTRADIOL VAGINAL TABLETS VAGIFEMESTROGENS, CONJUGATED VAGINAL CREAM PREMARIN 1.00 30.00VAGINAL PROGESTINSPROGESTERONE (VAGINAL) GEL CRINONE PA RequiredVASOPRESSORSANAPHYLAXIS THERAPY AGENTSEPINEPHRINE SELF-INJECTABLE EPINEPHRINE SELF-INJECTABLE (By Mylan) Mylan Generic Preferred Drug PA Required for > 2 Per Month 2.00 30.00EPINEPHRINE SELF-INJECTABLE EPINEPHRINE SELF-INJECTABLE (By Mylan) Mylan Generic Preferred Drug PA Required for > 2 Per Month 2.00 30.00SYMJEPI SELF-INJECTABLE EPINEPHRINE SELF-INJECTABLE Preferred Drug PA Required for > 2 Per Month 2.00 30.00VASOPRESSORSMIDODRINE HCL TABLETS MIDODRINE HCLVACCINES




Limit QL Days



VIRAL VACCINESHEPATITIS B VACCINE (RECOMB) INJECTION ENGERIX-BHEPATITIS B VACCINE (RECOMB) SUSPENSION RECOMBIVAX HB

HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMBINANT VACCINE SUSPENSION GARDASIL 9HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMBINANT VACCINE SUSPENSION PREFILLED SYRINGE GARDASIL 9

HUMAN PAPILLOMAVIRUS (HPV) BIVALENT (TYPES 16, 18) RECMB VA SUSPENSION CERVARIXHUMAN PAPILLOMAVIRUS (HPV) QUADRIVALENT RECOMBINANT VACCINE SUSPENSION GARDASIL

INFLUENZA VIRUS VACCINE RECOMBINANT HEMAGGLUTININ (HA) SOLUTION FLUBLOKINFLUENZA VIRUS VACCINE SPLIT SUSPENSION FLUZONE SPLIT INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE PRESERVATIVE FREE SUSPENSION PREFILLED SYRINGE FLUZONE HIGH-DOSE PF INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE SUSPENSION PREFILLED SYRINGE FLUZONE PF INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT SUSPENSION FLUZONE QUADRIVALENT

INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT SUSPENSION PREFILLED SYRINGE FLUZONE QUADRIVALENT INFLUENZA VIRUS VACCINE TISSUE-CULTURED SUBUNIT PSKT MEDICAL PROVIDER EZ FLU SHOT INFLUENZA VIRUS VACCINE TISSUE-CULTURED SUBUNIT SUSPENSION PREFILLED SYRINGE FLUCELVAX INFLUENZA VIRUS VACCINE TISSUE-CULTURED SUBUNIT QUADRIVALEN SUSPENSION PREFILLED SYRINGE FLUCELVAX QUADRIVALENTINFLUENZA VIRUS VACCINE TYPES A & B PRESERVATIVE FREE PSKT MEDICAL PROVIDER EZ FLU SHOT PF INFLUENZA VIRUS VACCINE TYPES A & B PRESERVATIVE FREE SUSPENSION PREFILLED SYRINGE FLUVIRIN PF INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN PSKT MEDICAL PROVIDER SINGLE USE EZ FLU SHOTINFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN SUSPENSION FLUVIRIN INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN SUSPENSION PREFILLED SYRINGE FLUVIRIN INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN ADJUVAN SUSPENSION PREFILLED SYRINGE FLUADMEASLES, MUMPS & RUBELLA VIRUS VACCINES INJECTION M-M-R IIMEASLES-MUMPS-RUBELLA-VARICELLA VIRUS VACCINES INJECTION PROQUADPNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE SUSPENSION PREVNAR 13PNEUMOCOCCAL VAC POLYVALENT INJECTION PNEUMOVAX 23/5 DOSEZOSTER VACCINE LIVE SOLUTION RECONSTITUED ZOSTAVAXVITAMINSOIL SOLUBLE VITAMINSERGOCALCIFEROL CAPSULES DRISDOL 12.00 30.00VITAMIN E CAPSULES VITAMIN EVITAMIN D DROPS 400UNIT D-VI-SOL PA Required for > 2 years of ageWATER SOLUBLE VITAMINSNIACIN CAPSULE CONTROLLED RELEASE NIACINNIACIN TABLETS NIACINNIACIN TABLET CONTROLLED RELEASE ENDUR-ACINPYRIDOXINE HCL TABLETS PYRIDOXINE HCLTHIAMINE HCL TABLETS VITAMIN B-1

Documents

CMDP Preferred Drug List - AZ Preferred Drug List October 2019.pdfPreferred Drug Status PA Type Step Therapy Requirements Quantity Limit QL Days ADHD/ANTI-NARCOLEPSY AMPHETAMINES AMPHETAMINE