Illinois Medicaid Preferred Drug List

Illinois Medicaid Preferred Drug List Effective January 1, 2021

▪ The Preferred Drug List (PDL) has products listed in groups by drug class, drug name, dosage form, and PDL status

▪ Multi-source drugs are listed by both brand and generic names when applicable

▪ ADHD Agents: Prior authorization required for participants under 6 years of age and participants 19 years of age and older

▪ Spiriva AER 1.25mcg: Prior authorization NOT required for participants ages 6-17 years

▪ Budesonide: Prior authorization NOT required for participants age 7 years and under

▪ Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those participants with a diagnosis of epilepsy or seizure disorder in Department records

▪ Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents

▪ Proton Pump Inhibitors, oral: Prior authorization required for participants age 21 and over. Adults with non-complicated GERD have to pay out of pocket for a PPI or use a prescribed H2 blocker. PA is needed for coverage of indications requiring longer term use.

▪ Lansoprazole ODT: Prior authorization NOT required for participants age 10 years and under.

▪ For drugs not found on this list, go to the drug search engine at: www.ilpriorauth.com

Page 1 of 102

DRUG CLASS DRUG NAMEDOSAGE

FORM

ADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINES ADZENYS ER SUER NON_PREFERRED

AMPHETAMINE ER SUER NON_PREFERRED

DYANAVEL XR SUER NON_PREFERRED

ADZENYS XR-ODT TBED NON_PREFERRED

AMPHETAMINE SULFATE TABS NON_PREFERRED

EVEKEO TABS NON_PREFERRED

EVEKEO ODT TBDP NON_PREFERRED

DEXEDRINE CP24 NON_PREFERRED

DEXTROAMPHETAMINE SULFATE ER CP24 NON_PREFERRED

DEXTROAMPHETAMINE SULFATE SOLN NON_PREFERRED

PROCENTRA SOLN NON_PREFERRED

DEXEDRINE TABS NON_PREFERRED

DEXTROAMPHETAMINE SULFATE TABS NON_PREFERRED

ZENZEDI TABS NON_PREFERRED

VYVANSE CAPS PREFERRED

VYVANSE CHEW PREFERRED

DESOXYN TABS NON_PREFERRED

METHAMPHETAMINE HCL TABS NON_PREFERRED

ADDERALL XR CP24 NON_PREFERRED

AMPHETAMINE/DEXTROAMPHETAMINE CP24 PREFERRED

MYDAYIS CP24 NON_PREFERRED

ADDERALL TABS NON_PREFERRED

AMPHETAMINE/DEXTROAMPHETAMINE TABS PREFERRED

ADHD / ANTI-NARCOLEPSY AGENTS : MISC CLONIDINE HCL ER TB12 PREFERRED

CLONIDINE HYDROCHLORIDE ER TB12 PREFERRED

GUANFACINE ER TB24 PREFERRED

GUANFACINE HYDROCHLORIDE TB24 PREFERRED

INTUNIV TB24 NON_PREFERRED

ATOMOXETINE CAPS NON_PREFERRED

ATOMOXETINE HYDROCHLORIDE CAPS NON_PREFERRED

STRATTERA CAPS NON_PREFERRED

SUNOSI TABS NON_PREFERRED

WAKIX TABS NON_PREFERRED

ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTS ARMODAFINIL TABS NON_PREFERRED

NUVIGIL TABS NON_PREFERRED

DEXMETHYLPHENIDATE HCL ER CP24 NON_PREFERRED

DEXMETHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED

FOCALIN XR CP24 PREFERRED

DEXMETHYLPHENIDATE HCL TABS PREFERRED

DEXMETHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED

FOCALIN TABS NON_PREFERRED

DAYTRANA PTCH NON_PREFERRED

COTEMPLA XR-ODT TBED NON_PREFERRED

QUILLICHEW ER CHER NON_PREFERRED

PDL STATUS

Page 2 of 102


FORMPDL STATUS

METHYLPHENIDATE HYDROCHLORIDE CHEW NON_PREFERRED

ADHANSIA XR CP24 NON_PREFERRED

APTENSIO XR CP24 NON_PREFERRED

JORNAY PM CP24 NON_PREFERRED

METHYLPEHNIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24 NON_PREFERRED

RITALIN LA CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE CD CPCR NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER CPCR NON_PREFERRED

METHYLIN SOLN NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE SOLN NON_PREFERRED

QUILLIVANT XR SRER NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED

RITALIN TABS NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER TB24 NON_PREFERRED

METHYLPHENID TAB 10MG ER TBCR PREFERRED

METHYLPHENID TAB 20MG ER TBCR PREFERRED

CONCERTA TBCR PREFERRED

METHYLPHENID TAB 18MG ER TBCR NON_PREFERRED





METHYLPHENIDATE HYDROCHLORIDE ER TBCR NON_PREFERRED

RELEXXII TBCR NON_PREFERRED

MODAFINIL TABS NON_PREFERRED

PROVIGIL TABS NON_PREFERRED

ANALGESICS - ANTI-INFLAMMATORY : MISC RIDAURA CAPS NON_PREFERRED

OTREXUP SOAJ NON_PREFERRED

RASUVO SOAJ NON_PREFERRED

REDITREX SOSY NON_PREFERRED

ARAVA TABS NON_PREFERRED

LEFLUNOMIDE TABS PREFERRED

ANALGESICS - ANTI-INFLAMMATORY : NONSTEROIDAL ANTI-

INFLAMMATORY AGENTS (NSAIDs) ZORVOLEX CAPS NON_PREFERRED

ZIPSOR CAPS NON_PREFERRED

DICLOFENAC POTASSIUM TABS PREFERRED

DICLOFENAC SODIUM ER TB24 PREFERRED

DICLOFENAC SODIUM DR TBEC PREFERRED

ETODOLAC CAPS PREFERRED

ETODOLAC TABS PREFERRED

ETODOLAC ER TB24 PREFERRED

FENOPROFEN CALCIUM CAPS NON_PREFERRED

Page 3 of 102


FORMPDL STATUS

NALFON CAPS NON_PREFERRED

FENOPROFEN CALCIUM TABS NON_PREFERRED

NALFON TABS NON_PREFERRED

FLURBIPROFEN TABS PREFERRED

IBUPAK KIT NON_PREFERRED

IBUPROFEN SUSP NON_PREFERRED

IBU TABS PREFERRED

IBUPROFEN TABS PREFERRED

INDOMETHACIN CAPS PREFERRED

TIVORBEX CAPS NON_PREFERRED

INDOMETHACIN ER CPCR PREFERRED

INDOCIN SUPP NON_PREFERRED

INDOCIN SUSP NON_PREFERRED

KETOPROFEN CAPS PREFERRED

KETOPROFEN ER CP24 NON_PREFERRED

KETOROLAC TROMETHAMINE SOLN NON_PREFERRED

SPRIX SOLN NON_PREFERRED

KETOROLAC TROMETHAMINE TABS PREFERRED

MECLOFENAMATE SODIUM CAPS NON_PREFERRED

MEFENAMIC ACID CAPS NON_PREFERRED

VIVLODEX CAPS NON_PREFERRED

MELOXICAM TABS PREFERRED

MOBIC TABS NON_PREFERRED

QMIIZ ODT TBDP NON_PREFERRED

NABUMETONE TABS PREFERRED

RELAFEN DS TABS NON_PREFERRED

NAPROXEN SUSP PREFERRED

NAPROXEN TABS PREFERRED

EC-NAPROXEN TBEC PREFERRED

NAPROXEN DR TBEC PREFERRED

NAPROXEN SODIUM TABS PREFERRED

NAPRELAN TB24 NON_PREFERRED

NAPROXEN SODIUM TB24 NON_PREFERRED

NAPROXEN SODIUM CR TB24 NON_PREFERRED

NAPROXEN SODIUM ER TB24 NON_PREFERRED

DAYPRO TABS NON_PREFERRED

OXAPROZIN TABS NON_PREFERRED

FELDENE CAPS NON_PREFERRED

PIROXICAM CAPS NON_PREFERRED

SULINDAC TABS PREFERRED

TOLMETIN SODIUM CAPS NON_PREFERRED

TOLMETIN SODIUM TABS NON_PREFERRED

CELEBREX CAPS NON_PREFERRED

CELECOXIB CAPS PREFERRED

Page 4 of 102


FORMPDL STATUS

ARTHROTEC 50 TBEC NON_PREFERRED

ARTHROTEC 75 TBEC NON_PREFERRED

DICLOFENAC SODIUM/MISOPROSTOL TBEC NON_PREFERRED

DUEXIS TABS NON_PREFERRED

NAPROXEN/ESOMEPRAZOLE MAGNESIUM TBEC NON_PREFERRED

VIMOVO TBEC NON_PREFERRED

ANALGESICS - NONNARCOTIC DIFLUNISAL TABS PREFERRED

SALSALATE TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN CAPS NON_PREFERRED

ALLZITAL TABS NON_PREFERRED

BUPAP TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN TABS PREFERRED

MARTEN-TAB TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPS PREFERRED

ESGIC CAPS PREFERRED

FIORICET CAPS NON_PREFERRED

ZEBUTAL CAPS PREFERRED

VANATOL LQ SOLN NON_PREFERRED

VANATOL S SOLN NON_PREFERRED

VTOL LQ SOLN NON_PREFERRED

BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS PREFERRED

ESGIC TABS NON_PREFERRED

BUTALBITAL/ASPIRIN/CAFFEINE CAPS PREFERRED

FIORINAL CAPS NON_PREFERRED

BUTALBITAL/ASPIRIN/CAFFEINE TABS PREFERRED

ANALGESICS : OPIOID CODEINE SULFATE TABS PREFERRED

DURAGESIC PT72 NON_PREFERRED

FENTANYL PT72 NON_PREFERRED

ACTIQ LPOP NON_PREFERRED

FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP NON_PREFERRED

ABSTRAL SUBL NON_PREFERRED

FENTANYL CITRATE TABS NON_PREFERRED

FENTORA TABS NON_PREFERRED

HYDROCODONE BITARTRATE ER CP12 NON_PREFERRED

ZOHYDRO ER CP12 NON_PREFERRED

HYSINGLA ER T24A NON_PREFERRED

DILAUDID LIQD NON_PREFERRED

HYDROMORPHONE HCL LIQD PREFERRED

HYDROMORPHONE HCL SUPP PREFERRED

DILAUDID TABS NON_PREFERRED

HYDROMORPHONE HCL TABS PREFERRED

HYDROMORPHONE HCL ER TB24 NON_PREFERRED

HYDROMORPHONE HYDROCHLORIDE ER TB24 NON_PREFERRED

LEVORPHANOL TARTRATE TABS NON_PREFERRED

Page 5 of 102


FORMPDL STATUS

MEPERIDINE HCL SOLN NON_PREFERRED

MEPERIDINE HCL TABS NON_PREFERRED

METHADONE HCL CONC NON_PREFERRED

METHADONE HCL INTENSOL CONC NON_PREFERRED

METHADOSE CONC NON_PREFERRED

METHADOSE SUGAR-FREE CONC NON_PREFERRED

METHADONE HCL SOLN NON_PREFERRED

METHADONE HCL TABS NON_PREFERRED

METHADONE HYDROCHLORIDE TABS NON_PREFERRED

METHADONE HCL TBSO NON_PREFERRED

METHADOSE TBSO NON_PREFERRED

KADIAN CP24 NON_PREFERRED

MORPHINE SULFATE ER CP24 NON_PREFERRED

MORPHINE SULFATE SOLN PREFERRED

MORPHINE SULFATE SUPP PREFERRED

MORPHABOND ER T12A NON_PREFERRED

MORPHINE SULFATE TABS PREFERRED

MORPHINE SULFATE ER TBCR PREFERRED_WITH_PA

MS CONTIN TBCR NON_PREFERRED

ARYMO ER TBEA NON_PREFERRED

MORPHINE SULFATE ER CP24 NON_PREFERRED

XTAMPZA ER C12A NON_PREFERRED

OXYCODONE HCL CAPS PREFERRED

OXYCODONE HYDROCHLORIDE CAPS PREFERRED

OXYCODONE HCL CONC PREFERRED

OXYCODONE HYDROCHLORIDE CONC PREFERRED

OXYCODONE HYDROCHLORIDE SOLN PREFERRED

OXYCODONE HCL ER T12A NON_PREFERRED

OXYCODONE HYDROCHLORIDE ER T12A NON_PREFERRED

OXYCONTIN T12A NON_PREFERRED

OXAYDO TABS NON_PREFERRED

OXYCODONE HCL TABS PREFERRED

OXYCODONE HYDROCHLORIDE TABS PREFERRED

ROXICODONE TABS NON_PREFERRED

OXYMORPHONE HYDROCHLORIDE TABS NON_PREFERRED

OXYMORPHONE HYDROCHLORIDE ER TB12 NON_PREFERRED

OXYMORPHONE HYDROCHLORIDEER TB12 NON_PREFERRED

NUCYNTA TABS NON_PREFERRED

NUCYNTA ER TB12 NON_PREFERRED

CONZIP CP24 NON_PREFERRED

TRAMADOL HCL ER CP24 NON_PREFERRED

TRAMADOL HCL TABS PREFERRED

TRAMADOL HYDROCHLORIDE TABS NON_PREFERRED

TRAMADOL HYDROCHLORIDE TABS PREFERRED

Page 6 of 102


FORMPDL STATUS

ULTRAM TABS NON_PREFERRED

TRAMADOL HCL ER TB24 NON_PREFERRED

BUPRENORPHINE PTWK NON_PREFERRED

BUTRANS PTWK NON_PREFERRED

BELBUCA FILM NON_PREFERRED

BUTORPHANOL TARTRATE SOLN NON_PREFERRED

PENTAZOCINE/NALOXONE HCL TABS NON_PREFERRED

ANALGESICS : OPIOID COMBINATIONS APADAZ TABS NON_PREFERRED

BENZHYDROCODONE/ACETAMINOPHEN TABS NON_PREFERRED

ENDOCET TABS PREFERRED

NALOCET TABS NON_PREFERRED

OXYCODONE/ACETAMINOPHEN TABS PREFERRED

PERCOCET TABS NON_PREFERRED

PRIMLEV TABS NON_PREFERRED

PROLATE TABS NON_PREFERRED

OXYCODONE/ASPIRIN TABS NON_PREFERRED

OXYCODONE/IBUPROFEN TABS NON_PREFERRED

ACETAMINOPHEN/CODEINE SOLN PREFERRED

ACETAMINOPHEN/CODEINE TABS PREFERRED

ACETAMINOPHEN/CODEINE PHOSPHATE TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE CAPS NON_PREFERRED

ASCOMP/CODEINE CAPS PREFERRED

BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS PREFERRED

FIORINAL/CODEINE #3 CAPS NON_PREFERRED

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPS NON_PREFERRED

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE TABS NON_PREFERRED

PANLOR TABS NON_PREFERRED

LORTAB ELIX NON_PREFERRED

HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN PREFERRED

HYDROCODONE BITARTRATE/ACETAMINOPHEN TABS PREFERRED

HYDROCODONE/ACETAMINOPHEN TABS PREFERRED

LORCET TABS PREFERRED

LORCET HD TABS PREFERRED

LORCET PLUS TABS PREFERRED

NORCO TABS NON_PREFERRED

VERDROCET TABS NON_PREFERRED

HYDROCODONE/IBUPROFEN TABS PREFERRED

REPREXAIN TABS NON_PREFERRED

REPREXAIN TABS PREFERRED

XYLON TABS PREFERRED

TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN TABS NON_PREFERRED

ULTRACET TABS NON_PREFERRED

ANAPHYLAXIS THERAPY AGENTS ADRENACLICK SOAJ PREFERRED

EPINEPHRINE SOAJ PREFERRED

Page 7 of 102


FORMPDL STATUS

EPIPEN 2-PAK SOAJ NON_PREFERRED

EPIPEN-JR 2-PAK SOAJ NON_PREFERRED

SYMJEPI SOSY NON_PREFERRED

ANORECTAL AGENTS ANUSOL-HC CREA NON_PREFERRED

HYDROCORTISONE CREA PREFERRED

PROCTO-MED HC CREA PREFERRED

PROCTOSOL HC CREA PREFERRED

PROCTOZONE-HC CREA PREFERRED

UCERIS FOAM NON_PREFERRED

CORTENEMA ENEM NON_PREFERRED

HYDROCORTISONE ENEM PREFERRED

CORTIFOAM FOAM NON_PREFERRED

RECTIV OINT NON_PREFERRED

LIDOCAINE HCL/HYDROCORTISONE ACETATE CREA NON_PREFERRED

LIDOCORT CREA NON_PREFERRED

LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE GEL NON_PREFERRED

ANA-LEX KIT NON_PREFERRED

LIDOCAINE HCL/HYDROCORTISONE ACETATE KIT NON_PREFERRED

PROCTOFOAM HC FOAM NON_PREFERRED

ANTIANXIETY AGENTS : BENZODIAZEPINES ALPRAZOLAM INTENSOL CONC PREFERRED

ALPRAZOLAM TABS PREFERRED

XANAX TABS NON_PREFERRED

ALPRAZOLAM ER TB24 NON_PREFERRED

ALPRAZOLAM XR TB24 NON_PREFERRED

XANAX XR TB24 NON_PREFERRED

ALPRAZOLAM ODT TBDP NON_PREFERRED

CHLORDIAZEPOXIDE HCL CAPS PREFERRED

CHLORDIAZEPOXIDE HYDROCHLORIDE CAPS PREFERRED

CLORAZEPATE DIPOTASSIUM TABS PREFERRED

TRANXENE T TABS NON_PREFERRED

DIAZEPAM CONC PREFERRED

DIAZEPAM INTENSOL CONC PREFERRED

DIAZEPAM SOLN PREFERRED

DIAZEPAM TABS PREFERRED

LORAZEPAM CONC PREFERRED

LORAZEPAM INTENSOL CONC PREFERRED

ATIVAN TABS NON_PREFERRED

LORAZEPAM TABS PREFERRED

OXAZEPAM CAPS PREFERRED

ANTIANXIETY AGENTS : MISC BUSPIRONE HCL TABS PREFERRED

BUSPIRONE HYDROCHLORIDE TABS PREFERRED

HYDROXYZINE HCL SYRP PREFERRED

HYDROXYZINE HCL TABS PREFERRED

HYDROXYZINE HYDROCHLORIDE TABS PREFERRED

Page 8 of 102


FORMPDL STATUS

HYDROXYZINE PAMOATE CAPS PREFERRED

VISTARIL CAPS NON_PREFERRED

MEPROBAMATE TABS NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : ADRENERGIC

COMBINATIONS COMBIVENT RESPIMAT AERS NON_PREFERRED

IPRATROPIUM BROMIDE/ALBUTEROL SULFATE SOLN PREFERRED

DUAKLIR PRESSAIR AEPB NON_PREFERRED

BUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE AERO NON_PREFERRED

SYMBICORT AERO PREFERRED

BEVESPI AEROSPHERE AERO PREFERRED

UTIBRON NEOHALER CAPS NON_PREFERRED

ADVAIR DISKUS AEPB NON_PREFERRED

AIRDUO DIGIHALER 113/14 AEPB NON_PREFERRED



AIRDUO RESPICLICK 113/14 AEPB NON_PREFERRED



FLUTICASONE PROPIONATE/SALMETEROL AEPB NON_PREFERRED

FLUTICASONE PROPIONATE/SALMETEROL DISKUS AEPB NON_PREFERRED

WIXELA INHUB AEPB PREFERRED

ADVAIR HFA AERO NON_PREFERRED

BREO ELLIPTA AEPB NON_PREFERRED

DULERA AERO PREFERRED

STIOLTO RESPIMAT AERS NON_PREFERRED

ANORO ELLIPTA AEPB NON_PREFERRED

BREZTRI AEROSPHERE AERO NON_PREFERRED

TRELEGY ELLIPTA AEPB NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS :

ANTICHOLINERGICS TUDORZA PRESSAIR AEPB NON_PREFERRED

SEEBRI NEOHALER CAPS NON_PREFERRED

LONHALA MAGNAIR REFILL KIT SOLN NON_PREFERRED

LONHALA MAGNAIR STARTER KIT SOLN NON_PREFERRED

IPRATROPIUM BROMIDE SOLN PREFERRED

ATROVENT HFA AERS PREFERRED

YUPELRI SOLN NON_PREFERRED

SPIRIVA AER 1.25MCG AERS PREFERRED

SPIRIVA SPR 2.5MCG AERS NON_PREFERRED

SPIRIVA HANDIHALER CAPS PREFERRED

INCRUSE ELLIPTA AEPB NON_PREFERRED

CROMOLYN SODIUM NEBU PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : BETA

ADRENERGICS PROAIR DIGIHALER AEPB NON_PREFERRED

PROAIR RESPICLICK AEPB NON_PREFERRED

Page 9 of 102


FORMPDL STATUS

ALBUTEROL SULFATE HFA AERS PREFERRED

PROAIR HFA AERS PREFERRED

PROVENTIL HFA AERS PREFERRED

VENTOLIN HFA AERS PREFERRED

ALBUTEROL SULFATE NEBU PREFERRED

ALBUTEROL SULFATE SYRP PREFERRED

ALBUTEROL TABS NON_PREFERRED

ALBUTEROL SULFATE TABS NON_PREFERRED

ALBUTEROL SULFATE ER TB12 NON_PREFERRED

BROVANA NEBU NON_PREFERRED

PERFOROMIST NEBU NON_PREFERRED

ARCAPTA NEOHALER CAPS NON_PREFERRED

LEVALBUTEROL NEBU PREFERRED

LEVALBUTEROL HCL NEBU PREFERRED

LEVALBUTEROL HYDROCHLORIDE NEBU PREFERRED

XOPENEX NEBU NON_PREFERRED

XOPENEX CONCENTRATE NEBU NON_PREFERRED

LEVALBUTEROL TARTRATE HFA AERO PREFERRED

XOPENEX HFA AERO PREFERRED

METAPROTERENOL SULFATE SYRP NON_PREFERRED

STRIVERDI RESPIMAT AERS NON_PREFERRED

SEREVENT DISKUS AEPB PREFERRED

TERBUTALINE SULFATE TABS PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : LEUKOTRIENE

MODULATORS ZYFLO TABS NON_PREFERRED

ZILEUTON ER TB12 NON_PREFERRED

MONTELUKAST SODIUM CHEW PREFERRED

SINGULAIR CHEW NON_PREFERRED

MONTELUKAST SODIUM PACK PREFERRED

SINGULAIR PACK NON_PREFERRED

MONTELUKAST SODIUM TABS PREFERRED

SINGULAIR TABS NON_PREFERRED

ACCOLATE TABS NON_PREFERRED

ZAFIRLUKAST TABS PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MISC THEO-24 CP24 PREFERRED

THEOPHYLLINE SOLN PREFERRED

THEOPHYLLINE ER TB12 PREFERRED

THEOPHYLLINE ER TB24 PREFERRED

DALIRESP TABS NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MONOCLONAL

ANTIBODIES XOLAIR SOLR NON_PREFERRED

XOLAIR SOSY NON_PREFERRED

FASENRA PEN SOAJ NON_PREFERRED

FASENRA SOSY NON_PREFERRED

Page 10 of 102


FORMPDL STATUS

NUCALA SOAJ NON_PREFERRED

NUCALA SOLR PREFERRED_WITH_PA

NUCALA SOSY NON_PREFERRED

CINQAIR SOLN NON_PREFERRED

DUPIXENT SOPN NON_PREFERRED

DUPIXENT INJ 200/1.14 SOSY PREFERRED_WITH_PA

DUPIXENT INJ 300/2ML SOSY NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : STEROID

INHALANTS QVAR REDIHALER AERB NON_PREFERRED

PULMICORT FLEXHALER AEPB NON_PREFERRED

BUDESONIDE SUSP PREFERRED

PULMICORT SUSP NON_PREFERRED

ALVESCO AERS NON_PREFERRED

ARNUITY ELLIPTA AEPB NON_PREFERRED

ARMONAIR DIGIHALER AEPB NON_PREFERRED

FLOVENT DISKUS AEPB PREFERRED

FLOVENT HFA AERO PREFERRED

ASMANEX TWISTHALER 120 METERED DOSES AEPB PREFERRED




ASMANEX HFA AERO NON_PREFERRED

ANTIBIOITCS : FLUOROQUINOLONES CIPRO SUSR NON_PREFERRED

CIPROFLOXACIN SUSR PREFERRED

CIPRO XR TB24 NON_PREFERRED

CIPRO TABS NON_PREFERRED

CIPROFLOXACIN HCL TABS PREFERRED

CIPROFLOXACIN HYDROCHLORIDE TABS PREFERRED

BAXDELA TABS NON_PREFERRED

LEVOFLOXACIN SOLN PREFERRED

LEVOFLOXACIN TABS PREFERRED

AVELOX TABS NON_PREFERRED

MOXIFLOXACIN HYDROCHLORIDE TABS NON_PREFERRED

OFLOXACIN TABS NON_PREFERRED

ANTIBIOTICS : AMINOGLYCOSIDES NEOMYCIN SULFATE TABS PREFERRED

PAROMOMYCIN SULFATE CAPS PREFERRED

ANTIBIOTICS : AMINOGLYCOSIDES - INHALED ARIKAYCE SUSP NON_PREFERRED

TOBI PODHALER CAPS NON_PREFERRED

BETHKIS NEBU NON_PREFERRED

KITABIS PAK NEBU PREFERRED

TOBI NEBU NON_PREFERRED

TOBRAMYCIN NEBU NON_PREFERRED

ANTIBIOTICS : ANTI-INFECTIVE AGENTS SULFADIAZINE TABS PREFERRED

SOLOSEC PACK NON_PREFERRED

Page 11 of 102


FORMPDL STATUS

FLAGYL CAPS NON_PREFERRED

METRONIDAZOLE CAPS NON_PREFERRED

FLAGYL TABS NON_PREFERRED

METRONIDAZOLE TABS PREFERRED

NEBUPENT SOLR PREFERRED

PENTAMIDINE ISETHIONATE SOLR PREFERRED

XIFAXAN TABS NON_PREFERRED

TINIDAZOLE TABS NON_PREFERRED

TRIMETHOPRIM TABS PREFERRED

CAYSTON SOLR NON_PREFERRED

CLEOCIN CAPS NON_PREFERRED

CLINDAMYCIN HCL CAPS PREFERRED

CLINDAMYCIN HYDROCHLORIDE CAPS PREFERRED

CLEOCIN PEDIATRIC GRANULES SOLR NON_PREFERRED

CLINDAMYCIN PALMITATE HCL SOLR PREFERRED

CLINDAMYCIN PALMITATE HYDROCHLORIDE SOLR PREFERRED

LINEZOLID SUSR NON_PREFERRED

ZYVOX SUSR NON_PREFERRED

LINEZOLID TABS NON_PREFERRED

ZYVOX TABS NON_PREFERRED

SIVEXTRO TABS NON_PREFERRED

XENLETA TABS NON_PREFERRED

VANCOCIN CAPS NON_PREFERRED

VANCOCIN HCL CAPS NON_PREFERRED

VANCOMYCIN HYDROCHLORIDE CAPS PREFERRED

FIRST-VANCOMYCIN 25 SOLN NON_PREFERRED

FIRST-VANCOMYCIN 50 SOLN NON_PREFERRED

FIRVANQ SOLR NON_PREFERRED

VANCOMYCIN HYDROCHLORIDE SOLR PREFERRED

DAPSONE TABS PREFERRED

ATOVAQUONE SUSP PREFERRED

MEPRON SUSP NON_PREFERRED

LAMPIT TABS NON_PREFERRED

FOSFOMYCIN TROMETHAMINE PACK PREFERRED

MONUROL PACK PREFERRED

METHENAMINE MANDELATE TABS PREFERRED

HIPREX TABS NON_PREFERRED

METHENAMINE HIPPURATE TABS PREFERRED

NITROFURANTOIN SUSP PREFERRED

MACRODANTIN CAPS NON_PREFERRED

NITROFURANTOIN MACROCRYSTALS CAPS PREFERRED

MACROBID CAPS NON_PREFERRED

NITROFURANTOIN MONOHYDRATE CAPS PREFERRED

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS CAPS PREFERRED

Page 12 of 102


FORMPDL STATUS

SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP PREFERRED

SULFATRIM PEDIATRIC SUSP PREFERRED

BACTRIM TABS NON_PREFERRED

BACTRIM DS TABS NON_PREFERRED

SULFAMETHOXAZOLE/TRIMETHOPRIM TABS PREFERRED

SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS PREFERRED

ME/NAPHOS/MB/HYO 1 TABS NON_PREFERRED

UROGESIC-BLUE TABS NON_PREFERRED

HYOPHEN TABS NON_PREFERRED

URAMIT MB CAPS NON_PREFERRED

URO-MP CAPS NON_PREFERRED

USTELL CAPS NON_PREFERRED

HYOLEV MB TABS NON_PREFERRED

PHOSPHASAL TABS NON_PREFERRED

URIMAR-T TABS NON_PREFERRED

URIN D/S TABS NON_PREFERRED

URO-458 TABS NON_PREFERRED

ANTIBIOTICS : ANTIMYCOBACTERIAL AGENTS PASER PACK NON_PREFERRED

SIRTURO TABS NON_PREFERRED

CYCLOSERINE CAPS PREFERRED

ETHAMBUTOL HCL TABS PREFERRED

ETHAMBUTOL HYDROCHLORIDE TABS PREFERRED

MYAMBUTOL TABS NON_PREFERRED

TRECATOR TABS PREFERRED

ISONIAZID SYRP PREFERRED

ISONIAZID TABS PREFERRED

PRETOMANID TABS NON_PREFERRED

PYRAZINAMIDE TABS PREFERRED

MYCOBUTIN CAPS NON_PREFERRED

RIFABUTIN CAPS PREFERRED

RIFAMPIN CAPS PREFERRED

PRIFTIN TABS NON_PREFERRED

ANTIBIOTICS : CEPHALOSPORINS CEFADROXIL CAPS PREFERRED

CEFADROXIL SUSR PREFERRED

CEFADROXIL TABS PREFERRED

CEPHALEXIN CAPS PREFERRED

KEFLEX CAPS NON_PREFERRED

CEPHALEXIN SUSR PREFERRED

CEPHALEXIN TABS PREFERRED

CEFACLOR CAPS PREFERRED

CEFACLOR SUSR PREFERRED

CEFACLOR ER TB12 NON_PREFERRED

CEFPROZIL SUSR PREFERRED

CEFPROZIL TABS NON_PREFERRED

Page 13 of 102


FORMPDL STATUS

CEFUROXIME AXETIL TABS PREFERRED

CEFDINIR CAPS PREFERRED

CEFDINIR SUSR PREFERRED

CEFIXIME CAPS PREFERRED

SUPRAX CAPS PREFERRED

SUPRAX CHEW NON_PREFERRED

CEFIXIME SUSR NON_PREFERRED

SUPRAX SUSR NON_PREFERRED

CEFPODOXIME PROXETIL SUSR NON_PREFERRED

CEFPODOXIME PROXETIL TABS NON_PREFERRED

ANTIBIOTICS : MACROLIDES ERYTHROMYCIN CPEP PREFERRED

ERYTHROMYCIN BASE TABS PREFERRED

ERY-TAB TBEC PREFERRED

ERYTHROMYCIN DR TBEC PREFERRED

PCE TBEC PREFERRED

ERYTHROCIN STEARATE TABS PREFERRED

E.E.S. GRANULES SUSR PREFERRED

ERYPED 200 SUSR PREFERRED

ERYPED 400 SUSR PREFERRED

ERYTHROMYCIN ETHYLSUCCINATE SUSR PREFERRED

E.E.S. 400 TABS PREFERRED

ERYTHROMYCIN ETHYLSUCCINATE TABS PREFERRED

AZITHROMYCIN PACK PREFERRED

ZITHROMAX PACK PREFERRED

AZITHROMYCIN SUSR PREFERRED

ZITHROMAX SUSR NON_PREFERRED

AZITHROMYCIN TABS PREFERRED

ZITHROMAX TABS NON_PREFERRED

ZITHROMAX TRI-PAK TABS NON_PREFERRED

ZITHROMAX Z-PAK TABS NON_PREFERRED

CLARITHROMYCIN SUSR PREFERRED

CLARITHROMYCIN TABS PREFERRED

CLARITHROMYCIN ER TB24 PREFERRED

DIFICID TABS NON_PREFERRED

ANTIBIOTICS : PENICILLINS PENICILLIN V POTASSIUM SOLR PREFERRED

PENICILLIN V POTASSIUM TABS PREFERRED

AMOXICILLIN CAPS PREFERRED

AMOXICILLIN CHEW PREFERRED

AMOXICILLIN SUSR PREFERRED

AMOXICILLIN TABS PREFERRED

AMPICILLIN CAPS PREFERRED

DICLOXACILLIN SODIUM CAPS PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM SUSR PREFERRED

Page 14 of 102


FORMPDL STATUS

AUGMENTIN SUSR PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM TABS PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 NON_PREFERRED

ANTIBIOTICS : TETRACYCLINES DEMECLOCYCLINE HCL TABS PREFERRED

DEMECLOCYCLINE HYDROCHLORIDE TABS PREFERRED

DOXYCYCLINE MONOHYDRATE CAPS PREFERRED

DOXYCYCLINE SUSR PREFERRED

VIBRAMYCIN SUSR NON_PREFERRED

DOXYCYCLINE TABS PREFERRED

DOXYCYCLINE MONOHYDRATE TABS PREFERRED

DOXYCYCLINE HYCLATE CAPS PREFERRED

MORGIDOX 1X100MG CAPS PREFERRED



VIBRAMYCIN CAPS NON_PREFERRED

DOXYCYCLINE HYCLATE TABS PREFERRED

DORYX TBEC NON_PREFERRED

DORYX MPC TBEC NON_PREFERRED

DOXYCYCLINE HYCLATE TBEC NON_PREFERRED

DOXYCYCLINE HYCLATE DR TBEC NON_PREFERRED

VIBRAMYCIN SYRP PREFERRED

MORGIDOX 1X100MG KIT NON_PREFERRED

MORGIDOX 1X50MG KIT KIT NON_PREFERRED

MORGIDOX 2X100MG KIT NON_PREFERRED

MINOCIN CAPS NON_PREFERRED

MINOCYCLINE HCL CAPS PREFERRED

MINOCYCLINE HYDROCHLORIDE CAPS PREFERRED

XIMINO CP24 NON_PREFERRED

MINOCYCLINE HCL TABS PREFERRED

MINOCYCLINE HYDROCHLORIDE TABS PREFERRED

MINOCYCLINE HCL ER TB24 NON_PREFERRED

MINOCYCLINE HYDROCHLORIDE ER TB24 NON_PREFERRED

MINOCYCLINE HYDROCHLORIDEER TB24 NON_PREFERRED

MINOLIRA TB24 NON_PREFERRED

SOLODYN TB24 NON_PREFERRED

TETRACYCLINE HYDROCHLORIDE CAPS PREFERRED

NUZYRA TABS NON_PREFERRED

ANTICOAGULANTS : COUMARIN COUMADIN TABS NON_PREFERRED

JANTOVEN TABS PREFERRED

WARFARIN SODIUM TABS PREFERRED

ANTICOAGULANTS : DIRECT FACTOR XA INHIBITORS & MISC PRADAXA CAPS NON_PREFERRED

ELIQUIS TABS PREFERRED_WITH_PA

ELIQUIS STARTER PACK TBPK PREFERRED_WITH_PA

BEVYXXA CAPS NON_PREFERRED

Page 15 of 102


FORMPDL STATUS

SAVAYSA TABS NON_PREFERRED

XARELTO TABS PREFERRED_WITH_PA

XARELTO STARTER PACK TBPK PREFERRED_WITH_PA

ANTICOAGULANTS : HEPARIN AND HEPARINOID-LIKE AGENTS HEPARIN SODIUM SOLN PREFERRED

HEPARIN SODIUM DCU SOLN PREFERRED

HEPARIN SODIUM SOSY PREFERRED

FRAGMIN SOLN PREFERRED

ENOXAPARIN SODIUM SOLN PREFERRED

LOVENOX SOLN NON_PREFERRED

ARIXTRA SOLN NON_PREFERRED

FONDAPARINUX SODIUM SOLN PREFERRED

ANTICONVULSANTS SYMPAZAN FILM NON_PREFERRED

CLOBAZAM SUSP NON_PREFERRED

ONFI SUSP NON_PREFERRED

CLOBAZAM TABS NON_PREFERRED

ONFI TABS NON_PREFERRED

CLONAZEPAM TABS PREFERRED

KLONOPIN TABS NON_PREFERRED

CLONAZEPAM ODT TBDP NON_PREFERRED

DIASTAT ACUDIAL GEL PREFERRED

DIASTAT PEDIATRIC GEL PREFERRED

DIAZEPAM GEL PREFERRED

DIAZEPAM RECTAL GEL GEL PREFERRED

VALTOCO LIQD NON_PREFERRED

VALTOCO LQPK NON_PREFERRED

NAYZILAM SOLN NON_PREFERRED

XCOPRI TABS NON_PREFERRED

XCOPRI TBPK NON_PREFERRED

FELBAMATE SUSP NON_PREFERRED

FELBATOL SUSP NON_PREFERRED

FELBAMATE TABS NON_PREFERRED

FELBATOL TABS NON_PREFERRED

GABITRIL TABS NON_PREFERRED

TIAGABINE HYDROCHLORIDE TABS NON_PREFERRED

SABRIL PACK NON_PREFERRED

VIGABATRIN PACK NON_PREFERRED

VIGADRONE PACK NON_PREFERRED

SABRIL TABS NON_PREFERRED

VIGABATRIN TABS NON_PREFERRED

PEGANONE TABS NON_PREFERRED

DILANTIN INFATABS CHEW NON_PREFERRED

PHENYTOIN CHEW PREFERRED

PHENYTOIN INFATABS CHEW PREFERRED

Page 16 of 102


FORMPDL STATUS

DILANTIN-125 SUSP NON_PREFERRED

PHENYTOIN SUSP PREFERRED

DILANTIN CAPS NON_PREFERRED

PHENYTEK CAPS NON_PREFERRED

PHENYTOIN SODIUM EXTENDED CAPS PREFERRED

ETHOSUXIMIDE CAPS PREFERRED

ZARONTIN CAPS NON_PREFERRED

ETHOSUXIMIDE SOLN PREFERRED

ZARONTIN SOLN NON_PREFERRED

CELONTIN CAPS NON_PREFERRED

DEPAKOTE SPRINKLES CSDR NON_PREFERRED

DIVALPROEX SODIUM CSDR PREFERRED

DEPAKOTE ER TB24 NON_PREFERRED

DIVALPROEX SODIUM ER TB24 PREFERRED

DEPAKOTE TBEC NON_PREFERRED

DIVALPROEX SODIUM DR TBEC PREFERRED

VALPROIC ACID SOLN PREFERRED

VALPROIC ACID CAPS PREFERRED

FYCOMPA SUSP NON_PREFERRED

FYCOMPA TABS NON_PREFERRED

BRIVIACT SOLN NON_PREFERRED

BRIVIACT TABS NON_PREFERRED

EPIDIOLEX SOLN NON_PREFERRED

CARBAMAZEPINE CHEW PREFERRED

CARBAMAZEPINE ER CP12 NON_PREFERRED

CARBATROL CP12 NON_PREFERRED

CARBAMAZEPINE SUSP PREFERRED

TEGRETOL SUSP NON_PREFERRED

CARBAMAZEPINE TABS PREFERRED

EPITOL TABS PREFERRED

TEGRETOL TABS NON_PREFERRED

CARBAMAZEPINE ER TB12 PREFERRED

TEGRETOL-XR TB12 NON_PREFERRED

APTIOM TABS NON_PREFERRED

FINTEPLA SOLN NON_PREFERRED

GABAPENTIN CAPS PREFERRED

NEURONTIN CAPS NON_PREFERRED

GABAPENTIN SOLN PREFERRED

NEURONTIN SOLN NON_PREFERRED

GABAPENTIN TABS PREFERRED

NEURONTIN TABS NON_PREFERRED

VIMPAT SOLN NON_PREFERRED

VIMPAT TABS NON_PREFERRED

LAMICTAL CHEWABLE DISPERSIBLE CHEW NON_PREFERRED

Page 17 of 102


FORMPDL STATUS

LAMOTRIGINE CHEW PREFERRED

LAMICTAL ODT KIT NON_PREFERRED

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT NON_PREFERRED

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE KIT NON_PREFERRED

LAMICTAL STARTER/TAKING VALPROATE KIT NON_PREFERRED

LAMICTAL XR KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/BLUE KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/GREEN KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/ORANGE KIT NON_PREFERRED

LAMOTRIGINE TITRATION KIT NON_PREFERRED

SUBVENITE STARTER KIT/BLUE KIT NON_PREFERRED

SUBVENITE STARTER KIT/GREEN KIT NON_PREFERRED

SUBVENITE STARTER KIT/ORANGE KIT NON_PREFERRED

LAMICTAL TABS NON_PREFERRED

LAMOTRIGINE TABS PREFERRED

SUBVENITE TABS PREFERRED

LAMICTAL XR TB24 NON_PREFERRED

LAMOTRIGINE ER TB24 NON_PREFERRED

LAMICTAL ODT TBDP NON_PREFERRED

LAMOTRIGINE ODT TBDP NON_PREFERRED

KEPPRA SOLN NON_PREFERRED

LEVETIRACETAM SOLN PREFERRED

KEPPRA TABS NON_PREFERRED

LEVETIRACETAM TABS PREFERRED

ROWEEPRA TABS PREFERRED

KEPPRA XR TB24 NON_PREFERRED

LEVETIRACETAM ER TB24 PREFERRED

SPRITAM TB3D NON_PREFERRED

OXCARBAZEPINE SUSP PREFERRED

TRILEPTAL SUSP NON_PREFERRED

OXCARBAZEPINE TABS PREFERRED

TRILEPTAL TABS NON_PREFERRED

OXTELLAR XR TB24 NON_PREFERRED

LYRICA CAPS NON_PREFERRED

PREGABALIN CAPS PREFERRED

LYRICA SOLN NON_PREFERRED

PREGABALIN SOLN PREFERRED

MYSOLINE TABS NON_PREFERRED

PRIMIDONE TABS PREFERRED

BANZEL SUSP NON_PREFERRED

RUFINAMIDE SUSP NON_PREFERRED

BANZEL TABS NON_PREFERRED

DIACOMIT CAPS NON_PREFERRED

DIACOMIT PACK NON_PREFERRED

Page 18 of 102


FORMPDL STATUS

TROKENDI XR CP24 NON_PREFERRED

TOPAMAX SPRINKLE CPSP NON_PREFERRED

TOPIRAMATE CPSP PREFERRED

QUDEXY XR CS24 NON_PREFERRED

TOPIRAMATE ER CS24 NON_PREFERRED

TOPAMAX TABS NON_PREFERRED

TOPIRAMATE TABS PREFERRED

ZONISAMIDE CAPS PREFERRED

ANTIDEPRESSANTS : MISC MIRTAZAPINE TABS PREFERRED

REMERON TABS NON_PREFERRED

MIRTAZAPINE ODT TBDP PREFERRED

REMERON SOLTAB TBDP NON_PREFERRED

MARPLAN TABS NON_PREFERRED

NARDIL TABS NON_PREFERRED

PHENELZINE SULFATE TABS PREFERRED

EMSAM PT24 NON_PREFERRED

TRANYLCYPROMINE SULFATE TABS PREFERRED

SPRAVATO 56MG DOSE SOPK NON_PREFERRED

SPRAVATO 84MG DOSE SOPK NON_PREFERRED

NEFAZODONE HCL TABS NON_PREFERRED

NEFAZODONE HYDROCHLORIDE TABS NON_PREFERRED

TRAZODONE HYDROCHLORIDE TABS PREFERRED

VIIBRYD STARTER PACK KIT NON_PREFERRED

VIIBRYD TABS NON_PREFERRED

TRINTELLIX TABS NON_PREFERRED

AMITRIPTYLINE HCL TABS PREFERRED

AMITRIPTYLINE HYDROCHLORIDE TABS PREFERRED

AMOXAPINE TABS NON_PREFERRED

ANAFRANIL CAPS NON_PREFERRED

CLOMIPRAMINE HCL CAPS PREFERRED

CLOMIPRAMINE HYDROCHLORIDE CAPS PREFERRED

DESIPRAMINE HCL TABS PREFERRED

DESIPRAMINE HYDROCHLORIDE TABS PREFERRED

NORPRAMIN TABS NON_PREFERRED

DOXEPIN HCL CAPS PREFERRED

DOXEPIN HYDROCHLORIDE CAPS PREFERRED

DOXEPIN HCL CONC PREFERRED

IMIPRAMINE HCL TABS PREFERRED

IMIPRAMINE HYDROCHLORIDE TABS PREFERRED

TOFRANIL TABS NON_PREFERRED

IMIPRAMINE PAMOATE CAPS NON_PREFERRED

NORTRIPTYLINE HCL CAPS PREFERRED

NORTRIPTYLINE HYDROCHLORIDE CAPS PREFERRED

PAMELOR CAPS NON_PREFERRED

Page 19 of 102


FORMPDL STATUS

NORTRIPTYLINE HCL SOLN PREFERRED

PROTRIPTYLINE HCL TABS PREFERRED

SURMONTIL CAPS NON_PREFERRED

TRIMIPRAMINE MALEATE CAPS NON_PREFERRED

MAPROTILINE HCL TABS PREFERRED

BUPROPION HCL TABS PREFERRED

BUPROPION HYDROCHLORIDE TABS PREFERRED

BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED

WELLBUTRIN SR TB12 NON_PREFERRED

BUPROPION HYDROCHLORIDE ER (XL) TB24 PREFERRED

FORFIVO XL TB24 NON_PREFERRED

WELLBUTRIN XL TB24 NON_PREFERRED

APLENZIN TB24 NON_PREFERRED

PRAMLYTE THPK NON_PREFERRED

ANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE INHIBITOR

(SSRIs) CITALOPRAM HYDROBROMIDE SOLN PREFERRED

CELEXA TABS NON_PREFERRED

CITALOPRAM TABS PREFERRED

CITALOPRAM HYDROBROMIDE TABS PREFERRED

ESCITALOPRAM OXALATE SOLN PREFERRED

ESCITALOPRAM OXALATE TABS PREFERRED

LEXAPRO TABS NON_PREFERRED

FLUOXETINE HCL CAPS PREFERRED

FLUOXETINE HYDROCHLORIDE CAPS PREFERRED

PROZAC CAPS NON_PREFERRED

FLUOXETINE DR CPDR NON_PREFERRED

FLUOXETINE HCL SOLN PREFERRED

FLUOXETINE HYDROCHLORIDE SOLN PREFERRED

FLUOXETINE HYDROCHLORIDE TABS PREFERRED

FLUVOXAMINE MALEATE ER CP24 NON_PREFERRED

FLUVOXAMINE MALEATE TABS PREFERRED

PAXIL SUSP NON_PREFERRED

PAROXETINE HCL TABS PREFERRED

PAROXETINE HYDROCHLORIDE TABS PREFERRED

PAXIL TABS NON_PREFERRED

PAROXETINE HCL ER TB24 NON_PREFERRED

PAROXETINE HYDROCHLORIDEER TB24 NON_PREFERRED

PAXIL CR TB24 NON_PREFERRED

PEXEVA TABS NON_PREFERRED

SERTRALINE HCL CONC PREFERRED

SERTRALINE HYDROCHLORIDE CONC PREFERRED

ZOLOFT CONC NON_PREFERRED

SERTRALINE HCL TABS PREFERRED

SERTRALINE HYDROCHLORIDE TABS PREFERRED

Page 20 of 102


FORMPDL STATUS

ZOLOFT TABS NON_PREFERRED

ANTIDEPRESSANTS : SELECTIVE SEROTONIN-NOREPINEPHRINE

REUPTAKE INHIBITOR (SNRIs) DESVENLAFAXINE ER TB24 NON_PREFERRED

DESVENLAFAXINE ER TB24 NON_PREFERRED

DESVENLAFAXINE ER TB24 NON_PREFERRED

PRISTIQ TB24 NON_PREFERRED

CYMBALTA CPEP NON_PREFERRED

DULOXETINE HCL CPEP PREFERRED

DULOXETINE HYDROCHLORIDE CPEP PREFERRED

DRIZALMA SPRINKLE CSDR NON_PREFERRED

FETZIMA TITRATION PACK C4PK NON_PREFERRED

FETZIMA CP24 NON_PREFERRED

EFFEXOR XR CP24 NON_PREFERRED

VENLAFAXINE HCL ER CP24 PREFERRED

VENLAFAXINE HYDROCHLORIDE ER CP24 PREFERRED

VENLAFAXINE HYDROCHLORIDEER CP24 PREFERRED

VENLAFAXINE HCL TABS PREFERRED

VENLAFAXINE HYDROCHLORIDE TABS PREFERRED

VENLAFAXINE HCL ER TB24 NON_PREFERRED

VENLAFAXINE HYDROCHLORIDE ER TB24 NON_PREFERRED

ANTIDIABETICS : COMBINATIONS XULTOPHY 100/3.6 SOPN NON_PREFERRED

SOLIQUA 100/33 SOPN NON_PREFERRED

ALOGLIPTIN/METFORMIN HCL TABS NON_PREFERRED

KAZANO TABS NON_PREFERRED

JENTADUETO TABS NON_PREFERRED

JENTADUETO XR TB24 NON_PREFERRED

KOMBIGLYZE XR TB24 NON_PREFERRED

JANUMET TABS NON_PREFERRED

JANUMET XR TB24 NON_PREFERRED

ALOGLIPTIN/PIOGLITAZONE TABS NON_PREFERRED

OSENI TABS NON_PREFERRED

REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS NON_PREFERRED

INVOKAMET TABS NON_PREFERRED

INVOKAMET XR TB24 NON_PREFERRED

XIGDUO XR TB24 NON_PREFERRED

SYNJARDY TABS NON_PREFERRED

SYNJARDY XR TB24 NON_PREFERRED

SEGLUROMET TABS NON_PREFERRED

QTERN TABS NON_PREFERRED

GLYXAMBI TABS NON_PREFERRED

STEGLUJAN TABS NON_PREFERRED

TRIJARDY XR TB24 NON_PREFERRED

GLIPIZIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED

GLIPIZIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED

Page 21 of 102


FORMPDL STATUS

GLYBURIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED

DUETACT TABS NON_PREFERRED

PIOGLITAZONE HCL-GLIMEPIRIDE TABS NON_PREFERRED

ACTOPLUS MET TABS NON_PREFERRED

PIOGLITAZONE HCL/METFORMIN HCL TABS NON_PREFERRED

ANTIDIABETICS : DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS ALOGLIPTIN TABS NON_PREFERRED

NESINA TABS NON_PREFERRED

TRADJENTA TABS PREFERRED

ONGLYZA TABS NON_PREFERRED

JANUVIA TABS PREFERRED

ANTIDIABETICS : INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR

AGONISTS) TRULICITY SOPN NON_PREFERRED

BYDUREON BCISE AUIJ NON_PREFERRED

BYDUREON PEN PEN NON_PREFERRED

BYETTA SOPN PREFERRED

BYDUREON SRER NON_PREFERRED

VICTOZA SOPN PREFERRED

ADLYXIN STARTER PACK PNKT NON_PREFERRED

ADLYXIN SOPN NON_PREFERRED

OZEMPIC SOPN NON_PREFERRED

RYBELSUS TABS NON_PREFERRED

ANTIDIABETICS : INSULIN INSULIN ASPART PENFILL SOCT NON_PREFERRED

NOVOLOG PENFILL SOCT NON_PREFERRED

INSULIN ASPART SOLN NON_PREFERRED

NOVOLOG SOLN NON_PREFERRED

INSULIN ASPART FLEXPEN SOPN NON_PREFERRED

NOVOLOG FLEXPEN SOPN NON_PREFERRED

FIASP PENFILL SOCT NON_PREFERRED

FIASP SOLN NON_PREFERRED

FIASP FLEXTOUCH SOPN NON_PREFERRED

LANTUS SOLN PREFERRED

SEMGLEE SOLN NON_PREFERRED

BASAGLAR KWIKPEN SOPN NON_PREFERRED

LANTUS SOLOSTAR SOPN PREFERRED

SEMGLEE SOPN NON_PREFERRED

TOUJEO MAX SOLOSTAR SOPN NON_PREFERRED

TOUJEO SOLOSTAR SOPN NON_PREFERRED

APIDRA SOLN NON_PREFERRED

APIDRA SOLOSTAR SOPN NON_PREFERRED

HUMALOG SOCT PREFERRED

ADMELOG SOLN NON_PREFERRED

HUMALOG SOLN PREFERRED

INSULIN LISPRO SOLN PREFERRED

Page 22 of 102


FORMPDL STATUS

ADMELOG SOLOSTAR SOPN NON_PREFERRED

HUMALOG JUNIOR KWIKPEN SOPN PREFERRED

HUMALOG KWIKPEN SOPN PREFERRED

INSULIN LISPRO JUNIOR KWIKPEN SOPN PREFERRED

INSULIN LISPRO KWIKPEN SOPN PREFERRED

LYUMJEV SOLN NON_PREFERRED

LYUMJEV KWIKPEN SOPN NON_PREFERRED

LEVEMIR SOLN PREFERRED

LEVEMIR FLEXTOUCH SOPN PREFERRED

TRESIBA SOLN NON_PREFERRED

TRESIBA FLEXTOUCH SOPN NON_PREFERRED

AFREZZA POWD NON_PREFERRED

HUMULIN R SOLN PREFERRED

HUMULIN R U-500 (CONCENTRATED) SOLN PREFERRED

NOVOLIN R SOLN NON_PREFERRED

NOVOLIN R RELION SOLN NON_PREFERRED

HUMULIN R U-500 KWIKPEN SOPN PREFERRED

NOVOLIN R FLEXPEN SOPN NON_PREFERRED

NOVOLIN R FLEXPEN RELION SOPN NON_PREFERRED

HUMULIN N KWIKPEN SUPN PREFERRED

NOVOLIN N FLEXPEN SUPN NON_PREFERRED

NOVOLIN N FLEXPEN RELION SUPN NON_PREFERRED

HUMULIN N SUSP PREFERRED

NOVOLIN N SUSP NON_PREFERRED

NOVOLIN N RELION SUSP NON_PREFERRED

INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN SUPN NON_PREFERRED

NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN NON_PREFERRED

INSULIN ASPART PROTAMINE/INSULIN ASPART SUSP NON_PREFERRED

NOVOLOG MIX 70/30 SUSP NON_PREFERRED

HUMALOG MIX 50/50 KWIKPEN SUPN PREFERRED

HUMALOG MIX 75/25 KWIKPEN SUPN PREFERRED

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN SUPN PREFERRED

HUMALOG MIX 50/50 SUSP PREFERRED

HUMALOG MIX 75/25 SUSP PREFERRED

HUMULIN 70/30 KWIKPEN SUPN PREFERRED

NOVOLIN 70/30 FLEXPEN SUPN NON_PREFERRED

NOVOLIN 70/30 FLEXPEN RELION SUPN NON_PREFERRED

HUMULIN 70/30 SUSP PREFERRED

NOVOLIN 70/30 SUSP NON_PREFERRED

NOVOLIN 70/30 RELION SUSP NON_PREFERRED

ANTIDIABETICS : MISC SYMLINPEN 120 SOPN NON_PREFERRED

SYMLINPEN 60 SOPN NON_PREFERRED

AMARYL TABS NON_PREFERRED

GLIMEPIRIDE TABS PREFERRED

Page 23 of 102


FORMPDL STATUS

GLIPIZIDE TABS PREFERRED

GLUCOTROL TABS NON_PREFERRED

GLIPIZIDE ER TB24 PREFERRED

GLIPIZIDE XL TB24 PREFERRED

GLUCOTROL XL TB24 NON_PREFERRED

GLYBURIDE TABS PREFERRED

GLYBURIDE TABS PREFERRED

GLYBURIDE MICRONIZED TABS PREFERRED

GLYNASE TABS NON_PREFERRED

TOLBUTAMIDE TABS PREFERRED

METFORMIN HYDROCHLORIDE SOLN NON_PREFERRED

RIOMET SOLN NON_PREFERRED

RIOMET ER SRER NON_PREFERRED

METFORMIN HYDROCHLORIDE TABS PREFERRED

FORTAMET TB24 NON_PREFERRED

GLUCOPHAGE XR TB24 NON_PREFERRED

GLUMETZA TB24 NON_PREFERRED

METFORMIN HYDROCHLORIDE ER TB24 PREFERRED

NATEGLINIDE TABS PREFERRED

STARLIX TABS NON_PREFERRED

PRANDIN TABS NON_PREFERRED

REPAGLINIDE TABS NON_PREFERRED

BAQSIMI ONE PACK POWD NON_PREFERRED

BAQSIMI TWO PACK POWD NON_PREFERRED

GVOKE HYPOPEN SOAJ NON_PREFERRED

GVOKE PFS SOSY NON_PREFERRED

GLUCAGON EMERGENCY KIT KIT PREFERRED

GLUCAGEN HYPOKIT SOLR PREFERRED

GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR SOLR PREFERRED

DIAZOXIDE SUSP PREFERRED

PROGLYCEM SUSP PREFERRED

KORLYM TABS NON_PREFERRED

ACARBOSE TABS PREFERRED

PRECOSE TABS NON_PREFERRED

GLYSET TABS NON_PREFERRED

MIGLITOL TABS PREFERRED

CYCLOSET TABS NON_PREFERRED

ACTOS TABS NON_PREFERRED

PIOGLITAZONE HCL TABS PREFERRED

PIOGLITAZONE HYDROCHLORIDE TABS PREFERRED

AVANDIA TABS PREFERRED

ANTIDIABETICS : SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS INVOKANA TABS PREFERRED

FARXIGA TABS NON_PREFERRED

Page 24 of 102


FORMPDL STATUS

JARDIANCE TABS PREFERRED

STEGLATRO TABS NON_PREFERRED

ANTIDOTES AND SPECIFIC ANTAGONISTS : ANTIDOTES - CHELATING

AGENTS DEFERASIROX PACK NON_PREFERRED

DEFERSIROX PACK NON_PREFERRED

JADENU SPRINKLE PACK NON_PREFERRED

DEFERASIROX TABS NON_PREFERRED

JADENU TABS NON_PREFERRED

DEFERASIROX TBSO NON_PREFERRED

EXJADE TBSO NON_PREFERRED

FERRIPROX SOLN NON_PREFERRED

DEFERIPRONE TABS NON_PREFERRED

FERRIPROX TABS NON_PREFERRED

FERRIPROX TWICE-A-DAY TABS NON_PREFERRED

CHEMET CAPS PREFERRED

CLOVIQUE CAPS PREFERRED

SYPRINE CAPS NON_PREFERRED

TRIENTINE HYDROCHLORIDE CAPS PREFERRED

CUPRIMINE CAPS NON_PREFERRED

PENICILLAMINE CAPS PREFERRED

DEPEN TITRATABS TABS PREFERRED

PENICILLAMINE TABS PREFERRED

ANTIEMETICS : 5-HT3 RECEPTOR ANTAGONISTS ANZEMET TABS NON_PREFERRED

SANCUSO PTCH NON_PREFERRED

GRANISETRON HCL TABS NON_PREFERRED

ZUPLENZ FILM NON_PREFERRED

ONDANSETRON ODT TBDP PREFERRED

ONDANSETRON HCL SOLN PREFERRED

ONDANSETRON HYDROCHLORIDE SOLN PREFERRED

ONDANSETRON HYDROCHLORIDE TABS PREFERRED

ZOFRAN TABS NON_PREFERRED

ANTIEMETICS : MISC MECLIZINE HCL TABS PREFERRED

MECLIZINE HYDROCHLORIDE TABS PREFERRED

SCOPOLAMINE PT72 PREFERRED

TRANSDERM-SCOP PT72 PREFERRED

TIGAN CAPS NON_PREFERRED

TRIMETHOBENZAMIDE HYDROCHLORIDE CAPS NON_PREFERRED

DRONABINOL CAPS NON_PREFERRED

MARINOL CAPS NON_PREFERRED

BONJESTA TBCR NON_PREFERRED

DICLEGIS TBEC NON_PREFERRED

DOXYLAMINE SUCCINATE/PYRIDOXINE HYDROCHLORIDE TBEC NON_PREFERRED

AKYNZEO CAPS NON_PREFERRED

Page 25 of 102


FORMPDL STATUS

ANTIEMETICS : SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR

ANTAGONISTS APREPITANT CAPS PREFERRED

EMEND CAPS NON_PREFERRED

EMEND TRIPACK CAPS NON_PREFERRED

EMEND SUSR NON_PREFERRED

VARUBI TBPK NON_PREFERRED

ANTIFUNGALS ANCOBON CAPS NON_PREFERRED

FLUCYTOSINE CAPS NON_PREFERRED

GRISEOFULVIN MICROSIZE SUSP PREFERRED

GRISEOFULVIN MICROSIZE TABS PREFERRED

GRISEOFULVIN ULTRAMICROSIZE TABS PREFERRED

NYSTATIN TABS PREFERRED

TERBINAFINE HCL TABS PREFERRED

TERBINAFINE HYDROCHLORIDE TABS PREFERRED

KETOCONAZOLE TABS PREFERRED

DIFLUCAN SUSR NON_PREFERRED

FLUCONAZOLE SUSR PREFERRED

DIFLUCAN TABS NON_PREFERRED

FLUCONAZOLE TABS PREFERRED

CRESEMBA CAPS NON_PREFERRED

ITRACONAZOLE CAPS NON_PREFERRED

SPORANOX CAPS NON_PREFERRED

SPORANOX PULSEPAK CAPS NON_PREFERRED

TOLSURA CAPS NON_PREFERRED

ITRACONAZOLE SOLN NON_PREFERRED

SPORANOX SOLN NON_PREFERRED

ONMEL TABS NON_PREFERRED

NOXAFIL SUSP NON_PREFERRED

NOXAFIL TBEC NON_PREFERRED

POSACONAZOLE DR TBEC NON_PREFERRED

VFEND SUSR NON_PREFERRED

VORICONAZOLE SUSR NON_PREFERRED

VFEND TABS NON_PREFERRED

VORICONAZOLE TABS NON_PREFERRED

ANTIHYPERLIPIDEMICS CHOLESTYRAMINE PACK PREFERRED

QUESTRAN PACK NON_PREFERRED

CHOLESTYRAMINE POWD PREFERRED

QUESTRAN POWD NON_PREFERRED

CHOLESTYRAMINE LIGHT PACK PREFERRED

PREVALITE PACK PREFERRED

CHOLESTYRAMINE LIGHT POWD PREFERRED

PREVALITE POWD PREFERRED

QUESTRAN LIGHT POWD NON_PREFERRED

COLESEVELAM HYDROCHLORIDE PACK NON_PREFERRED

Page 26 of 102


FORMPDL STATUS

WELCHOL PACK NON_PREFERRED

COLESEVELAM HYDROCHLORIDE TABS NON_PREFERRED

WELCHOL TABS NON_PREFERRED

COLESTID GRAN NON_PREFERRED

COLESTID FLAVORED GRAN NON_PREFERRED

COLESTIPOL HCL GRAN NON_PREFERRED

COLESTID PACK NON_PREFERRED

COLESTID FLAVORED PACK NON_PREFERRED

COLESTIPOL HCL PACK NON_PREFERRED

COLESTID TABS NON_PREFERRED

COLESTIPOL HCL TABS NON_PREFERRED

FENOFIBRIC ACID DR CPDR PREFERRED

TRILIPIX CPDR NON_PREFERRED

FIBRICOR TABS NON_PREFERRED

FENOFIBRATE CAPS PREFERRED

LIPOFEN CAPS NON_PREFERRED

FENOFIBRATE TABS PREFERRED

FENOGLIDE TABS NON_PREFERRED

TRICOR TABS NON_PREFERRED

ANTARA CAPS NON_PREFERRED

FENOFIBRATE CAPS PREFERRED

FENOFIBRATE MICRONIZED CAPS PREFERRED

GEMFIBROZIL TABS PREFERRED

LOPID TABS NON_PREFERRED

EZETIMIBE TABS PREFERRED

ZETIA TABS NON_PREFERRED

PRALUENT SOAJ NON_PREFERRED

REPATHA SURECLICK SOAJ NON_PREFERRED

REPATHA PUSHTRONEX SYSTEM SOCT NON_PREFERRED

REPATHA SOSY NON_PREFERRED

NEXLETOL TABS NON_PREFERRED

ATORVASTATIN CALCIUM TABS PREFERRED

LIPITOR TABS NON_PREFERRED

FLUVASTATIN CAPS NON_PREFERRED

FLUVASTATIN SODIUM ER TB24 NON_PREFERRED

LESCOL XL TB24 NON_PREFERRED

LOVASTATIN TABS PREFERRED

ALTOPREV TB24 NON_PREFERRED

LIVALO TABS NON_PREFERRED

ZYPITAMAG TABS NON_PREFERRED

EZALLOR SPRINKLE CPSP NON_PREFERRED

CRESTOR TABS NON_PREFERRED

ROSUVASTATIN CALCIUM TABS PREFERRED

PRAVACHOL TABS NON_PREFERRED

Page 27 of 102


FORMPDL STATUS

PRAVASTATIN SODIUM TABS PREFERRED

SIMVASTATIN TABS PREFERRED

ZOCOR TABS NON_PREFERRED

NIACIN ER TBCR NON_PREFERRED

NIASPAN TBCR NON_PREFERRED

JUXTAPID CAPS NON_PREFERRED

ICOSAPENT ETHYL CAPS NON_PREFERRED

VASCEPA CAPS NON_PREFERRED

LOVAZA CAPS NON_PREFERRED

OMEGA-3-ACID ETHYL ESTERS CAPS NON_PREFERRED

NEXLIZET TABS NON_PREFERRED

EZETIMIBE/SIMVASTATIN TABS NON_PREFERRED

VYTORIN TABS NON_PREFERRED

ANTIMYASTHENIC AGENTS RUZURGI TABS NON_PREFERRED

FIRDAPSE TABS NON_PREFERRED

GUANIDINE HCL TABS NON_PREFERRED

MESTINON SOLN NON_PREFERRED

PYRIDOSTIGMINE BROMIDE SOLN PREFERRED

MESTINON TABS NON_PREFERRED

PYRIDOSTIGMINE BROMIDE TABS PREFERRED

MESTINON TIMESPAN TBCR NON_PREFERRED

PYRIDOSTIGMINE BROMIDE ER TBCR PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ALKYLATING

AGENTS MYLERAN TABS PREFERRED

LEUKERAN TABS PREFERRED

CYCLOPHOSPHAMIDE CAPS PREFERRED

ALKERAN TABS NON_PREFERRED

MELPHALAN TABS PREFERRED

GLEOSTINE CAPS PREFERRED

TEMODAR CAPS NON_PREFERRED

TEMOZOLOMIDE CAPS PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES :

ANTIMETABOLITES ONUREG TABS NON_PREFERRED

CAPECITABINE TABS NON_PREFERRED

XELODA TABS NON_PREFERRED

PURIXAN SUSP NON_PREFERRED

MERCAPTOPURINE TABS PREFERRED

XATMEP SOLN NON_PREFERRED

METHOTREXATE TABS PREFERRED

METHOTREXATE SODIUM TABS PREFERRED

TREXALL TABS PREFERRED

TABLOID TABS PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC -

HORMONAL AND RELATED AGENTS LYSODREN TABS PREFERRED

Page 28 of 102


FORMPDL STATUS

ERLEADA TABS NON_PREFERRED

BICALUTAMIDE TABS PREFERRED

CASODEX TABS NON_PREFERRED

NUBEQA TABS NON_PREFERRED

XTANDI CAPS NON_PREFERRED

FLUTAMIDE CAPS PREFERRED

NILUTAMIDE TABS PREFERRED

SOLTAMOX SOLN PREFERRED

TAMOXIFEN CITRATE TABS PREFERRED

FARESTON TABS NON_PREFERRED

TOREMIFENE CITRATE TABS PREFERRED

ANASTROZOLE TABS PREFERRED

ARIMIDEX TABS NON_PREFERRED

AROMASIN TABS NON_PREFERRED

EXEMESTANE TABS PREFERRED

FEMARA TABS NON_PREFERRED

LETROZOLE TABS PREFERRED

EMCYT CAPS PREFERRED

MEGESTROL ACETATE SUSP PREFERRED

MEGESTROL ACETATE TABS PREFERRED

ABIRATERONE ACETATE TABS PREFERRED

YONSA TABS NON_PREFERRED

ZYTIGA TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC

ENZYME INHIBITORS VERZENIO TABS NON_PREFERRED

IBRANCE CAPS NON_PREFERRED

IBRANCE TABS NON_PREFERRED

KISQALI TBPK NON_PREFERRED

FARYDAK CAPS NON_PREFERRED

ZOLINZA CAPS NON_PREFERRED

TAFINLAR CAPS NON_PREFERRED

BRAFTOVI CAPS NON_PREFERRED

ZELBORAF TABS NON_PREFERRED

BALVERSA TABS NON_PREFERRED

PEMAZYRE TABS NON_PREFERRED

AFINITOR TABS NON_PREFERRED

EVEROLIMUS TABS NON_PREFERRED

AFINITOR DISPERZ TBSO NON_PREFERRED

RYDAPT CAPS NON_PREFERRED

STIVARGA TABS NON_PREFERRED

NEXAVAR TABS PREFERRED

SUTENT CAPS PREFERRED

MEKTOVI TABS NON_PREFERRED

COTELLIC TABS NON_PREFERRED

Page 29 of 102


FORMPDL STATUS

KOSELUGO CAPS NON_PREFERRED

MEKINIST TABS NON_PREFERRED

TAZVERIK TABS NON_PREFERRED

ROZLYTREK CAPS NON_PREFERRED

VITRAKVI CAPS NON_PREFERRED

VITRAKVI SOLN NON_PREFERRED

CALQUENCE CAPS NON_PREFERRED

GILOTRIF TABS NON_PREFERRED

ALECENSA CAPS NON_PREFERRED

INLYTA TABS NON_PREFERRED

AYVAKIT TABS NON_PREFERRED

ALUNBRIG TABS NON_PREFERRED

ALUNBRIG TBPK NON_PREFERRED

BOSULIF TABS NON_PREFERRED

COMETRIQ KIT NON_PREFERRED

CABOMETYX TABS NON_PREFERRED

ZYKADIA TABS NON_PREFERRED

XALKORI CAPS NON_PREFERRED

TABRECTA TABS NON_PREFERRED

VIZIMPRO TABS NON_PREFERRED

SPRYCEL TABS NON_PREFERRED

ERLOTINIB HYDROCHLORIDE TABS PREFERRED

TARCEVA TABS NON_PREFERRED

IRESSA TABS PREFERRED

XOSPATA TABS NON_PREFERRED

IMBRUVICA CAPS NON_PREFERRED

IMBRUVICA TABS NON_PREFERRED

GLEEVEC TABS NON_PREFERRED

IMATINIB MESYLATE TABS NON_PREFERRED

LAPATINIB DITOSYLATE TABS NON_PREFERRED

TYKERB TABS NON_PREFERRED

LENVIMA 10 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 12MG DAILY DOSE CPPK NON_PREFERRED







LORBRENA TABS NON_PREFERRED

NERLYNX TABS NON_PREFERRED

TASIGNA CAPS NON_PREFERRED

TAGRISSO TABS NON_PREFERRED

VOTRIENT TABS PREFERRED

Page 30 of 102


FORMPDL STATUS

TURALIO CAPS NON_PREFERRED

ICLUSIG TABS NON_PREFERRED

GAVRETO CAPS NON_PREFERRED

QINLOCK TABS NON_PREFERRED

RETEVMO CAPS NON_PREFERRED

TUKYSA TABS NON_PREFERRED

CAPRELSA TABS PREFERRED

BRUKINSA CAPS NON_PREFERRED

TIBSOVO TABS NON_PREFERRED

IDHIFA TABS NON_PREFERRED

ZEJULA CAPS NON_PREFERRED

LYNPARZA TABS NON_PREFERRED

RUBRACA TABS NON_PREFERRED

TALZENNA CAPS NON_PREFERRED

NINLARO CAPS NON_PREFERRED

INREBIC CAPS NON_PREFERRED

JAKAFI TABS PREFERRED

PIQRAY 200MG DAILY DOSE TBPK NON_PREFERRED



COPIKTRA CAPS NON_PREFERRED

ZYDELIG TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : CHEMOTHERAPY

RESCUE / ANTIDOTE AGENTS LEUCOVORIN CALCIUM TABS PREFERRED

MESNEX TABS PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MISC DAURISMO TABS NON_PREFERRED

ODOMZO CAPS NON_PREFERRED

ERIVEDGE CAPS PREFERRED

POMALYST CAPS NON_PREFERRED

VENCLEXTA TABS NON_PREFERRED

VENCLEXTA STARTING PACK TBPK NON_PREFERRED

HYCAMTIN CAPS PREFERRED

XPOVIO 100 MG ONCE WEEKLY TBPK NON_PREFERRED


XPOVIO 40 MG TWICE WEEKLY TBPK NON_PREFERRED





HYDREA CAPS NON_PREFERRED

HYDROXYUREA CAPS PREFERRED

MATULANE CAPS PREFERRED

TRETINOIN CAPS PREFERRED

BEXAROTENE CAPS PREFERRED

Page 31 of 102


FORMPDL STATUS

TARGRETIN CAPS NON_PREFERRED

INQOVI TABS NON_PREFERRED

KISQALI FEMARA 200 DOSE TBPK NON_PREFERRED



LONSURF TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MITOTIC

INHIBITORS ETOPOSIDE CAPS PREFERRED

ANTIPARASITICS : ANTHELMINTICS ALBENDAZOLE TABS NON_PREFERRED

ALBENZA TABS NON_PREFERRED

BENZNIDAZOLE TABS NON_PREFERRED

IVERMECTIN TABS NON_PREFERRED

STROMECTOL TABS NON_PREFERRED

EMVERM CHEW NON_PREFERRED

BILTRICIDE TABS NON_PREFERRED

PRAZIQUANTEL TABS PREFERRED

EGATEN TABS NON_PREFERRED

ANTIPARASITICS : ANTIMALARIALS CHLOROQUINE PHOSPHATE TABS PREFERRED

HYDROXYCHLOROQUINE SULFATE TABS PREFERRED

MEFLOQUINE HCL TABS PREFERRED

PRIMAQUINE PHOSPHATE TABS PREFERRED

DARAPRIM TABS NON_PREFERRED

PYRIMETHAMINE TABS NON_PREFERRED

QUALAQUIN CAPS NON_PREFERRED

QUININE SULFATE CAPS NON_PREFERRED

KRINTAFEL TABS NON_PREFERRED

COARTEM TABS NON_PREFERRED

ATOVAQUONE/PROGUANIL HCL TABS PREFERRED

MALARONE TABS NON_PREFERRED

ANTIPARKINSON AND RELATED THERAPY AGENTS BENZTROPINE MESYLATE TABS PREFERRED

TRIHEXYPHENIDYL HCL SOLN PREFERRED

TRIHEXYPHENIDYL HYDROCHLORIDE TABS PREFERRED

TASMAR TABS NON_PREFERRED

TOLCAPONE TABS NON_PREFERRED

COMTAN TABS NON_PREFERRED

ENTACAPONE TABS PREFERRED

ONGENTYS CAPS NON_PREFERRED

AMANTADINE HCL CAPS PREFERRED

AMANTADINE HYDROCHLORIDE CAPS PREFERRED

GOCOVRI CP24 NON_PREFERRED

AMANTADINE HCL SYRP PREFERRED

OSMOLEX ER T4PK NON_PREFERRED

AMANTADINE HCL TABS PREFERRED

AMANTADINE HYDROCHLORIDE TABS PREFERRED

Page 32 of 102


FORMPDL STATUS

OSMOLEX ER TB24 NON_PREFERRED

BROMOCRIPTINE MESYLATE CAPS PREFERRED

PARLODEL CAPS NON_PREFERRED

BROMOCRIPTINE MESYLATE TABS PREFERRED

PARLODEL TABS NON_PREFERRED

INBRIJA CAPS NON_PREFERRED

KYNMOBI FILM NON_PREFERRED

KYNMOBI TITRATION KIT KIT NON_PREFERRED

APOKYN SOCT NON_PREFERRED

PRAMIPEXOLE DIHYDROCHLORIDE TABS PREFERRED

MIRAPEX ER TB24 NON_PREFERRED

PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 NON_PREFERRED

ROPINIROLE HCL TABS PREFERRED

ROPINIROLE HYDROCHLORIDE TABS PREFERRED

ROPINIROLE ER TB24 NON_PREFERRED

NEUPRO PT24 NON_PREFERRED

RYTARY CPCR NON_PREFERRED

CARBIDOPA/LEVODOPA TABS PREFERRED

SINEMET TABS NON_PREFERRED

CARBIDOPA/LEVODOPA ER TBCR PREFERRED

CARBIDOPA/LEVODOPA ODT TBDP NON_PREFERRED

CARBIDOPA/LEVODOPA/ENTACAPONE TABS NON_PREFERRED

STALEVO 100 TABS NON_PREFERRED






AZILECT TABS NON_PREFERRED

RASAGILINE MESYLATE TABS NON_PREFERRED

XADAGO TABS NON_PREFERRED

SELEGILINE HCL CAPS PREFERRED

SELEGILINE HYDROCHLORIDE CAPS PREFERRED

SELEGILINE HCL TABS PREFERRED

ZELAPAR TBDP NON_PREFERRED

NOURIANZ TABS NON_PREFERRED

CARBIDOPA TABS PREFERRED

LODOSYN TABS NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : BENZISOXAZOLES FANAPT TABS NON_PREFERRED

FANAPT TITRATION PACK TABS NON_PREFERRED

INVEGA TB24 NON_PREFERRED

PALIPERIDONE ER TB24 NON_PREFERRED

INVEGA SUSTENNA SUSY PREFERRED_WITH_PA

INVEGA TRINZA SUSY PREFERRED_WITH_PA

Page 33 of 102


FORMPDL STATUS

PERSERIS PRSY NON_PREFERRED

RISPERDAL SOLN NON_PREFERRED

RISPERIDONE SOLN PREFERRED

RISPERDAL TABS NON_PREFERRED

RISPERIDONE TABS PREFERRED

RISPERIDONE ODT TBDP NON_PREFERRED

RISPERDAL CONSTA SRER NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : DIBENZAPINES VERSACLOZ SUSP NON_PREFERRED

CLOZAPINE TABS PREFERRED

CLOZARIL TABS NON_PREFERRED

CLOZAPINE ODT TBDP NON_PREFERRED

FAZACLO TBDP NON_PREFERRED

QUETIAPINE FUMARATE TABS PREFERRED

SEROQUEL TABS NON_PREFERRED

QUETIAPINE FUMARATE ER TB24 PREFERRED

SEROQUEL XR TB24 NON_PREFERRED

ADASUVE AEPB NON_PREFERRED

LOXAPINE CAPS PREFERRED

LOXAPINE SUCCINATE CAPS PREFERRED

SECUADO PT24 NON_PREFERRED

SAPHRIS SUBL NON_PREFERRED

OLANZAPINE SOLR NON_PREFERRED

ZYPREXA SOLR NON_PREFERRED

OLANZAPINE TABS PREFERRED

ZYPREXA TABS NON_PREFERRED

OLANZAPINE ODT TBDP PREFERRED

ZYPREXA ZYDIS TBDP NON_PREFERRED

ZYPREXA RELPREVV SUSR NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : MISC HALOPERIDOL TABS PREFERRED

HALOPERIDOL CONC PREFERRED

MOLINDONE HYDROCHLORIDE TABS NON_PREFERRED

CHLORPROMAZINE HCL TABS PREFERRED

CHLORPROMAZINE HYDROCHLORIDE TABS PREFERRED

FLUPHENAZINE HCL CONC PREFERRED

FLUPHENAZINE HYDROCHLORIDE ELIX PREFERRED

FLUPHENAZINE HCL TABS PREFERRED

PERPHENAZINE TABS PREFERRED

COMPRO SUPP PREFERRED

PROCHLORPERAZINE SUPP PREFERRED

PROCHLORPERAZINE MALEATE TABS PREFERRED

THIORIDAZINE HCL TABS PREFERRED

TRIFLUOPERAZINE HCL TABS PREFERRED

TRIFLUOPERAZINE HYDROCHLORIDE TABS PREFERRED

THIOTHIXENE CAPS PREFERRED

Page 34 of 102


FORMPDL STATUS

EQUETRO CP12 NON_PREFERRED

VRAYLAR CAPS NON_PREFERRED

VRAYLAR CPPK NON_PREFERRED

CAPLYTA CAPS NON_PREFERRED

LATUDA TABS NON_PREFERRED

NUPLAZID CAPS NON_PREFERRED

NUPLAZID TABS NON_PREFERRED

GEODON CAPS NON_PREFERRED

ZIPRASIDONE HCL CAPS PREFERRED

ZIPRASIDONE HYDROCHLORIDE CAPS PREFERRED

GEODON SOLR NON_PREFERRED

ZIPRASIDONE MESYLATE SOLR NON_PREFERRED

LITHIUM SOLN PREFERRED

LITHIUM CARBONATE CAPS PREFERRED

LITHIUM CARBONATE TABS PREFERRED

LITHIUM CARBONATE ER TBCR PREFERRED

LITHOBID TBCR NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : QUINOLINONE

DERIVATIVES ABILIFY MAINTENA PRSY PREFERRED_WITH_PA

ARIPIPRAZOLE SOLN NON_PREFERRED

ABILIFY MAINTENA SRER PREFERRED_WITH_PA

ABILIFY TABS NON_PREFERRED

ABILIFY MYCITE TABS NON_PREFERRED

ARIPIPRAZOLE TABS PREFERRED

ARIPIPRAZOLE ODT TBDP NON_PREFERRED

ARISTADA PRSY PREFERRED_WITH_PA

ARISTADA INITIO PRSY PREFERRED_WITH_PA

REXULTI TABS NON_PREFERRED

ANTIVIRALS : ANTIRETROVIRALS (HIV) SELZENTRY SOLN NON_PREFERRED

SELZENTRY TABS NON_PREFERRED

TROGARZO SOLN PREFERRED_WITH_PA

RUKOBIA TB12 NON_PREFERRED

FUZEON SOLR NON_PREFERRED

TIVICAY TABS PREFERRED

TIVICAY PD TBSO PREFERRED

ISENTRESS CHEW PREFERRED

ISENTRESS PACK PREFERRED

ISENTRESS TABS PREFERRED

ISENTRESS HD TABS PREFERRED

ATAZANAVIR CAPS PREFERRED

ATAZANAVIR SULFATE CAPS PREFERRED

REYATAZ CAPS PREFERRED

REYATAZ PACK PREFERRED

PREZISTA SUSP PREFERRED

Page 35 of 102


FORMPDL STATUS

PREZISTA TABS PREFERRED

LEXIVA SUSP PREFERRED

FOSAMPRENAVIR CALCIUM TABS PREFERRED

LEXIVA TABS PREFERRED

CRIXIVAN CAPS PREFERRED

VIRACEPT TABS PREFERRED

NORVIR PACK PREFERRED

NORVIR SOLN PREFERRED

NORVIR TABS PREFERRED

RITONAVIR TABS PREFERRED

INVIRASE TABS PREFERRED

APTIVUS CAPS PREFERRED

APTIVUS SOLN PREFERRED

ABACAVIR SOLN PREFERRED

ZIAGEN SOLN PREFERRED

ABACAVIR TABS PREFERRED

ABACAVIR SULFATE TABS PREFERRED

ZIAGEN TABS NON_PREFERRED

DIDANOSINE CPDR PREFERRED

VIDEX EC CPDR NON_PREFERRED

VIDEXPEDIATRIC SOLR PREFERRED

EMTRICITABINE CAPS PREFERRED

EMTRIVA CAPS PREFERRED

EMTRIVA SOLN PREFERRED

EPIVIR SOLN NON_PREFERRED

LAMIVUDINE SOLN PREFERRED

EPIVIR TABS NON_PREFERRED

LAMIVUDINE TABS PREFERRED

STAVUDINE CAPS PREFERRED

RETROVIR CAPS NON_PREFERRED

ZIDOVUDINE CAPS PREFERRED

RETROVIR SYRP NON_PREFERRED

ZIDOVUDINE SYRP PREFERRED

ZIDOVUDINE TABS PREFERRED

VIREAD POWD PREFERRED

TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED

VIREAD TABS PREFERRED

PIFELTRO TABS NON_PREFERRED

EFAVIRENZ CAPS PREFERRED

SUSTIVA CAPS PREFERRED

EFAVIRENZ TABS PREFERRED

SUSTIVA TABS PREFERRED

INTELENCE TABS PREFERRED

NEVIRAPINE SUSP PREFERRED

Page 36 of 102


FORMPDL STATUS

VIRAMUNE SUSP PREFERRED

NEVIRAPINE TABS PREFERRED

VIRAMUNE TABS NON_PREFERRED

NEVIRAPINE ER TB24 PREFERRED

VIRAMUNE XR TB24 NON_PREFERRED

EDURANT TABS PREFERRED

TYBOST TABS NON_PREFERRED

ABACAVIR SULFATE/LAMIVUDINE TABS PREFERRED

EPZICOM TABS NON_PREFERRED

EVOTAZ TABS NON_PREFERRED

DOVATO TABS PREFERRED

PREZCOBIX TABS NON_PREFERRED

JULUCA TABS NON_PREFERRED

DESCOVY TABS PREFERRED

EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED

TRUVADA TABS PREFERRED

CIMDUO TABS NON_PREFERRED

TEMIXYS TABS NON_PREFERRED

COMBIVIR TABS NON_PREFERRED

LAMIVUDINE/ZIDOVUDINE TABS PREFERRED

KALETRA SOLN NON_PREFERRED

LOPINAVIR/RITONAVIR SOLN PREFERRED

KALETRA TABS PREFERRED

TRIUMEQ TABS PREFERRED

ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE TABS PREFERRED

TRIZIVIR TABS NON_PREFERRED

BIKTARVY TABS PREFERRED

DELSTRIGO TABS PREFERRED

ATRIPLA TABS PREFERRED

EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED

EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPROXIL FUMARATE TABS NON_PREFERRED

SYMFI TABS PREFERRED

SYMFI LO TABS PREFERRED

ODEFSEY TABS PREFERRED

COMPLERA TABS PREFERRED

SYMTUZA TABS NON_PREFERRED

GENVOYA TABS PREFERRED

STRIBILD TABS NON_PREFERRED

ANTIVIRALS : HEPATITIS B AGENTS ADEFOVIR DIPIVOXIL TABS NON_PREFERRED

HEPSERA TABS NON_PREFERRED

BARACLUDE SOLN NON_PREFERRED

BARACLUDE TABS NON_PREFERRED

ENTECAVIR TABS PREFERRED

EPIVIR HBV SOLN NON_PREFERRED

Page 37 of 102


FORMPDL STATUS

EPIVIR HBV TABS NON_PREFERRED

LAMIVUDINE TABS NON_PREFERRED

VEMLIDY TABS NON_PREFERRED

ANTIVIRALS : HEPATITIS C AGENTS PEGASYS SOLN NON_PREFERRED

PEGINTRON KIT PREFERRED_WITH_PA

RIBASPHERE CAPS PREFERRED

RIBAVIRIN CAPS PREFERRED

RIBASPHERE TABS PREFERRED

RIBAVIRIN TABS PREFERRED

MODERIBA 1200 DOSE PACK TBPK NON_PREFERRED

MODERIBA 800 DOSE PACK TBPK NON_PREFERRED

RIBASPHERE RIBAPAK TBPK NON_PREFERRED

SOVALDI PACK NON_PREFERRED

SOVALDI TABS NON_PREFERRED

ZEPATIER TABS NON_PREFERRED

MAVYRET TABS PREFERRED_WITH_PA

HARVONI PACK NON_PREFERRED

HARVONI TABS NON_PREFERRED

LEDIPASVIR/SOFOSBUVIR TABS NON_PREFERRED

EPCLUSA TABS NON_PREFERRED

SOFOSBUVIR/VELPATASVIR TABS PREFERRED_WITH_PA

VOSEVI TABS NON_PREFERRED

VIEKIRA PAK TBPK NON_PREFERRED

ANTIVIRALS : MISC PREVYMIS TABS NON_PREFERRED

VALCYTE SOLR NON_PREFERRED

VALGANCICLOVIR HYDROCHLORDE SOLR NON_PREFERRED

VALCYTE TABS NON_PREFERRED

VALGANCICLOVIR TABS PREFERRED

ACYCLOVIR CAPS PREFERRED

ACYCLOVIR SUSP PREFERRED

ZOVIRAX SUSP NON_PREFERRED

ACYCLOVIR TABS PREFERRED

SITAVIG TABS NON_PREFERRED

VALACYCLOVIR HCL TABS PREFERRED

VALACYCLOVIR HYDROCHLORIDE TABS PREFERRED

VALTREX TABS NON_PREFERRED

FAMCICLOVIR TABS NON_PREFERRED

FLUMADINE TABS NON_PREFERRED

RIMANTADINE HCL TABS NON_PREFERRED

XOFLUZA TBPK NON_PREFERRED

OSELTAMIVIR PHOSPHATE CAPS PREFERRED

TAMIFLU CAPS NON_PREFERRED

OSELTAMIVIR PHOSPHATE SUSR PREFERRED

TAMIFLU SUSR NON_PREFERRED

Page 38 of 102


FORMPDL STATUS

RELENZA DISKHALER AEPB PREFERRED

RIBAVIRIN SOLR PREFERRED

VIRAZOLE SOLR NON_PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITOR

COMBINATIONS AMLODIPINE BESYLATE/BENAZEPRIL HCL CAPS PREFERRED

AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE CAPS PREFERRED

LOTREL CAPS NON_PREFERRED

TARKA TBCR NON_PREFERRED

TRANDOLAPRIL/VERAPAMIL HCL ER TBCR PREFERRED

BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS PREFERRED

BENAZEPRIL HYDROCHLORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED

LOTENSIN HCT TABS NON_PREFERRED

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED

ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE TABS PREFERRED

VASERETIC TABS NON_PREFERRED

FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED

LISINOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED

ZESTORETIC TABS NON_PREFERRED

ACCURETIC TABS NON_PREFERRED

QUINAPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITORS BENAZEPRIL HCL TABS PREFERRED

BENAZEPRIL HYDROCHLORIDE TABS PREFERRED

LOTENSIN TABS NON_PREFERRED

CAPTOPRIL TABS PREFERRED

EPANED SOLN NON_PREFERRED

ENALAPRIL MALEATE TABS PREFERRED

VASOTEC TABS NON_PREFERRED

FOSINOPRIL SODIUM TABS PREFERRED

QBRELIS SOLN NON_PREFERRED

LISINOPRIL TABS PREFERRED

PRINIVIL TABS NON_PREFERRED

ZESTRIL TABS NON_PREFERRED

MOEXIPRIL HCL TABS PREFERRED

PERINDOPRIL ERBUMINE TABS NON_PREFERRED

ACCUPRIL TABS NON_PREFERRED

QUINAPRIL HCL TABS PREFERRED

QUINAPRIL HYDROCHLORIDE TABS PREFERRED

ALTACE CAPS NON_PREFERRED

RAMIPRIL CAPS PREFERRED

TRANDOLAPRIL TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II

RECEPTOR BLOCKER COMBINATIONS AMLODIPINE/OLMESARTAN MEDOXOMIL TABS NON_PREFERRED

AZOR TABS NON_PREFERRED

Page 39 of 102


FORMPDL STATUS

AMLODIPINE BESYLATE/VALSARTAN TABS NON_PREFERRED

EXFORGE TABS NON_PREFERRED

TELMISARTAN/AMLODIPINE TABS NON_PREFERRED

EDARBYCLOR TABS NON_PREFERRED

ATACAND HCT TABS NON_PREFERRED

CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

AVALIDE TABS NON_PREFERRED

IRBESARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED

HYZAAR TABS NON_PREFERRED

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED

BENICAR HCT TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

MICARDIS HCT TABS NON_PREFERRED

TELMISARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

DIOVAN HCT TABS NON_PREFERRED

VALSARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED

AMLODIPINE/VALSARTAN/HCTZ TABS NON_PREFERRED

AMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

EXFORGE HCT TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

TRIBENZOR TABS NON_PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II

RECEPTOR BLOCKERS EDARBI TABS NON_PREFERRED

ATACAND TABS NON_PREFERRED

CANDESARTAN CILEXETIL TABS NON_PREFERRED

AVAPRO TABS NON_PREFERRED

IRBESARTAN TABS PREFERRED

COZAAR TABS NON_PREFERRED

LOSARTAN POTASSIUM TABS PREFERRED

BENICAR TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL TABS NON_PREFERRED

MICARDIS TABS NON_PREFERRED

TELMISARTAN TABS NON_PREFERRED

DIOVAN TABS NON_PREFERRED

VALSARTAN TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES :

ANTIADRENERGICS CATAPRES-TTS-1 PTWK NON_PREFERRED

CATAPRES-TTS-2 PTWK NON_PREFERRED

CATAPRES-TTS-3 PTWK NON_PREFERRED

CLONIDINE HCL PTWK PREFERRED

CATAPRES TABS NON_PREFERRED

CLONIDINE HCL TABS PREFERRED

CLONIDINE HYDROCHLORIDE TABS PREFERRED

GUANFACINE HCL TABS PREFERRED

Page 40 of 102


FORMPDL STATUS

GUANFACINE HYDROCHLORIDE TABS PREFERRED

METHYLDOPA TABS PREFERRED

CARDURA TABS NON_PREFERRED

DOXAZOSIN TABS PREFERRED

DOXAZOSIN MESYLATE TABS PREFERRED

MINIPRESS CAPS NON_PREFERRED

PRAZOSIN HCL CAPS PREFERRED

PRAZOSIN HYDROCHLORIDE CAPS PREFERRED

TERAZOSIN HCL CAPS PREFERRED

TERAZOSIN HYDROCHLORIDE CAPS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKER

COMBINATIONS ATENOLOL/CHLORTHALIDONE TABS PREFERRED

TENORETIC 100 TABS NON_PREFERRED

TENORETIC 50 TABS NON_PREFERRED

BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TABS PREFERRED

ZIAC TABS NON_PREFERRED

METOPROLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED

NADOLOL/BENDROFLUMETHIAZIDE TABS PREFERRED

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKERS CORGARD TABS NON_PREFERRED

NADOLOL TABS PREFERRED

PINDOLOL TABS PREFERRED

INDERAL LA CP24 NON_PREFERRED

PROPRANOLOL HCL ER CP24 PREFERRED

PROPRANOLOL HYDROCHLORIDE ER CP24 PREFERRED

HEMANGEOL SOLN PREFERRED_WITH_PA

PROPRANOLOL HCL SOLN PREFERRED

PROPRANOLOL HCL TABS PREFERRED

PROPRANOLOL HYDROCHLORIDE TABS PREFERRED

INDERAL XL CP24 NON_PREFERRED

INNOPRAN XL CP24 NON_PREFERRED

SOTYLIZE SOLN NON_PREFERRED

BETAPACE TABS NON_PREFERRED

SORINE TABS PREFERRED

SOTALOL HCL TABS PREFERRED

SOTALOL HYDROCHLORIDE TABS PREFERRED

SOTALOL HYDROCHOLRIDE TABS PREFERRED

BETAPACE AF TABS NON_PREFERRED

SOTALOL HCL (AF) TABS NON_PREFERRED

SOTALOL HCL AF TABS NON_PREFERRED

SOTALOL HYDROCHLORIDE (AF) TABS NON_PREFERRED

SOTALOL HYDROCHLORIDE AF TABS NON_PREFERRED

TIMOLOL MALEATE TABS PREFERRED

Page 41 of 102


FORMPDL STATUS

ACEBUTOLOL HCL CAPS PREFERRED

ACEBUTOLOL HYDROCHLORIDE CAPS PREFERRED

FIRST-ATENOLOL SOLN NON_PREFERRED

ATENOLOL TABS PREFERRED

TENORMIN TABS NON_PREFERRED

BETAXOLOL HCL TABS PREFERRED

BISOPROLOL FUMARATE TABS PREFERRED

KAPSPARGO SPRINKLE CS24 NON_PREFERRED

METOPROLOL SUCCINATE ER TB24 PREFERRED

TOPROL XL TB24 NON_PREFERRED

FIRST - METOPROLOL SOLN NON_PREFERRED

LOPRESSOR TABS NON_PREFERRED

METOPROLOL TARTRATE TABS PREFERRED

BYSTOLIC TABS NON_PREFERRED

CARVEDILOL TABS PREFERRED

COREG TABS NON_PREFERRED

CARVEDILOL PHOSPHATE CP24 NON_PREFERRED

COREG CR CP24 NON_PREFERRED

LABETALOL HYDROCHLORIDE TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM

CHANNEL BLOCKERS KATERZIA SUSP NON_PREFERRED

AMLODIPINE BESYLATE TABS PREFERRED

NORVASC TABS NON_PREFERRED

DILTIAZEM HCL ER CP12 PREFERRED

DILT-XR CP24 PREFERRED

DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED

CARDIZEM TABS NON_PREFERRED

DILTIAZEM HCL TABS PREFERRED

DILTIAZEM HYDROCHLORIDE TABS PREFERRED



TAZTIA XT CP24 PREFERRED

TIADYLT ER CP24 PREFERRED

TIAZAC CP24 NON_PREFERRED

CARDIZEM CD CP24 NON_PREFERRED

CARTIA XT CP24 PREFERRED

DILTIAZEM HCL CD CP24 PREFERRED



CARDIZEM LA TB24 NON_PREFERRED

DILTIAZEM HCL ER TB24 PREFERRED

MATZIM LA TB24 PREFERRED

FELODIPINE ER TB24 PREFERRED

ISRADIPINE CAPS NON_PREFERRED

Page 42 of 102


FORMPDL STATUS

NICARDIPINE HCL CAPS NON_PREFERRED

NIFEDIPINE CAPS PREFERRED

PROCARDIA CAPS NON_PREFERRED

ADALAT CC TB24 NON_PREFERRED

NIFEDIPINE ER TB24 PREFERRED

PROCARDIA XL TB24 NON_PREFERRED

NIMODIPINE CAPS PREFERRED

NYMALIZE SOLN NON_PREFERRED

NISOLDIPINE ER TB24 NON_PREFERRED

SULAR TB24 NON_PREFERRED

VERAPAMIL HCL ER CP24 PREFERRED

VERAPAMIL HCL SR CP24 PREFERRED

VERELAN CP24 NON_PREFERRED

VERELAN PM CP24 NON_PREFERRED

VERAPAMIL HCL TABS PREFERRED

VERAPAMIL HYDROCHLORIDE TABS PREFERRED

CALAN SR TBCR NON_PREFERRED

VERAPAMIL HCL ER TBCR PREFERRED

VERAPAMIL HYDROCHLORIDE ER TBCR PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : MISC ALISKIREN TABS NON_PREFERRED

TEKTURNA TABS NON_PREFERRED

EPLERENONE TABS NON_PREFERRED

INSPRA TABS NON_PREFERRED

PHENOXYBENZAMINE HYDROCHLORIDE CAPS NON_PREFERRED

DEMSER CAPS PREFERRED

METYROSINE CAPS PREFERRED

HYDRALAZINE HYDROCHLORIDE SOLN PREFERRED

HYDRALAZINE HCL TABS PREFERRED

HYDRALAZINE HYDROCHLORIDE TABS PREFERRED

MINOXIDIL TABS PREFERRED

VECAMYL TABS NON_PREFERRED

METHYLDOPA/HYDROCHLOROTHIAZIDE TABS PREFERRED

TEKTURNA HCT TABS NON_PREFERRED

CARDIOVASCULAR AGENTS - CARDIOTONICS : CARDIAC GLYCOSIDES DIGOXIN SOLN PREFERRED

DIGITEK TABS PREFERRED

DIGOX TABS PREFERRED

DIGOXIN TABS PREFERRED

CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS DILATRATE SR CPCR PREFERRED

ISORDIL TITRADOSE TABS NON_PREFERRED

ISOSORBIDE DINITRATE TABS PREFERRED

ISOSORBIDE MONONITRATE TABS PREFERRED

ISOSORBIDE MONONITRATE ER TB24 PREFERRED

NITROMIST AERS NON_PREFERRED

Page 43 of 102


FORMPDL STATUS

NITRO-BID OINT PREFERRED

GONITRO PACK NON_PREFERRED

MINITRAN PT24 PREFERRED

NITRO-DUR PT24 NON_PREFERRED

NITROGLYCERIN TRANSDERMAL PT24 PREFERRED

NITROGLYCERIN LINGUAL SOLN NON_PREFERRED

NITROLINGUAL PUMPSPRAY SOLN NON_PREFERRED

NITROGLYCERIN SUBL PREFERRED

NITROSTAT SUBL NON_PREFERRED

RANEXA TB12 NON_PREFERRED

RANOLAZINE ER TB12 NON_PREFERRED

CARDIOVASCULAR AGENTS : ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAPS PREFERRED

NORPACE CAPS NON_PREFERRED

NORPACE CR CP12 PREFERRED

QUINIDINE GLUCONATE CR TBCR PREFERRED

QUINIDINE SULFATE TABS PREFERRED

MEXILETINE HCL CAPS PREFERRED

MEXILETINE HYDROCHLORIDE CAPS PREFERRED

FLECAINIDE ACETATE TABS PREFERRED

PROPAFENONE HYDROCHLORIDE ER CP12 NON_PREFERRED

RYTHMOL SR CP12 NON_PREFERRED

PROPAFENONE HCL TABS PREFERRED

PROPAFENONE HYDROCHLORIDE TABS PREFERRED

AMIODARONE HCL TABS PREFERRED

AMIODARONE HYDROCHLORIDE TABS PREFERRED

PACERONE TABS PREFERRED

DOFETILIDE CAPS PREFERRED

TIKOSYN CAPS NON_PREFERRED

MULTAQ TABS NON_PREFERRED

CARDIOVASCULAR AGENTS : DIURETICS ACETAZOLAMIDE ER CP12 PREFERRED

ACETAZOLAMIDE TABS PREFERRED

KEVEYIS TABS NON_PREFERRED

METHAZOLAMIDE TABS PREFERRED

BUMETANIDE TABS PREFERRED

BUMEX TABS NON_PREFERRED

EDECRIN TABS NON_PREFERRED

ETHACRYNIC ACID TABS PREFERRED

FUROSEMIDE SOLN PREFERRED

FUROSEMIDE TABS PREFERRED

LASIX TABS NON_PREFERRED

TORSEMIDE TABS PREFERRED

AMILORIDE HCL TABS PREFERRED

CAROSPIR SUSP NON_PREFERRED

ALDACTONE TABS NON_PREFERRED

Page 44 of 102


FORMPDL STATUS

SPIRONOLACTONE TABS PREFERRED

TRIAMTERENE CAPS PREFERRED

DIURIL SUSP PREFERRED

CHLOROTHIAZIDE TABS PREFERRED

CHLORTHALIDONE TABS PREFERRED

HYDROCHLOROTHIAZIDE CAPS PREFERRED

HYDROCHLOROTHIAZIDE TABS PREFERRED

INDAPAMIDE TABS PREFERRED

METOLAZONE TABS PREFERRED

AMILORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED

ALDACTAZIDE TABS NON_PREFERRED

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS PREFERRED

DYAZIDE CAPS NON_PREFERRED

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS PREFERRED

MAXZIDE TABS NON_PREFERRED

MAXZIDE-25 TABS NON_PREFERRED

TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS PREFERRED

CARDIOVASCULAR AGENTS : MISC MIDODRINE HCL TABS PREFERRED

MIDODRINE HYDROCHLORIDE TABS PREFERRED

NORTHERA CAPS NON_PREFERRED

CIALIS TABS NON_PREFERRED

TADALAFIL TABS NON_PREFERRED

VYNDAMAX CAPS NON_PREFERRED

VYNDAQEL CAPS NON_PREFERRED

CORLANOR SOLN NON_PREFERRED

CORLANOR TABS NON_PREFERRED

ENTRESTO TABS NON_PREFERRED

AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS NON_PREFERRED

CADUET TABS NON_PREFERRED

BIDIL TABS PREFERRED

CARDIOVASCULAR AGENTS : PULMONARY HYPERTENSION UPTRAVI TABS NON_PREFERRED

UPTRAVI TBPK NON_PREFERRED

ADEMPAS TABS NON_PREFERRED

REVATIO SOLN NON_PREFERRED

SILDENAFIL SOLN NON_PREFERRED

REVATIO SUSR PREFERRED_WITH_PA

SILDENAFIL CITRATE SUSR NON_PREFERRED

REVATIO TABS NON_PREFERRED

SILDENAFIL CITRATE TABS PREFERRED_WITH_PA

ADCIRCA TABS PREFERRED_WITH_PA

ALYQ TABS PREFERRED_WITH_PA

TADALAFIL TABS PREFERRED_WITH_PA

AMBRISENTAN TABS NON_PREFERRED

LETAIRIS TABS PREFERRED_WITH_PA

Page 45 of 102


FORMPDL STATUS

BOSENTAN TABS NON_PREFERRED

TRACLEER TABS PREFERRED_WITH_PA

TRACLEER TBSO PREFERRED_WITH_PA

OPSUMIT TABS NON_PREFERRED

EPOPROSTENOL SODIUM SOLR PREFERRED_WITH_PA

FLOLAN SOLR PREFERRED_WITH_PA

VELETRI SOLR NON_PREFERRED

VENTAVIS SOLN NON_PREFERRED

REMODULIN SOLN NON_PREFERRED

TREPROSTINIL SOLN NON_PREFERRED

TYVASO SOLN NON_PREFERRED

TYVASO REFILL SOLN NON_PREFERRED

TYVASO STARTER SOLN NON_PREFERRED

ORENITRAM TBCR NON_PREFERRED

CONTRACEPTIVES : COMBINATION CONTRACEPTIVES XULANE PTWK PREFERRED

ELURYNG RING PREFERRED

ETONOGESTREL/ETHINYL ESTR RING PREFERRED

NUVARING RING PREFERRED

ANNOVERA RING PREFERRED

APRI TABS PREFERRED

CYRED TABS PREFERRED

CYRED EQ TABS PREFERRED

EMOQUETTE TABS PREFERRED

ENSKYCE TABS PREFERRED

ISIBLOOM TABS PREFERRED

JULEBER TABS PREFERRED

KALLIGA TABS PREFERRED

RECLIPSEN TABS PREFERRED

DROSPIRENONE/ETHINYL ESTRADIOL TABS PREFERRED

GIANVI TABS PREFERRED

JASMIEL TABS PREFERRED

LO-ZUMANDIMINE TABS PREFERRED

LORYNA TABS PREFERRED

NIKKI TABS PREFERRED

OCELLA TABS PREFERRED

SYEDA TABS PREFERRED

YASMIN 28 TABS PREFERRED

YAZ TABS PREFERRED

ZARAH TABS PREFERRED

ZUMANDIMINE TABS PREFERRED

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL TABS PREFERRED

KELNOR 1/35 TABS PREFERRED

KELNOR 1/50 TABS PREFERRED

ZOVIA 1/35E TABS PREFERRED

Page 46 of 102


FORMPDL STATUS

AFIRMELLE TABS PREFERRED

ALTAVERA TABS PREFERRED

AUBRA TABS PREFERRED

AUBRA EQ TABS PREFERRED

AVIANE TABS PREFERRED

AYUNA TABS PREFERRED

CHATEAL TABS PREFERRED

CHATEAL EQ TABS PREFERRED

FALMINA TABS PREFERRED

KURVELO TABS PREFERRED

LARISSIA TABS PREFERRED

LESSINA TABS PREFERRED

LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

LEVORA 0.15/30-28 TABS PREFERRED

LILLOW TABS PREFERRED

LUTERA TABS PREFERRED

MARLISSA TABS PREFERRED

ORSYTHIA TABS PREFERRED

PORTIA-28 TABS PREFERRED

SRONYX TABS PREFERRED

TYBLUME TABS PREFERRED

VIENVA TABS PREFERRED

ALYACEN 1/35 TABS PREFERRED

BALZIVA TABS PREFERRED

BRIELLYN TABS PREFERRED

CYCLAFEM 1/35 TABS PREFERRED

DASETTA 1/35 TABS PREFERRED

NECON 0.5/35-28 TABS PREFERRED

NORTREL 0.5/35 (28) TABS PREFERRED

NORTREL 1/35 TABS PREFERRED

PHILITH TABS PREFERRED

PIRMELLA 1/35 TABS PREFERRED

VYFEMLA TABS PREFERRED

WERA TABS PREFERRED

ZENCHENT TABS PREFERRED

AUROVELA 1.5/30 TABS PREFERRED

AUROVELA 1/20 TABS PREFERRED

HAILEY 1.5/30 TABS PREFERRED

JUNEL 1.5/30 TABS PREFERRED

JUNEL 1/20 TABS PREFERRED

LARIN 1.5/30 TABS PREFERRED

LARIN 1/20 TABS PREFERRED

LOESTRIN 1.5/30-21 TABS PREFERRED

LOESTRIN 1/20-21 TABS PREFERRED

Page 47 of 102


FORMPDL STATUS

MICROGESTIN 1.5/30 TABS PREFERRED

MICROGESTIN 1/20 TABS PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS PREFERRED

CRYSELLE-28 TABS PREFERRED

ELINEST TABS PREFERRED

LOW-OGESTREL TABS PREFERRED

OGESTREL TABS PREFERRED

ESTARYLLA TABS PREFERRED

FEMYNOR TABS PREFERRED

MILI TABS PREFERRED

MONO-LINYAH TABS PREFERRED

NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED

PREVIFEM TABS PREFERRED

SPRINTEC 28 TABS PREFERRED

VYLIBRA TABS PREFERRED

BEYAZ TABS PREFERRED

DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM TABS PREFERRED

SAFYRAL TABS PREFERRED

TYDEMY TABS PREFERRED

BALCOLTRA TABS PREFERRED

FALESSA KIT PREFERRED

GENERESS FE CHEW PREFERRED

KAITLIB FE CHEW PREFERRED

LAYOLIS FE CHEW PREFERRED

NORETHINDRONE & ETHINYL ESTRADIOL FERROUS FUMARATE CHEW PREFERRED

NORETHINDRONE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED

WYMZYA FE CHEW PREFERRED

TAYTULLA CAPS PREFERRED

CHARLOTTE 24 FE CHEW PREFERRED

MELODETTA 24 FE CHEW PREFERRED

MIBELAS 24 FE CHEW PREFERRED

MINASTRIN 24 FE CHEW PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED

AUROVELA 24 FE TABS PREFERRED

AUROVELA FE 1.5/30 TABS PREFERRED

AUROVELA FE 1/20 TABS PREFERRED

BLISOVI 24 FE TABS PREFERRED

BLISOVI FE 1.5/30 TABS PREFERRED

BLISOVI FE 1/20 TABS PREFERRED

HAILEY 24 FE TABS PREFERRED

HAILEY FE 1.5/30 TABS PREFERRED

HAILEY FE 1/20 TABS PREFERRED

JUNEL FE 1.5/30 TABS PREFERRED

JUNEL FE 1/20 TABS PREFERRED

Page 48 of 102


FORMPDL STATUS

JUNEL FE 24 TABS PREFERRED

LARIN 24 FE TABS PREFERRED

LARIN FE 1.5/30 TABS PREFERRED

LARIN FE 1/20 TABS PREFERRED

LOESTRIN FE 1.5/30 TABS PREFERRED

LOESTRIN FE 1/20 TABS PREFERRED

MICROGESTIN 24 FE TABS PREFERRED

MICROGESTIN FE TABS PREFERRED

MICROGESTIN FE 1.5/30 TABS PREFERRED

MICROGESTIN FE 1/20 TABS PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE TABS PREFERRED

TARINA 24 FE TABS PREFERRED

TARINA FE 1/20 TABS PREFERRED

TARINA FE 1/20 EQ TABS PREFERRED

AZURETTE TABS PREFERRED

BEKYREE TABS PREFERRED

DESOGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

KARIVA TABS PREFERRED

MIRCETTE TABS PREFERRED

PIMTREA TABS PREFERRED

SIMLIYA TABS PREFERRED

VIORELE TABS PREFERRED

VOLNEA TABS PREFERRED

LO LOESTRIN FE TABS PREFERRED

CAZIANT TABS PREFERRED

CYCLESSA TABS PREFERRED

VELIVET TABS PREFERRED

ENPRESSE-28 TABS PREFERRED

LEVONEST TABS PREFERRED


TRIVORA-28 TABS PREFERRED

ALYACEN 7/7/7 TABS PREFERRED

ARANELLE TABS PREFERRED

CYCLAFEM 7/7/7 TABS PREFERRED

DASETTA 7/7/7 TABS PREFERRED

LEENA TABS PREFERRED

NORTREL 7/7/7 TABS PREFERRED

PIRMELLA 7/7/7 TABS PREFERRED

NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED

TRI FEMYNOR TABS PREFERRED

TRI-ESTARYLLA TABS PREFERRED

TRI-LINYAH TABS PREFERRED

TRI-LO-ESTARYLLA TABS PREFERRED

TRI-LO-MARZIA TABS PREFERRED

Page 49 of 102


FORMPDL STATUS

TRI-LO-MILI TABS PREFERRED

TRI-LO-SPRINTEC TABS PREFERRED

TRI-MILI TABS PREFERRED

TRI-PREVIFEM TABS PREFERRED

TRI-SPRINTEC TABS PREFERRED

TRI-VYLIBRA TABS PREFERRED

TRI-VYLIBRA LO TABS PREFERRED

TRINESSA TABS PREFERRED

ESTROSTEP FE TABS PREFERRED

TILIA FE TABS PREFERRED

TRI-LEGEST FE TABS PREFERRED

NATAZIA TABS PREFERRED

AMETHIA TABS PREFERRED

AMETHIA LO TABS PREFERRED

ASHLYNA TABS PREFERRED

CAMRESE TABS PREFERRED

CAMRESE LO TABS PREFERRED

DAYSEE TABS PREFERRED

FAYOSIM TABS PREFERRED

INTROVALE TABS PREFERRED

JAIMIESS TABS PREFERRED

JOLESSA TABS PREFERRED

LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED


LOJAIMIESS TABS PREFERRED

LOSEASONIQUE TABS PREFERRED

QUARTETTE TABS PREFERRED

RIVELSA TABS PREFERRED

SEASONIQUE TABS PREFERRED

SETLAKIN TABS PREFERRED

SIMPESSE TABS PREFERRED

AMETHYST TABS PREFERRED

LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED

CONTRACEPTIVES : EMERGENCY CONTRACEPTIVES AFTERA TABS PREFERRED

ECONTRA EZ TABS PREFERRED

ECONTRA ONE-STEP TABS PREFERRED

FALLBACK SOLO TABS PREFERRED

LEVONORGESTREL TABS PREFERRED

MY CHOICE TABS PREFERRED

MY WAY TABS PREFERRED

NEW DAY TABS PREFERRED

OPCICON ONE-STEP TABS PREFERRED

OPTION 2 TABS PREFERRED

PLAN B ONE-STEP TABS PREFERRED

Page 50 of 102


FORMPDL STATUS

TAKE ACTION TABS PREFERRED

ELLA TABS PREFERRED

CONTRACEPTIVES : PROGESTIN CONTRACEPTIVES CAMILA TABS PREFERRED

DEBLITANE TABS PREFERRED

ERRIN TABS PREFERRED

HEATHER TABS PREFERRED

INCASSIA TABS PREFERRED

JENCYCLA TABS PREFERRED

JOLIVETTE TABS PREFERRED

LYZA TABS PREFERRED

NORA-BE TABS PREFERRED

NORETHINDRONE TABS PREFERRED

NORLYDA TABS PREFERRED

ORTHO MICRONOR TABS PREFERRED

SHAROBEL TABS PREFERRED

TULANA TABS PREFERRED

SLYND TABS PREFERRED

DEPO-PROVERA CONTRACEPTIVE SUSP PREFERRED

MEDROXYPROGESTERONE ACETATE SUSP PREFERRED

DEPO-PROVERA CONTRACEPTIVE SUSY PREFERRED

DEPO-SUBQ PROVERA 104 SUSY PREFERRED

MEDROXYPROGESTERONE ACETATE SUSY PREFERRED

CORTICOSTEROIDS ORTIKOS CP24 NON_PREFERRED

BUDESONIDE CPEP NON_PREFERRED

ENTOCORT EC CPEP NON_PREFERRED

BUDESONIDE ER TB24 NON_PREFERRED

UCERIS TB24 NON_PREFERRED

CORTISONE ACETATE TABS NON_PREFERRED

EMFLAZA SUSP NON_PREFERRED

EMFLAZA TABS NON_PREFERRED

DEXAMETHASONE INTENSOL CONC PREFERRED

DECADRON ELIX PREFERRED

DEXAMETHASONE ELIX PREFERRED

DEXAMETHASONE SOLN PREFERRED

DECADRON TABS PREFERRED

DEXAMETHASONE TABS PREFERRED

HEMADY TABS NON_PREFERRED

DEXAMETHASONE 10-DAY DOSE PACK TBPK PREFERRED

DEXAMETHASONE 13-DAY DOSE PACK TBPK PREFERRED

DEXAMETHASONE 6-DAY DOSEPACK TBPK PREFERRED

DEXAMETHASONE 6-DAY THERAPY PACK TBPK PREFERRED

TAPERDEX 12-DAY TBPK NON_PREFERRED



Page 51 of 102


FORMPDL STATUS

ALKINDI SPRINKLE CPSP NON_PREFERRED

CORTEF TABS NON_PREFERRED

HYDROCORTISONE TABS PREFERRED

MEDROL TABS NON_PREFERRED

METHYLPREDNISOLONE TABS PREFERRED

MEDROL DOSEPAK TBPK NON_PREFERRED

METHYLPREDNISOLONE DOSE PACK TBPK PREFERRED

PREDNISOLONE SOLN PREFERRED

MILLIPRED TABS PREFERRED

MILLIPRED DP TBPK PREFERRED

PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED

PREDNISOLONE SODIUM PHOSPHATE ODT TBDP NON_PREFERRED

PREDNISONE INTENSOL CONC PREFERRED

PREDNISONE SOLN PREFERRED

PREDNISONE TABS PREFERRED

RAYOS TBEC NON_PREFERRED

PREDNISONE TBPK PREFERRED

FLUDROCORTISONE ACETATE TABS PREFERRED

DERMATOLOGICALS : ACNE PRODUCTS ADAPALENE CREA NON_PREFERRED

DIFFERIN CREA NON_PREFERRED

ADAPALENE GEL NON_PREFERRED

ADAPALENE PUMP GEL NON_PREFERRED

DIFFERIN GEL NON_PREFERRED

DIFFERIN LOTN NON_PREFERRED

ADAPALENE SOLN NON_PREFERRED

AZELEX CREA NON_PREFERRED

ABSORICA CAPS NON_PREFERRED

AMNESTEEM CAPS NON_PREFERRED

CLARAVIS CAPS NON_PREFERRED

ISOTRETINOIN CAPS NON_PREFERRED

MYORISAN CAPS NON_PREFERRED

ZENATANE CAPS NON_PREFERRED

ABSORICA LD CAPS NON_PREFERRED

FABIOR FOAM NON_PREFERRED

ARAZLO LOTN NON_PREFERRED

AVITA CREA PREFERRED

RETIN-A CREA NON_PREFERRED

TRETIN-X CREA NON_PREFERRED

TRETINOIN CREA PREFERRED

ATRALIN GEL NON_PREFERRED

AVITA GEL PREFERRED

RETIN-A GEL NON_PREFERRED

TRETINOIN GEL PREFERRED

ALTRENO LOTN NON_PREFERRED

Page 52 of 102


FORMPDL STATUS

RETIN-A MICRO GEL NON_PREFERRED

RETIN-A MICRO PUMP GEL NON_PREFERRED

TRETINOIN MICROSPHERE GEL NON_PREFERRED

TRETINOIN MICROSPHERE PUMP GEL NON_PREFERRED

AKLIEF CREA NON_PREFERRED

CLINDAMYCIN PHOSPHATE FOAM NON_PREFERRED

EVOCLIN FOAM NON_PREFERRED

CLEOCIN-T GEL NON_PREFERRED

CLINDAGEL GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE GEL PREFERRED

CLEOCIN-T LOTN NON_PREFERRED

CLINDAMYCIN PHOSPHATE LOTN PREFERRED

CLINDAMYCIN PHOSPHATE SOLN PREFERRED

CLINDACIN ETZ PLEDGETS SWAB PREFERRED

CLINDACIN-P SWAB PREFERRED

CLINDAMYCIN PHOSPHATE SWAB PREFERRED

ACZONE GEL NON_PREFERRED

DAPSONE GEL NON_PREFERRED

ERYGEL GEL NON_PREFERRED

ERYTHROMYCIN GEL PREFERRED

ERY PADS NON_PREFERRED

ERYTHROMYCIN PADS NON_PREFERRED

ERYTHROMYCIN SOLN PREFERRED

KLARON LOTN NON_PREFERRED

SODIUM SULFACETAMIDE LOTN NON_PREFERRED

SULFACETAMIDE SODIUM LOTN NON_PREFERRED

AMZEEQ FOAM NON_PREFERRED

ADAPALENE/BENZOYL PEROXIDE GEL NON_PREFERRED

EPIDUO GEL NON_PREFERRED

EPIDUO FORTE GEL NON_PREFERRED

BENZAMYCIN GEL NON_PREFERRED

ERYTHROMYCIN/BENZOYL PEROXIDE GEL PREFERRED

AKTIPAK PACK PREFERRED

ACANYA GEL NON_PREFERRED

BENZACLIN GEL NON_PREFERRED

BENZACLIN WITH PUMP GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED

CLINDAMYCIN/BENZOYL PEROXIDE GEL NON_PREFERRED

ONEXTON GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED

NEUAC GEL NON_PREFERRED

CLINDACIN ETZ KIT NON_PREFERRED

CLINDACIN PAC KIT NON_PREFERRED

CLINDAMYCIN PHOSPHATE/TRETINOIN GEL NON_PREFERRED

Page 53 of 102


FORMPDL STATUS

ZIANA GEL NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CREA NON_PREFERRED

SSS 10%-5% CREA NON_PREFERRED

BP 10-1 EMUL NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CLEANSER EMUL NON_PREFERRED

SULFACETAMIDE SODIUM/SULFUR CLEANSER EMUL NON_PREFERRED

SSS 10-5 FOAM NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CLEANSER LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR WASH LIQD NON_PREFERRED

SUMADAN WASH LIQD NON_PREFERRED

SUMAXIN WASH LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR PADS NON_PREFERRED

SUMAXIN PADS NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR SUSP NON_PREFERRED

SUMAXIN TS SUSP NON_PREFERRED

BP CLEANSING WASH EMUL NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA EMUL NON_PREFERRED

SUMADAN KIT KIT NON_PREFERRED

SUMAXIN CP KIT KIT NON_PREFERRED

SUMADAN XLT KIT NON_PREFERRED

NEUAC KIT KIT NON_PREFERRED

DERMATOLOGICALS : ANTIBIOTICS GENTAMICIN SULFATE CREA PREFERRED

GENTAMICIN SULFATE OINT PREFERRED

XEPI CREA NON_PREFERRED

CENTANY AT KIT NON_PREFERRED

CENTANY OINT NON_PREFERRED

MUPIROCIN OINT PREFERRED

MUPIROCIN CREA NON_PREFERRED

NEO-SYNALAR CREA NON_PREFERRED

CORTISPORIN CREA NON_PREFERRED

NEO-SYNALAR KIT KIT NON_PREFERRED

CORTISPORIN OINT PREFERRED

DERMATOLOGICALS : ANTIFUNGALS MENTAX CREA NON_PREFERRED

CICLOPIROX GEL NON_PREFERRED

CICLODAN SOLUTION KIT KIT NON_PREFERRED

CICLOPIROX TREATMENT KIT NON_PREFERRED

CICLOPIROX SHAM NON_PREFERRED

LOPROX SHAMPOO SHAM NON_PREFERRED

CICLODAN SOLN NON_PREFERRED

CICLOPIROX NAIL LACQUER SOLN NON_PREFERRED

CICLODAN CREA NON_PREFERRED

CICLOPIROX OLAMINE CREA NON_PREFERRED

LOPROX CREA NON_PREFERRED

Page 54 of 102


FORMPDL STATUS

CICLOPIROX SUSP NON_PREFERRED

LOPROX SUSP NON_PREFERRED

CICLODAN CREAM KIT KIT NON_PREFERRED

LOPROX KIT NON_PREFERRED

LOPROX KIT KIT NON_PREFERRED

NAFTIFINE HCL CREA NON_PREFERRED

NAFTIFINE HYDROCHLORIDE CREA NON_PREFERRED

NAFTIN CREA NON_PREFERRED

NAFTIFINE HYDROCHLORIDE GEL NON_PREFERRED

NAFTIN GEL NON_PREFERRED

NYSTATIN CREA PREFERRED

NYSTATIN OINT PREFERRED

NYAMYC POWD PREFERRED

NYSTATIN POWD PREFERRED

NYSTOP POWD PREFERRED

CLOTRIMAZOLE CREA PREFERRED

CLOTRIMAZOLE SOLN NON_PREFERRED

ECONAZOLE NITRATE CREA PREFERRED

JUBLIA SOLN NON_PREFERRED

KETOCONAZOLE CREA PREFERRED

EXTINA FOAM NON_PREFERRED

KETOCONAZOLE FOAM NON_PREFERRED

KETODAN FOAM NON_PREFERRED

KETOCONAZOLE SHAM PREFERRED

KETODAN KIT KIT NON_PREFERRED

LULICONAZOLE CREA NON_PREFERRED

LUZU CREA NON_PREFERRED

OXICONAZOLE NITRATE CREA NON_PREFERRED

OXISTAT CREA NON_PREFERRED

OXISTAT LOTN NON_PREFERRED

ERTACZO CREA NON_PREFERRED

EXELDERM CREA NON_PREFERRED

EXELDERM SOLN NON_PREFERRED

KERYDIN SOLN NON_PREFERRED

TAVABOROLE SOLN NON_PREFERRED

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED

ZOLPAK KIT NON_PREFERRED

NYSTATIN/TRIAMCINOLONE CREA NON_PREFERRED

NYSTATIN/TRIAMCINOLONE ACETONIDE CREA NON_PREFERRED

NYSTATIN/TRIAMCINOLONE OINT NON_PREFERRED

NYSTATIN/TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED

ECONASIL KIT NON_PREFERRED

MICONAZOLE NITRATE/ZINC OXIDE/WHITE PETROLATUM OINT NON_PREFERRED

Page 55 of 102


FORMPDL STATUS

VUSION OINT NON_PREFERRED

DERMATOLOGICALS : ANTIPSORIATICS CALCIPOTRIENE CREA PREFERRED

DOVONEX CREA NON_PREFERRED

SORILUX FOAM NON_PREFERRED

CALCIPOTRIENE OINT PREFERRED

CALCIPOTRIENE SOLN PREFERRED

CALCITRIOL OINT NON_PREFERRED

VECTICAL OINT NON_PREFERRED

TAZAROTENE CREA NON_PREFERRED

TAZORAC CREA NON_PREFERRED

TAZORAC GEL NON_PREFERRED

ACITRETIN CAPS NON_PREFERRED

SORIATANE CAPS NON_PREFERRED

SILIQ SOSY NON_PREFERRED

TREMFYA SOPN NON_PREFERRED

TREMFYA SOSY NON_PREFERRED

TALTZ SOAJ NON_PREFERRED

TALTZ SOSY NON_PREFERRED

METHOXSALEN CAPS NON_PREFERRED

OXSORALEN ULTRA CAPS NON_PREFERRED

SKYRIZI PSKT NON_PREFERRED

COSENTYX SENSOREADY PEN SOAJ NON_PREFERRED

COSENTYX SOSY NON_PREFERRED

ILUMYA SOSY NON_PREFERRED

STELARA SOLN NON_PREFERRED

STELARA SOSY NON_PREFERRED

DERMATOLOGICALS : CORTICOSTEROIDS - TOPICAL ALCLOMETASONE DIPROPIONATE CREA PREFERRED

ALCLOMETASONE DIPROPIONATE OINT PREFERRED

AMCINONIDE CREA NON_PREFERRED

AMCINONIDE LOTN NON_PREFERRED

BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED

SERNIVO EMUL NON_PREFERRED

BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED

BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED

AUGMENTED BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED

AUGMENTED BETAMETHASONE DIPROPIONATE GEL NON_PREFERRED

AUGMENTED BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED

AUGMENTED BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED

DIPROLENE OINT NON_PREFERRED

BETAMETHASONE VALERATE CREA PREFERRED

BETAMETHASONE VALERATE FOAM NON_PREFERRED

LUXIQ FOAM NON_PREFERRED

BETAMETHASONE VALERATE LOTN PREFERRED

BETAMETHASONE VALERATE OINT PREFERRED

Page 56 of 102


FORMPDL STATUS

CLOBETASOL PROPIONATE CREA PREFERRED

TEMOVATE CREA NON_PREFERRED

CLOBETASOL PROPIONATE FOAM NON_PREFERRED

OLUX FOAM NON_PREFERRED

CLOBETASOL PROPIONATE GEL PREFERRED

TASOPROL KIT NON_PREFERRED

CLOBETASOL PROPIONATE LIQD NON_PREFERRED

CLOBEX LIQD NON_PREFERRED

CLOBETASOL PROPIONATE LOTN NON_PREFERRED

CLOBEX LOTN NON_PREFERRED

IMPEKLO LOTN NON_PREFERRED

CLOBETASOL PROPIONATE OINT PREFERRED

TEMOVATE OINT NON_PREFERRED

CLOBETASOL PROPIONATE SHAM NON_PREFERRED

CLOBEX SHAM NON_PREFERRED

CLODAN SHAM NON_PREFERRED

CLOBETASOL PROPIONATE SOLN PREFERRED

CLOBETASOL PROPIONATE E CREA PREFERRED

CLOBETASOL PROPIONATE EMOLLIENT CREA PREFERRED

CLOBETASOL PROPIONATE FOAM NON_PREFERRED

CLOBETASOL PROPIONATE EMOLLIENT FOAM NON_PREFERRED

OLUX-E FOAM NON_PREFERRED

TOVET FOAM NON_PREFERRED

TOVET KIT KIT NON_PREFERRED

CLOCORTOLONE PIVALATE CREA NON_PREFERRED

CLODERM CREA NON_PREFERRED

DESONIDE CREA PREFERRED

DESONATE GEL NON_PREFERRED

DESONIDE LOTN NON_PREFERRED

DESONIDE OINT PREFERRED

DESOXIMETASONE CREA NON_PREFERRED

TOPICORT CREA NON_PREFERRED

DESOXIMETASONE GEL NON_PREFERRED

TOPICORT GEL NON_PREFERRED

DESOXIMETASONE LIQD NON_PREFERRED

TOPICORT LIQD NON_PREFERRED

DESOXIMETASONE OINT NON_PREFERRED

TOPICORT OINT NON_PREFERRED

DIFLORASONE DIACETATE CREA PREFERRED

PSORCON CREA NON_PREFERRED

DIFLORASONE DIACETATE OINT PREFERRED

APEXICON E CREA NON_PREFERRED

FLUOCINOLONE ACETONIDE CREA PREFERRED

SYNALAR CREA NON_PREFERRED

Page 57 of 102


FORMPDL STATUS

DERMA-SMOOTHE/FS BODY OIL NON_PREFERRED

DERMA-SMOOTHE/FS SCALP OIL NON_PREFERRED

FLUOCINOLONE ACETONIDE BODY OIL PREFERRED

FLUOCINOLONE ACETONIDE SCALP OIL PREFERRED

FLUOCINOLONE ACETONIDE OINT PREFERRED

SYNALAR OINT NON_PREFERRED

CAPEX SHAM NON_PREFERRED

FLUOCINOLONE ACETONIDE SOLN PREFERRED

SYNALAR SOLN NON_PREFERRED

FLUOCINONIDE CREA PREFERRED

VANOS CREA NON_PREFERRED

FLUOCINONIDE GEL PREFERRED

FLUOCINONIDE OINT PREFERRED

FLUOCINONIDE SOLN PREFERRED

FLUOCINONIDE EMULSIFIED BASE CREA PREFERRED

FLUOCINONIDE EMULSIFIEDBASE CREA PREFERRED

FLURANDRENOLIDE CREA NON_PREFERRED

FLURANDRENOLIDE LOTN NON_PREFERRED

FLURANDRENOLIDE OINT NON_PREFERRED

CORDRAN TAPE NON_PREFERRED

FLUTICASONE PROPIONATE CREA PREFERRED

BESER LOTN NON_PREFERRED

CUTIVATE LOTN NON_PREFERRED

FLUTICASONE PROPIONATE LOTN NON_PREFERRED

FLUTICASONE PROPIONATE OINT PREFERRED

HALCINONIDE CREA NON_PREFERRED

HALOG CREA NON_PREFERRED

HALOG OINT NON_PREFERRED

HALOG SOLN NON_PREFERRED

HALOBETASOL PROPIONATE CREA PREFERRED

ULTRAVATE CREA NON_PREFERRED

HALOBETASOL PROPIONATE FOAM NON_PREFERRED

LEXETTE FOAM NON_PREFERRED

BRYHALI LOTN NON_PREFERRED

ULTRAVATE LOTN NON_PREFERRED

HALOBETASOL PROPIONATE OINT PREFERRED

ULTRAVATE OINT NON_PREFERRED

HYDROCORTISONE CREA PREFERRED

HYDROCORTISONE LOTN PREFERRED

HYDROCORTISONE OINT PREFERRED

HYDROCORTISONE IN ABSORBASE OINT PREFERRED

TEXACORT SOLN NON_PREFERRED

HYDROCORTISONE VALERATE CREA PREFERRED

HYDROCORTISONE VALERATE OINT PREFERRED

Page 58 of 102


FORMPDL STATUS

PANDEL CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE LOTN NON_PREFERRED

LOCOID LOTN NON_PREFERRED

HYDROCORTISONE BUTYRATE OINT NON_PREFERRED

HYDROCORTISONE BUTYRATE SOLN NON_PREFERRED

HYDROCORTISONE BUTYRATE CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE (LIPID) CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE (LIPOPHILIC) CREA NON_PREFERRED

LOCOID LIPOCREAM CREA NON_PREFERRED

MOMETASONE FUROATE CREA PREFERRED

MOMETASONE FUROATE OINT PREFERRED

MOMETASONE FUROATE SOLN PREFERRED

PREDNICARBATE CREA NON_PREFERRED

PREDNICARBATE OINT NON_PREFERRED

KENALOG AERS NON_PREFERRED

TRIAMCINOLONE ACETONIDE AERS NON_PREFERRED

TRIAMCINOLONE ACETONIDE CREA PREFERRED

TRIAMCINOLONE ACETONIDE LOTN PREFERRED

TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED

TRIAMCINOLONE ACETONIDE OINT PREFERRED

TRIANEX OINT NON_PREFERRED

EPIFOAM FOAM NON_PREFERRED

ENSTILAR FOAM NON_PREFERRED

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED

TACLONEX OINT NON_PREFERRED

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE SUSP NON_PREFERRED

TACLONEX SUSP NON_PREFERRED

CLODAN KIT KIT NON_PREFERRED

SYNALAR TS KIT NON_PREFERRED

SYNALAR CREAM KIT KIT NON_PREFERRED

SYNALAR OINTMENT KIT KIT NON_PREFERRED

FLUOPAR KIT NON_PREFERRED

BESER KIT NON_PREFERRED

DUOBRII LOTN NON_PREFERRED

ULTRAVATE X KIT NON_PREFERRED

DERMATOLOGICALS : MISC FINACEA FOAM NON_PREFERRED

AZELAIC ACID GEL NON_PREFERRED

FINACEA GEL NON_PREFERRED

MIRVASO GEL NON_PREFERRED

DOXYCYCLINE CPDR NON_PREFERRED

ORACEA CPDR NON_PREFERRED

IVERMECTIN CREA NON_PREFERRED

SOOLANTRA CREA NON_PREFERRED

Page 59 of 102


FORMPDL STATUS

METROCREAM CREA NON_PREFERRED

METRONIDAZOLE CREA PREFERRED

NORITATE CREA NON_PREFERRED

ROSADAN CREA PREFERRED

METROGEL GEL NON_PREFERRED

METRONIDAZOLE GEL PREFERRED

ROSADAN GEL PREFERRED

METRONIDAZOLE LOTN PREFERRED

ROSADAN KIT KIT NON_PREFERRED

ZILXI FOAM NON_PREFERRED

RHOFADE CREA NON_PREFERRED

LICART PT24 NON_PREFERRED

DICLOFENAC EPOLAMINE PTCH NON_PREFERRED

FLECTOR PTCH NON_PREFERRED

DICLOFENAC SODIUM GEL NON_PREFERRED

VOLTAREN GEL NON_PREFERRED

VOPAC MDS KIT NON_PREFERRED

DICLOFENAC SODIUM SOLN NON_PREFERRED

PENNSAID SOLN NON_PREFERRED

DYNABAC 5.0 THPK NON_PREFERRED

DICLOFEX DC THPK NON_PREFERRED

DICLOTREX THPK NON_PREFERRED

DOXEPIN HYDROCHLORIDE CREA NON_PREFERRED

PRUDOXIN CREA NON_PREFERRED

ZONALON CREA NON_PREFERRED

EUCRISA OINT PREFERRED_WITH_PA

SELENIUM SULFIDE LOTN PREFERRED

SELENIUM SULFIDE SHAM NON_PREFERRED

SELENIUM SULFIDE SHAMPOO SHAM NON_PREFERRED

SODIUM SULFACETAMIDE GEL NON_PREFERRED

SODIUM SULFACETAMIDE WASH LIQD NON_PREFERRED

OVACE PLUS LOTN NON_PREFERRED

ACYCLOVIR CREA NON_PREFERRED

ZOVIRAX CREA NON_PREFERRED

ACYCLOVIR OINT NON_PREFERRED

ZOVIRAX OINT NON_PREFERRED

DENAVIR CREA NON_PREFERRED

XERESE CREA NON_PREFERRED

VALCHLOR GEL NON_PREFERRED

CARAC CREA NON_PREFERRED

EFUDEX CREA NON_PREFERRED

FLUOROURACIL CREA NON_PREFERRED

TOLAK CREA NON_PREFERRED

FLUOROURACIL SOLN NON_PREFERRED

Page 60 of 102


FORMPDL STATUS

DICLOFENAC SODIUM GEL NON_PREFERRED

AMELUZ GEL NON_PREFERRED

LEVULAN KERASTICK SOLR PREFERRED

PANRETIN GEL PREFERRED

TARGRETIN GEL PREFERRED

PICATO GEL NON_PREFERRED

ORMECA KIT NON_PREFERRED

SULFAMYLON CREA PREFERRED

MAFENIDE ACETATE PACK PREFERRED

SULFAMYLON PACK NON_PREFERRED

SILVADENE CREA NON_PREFERRED

SILVER SULFADIAZINE CREA PREFERRED

SSD CREA PREFERRED

SILVER NITRATE SOLN NON_PREFERRED

ARZOL SILVER NITRATE APPLICATORS MISC NON_PREFERRED

GRAFCO SILVER NITRATE APPLICATOR MISC NON_PREFERRED

AMMONIUM LACTATE CREA NON_PREFERRED

AMMONIUM LACTATE LOTN PREFERRED

UREA CREA PREFERRED

UREA LOTN PREFERRED

UREA HYDRATING FOAM NON_PREFERRED

SANTYL OINT NON_PREFERRED

CONDYLOX GEL PREFERRED

PODOFILOX SOLN PREFERRED

PODOCON 25 IN BENZOIN TINCTURE SOLN NON_PREFERRED

SALICYLIC ACID FOAM NON_PREFERRED

SALICYLIC ACID GEL PREFERRED

SALICYLIC ACID WART REMOVER LIQD PREFERRED

SALEX SHAM NON_PREFERRED

SALEX CREAM KIT NON_PREFERRED

SALEX LOTION KIT NON_PREFERRED

BENSAL HP OINT NON_PREFERRED

VEREGEN OINT NON_PREFERRED

ALDARA CREA NON_PREFERRED

IMIQUIMOD CREA PREFERRED

IMIQUIMOD PUMP CREA NON_PREFERRED

ZYCLARA CREA NON_PREFERRED

ZYCLARA PUMP CREA NON_PREFERRED

ELIDEL CREA PREFERRED_WITH_PA

PIMECROLIMUS CREA PREFERRED_WITH_PA

PROTOPIC OINT PREFERRED_WITH_PA

TACROLIMUS OINT PREFERRED_WITH_PA

QUTENZA KIT NON_PREFERRED

LIDOCAINE OINT PREFERRED

Page 61 of 102


FORMPDL STATUS

LIDOCAINE PTCH PREFERRED

LIDOCAINE PATCH 5% PTCH PREFERRED

LIDODERM PTCH NON_PREFERRED

ZTLIDO PTCH NON_PREFERRED

LIDOCAINE CREA PREFERRED

LIDOCAINE HYDROCHLORIDE CREA PREFERRED

LYDEXA CREA NON_PREFERRED

LIDOCAINE HCL JELLY GEL PREFERRED

LIDOZION LOTN NON_PREFERRED

GLYDO PRSY PREFERRED

LIDOCAINE HCL PRSY PREFERRED

LIDOCAINE HCL JELLY PRSY PREFERRED

LIDOCAINE HCL SOLN PREFERRED

LIDOCAINE HYDROCHLORIDE SOLN PREFERRED

PLIAGLIS CREA NON_PREFERRED

SYNERA PTCH NON_PREFERRED

LIDOCAINE/PRILOCAINE CREA NON_PREFERRED

LIDOCAINE/PRILOCAINE KIT NON_PREFERRED

PRILOXX LP KIT NON_PREFERRED

PRIZOTRAL II KIT NON_PREFERRED

APRIZIO PAK II KIT NON_PREFERRED

EMPRICAINE II KIT NON_PREFERRED

PRIZOPAK II KIT NON_PREFERRED

NUVAKAAN II KIT NON_PREFERRED

REGRANEX GEL NON_PREFERRED

BPCO OINT NON_PREFERRED

QBREXZA PADS NON_PREFERRED

XERAC AC SOLN NON_PREFERRED

HYCLODEX SOLN NON_PREFERRED

HYPOCYN SOLN NON_PREFERRED

HYLATOPIC PLUS CREA NON_PREFERRED

TETRIX CREA NON_PREFERRED

HYLATOPIC PLUS LOTN NON_PREFERRED

NUVAIL SOLN NON_PREFERRED

DERMATOLOGICALS : SCABICIDES & PEDICULICIDES EURAX CREA PREFERRED

CROTAN LOTN NON_PREFERRED

EURAX LOTN NON_PREFERRED

SKLICE LOTN NON_PREFERRED

LINDANE SHAM NON_PREFERRED

MALATHION LOTN NON_PREFERRED

OVIDE LOTN NON_PREFERRED

ELIMITE CREA NON_PREFERRED

PERMETHRIN CREA PREFERRED

GNP LICE TREATMENT LIQD PREFERRED

Page 62 of 102


FORMPDL STATUS

HM LICE TREATMENT LIQD PREFERRED

LICE TREATMENT LOTN PREFERRED

SM LICE TREATMENT LOTN PREFERRED

NATROBA SUSP PREFERRED

SPINOSAD SUSP NON_PREFERRED

GNP LICE TREATMENT SHAM PREFERRED

HM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED

LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED

LICE KILLING SHAMPOO SHAM PREFERRED

SM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED

DIGESTIVE ENZYMES CREON CPEP PREFERRED

PANCREAZE CPEP PREFERRED

PERTZYE CPEP NON_PREFERRED

ZENPEP CPEP PREFERRED

VIOKACE TABS NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY

REGULATORS ALENDRONATE SODIUM SOLN PREFERRED

ALENDRONATE SODIUM TABS PREFERRED

FOSAMAX TABS NON_PREFERRED

BINOSTO TBEF NON_PREFERRED

FOSAMAX PLUS D TABS NON_PREFERRED

BONIVA TABS NON_PREFERRED

IBANDRONATE SODIUM TABS NON_PREFERRED

ACTONEL TABS NON_PREFERRED

RISEDRONATE SODIUM TABS NON_PREFERRED

ATELVIA TBEC NON_PREFERRED

RISEDRONATE SODIUM DR TBEC NON_PREFERRED

CALCITONIN SALMON SOLN PREFERRED

CALCITONIN-SALMON SOLN PREFERRED

ENDOCRINE AND METABOLIC AGENTS : GROWTH HORMONES OMNITROPE SOCT NON_PREFERRED

GENOTROPIN SOLR PREFERRED_WITH_PA

GENOTROPIN MINIQUICK SOLR PREFERRED_WITH_PA

HUMATROPE SOLR NON_PREFERRED

HUMATROPE COMBO PACK SOLR NON_PREFERRED

OMNITROPE SOLR NON_PREFERRED

ZOMACTON SOLR NON_PREFERRED

NORDITROPIN FLEXPRO SOPN NON_PREFERRED

NUTROPIN AQ NUSPIN 10 SOPN NON_PREFERRED



SAIZEN SOLR NON_PREFERRED

SAIZENPREP RECONSTITUTIONKIT SOLR NON_PREFERRED

SEROSTIM SOLR NON_PREFERRED

Page 63 of 102


FORMPDL STATUS

ZORBTIVE SOLR NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS : MISC ISTURISA TABS NON_PREFERRED

OSPHENA TABS NON_PREFERRED

EVISTA TABS NON_PREFERRED

RALOXIFENE HYDROCHLORIDE TABS NON_PREFERRED

SYNAREL SOLN NON_PREFERRED

ORILISSA TABS PREFERRED_WITH_PA

EGRIFTA SOLR NON_PREFERRED

EGRIFTA SV SOLR NON_PREFERRED

INCRELEX SOLN NON_PREFERRED

SOMATULINE DEPOT SOLN NON_PREFERRED

MYCAPSSA CPDR NON_PREFERRED

SANDOSTATIN LAR DEPOT KIT NON_PREFERRED

OCTREOTIDE ACETATE SOLN NON_PREFERRED

SANDOSTATIN SOLN NON_PREFERRED

BYNFEZIA PEN SOPN NON_PREFERRED

SIGNIFOR SOLN NON_PREFERRED

SIGNIFOR LAR SRER NON_PREFERRED

STIMATE SOLN PREFERRED

NOCDURNA SUBL NON_PREFERRED

DDAVP TABS NON_PREFERRED

DESMOPRESSIN ACETATE TABS PREFERRED

DDAVP SOLN NON_PREFERRED

DESMOPRESSIN ACETATE SOLN PREFERRED

DDAVP SOLN NON_PREFERRED

DESMOPRESSIN ACETATE SOLN PREFERRED

CABERGOLINE TABS PREFERRED

JYNARQUE TABS NON_PREFERRED

SAMSCA TABS NON_PREFERRED

TOLVAPTAN TABS NON_PREFERRED

JYNARQUE TBPK NON_PREFERRED

MIFEPREX TABS NON_PREFERRED

MIFEPRISTONE TABS NON_PREFERRED

CARNITOR SOLN NON_PREFERRED

CARNITOR SF SOLN NON_PREFERRED

LEVOCARNITINE SOLN NON_PREFERRED

LEVOCARNITINE SF SOLN NON_PREFERRED

CARNITOR TABS NON_PREFERRED

LEVOCARNITINE TABS NON_PREFERRED

GALAFOLD CAPS NON_PREFERRED

NITISINONE CAPS PREFERRED

ORFADIN CAPS PREFERRED

ORFADIN SUSP NON_PREFERRED

NITYR TABS NON_PREFERRED

Page 64 of 102


FORMPDL STATUS

CYSTADANE POWD NON_PREFERRED

CINACALCET HYDROCHLORIDE TABS NON_PREFERRED

SENSIPAR TABS NON_PREFERRED

RAVICTI LIQD NON_PREFERRED

BUPHENYL POWD NON_PREFERRED

SODIUM PHENYLBUTYRATE POWD NON_PREFERRED

BUPHENYL TABS NON_PREFERRED

SODIUM PHENYLBUTYRATE TABS NON_PREFERRED

CARBAGLU TABS NON_PREFERRED

KUVAN PACK NON_PREFERRED

SAPROPTERIN DIHYDROCHLORIDE PACK NON_PREFERRED

KUVAN TBSO NON_PREFERRED

SAPROPTERIN DIHYDROCHLORIDE TBSO NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS : VITAMIN D ANALOGS RAYALDEE CPCR NON_PREFERRED

CALCITRIOL CAPS PREFERRED

ROCALTROL CAPS NON_PREFERRED

CALCITRIOL SOLN PREFERRED

ROCALTROL SOLN NON_PREFERRED

DOXERCALCIFEROL CAPS PREFERRED

PARICALCITOL CAPS NON_PREFERRED

ZEMPLAR CAPS NON_PREFERRED

ESTROGENS PREMARIN TABS PREFERRED

MENEST TABS PREFERRED

DIVIGEL GEL NON_PREFERRED

ELESTRIN GEL NON_PREFERRED

ALORA PTTW NON_PREFERRED

DOTTI PTTW PREFERRED

ESTRADIOL PTTW PREFERRED

MINIVELLE PTTW NON_PREFERRED

VIVELLE-DOT PTTW NON_PREFERRED

CLIMARA PTWK NON_PREFERRED

ESTRADIOL PTWK PREFERRED

MENOSTAR PTWK NON_PREFERRED

EVAMIST SOLN NON_PREFERRED

ESTRACE TABS NON_PREFERRED

ESTRADIOL TABS PREFERRED

PREMPHASE TABS PREFERRED

PREMPRO TABS PREFERRED

COMBIPATCH PTTW PREFERRED

ACTIVELLA TABS NON_PREFERRED

AMABELZ TABS PREFERRED

ESTRADIOL/NORETHINDRONE ACETATE TABS PREFERRED

LOPREEZA TABS PREFERRED

Page 65 of 102


FORMPDL STATUS

MIMVEY TABS PREFERRED

MIMVEY LO TABS PREFERRED

BIJUVA CAPS NON_PREFERRED

FEMHRT LOW DOSE TABS NON_PREFERRED

FYAVOLV TABS NON_PREFERRED

JINTELI TABS NON_PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS NON_PREFERRED

ANGELIQ TABS NON_PREFERRED

CLIMARA PRO PTWK NON_PREFERRED

PREFEST TABS NON_PREFERRED

ORIAHNN CPPK NON_PREFERRED

DUAVEE TABS NON_PREFERRED

GASTROINTESTINAL AGENTS : INFLAMMATORY BOWEL AGENTS BALSALAZIDE DISODIUM CAPS PREFERRED

COLAZAL CAPS NON_PREFERRED

APRISO CP24 NON_PREFERRED

MESALAMINE ER CP24 NON_PREFERRED

PENTASA CPCR PREFERRED

DELZICOL CPDR NON_PREFERRED

MESALAMINE DR CPDR NON_PREFERRED

MESALAMINE ENEM PREFERRED

SFROWASA ENEM PREFERRED

CANASA SUPP NON_PREFERRED

MESALAMINE SUPP PREFERRED

ASACOL HD TBEC NON_PREFERRED

LIALDA TBEC NON_PREFERRED

MESALAMINE DR TBEC NON_PREFERRED

MESALAMINE KIT NON_PREFERRED

ROWASA KIT NON_PREFERRED

DIPENTUM CAPS NON_PREFERRED

AZULFIDINE TABS NON_PREFERRED

SULFASALAZINE TABS PREFERRED

AZULFIDINE EN-TABS TBEC NON_PREFERRED

SULFASALAZINE TBEC PREFERRED

GASTROINTESTINAL AGENTS : MISC CHENODAL TABS NON_PREFERRED

ACTIGALL CAPS NON_PREFERRED

URSODIOL CAPS PREFERRED

URSO 250 TABS NON_PREFERRED

URSO FORTE TABS NON_PREFERRED

URSODIOL TABS NON_PREFERRED

CROMOLYN SODIUM CONC PREFERRED

GASTROCROM CONC NON_PREFERRED

METOCLOPRAMIDE HCL SOLN PREFERRED

METOCLOPRAMIDE HCL TABS PREFERRED

Page 66 of 102


FORMPDL STATUS

METOCLOPRAMIDE HYDROCHLORIDE TABS PREFERRED

REGLAN TABS NON_PREFERRED

METOCLOPRAMIDE ODT TBDP NON_PREFERRED

ENULOSE SOLN PREFERRED

GENERLAC SOLN PREFERRED

LACTULOSE SOLN PREFERRED

AMITIZA CAPS NON_PREFERRED

GATTEX KIT NON_PREFERRED

TRULANCE TABS NON_PREFERRED

ALOSETRON HYDROCHLORIDE TABS NON_PREFERRED

LOTRONEX TABS NON_PREFERRED

ZELNORM TABS NON_PREFERRED

LINZESS CAPS NON_PREFERRED

VIBERZI TABS NON_PREFERRED

MOTEGRITY TABS NON_PREFERRED

XERMELO TABS NON_PREFERRED

ENTEREG CAPS NON_PREFERRED

RELISTOR SOLN NON_PREFERRED

RELISTOR TABS NON_PREFERRED

SYMPROIC TABS NON_PREFERRED

MOVANTIK TABS NON_PREFERRED

CHOLBAM CAPS NON_PREFERRED

OCALIVA TABS NON_PREFERRED

GASTROINTESTINAL AGENTS : PHOSPHATE BINDER AGENTS CALCIUM ACETATE CAPS PREFERRED

PHOSLYRA SOLN NON_PREFERRED

CALCIUM ACETATE TABS PREFERRED

AURYXIA TABS NON_PREFERRED

FOSRENOL CHEW NON_PREFERRED

LANTHANUM CARBONATE CHEW PREFERRED

FOSRENOL PACK PREFERRED

RENVELA PACK NON_PREFERRED

SEVELAMER CARBONATE PACK NON_PREFERRED

RENVELA TABS NON_PREFERRED

SEVELAMER CARBONATE TABS PREFERRED

RENAGEL TABS NON_PREFERRED

SEVELAMER HYDROCHLORIDE TABS PREFERRED

VELPHORO CHEW NON_PREFERRED

GENITOURINARY AGENTS : MISC K-PHOS NO 2 TABS NON_PREFERRED

POTASSIUM CITRATE ER TBCR NON_PREFERRED

UROCIT-K 10 TBCR NON_PREFERRED



ORACIT SOLN PREFERRED

SODIUM CITRATE/CITRIC ACID SOLN PREFERRED

Page 67 of 102


FORMPDL STATUS

CYTRA K CRYSTALS PACK NON_PREFERRED

POTASSIUM CITRATE-CITRICACID CRYSTALS PACK NON_PREFERRED

TARON-CRYSTALS PACK NON_PREFERRED

POTASSIUM CITRATE/CITRICACID SOLN NON_PREFERRED

POTASSIUM CITRATE/SODIUMCITRATE/CITRIC ACID SOLN NON_PREFERRED

TRICITRATES SOLN NON_PREFERRED

PHENAZOPYRIDINE HCL TABS PREFERRED

PHENAZOPYRIDINE HYDROCHLORIDE TABS PREFERRED

PYRIDIUM TABS NON_PREFERRED

CYSTAGON CAPS PREFERRED

PROCYSBI CPDR NON_PREFERRED

PROCYSBI PACK NON_PREFERRED

ELMIRON CAPS NON_PREFERRED

LITHOSTAT TABS NON_PREFERRED

THIOLA TABS NON_PREFERRED

THIOLA EC TBEC NON_PREFERRED

GENITOURINARY AGENTS : PROSTATIC HYPERTROPHY AGENTS AVODART CAPS NON_PREFERRED

DUTASTERIDE CAPS NON_PREFERRED

FINASTERIDE TABS PREFERRED

PROSCAR TABS NON_PREFERRED

ALFUZOSIN HCL ER TB24 PREFERRED

CARDURA XL TB24 NON_PREFERRED

RAPAFLO CAPS NON_PREFERRED

SILODOSIN CAPS NON_PREFERRED

FLOMAX CAPS NON_PREFERRED

TAMSULOSIN HYDROCHLORIDE CAPS PREFERRED

DUTASTERIDE/TAMSULOSIN HCL CAPS NON_PREFERRED

DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS NON_PREFERRED

JALYN CAPS NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : CGMs DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT DEVI NON_PREFERRED

DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT/SHARE DEVI NON_PREFERRED

DEXCOM G4 PLATINUM RECEIVER KIT DEVI NON_PREFERRED

DEXCOM G4 PLATINUM RECEIVER KIT/SHARE DEVI NON_PREFERRED

DEXCOM G5 MOBILE RECEIVERKIT DEVI NON_PREFERRED

DEXCOM G6 RECEIVER DEVI PREFERRED_WITH_PA

DEXCOM RECEIVER KIT DEVI NON_PREFERRED

FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED

FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED

GUARDIAN REAL-TIME REPLACEMENT MONITOR DEVI NON_PREFERRED

GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC DEVI NON_PREFERRED

DEXCOM G4 SENSOR KIT MISC NON_PREFERRED

DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT MISC NON_PREFERRED

Page 68 of 102


FORMPDL STATUS

DEXCOM G6 SENSOR MISC PREFERRED_WITH_PA

ENLITE GLUCOSE SENSOR MISC NON_PREFERRED

EVERSENSE SENSOR/HOLDER MISC NON_PREFERRED

EVERSENSE SENSOR/HOLDER KIT MISC NON_PREFERRED

FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED

FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM MISC NON_PREFERRED

FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED

GUARDIAN SENSOR (3) MISC NON_PREFERRED

MINIMED GUARDIAN SENSOR 3 MISC NON_PREFERRED

SOF-SENSOR MISC NON_PREFERRED

DEXCOM G4 PLATINUM TRANSMITTER KIT MISC NON_PREFERRED

DEXCOM G5 MOBILE TRANSMITTER KIT MISC NON_PREFERRED

DEXCOM G6 TRANSMITTER MISC PREFERRED_WITH_PA

EVERSENSE SMART TRANSMITTER MISC NON_PREFERRED

GUARDIAN CONNECT TRANSMITTER MISC NON_PREFERRED

GUARDIAN CONNECT TRANSMITTER KIT MISC NON_PREFERRED

GUARDIAN LINK 3 MISC NON_PREFERRED

GUARDIAN LINK 3 TRANSMITTER KIT MISC NON_PREFERRED

GUARDIAN TRANSMITTER MISC NON_PREFERRED

GUARDIAN REAL-TIME STARTER KIT KIT NON_PREFERRED

GUARDIAN REAL-TIME SYSTEM KIT NON_PREFERRED

GUARDIAN REAL-TIME SYSTEMPEDIATRIC KIT NON_PREFERRED

GUARDIAN RT STARTER KIT KIT NON_PREFERRED

GUARDIAN RT SYSTEM KIT NON_PREFERRED

PARADIGM REAL-TIME STARTER KIT KIT NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : DEVICES AND KITS ACCU-CHEK AVIVA DEVI NON_PREFERRED

ADVANCE INTUITION BLOOD GLUCOSE METER DEVI NON_PREFERRED

ADVANCE MICRO-DRAW METER DEVI NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ADVOCATE REDI-CODE DEVI NON_PREFERRED

ADVOCATE REDI-CODE+ BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED

ADVOCATE REDI-CODE+ BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

AGAMATRIX AMP NO CODE ADVANCED BLOOD GLUCOSE MONITORING SYST DEVI NON_PREFERRED

AGAMATRIX PRESTO PRO METER DEVI NON_PREFERRED

ASSURE 4 BLOOD GLUCOSE METER DEVI NON_PREFERRED

ASSURE PLATINUM BLOOD GLUCOSE METER DEVI NON_PREFERRED

ASSURE PRISM MULTI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ASSURE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED

BAYER CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CARESENS N GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CARESENS N VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHEK AUTO CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHEK AUTO-CODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHEK AUTO-CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

Page 69 of 102


FORMPDL STATUS

CLEVER CHOICE AUTO-CODE PRO BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHOICE MINI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHOICE TALK BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

COOL BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

DIATHRIVE BLOOD GLUCOSE METER DEVI NON_PREFERRED

DIATHRIVE+ BLOOD GLUCOSEMONITORING SYSTEM/BLUETOOTH DEVI NON_PREFERRED

DIATRUE PLUS BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASY PLUS BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

EASY PLUS II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASY STEP BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASY TRAK II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASYMAX L BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

EASYMAX N BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

EASYMAX V BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED

ELEMENT COMPACT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ELEMENT COMPACT V BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ELEMENT PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED

EMBRACE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EMBRACE BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED

EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

EVENCARE G2 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED

EVENCARE G3 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED

EVENCARE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EVOLUTION AUTOCODE DEVI NON_PREFERRED

EZ SMART DIABETES MONITORING SYSTEM DEVI NON_PREFERRED

EZ SMART PLUS DIABETES MONITORING SYSTEM DEVI NON_PREFERRED

FORA G30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA GD20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA GD50 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA GTEL BLOOD GLUCOSE MONITORING SYSTEM/MULTI-FUNCTIONAL DEVI NON_PREFERRED

FORA PREMIUM V10 BLE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA TEST N' GO VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA V10 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/NO-CODING DEVI NON_PREFERRED

FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

FORA V20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA V30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORACARE GD40 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

Page 70 of 102


FORMPDL STATUS

FORACARE PREMIUM V10 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORACARE TEST N GO BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM EMV3.1 DEVI NON_PREFERRED

FORTISCARE T1 SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

GE100 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

GLUCO PERFECT 3 BLOOD GLUCOSE METER DEVI NON_PREFERRED

GLUCO PERFECT 3 BLOOD GLUCOSE MONITORING SYSTEM/VOICE DEVI NON_PREFERRED

GLUCOCARD 01 BLOOD GLUCOSE METER DEVI NON_PREFERRED

GLUCOCARD SHINE DEVI NON_PREFERRED

GLUCOCARD SHINE XL DEVI NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

GNP EASY TOUCH GLUCOSE MONITORING SYSTEM/NO CODING DEVI NON_PREFERRED

HW EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED

HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

IN TOUCH DEVI NON_PREFERRED

LIBERTY BLOOD GLUCOSE METER DEVI NON_PREFERRED

LIBERTY BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

LIBERTY NEXT GENERATION BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ON CALL EXPRESS BLOOD GLUCOSE METER DEVI NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE METER DEVI NON_PREFERRED

ON CALL VIVID PAL BLOOD GLUCOSE METER DEVI NON_PREFERRED

OPTIUM BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PHARMACIST CHOICE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PRECISION QID MONITOR DEVI NON_PREFERRED

PRECISION SOF-TACT MONITOR DEVI NON_PREFERRED

PRECISION XTRA DEVI NON_PREFERRED

PRECISION XTRA MONITOR DEVI NON_PREFERRED

PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

QUINTET AC BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED

QUINTET BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RA BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

RELION PREMIER BLU BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PREMIER CLASSIC BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PREMIER VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PRIME BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RIGHTSOURCE BLOOD GLUCOSE METER DEVI NON_PREFERRED

SMARTEST EJECT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SMARTEST PROTEGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM DEVI NON_PREFERRED

Page 71 of 102


FORMPDL STATUS

SURE EDGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SURE-TEST EASYPLUS MINI SELF MONITORING BLOOD GLUCOSE METER DEVI NON_PREFERRED

SURECHEK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

TRUE FOCUS BLOOD GLUCOSESELF MONITORING METER DEVI NON_PREFERRED

TRUE METRIX DEVI NON_PREFERRED

TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH DEVI NON_PREFERRED

TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ULTRATRAK ACTIVE DEVI NON_PREFERRED

ULTRATRAK PRO DEVI NON_PREFERRED

ULTRATRAK ULTIMATE MONITOR DEVI NON_PREFERRED

VERASENS BLOOD GLUCOSE MONITORING SYSTEM METER KIT DEVI NON_PREFERRED

VICTORY BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

VIVAGUARD INO BLOOD GLUCOSE METER DEVI NON_PREFERRED

VOCAL POINT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

WAVESENSE KEYNOTE PRO METER DEVI NON_PREFERRED

ACCU-CHEK AVIVA CONNECT KIT NON_PREFERRED

ACCU-CHEK AVIVA PLUS KIT NON_PREFERRED

ACCU-CHEK COMPACT PLUS CARE KIT KIT NON_PREFERRED

ACCU-CHEK GUIDE KIT NON_PREFERRED

ACCU-CHEK GUIDE ME KIT NON_PREFERRED

ACCU-CHEK NANO SMARTVIEW KIT NON_PREFERRED

ACURA BLOOD GLUCOSE MONITORING SYSTEM METER KIT KIT NON_PREFERRED

ACURA BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED

ACURA PLUS BLOOD GLUCOSEMONITORING SYSTEM METER KIT KIT NON_PREFERRED

ACURA PLUS BLOOD GLUCOSEMONITORING SYSTEM STARTER KIT KIT NON_PREFERRED

ADVANCE INTUITION BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT NON_PREFERRED

ADVOCATE REDI-CODE+/ TALKING KIT NON_PREFERRED

ADVOCATE REDI-CODE/TALKING KIT NON_PREFERRED

AGAMATRIX JAZZ WIRELESS 2 KIT NON_PREFERRED

AGAMATRIX PRESTO KIT NON_PREFERRED

ASSURE 3 METER KIT NON_PREFERRED

AT LAST BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

BAYER BREEZE 2 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

BAYER CONTOUR LINK 2.4 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

BAYER CONTOUR LINK BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

BD LATITUDE DIABETES MANAGEMENT SYSTEM KIT NON_PREFERRED

BD LOGIC BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

BIOTEL CARE CONNECTED BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

BLOOD GLUCOSE MONITORINGSYSTEM KIT NON_PREFERRED

BLOOD GLUCOSE MONITORINGSYSTEM PREMIUM KIT NON_PREFERRED

BLOOD GLUCOSE SYSTEM PAK KIT NON_PREFERRED

CAREONE BLOOD GLUCOSE MONITORING SYSTEM/PREMIUM KIT NON_PREFERRED

Page 72 of 102


FORMPDL STATUS

CAREONE BLOOD GLUCOSE MONITORING SYSTEM/VALUE KIT NON_PREFERRED

CARETOUCH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CHOICE DM DIABETES RISK IN-HOME TEST KIT KIT NON_PREFERRED

CLEVER CHEK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CLEVER CHOICE MICRO BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT LINK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT LINK WIRELESS BLOOD GLUCOSE MONITORING SY KIT NON_PREFERRED

CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT USB BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTROL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

COOL BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

CVS ADVANCED GLUCOSE METER KIT NON_PREFERRED

D-CARE GLUCOMETER KIT/GLUCOSE TEST STRIPS KIT NON_PREFERRED

EASY PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASY STEP BLOOD GLUCOSE MONITOR STARTER KIT KIT NON_PREFERRED

EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT NON_PREFERRED

EASY TOUCH GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASY TOUCH HEALTHPRO GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASYGLUCO KIT NON_PREFERRED

EASYGLUCO PLUS BLOOD GLUCOSE MONITORING SYSTEM METER KIT KIT NON_PREFERRED

EASYGLUCO PLUS BLOOD GLUCSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED

EASYGLUCO STARTER KIT KIT NON_PREFERRED

EASYMAX L BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

EASYMAX N BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

EASYMAX V BLOOD GLUCOSE SYSTEM/TALKING KIT NON_PREFERRED

EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT NON_PREFERRED

EASYPLUS R13N SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

EASYPLUS V SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT NON_PREFERRED

EASYPRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASYPRO PLUS KIT NON_PREFERRED

ELEMENT AUTOCODE SYSTEM KIT NON_PREFERRED

EMBRACE EVO BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EVENCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FIFTY50 GLUCOSE METER 2.0 KIT NON_PREFERRED

FORA G20 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FORA TN'G VOICE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FORA V10/V12/D10/D20 BLOOD GLUCOSE TEST STRIPS/LANCETS 30G KIT NON_PREFERRED

FORA V30A BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

Page 73 of 102


FORMPDL STATUS

FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

FREESTYLE FLASH SYSTEM KIT NON_PREFERRED

FREESTYLE FREEDOM KIT NON_PREFERRED

FREESTYLE FREEDOM LITE KIT NON_PREFERRED

FREESTYLE INSULINX BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FREESTYLE SIDEKICK II VALUEPACK KIT NON_PREFERRED

FREESTYLE SYSTEM KIT KIT NON_PREFERRED

GE100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GHT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD 01 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD 01-MINI BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD EXPRESSION AUDIO-ENABLED BLOOD GLUCOSE MONITORING KIT NON_PREFERRED

GLUCOCARD SHINE KIT NON_PREFERRED

GLUCOCARD SHINE CONNEX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD SHINE EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLACK KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLUE KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM PINK KIT NON_PREFERRED

GLUCOCARD X-METER KIT NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM VALUE KIT KIT NON_PREFERRED

GLUCONAVII BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

GOODSENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

IBG STAR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

IGLUCOSE BLOOD GLUCOSE MOITORING SYSTEM KIT NON_PREFERRED

INFINITY BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

INFINITY BLOOD GLUCOSE MONITORING SYSTEM/STARTER KIT KIT NON_PREFERRED

INFINITY VOICE KIT NON_PREFERRED

KROGER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

KROGER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

LDR BLOOD GLUCOSE TRUETEST KIT KIT NON_PREFERRED

MAXIMA BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MAXIMA METER KIT KIT NON_PREFERRED

MAXIMA STARTER KIT KIT NON_PREFERRED

MEIJER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

MEIJER ESSENTIAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MEIJER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

MEIJER TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MEIJER TRUERESULT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MEIJER TRUETRACK BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

MICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

Page 74 of 102


FORMPDL STATUS

MM EASY TOUCH BLOOD GLUCOSE METER KIT NON_PREFERRED

MYGLUCOHEALTH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

NEXGEN METER KIT KIT NON_PREFERRED

NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE METER KIT NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE METER KIT NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL VIVID PAL BLOOD GLUCOSE METER KIT NON_PREFERRED

ONE DROP BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ONETOUCH ULTRA 2 KIT PREFERRED

ONETOUCH ULTRA MINI KIT PREFERRED

ONETOUCH VERIO KIT PREFERRED

ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED

ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED

ONETOUCH VERIO REFLECT KIT PREFERRED

OPTIUM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

OPTUMRX BLOOD GLUCOSE METER KIT NON_PREFERRED

OPTUMRX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

PARADIGM LINK BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

POCKETCHEM EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

PRECISION LINK KIT NON_PREFERRED

PRECISION XTRA KIT NON_PREFERRED

PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING/TALKING KIT NON_PREFERRED

PRODIGY NO CODING BLOOD GLUCOSE KIT NON_PREFERRED

PRODIGY POCKET BLOOD GLUCOSE METER KIT KIT NON_PREFERRED

PRODIGY VOICE BLOOD GLUCOSE METER KIT KIT NON_PREFERRED

QUICKTEK KIT NON_PREFERRED

RA TRUE2GO BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

RA TRUERESULT BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

REFUAH PLUS BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

RELION CONFIRM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RELION MICRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RELION PREMIER COMPACT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RELION ULTIMA BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

REVEAL BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

REXALL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RIGHTEST GM100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED



SMART SENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

Page 75 of 102


FORMPDL STATUS

SMART SENSE VALUE BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

SMARTEST EJECT STARTER KIT KIT NON_PREFERRED

SMARTEST PERSONA STARTERKIT KIT NON_PREFERRED

SMARTEST PRONTO STARTERKIT KIT NON_PREFERRED

SMARTEST PROTEGE STARTERKIT KIT NON_PREFERRED

SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM KIT NON_PREFERRED

SURECHEK BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED

TELCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TGT BLOOD GLUCOSE METER MONITORING SYSTEM KIT NON_PREFERRED

TGT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TGT BLOOD GLUCOSE MONITORING SYSTEM PREMIUM KIT NON_PREFERRED

TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH SMART KIT NON_PREFERRED

TRUE METRIX AIR W/BLUETOOTH SMART KIT NON_PREFERRED

TRUE METRIX BLOOD GLUCOSEMETER KIT NON_PREFERRED

TRUE METRIX GO BLOOD GLUCOSE METER KIT NON_PREFERRED

TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM/NO CODING KIT NON_PREFERRED

TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TRUETRACK SMART SYSTEM KIT NON_PREFERRED

ULTIMA KIT NON_PREFERRED

ULTRA TRAK PRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

VERASENS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

WAVESENSE AMP KIT NON_PREFERRED

WAVESENSE KEYNOTE KIT NON_PREFERRED

RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM DEVI NON_PREFERRED

SIDEKICK BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : INSULIN INFUSION DISPOSABLE

PUMP OMNIPOD DASH SYSTEM KIT PREFERRED_WITH_PA

OMNIPOD STARTER KIT KIT PREFERRED_WITH_PA

V-GO 20 KIT NON_PREFERRED



OMNIPOD 10 PACK MISC PREFERRED_WITH_PA

OMNIPOD 5 PACK MISC PREFERRED_WITH_PA

OMNIPOD DASH 5 PACK MISC PREFERRED_WITH_PA

GLUCOSE MONITORING SUPPLIES : TEST STRIPS ACCU-CHEK AVIVA PLUS STRP NON_PREFERRED

ACCU-CHEK COMPACT PLUS STRP NON_PREFERRED

ACCU-CHEK GUIDE STRP NON_PREFERRED

ACCU-CHEK SMARTVIEW STRIPS STRP NON_PREFERRED

ACCUTREND GLUCOSE STRP NON_PREFERRED

ADVANCE INTUITION TEST STRIPS STRP NON_PREFERRED

ADVANCE MICRO-DRAW TEST STRIPS STRP NON_PREFERRED

ADVOCATE REDI-CODE STRP NON_PREFERRED

Page 76 of 102


FORMPDL STATUS

ADVOCATE REDI-CODE+ TESTSTRIPS STRP NON_PREFERRED

ADVOCATE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX AMP NO CODE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX JAZZ TEST STRIPS STRP NON_PREFERRED

AGAMATRIX KEYNOTE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX PRESTO TEST STRIPS STRP NON_PREFERRED

ASSURE 3 TEST STRIPS STRP NON_PREFERRED

ASSURE 4 TEST STRIPS STRP NON_PREFERRED

ASSURE II STRP NON_PREFERRED

ASSURE II CHECK STRIP STRP NON_PREFERRED

ASSURE II TEST STRIPS STRP NON_PREFERRED

ASSURE PLATINUM TEST STRIPS STRP NON_PREFERRED

ASSURE PRISM MULTI TEST STRIPS STRP NON_PREFERRED

ASSURE PRO TEST STRIPS STRP NON_PREFERRED

BIOSCANNER GLUCOSE TEST STRIPS STRP NON_PREFERRED

BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED

CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP NON_PREFERRED

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP NON_PREFERRED

CARESENS N BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

CARETOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CLEVER CHEK AUTO-CODE TEST STRIPS STRP NON_PREFERRED

CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP NON_PREFERRED

CLEVER CHEK TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE MICRO TESTSTRIPS STRP NON_PREFERRED

CLEVER CHOICE NO CODING TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE TALK NO CODING TEST STRIPS STRP NON_PREFERRED

CONTOUR BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CONTOUR NEXT BLOOD GLUCOSE TEST STRP NON_PREFERRED

COOL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CVS ADVANCED GLUCOSE METER TEST STRIPS STRP NON_PREFERRED

CVS GLUCOSE METER TEST STRIPS STRP NON_PREFERRED

D-CARE BLOOD GLUCOSE STRP NON_PREFERRED

DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

DIATHRIVE+ BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

DUO-CARE TEST STRIPS STRP NON_PREFERRED

EASY PLUS II BLOOD GLUCOSE TEST STRP NON_PREFERRED

EASY STEP TEST STRIPS STRP NON_PREFERRED

EASY TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TRAK II BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

Page 77 of 102


FORMPDL STATUS

EASYGLUCO STRP NON_PREFERRED

EASYGLUCO PLUS STRP NON_PREFERRED

EASYMAX 15 TEST STRIPS STRP NON_PREFERRED

EASYMAX TEST STRIPS STRP NON_PREFERRED

EASYPLUS BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED

EASYPRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASYPRO PLUS STRP NON_PREFERRED

ELEMENT COMPACT TEST STRIPS STRP NON_PREFERRED

ELEMENT TEST STRIPS STRP NON_PREFERRED

EMBRACE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EQ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EVENCARE + BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED

EVENCARE BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED

EVENCARE G2 TEST STRIPS STRP NON_PREFERRED

EVENCARE G3 TEST STRIPS STRP NON_PREFERRED

EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EVENCARE PROVIEW BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EVOLUTION AUTOCODE STRP NON_PREFERRED

EXACTECH R-S-G TEST STRIPS STRP NON_PREFERRED

EXACTECH TEST STRIPS STRP NON_PREFERRED

EZ SMART BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NON_PREFERRED

FORA 6 CONNECT STRP NON_PREFERRED

FORA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA D15G BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA D20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA D40/G31 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA G20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA GD20 TEST STRIPS STRP NON_PREFERRED

FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA GTEL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED



FORA V30A BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORACARE GD40 STRP NON_PREFERRED

FORACARE PREMIUM V10 TESTSTRIPS STRP NON_PREFERRED

FORACARE TEST N GO TEST STRIPS STRP NON_PREFERRED

Page 78 of 102


FORMPDL STATUS

FORTISCARE BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED

FREESTYLE INSULINX BLOODGLUCOSE TEST STRP NON_PREFERRED

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP NON_PREFERRED

FREESTYLE LITE TEST STRIPS STRP NON_PREFERRED

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FREESTYLE TEST STRIPS STRP NON_PREFERRED

GE100 BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

GENSTRIP 50 STRP NON_PREFERRED

GENULTIMATE TEST STRIPS STRP NON_PREFERRED

GHT TEST STRIPS STRP NON_PREFERRED

GLUCO PERFECT 3 TEST STRIPS STRP NON_PREFERRED

GLUCOCARD 01 SENSOR PLUS STRP NON_PREFERRED

GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP NON_PREFERRED

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GLUCOCARD SHINE TEST STRIPS STRP NON_PREFERRED

GLUCOCARD VITAL TEST STRIPS STRP NON_PREFERRED

GLUCOCARD X-SENSOR STRP NON_PREFERRED

GLUCOCOM TEST STRIPS STRP NON_PREFERRED

GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

GLUCOSE METER TEST STRIPS ADVANCED STRP NON_PREFERRED

GNP EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED

GOJJI BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

GOJJI BLOOD GLUCOSE TESTSTRIPS/GOJJI STERILE LANCETS 30G STRP NON_PREFERRED

GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

HARMONY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

IGLUCOSE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

INFINITY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

INFINITY VOICE STRP NON_PREFERRED

KROGER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

KROGER HEALTHPRO GLUCOSETEST STRIPS STRP NON_PREFERRED

KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

KROGER TEST STRIPS STRP NON_PREFERRED

LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

LIBERTY TEST STRIPS STRP NON_PREFERRED

MEIJER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MICRODOT TEST STRIPS STRP NON_PREFERRED

MICRODOT XTRA TEST STRIPS STRP NON_PREFERRED

Page 79 of 102


FORMPDL STATUS

MM EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED

MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP NON_PREFERRED

NEUTEK 2TEK TEST STRIPS STRP NON_PREFERRED

NOVA MAX GLUCOSE TEST STRIPS STRP NON_PREFERRED

ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE TEST STRP NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE TEST STRP NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

ONE DROP BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

ONETOUCH ULTRA BLUE STRP PREFERRED

ONETOUCH VERIO TEST STRIPS STRP PREFERRED

OPTIUM TEST STRIPS STRP NON_PREFERRED

OPTIUMEZ TEST STRIPS STRP NON_PREFERRED

OPTUMRX BLOOD GLUCOSE TEST STRP NON_PREFERRED

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PRECISION PCX STRP NON_PREFERRED

PRECISION PCX PLUS TEST STRIPS STRP NON_PREFERRED

PRECISION POINT OF CARE TEST STRIPS STRP NON_PREFERRED

PRECISION QID TEST STRIPS STRP NON_PREFERRED

PRECISION SOF-TACT TEST STRIPS STRP NON_PREFERRED

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PTS PANELS GLUCOSE TEST STRP NON_PREFERRED

QUICKTEK TEST STRIPS STRP NON_PREFERRED

QUINTET AC BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

QUINTET BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RA TRUETEST STRIPS STRP NON_PREFERRED

REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

RELION BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

RELION CONFIRM/MICRO TEST STRIPS STRP NON_PREFERRED

RELION PREMIER BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION ULTIMA TEST STRIPS STRP NON_PREFERRED

REVEAL BLOOD GLUCOSE TEST STRP NON_PREFERRED

REXALL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED



SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP NON_PREFERRED

Page 80 of 102


FORMPDL STATUS

SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP NON_PREFERRED

SMARTEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SOLUS V2 AUDIBLE TEST STRP NON_PREFERRED

SUPREME TEST STRIPS STRP NON_PREFERRED

SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SURECHEK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TELCARE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TGT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED

TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

TRUE METRIX PRO GLUCOSE TEST STRIPS STRP NON_PREFERRED

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP NON_PREFERRED

TRUETEST STRIPS STRP NON_PREFERRED

TRUETRACK BLOOD GLUCOSE TEST STRP NON_PREFERRED

TRUETRACK TEST STRP NON_PREFERRED

ULTIMA TEST STRIPS STRP NON_PREFERRED

ULTRATRAK PRO TEST STRIPS STRP NON_PREFERRED

ULTRATRAK ULTIMATE TEST STRIPS STRP NON_PREFERRED

UNISTRIP1 GENERIC STRP NON_PREFERRED

VERASENS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

VICTORY AGM-4000 TEST STRIPS STRP NON_PREFERRED

VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

WAVESENSE PRESTO TEST STRIPS STRP NON_PREFERRED

GOUT AGENTS ALLOPURINOL TABS PREFERRED

ZYLOPRIM TABS NON_PREFERRED

COLCHICINE CAPS NON_PREFERRED

MITIGARE CAPS NON_PREFERRED

GLOPERBA SOLN NON_PREFERRED

COLCHICINE TABS NON_PREFERRED

COLCRYS TABS NON_PREFERRED

FEBUXOSTAT TABS NON_PREFERRED

ULORIC TABS NON_PREFERRED

PROBENECID TABS PREFERRED

PROBENECID/COLCHICINE TABS PREFERRED

HEMATOLOGICAL AGENTS : ANTIHEMOPHILIC PRODUCTS HEMOFIL M SOLR PREFERRED_WITH_PA

KOATE SOLR PREFERRED_WITH_PA

KOATE-DVI SOLR PREFERRED_WITH_PA

KOGENATE FS KIT PREFERRED_WITH_PA

RECOMBINATE SOLR PREFERRED_WITH_PA

NUWIQ KIT PREFERRED_WITH_PA

NUWIQ SOLR PREFERRED_WITH_PA

Page 81 of 102


FORMPDL STATUS

ADVATE SOLR PREFERRED_WITH_PA

KOVALTRY SOLR PREFERRED_WITH_PA

XYNTHA KIT PREFERRED_WITH_PA

XYNTHA SOLOFUSE KIT PREFERRED_WITH_PA

ELOCTATE SOLR PREFERRED_WITH_PA

NOVOEIGHT SOLR PREFERRED_WITH_PA

ESPEROCT SOLR PREFERRED_WITH_PA

ADYNOVATE SOLR PREFERRED_WITH_PA

JIVI SOLR PREFERRED_WITH_PA

OBIZUR SOLR PREFERRED_WITH_PA

AFSTYLA KIT PREFERRED_WITH_PA

WILATE KIT PREFERRED_WITH_PA

ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN SOLR PREFERRED_WITH_PA

HUMATE-P SOLR PREFERRED_WITH_PA

FEIBA SOLR PREFERRED_WITH_PA

NOVOSEVEN RT SOLR PREFERRED_WITH_PA

ALPHANINE SD SOLR PREFERRED_WITH_PA

MONONINE SOLR PREFERRED_WITH_PA

BENEFIX KIT PREFERRED_WITH_PA

IXINITY SOLR PREFERRED_WITH_PA

RIXUBIS SOLR PREFERRED_WITH_PA

IDELVION SOLR PREFERRED_WITH_PA

ALPROLIX SOLR PREFERRED_WITH_PA

REBINYN SOLR PREFERRED_WITH_PA

PROFILNINE SOLR PREFERRED_WITH_PA

PROFILNINE SD SOLR PREFERRED_WITH_PA

COAGADEX SOLR PREFERRED_WITH_PA

TRETTEN SOLR PREFERRED_WITH_PA

CORIFACT KIT PREFERRED_WITH_PA

VONVENDI SOLR PREFERRED_WITH_PA

HEMLIBRA SOLN PREFERRED_WITH_PA

HEMATOLOGICAL AGENTS : MISC PENTOXIFYLLINE ER TBCR PREFERRED

TAVALISSE TABS NON_PREFERRED

HAEGARDA SOLR NON_PREFERRED

FIRAZYR SOLN NON_PREFERRED

ICATIBANT ACETATE SOLN NON_PREFERRED

KALBITOR SOLN NON_PREFERRED

TAKHZYRO SOLN NON_PREFERRED

HEMATOLOGICAL AGENTS : PLATELET AGGREGATION INHIBITORS DIPYRIDAMOLE TABS PREFERRED

CILOSTAZOL TABS NON_PREFERRED

ZONTIVITY TABS NON_PREFERRED

AGRYLIN CAPS NON_PREFERRED

ANAGRELIDE HYDROCHLORIDE CAPS PREFERRED

Page 82 of 102


FORMPDL STATUS

CLOPIDOGREL TABS PREFERRED

PLAVIX TABS NON_PREFERRED

EFFIENT TABS NON_PREFERRED

PRASUGREL TABS NON_PREFERRED

BRILINTA TABS PREFERRED

YOSPRALA TBEC NON_PREFERRED

AGGRENOX CP12 NON_PREFERRED

ASPIRIN/DIPYRIDAMOLE CP12 PREFERRED

ASPIRIN/DIPYRIDAMOLE ER CP12 PREFERRED

HEMATOPOIETIC AGENTS : HEMATOPOIETIC GROWTH FACTORS REBLOZYL SOLR NON_PREFERRED

ARANESP ALBUMIN FREE SOLN NON_PREFERRED

ARANESP ALBUMIN FREE SOSY NON_PREFERRED

EPOGEN SOLN PREFERRED_WITH_PA

PROCRIT SOLN PREFERRED_WITH_PA

RETACRIT SOLN NON_PREFERRED

MIRCERA SOSY NON_PREFERRED

NEUPOGEN SOLN PREFERRED

NEUPOGEN SOSY PREFERRED

NIVESTYM SOLN NON_PREFERRED

NIVESTYM SOSY NON_PREFERRED

ZARXIO SOSY NON_PREFERRED

GRANIX SOLN NON_PREFERRED

GRANIX SOSY NON_PREFERRED

NEULASTA ONPRO KIT PSKT NON_PREFERRED

NEULASTA SOSY NON_PREFERRED

ZIEXTENZO SOSY NON_PREFERRED

UDENYCA SOSY NON_PREFERRED

FULPHILA SOSY NON_PREFERRED

LEUKINE SOLR PREFERRED

DOPTELET TABS NON_PREFERRED

PROMACTA PACK NON_PREFERRED

PROMACTA TABS NON_PREFERRED

MULPLETA TABS NON_PREFERRED

NPLATE SOLR NON_PREFERRED

HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS :

BENZODIAZEPINE HYPNOTICS ESTAZOLAM TABS PREFERRED

FLURAZEPAM HCL CAPS NON_PREFERRED

MIDAZOLAM HCL SYRP NON_PREFERRED

RESTORIL CAPS NON_PREFERRED

TEMAZEPAM CAPS PREFERRED

HALCION TABS NON_PREFERRED

TRIAZOLAM TABS PREFERRED

HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : MISC PHENOBARBITAL ELIX PREFERRED

Page 83 of 102


FORMPDL STATUS

PHENOBARBITAL TABS PREFERRED

SECONAL SODIUM CAPS NON_PREFERRED

RAMELTEON TABS NON_PREFERRED

ROZEREM TABS NON_PREFERRED

HETLIOZ CAPS NON_PREFERRED

DOXEPIN HYDROCHLORIDE TABS NON_PREFERRED

SILENOR TABS NON_PREFERRED

DAYVIGO TABS NON_PREFERRED

BELSOMRA TABS NON_PREFERRED

HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : NON -

BENZODIAZEPINE HYPNOTICS ESZOPICLONE TABS NON_PREFERRED

LUNESTA TABS NON_PREFERRED

ZALEPLON CAPS NON_PREFERRED

ZOLPIMIST SOLN NON_PREFERRED

EDLUAR SUBL NON_PREFERRED

INTERMEZZO SUBL NON_PREFERRED

ZOLPIDEM TARTRATE SUBL NON_PREFERRED

AMBIEN TABS NON_PREFERRED

ZOLPIDEM TARTRATE TABS PREFERRED

AMBIEN CR TBCR NON_PREFERRED

ZOLPIDEM TARTRATE ER TBCR NON_PREFERRED

IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAPS PREFERRED

SANDIMMUNE CAPS NON_PREFERRED

SANDIMMUNE SOLN PREFERRED

CYCLOSPORINE MODIFIED CAPS PREFERRED

GENGRAF CAPS PREFERRED

NEORAL CAPS NON_PREFERRED

CYCLOSPORINE MODIFIED SOLN PREFERRED

GENGRAF SOLN PREFERRED

NEORAL SOLN NON_PREFERRED

CELLCEPT CAPS NON_PREFERRED

MYCOPHENOLATE MOFETIL CAPS PREFERRED

CELLCEPT SUSR NON_PREFERRED

MYCOPHENOLATE MOFETIL SUSR PREFERRED

CELLCEPT TABS NON_PREFERRED

MYCOPHENOLATE MOFETIL TABS PREFERRED

MYCOPHENOLIC ACID DR TBEC PREFERRED

MYFORTIC TBEC NON_PREFERRED

EVEROLIMUS TABS NON_PREFERRED

ZORTRESS TABS NON_PREFERRED

RAPAMUNE SOLN NON_PREFERRED

SIROLIMUS SOLN PREFERRED

RAPAMUNE TABS NON_PREFERRED

SIROLIMUS TABS PREFERRED

Page 84 of 102


FORMPDL STATUS

PROGRAF CAPS NON_PREFERRED

TACROLIMUS CAPS PREFERRED

ASTAGRAF XL CP24 NON_PREFERRED

PROGRAF PACK NON_PREFERRED

ENVARSUS XR TB24 NON_PREFERRED

AZASAN TABS NON_PREFERRED

AZATHIOPRINE TABS PREFERRED

IMURAN TABS NON_PREFERRED

MIGRAINE PRODUCTS : CALCITONIN GENE-RELATED PEPTIDE (CGRP)

RECEPTOR ANTAG NURTEC TBDP NON_PREFERRED

UBRELVY TABS NON_PREFERRED

VYEPTI SOLN NON_PREFERRED

AIMOVIG SOAJ PREFERRED_WITH_PA

AJOVY SOAJ NON_PREFERRED

AJOVY SOSY NON_PREFERRED

EMGALITY SOAJ NON_PREFERRED

EMGALITY SOSY NON_PREFERRED

MIGRAINE PRODUCTS : MISC ERGOMAR SUBL NON_PREFERRED

DIHYDROERGOTAMINE MESYLATE SOLN NON_PREFERRED

MIGRANAL SOLN NON_PREFERRED

CAMBIA PACK NON_PREFERRED

MIGERGOT SUPP PREFERRED

CAFERGOT TABS NON_PREFERRED

SUMATRIPTAN/NAPROXEN SODIUM TABS NON_PREFERRED

TREXIMET TABS NON_PREFERRED

MIGRAINE PRODUCTS : SELECTIVE SEROTONIN AGONISTS 5-HT(1F) ALMOTRIPTAN TABS NON_PREFERRED

ALMOTRIPTAN MALATE TABS NON_PREFERRED

ELETRIPTAN HYDROBROMIDE TABS NON_PREFERRED

RELPAX TABS NON_PREFERRED

FROVA TABS NON_PREFERRED

FROVATRIPTAN SUCCINATE TABS NON_PREFERRED

AMERGE TABS NON_PREFERRED

NARATRIPTAN HCL TABS NON_PREFERRED

MAXALT TABS NON_PREFERRED

RIZATRIPTAN BENZOATE TABS PREFERRED

MAXALT-MLT TBDP NON_PREFERRED

RIZATRIPTAN BENZOATE ODT TBDP PREFERRED

IMITREX SOLN NON_PREFERRED

SUMATRIPTAN SOLN PREFERRED

TOSYMRA SOLN NON_PREFERRED

ONZETRA XSAIL EXHP NON_PREFERRED

IMITREX STATDOSE SYSTEM SOAJ NON_PREFERRED

SUMATRIPTAN SUCCINATE SOAJ PREFERRED

Page 85 of 102


FORMPDL STATUS

ZEMBRACE SYMTOUCH SOAJ NON_PREFERRED

IMITREX STATDOSE REFILL SOCT NON_PREFERRED

SUMATRIPTAN SUCCINATE REFILL SOCT PREFERRED

IMITREX SOLN NON_PREFERRED

SUMATRIPTAN SUCCINATE SOLN PREFERRED

SUMATRIPTAN SUCCINATE SOSY PREFERRED

IMITREX TABS NON_PREFERRED

SUMATRIPTAN SUCCINATE TABS PREFERRED

ZOMIG SOLN NON_PREFERRED

ZOLMITRIPTAN TABS NON_PREFERRED

ZOMIG TABS NON_PREFERRED

ZOLMITRIPTAN ODT TBDP NON_PREFERRED

ZOMIG ZMT TBDP NON_PREFERRED

REYVOW TABS NON_PREFERRED

MISCELLANEOUS THERAPEUTIC CLASSES THALOMID CAPS NON_PREFERRED

REVLIMID CAPS NON_PREFERRED

BENLYSTA SOAJ NON_PREFERRED

BENLYSTA SOSY NON_PREFERRED

SODIUM POLYSTYRENE SULFONATE POWD PREFERRED

KIONEX SUSP PREFERRED

SODIUM POLYSTYRENE SULFONATE SUSP PREFERRED

SPS SUSP PREFERRED

LOKELMA PACK NON_PREFERRED

VELTASSA PACK NON_PREFERRED

MOUTH / THROAT / DENTAL AGENTS NYSTATIN SUSP PREFERRED

CLOTRIMAZOLE LOZG PREFERRED

CLOTRIMAZOLE TROC PREFERRED

ORAVIG TABS NON_PREFERRED

CHLORHEXIDINE GLUCONATE SOLN PREFERRED

PAROEX SOLN PREFERRED

ORALONE DENTAL PASTE PSTE PREFERRED

TRIAMCINOLONE ACETONIDE DENTAL PASTE PSTE PREFERRED

LIDOCAINE HCL SOLN PREFERRED

LIDOCAINE HCL VISCOUS SOLN PREFERRED

LIDOCAINE VISCOUS SOLN PREFERRED

DENTA 5000 PLUS CREA NON_PREFERRED

SF 5000 PLUS CREA NON_PREFERRED

SODIUM FLUORIDE 5000 PLUS CREA NON_PREFERRED

SODIUM FLUORIDE 5000 PPM CREA NON_PREFERRED

DENTAGEL GEL NON_PREFERRED

SF GEL NON_PREFERRED

SODIUM FLUORIDE GEL NON_PREFERRED

SODIUM FLUORIDE 5000 PPM PSTE NON_PREFERRED

SODIUM FLUORIDE 5000 PPMSENSITIVE PSTE NON_PREFERRED

Page 86 of 102


FORMPDL STATUS

AQUORAL SOLN NON_PREFERRED

CEVIMELINE HCL CAPS NON_PREFERRED

CEVIMELINE HYDROCHLORIDE CAPS NON_PREFERRED

EVOXAC CAPS NON_PREFERRED

PILOCARPINE HCL TABS PREFERRED

PILOCARPINE HYDROCHLORIDE TABS PREFERRED

SALAGEN TABS NON_PREFERRED

GELX GEL NON_PREFERRED

MULTIVITAMINS : PRENATAL VITAMINS VITAFOL STRIPS FILM NON_PREFERRED

VP-GGR-B6 PRENATAL TABS NON_PREFERRED

PREMESISRX TABS NON_PREFERRED

PRENATE AM TABS NON_PREFERRED

PRENATE CHEW NON_PREFERRED

TRICARE PRENATAL DHA ONE/FOLATE CAPS NON_PREFERRED

VITAFOL GUMMIES CHEW NON_PREFERRED

ENBRACE HR CAPS NON_PREFERRED

ELITE-OB TABS PREFERRED

OB COMPLETE TABS PREFERRED

PNV TABS 29-1 TABS PREFERRED

THRIVITE RX TABS PREFERRED

PRENATE STAR TABS NON_PREFERRED

PRENATE ELITE TABS NON_PREFERRED

OB COMPLETE/DHA CAPS NON_PREFERRED

OB COMPLETE PREMIER TABS NON_PREFERRED

COMPLETENATE CHEW PREFERRED

SE-NATAL 19 CHEW PREFERRED

M-NATAL PLUS TABS PREFERRED

NIVA-PLUS TABS PREFERRED

PRENATAL TABS PREFERRED

PRENATAL VITAMINS PLUS LOW IRON TABS PREFERRED

PRENATRIX TABS PREFERRED

PREPLUS TABS PREFERRED

PRETAB TABS PREFERRED

TRICARE TABS PREFERRED

TRINATAL RX 1 TABS PREFERRED

VIRT NATE TABS PREFERRED

VITAFOL-OB TABS PREFERRED

VOL-PLUS TABS PREFERRED

WESTAB PLUS TABS PREFERRED

C-NATE DHA CAPS NON_PREFERRED

RELNATE DHA CAPS NON_PREFERRED

VIRT-NATE DHA CAPS NON_PREFERRED

VP-PNV-DHA CAPS NON_PREFERRED

PNV-SELECT TABS NON_PREFERRED

Page 87 of 102


FORMPDL STATUS

VIRT-PN TABS NON_PREFERRED

SELECT-OB CHEW NON_PREFERRED

SELECT-OB CHEW NON_PREFERRED

PNV-VP-U CAPS PREFERRED

VITAFOL-NANO TABS NON_PREFERRED

CITRANATAL RX TABS NON_PREFERRED

CONCEPT OB CAPS NON_PREFERRED

FOLIVANE-OB CAPS NON_PREFERRED

PROVIDA OB CAPS NON_PREFERRED

PUREFE OB PLUS CAPS NON_PREFERRED

CALCIUM PNV CAPS NON_PREFERRED

OB COMPLETE ADVANCED CAPS NON_PREFERRED

PNV-OMEGA CAPS NON_PREFERRED

VIRT-PN PLUS CAPS NON_PREFERRED

ZATEAN-PN PLUS CAPS NON_PREFERRED

NESTABS TABS NON_PREFERRED

NESTABS DHA MISC NON_PREFERRED

TRI-TABS DHA MISC NON_PREFERRED

SE-NATAL 19 TABS PREFERRED

CITRANATAL B-CALM MISC NON_PREFERRED

OB COMPLETE ONE CAPS NON_PREFERRED

OB COMPLETE PETITE CAPS NON_PREFERRED

VINATE DHA RF CAPS NON_PREFERRED

PRIMACARE CAPS NON_PREFERRED

CITRANATAL BLOOM TABS NON_PREFERRED

VP-HEME OB TABS NON_PREFERRED

CONCEPT DHA CAPS NON_PREFERRED

TARON-C DHA CAPS NON_PREFERRED

VIRT-C DHA CAPS NON_PREFERRED

TRICARE PRENATAL DHA ONE CAPS NON_PREFERRED

COMPLETE NATAL DHA MISC NON_PREFERRED

VITAFOL-OB+DHA MISC NON_PREFERRED

TRISTART DHA CAPS NON_PREFERRED

TRISTART ONE CAPS NON_PREFERRED

WESTGEL DHA CAPS NON_PREFERRED

PNV-DHA CAPS NON_PREFERRED

PRENATE ENHANCE CAPS NON_PREFERRED

PRENATE RESTORE CAPS NON_PREFERRED

VIRT-PN DHA CAPS NON_PREFERRED

ZATEAN-PN DHA CAPS NON_PREFERRED

PRENATE DHA CAPS NON_PREFERRED

PRENATE ESSENTIAL CAPS NON_PREFERRED

PRENATE PIXIE CAPS NON_PREFERRED

VITAFOL-ONE CAPS NON_PREFERRED

Page 88 of 102


FORMPDL STATUS

SELECT-OB+DHA MISC NON_PREFERRED

PRENAISSANCE PLUS CAPS NON_PREFERRED

VP-CH PLUS CAPS NON_PREFERRED

VP-CH-PNV CAPS NON_PREFERRED

PNV-DHA+DOCUSATE CAPS NON_PREFERRED

PRENAISSANCE CAPS NON_PREFERRED

TARON-PREX CAPS NON_PREFERRED

VIRT-SELECT CAPS NON_PREFERRED

VIRTPREX CAPS NON_PREFERRED

CITRANATAL 90 DHA MISC NON_PREFERRED

CITRANATAL ASSURE MISC NON_PREFERRED

CITRANATAL BLOOM DHA MISC NON_PREFERRED

CITRANATAL DHA MISC NON_PREFERRED

PNV OB+DHA MISC NON_PREFERRED

PRENATE MINI CAPS NON_PREFERRED

CITRANATAL HARMONY CAPS NON_PREFERRED

VP-HEME ONE CAPS NON_PREFERRED

VITAFOL FE+ CAPS NON_PREFERRED

VITAFOL ULTRA CAPS NON_PREFERRED

NESTABS ONE CAPS NON_PREFERRED

VITAFOL FE+ CPPK NON_PREFERRED

MUSCULOSKELETAL THERAPY AGENTS BACLOFEN TABS PREFERRED

CARISOPRODOL TABS NON_PREFERRED

SOMA TABS NON_PREFERRED

CHLORZOXAZONE TABS PREFERRED

LORZONE TABS PREFERRED

AMRIX CP24 NON_PREFERRED

CYCLOBENZAPRINE HYDROCHLORIDE ER CP24 NON_PREFERRED

CYCLOBENZAPRINE HYDROCHLORIDE TABS PREFERRED

FEXMID TABS NON_PREFERRED

METAXALL TABS NON_PREFERRED

METAXALONE TABS NON_PREFERRED

SKELAXIN TABS NON_PREFERRED

METHOCARBAMOL TABS PREFERRED

ROBAXIN-750 TABS NON_PREFERRED

ORPHENADRINE CITRATE ER TB12 PREFERRED

TIZANIDINE HCL CAPS NON_PREFERRED

TIZANIDINE HYDROCHLORIDE CAPS NON_PREFERRED

ZANAFLEX CAPS NON_PREFERRED

TIZANIDINE HCL TABS PREFERRED

TIZANIDINE HYDROCHLORIDE TABS PREFERRED

ZANAFLEX TABS NON_PREFERRED

DANTRIUM CAPS NON_PREFERRED

DANTROLENE SODIUM CAPS PREFERRED

Page 89 of 102


FORMPDL STATUS

CARISOPRODOL/ASPIRIN/CODEINE TABS NON_PREFERRED

NORGESIC FORTE TABS NON_PREFERRED

NASAL AGENTS - SYSTEMIC AND TOPICAL : MISC QNASL AERS NON_PREFERRED

QNASL CHILDRENS AERS NON_PREFERRED

BECONASE AQ SUSP NON_PREFERRED

ZETONNA AERS NON_PREFERRED

OMNARIS SUSP NON_PREFERRED

FLUNISOLIDE SOLN PREFERRED

XHANCE EXHU NON_PREFERRED

FLUTICASONE PROPIONATE SUSP PREFERRED

SINUVA IMPL NON_PREFERRED

MOMETASONE FUROATE SUSP NON_PREFERRED

NASONEX SUSP NON_PREFERRED

IPRATROPIUM BROMIDE SOLN NON_PREFERRED

ASTEPRO SOLN NON_PREFERRED

AZELASTINE HCL SOLN PREFERRED

AZELASTINE HYDROCHLORIDE SOLN PREFERRED

OLOPATADINE HCL SOLN PREFERRED

OLOPATADINE HYDROCHLORIDE SOLN PREFERRED

PATANASE SOLN NON_PREFERRED

AZELASTINE HYDROCHLORIDE/FLUTICASONE PROPIONATE SUSP NON_PREFERRED

DYMISTA SUSP NON_PREFERRED

NEUROMUSCULAR AGENTS TIGLUTIK SUSP NON_PREFERRED

RILUTEK TABS NON_PREFERRED

RILUZOLE TABS PREFERRED

OPHTHALMIC AGENTS : BETA-BLOCKERS - OPHTHALMIC BETAXOLOL HCL SOLN PREFERRED

BETOPTIC-S SUSP NON_PREFERRED

CARTEOLOL HCL SOLN PREFERRED

LEVOBUNOLOL HCL SOLN PREFERRED

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG PREFERRED

TIMOPTIC-XE SOLG NON_PREFERRED

ISTALOL SOLN NON_PREFERRED

TIMOLOL MALEATE SOLN PREFERRED

TIMOPTIC SOLN NON_PREFERRED

TIMOPTIC OCUDOSE SOLN NON_PREFERRED

COMBIGAN SOLN NON_PREFERRED

COSOPT SOLN NON_PREFERRED

COSOPT PF SOLN NON_PREFERRED

DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN PREFERRED

DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF SOLN NON_PREFERRED

OPHTHALMIC AGENTS : MISC LACRISERT INST PREFERRED

BIMATOPROST SOLN NON_PREFERRED

LUMIGAN SOLN NON_PREFERRED

XELPROS EMUL NON_PREFERRED

Page 90 of 102


FORMPDL STATUS

LATANOPROST SOLN PREFERRED

XALATAN SOLN NON_PREFERRED

VYZULTA SOLN NON_PREFERRED

ZIOPTAN SOLN NON_PREFERRED

TRAVATAN Z SOLN NON_PREFERRED

TRAVOPROST SOLN NON_PREFERRED

ATROPINE SULFATE OINT PREFERRED

ATROPINE SULFATE SOLN PREFERRED

ISOPTO ATROPINE SOLN NON_PREFERRED

CYCLOGYL SOLN NON_PREFERRED

CYCLOPENTOLATE HCL SOLN PREFERRED

CYCLOPENTOLATE HYDROCHLORIDE SOLN PREFERRED

PHENYLEPHRINE HCL SOLN NON_PREFERRED

MYDRIACYL SOLN NON_PREFERRED

TROPICAMIDE SOLN PREFERRED

CYCLOMYDRIL SOLN PREFERRED

ISOPTO CARPINE SOLN NON_PREFERRED

PILOCARPINE HCL SOLN PREFERRED

PILOCARPINE HYDROCHLORIDE SOLN PREFERRED

PHOSPHOLINE IODIDE SOLR PREFERRED

RHOPRESSA SOLN NON_PREFERRED

ROCKLATAN SOLN NON_PREFERRED

APRACLONIDINE SOLN NON_PREFERRED

IOPIDINE SOLN NON_PREFERRED

ALPHAGAN P SOLN PREFERRED

BRIMONIDINE TARTRATE SOLN PREFERRED

SIMBRINZA SUSP NON_PREFERRED

RESTASIS EMUL NON_PREFERRED

RESTASIS MULTIDOSE EMUL NON_PREFERRED

CEQUA SOLN NON_PREFERRED

XIIDRA SOLN NON_PREFERRED

AKTEN GEL NON_PREFERRED

ALCAINE SOLN NON_PREFERRED

PROPARACAINE HCL SOLN NON_PREFERRED

TETRACAINE HCL SOLN NON_PREFERRED

TETRACAINE HYDROCHLORIDE SOLN NON_PREFERRED

OXERVATE SOLN NON_PREFERRED

AZOPT SUSP NON_PREFERRED

DORZOLAMIDE HCL SOLN PREFERRED

DORZOLAMIDE HYDROCHLORIDE SOLN PREFERRED

TRUSOPT SOLN NON_PREFERRED

BROMFENAC SOLN NON_PREFERRED

BROMSITE SOLN NON_PREFERRED

PROLENSA SOLN NON_PREFERRED

Page 91 of 102


FORMPDL STATUS

DICLOFENAC SODIUM SOLN PREFERRED

FLURBIPROFEN SODIUM SOLN PREFERRED

ACULAR SOLN NON_PREFERRED

ACULAR LS SOLN NON_PREFERRED

ACUVAIL SOLN NON_PREFERRED

KETOROLAC TROMETHAMINE SOLN PREFERRED

ILEVRO SUSP NON_PREFERRED

NEVANAC SUSP NON_PREFERRED

CYSTADROPS SOLN NON_PREFERRED

CYSTARAN SOLN NON_PREFERRED

GLOSTRIPS STRP NON_PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC ANTI-INFECTIVES AZASITE SOLN NON_PREFERRED

BACITRACIN OINT PREFERRED

BESIVANCE SUSP NON_PREFERRED

CILOXAN OINT PREFERRED

CILOXAN SOLN NON_PREFERRED

CIPROFLOXACIN HYDROCHLORIDE SOLN PREFERRED

ERYTHROMYCIN OINT PREFERRED

GATIFLOXACIN SOLN NON_PREFERRED

ZYMAXID SOLN NON_PREFERRED

GENTAK OINT PREFERRED

GENTAMICIN SULFATE SOLN PREFERRED

LEVOFLOXACIN SOLN PREFERRED

MOXEZA SOLN NON_PREFERRED

MOXIFLOXACIN HYDROCHLORIDE SOLN NON_PREFERRED

VIGAMOX SOLN NON_PREFERRED

OCUFLOX SOLN NON_PREFERRED

OFLOXACIN SOLN PREFERRED

TOBREX OINT PREFERRED

TOBRAMYCIN SOLN PREFERRED

TOBRAMYCIN SULFATE SOLN PREFERRED

TOBREX SOLN NON_PREFERRED

SULFACETAMIDE SODIUM OINT PREFERRED

BLEPH-10 SOLN NON_PREFERRED

SODIUM SULFACETAMIDE SOLN PREFERRED

SULFACETAMIDE SODIUM SOLN PREFERRED

ZIRGAN GEL PREFERRED

TRIFLURIDINE SOLN PREFERRED

NATACYN SUSP PREFERRED

BETADINE OPHTHALMIC PREP SOLN NON_PREFERRED

AK-POLY-BAC OINT PREFERRED

BACITRACIN/POLYMYXIN B OINT PREFERRED

POLYCIN OINT PREFERRED

POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN PREFERRED

Page 92 of 102


FORMPDL STATUS

POLYTRIM SOLN NON_PREFERRED

TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE SOLN PREFERRED

NEO-POLYCIN OINT PREFERRED

NEOMYCIN/BACITRACIN/POLYMYXIN OINT PREFERRED

NEOMYCIN/POLYMYXIN/BACITRACIN ZINC OINT PREFERRED

NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC ANTIALLERGIC LASTACAFT SOLN NON_PREFERRED

AZELASTINE HCL SOLN PREFERRED

AZELASTINE HYDROCHLORIDE SOLN PREFERRED

BEPREVE SOLN NON_PREFERRED

ZERVIATE SOLN NON_PREFERRED

CROMOLYN SODIUM SOLN PREFERRED

EPINASTINE HCL SOLN NON_PREFERRED

ALOMIDE SOLN NON_PREFERRED

ALOCRIL SOLN NON_PREFERRED

OLOPATADINE HCL SOLN NON_PREFERRED

OLOPATADINE HYDROCHLORIDE SOLN NON_PREFERRED

PATADAY SOLN NON_PREFERRED

PATANOL SOLN NON_PREFERRED

PAZEO SOLN PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC STEROIDS DEXTENZA INST NON_PREFERRED

MAXIDEX SUSP PREFERRED

DEXAMETHASONE SODIUM PHOSPHATE SOLN PREFERRED

DUREZOL EMUL NON_PREFERRED

FML OINT PREFERRED

FLUOROMETHOLONE SUSP PREFERRED

FML FORTE SUSP PREFERRED

FML LIQUIFILM SUSP NON_PREFERRED

FLAREX SUSP PREFERRED

LOTEMAX GEL NON_PREFERRED

LOTEMAX SM GEL NON_PREFERRED

LOTEMAX OINT NON_PREFERRED

ALREX SUSP PREFERRED

INVELTYS SUSP NON_PREFERRED

LOTEMAX SUSP NON_PREFERRED

LOTEPREDNOL ETABONATE SUSP PREFERRED

OMNIPRED SUSP NON_PREFERRED

PRED FORTE SUSP NON_PREFERRED

PRED MILD SUSP PREFERRED

PREDNISOLONE ACETATE SUSP PREFERRED

PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED

PRED-G S.O.P. OINT NON_PREFERRED

PRED-G SUSP NON_PREFERRED

ZYLET SUSP NON_PREFERRED

Page 93 of 102


FORMPDL STATUS

BLEPHAMIDE S.O.P. OINT NON_PREFERRED

SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SOLN NON_PREFERRED

BLEPHAMIDE SUSP NON_PREFERRED

TOBRADEX OINT NON_PREFERRED

TOBRADEX SUSP NON_PREFERRED

TOBRADEX ST SUSP NON_PREFERRED

TOBRAMYCIN/DEXAMETHASONE SUSP PREFERRED

MAXITROL OINT NON_PREFERRED

NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT PREFERRED

MAXITROL SUSP NON_PREFERRED

NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP PREFERRED

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED

NEO-POLYCIN HC OINT PREFERRED

NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT PREFERRED

OTIC AGENTS CIPROFLOXACIN SOLN NON_PREFERRED

FLOXIN OTIC SOLN NON_PREFERRED

OFLOXACIN SOLN PREFERRED

DERMOTIC OIL NON_PREFERRED

FLAC OIL NON_PREFERRED

FLUOCINOLONE ACETONIDE OIL NON_PREFERRED

HYDROCORTISONE/ACETIC ACID SOLN NON_PREFERRED

ACETIC ACID SOLN PREFERRED

OTIC AGENTS : OTIC COMBINATIONS CIPRODEX SUSP PREFERRED

CIPROFLOXACIN/DEXAMETHASONE SUSP PREFERRED

CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF SOLN NON_PREFERRED

OTOVEL SOLN NON_PREFERRED

CIPRO HC SUSP NON_PREFERRED

NEOMYCIN/POLYMYXIN/HC SOLN PREFERRED

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SOLN PREFERRED

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED

CORTISPORIN-TC SUSP NON_PREFERRED

PROGESTINS HYDROXYPROGESTERONE CAPROATE OIL NON_PREFERRED

MAKENA OIL PREFERRED_WITH_PA

MAKENA SOAJ PREFERRED_WITH_PA

MEDROXYPROGESTERONE ACETATE TABS PREFERRED

PROVERA TABS NON_PREFERRED

MEGESTROL ACETATE SUSP NON_PREFERRED

AYGESTIN TABS NON_PREFERRED

NORETHINDRONE ACETATE TABS NON_PREFERRED

PROGESTERONE OIL PREFERRED

PROGESTERONE CAPS PREFERRED

PROMETRIUM CAPS NON_PREFERRED

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS :

ANTIDEMENTIA AGENTS ARICEPT TABS NON_PREFERRED

Page 94 of 102


FORMPDL STATUS

DONEPEZIL HCL TABS PREFERRED

DONEPEZIL HYDROCHLORIDE TABS PREFERRED

DONEPEZIL HCL TBDP PREFERRED

DONEPEZIL HYDROCHLORIDE ODT TBDP PREFERRED

GALANTAMINE HYDROBROMIDEER CP24 NON_PREFERRED

RAZADYNE ER CP24 NON_PREFERRED

GALANTAMINE HYDROBROMIDE SOLN NON_PREFERRED

GALANTAMINE HYDROBROMIDE TABS NON_PREFERRED

EXELON PT24 NON_PREFERRED

RIVASTIGMINE TRANSDERMALSYSTEM PT24 NON_PREFERRED

RIVASTIGMINE TARTRATE CAPS NON_PREFERRED

MEMANTINE HYDROCHLORIDE ER CP24 NON_PREFERRED

NAMENDA XR CP24 NON_PREFERRED

NAMENDA XR TITRATION PACK CP24 NON_PREFERRED

MEMANTINE HYDROCHLORIDE SOLN NON_PREFERRED

MEMANTINE HCL TITRATION PAK TABS NON_PREFERRED

MEMANTINE HYDROCHLORIDE TABS PREFERRED

NAMENDA TABS NON_PREFERRED

NAMENDA TITRATION PAK TABS NON_PREFERRED

NAMZARIC C4PK NON_PREFERRED

NAMZARIC CP24 NON_PREFERRED

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MISC ERGOLOID MESYLATES TABS PREFERRED

PIMOZIDE TABS PREFERRED

FLUOXETINE HYDROCHLORIDE TABS NON_PREFERRED

SARAFEM TABS NON_PREFERRED

BRISDELLE CAPS NON_PREFERRED

PAROXETINE CAPS NON_PREFERRED

AUSTEDO TABS NON_PREFERRED

TETRABENAZINE TABS NON_PREFERRED

XENAZINE TABS NON_PREFERRED

INGREZZA CAPS NON_PREFERRED

INGREZZA CPPK NON_PREFERRED

XYREM SOLN NON_PREFERRED

XYWAV SOLN NON_PREFERRED

SAVELLA TITRATION PACK MISC NON_PREFERRED

SAVELLA TABS NON_PREFERRED

GRALISE TABS NON_PREFERRED

LYRICA CR TB24 NON_PREFERRED

PENTICAN THPK NON_PREFERRED

GABAPAL THPK NON_PREFERRED

LIDOTIN THPK NON_PREFERRED

LIPRITIN THPK NON_PREFERRED

LIPRITIN II THPK NON_PREFERRED

PRILOPENTIN THPK NON_PREFERRED

Page 95 of 102


FORMPDL STATUS

HORIZANT TBCR NON_PREFERRED

NUEDEXTA CAPS NON_PREFERRED

TEGSEDI SOSY NON_PREFERRED

CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS PREFERRED

PERPHENAZINE/AMITRIPTYLINE TABS PREFERRED

OLANZAPINE/FLUOXETINE CAPS NON_PREFERRED

SYMBYAX CAPS NON_PREFERRED

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MULTIPLE

SCLEROSIS AGENTS COPAXONE INJ 20MG/ML SOSY PREFERRED

COPAXONE INJ 40MG/ML SOSY NON_PREFERRED

GLATIRAMER ACETATE SOSY NON_PREFERRED

GLATOPA SOSY NON_PREFERRED

MAVENCLAD TBPK NON_PREFERRED

AVONEX PEN AJKT NON_PREFERRED

AVONEX KIT NON_PREFERRED

AVONEX PSKT NON_PREFERRED

REBIF REBIDOSE SOAJ PREFERRED

REBIF REBIDOSE TITRATIONPACK SOAJ PREFERRED

REBIF SOSY PREFERRED

REBIF TITRATION PACK SOSY PREFERRED

BETASERON KIT PREFERRED

EXTAVIA KIT NON_PREFERRED

PLEGRIDY SOPN NON_PREFERRED

PLEGRIDY STARTER PACK SOPN NON_PREFERRED

PLEGRIDY SOSY NON_PREFERRED

PLEGRIDY STARTER PACK SOSY NON_PREFERRED

AUBAGIO TABS NON_PREFERRED

LEMTRADA SOLN NON_PREFERRED

TYSABRI CONC NON_PREFERRED

OCREVUS SOLN NON_PREFERRED

KESIMPTA SOAJ NON_PREFERRED

DIMETHYL FUMARATE CPDR NON_PREFERRED

TECFIDERA CPDR PREFERRED_WITH_PA

DIMETHYL FUMARATE STARTERPACK MISC NON_PREFERRED

TECFIDERA STARTER PACK MISC PREFERRED_WITH_PA

VUMERITY CPDR NON_PREFERRED

BAFIERTAM CPDR NON_PREFERRED

AMPYRA TB12 NON_PREFERRED

DALFAMPRIDINE ER TB12 NON_PREFERRED

GILENYA CAPS NON_PREFERRED

ZEPOSIA CAPS NON_PREFERRED

ZEPOSIA 7-DAY STARTER PACK CPPK NON_PREFERRED

ZEPOSIA STARTER KIT CPPK NON_PREFERRED

MAYZENT TABS NON_PREFERRED

Page 96 of 102


FORMPDL STATUS

MAYZENT STARTER PACK TBPK NON_PREFERRED

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : SMOKING

DETERRENTS BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED

NICOTROL INHALER INHA PREFERRED

NICOTINE TRANSDERMAL SYSTEM KIT PREFERRED

GNP NICOTINE TRANSDERMALSYSTEM PT24 PREFERRED

GNP NICOTINE TRANSDERMALSYSTEM STEP 2 PT24 PREFERRED

HM NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED



NICOTINE TRANSDERMAL SYSTEM PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED



SM NICOTINE TRANSDERMAL SYSTEM/STEP 1/CLEAR PT24 PREFERRED



NICOTROL NS SOLN PREFERRED

GNP NICOTINE GUM GUM PREFERRED

GNP NICOTINE POLACRILEX GUM PREFERRED

GOODSENSE NICOTINE GUM GUM PREFERRED

GOODSENSE NICOTINE POLACRILEX GUM GUM PREFERRED

HM NICOTINE POLACRILEX GUM PREFERRED

NICOTINE POLACRILEX GUM PREFERRED

SM NICOTINE GUM PREFERRED

SM NICOTINE POLACRILEX GUM PREFERRED

GNP NICOTINE MINI LOZENGE LOZG PREFERRED

GNP NICOTINE POLACRILEX LOZG PREFERRED

GNP NICOTINE POLACRILEX MINI LOZG PREFERRED

GOODSENSE NICOTINE LOZG PREFERRED

GOODSENSE NICOTINE POLACRILEX LOZG PREFERRED

HM NICOTINE POLACRILEX LOZG PREFERRED

NICOTINE LOZG PREFERRED

NICOTINE MINI LOZENGE LOZG PREFERRED

NICOTINE POLACRILEX LOZG PREFERRED

SM NICOTINE LOZG PREFERRED

SM NICOTINE POLACRILEX LOZG PREFERRED

CHANTIX TABS PREFERRED

CHANTIX CONTINUING MONTHPAK TABS PREFERRED

CHANTIX STARTING MONTH PAK TABS PREFERRED

RESPIRATORY AGENTS : CYSTIC FIBROSIS AGENTS KALYDECO PACK NON_PREFERRED

KALYDECO TABS NON_PREFERRED

PULMOZYME SOLN PREFERRED

ORKAMBI PACK NON_PREFERRED

Page 97 of 102


FORMPDL STATUS

ORKAMBI TABS NON_PREFERRED

SYMDEKO TBPK NON_PREFERRED

TRIKAFTA TBPK NON_PREFERRED

RESPIRATORY AGENTS : MISC ESBRIET CAPS NON_PREFERRED

ESBRIET TABS NON_PREFERRED

OFEV CAPS NON_PREFERRED

SUBSTANCE USE DISORDER AGENTS ACAMPROSATE CALCIUM DR TBEC PREFERRED

ANTABUSE TABS PREFERRED

DISULFIRAM TABS PREFERRED

LUCEMYRA TABS PREFERRED

SUBLOCADE SOSY PREFERRED

PROBUPHINE IMPLANT KIT IMPL PREFERRED

BUPRENORPHINE HCL SUBL PREFERRED

BUPRENORPHINE HYDROCHLORIDE SUBL PREFERRED

BUNAVAIL FILM PREFERRED

BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE FILM PREFERRED

SUBOXONE FILM PREFERRED

BUPRENORPHINE HCL/NALOXONE HCL SUBL PREFERRED

BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE SUBL PREFERRED

ZUBSOLV SUBL PREFERRED

NARCAN LIQD PREFERRED

NALOXONE HCL SOCT PREFERRED

NALOXONE HCL SOLN PREFERRED

NALOXONE HYDROCHLORIDE SOLN PREFERRED

NALOXONE HCL SOSY PREFERRED

NALOXONE HYDROCHLORIDE SOSY PREFERRED

VIVITROL SUSR PREFERRED

NALTREXONE HCL TABS PREFERRED

NALTREXONE HYDROCHLORIDE TABS PREFERRED

THYROID AGENTS LEVOTHYROXINE SODIUM CAPS NON_PREFERRED

TIROSINT CAPS NON_PREFERRED

TIROSINT-SOL SOLN NON_PREFERRED

EUTHYROX TABS PREFERRED

LEVO-T TABS PREFERRED

LEVOTHYROXINE SODIUM TABS PREFERRED

LEVOXYL TABS PREFERRED

SYNTHROID TABS NON_PREFERRED

UNITHROID TABS PREFERRED

CYTOMEL TABS NON_PREFERRED

LIOTHYRONINE SODIUM TABS PREFERRED

ARMOUR THYROID TABS PREFERRED

LEVOTHYROXINE/LIOTHYRONINE TABS PREFERRED

NP THYROID 120 TABS PREFERRED


Page 98 of 102


FORMPDL STATUS




METHIMAZOLE TABS PREFERRED

TAPAZOLE TABS NON_PREFERRED

PROPYLTHIOURACIL TABS PREFERRED

TUMOR NECROSIS FACTOR ALPHA INHIBITORS AND MISC

IMMUNOSUPPRESSIVES ENTYVIO SOLR NON_PREFERRED

STELARA SOLN NON_PREFERRED

CIMZIA KIT KIT NON_PREFERRED

CIMZIA PREFL KIT 200MG/ML KIT PREFERRED_WITH_PA

CIMZIA STARTER KIT KIT PREFERRED_WITH_PA

REMICADE SOLR NON_PREFERRED

RENFLEXIS SOLR NON_PREFERRED

AVSOLA SOLR NON_PREFERRED

INFLECTRA SOLR NON_PREFERRED

KINERET SOSY NON_PREFERRED

HUMIRA PEN PNKT PREFERRED_WITH_PA

HUMIRA PEN-CD/UC/HS STARTER PNKT PREFERRED_WITH_PA

HUMIRA PEN-PS/UV STARTER PNKT PREFERRED_WITH_PA

HUMIRA PSKT PREFERRED_WITH_PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT PREFERRED_WITH_PA

SIMPONI SOAJ NON_PREFERRED

SIMPONI ARIA SOLN NON_PREFERRED

SIMPONI SOSY NON_PREFERRED

ENBREL SURECLICK SOAJ PREFERRED_WITH_PA

ENBREL MINI SOCT PREFERRED_WITH_PA

ENBREL SOLN PREFERRED_WITH_PA

ENBREL SOLR PREFERRED_WITH_PA

ENBREL SOSY PREFERRED_WITH_PA

ORENCIA CLICKJECT SOAJ NON_PREFERRED

ORENCIA SOLR NON_PREFERRED

ORENCIA SOSY NON_PREFERRED

ARCALYST SOLR NON_PREFERRED

ILARIS SOLN NON_PREFERRED

KEVZARA SOAJ NON_PREFERRED

KEVZARA SOSY NON_PREFERRED

ACTEMRA ACTPEN SOAJ NON_PREFERRED

ACTEMRA SOLN NON_PREFERRED

ACTEMRA SOSY NON_PREFERRED

OLUMIANT TABS NON_PREFERRED

XELJANZ TABS PREFERRED_WITH_PA

XELJANZ XR TB24 PREFERRED_WITH_PA

RINVOQ TB24 NON_PREFERRED

Page 99 of 102


FORMPDL STATUS

OTEZLA TABS NON_PREFERRED

OTEZLA TBPK NON_PREFERRED

ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : H-2

ANTAGONISTS CIMETIDINE TABS PREFERRED

CIMETIDINE HCL SOLN PREFERRED

CIMETIDINE HYDROCHLORIDE SOLN PREFERRED

RANITIDINE HYDROCHLORIDE CAPS NON_PREFERRED

RANITIDINE HCL SYRP NON_PREFERRED

RANITIDINE HYDROCHLORIDE SYRP NON_PREFERRED

RANITIDINE HCL TABS NON_PREFERRED

RANITIDINE HYDROCHLORIDE TABS NON_PREFERRED

FAMOTIDINE SUSR PREFERRED

FAMOTIDINE TABS PREFERRED

PEPCID TABS NON_PREFERRED

NIZATIDINE CAPS PREFERRED

NIZATIDINE SOLN PREFERRED

ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : MISC HYOSCYAMINE SULFATE ELIX PREFERRED

HYOSCYAMINE SULFATE SOLN PREFERRED

HYOSCYAMINE SULFATE SUBL PREFERRED

LEVSIN/SL SUBL NON_PREFERRED

OSCIMIN SUBL PREFERRED

HYOSCYAMINE SULFATE TABS PREFERRED

LEVSIN TABS NON_PREFERRED

OSCIMIN TABS PREFERRED

OSCIMIN SR TB12 PREFERRED

ANASPAZ TBDP NON_PREFERRED

ED-SPAZ TBDP PREFERRED

HYOSCYAMINE SULFATE TBDP PREFERRED

HYOSCYAMINE SULFATE ODT TBDP PREFERRED

NULEV TBDP PREFERRED

OSCIMIN TBDP PREFERRED

CUVPOSA SOLN NON_PREFERRED

GLYCATE TABS NON_PREFERRED

GLYCOPYRROLATE TABS PREFERRED

METHSCOPOLAMINE BROMIDE TABS NON_PREFERRED

PROPANTHELINE BROMIDE TABS PREFERRED

DICYCLOMINE HYDROCHLORIDE CAPS PREFERRED

DICYCLOMINE HCL SOLN PREFERRED

DICYCLOMINE HYDROCHLORIDE SOLN PREFERRED

DICYCLOMINE HYDROCHLORIDE TABS PREFERRED

BELLADONNA/OPIUM SUPP PREFERRED

CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS NON_PREFERRED

CHLORDIAZEPOXIDE HYDROCHLORIDE/CLIDINIUM BROMIDE CAPS NON_PREFERRED

Page 100 of 102


FORMPDL STATUS

LIBRAX CAPS NON_PREFERRED

CYTOTEC TABS NON_PREFERRED

MISOPROSTOL TABS PREFERRED

CARAFATE SUSP PREFERRED

SUCRALFATE SUSP PREFERRED

CARAFATE TABS NON_PREFERRED

SUCRALFATE TABS PREFERRED

PYLERA CAPS NON_PREFERRED

HELIDAC THERAPY MISC NON_PREFERRED

LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN MISC NON_PREFERRED

OMECLAMOX-PAK MISC NON_PREFERRED

TALICIA CPDR NON_PREFERRED

OMEPRAZOLE/SODIUM BICARBONATE CAPS NON_PREFERRED

ZEGERID CAPS NON_PREFERRED

OMEPRAZOLE/SODIUM BICARBONATE PACK NON_PREFERRED

ZEGERID PACK NON_PREFERRED

ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : PROTON

PUMP INHIBITORS DEXILANT CPDR NON_PREFERRED

ESOMEPRAZOLE MAGNESIUM CPDR NON_PREFERRED

NEXIUM CPDR NON_PREFERRED

ESOMEPRAZOLE MAGNESIUM PACK NON_PREFERRED

NEXIUM PACK NON_PREFERRED

ESOMEPRAZOLE STRONTIUM CPDR NON_PREFERRED

LANSOPRAZOLE CPDR NON_PREFERRED

PREVACID CPDR NON_PREFERRED

LANSOPRAZOLE TBDD PREFERRED

LANSOPRAZOLE ODT TBDD PREFERRED

PREVACID SOLUTAB TBDD NON_PREFERRED

OMEPRAZOLE CPDR PREFERRED

OMEPRAZOLE DR CPDR PREFERRED

PRILOSEC PACK NON_PREFERRED

PANTOPRAZOLE SODIUM PACK NON_PREFERRED

PROTONIX PACK NON_PREFERRED

PANTOPRAZOLE SODIUM TBEC PREFERRED

PANTOPRAZOLE SODIUM DR TBEC PREFERRED

PROTONIX TBEC NON_PREFERRED

ACIPHEX SPRINKLE CPSP NON_PREFERRED

ACIPHEX TBEC NON_PREFERRED

RABEPRAZOLE SODIUM TBEC NON_PREFERRED

URINARY ANTISPASMODICS DARIFENACIN HYDROBROMIDEER TB24 NON_PREFERRED

ENABLEX TB24 NON_PREFERRED

TOVIAZ TB24 NON_PREFERRED

OXYTROL PTTW NON_PREFERRED

GELNIQUE GEL NON_PREFERRED

Page 101 of 102


FORMPDL STATUS

OXYBUTYNIN CHLORIDE SYRP PREFERRED

OXYBUTYNIN CHLORIDE TABS PREFERRED

DITROPAN XL TB24 NON_PREFERRED

OXYBUTYNIN CHLORIDE ER TB24 PREFERRED

SOLIFENACIN SUCCINATE TABS PREFERRED

VESICARE TABS NON_PREFERRED

DETROL LA CP24 NON_PREFERRED

TOLTERODINE TARTRATE ER CP24 NON_PREFERRED

DETROL TABS NON_PREFERRED

TOLTERODINE TARTRATE TABS NON_PREFERRED

TROSPIUM CHLORIDE ER CP24 NON_PREFERRED

TROSPIUM CHLORIDE TABS NON_PREFERRED

MYRBETRIQ TB24 NON_PREFERRED

BETHANECHOL CHLORIDE TABS PREFERRED

URECHOLINE TABS NON_PREFERRED

FLAVOXATE HCL TABS NON_PREFERRED

VAGINAL PRODUCTS CLEOCIN CREA NON_PREFERRED

CLINDAMYCIN PHOSPHATE CREA PREFERRED

CLEOCIN SUPP PREFERRED

CLINDESSE CREA NON_PREFERRED

METROGEL-VAGINAL GEL NON_PREFERRED

METRONIDAZOLE VAGINAL GEL PREFERRED

NUVESSA GEL NON_PREFERRED

VANDAZOLE GEL PREFERRED

GYNAZOLE-1 CREA NON_PREFERRED

MICONAZOLE 3 SUPP PREFERRED

TERCONAZOLE CREA PREFERRED

TERCONAZOLE SUPP PREFERRED

ESTRACE CREA NON_PREFERRED

ESTRADIOL CREA PREFERRED

IMVEXXY MAINTENANCE PACK INST NON_PREFERRED

IMVEXXY STARTER PACK INST NON_PREFERRED

ESTRING RING NON_PREFERRED

ESTRADIOL TABS NON_PREFERRED

VAGIFEM TABS NON_PREFERRED

YUVAFEM TABS NON_PREFERRED

FEMRING RING NON_PREFERRED

PREMARIN CREA PREFERRED

CRINONE GEL NON_PREFERRED

ENDOMETRIN INST PREFERRED

INTRAROSA INST NON_PREFERRED

TRIMO-SAN GEL NON_PREFERRED

Page 102 of 102

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