Molina Healthcare of Ohio Prior Authorization (PA) List · prior authorization (pa) list ... alinia...

DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIA8-MOP 10 MG CAPSULE CLINICAL REVIEW CUTANEOUS T CELL LYMPHOMAABILIFY SOLUTION LOWER COST ALTERNATIVES RISPERIDONE, OLANZAPINE, ZIPRASIDONEABILIFY DISCMELT LOWER COST ALTERNATIVES RISPERIDONE, OLANZAPINE, ZIPRASIDONEABILIFY DISCMELT TABLET LOWER COST ALTERNATIVES RISPERIDONE, OLANZAPINE, ZIPRASIDONEABILIFY TABLET LOWER COST ALTERNATIVES RISPERIDONE, OLANZAPINE, ZIPRASIDONEABSTRAL TAB SUBLING CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,

MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ACANYA GEL PUMP LOWER COST ALTERNATIVES CLINDAMYCIN/BENZOYL PEROXIDE GELACIDOPHILUS CAPLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWACIPHEX EC 20 MG TABLET LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.ACIPHEX SPRINKLE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWACTEMRA SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ACTIMMUNE 2 MILLION UNIT VI

CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ACTIQ LOZENGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWACTIVE OB SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONACTIVELLA TABLET LOWER COST ALTERNATIVES PREMPROACTONEL TABLET LOWER COST ALTERNATIVES GENERIC ALENDRONATEACTONEL WITH CALCIUM TABLET

LOWER COST ALTERNATIVES GENERIC ALENDRONATE PLUS CALCIUM

ACTOPLUS MET XR LOWER COST ALTERNATIVES ACTOPLUS METACUVAIL 0.45% OPHTH SOLUTIO

LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTION

ACZONE 5% GEL LOWER COST ALTERNATIVES CLINDAMYCIN/BENZOYL PEROXIDE GELADCETRIS INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ADCIRCA 20 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ADEMPAS TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ADRENACLICK 0.15 MG AUTO-IN LOWER COST ALTERNATIVES EPI PEN, EPI PEN JRADOXA TABLET LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAPADOXA PAK 1-150 MG TABLET LOWER COST ALTERNATIVES DOXYCYCLINE ADVAIR DISKUS LOWER COST ALTERNATIVES QVAR, ASMANEX, PULMICORT FLEXHALERADVAIR HFA LOWER COST ALTERNATIVES QVAR, ASMANEX, PULMICORT FLEXHALERADVICOR TABLETS LOWER COST ALTERNATIVES NIACIN PLUS SIMVASTATINADVIL 200 MG LIQUI-GEL CAPS LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACAEROSPAN 80 MCG INHALER LOWER COST ALTERNATIVES ASMANEX, QVAR, PULMICORT FLEXHALERAFINITOR CLINICAL REVIEW REQUIRES CLINICAL REVIEWAFINITOR DISPERZ 2 MG TABLE LOWER COST ALTERNATIVES SIROLIMUS, TACROLIMUS

Effective October 1, 2014

Molina Healthcare of OhioPrior Authorization (PA) List

45767 OH Medicaid Pharmacy Carve In Drug List with letter.indd 2 10/14/14 10:21 AM

DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAAFINITOR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AIRAVITE TABLET LOWER COST ALTERNATIVES FOLIC ACIDAKNE-MYCIN 2% OINTMENT LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN

GELALAMAST 0.1% DROPS LOWER COST ALTERNATIVES CROMOLYN 4% EYE DROPSALBENZA 200 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWALINIA 100 MG/5 ML SUSPENSI LOWER COST ALTERNATIVES ALINIA 500 MG TABLETALLEGRA 30 MG/5 ML SUSPENSI LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEALLEGRA ODT 30 MG TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEALLEGRA-D TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEALLFEN CD TABLET LOWER COST ALTERNATIVES GUAIFENESIN-CODEINE SYRUPALOCRIL 2% OPHTH DROPS LOWER COST ALTERNATIVES CROMOLYN SODIUM 4% OPHTH SOLALPHAGAN P 0.1% DROPS LOWER COST ALTERNATIVES ALPHAGAN P 0.15% EYE DROPSALPRAZOLAM ER TABLET LOWER COST ALTERNATIVES ALPRAZOLAM REG. STRENGTH TABLETSALPRAZOLAM ODT LOWER COST ALTERNATIVES ALPRAZOLAM REG. STRENGTH TABLETSALREX EYE DROPS LOWER COST ALTERNATIVES FLUOROMETHOLONE, PREDNISOLONE ACETATEALTABAX 1% OINTMENT LOWER COST ALTERNATIVES MURIPROCIN CREAM/OINTMENTALTOPREV TABLET LOWER COST ALTERNATIVES SIMVASTATINALVESCO INHALER LOWER COST ALTERNATIVES QVAR, PULMICORT FLEXHALER, ASMANEXAMINOSYN II 15% IV SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAMITIZA CAPSULE LOWER COST ALTERNATIVES MIRALAX , LACTULOSEAMPYRA ER 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AMRIX ER CAPSULE LOWER COST ALTERNATIVES CYCLOBENZAPRINE TABLETAMTURNIDE TAB STEP THERAPY FAILURE ACE/ARBANABAR CAPLET LOWER COST ALTERNATIVES ACETOMINOPHEN PLUS ANTIHISTAMINEANADROL-50 TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWANDRODERM PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ANDROGEL ALL STRENGTHS STEP/CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW, REQUIRES LAB VALUES

ANDROGEN PRODUCTS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ANGELIQ 0.5 MG-1 MG TABLET LOWER COST ALTERNATIVES PREMPROANTARA 30 MG CAPSULE LOWER COST ALTERNATIVES FENOFIBRATE GENERICANTARA CAPSULE LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGANZEMET TABLET LOWER COST ALTERNATIVES ONDANSETRON/ODT, GRANISETRONAPIDRA 100 UNITS/ML VIAL LOWER COST ALTERNATIVES APIDRA SOLOSTAR 100 UNITS/MAPLENZIN ER TABLET LOWER COST ALTERNATIVES WELLBUTRIN XLAPOKYN 30 MG/3 ML CARTRIDGE


ARANESP INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ARCALYST 220 MG INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ARCAPTA NEOHALER LOWER COST ALTERNATIVES SALMETEROL, FORMOTEROL INHALERS


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAARICEPT 23 MG TABLET LOWER COST ALTERNATIVES GENERIC DONEPEZIL 20MGARIXTRA SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ARTHROTEC EC LOWER COST ALTERNATIVES DICLOFENAC SODIUM PLUS MISOPROSTOLASTAGRAF XL CAPSULE LOWER COST ALTERNATIVES GENERIC TACROLIMUSATACAND TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORATACAND HCT TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZATELVIA DR 35 MG TABLET LOWER COST ALTERNATIVES GENRIC ALENDRONATEATGAM 50 MG/ML AMPUL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AUBAGIO 14 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

AUBAGIO 7 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

AVALIDE TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZAVANDAMET TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVANDARYL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVANDIA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVAPRO TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORAVAR CLEANSING PADS LOWER COST ALTERNATIVES SULFACETAMIDE/SULFUR CRM, GEL, LOTION, PADS

GENERICAVELOX 400 MG TABLET LOWER COST ALTERNATIVES OFLOXACIN, LEVOFLOXACINAVINZA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVODART 0.5 MG SOFTGEL LOWER COST ALTERNATIVES FINASTERIDE (PROSCAR)AVONEX ADMIN PACK 30 MCG VL


AXERT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEAZASITE 1% EYE DROPS LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTH, ERYTHROMYCIN EYE

OINTMENTAZELEX 20% CREAM LOWER COST ALTERNATIVES CLINDAMYCIN/BENZOYL PEROXIDE GELAZILECT TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AZOR TABLET LOWER COST ALTERNATIVES LOSARTAN PLUS AMLODIPINEBANZEL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


BECONASE AQ 0.042% SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONEBENICAR HCT TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZBENICAR TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORBENZACLIN GEL 35G PUMP LOWER COST ALTERNATIVES CLINDAMYCIN/BENZOYL PEROXIDE GELBENZAMYCINPAK GEL LOWER COST ALTERNATIVES CLINDAMYCIN BENZOYL PEROXIDE GELBENZEFOAM 5.3% EMOLLIENT FO

LOWER COST ALTERNATIVES BENZOYL PEROXIDE

BENZEFOAM ULTRA 9.8% FOAM LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZIQ 5.25% GEL LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZIQ 5.25% WASH LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZOYL PEROXIDE 7% WASH LOWER COST ALTERNATIVES BENZOYL PEROXIDEBEPREVE 1.5% EYE DROPS LOWER COST ALTERNATIVES OPTIVAR, ZADITOR


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIABESIVANCE 0.6% SUSP LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTHBETASERON 0.3 MG KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


BETHKIS 300 MG/4 ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

BILTRICIDE 600 MG TABLET LOWER COST ALTERNATIVES MEBENDAZOLE 100 MG TAB CHEWBLEPHAMIDE EYE DROPS LOWER COST ALTERNATIVES FLUOROMETHOLONE, PREDNISOLONE ACETATEBONIVA 150 MG TABLET LOWER COST ALTERNATIVES GENRIC ALENDRONATEBOSULIF 500 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWB-PLEX TABLET LOWER COST ALTERNATIVES FOLBEE PLUS TABLETBREO ELLIPTA INHALER CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBREVOXYL COMPLETE PACK LOWER COST ALTERNATIVES BENZOYL PEROXIDEBREVOXYL-4 COMPLETE PACK LOWER COST ALTERNATIVES BENZOYL PEROXIDEBREVOXYL-8 COMPLETE PACK LOWER COST ALTERNATIVES BENZOYL PEROXIDEBRILINTA CLINICAL REVIEW REQUIRES CLINICAL REVIEWBRILLINTA TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


BRINTELLIX TABLET LOWER COST ALTERNATIVES SSRI, VENLAFAXINE, BUPROPIONBRISDELLE 7.5 MG CAPSULE LOWER COST ALTERNATIVES PAROXETINE TABLETSBROMDAY 0.09% EYE DROPS LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONBROVANA 15 MCG/2 ML SOLUTIO

CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW

BUPHENYL POWDER LOWER COST ALTERNATIVES BUPHENYL 500 MG TABLETBUTISOL SODIUM 30 MG/5 ML E LOWER COST ALTERNATIVES PHENOBARBITAL TABLETBUTISOL SODIUM TABLET LOWER COST ALTERNATIVES PHENOBARBITAL TABLETBUTRANS 15 MCG/HR PATCH LOWER COST ALTERNATIVES METHADONE, MORPHINE SULF ERBUTRANS PATCH LOWER COST ALTERNATIVES METHADONE, MORPHINE SULFATE ER, KADIANBYDUREON 2MG CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBYETTA DOSE PEN INJ STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICSBYSTOLIC TABLET LOWER COST ALTERNATIVES ATENOLOL, BISOPROLOL, METOPROLOLCADUET TABLET LOWER COST ALTERNATIVES AMLODIPINE PLUS SIMVASTATINCAMBIA 50 MG POWDER PACKET

LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLAC

CAMPRAL DR 333 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCANTIL 25 MG TABLET LOWER COST ALTERNATIVES PROPANTHELINE , GLYCOPYRROLATECAPCOF LIQUID LOWER COST ALTERNATIVES PROMETHAZINE VC-CODEINE SYRCAPRELSA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CARBAGLU 200 MG DISPER TABL


CARDURA XL TABLET LOWER COST ALTERNATIVES DOXAZOSIN, TERAZOSIN, TAMSULOSINCARIMUNE NF 12 GM VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CARIMUNE NF 3 GM VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CARIMUNE NF 6 GM VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIACARISOPRODOL CPD-CODEINE TA

LOWER COST ALTERNATIVES ORPHENADRINE COMP AND COMP-DS TABLETS

CAVAN-EC SOD DHA VITAMINS LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCAVAN-FOLATE DHA COMBO PACK

LOWER COST ALTERNATIVES LACTOCAL-F TABLET

CAVAN-HEME OB TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCAYSTON 75 MG INHAL SOLUTIO


CEDAX TABLETS/SUSPENSION LOWER COST ALTERNATIVES CEFPODOXIME PROXETILCELEBREX CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CENESTIN TABLET LOWER COST ALTERNATIVES PREMARIN, ESTRADIOL TABLETSCEREDASE 80 UNITS/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CEREFOLIN NAC CAPLET LOWER COST ALTERNATIVES FOLIC ACIDCERISA WASH LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN

GELCESAMET 1 MG CAPSULE LOWER COST ALTERNATIVES ONDANSETRON/ODT, GRANISETRONCETRAXAL 0.2% EAR SOLUTION LOWER COST ALTERNATIVES CIPRODEX OTIC SUSPENSIONCHANTIX TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCHENODAL 250 MG TABLET LOWER COST ALTERNATIVES URSODIOL TABLETCHILD DELSYM COUGH+COLD LOWER COST ALTERNATIVES ACETOMINOPHEN, DIPHENHYDRAMINE,

PHENYLEPHRINECHILDREN’S MUCINEX LOWER COST ALTERNATIVES GUAIFENESIN/DEXTROMETHORPHAN SYRUPCICLOPIROX 8 % KIT LOWER COST ALTERNATIVES AUTO APPROVE MEMBER ACTIVECIMZIA 200 MG/ML SYRINGE KI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CIPRO HC OTIC SUSPENSION LOWER COST ALTERNATIVES CIPRODEX OTIC SUSPENSIONCITRANATAL 90 DHA PACK LOWER COST ALTERNATIVES COMPLETE-RF PRENATAL TABLETCITRANATAL ASSURE COMBO PAC

LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRON

CITRANATAL DHA PACK LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCITRANATAL HARMONY CAPSULE

LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMINS

CLARAVIS CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCLARIFOAM EF EMOLLIENT FOAM

LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL

CLARINEX TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINECLARINEX-D TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINECLARIS CLARIFYING WASH LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN

GELCLARITIN REDITABS LOWER COST ALTERNATIVES CETIRIZINE; LORATADINECLIMARA PRO PATCH LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHCLOBEX 0.05% SPRAY LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONECLOBEX 0.05% TOPICAL LOTION

LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

CLODERM 0.1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

CLONAZEPAM 0.25 MG ODT LOWER COST ALTERNATIVES CLONAZEPAM ORAL TABLETSCLONAZEPAM DIS TABLET LOWER COST ALTERNATIVES CLONAZEPAM TABLETS


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIACLONIDINE PATCH LOWER COST ALTERNATIVES CLONIDINE TABLETCLORPRES TABLET LOWER COST ALTERNATIVES CHLORTHALIDONE/CLONIDINE TABSCOCET TABLET LOWER COST ALTERNATIVES ACETAMINOPHEN-COD #2 TABLETCOLCRYS 0.6 MG TABLET STEP THERAPY FAILURE OF NSAID PROPHYLAXISCOLESTID TABLET/GRANULES PACKET

LOWER COST ALTERNATIVES CHOLESTYRAMINE

COLY-MYCIN S EAR DROPS LOWER COST ALTERNATIVES CORTOMYCIN EAR SUSPENSIONCOMETRIQ 100 MG DAILY-DOSE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


COMETRIQ 140 MG DAILY-DOSE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

COMETRIQ 60 MG DAILY-DOSE P CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

COMPLETE NATAL DHA LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCONCEPT DHA CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCONZIP TABLETS LOWER COST ALTERNATIVES TRAMADOL ERCOPAXONE INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


COREG CR CAPSULE LOWER COST ALTERNATIVES CARVEDILOLCORTISPORIN CREAM LOWER COST ALTERNATIVES CORTISPORIN OINTCOSOPT PF LOWER COST ALTERNATIVES DORZOLAMIDE/TIMOLOL OPHTH SOLCOTAB AX TABLET LOWER COST ALTERNATIVES DIMETAPP LONG-ACTING COUGHCOVERA-HS ER 180 MG TABLET LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASECOVERA-HS ER 240 MG TABLET LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASECOVERA-HS MG TABLET LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASECRESTOR TABLET LOWER COST ALTERNATIVES SIMVASTATIN, ATORVASTATINCRINONE 8% GEL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CUBICIN 500 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CUTIVATE 0.05% LOTION LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

CUVPOSA 1 MG/5 ML SOLUTION

LOWER COST ALTERNATIVES GLYCOPYRROLATE TABLETS, GENERIC DONNATAL

CYCLIVERT LOWER COST ALTERNATIVES MECLIZINE, DIPHENHYDRAMINECYCLOPHOSPHAMIDE 500 MG VIA


CYSTADANE POWDER CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CYTOGAM 2.5 GM/50 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

DALIRESP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDAYTRANA PATCH LOWER COST ALTERNATIVES METADATE CD CAPSULEDELZICOL DR 400 MG CAPSULE LOWER COST ALTERNATIVES PENTASA, ASACOL HDDEMECLOCYCLINE TABLET LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAPDEMSER 250 MG CAPSULE LOWER COST ALTERNATIVES PHENTOLAMINE


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIADERMATOP CREAM/ OINTMENT

LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

DESONATE 0.05% GEL LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

DESOWEN 0.05% LOTION KIT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

DESOXYN 5 MG TABLET LOWER COST ALTERNATIVES AMPHETAMINE, DEXTROAMPHETAMINE,DESVENLAFAXINE ER TAB LOWER COST ALTERNATIVES VENLAFAXINE, SSRIDETROL LA CAPSULE LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGDEXILANT DR CAPSULE LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.DEXRAZOXANE 250 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDEXRAZOXANE 500 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIALYVITE 3,000 TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIALYVITE 5000 TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIALYVITE SUPREME D TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIALYVITE WITH ZINC TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIATX ZN TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDICLEGIS DR 10-10 MG TABLET LOWER COST ALTERNATIVES DOXYLAMINE AND PYRIDOXINEDIFICID TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIFIL-G 400 TABLET LOWER COST ALTERNATIVES THEOPHYLLINE TABLETDILATRATE-SR 40 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIOVAN HCT TABLET STEP THERAPY FAILURE ACE INHIBITORDIOVAN TABLET STEP THERAPY FAILURE ACE INHIBITORDIPYRIDAMOLE 5 MG/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIVIGEL 0.25 MG GEL PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHDIVIGEL 0.5 MG GEL PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHDIVIGEL 1 MG GEL PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHDORAL 15 MG TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLON, TEMAZEPAMDORYX DR TABLET LOWER COST ALTERNATIVES DOXYCYCLINE 100MGDOXYCYCLINE HYC DR 75 MG TA

LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAP

DOXYCYCLINE MONO 75 MG CAPS

LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAP

DRONABINOL CAPSULE LOWER COST ALTERNATIVES ONDANSETRON/ODT, GRANISETRONDUET DHA COMPLETE COMBO PAC


DUETACT TABLET LOWER COST ALTERNATIVES SULPHONYLUREA PLUS METFORMINDUEXIS LOWER COST ALTERNATIVES IBUPROFEN AND FAMOTIDINEDULERA INHALER CLINICAL CRITERIA FAILURE OF INHALED STEROID MAX DOSEDURAFLU TABLET LOWER COST ALTERNATIVES COLD MULTI-SYMPTOM CAPLETDUTOPROL LOWER COST ALTERNATIVES METOPROLOL/HCTZDYLIX 100 MG/15 ML ELIXIR LOWER COST ALTERNATIVES THEOPHYLLINE SOLUTIONDYMISTA 137/50 MCG SPRAY LOWER COST ALTERNATIVES LORATADINE PLUS FLUTICASONE OR FLUNISOLIDEDYMISTA LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE NASAL SPRAYDYNACIRC CR TABLET LOWER COST ALTERNATIVES NIFEDIPINE; AMLODIPINEED CHLORPED D PEDIATRIC DRO

LOWER COST ALTERNATIVES RYNATAN PEDIATRIC ORAL SUSP

ED CYTE F TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLEDARBI 40 LOWER COST ALTERNATIVES LOSARTAN, ACE-INHIBITOREDARBI 80 LOWER COST ALTERNATIVES LOSARTAN, ACE-INHIBITOREDARBYCLOR LOWER COST ALTERNATIVES LOSARTAN PLUS HCTZED-FLEX CAPSULE LOWER COST ALTERNATIVES ACETAMINOPHEN WITH CODEINE


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAEDLUAR 10 MG SL TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONEDLUAR 5 MG SL TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONEFFER-K TABLET EFF LOWER COST ALTERNATIVES K-TAB ER 10 MEQ TABLETEFFIENT TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWELESTAT 0.05% EYE DROPS LOWER COST ALTERNATIVES OPTIVAR, ZADITORELESTRIN 0.06% GEL LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHELIDEL 1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEELIQUIS 2.5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWELIQUIS 5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWEMADINE 0.05% EYE DROPS LOWER COST ALTERNATIVES OPTIVAR, ZADITOREMCYT 140 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


EMEND LOWER COST ALTERNATIVES ONDANSETRON/ODT, GRANISETRONEMSAM PATCH LOWER COST ALTERNATIVES SELEGILINE TABLETSENABLEX TABLET LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGENBREL INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


EPIDUO GEL LOWER COST ALTERNATIVES CLINDAMYCIN/BENZOYL PEROXIDE GELEPLERENONE TABLET LOWER COST ALTERNATIVES SPIRONOLACTONEEPOGEN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ERTACZO 2% CREAM LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMESOMEPRAZOLE DR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWESTRADERM PATCH LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHESTRASORB PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHESTRING 2 MG VAGINAL RING LOWER COST ALTERNATIVES USE PREMARIN OR ESTRACE CREAMEVAMIST 1.53 MG/SPRAY LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHEVOCLIN 1% FOAM LOWER COST ALTERNATIVES CLINDAMYCIN BENZOYL PEROXIDE GELEXALGO ER TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWEXELDERM CREAM/ SOLUTION LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMEXELON PATCH LOWER COST ALTERNATIVES RIVASTIGMINE, GALANTAMINE/ER TABLETSEXELON 2 MG/ML ORAL SOLUTIO

LOWER COST ALTERNATIVES RIVASTIGMINE, GALANTAMINE/ER TABLETS

EXFORGE TABLET LOWER COST ALTERNATIVES LOSARTAN PLUS AMLODIPINEEXFORGE HCT TAB LOWER COST ALTERNATIVES LOSARTAN-HCTZ PLUS AMLODIPINEEXJADE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


EXTAVIA 0.3 MG KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

EXTINA 2% FOAM LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMFACTIVE 320 MG TABLET LOWER COST ALTERNATIVES CIPROFLOXACINFABIOR 0.1% FOAM LOWER COST ALTERNATIVES TAZAROTENE CRM/GELFANAPT TABLET LOWER COST ALTERNATIVES RISPERIDONE, GEODON, ZYPREXA, SEROQUELFAZACLO ODT LOWER COST ALTERNATIVES RISPERIDONE, CLOZAPINEFEMECAL OB TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONFEMRING 0.05 MG VAGINAL RIN LOWER COST ALTERNATIVES USE PREMARIN OR ESTRACE CREAMFEMTRACE TABLET LOWER COST ALTERNATIVES PREMARIN, ESTRADIOL TABLETS


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAFENTANYL CITRATE BUCCAL TABLETS


FENTANYL CITRATE OTFC 200 M


FENTANYL PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFENTORA BUCCAL TABL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFERRALET 90 DUAL-IRON TABLE

LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABL

FERRAPLUS 90 TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFERREX 28 TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFERRIPROX TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FETZIMA ER CAPSULE LOWER COST ALTERNATIVES VENLAFAXINE, SSRIFEXMID 7.5 MG TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLETFEXOFENADINE HCL TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEFIBRICOR TABLET LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGFINACEA 15% GEL LOWER COST ALTERNATIVES CLINDAMYCIN, ERYTHROMYCINFINACEA PLUS KIT LOWER COST ALTERNATIVES CLINDAMYCIN GELFIORICET-COD 50-300-40-30 C LOWER COST ALTERNATIVES FIORINAL, FIORICETFIRAZYR SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FLAGYL ER 750 MG TABLET LOWER COST ALTERNATIVES METRONIDAZOLE TAB 500MG &250MGFLEBOGAMMA DIF 5% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FLECTOR 1.3% PATCH LOWER COST ALTERNATIVES USE VOLTAREN GELFLO-PRED LOWER COST ALTERNATIVES PREDNISOLONE SOLUTIONFLO-PRED ORAL SUSPENSION LOWER COST ALTERNATIVES PREDNISOLONE ORAL SOLUTIONFLOVENT INHALER LOWER COST ALTERNATIVES ASMANEX, QVAR, PULMICORT FLEXHALERFLUOR-A-DAY TABLET CHEWABLE

LOWER COST ALTERNATIVES FLUORITAB 1 MG TABLET CHEW, EPIFLUR 0.25, 0.5MG

FLUOXETINE DR 90 MG CAPSULE

LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINE

FLUOXETINE HCL TABLET LOWER COST ALTERNATIVES FLUOXETINE 10MG, 20MG, 40MG TABLETFOCALIN XR CAPSULE LOWER COST ALTERNATIVES METADATE CD CAPSULEFOLAST TABLET LOWER COST ALTERNATIVES FOLIC ACIDFOLCAPS TABLET LOWER COST ALTERNATIVES FOLIC ACIDFOLGARD RX TABLET LOWER COST ALTERNATIVES FOLIC ACIDFOLIVANE-EC CALCIUM DHA COM


FOLIVANE-OB CAPSULE LOWER COST ALTERNATIVES COMPLETE-RF PRENATAL TABLETFOLIVANE-PRX DHA NF CAPSULE


FORTAMET ER TABLET LOWER COST ALTERNATIVES METFORMIN EXTENDED RELEASEFORTEO 600 MCG/2.4 ML PEN I CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FOSAMAX PLUS D LOWER COST ALTERNATIVES GENRIC ALENDRONATE PLUS VIT DFOSRENOL TABLET CHEW LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSFRAGMIN SYRINGE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIAFRESHKOTE EYE DROPS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAFROVA 2.5 MG TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEFULYZAQ 125 MG DR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFUMATINIC ER CAPSULE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFUZEON CONVENIENCE KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FYCOMPA 2 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGABLOFEN 10,000 MCG/20 ML V CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGABLOFEN 40,000 MCG/20 ML V CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGABLOFEN 50 MCG/ML SYRINGE


GAMASTAN S/D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMASTAN S-D VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD LIQUID 10% VIAL


GAMMAGARD S-D 10 GM VL W/ST


GAMMAGARD S-D 2.5 GM VL W/S


GAMMAGARD S-D 5 G (IGA<1) S CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD S-D 5 GM VL W/SET


GAMUNEX 10% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX-C 1 GRAM/10 ML VIAL


GAMUNEX-C 10 GRAM/100 ML VI


GAMUNEX-C 2.5 GRAM/25 ML VI


GAMUNEX-C 20 GRAM/200 ML VI


GAMUNEX-C 5 GRAM/50 ML VIAL


GATTEX VIAL KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GELNIQUE 10% GEL SACHETS LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGGIAZO 1.1 GM TABLET LOWER COST ALTERNATIVES GENERIC BALSALAZIDE, PENTASA, ASACOL HDGILENYA 0.5 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,



DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAGILOTRIF TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


GLEEVEC TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GLUMETZA ER TABLET LOWER COST ALTERNATIVES METFORMIN EXTENDED RELEASEGRALISE LOWER COST ALTERNATIVES GABAPENTINGROWTH HORMONES CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


GUANIDINE HCL 125 MG TABLET


HALOG CREAM/ OINTMENT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

HELIDAC THERAPY LOWER COST ALTERNATIVES PREVPAC PATIENT PACKHEMATOGEN FA SOFTGEL LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMATOGEN SOFTGEL LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMOCYTE PLUS CAPSULE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMOCYTE-F TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMOPHILIA CLOTTING FACTORS


HEPAGAM B VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HEPAGAM B VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HIZENTRA 1 GRAM/5 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



HORIZANT ER TABLET LOWER COST ALTERNATIVES GABAPENTINHUMIRA INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


HYCAMTIN CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HYDROCORT BUTY 0.1% LIPO CR LOWER COST ALTERNATIVES HYDROCORTISONE CREAMHYPERRAB S/D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


HYPERRAB S-D VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HYPERRHO S-D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HYPERRHO S-D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAIBUDONE TABLET LOWER COST ALTERNATIVES HYDROCODONE WITH IBUPROFEN TABLETSILEVRO 0.3% OPHTH DROPS LOWER COST ALTERNATIVES BROMDAY, VOLTAREN OPHTH SOLIMBRUVICA 140 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


IMIQUIMOD 5% CREAM PACKET

LOWER COST ALTERNATIVES REQUEST MUST GO THROUGH CLINICAL REVIEW

IMMUNE GLOBULIN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

INCIVEK CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

INCRELEX 40 MG/4 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

INFANATE BALANCE SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONINFERGEN VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


INLYTA CLINICAL REVIEW REQUIRES CLINICAL REVIEWINNOHEP 20,000 UNIT/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWINNOPRAN XL CAPSULE LOWER COST ALTERNATIVES GENERIC PROPRANOLOL ERINOVA EASY PAD LOWER COST ALTERNATIVES BENZOYL PEROXIDEINTERMEZZO LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONINTRON A INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


INTUNIV ER TABLET LOWER COST ALTERNATIVES GENERIC GUANFACINEINVEGA ER 1.5 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA ER 3 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA ER 6 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA ER 9 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA TABLET LOWER COST ALTERNATIVES RISPERIDONEINVOKANA TABLET CLINICAL REVIEW METFORMIN, PIOGLITAZONE, SULFONYLUREAS,

MEGLITINIDESIOPIDINE 0.5% EYE DROPS LOWER COST ALTERNATIVES ALPHAGAN P 0.15% EYE DROPSIQUIX 1.5% EYE DROPS LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTHIRESSA 250 MG TABLET CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIA, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ISENTRESS 100 MG TABLET CHE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWISRADIPINE CAPSULE LOWER COST ALTERNATIVES NIFEDIPINE; AMLODIPINEISTALOL 0.5% EYE DROPS LOWER COST ALTERNATIVES TIMOPTIC OPHTH SOLUTIONJAKAFI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


JALYN 0.5-0.4 MG CAPSULE LOWER COST ALTERNATIVES FINASTERIDE PLUS TAMSULOSINJANUMET XR CLINICAL REVIEW METFORMIN, SULFONYLUREA,PIOGLITAZONJANUVIA CLINICAL REVIEW MUST HAVE TRIED METFORMIN, SULFONYLUREAS,

PIOGLITAZONEJENTADUETO CLINICAL REVIEW METFORMIN, SULFONYLUREA,PIOGLITAZONJUVISYNC 50-10 MG TABLET CLINICAL REVIEW METFORMIN, SULFONYLUREA,PIOGLITAZONJUVISYNC 50-20 MG TABLET CLINICAL REVIEW METFORMIN, SULFONYLUREA,PIOGLITAZONJUVISYNC 50-40 MG TABLET CLINICAL REVIEW METFORMIN, SULFONYLUREA,PIOGLITAZON


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAJUXTAPID 10 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWJUXTAPID 20 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWKADIAN LOWER COST ALTERNATIVES MORPHINE SULFATE ER 12HR, 24 HR, METHADONEKAPVAY ER 0.1 MG TABLET LOWER COST ALTERNATIVES CLONIDINE (CATAPRES)KAZANO 12.5-1,000 MG TABLET STEP THERAPY USE JANUMET + METFORMINKAZANO 12.5-500 MG TABLET STEP THERAPY USE JANUMET + METFORMINKEFLEX 750 MG CAPSULE LOWER COST ALTERNATIVES CEPHALEXIN 500MGKENALOG AEROSOL SPRAY LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEKEPPRA XR TABLET LOWER COST ALTERNATIVES LEVETIRACETAM TABLETKEROL AD 45% EMULSION LOWER COST ALTERNATIVES UREA 40% CREAM , LOTIONKINERET 100 MG/0.67 ML SYR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


KIONEX 15 GM/60 ML SUSPENSI LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSKOGENATE FS VIAL MEDICATION MUST BE OBTAINED FROM SPECIALTY

PHARMACYKORLYM CLINICAL REVIEW REQUIRES CLINICAL REVIEWK-PHOS #2 TABLET LOWER COST ALTERNATIVES K-PHOS NEUTRAL TABLETK-PHOS M.F. TABLET LOWER COST ALTERNATIVES K-PHOS NEUTRAL TABLETKYNAMRO 200 MG/ML SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLACRISERT 5 MG EYE INSERT LOWER COST ALTERNATIVES ARTIFICIAL TEARSLAMICTAL ODT TABLET LOWER COST ALTERNATIVES LAMOTRIGINE TABLETLAMICTAL XR TABLET LOWER COST ALTERNATIVES LAMOTRIGINE TABLETLAMISIL GRANULES PAC LOWER COST ALTERNATIVES TERBINAFINE HCL 250 MG TABLLANSOPRAZOLE ODT TABLET LOWER COST ALTERNATIVES LANSOPRAZOLE DR CAPSULESLASTACAFT 0.25% EYE DROPS LOWER COST ALTERNATIVES OPTIVAR, ZADITORLATUDA ALL STRENGTHS LOWER COST ALTERNATIVES OLANZAPINE, RISPERIDONE, ZIPRASIDONE LATUDA TABLET LOWER COST ALTERNATIVES OLANZAPINE, RISPERIDONE, ZIPRASIDONELESCOL CAPSULE LOWER COST ALTERNATIVES SIMVASTATIN, ATORVASTATINLESCOL XL 80 MG TABLET LOWER COST ALTERNATIVES SIMVASTATIN, ATORVASTATINLETAIRIS TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


LEUKINE VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

LEVATOL 20 MG TABLET LOWER COST ALTERNATIVES ATENOLOL, BISOPROLOL, METOPROLOLLEVORPHANOL 2 MG TABLET LOWER COST ALTERNATIVES MORPHINE SULFATE, OXYCODONELEXAPRO TABLET/ SOLUTION LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINELIALDA DR TABLET LOWER COST ALTERNATIVES ASACOL EC 400 MG TABLETLIDODERM 5% PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIDOVIR 4%-4% LOWER COST ALTERNATIVES ACYCLOVIR OINTMENTLINDANE LOTION/ SHAMPOO STEP THERAPY FAILURE OF PERMETHRIN/RIDLINZESS 145 MCG CAPSULE LOWER COST ALTERNATIVES LACTULOSE, PEGLINZESS 290 MCG CAPSULE LOWER COST ALTERNATIVES LACTULOSE, PEGLIORESAL IT 0.05 MG/1 ML AM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIORESAL IT 10 MG/20 ML KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIORESAL IT 10 MG/5 ML KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIPOFEN CAPSULE LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGLIPTRUZET TABLET LOWER COST ALTERNATIVES ATORVASTATIN, SIMVASTATINLITHOSTAT 250 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIVALO TABLET LOWER COST ALTERNATIVES SIMVASTATIN


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIALMX 4 PLUS KIT LOWER COST ALTERNATIVES LIDOCAINE OINT, LMX 4 4%CREAMLODOSYN 25 MG TABLET LOWER COST ALTERNATIVES SINEMET CRLOFIBRA LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGLO MINASTRIN FE TABLET CHEW LOWER COST ALTERNATIVES GENERIC ETHINYL ESTRADIOL/ NORETHINDRONELORZONE LOWER COST ALTERNATIVES CHLORZOXAZONE 500MG, TIZANIDINE,

CARISPRODOLLOTRISONE LOWER COST ALTERNATIVES CLOTRIMAZOLE CRM SOLUTION LOTRONEX TABLET STEP THERAPY FAILURE OF METAMUCIL,PSYLLIUM, DICYCLOMINELOVAZA 1 GM CAPSULE LOWER COST ALTERNATIVES GENERIC FISH OIL CAPSULESLOVENOXPREFILLED SYR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLUMIGAN EYE DROPS LOWER COST ALTERNATIVES LATANAPROSTLUMINAL 130 MG/ML CARPUJECT


LUNESTA TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONLUVOX CR CAPSULE LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINELUXIQ 0.12% FOAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONELYRICA CAPSULE LOWER COST ALTERNATIVES GABAPENTINMAGNACET MG TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENMAGNEBIND RX TABLET LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSMARNATAL-F CAPSULE LOWER COST ALTERNATIVES LACTOCAL-F TABLETMAXAIR AUTOHALER 0.2 MG AER

LOWER COST ALTERNATIVES PRO-AIR HFA

MAXALT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEMAXALT MLT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEMAXIDONE 10-750 MG TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENMAXIFED-G CD TABLET LOWER COST ALTERNATIVES GUAIFENESIN-CODEINE SYRUPMAXIFLU CD TABLET LOWER COST ALTERNATIVES PSEUDOEPHEDRINE, ACETOMINOPHEN TABLETSMEBARAL TABLET LOWER COST ALTERNATIVES PHENOBARBITALMEFENAMIC ACID 250 MG CAPSU


MEGACE ES 625 MG/5 ML SUSP LOWER COST ALTERNATIVES MEGESTROL ACET 40 MG/ML SUSMEKINIST TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


M-END PE LIQUID LOWER COST ALTERNATIVES PROMETHAZINE VC-CODEINE SYRMENEST TABLET LOWER COST ALTERNATIVES PREMARIN, ESTRADIOL TABLETSMENTAX 1% CREAM LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMMETANX TABLET LOWER COST ALTERNATIVES FOLIC ACIDMETAXALONE 800 MG TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLETMETOZOLV ODT TABLET LOWER COST ALTERNATIVES METOCLOPRAMIDE, TABLETS, SOLUTIONMICARDIS HCT TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZMICARDIS TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORMILLIPRED DP SOLUTION/ DOSE PACK

LOWER COST ALTERNATIVES PREDNISOLONE

MINASTRIN 24 FE CHEWABLE TA LOWER COST ALTERNATIVES MULTIVITAMIN WITH IRONMIRAPEX ER TABLET LOWER COST ALTERNATIVES PRAMIPEXOLE IMMEDIATE RELEASE TABLETMONUROL 3 GM SACHET LOWER COST ALTERNATIVES CEPHALOSPORIN, CIPROFLOXACINMOTOFEN TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWMOVIPREP POWDER KIT LOWER COST ALTERNATIVES HALFLYTELY-BISACODYL BOWELMOXATAG ER 775 MG TABLET LOWER COST ALTERNATIVES AMOXICILLIN 500 MG TABLETMOXEZA 0.5% EYE DROPS LOWER COST ALTERNATIVES CIPROFLOXACIN 0.3% EYE DROPMUCINEX COLD & SINUS LOWER COST ALTERNATIVES GUAIFENESIN SYRUP


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAMUCINEX COLD-FLU & SORE THROAT

LOWER COST ALTERNATIVES GUAIFENESIN/DEXTROMETHORPHAN/PHENYLEPHRINE

MYCOLOG II LOWER COST ALTERNATIVES NYSTATIN CRM OINTMYTELASE 10 MG CAPLET LOWER COST ALTERNATIVES NEOSTIGMINE, PYRIDOSTIGMINENAFTIN LOWER COST ALTERNATIVES CLOTRIMAZOLE, KETOCONAZOLE TOPICALNAFTIN 1% CREAM/GEL LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMNAFTIN 2% GEL LOWER COST ALTERNATIVES CLOTRIMAZOLE CRM SOLUTION, MICONAZOLE CRMNALFON 200 MG PULVULE LOWER COST ALTERNATIVES FENOPROFEN, OTHER GENERIC NSAIDS, NALFON CAPSULE LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACNAPRELAN CR LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACNASACORT AQ NASAL SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONENASCOBAL 500 MCG NASAL SPRA

LOWER COST ALTERNATIVES CYANOCOBALAMIN 1,000 MCG/ML

NASONEX 50 MCG NASAL SPRAY

LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE

NATACYN EYE DROPS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNATELLE ONE CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNATROBA 0.9% TOPICAL SUSP LOWER COST ALTERNATIVES OVIDE, PERMETHRIN, LICE TREATMENTNEEVO DHA GELCAP LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNEOBENZ MICRO CREAM/ WASH PLUS PAC

LOWER COST ALTERNATIVES BENZOYL PEROXIDE 5% OR 10% LOTION

NEPHPLEX RX TABLET LOWER COST ALTERNATIVES FOLIC ACIDNEPHROCAPS QT TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEPHRON FA TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLNESINA 12.5 MG TABLET STEP THERAPY MUST HAVE TRIED METFORMIN, SULFONYLUREAS,

PIOGLITAZONENESINA 25 MG TABLET STEP THERAPY MUST HAVE TRIED METFORMIN, SULFONYLUREAS,

PIOGLITAZONENESINA 6.25 MG TABLET STEP THERAPY MUST HAVE TRIED METFORMIN, SULFONYLUREAS,

PIOGLITAZONENESTABS ABC PRENATAL COMBO

LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRON

NEULASTA 6 MG/0.6 ML SYRING CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEUMEGA 5 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEUPOGEN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEVANAC 0.1% DROPTAINER LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONNEXA SELECT CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNEXA SELECT SOFTGEL LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNEXAVAR 200 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEXICLON SUSPENSION/ TABLET

LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITOR

NEXICLON XR 0.09 MG/ML SUSP LOWER COST ALTERNATIVES CLONIDINE TABLETSNEXICLON XR 0.17 MG TABLET LOWER COST ALTERNATIVES CLONIDINE TABLETSNEXIUM LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.NEXIUM DR 10 MG PACKET LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.NEXIUM DR 20 MG CAPSULE LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.NEXIUM DR 20 MG PACKET LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.NEXIUM DR 40 MG CAPSULE LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.NEXIUM DR 40 MG PACKET LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.NIASPAN ER TABLET LOWER COST ALTERNATIVES GENERIC ER NIACINNICOTROL CARTRIDGE INHALER


NICOTROL NS 10 MG/ML SPRAY CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIANOROXIN 400 MG TABLET LOWER COST ALTERNATIVES CIPROFLOXACINNOXAFIL 40 MG/ML SUSPENSION

LOWER COST ALTERNATIVES FLUCONAZOLE, ITRACONAZOLE,

NOXAFIL DR 100 MG TABLET LOWER COST ALTERNATIVES ITRACONAZOLE, VORICONAZOLENUCYNTA ER LOWER COST ALTERNATIVES TRAMADOL ERNUCYNTA TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETNUEDEXTA 20-10 MG CAPSULE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIANUOX GEL LOWER COST ALTERNATIVES BENZOYL PEROXIDE 5% OR 10% LOTIONNUVIGIL 150 MG TABLET CLINICAL REVIEW NARCOLEPSY, SLEEP APNEA, HYPERSOMNIANUVIGIL 250 MG TABLET CLINICAL REVIEW NARCOLEPSY, SLEEP APNEA, HYPERSOMNIANUVIGIL 50 MG TABLET CLINICAL REVIEW NARCOLEPSY, SLEEP APNEA, HYPERSOMNIANYDAMAX 0.75% GEL LOWER COST ALTERNATIVES METROLOTION TOPICAL 0.75%,NYMALIZE 60 MG/20 ML SOLUTI LOWER COST ALTERNATIVES NIMODIPINE TABLETSOB COMPLETE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONOB COMPLETE PETITE SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMINSOLEPTRO ER 150 MG TABLET LOWER COST ALTERNATIVES TRAZODONEOLEPTRO ER 300 MG TABLET LOWER COST ALTERNATIVES TRAZODONEOLYSIO 150 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


OMECLAMOX-PAK COMBO PACK 20(20)-500

LOWER COST ALTERNATIVES PREV-PAK

OMEPRAZOLE-BICARB 40-1,100 LOWER COST ALTERNATIVES OMEPRAZOLE; PLUS SODIUM BICARB.OMNARIS 50 MCG NASAL SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONEONFI TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWONGLYZA CLINICAL REVIEW MUST HAVE TRIED METFORMIN, SULFONYLUREAS,

PIOGLITAZONEONMEL 200 MG TABLET LOWER COST ALTERNATIVES ITRACONAZOLE 100 MG TABLETSONSOLIS SOLUBLE FILM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOPANA TABLET LOWER COST ALTERNATIVES OXYMORPHONE TABLETSOPANA ER TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOPIUM TINCTURE 10 MG/ML LOWER COST ALTERNATIVES AUTO APPROVEOPSUMIT 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ORACEA 40 MG CAPSULE LOWER COST ALTERNATIVES DOXYCYCLINE 50MG CAPSULEORAPRED ODT TABLET LOWER COST ALTERNATIVES PREDNISOLONEORAVIG 50 MG BUCCAL TABLET LOWER COST ALTERNATIVES NYSTATIN 100,000 UNITS/ML SORENCIA INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWORENCIA SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ORFADIN CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWORPHENADRINE COMP FORTE TAB

LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLET

ORPHENADRINE COMP TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLETOSENI 12.5-15 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA)

PLUS PIOGLITAZONEOSENI 12.5-30 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA)

PLUS PIOGLITAZONEOSENI 12.5-45 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA)

PLUS PIOGLITAZONE


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAOSENI 25-15 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA)

PLUS PIOGLITAZONEOSENI 25-30 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA)

PLUS PIOGLITAZONEOSENI 25-45 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA)

PLUS PIOGLITAZONEOTREXUP AUTO-INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


OVACE PLUS 10% WASH LOWER COST ALTERNATIVES SODIUM SULFACETAMIDE WASH 10%OXANDROLONE 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXANDROLONE 2.5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXECTA LOWER COST ALTERNATIVES OXYCODONE GENERIC TABLETOXISTAT 1% CREAM/LOTION LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMOXSORALEN 1% LOTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXYTROL FOR WOMEN 3.9 MG/24

LOWER COST ALTERNATIVES OXYBUTYNIN/ER, TROSPIUM TABLETS

OXYCODONE-IBUPROFEN 5-400 T

LOWER COST ALTERNATIVES HYDROCODONE WITH IBUPROFEN TABLETS

OXYCONTIN TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXYMORPHONE HCL ER TAB LOWER COST ALTERNATIVES METHADONE, MORPHINE SULF EROXYTROL 3.9 MG/24HR PATCH LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGPACNEX HP 7% CLEANSING PADS

LOWER COST ALTERNATIVES BENZOYL PEROXIDE SOLUTION

PACNEX LP 4.25% CLEANSING P LOWER COST ALTERNATIVES BENZOYL PEROXIDE SOLUTIONPACNEX MX 4.25% CLEANSER LOWER COST ALTERNATIVES BENZOYL PEROXIDE SOLUTIONPACNEX WASH/PADS LOWER COST ALTERNATIVES BENZOYL PEROXIDE 5% OR 10% LOTIONPAIRE OB PLUS DHA COMBO PAC


PALGIC 4 MG TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEPANDEL 0.1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEPANRETIN 0.1% GEL LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEPARCOPA ODT LOWER COST ALTERNATIVES CARBIDOPA-LEVO 25-250 MG ODTPAROXETINE CR TABLET LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINEPATANASE 0.6% NASAL SPRAY LOWER COST ALTERNATIVES ASTEPRO 0.15% NASAL SPRAYPATANOL 0.1% EYE DROPS LOWER COST ALTERNATIVES KETOTIFENPEDIADERM AF KIT LOWER COST ALTERNATIVES NYSTATIN CREAM, OINTMENTPEDIADERM TOPICAL LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEPEDIPIROX-4 LOWER COST ALTERNATIVES CICLOPIROX 8%/VITAMIN E KITPEGASYS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PEGINTRON INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PENNSAID 1.5% SOLUTION LOWER COST ALTERNATIVES USE VOLTAREN GELPENTAM 300 VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPENTAZOCIN-ACETAMINOPHN LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENPERFOROMIST 20 MCG/2 ML SOLN

LOWER COST ALTERNATIVES FORADIL, SEREVENT

PEXEVA TABLET LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINE


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAPHOSLYRA SOLUTION LOWER COST ALTERNATIVES CALCIUM ACETATE 667MG TABLETPICATO LOWER COST ALTERNATIVES REQUEST MUST GO THROUGH CLINICAL REVIEWPLEXION CLEANSING CLOTHS LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN

GELPNV-DHA PLUS SOFTGEL LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPNV FOLIC ACID + IRON TABLET

LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRON

PNV-IRON TABLET LOWER COST ALTERNATIVES LACTOCAL-F TABLETPOLY IRON PN FORTE TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPOMALYST 1 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOMALYST 2 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOMALYST 3 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOMALYST 4 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOTASSIUM CL 25 MEQ TAB EFF LOWER COST ALTERNATIVES KLOR-CON 25 MEQ PACKETPOTIGA ALL STRENGTHS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPRADAXA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPRANDIMET TABLET LOWER COST ALTERNATIVES SULPHONYLUREA PLUS METFORMINPRASCION RA CREAM LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN

GELPREFERA-OB/ PLUS DHA COMBO P


PREGNYL 10,000 UNITS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PRENACARE TABLET LOWER COST ALTERNATIVES COMPLETE-RF PRENATAL TABLETPRENAISSANCE NEXT LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH MINERALSPRENAISSANCE NEXT-B TABLET LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERICPRENATE AM TABLET LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONPRENATE SOFTGEL LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERICPRENATE SOFTGEL/ TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPRENEXA CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPREQUE 10 TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPRIFTIN 150 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPRIMLEV TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENPRIMSOL 50 MG/5 ML ORAL SOL LOWER COST ALTERNATIVES CEPHALOSPORIN, CIPROFLOXACINPRISTIQ TABLET LOWER COST ALTERNATIVES VENLAFAXINE ER CAPSULESPRIVIGEN 10% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PROBARIMIN QT TABLET LOWER COST ALTERNATIVES MULTIVITAMIN GENERICPROCENTRA 5 MG/5 ML SOLUTIO

LOWER COST ALTERNATIVES AMPHETAMINE, DEXTROAMPHETAMINE, ADDERALL XR

PROCRIT 10,000 UNITS/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY


PROCRIT 20,000 UNITS/ML VIA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAPROCRIT 4,000 UNITS/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PROCRIT 40,000 UNITS/ML VIA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PROLENSA 0.07% EYE DROPS LOWER COST ALTERNATIVES BROMFENAC OPHTH, KETOROLAC OPHTHPROLEUKIN 22 MILLION UNIT V


PROMACTA 12.5MG CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPROMACTA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPROPARACAINE 0.5% EYE DROPS

LOWER COST ALTERNATIVES TETRACAINE OPHTH SOLUTION

PROQUIN XR 500 MG TABLET LOWER COST ALTERNATIVES CIPROFLOXACINPRO-RED AC SYRUP LOWER COST ALTERNATIVES CODEINE, ANTIHISTAMINE, PHENYLEPHRINE

COMBINATIONPROSED-DS TABLET LOWER COST ALTERNATIVES URELLE TABLETPROTONIX 40 MG SUSPENSION LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.PROTOPIC OINTMENT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEPROVENTIL HFA 90 MCG INHALE

LOWER COST ALTERNATIVES PROAIR HFA 90 MCG INHALER

PROVIDA OB CAPSULE LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONPROVIGIL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPULMOZYME AMPUL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPV VITAMIN D 400 UNIT TABLET LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERIC PYLERA CAPSULE LOWER COST ALTERNATIVES PREVPAC PATIENT PACKQNASL 80 MCG LOWER COST ALTERNATIVES FLUTICASONE, FLUNISOLIDE NASAL SPRAYQUARTETTE TABLET LOWER COST ALTERNATIVES EE/LEVONORGESTREL GENERICQUILLIVANT XR 25 MG/5 ML SU LOWER COST ALTERNATIVES GENERIC METHYLPHENIDATE WITH SPRINKLE

CAPABILITY (METADATE CD)QUIXIN 0.5% EYE DROPS LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTHRAPAFLO CAPSULE LOWER COST ALTERNATIVES TAMSULOSIN, TERAZOSIN AND DOXAZOSIN.REBETOL 40 MG/ML SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


REBIF REBIDOSE 22 MCG/0.5 M CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REBIF REBIDOSE 44 MCG/0.5 M CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REBIF REBIDOSE TITRATION PA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REBIF SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RECTIV LOWER COST ALTERNATIVES ANUSOL HC OINTMENTREGRANEX 0.01% GEL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWRELPAX TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEREMICADE 100 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,



DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAREMODULIN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


RENAGEL TABLET LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSRENVELA POWDER/TABLET LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSREPREXAIN TABLET LOWER COST ALTERNATIVES HYDROCODONE WITH IBUPROFEN TABLETSREQUIP XL TABLET LOWER COST ALTERNATIVES REQUIP IMMEDIATE RELEASE TABLETRESCULA 0.15% EYE DROPS LOWER COST ALTERNATIVES LATANOPROST OPHTH SOLUTIONREVATIO INJECTION AND TABLETS


REVLIMID 20 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REVLIMID CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWRHINARIS NASAL GEL LOWER COST ALTERNATIVES SODIUM CHLORIDE NASAL SOLUTIONRHINOCORT AQUA NASAL SPRAY

LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE

RHOPHYLAC 300 MCG/2 ML SYR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIBAPAK CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIBASPHERE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIBAVIRIN CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIFAMATE CAPSULE LOWER COST ALTERNATIVES RIFAMPIN 300 MG PLUS ISONIAZIDRILUTEK 50 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


RITALIN LA CAPSULE LOWER COST ALTERNATIVES METADATE CD CAPSULERITUXAN 10 MG/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


RIXUBIS INFUSION MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACYROVIN-A DHA LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH MINERALSROVIN-NV DHA CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONROZEREM TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONRYBIX ODT 50 MG TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETRYNATAN PEDIATRIC CHEWABLE

LOWER COST ALTERNATIVES RYNATAN PEDIATRIC ORAL SUSP

RYZOLT ER TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETSABRIL 500 MG TABLET\ POWDER

CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA

SAIZEN 5 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SAIZEN 8.8 MG CLICK.EASY CA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SAIZEN 8.8 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIASALKERA 6% FOAM LOWER COST ALTERNATIVES SALICYLIC ACID 6% LOTION KISAMSCA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSANCTURA 20 MG TABLET STEP THERAPY FAILURE OXYBUTYNIN/ERSANCTURA XR 60 MG CAPSULE LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGSANCUSO 3.1 MG/24 HR PATCH LOWER COST ALTERNATIVES ONDANSETRON/ODT, GRANISETRONSAPHRIS TABLET SUBLING LOWER COST ALTERNATIVES RISPERIDONE, GEODON, ZYPREXA, SEROQUELSAVELLA TABLET LOWER COST ALTERNATIVES GABAPENTINSCOPACE 0.4 MG TABLET LOWER COST ALTERNATIVES MECLIZINE TABLETSEA-OMEGA CAPSULE LOWER COST ALTERNATIVES GENERIC FISH OIL CAPSULESSE-CARE TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONSENSIPAR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSEROMYCIN 250 MG CAPSULE LOWER COST ALTERNATIVES RIFAMPIN 300 MG PLUS ISONIAZIDSEROQUEL XR LOWER COST ALTERNATIVES GENERIC QUETIAPINE IRSEROSTIM INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SE-TAN CAPSULE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLSIGNIFOR 0.3 MG/ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSIGNIFOR 0.6 MG/ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSIGNIFOR 0.9 MG/ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSILENOR TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLON, TEMAZEPAMSIMBRINZA 1%-0.2% EYE DROPS LOWER COST ALTERNATIVES DORZOLAMIDE/TIMOLOL OPHTHSIMCOR TABLET LOWER COST ALTERNATIVES NIACIN PLUS SIMVASTATINSIMPONI 50 MG/ML SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SIMPONI INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SINGULAIR TAB/GRAN/CHEW STEP THERAPY FAILURE OF INHALED STEROIDSINUS RELIEF CONGESTION & PAIN

LOWER COST ALTERNATIVES OTC DECONGESTANT/ACETOMINOPHEN

SIRTURO 100 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSKELID 200 MG TABLET LOWER COST ALTERNATIVES GENRIC ALENDRONATESOLARAZE 3% GEL CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIASOLODYN ER TABLET LOWER COST ALTERNATIVES MINOCYCLINE 75MG, 100 MG CAPSULESOMA 250 MG TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLETSOMAVERT INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SORIATANE CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSORILUX 0.005% FOAM LOWER COST ALTERNATIVES DOVONEX OINT, CREAMSOVALDI 400 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SPECTRACEF DOSE PACK LOWER COST ALTERNATIVES CEFPODOXIME PROXETILSPIRIVA INHALER LOWER COST ALTERNATIVES TUDORZA INHALERSPORANOX 10 MG/ML SOLUTION

LOWER COST ALTERNATIVES FLUCONAZOLE 10 MG/ML SUSP

SPRYCEL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

STAVZOR DR CAPSULE LOWER COST ALTERNATIVES DEPAKOTE ER 500 MG TABLET


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIASTIMATE 1.5 MG/ML NASAL SPR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSTIVARGA 40 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


STRATTERA CAPSULE STEP THERAPY FAILURE OF METHYLPHENIDATE, AMPHETAMINE PRODUCT

STRIANT 30 MG MUCOADHESIVE

CLINICAL/STEP REQUEST MUST GO THROUGH CLINICAL REVIEW, REQUIRES LAB VALUES

STRIBILD TABLETS ALL STRENGTHS


SUBOXONE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSUBOXONE 12 MG-3 MG SL FILM


SUBOXONE 4 MG-1 MG SL FILM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSUBSYS LOWER COST ALTERNATIVES FENTANYL SOLUTION MORPHINE SULFATE

SOLUTIONSUCRAID 8,500 UNITS/ML SOLN CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSULFAMYLON POWDER PACKET

LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL

SUMADAN LOWER COST ALTERNATIVES SULFACETAMIDE SOLUTIONSUMADAN LOWER COST ALTERNATIVES SULFACETAMIDE TOPICAL LOTIONSUMADAN LOTION LOWER COST ALTERNATIVES SULFACETAMIDE SODIUM LOTIONSUMAVEL DOSEPRO 6 MG/0.5 ML

LOWER COST ALTERNATIVES SUMATRIPTAN INJECTION, TABLETS

SUMAXIN CP LOWER COST ALTERNATIVES SULFACETAMIDE TOPICAL LOTIONSUMAXIN PADS/WASH LOWER COST ALTERNATIVES CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN

GELSUMAXIN TS TOPICAL SUSPENSI

LOWER COST ALTERNATIVES SULFACETAMIDE SOLUTION

SUPRAX SUSPENSION LOWER COST ALTERNATIVES CEFPODOXIME PROXETILSUPRAX 100 MG TABLET CHEWABLE

LOWER COST ALTERNATIVES GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME)

SUPRAX 200 MG TABLET CHEWABLE

LOWER COST ALTERNATIVES GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME)

SUPRAX 400 MG TABLET LOWER COST ALTERNATIVES CEFPODOXIME PROXETILSUPRAX CAPSULE, SUSPENSION LOWER COST ALTERNATIVES CEFPODOXIME SUSPENSION/CAPSULESSUPREP BOWEL PREP KIT LOWER COST ALTERNATIVES HALFLYTELY-BISACODYL BOWELSUTENT CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SYLATRON CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SYMBICORT INHALER CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYMBYAX CAPSULE LOWER COST ALTERNATIVES ZYPREXA PLUS FLUOXETINESYMLIN 0.6 MG/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYMLINPEN PEN/VIAL STEP THERAPY FAILURE OF INSULIN THERAPYSYNAGIS INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SYNALGOS-DC CAPSULE LOWER COST ALTERNATIVES CODEINE WITH ACETOMINOPHEN,SYNAREL 2 MG/ML NASAL SPRAY


SYNERCID 500 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYPRINE 250 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIATAFINLAR CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TARCEVA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TARON EC CALCIUM DHA COMB P


TARON-DUO EC COMB PACK LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTARON-EC CAL TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTARON-PREX PRENATAL DHA CAP


TASIGNA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TECFIDERA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TEKAMLO TABLET STEP THERAPY FAILURE ACE/ARBTEKTURNA HCT TABLET STEP THERAPY FAILURE ACE/ARBTEKTURNA TABLET STEP THERAPY FAILURE ACE/ARBTEMODAR CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TEVETEN HCT TAB LOWER COST ALTERNATIVES LOSARTAN-HCTZTEVETEN TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORTEV-TROPIN 5 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


THALOMID CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

THEROBEC TABLET LOWER COST ALTERNATIVES FOLBEE PLUSTINDAMAX TABLET LOWER COST ALTERNATIVES METRONIDAZOLE 250 MG TABLETTIROSINT CAPSULE LOWER COST ALTERNATIVES GENERIC LEVOTHYROXINETL-ASSURE + DHA LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH MINERALSTL-SELECT DHA SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMINSTOBI PODHALER 28 MG INHALE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TOBI PODHALER INHALER CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TOLMETIN SODIUM 600 MG TAB


TOPICORT 0.25% SPRAY LOWER COST ALTERNATIVES BETAMETHASONE CRM/LOT, DESOXIMETASONE CRMTOVIAZ ER TABLET LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGTRACLEER TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TRADJENTA TABLET CLINICAL REVIEW MUST HAVE TRIED METFORMIN, SULFONYLUREAS, PIOGLITAZONE

TRAVATAN Z 0.004% EYE DROP LOWER COST ALTERNATIVES LATANAPROSTTRAVOPROST 0.004% EYE DROP LOWER COST ALTERNATIVES LATANOPROST OPHTH SOLTREXIMET 85-500 MG TABLET LOWER COST ALTERNATIVES SUMATRIPTAN AND NAPROXEN TABLETS


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIATRIAZ PAD/FOAM LOWER COST ALTERNATIVES TRIAZ CLEANSERTRIBENZOR TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZ PLUS AMLODIPINETRICARE PRENATAL COMPLEAT P

LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERIC IN WITH IRON

TRICARE PRENATAL TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTRICOR TABLET LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGTRIGLIDE TABLET LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGTRILIPIX DR CAPSULE LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54MG OR 160MGTRI-LUMA CREAM LOWER COST ALTERNATIVES RETIN A CREAM/GELTRIMESIS RX TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTRI-TABS DHA COMBO PACK LOWER COST ALTERNATIVES PRENATAL VITAMIN WITH IRONTROKENDI XR CAPSULE LOWER COST ALTERNATIVES TOPIRAMATETUSSIONEX PENNKINETIC SUSP LOWER COST ALTERNATIVES HYDROCODONE-HOMATROPINE SYRTWINJECT AUTO-INJECT LOWER COST ALTERNATIVES EPI PEN, EPI PEN JRTWYNSTA TABLET LOWER COST ALTERNATIVES LOSARTAN PLUS AMLODIPINETYGACIL 50 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TYKERB TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TYVASO INHALATION SOLUTION


TYZINE NOSE DROPS/ SPRAY LOWER COST ALTERNATIVES NOSE DROPS 1%, AFRIN NASAL SPRAYTYZINE PEDIATRIC 0.05% DROP LOWER COST ALTERNATIVES OXYMETOLAZINE NASAL SPRAYULESFIA 5% LOTION STEP THERAPY FAILURE OF PERMETHRIN AND RID AND

MALATHIONULORIC TABLET LOWER COST ALTERNATIVES ALLOPURINOL TABLETULTRACET TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLET AND ACETAMINOPHEN

TABULTRAM ER TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETULTRAVATE 0.05% CR/OINT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEULTRESA DR 20,700 UNIT CAPS LOWER COST ALTERNATIVES CREON, ZENPEP, PANCREAZEULTRESA DR 23,000 UNIT CAPS LOWER COST ALTERNATIVES CREON, ZENPEP, PANCREAZEUREA LOTION/GEL LOWER COST ALTERNATIVES UREA 40% CREAM , LOTIONUROQID-ACID NO.2 500-500 TB LOWER COST ALTERNATIVES K-PHOS NEUTRAL TABLETUROXATRAL 10 MG TABLET LOWER COST ALTERNATIVES TAMSULOSIN, TERAZOSIN AND DOXAZOSIN.VAGIFEM 10 MCG VAGINAL TAB LOWER COST ALTERNATIVES USE PREMARIN OR ESTRACE CREAMVALCHLOR 0.016% GEL LOWER COST ALTERNATIVES HP STEROID CREAMVALTURNA TABLET STEP THERAPY FAILURE ACE/ARBVANOS 0.1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEVASCEPA 1 GM CAPSULE LOWER COST ALTERNATIVES FENOFIBRATE 54 MG OR 160 MG, NIACIN ER. ONLY

USED TO TREAT TRIGLYERIDE >500VECAMYL TABLET LOWER COST ALTERNATIVES METHYLPHENIDATE, CLONIDINE, PERGOLIDE VELETRI INFUSION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VENTAVIS SOLUTI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

VERAMYST 27.5 MCG NASAL SPR LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAVEREGEN 15% OINTMENT LOWER COST ALTERNATIVES REQUEST MUST GO THROUGH CLINICAL REVIEWVERELAN PM CAP PELLE LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASEVERSACLOZ 50 MG/ML SUSPENSI

LOWER COST ALTERNATIVES CLOZAPINE GENERIC

VESICARE TABLET LOWER COST ALTERNATIVES OXYBUTYNIN/XL,TROSPIUM 20MGVFEND TABLET/SUSPENSION LOWER COST ALTERNATIVES FLUCONAZOLE, ITRACONAZOLE,VICTOZA INJECTION STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICSVICTRELIS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VIGAMOX 0.5% EYE DROPS LOWER COST ALTERNATIVES OFLOXACIN, LEVOFLOXACIN OPHTH DROPSVIIBRYD LOWER COST ALTERNATIVES SSRI, VENLAFAXINE, BUPROPIONVIIBRYD ALL STRENGTHS LOWER COST ALTERNATIVES GENERIC SSRI, GENERIC SNRI, BUPROPIONVIMOVO TABLET LOWER COST ALTERNATIVES OMEPRAZOLE PLUS NAPROXENVIRAMUNE XR 100 MG TABLET LOWER COST ALTERNATIVES GENERIC IR AVAILABLEVISICOL TABLET LOWER COST ALTERNATIVES HALFLYTELY-BISACODYL BOWELVITAFOL ULTRA SOFTGEL LOWER COST ALTERNATIVES MULTIVITAMIN WITH IRONVIVAGLOBIN 16% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VIVELLE-DOT PATCH LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHVOTRIENT 200 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWVUSION OINTMENT LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMVYTORIN TABLET LOWER COST ALTERNATIVES SIMVASTATINVYVANSE CAPSULE LOWER COST ALTERNATIVES AMPHETAMINE, DEXTROAMPHETAMINE, ADDERALL

XRWELCHOL TABLET/PACKET LOWER COST ALTERNATIVES CHOLESTYRAMINEWINRHO SDF 1,500 UNITS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


WINRHO SDF 15,000 UNITS VIA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

WINRHO SDF 2,500 UNITS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

WINRHO SDF 5,000 UNITS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

XARELTO TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXALKORI CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


XELJANZ 5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

XELODA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

XENAZINE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXERESE 5%-1% CREAM LOWER COST ALTERNATIVES ZOVIRAX CREAMXIBROM 0.09% EYE DROPS LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONXIFAXAN TABLET LOWER COST ALTERNATIVES NEOMYCIN 500 MG TABLETXODOL TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENXOLEGEL 2% GEL LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAM


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAXOLOX 10-500 MG TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENXOPENEX CONC 1.25 MG/0.5 ML LOWER COST ALTERNATIVES ALBUTEROL NEBULIZER SOLUTIONXOPENEX HFA 45 MCG INHALER

LOWER COST ALTERNATIVES PROAIR HFA 90 MCG INHALER

XOPENEX INHAL SOLUTION LOWER COST ALTERNATIVES ALBUTEROL NEBULIZER SOLUTIONXTANDI 40 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXYREM 500 MG/ML ORAL SOLUTI

CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA

XYZAL TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEZAMICET SOLUTION LOWER COST ALTERNATIVES HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIRZANAFLEX CAPSULE LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLETZATEAN CAPSULE LOWER COST ALTERNATIVES PRENATAL PLUS IRON TABLETZAVESCA 100 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZEGERID OTC 20-1,100 MG CAP LOWER COST ALTERNATIVES OMEPRAZOLE; PLUS SODIUM BICARB.ZELBORAF TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZENZEDI TABLET LOWER COST ALTERNATIVES METHYLPHENIDATE, AMPHETAMINEZETIA 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZETONNA LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE NASAL SPRAYZETONNA NASAL AEROSOL LOWER COST ALTERNATIVES FLUTICASONE, FLUNISOLIDE NASAL SPRAYZIANA GEL LOWER COST ALTERNATIVES CLINDAMYCIN/BENZOYL PEROXIDE GELZIOPTAN LOWER COST ALTERNATIVES LATANOPROST OPHTH SOLZIOPTAN OPHTH SOL LOWER COST ALTERNATIVES LATANAPROST OPHTH SOLUTION ZIPSOR 25 MG CAPSULE LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACZIRGAN 0.15% OPHTHALMIC GEL

LOWER COST ALTERNATIVES VIROPTIC 1% EYE DROPS

ZIRGAN OPHTH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZOLINZA 100 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZOLPIDEM TART ER TABLET LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONZOLPIMIST 5 MG ORAL SPRAY LOWER COST ALTERNATIVES ZOLPIDEM, ZALEPLONZOLVIT 10 MG-300 MG/15 ML S LOWER COST ALTERNATIVES HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIRZOMIG 2.5 MG NASAL SPRAY LOWER COST ALTERNATIVES SUMATRIPTAN TAB/NASAL SPRAY, NARATRIPTAN TABZOMIG 5 MG NASAL SPRAY LOWER COST ALTERNATIVES SUMATRIPTAN, NARATRIPTANZOMIG TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEZOMIG ZMT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEZONALON 5% CREAM LOWER COST ALTERNATIVES HYDROCORTISONE CREAM 1%ZONATUSS LOWER COST ALTERNATIVES BENZONATATE CAPSULE 100MG OR 200MGZORBTIVE 8.8 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZORVOLEX CAPSULE LOWER COST ALTERNATIVES DICLOFENAC, NSAIDZOVIRAX OINTMENT, CREAM LOWER COST ALTERNATIVES ABREVA, ORAL ACYCLOVIRZUBSOLV TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZUPLENZ SOLUBLE FILM LOWER COST ALTERNATIVES ONDANSETRON ODT TABLETZYCLARA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZYCLARA 3.75% CREAM LOWER COST ALTERNATIVES IMIQUIMOD CREAM 5%ZYDONE TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENZYFLO 600 MG FILMTAB STEP THERAPY FAILURE OF INHALED STEROIDZYFLO CR 600 MG TABLET STEP THERAPY FAILURE OF INHALED STEROIDZYMAXID 0.5% EYE DROPS LOWER COST ALTERNATIVES CIPROFLOXACIN 0.3% EYE DROP


DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIAZYTIGA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZYVOX TABLET/SUSP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW


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