Prior Quantity Step NAME GENERIC NAME Authorization Limit ...
Transcript of Prior Quantity Step NAME GENERIC NAME Authorization Limit ...
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 ABACAVIR SULFATE ABACAVIR SULFATE X
1 ABACAVIR SULFATE/LAMIVUDINE ABACAVIR SULFATE/LAMIVUDINE X
1 ABACAVIR/LAMIVUDINE/ZIDOVUDINE ABACAVIR/LAMIVUDINE/ZIDOVUDINE X
2 ABILIFY ARIPIPRAZOLE X X
Excluded ABRSTRAL
3 ABSORICA ISOTRETINOIN X
1 ACAMPROSATE CALCIUM ACAMPROSATE CALCIUM
3 ACANYA CLINDAMYCIN PHOS/BENZOYL PEROX X
1 ACARBOSE TABLET ACARBOSE
3 ACCOLATE ZAFIRLUKAST
Excluded ACCUCAINE
3 ACCU‐CHEK INSULIN PUMP/INFUS. SET/METER
3 ACCU‐CHEK RAPID D SUB‐Q ADMINISTRATION SET
3 ACCU‐CHEK SPIRIT SUB‐Q INFUSION PUMP ACCESSORY
2 ACCUPRIL QUINAPRIL HCL
2 ACCURETIC QUINAPRIL/HYDROCHLOROTHIAZIDE
3 ACD DEXTROSE/SOD CITRATE/CITRIC AC
3 ACD‐A CITRATE DEXTROSE SOLUTION
3 ACE AEROSOL CLOUD ENHANCER INHALER, ASSIST DEVICES
1 ACEBUTOLOL HCL ACEBUTOLOL HCL
1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE X
1 ACETAMINOPHEN/CAFF/DIHYDROCOD ACETAMINOPHEN/CAFF/DIHYDROCOD X
1 ACETAZOLAMIDE ER 500MG CAPSULE ACETAZOLAMIDE
1 ACETAZOLAMIDE IR TABLET ACETAZOLAMIDE
1 ACETIC ACID/ALUMINUM ACETATE ACETIC ACID/ALUMINUM ACETATE
2 ACETIC ACID/HYDROCORTISONE 2%‐1% DROPS ACETIC ACID
1 ACETYLCYSTEINE ACETYLCYSTEINE
1 ACETYLCYSTEINE IN WATER/PF ACETYLCYSTEINE IN WATER/PF
3 ACIPHEX RABEPRAZOLE SODIUM X X
3 ACIPHEX SPRINKLE RABEPRAZOLE SODIUM X
3 ACTEMRA TOCILIZUMAB X
Excluded ACTHAR ADRENCORTICOTROPIC HORMONE
3 ACTICLATE DOXYCYCLINE HYCLATE X X
3 ACTICOAT SILVER
3 ACTICOAT 7 SILVER
3 ACTICOAT FLEX 3 SILVER
3 ACTICOAT FLEX 7 SILVER
3 ACTICOAT SURGICAL SILVER/FOAM BANDAGE
2 ACTIGALL URSODIOL
2 ACTIQ FENTANYL CITRATE X X
3 ACTIVE FE IRON,CARBONYL/FOLIC ACID/MV‐MN
3 ACTIVELLA ESTRADIOL/NORETHINDRONE ACET
Excluded ACTIVE‐PAC KIT
3 ACTONEL RISEDRONATE SODIUM X X
2 ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL X
2 ACTOPLUS MET XR PIOGLITAZONE HCL/METFORMIN HCL X
2 ACTOS PIOGLITAZONE HCL
3 ACUICYN HYPOCHLOROUS ACID/SODIUM CHLOR
2 ACULAR KETOROLAC TROMETHAMINE
2 ACULAR LS KETOROLAC TROMETHAMINE
3 ACUVAIL KETOROLAC TROMETHAMINE/PF
1 ACYCLOVIR ACYCLOVIR
3 ACZONE DAPSONE
2 ADALAT CC (30 MG) TABLET ER NIFEDIPINE
3 ADALAT CC (60, 90 MG) TABLET ER NIFEDIPINE
1 ADAPALENE (0.1 %) CREAM ADAPALENE
2 ADAPALENE (0.1 %) LOTION ADAPALENE
2 ADAPALENE (0.3 %) GEL ADAPALENE
3 ADASUVE LOXAPINE
3 ADAZIN LIDOCAINE/BENZOCAIN/ME‐SAL/CAP
1 ADDERALL XR (5, 10, 15, 20, 25, 30 MG) CAP ER 24H DEXTROAMPHETAMINE/AMPHETAMINE X
3 ADDYI FLIBANSERIN X X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 ADENOVIRUS TYPE 4 ADENOVIRUS VACCINE LIVE TYPE‐4
3 ADENOVIRUS TYPE 4 AND TYPE 7 ADENOVIRUS LIVE TYPES‐4,7 VACC
3 ADENOVIRUS TYPE 7 ADENOVIRUS VACCINE LIVE TYPE‐7
Excluded ADLYXIN
3 ADRENACLICK EPINEPHRINE
3 ADRENALIN CHLORIDE EPINEPHRINE HCL
2 ADVAIR DISKUS FLUTICASONE/SALMETEROL X
2 ADVAIR HFA FLUTICASONE/SALMETEROL X
3 ADVANCE PLUS INTERMITTENT CATHETER
3 ADVICOR X X
Excluded ADZEBYS XR ODT
3 AEROBIKA MUCUS CLEARING DEVICE
3 AEROCHAMBER MINI INHALER, ASSIST DEVICES
3 AEROCHAMBER MV INHALER, ASSIST DEVICES
3 AEROCHAMBER PLUS FLOW‐VU INHALER, ASSIST DEVICES
3 AEROCHAMBER PLUS Z STAT INHALER, ASSIST DEVICES
3 AEROCHAMBER WITH FLOWSIGNAL INHALER, ASSIST DEVICES
3 AEROCHAMBER Z‐STAT PLUS INHALER, ASSIST DEVICES
3 AEROECLIPSE NEBULIZER
3 AEROECLIPSE II NEBULIZER
3 AEROGEAR ASTHMA ACTION KIT PEAK FLOW METER/INH ASSIT DEV
3 AERONEB GO NEBULIZER ACCESSORIES
3 AERONEB GO NEBULIZER NEBULIZER
3 AEROSPAN FLUNISOLIDE X X
3 AEROTRACH PLUS INHALER, ASSIST DEVICES
3 AEROVENT PLUS INHALER, ASSIST DEVICES
3 AFREZZA INSULIN REGULAR, HUMAN X X
3 AGGRENOX ASPIRIN/DIPYRIDAMOLE
3 AKTEN LIDOCAINE HCL/PF
2 AKYNZEO NETUPITANT/PALONOSETRON HCL X
3 ALA‐QUIN CLIOQUINOL/HYDROCORTISONE
3 ALBENZA ALBENDAZOLE
1 ALBUTEROL INHALTION SOLUTION ALBUTEROL
1 ALBUTEROL/IPRATOPIUM ALBUTERAL/IPRATROPIUM
1 ALCLOMETASONE DIPROPIONATE 0.05% CREAM (LOW) ALCLOMETASONE DIPROPIONATE
Excluded ALCORTIN A HYDROCORTISONE/IODOQUIN/ALOE 2
3 ALDACTAZIDE SPIRONOLACT/HYDROCHLOROTHIAZID
2 ALDACTONE SPIRONOLACTONE
2 ALDARA IMIQUIMOD X X
1 ALENDRONATE ALENDRONATE X
3 ALEVICYN ANTIPRURITIC SG EMOLLIENT COMBINATION NO.60
3 ALEVICYN PLUS E101/NAMG FL/NA PH/NACL/HA‐NAH
1 ALFUZOSIN HCL ALFUZOSIN HCL
3 ALINIA NITAZOXANIDE
2 ALKERAN MELPHALAN
3 ALL FLOW 1000 NEBULIZER ACCESSORIES
3 ALL FLOW 3000 KIT NEBULIZER ACCESSORIES
3 ALL FLOW 3000 PFT NEBULIZER ACCESSORIES
3 ALL FLOW 4000, 5000, 6000 NEBULIZER ACCESSORIES
3 ALLEVYN FOAM BANDAGE
3 ALLEVYN ADHESIVE FOAM BANDAGE
3 ALLEVYN AG SILVER SULFADIAZ/FOAM BANDAGE
3 ALLEVYN AG ADHESIVE SILVER SULFADIAZ/FOAM BANDAGE
3 ALLEVYN AG GENTLE SILVER SULFADIAZ/FOAM BANDAGE
3 ALLEVYN HEEL FOAM BANDAGE
3 ALLEVYN LIFE FOAM BANDAGE
1 ALLOPURINOL ALLOPURINOL
Excluded ALLZITAL
2 ALMOTRIPTAN MALATE TABLET ALMOTRIPTAN MALATE
2 ALOCRIL NEDOCROMIL SODIUM
2 ALOMIDE LODOXAMIDE TROMETHAMINE
3 ALOQUIN IODOQUINOL/ALOE P‐SACCHARIDE 1
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 ALORA ESTRADIOL X
2 ALOSETRON HCL (0.5 MG) TABLET ALOSETRON HCL
1 ALOSETRON HCL (1 MG) TABLET ALOSETRON HCL
2 ALPHAGAN P BRIMONIDINE TARTRATE
1 ALPRAZOLAM (0.5 MG) TAB ER 24H ALPRAZOLAM
2 ALPRAZOLAM (0.5 MG) TAB RAPDIS ALPRAZOLAM
1 ALPRAZOLAM (1 MG) TAB ER 24H ALPRAZOLAM
2 ALPRAZOLAM (1 MG) TAB RAPDIS ALPRAZOLAM
1 ALPRAZOLAM (2 MG) TAB ER 24H ALPRAZOLAM
2 ALPRAZOLAM (2 MG) TAB RAPDIS ALPRAZOLAM
1 ALPRAZOLAM (3 MG) TAB ER 24H ALPRAZOLAM
2 ALPRAZOLAM INTENSOL ALPRAZOLAM
2 ALPRAZOLAM ODT ALPRAZOLAM
3 ALPROLIX Factor IX X X
2 ALREX LOTEPREDNOL ETABONATE
3 ALSUMA SUMATRIPTAN SUCCINATE X
3 ALTABAX RETAPAMULIN
2 ALTACE RAMIPRIL
3 ALTERA NEBULIZER NEBULIZER
Excluded ALTOPREV
Excluded ALVESCO
1 AMANTADINE HCL AMANTADINE HCL
2 AMARYL GLIMEPIRIDE
2 AMBIEN ZOLPIDEM TARTRATE X
2 AMBIEN CR ZOLPIDEM TARTRATE X
2 AMCINONIDE 0.1% CREAM (HIGH) AMCINONIDE
2 AMCINONIDE 0.1% LOTION (HIGH) AMCINONIDE
2 AMCINONIDE 0.1% OINTMENT (HIGH) AMCINONIDE
3 AMELUZ AMINOLEVULINIC ACID HCL
2 AMERGE NARATRIPTAN HCL X
3 AMETHYST LEVONORGESTREL‐ETHIN ESTRADIOL X
3 AMICAR AMINOCAPROIC ACID
3 AMIELLE VAGINAL TRAINER MEDICAL SUPPLY, MISCELLANEOUS
1 AMILORIDE HCL AMILORIDE HCL
1 AMILORIDE/HYDROCHLOROTHIAZIDE AMILORIDE/HYDROCHLOROTHIAZIDE
3 AMINOACETIC ACID GLYCINE UROLOGIC SOLUTION
1 AMIODARONE HCL AMIODARONE HCL
3 AMITIZA LUBIPROSTONE X X
1 AMITRIPTYLINE TABLET AMITRIPTYLINE
2 AMITRIPTYLINE/CHLORDIAZEPOXIDE (12.5MG‐5MG) TABLET AMITRIPTYLINE/CHLORDIAZEPOXIDE
1 AMITRIPTYLINE/CHLORDIAZEPOXIDE (25 MG‐10MG) TABLET AMITRIPTYLINE/CHLORDIAZEPOXIDE
1 AMLODIPINE TABLET AMLODIPINE
1 AMLODIPINE TABLET & ATORVASTATIN TABLET AMLODIPINE & ATORVASTATIN
1 AMLODIPINE TABLET & VALSARTAN/HCTZ TABLET AMLODIPINE & VALSARTAN/HCTZ
2 AMLODIPINE/ATORVASTATIN COMBO TABLET AMLODIPINE/ATORVASTATIN
1 AMLODIPINE/BENAZEPRIL AMLODIPINE/BENAZEPRIL
1 AMLODIPINE/OLMESARTAN AMLODIPINE/OLMESARTAN
1 AMLODIPINE/VALSARTAN COMBO TABLET & HCTZ AMLODIPINE/VALSARTAN & HCTZ
2 AMLODIPINE/VALSARTAN/HCTZ COMBO TABLET AMLODIPINE/VALSARTAN/HCTZ
1 AMMONIUM LACTATE AMMONIUM LACTATE
1 AMOXAPINE AMOXAPINE
2 AMOXICILLIN/CLAVULANATE ER TABLET AMOXICILLIN/CLAVULANATE
1 AMOXICILLIN/CLAVULANATE IR TABLET AMOXICILLIN/CLAVULANATE
1 AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE
3 AMPYRA DALFAMPRIDINE X
Excluded AMRIX
3 AMTURNIDE X
1 AMYL NITRITE AMYL NITRITE
3 ANACAINE BENZOCAINE
3 ANADROL‐50 OXYMETHOLONE X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 ANAFRANIL CLOMIPRAMINE HCL
1 ANAGRELIDE HCL ANAGRELIDE HCL
3 ANALPRAM E HYDROCORT/PRAMOXIN/EMOL/PRAM 1
2 ANALPRAM HC HYDROCORTISONE/PRAMOXINE
2 ANALPRAM HC (1 %‐1 %) CREAM/APPL HYDROCORTISONE/PRAMOXINE
2 ANALPRAM HC (2.5 %‐1 %) CREAM/APPL HYDROCORTISONE/PRAMOXINE
3 ANALPRAM HC (2.5‐1%(4G)) CREAM/APPL HYDROCORTISONE/PRAMOXINE
2 ANAPROX DS NAPROXEN SODIUM
3 ANASCORP CENTRUROIDES(SCORPN) ANTIVENOM
2 ANASPAZ HYOSCYAMINE SULFATE
3 ANASTIA LIDOCAINE HCL
1 ANASTROZOLE ANASTROZOLE
3 ANCOBON FLUCYTOSINE
3 ANDRODERM TESTOSTERONE X
2 ANDROGEL 1%, 1.62% TESTOSTERONE X
3 ANDROID METHYLTESTOSTERONE X
3 ANGELIQ DROSPIRENONE/ESTRADIOL
3 ANIMAS VIBE SUB‐Q INSULIN PUMP, CGM SYSTEM
3 ANIMI‐3 OM‐3/DHA/EPA/D3/B12/FA/B‐6/PHY
3 ANORO ELLIPTA UMECLIDINIUM BRM/VILANTEROL TR X
2 ANTABUSE DISULFIRAM
Excluded ANTARA
2 ANUSOL‐HC HYDROCORTISONE
3 ANZEMET (50, 100 MG) TABLET DOLASETRON MESYLATE X X
2 APEXICON E DIFLORASONE DIACETATE/EMOLL
Excluded APIDRA
Excluded APIDRA SOLOSTAR
3 APLENZIN BUPROPION HBR X X
3 APLIGRAF CULT SKIN SUBST,HUMAN‐BOVINE
3 APOGEE HC INTERMITTENT CATHETER
1 APRACLONIDINE HCL APRACLONIDINE HCL
1 APREPITANT (125MG‐80MG) CAP DS PK APREPITANT X
1 APREPITANT (80 MG) CAPSULE APREPITANT X
1 APRI
2 APRISO MESALAMINE
Excluded APTENSIO XR
3 APTIOM (200, 400, 600, 800 MG) TABLET ESLICARBAZEPINE ACETATE X X
2 APTIVUS TIPRANAVIR X
3 AQUA GLYCOLIC HC HYDROCORTISONE/SKIN CLEANSER25
3 AQUORAL SALIVA SUBSTITUTE COMBO NO.3
3 ARANESP EPOETIN X
2 ARAVA LEFLUNOMIDE
3 ARCAPTA INDACATEROL MALEATE X X
Excluded ARESTIN
3 ARGYLE MEDICAL SUPPLY, MISCELLANEOUS
2 ARICEPT DONEPEZIL HCL
2 ARIMIDEX ANASTROZOLE
1 ARIPIPRAZOLE ARIPIPRAZOLE X
2 ARIPIPRAZOLE ODT ARIPIPRAZOLE X X
2 ARIXTRA (10MG/0.8ML) SYRINGE FONDAPARINUX SODIUM X
2 ARIXTRA (2.5 MG/0.5) SYRINGE FONDAPARINUX SODIUM X
2 ARIXTRA (5MG/0.4ML) SYRINGE FONDAPARINUX SODIUM X
2 ARIXTRA (7.5MG/0.6) SYRINGE FONDAPARINUX SODIUM X
2 ARMOUR THYROID THYROID,PORK
3 ARNUITY ELLIPTA FLUTICASONE FUROATE X X
2 AROMASIN EXEMESTANE
3 ARTHROTEC 50, 75 DICLOFENAC SODIUM/MISOPROSTOL
3 ARTISS THROMBIN/FIBRINOG/APROT/CAL CL
1 ASCORBIC ACID ASCORBIC ACID
2 ASMANEX HFA MOMETASONE FUROATE X
2 ASMANEX TWISTHALER MOMETASONE FUROATE X
1 ASPIRIN/CAFFEIN/DIHYDROCODEINE ASPIRIN/CAFFEIN/DIHYDROCODEINE X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 ASPIRIN/DIPYRIDAMOLE ASPIRIN/DIPYRIDAMOLE
3 ASTAGRAF XL TACROLIMUS
2 ASTEPRO AZELASTINE HCL X X
3 ASTHMAPACK CHILDREN'S PEAK FLOW METER/INH ASSIT DEV
3 ASTRINGYN FERRIC SUBSULFATE
3 ATABEX EC PNV COMB.NO43/IRON,CARB/FA/DSS
3 ATACAND CANDESARTAN CILEXETIL
3 ATELVIA RISEDRONATE SODIUM X X
1 ATENOLOL TABLET ATENOLOL
1 ATENOLOL/CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE
2 ATIVAN LORAZEPAM
3 ATOPICLAIR VITE AC/GRAPE/HYALURONIC ACID
1 ATORVASTATIN ATORVASTATIN
1 ATORVASTATIN TABLET
1 ATOVAQUONE ATOVAQUONE
1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE/PROGUANIL HCL
3 ATRALIN TRETINOIN
3 ATRAPRO CP EMOLLIENT COMBOS NO.47, NO.60
3 ATRAPRO DERMAL SPRAY HYPOC ACID/SOD HYPO/NACL/WATER
3 ATRAPRO HYDROGEL EMOLLIENT COMBINATION NO.60
2 ATRIPLA EFAVIRENZ/EMTRICITAB/TENOFOVIR X
3 ATROPEN ATROPINE SULFATE
1 ATROPINE SULFATE ATROPINE SULFATE
1 ATROPINE SULFATE IN 0.9% NACL ATROPINE SULFATE IN 0.9% NACL
2 ATROVENT HFA IPRATROPIUM BROMIDE X
2 AUBAGIO X
2 AUGMENTIN AMOXICILLIN/POTASSIUM CLAV
2 AUGMENTIN ES‐600 AMOXICILLIN/POTASSIUM CLAV
2 AUGMENTIN XR AMOXICILLIN/POTASSIUM CLAV
3 AURUMHEEL HOMEOPATHIC DRUGS
3 AURYXIA FERRIC CITRATE X
Excluded AUVI‐Q
2 AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE
3 AVANDAMET ROSIGLITAZONE/METFORMIN HCL X
3 AVANDARYL X
3 AVANDIA ROSIGLITAZONE MALEATE X
2 AVAPRO IRBESARTAN
3 AVAR SULFACETAMIDE SODIUM/SULFUR
3 AVAR LS SULFACETAMIDE SODIUM/SULFUR
3 AVAR‐E SULFACETAMIDE SODIUM/SULFUR
3 AVAR‐E GREEN SULFACETAMIDE SODIUM/SULFUR
3 AVAR‐E LS SULFACETAMIDE SODIUM/SULFUR
2 AVC SULFANILAMIDE
2 AVELOX MOXIFLOXACIN HCL
3 AVENOVA HYPOCHLOROUS ACID/SODIUM CHLOR
1 AVIANE
3 AVIDOXY DOXYCYCLINE MONOHYDRATE X
3 AVITENE MICROFIBRILLAR COLLAGEN
2 AVODART DUTASTERIDE
2 AVONEX X
3 AXERT ALMOTRIPTAN MALATE X X
2 AXIRON TESTOSTERONE X
2 AYGESTIN NORETHINDRONE ACETATE
3 AZASAN AZATHIOPRINE
3 AZASITE AZITHROMYCIN
1 AZATHIOPRINE AZATHIOPRINE
1 AZELASTINE HCL AZELASTINE HCL
1 AZELASTINE NASAL SPRAY AZELASTINE X
1 AZELASTINE OPHTHALMIC DROPS AZELASTINE
3 AZELEX AZELAIC ACID
2 AZILECT RASAGILINE MESYLATE X
1 AZITHROMYCIN AZITHROMYCIN
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 AZOPT BRINZOLAMIDE
2 AZOR AMLODIPINE BES/OLMESARTAN MED X
2 AZULFIDINE SULFASALAZINE
1 B CMPLX 4/VIT D3/C/FA/ZINC OX B CMPLX 4/VIT D3/C/FA/ZINC OX
1 B COMPLEX W‐C NO.20/FOLIC ACID B COMPLEX W‐C NO.20/FOLIC ACID
1 BACITRACIN BACITRACIN
1 BACITRACIN/POLYMYXIN B SULFATE BACITRACIN/POLYMYXIN B SULFATE
1 BACLOFEN TABLET BACLOFEN
1 BACTERIOSTATIC SODIUM CHLORIDE BACTERIOSTATIC SODIUM CHLORIDE
2 BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM
2 BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM
2 BACTROBAN MUPIROCIN CALCIUM
2 BACTROBAN NASAL MUPIROCIN CALCIUM
1 BALSALAZIDE 750MG CAPSULE BALSALAZIDE
3 BANZEL (200 MG) TABLET RUFINAMIDE X X
3 BANZEL (40 MG/ML) ORAL SUSP RUFINAMIDE X X
3 BANZEL (400 MG) TABLET RUFINAMIDE X X
Excluded BASAGLAR
3 BCG (TICE STRAIN) BCG LIVE
Excluded BEAU RX
Excluded BECONASE AQ
Excluded BELBUCA
3 BELSOMRA SUVOREXANT X X
1 BENAZEPRIL TABLET BENAZEPRIL
1 BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE
2 BENICAR OLMESARTAN MEDOXOMIL X
1 BENOXINATE HCL/FLUORESCEIN NA BENOXINATE HCL/FLUORESCEIN NA
3 BENSAL HP SALICYLIC ACID
2 BENTYL DICYCLOMINE HCL
2 BENZACLIN (1 %‐5 %) GEL CLINDAMYCIN PHOS/BENZOYL PEROX
3 BENZACLIN (1 %‐5 %) GEL W/PUMP CLINDAMYCIN PHOS/BENZOYL PEROX
2 BENZAMYCIN ERYTHROMYCIN/BENZOYL PEROXIDE
3 BENZEFOAM BENZOYL PEROXIDE
3 BENZEFOAM ULTRA BENZOYL PEROXIDE
1 BENZONATATE BENZONATATE
1 BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE
2 BENZOYL PEROXIDE 4% GEL BENZOYL PEROXIDE
1 BENZOYL PEROXIDE 5% GEL BENZOYL PEROXIDE
2 BENZOYL PEROXIDE 6% TOWELETTE BENZOYL PEROXIDE
2 BENZOYL PEROXIDE 8% GEL BENZOYL PEROXIDE
1 BENZTROPINE MESYLATE BENZTROPINE MESYLATE
Excluded BEPREVE
2 BESIVANCE BESIFLOXACIN HCL
3 BETADINE POVIDONE‐IODINE
2 BETAGAN LEVOBUNOLOL HCL
3 BETALOAN SUIK BETAMETH AC,NA PH/R 134A,245FA
1
BETAMETHASONE DIPROPIONATE 0.05% AUGMENTED
LOTION (SUPER HIGH) BETAMETHASONE DIPROPIONATE
1 BETAMETHASONE DIPROPIONATE 0.05% CREAM (HIGH) BETAMETHASONE DIPROPIONATE
1 BETAMETHASONE DIPROPIONATE 0.05% GEL (HIGH) BETAMETHASONE DIPROPIONATE
1
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05%
CREAM (HIGH) BETAMETHASONE DIPROPIONATE
1
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05%
OINTMENT (HIGH) BETAMETHASONE DIPROPIONATE
1
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05%
OINTMENT (SUPER HIGH) BETAMETHASONE DIPROPIONATE
1 BETAMETHASONE VALERATE 0.025% LOTION (LOW) BETAMETHASONE VALERATE
1 BETAMETHASONE VALERATE 0.1 % CREAM (LOWER‐MID) BETAMETHASONE VALERATE
1 BETAMETHASONE VALERATE 0.1 % OINTMENT (HIGH) BETAMETHASONE VALERATE
2 BETAMETHASONE VALERATE 0.12 % FOAM (HIGH) BETAMETHASONE VALERATE
1 BETAMETHASONE/PROPYLENE GLYC BETAMETHASONE/PROPYLENE GLYC
2 BETAPACE SOTALOL HCL X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 BETAPACE AF SOTALOL HCL X
3 BETASERON X
1 BETAXOLOL HCL BETAXOLOL HCL
1 BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE
2 BETIMOL TIMOLOL
2 BETOPTIC S BETAXOLOL HCL
Excluded BEVESPI AEROSPHERE
3 BEYAZ DROSPIR/ETH ESTRA/LEVOMEFOL CA X
3 BIAFINE EMOLLIENT COMBINATION NO.10
2 BIAXIN CLARITHROMYCIN
1 BICALUTAMIDE BICALUTAMIDE
2 BIDIL ISOSORBIBE DINIT/HYDRALAZINE
3 BIFERA RX IRON POLYSAC/IRON HEME/FA/B12
2 BILTRICIDE PRAZIQUANTEL
1 BIMATOPROST 0.03% BIMATOPROST X
2 BIMATOPROST DROPS BIMATOPROST
Excluded BINOSTO
3 BIONECT HYALURONATE SODIUM
3 BIOSTEP COLLAGEN/SOD ALGIN/CARBOXYMETH
3 BIOSTEP AG DRESS,COLLAGEN/SILV/NA ALG/CMC
1 BISAC/NACL/NAHCO3/KCL/PEG 3350 BISAC/NACL/NAHCO3/KCL/PEG 3350
1 BISOPROL/HCTZ COMBO TABLET BISOPROL/HCTZ
2 BLEPHAMIDE SULFACETAMIDE/PREDNISOLONE
2 BLEPHAMIDE S.O.P. SULFACETAMIDE/PREDNISOLONE
3 BLUNT NEEDLE BLUNT NEEDLE, DISPOSABLE
2 BONIVA IBANDRONATE SODIUM
3 BOTOX ONABOTULINUMTOXIN A X X X
3 BREATHERITE INHALER, ASSIST DEVICES
3 BREATHRITE INHALER, ASSIST DEVICES
2 BREO ELLIPTA FLUTICASONE/VILANTEROL X
3 BRIJ L4 LAURETH 4
2 BRILINTA TICAGRELOR X
1 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE
Excluded BRINEURA CERLIPONASE ALFA
3 BRISDELLE PAROXETINE MESYLATE X X
3 BRIVIACT (10 MG) TABLET BRIVARACETAM X X
3 BRIVIACT (10 MG/ML) SOLUTION BRIVARACETAM X X
3 BRIVIACT (100 MG) TABLET BRIVARACETAM X X
3 BRIVIACT (25 MG) TABLET BRIVARACETAM X X
3 BRIVIACT (50 MG) TABLET BRIVARACETAM X X
3 BRIVIACT (50 MG/5 ML) VIAL BRIVARACETAM X
3 BRIVIACT (75 MG) TABLET BRIVARACETAM X X
2 BROMFENAC OPTHALMIC SOLUTION BROMFENAC
1 BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE
1 BROMPHENIRA/PSEUDOEPHED/CODEIN BROMPHENIRA/PSEUDOEPHED/CODEIN
1 BROMPHENIRAMINE/PSEUDOEPHED/DM BROMPHENIRAMINE/PSEUDOEPHED/DM
3 BROMSITE BROMFENAC SODIUM
3 BROVANA ARFORMOTEROL TARTRATE X
3 BUCALSEP B‐CAINE/ZINC CL/PINE/CETYLPYRD
2 BUDESONIDE EC 3MG CAPSULE BUDESONIDE
2 BUDESONIDE NASAL SPRAY BUDESONIDE
1 BUMETANIDE BUMETANIDE
3 BUNAVAIL BUPRENORPHINE HCL/NALOXONE HCL X
3 BUPAP BUTALBITAL/ACETAMINOPHEN X X
1 BUPIVACAINE HCL/0.9 % NACL/PF BUPIVACAINE HCL/0.9 % NACL/PF
3 BUPRENEX BUPRENORPHINE HCL
1 BUPRENORPHINE/NALOXONE SL TABS BUPRENORPHINE/NALOXONE X X
1 BUPROPION SR/XL (BEHAVIORAL HEALTH) BUPROPION HCL X X
1 BUSPIRONE TABLET BUSPIRONE
2 BUTALB/APAP/CAFFEINE 50‐300‐40 CAPSULE BUTALB/APAP/CAFFEINE
2 BUTALB/APAP/CAFFEINE 50‐325‐40 TABLET BUTALB/APAP/CAFFEINE
1 BUTALBITAL/ACETAMINOPHEN BUTALBITAL/ACETAMINOPHEN
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 BUTISOL SODIUM BUTABARBITAL SODIUM
1 BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE
2 BUTRANS BUPRENORPHINE X
3 BUTYLATED HYDROXYTOLUENE(BHT) BUTYLATED HYDROXYTOLUENE
Excluded BYDUREON
Excluded BYETTA
2 BYSTOLIC NEBIVOLOL HCL
2 BYVALSON NEBIVOLOL HCL/VALSARTAN
1 CABERGOLINE CABERGOLINE
3 CADEAU DHA PRENATAL VIT #83/IRON/FA#6/DHA
2 CADUET AMLODIPINE/ATORVASTATIN X
2 CAFERGOT ERGOTAMINE TARTRATE/CAFFEINE X
1 CAFFEINE CITRATE CAFFEINE CITRATE
2 CALAN VERAPAMIL HCL
2 CALAN SR VERAPAMIL HCL
1 CALCIPOTRIENE CALCIPOTRIENE X
2 CALCIPOTRIENE/BETAMETHASONE CALCIPOTRIENE/BETAMETHASONE X
1 CALCITONIN, SALMON SYNTHETIC CALCITONIN, SALMON SYNTHETIC
1 CALCITRIOL CAPSULE CALCITRIOL
1 CALCIUM ACETATE (667 MG) CAPSULE, TABLET CALCIUM ACETATE
1 CALCIUM CARB/MAG CARB/FOLIC AC CALCIUM CARB/MAG CARB/FOLIC AC
1 CALCIUM/MAG/D3/B12/FA/B6/BORON CALCIUM/MAG/D3/B12/FA/B6/BORON
3 CAMBIA DICLOFENAC POTASSIUM X
2 CANASA MESALAMINE
2 CANDESARTAN TABLET CANDESARTAN
2 CANDESARTAN/HCTZ COMBO TABLET CANDESARTAN/HCTZ
3 CANTHARIS COMPOSITUM HOMEOPATHIC DRUGS
3 CAPCOF CHLORPHENIRAMINE/PE/CODEINE X
3 CAPEX SHAMPOO FLUOCINOLONE ACETONIDE
3 CAPHOSOL SALIVA SUBSTITUTE COMBO NO.2
2 CAPITAL W‐CODEINE ACETAMINOPHEN WITH CODEINE X
2 CAPTOPRIL TABLET CAPTOPRIL
1 CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE
Excluded CAPXIB
3 CARAC FLUOROURACIL
2 CARAFATE SUCRALFATE
1 CARBAMAZEPINE CARBAMAZEPINE
2 CARBATROL CARBAMAZEPINE
1 CARBIDOPA CARBIDOPA
1 CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA
1 CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE
1 CARBINOXAMINE CARBINOXAMINE
3 CARDENE SR DILTIAZEM HCL
1 CARDIOPLEGIC NO.14 (MAINT 8:1) CARDIOPLEGIC NO.14 (MAINT 8:1)
1 CARDIOPLEGIC NO.15(INDUCT 8:1) CARDIOPLEGIC NO.15(INDUCT 8:1)
1 CARDIOPLEGIC NO.17(INDUCT 4:1) CARDIOPLEGIC NO.17(INDUCT 4:1)
1 CARDIOPLEGIC NO.18(INDUCT 8:1) CARDIOPLEGIC NO.18(INDUCT 8:1)
1 CARDIOPLEGIC NO.19 (MAINT 4:1) CARDIOPLEGIC NO.19 (MAINT 4:1)
1 CARDIOPLEGIC SOLUTION NO.1 CARDIOPLEGIC SOLUTION NO.1
1 CARDIOPLEGIC SOLUTION NO.10 CARDIOPLEGIC SOLUTION NO.10
1 CARDIOPLEGIC SOLUTION NO.16 CARDIOPLEGIC SOLUTION NO.16
2 CARDIZEM DILTIAZEM HCL
2 CARDIZEM CD DILTIAZEM HCL
3 CARDIZEM LA DILTIAZEM HCL
2 CARDURA DOXAZOSIN MESYLATE
3 CARDURA XL DOXAZOSIN MESYLATE
1 CARISOPRODOL CARISOPRODOL
1 CARISOPRODOL/ASPIRIN CARISOPRODOL/ASPIRIN
1 CARISOPRODOL/ASPIRIN/CODEINE CARISOPRODOL/ASPIRIN/CODEINE X
3 CARNITOR LEVOCARNITINE
3 CARNITOR LEVOCARNITINE (WITH SUGAR)
3 CARNITOR SF LEVOCARNITINE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 CARRASYN HYDROGEL WOUND GEL DRESSING
1 CARTEOLOL HCL CARTEOLOL HCL
3 CARTICEL AUTOLOGOUS CULT. CHONDROCYTES
1 CARVEDILOL TABLET CARVEDILOL
2 CASODEX BICALUTAMIDE
2 CATAPRES CLONIDINE HCL
3 CATAPRES‐TTS 1 CLONIDINE
3 CATAPRES‐TTS 2 CLONIDINE
3 CATAPRES‐TTS 3 CLONIDINE
3 CAVERJECT ALPROSTADIL X
3 CAYA CONTOURED DIAPHRAGMS, CONTOURED
3 CEDAX CEFTIBUTEN
1 CEFACLOR CEFACLOR
1 CEFADROXIL CEFADROXIL
1 CEFDINIR CEFDINIR
1 CEFDITOREN PIVOXIL CEFDITOREN PIVOXIL
1 CEFIXIME CEFIXIME
1 CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL
1 CEFPROZIL CEFPROZIL
1 CEFTIBUTEN CEFTIBUTEN
2 CEFTIN CEFUROXIME AXETIL
1 CEFUROXIME AXETIL CEFUROXIME AXETIL
3 CELACYN EMOLLIENT COMBINATION NO.60
3 CELACYN POST PROCEDURE EMOL #60/HYPO/SOD CHL,SUL,PHOS
2 CELEBREX CELECOXIB
1 CELECOXIB CELECOXIB
2 CELEXA CITALOPRAM HYDROBROMIDE
2 CELLCEPT MYCOPHENOLATE MOFETIL
3 CELONTIN METHSUXIMIDE
3 CENESTIN
2 CENTANY MUPIROCIN
3 CENTANY AT MUPIROCIN
1 CEPHALEXIN CEPHALEXIN
3 CERACADE EMOLLIENT COMBINATION NO.103
3 CERAMAX EMOLLIENT COMBINATION NO.101
3 CERVIDIL DINOPROSTONE
3 CESAMET NABILONE X X
3 CETACAINE TETRACAINE/BENZOCAINE/BUTAMBEN
3 CETACAINE ANESTHETIC TETRACAINE/BENZOCAINE/BUTAMBEN
1 CETIRIZINE HCL (10 MG) CAPSULE (OTC) CETIRIZINE HCL
1 CETIRIZINE HCL/PSEUDOEPHEDRINE CETIRIZINE HCL/PSEUDOEPHEDRINE
3 CETRAXAL CIPROFLOXACIN HCL
3 CETYLEV ACETYLCYSTEINE
2 CEVIMELINE CAPSULE CEVIMELINE
3 CHEMET SUCCIMER
3 CHENODAL CHENODIOL
1 CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL
1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE/CLIDINIUM BR
1 CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE
1 CHLOROQUINE CAPSULE CHLOROQUINE PHOSPHATE
1 CHLOROTHIAZIDE CHLOROTHIAZIDE
1 CHLORPHENIRAMINE CHLORPHENIRAMINE
1 CHLORPROMAZINE HCL CHLORPROMAZINE HCL
2 CHLORPROPAMIDE TABLET CHLORPROPAMIDE
1 CHLORZOXAZONE TABLET CHLORZOXAZONE
3 CHOLBAM X
1 CHOLESTYRAMINE CHOLESTYRAMINE
1 CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE/ASPARTAME
1 CHOLINE SALICYL/MAG SALICYLATE CHOLINE SALICYL/MAG SALICYLATE
3 CIALIS TADALAFIL X X
2 CICLODAN CICLOPIROX
3 CICLODAN CICLOPIROX/URE/CAMPH/MENTH/EUC
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 CICLOPIROX 0.77 % GEL CICLOPIROX
1 CICLOPIROX 0.77% CREAM CICLOPIROX
2 CICLOPIROX 1 % SHAMPOO CICLOPIROX
2 CICLOPIROX 8 % SOLUTION (CICLODAN GENERIC) CICLOPIROX
1 CICLOPIROX 8 % SOLUTION (PENLAC GENERIC) CICLOPIROX
1 CICLOPIROX OLAMINE CICLOPIROX OLAMINE
2 CICLOPIROX/URE/CAMPH/MENTH/EUC CICLOPIROX/URE/CAMPH/MENTH/EUC
3 CIDALEAZE LIDOCAINE HCL
1 CILOSTAZOL CILOSTAZOL
2 CILOXAN CIPROFLOXACIN HCL
1 CIMETIDINE CIMETIDINE
1 CIMETIDINE SOLUTION CIMETIDINE
Excluded CIMZIA CERTOLIZUMAB
Excluded CINQAIR RESLIZUMAB
2 CIPRO CIPROFLOXACIN
3 CIPRO HC CIPROFLOXACIN/HYDROCORTISONE
3 CIPRO XR CIPROFLOXACIN/CIPROFLOXA HCL
2 CIPRODEX CIPROFLOXACIN HCL/DEXAMETH
1 CIPROFLOXACIN CIPROFLOXACIN
1 CIPROFLOXACIN HCL CIPROFLOXACIN HCL
1 CIPROFLOXACIN/CIPROFLOXA HCL CIPROFLOXACIN/CIPROFLOXA HCL
1 CITALOPRAM CITALOPRAM
3 CITRANATAL 90 DHA PNV72/IRON,GLUC/FOLIC/DSS/DHA
3 CITRANATAL ASSURE PNV73/IRON,GLUC/FOLIC/DSS/DHA
3 CITRANATAL B‐CALM PRENATAL #48/IRON CB,GLU/FA/B6
3 CITRANATAL DHA PNV 76/IRON,GLUC/FOLIC/DSS/DHA
3 CITRANATAL HARMONY PNV59/IRON,CARB,FUM/FA/DSS/DHA
3 CITRANATAL RX PRENATAL81/IRON/FOLIC/DOCUSATE
1 CITRATE PHOSPHATE DEXTROS SOLN CITRATE PHOSPHATE DEXTROS SOLN
3 CITRIC ACID CITRIC ACID
3 CLARINEX (5 MG) TABLET DESLORATADINE X
3 CLARINEX D DESLORATADINE/PSEUDOEPHEDRINE X X
3 CLARINEX SYRUP DESLORATADINE X X
2 CLARITHROMYCIN 500 MG ER TABLET CLARITHROMYCIN
1 CLARITHROMYCIN IR TABLETS (250 MG, 500 MG) CLARITHROMYCIN
1 CLEMASTINE FUMARATE CLEMASTINE FUMARATE
3 CLEO 90 INFUSION SET INFUSION SET FOR INSULIN PUMP
3 CLEOCIN CLINDAMYCIN PHOSPHATE
2 CLEOCIN HCL CLINDAMYCIN HCL
2 CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL
2 CLEOCIN T CLINDAMYCIN PHOSPHATE
3 CLEVER CHOICE HOLDING CHAMBER INHALER, ASSIST DEVICES
3 CLEVER CHOICE NEBULIZER NEBULIZER AND COMPRESSOR
3 CLEVER CHOICE WHISPER AIRE PED NEBULIZER AND COMPRESSOR
2 CLIMARA ESTRADIOL X
3 CLIMARA PRO ESTRADIOL/LEVONORGESTREL X
2 CLINDACIN ETZ CLINDAMYCIN PHOSPHATE
2 CLINDACIN P CLINDAMYCIN PHOSPHATE
3 CLINDAGEL CLINDAMYCIN PHOSPHATE X
1 CLINDAMYCIN CAPSULE CLINDAMYCIN HCL
2
CLINDAMYCIN PHOS/BENZOYL PEROXIDE
(GEL OR GEL PUMP) CLINDAMYCIN PHOS/BENZOYL PEROX
1 CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE
1 CLINDAMYCIN PHOSPHATE 1 % GEL CLINDAMYCIN PHOSPHATE
2 CLINDAMYCIN PHOSPHATE FOAM CLINDAMYCIN PHOSPHATE
1 CLINDAMYCIN PHOSPHATE GEL 1%/TRETINION 0.025% GEL CLINDAMYCIN/TRETINOIN
1 CLINDAMYCIN PHOSPHATE SOLUTION CLINDAMYCIN PHOSPHATE
2 CLINDAMYCIN/TRETINOIN CLINDAMYCIN/TRETINOIN
3 CLINDESSE CLINDAMYCIN PHOSPHATE
3 CLINPRO 5000 SODIUM FLUORIDE
2 CLOBETASOL PROPIONATE 0.05 % FOAM (SUPER HIGH) CLOBETASOL PROPIONATE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 CLOBETASOL PROPIONATE 0.05 % GEL (SUPER HIGH) CLOBETASOL PROPIONATE
2 CLOBETASOL PROPIONATE 0.05 % LOTION (SUPER HIGH) CLOBETASOL PROPIONATE
2 CLOBETASOL PROPIONATE 0.05 % OINTMENT (SUPER HIGH) CLOBETASOL PROPIONATE
2 CLOBETASOL PROPIONATE 0.05 % SHAMPOO (SUPER HIGH) CLOBETASOL PROPIONATE
1 CLOBETASOL PROPIONATE 0.05 % SOLUTION (SUPER HIGH) CLOBETASOL PROPIONATE
1 CLOBETASOL PROPIONATE 0.05 % SOLUTION (SUPER HIGH) CLOBETASOL PROPIONATE
2 CLOBETASOL PROPIONATE 0.05 % SPRAY (SUPER HIGH) CLOBETASOL PROPIONATE
1
CLOBETASOL PROPIONATE EMOLLIENT 0.05 % CREAM
(SUPER HIGH) CLOBETASOL PROPIONATE/EMOLL
2
CLOBETASOL PROPIONATE/EMOLLIENT 0.05 % FOAM
(SUPER HIGH) CLOBETASOL PROPIONATE/EMOLL
2 CLOBEX CLOBETASOL PROPIONATE
2 CLOCORTOLONE PIVALATE 0.1% CREAM (MEDIUM) CLOCORTOLONE PIVALATE
2 CLODAN CLOBETASOL PROPIONATE
3 CLODAN CLOBETASOL/SKIN CLEANSER #28
3 CLODERM CLOCORTOLONE PIVALATE
2 CLOMIPRAMINE CAPSULE CLOMIPRAMINE
1 CLONAZEPAM CLONAZEPAM
2 CLONIDINE CLONIDINE
2 CLONIDINE HCL (BEHAVIORAL HEALTH) CLONIDINE HCL X
1 CLONIDINE HCL (CARDIOVASCULAR) CLONIDINE HCL
1 CLONIDINE HCL/CHLORTHALIDONE CLONIDINE HCL/CHLORTHALIDONE
1 CLONIDINE HCL/PF CLONIDINE HCL/PF
1 CLOPIDOGREL BISULFATE (300 MG) TABLET CLOPIDOGREL BISULFATE X
1 CLOPIDOGREL BISULFATE (75 MG) TABLET CLOPIDOGREL BISULFATE
1 CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM
1 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE
1 CLOTRIMAZOLE/BETAMETHASONE 1 %‐0.05 % CREAM CLOTRIMAZOLE/BETAMETHASONE
2 CLOTRIMAZOLE/BETAMETHASONE 2%‐0.05% LOTION CLOTRIMAZOLE/BETAMETHASONE
1 CLOZAPINE CLOZAPINE X
1 CLOZAPINE ODT CLOZAPINE X X
2 CLOZARIL CLOZAPINE X
3 CNL 8 CICLOPIROX/NAIL LACQUER REMOVR
3 COAGUCHEK XS PT/INR TEST METER
3 COARTEM ARTEMETHER/LUMEFANTRINE
1 COCAINE HCL COCAINE HCL
1 CODEINE PHOSPHATE/GUAIFENESIN CODEINE PHOSPHATE/GUAIFENESIN X
1 CODEINE SULFATE (15 MG) TABLET CODEINE SULFATE X
2 CODEINE SULFATE (30, 60 MG) TABLET CODEINE SULFATE X
1 CODEINE/BUTALBITAL/ASA/CAFFEIN CODEINE/BUTALBITAL/ASA/CAFFEIN X
3 CODITUSSIN DAC PSEUDOEPHED/CODEINE/GUAIFEN X
2 COLAZAL BALSALAZIDE DISODIUM
1 COLCHICINE (0.6 MG) CAPSULE COLCHICINE X
1 COLCHICINE (0.6 MG) TABLET COLCHICINE X
2 COLCRYS COLCHICINE X
2 COLESTID (1 G) TABLET COLESTIPOL HCL
2 COLESTID (5 G) GRANULES COLESTIPOL HCL
2 COLESTID (5 G) PACKET COLESTIPOL HCL
3 COLESTID (7.5 G) PACKET COLESTIPOL HCL
1 COLESTIPOL HCL COLESTIPOL HCL
3 COLY‐MYCIN S NEOMYC/COLIST/HYDROCORT/THONZN
2 COLYTE WITH FLAVOR PACKETS PEG3350/SOD SULF,BICARB,CL/KCL
2 COMBIGAN BRIMONIDINE TARTRATE/TIMOLOL
2 COMBIPATCH ESTRADIOL/NORETHINDRONE ACET X
2 COMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL SULFATE
2 COMBIVIR LAMIVUDINE/ZIDOVUDINE X
3 COMFORT PAC‐CYCLOBENZAPRINE CYCLOBENZAPRINE/IRR CNTR‐IRR 2
3 COMFORT PAC‐IBUPROFEN IBUPROFEN/IRR.COUNT‐IRRIT.NO.2
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 COMFORT PAC‐MELOXICAM MELOXICAM/IRRIT.CNTR‐IRR CMB 2
3 COMFORT PAC‐NAPROXEN NAPROXEN/IRRITANT CNTR‐IRRIT 2
3 COMFORT PAC‐TIZANIDINE TIZANIDINE/IRR CNTR‐IRR COMB#2
3 COMFORT SHORT INFUSION SET FOR INSULIN PUMP
3 COMPACT SPACE CHAMBER INHALER, ASSIST DEVICES
3 COMPACT SPACE CHAMBER PLUS INHALER, ASSIST DEVICES
3 COMP‐AIR ELITE COMPRESSOR SYST NEBULIZER AND COMPRESSOR
3 COMP‐AIR NEBULIZER COMPRESSOR NEBULIZER AND COMPRESSOR
2 COMPAZINE PROCHLORPERAZINE
2 COMPLERA EMTRICITA/RILPIVIRINE/TENOF DF X
3 COMPLETE NATAL DHA PRENATAL 2/IRON/FOLIC ACID/OM3
2 COMTAN ENTACAPONE
3 CONCEPT DHA PNV 16/IRON FUM,PS/FOLIC/OM‐3
3 CONCEPT OB PNV #15/IRON FUM,PS/FOLIC ACID
3 CONCEPTION CONCEPTION ASSIST.SUPPLIES NO1
1 CONCERTA (18,27,36,54 MG) TAB ER 24 METHYLPHENIDATE HCL X
2 CONDYLOX PODOFILOX
3 CONTACT DETACH INFUSION SET INFUSION SET FOR INSULIN PUMP
3 CONZIP TRAMADOL HCL X X
2 COPAXONE GLATIRAMER X
2 COPEGUS RIBAVIRIN
2 CORDRAN FLURANDRENOLIDE
2 COREG CARVEDILOL
2 COREG CR CARVEDILOL PHOSPHATE
2 CORGARD NADOLOL
2 CORLANOR IVABRADINE HCL X X
3 CORTANE‐B HC/PRAMOXINE HCL/CHLOROXYLENOL
2 CORTEF HYDROCORTISONE
2 CORTENEMA HYDROCORTISONE
3 CORTIFOAM HYDROCORTISONE ACETATE
1 CORTISONE ACETATE CORTISONE ACETATE
2 CORTISPORIN NEOMYC/BACIT/POLYMYX/HYDROCORT
2 CORTISPORIN NEOMYCIN/POLYMYXIN B/HYDROCORT
3 CORVITA FOLIC/MVI THER‐MIN/LYCOP/LUT
3 CORVITE FOLIC/MVI THER‐MIN/LYCOP/LUT
3 CORVITE 150 IRON,CARB/FA#6/MV, MIN NO.41
3 CORVITE FE IRON/FOLATE NO.6/MV,MINS NO.40
3 CORVITE FREE MV‐MINS 6/FOLIC ACID/LUT/COQ10
3 CORZIDE NADOLOL/BENDROFLUMETHIAZIDE
2 COSOPT DORZOLAMIDE HCL/TIMOLOL MALEAT
3 COSOPT PF DORZOLAMIDE/TIMOLOL/PF X X
2 COUMADIN WARFARIN SODIUM
3 COVERA‐HS VERAPAMIL
2 COZAAR LOSARTAN POTASSIUM
3 CRALONIN HOMEOPATHIC DRUGS
2 CREON LIPASE/PROTEASE/AMYLASE
3 CRESEMBA ISAVUCONAZONIUM SULFATE
2 CRESTOR ROSUVASTATIN CALCIUM X
2 CRINONE PROGESTERONE, MICRONIZED
2 CRIXIVAN INDINAVIR SULFATE
1 CROMOLYN CROMOLYN
3 CRYOSERV DIMETHYL SULFOXIDE
3 CURAFIL GEL DRESSING
3 CURITY DRAINAGE BAG
3 CURITY AMD GAUZE BANDAGE
3 CURITY IODOFORM IODOFORM
3 CUROSURF PORACTANT ALFA
2 CUTIVATE FLUTICASONE PROPIONATE
3 CUVPOSA GLYCOPYRROLATE
1 CYANOCOBALAMIN (VITAMIN B‐12) CYANOCOBALAMIN (VITAMIN B‐12)
1 CYANOCOBALAMIN/FOLIC AC/VIT B6 CYANOCOBALAMIN/FOLIC AC/VIT B6
1 CYANOCOBALAMIN/MECOBALAMIN CYANOCOBALAMIN/MECOBALAMIN
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 CYCLESSA DESOGESTREL‐ETHINYL ESTRADIOL X
1 CYCLOBENZAPRINE TABLET CYCLOBENZAPRINE HCL
2 CYCLOGYL CYCLOPENTOLATE HCL
3 CYCLOMYDRIL CYCLOPENTOLATE/PHENYLEPHRINE
1 CYCLOPENTOLAT/TROPIC/PHENYLEPH CYCLOPENTOLAT/TROPIC/PHENYLEPH
1 CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL
1 CYCLOSERINE CYCLOSERINE
3 CYCLOSET BROMOCRIPTINE MESYLATE X
1 CYCLOSPORINE CYCLOSPORINE
1 CYCLOSPORINE, MODIFIED CYCLOSPORINE, MODIFIED
2 CYMBALTA DULOXETINE HCL X
1 CYPROHEPTADINE HCL CYPROHEPTADINE HCL
3 CYSTAGON CYSTEAMINE BITARTRATE
2 CYTOMEL LIOTHYRONINE SODIUM
2 CYTOTEC MISOPROSTOL
3 D.H.E.45 DIHYDROERGOTAMINE MESYLATE X
Excluded DAKLINZA
2 DALIRESP ROFLUMILAST X X
1 DANAZOL DANAZOL
2 DANTRIUM DANTROLENE SODIUM
1 DANTROLENE SODIUM DANTROLENE SODIUM
1 DAPSONE DAPSONE
2 DARAPRIM PYRIMETHAMINE X
1 DARIFENACIN HYDROBROMIDE DARIFENACIN HYDROBROMIDE X
Excluded DAXBIA
2 DAYPRO OXAPROZIN
3 DAYTRANA METHYLPHENIDATE X X
2 DDAVP DESMOPRESSIN (NONREFRIGERATED)
2 DDAVP (0.1 MG) TABLET DESMOPRESSIN ACETATE
2 DDAVP (0.1 MG/ML) SOLUTION DESMOPRESSIN ACETATE
2 DDAVP (0.2 MG) TABLET DESMOPRESSIN ACETATE
3 DDAVP (4 MCG/ML) AMPUL DESMOPRESSIN ACETATE
3 DDAVP (4 MCG/ML) VIAL DESMOPRESSIN ACETATE
3 DEBACTEROL SULFURIC ACID/SULF PHENOL
1 DEFEROXAMINE MESYLATE DEFEROXAMINE MESYLATE
Excluded DELZICOL
2 DEMADEX TORSEMIDE
1 DEMECLOCYCLINE HCL DEMECLOCYCLINE HCL
3 DEMEROL MEPERIDINE HCL/PF
3 DEMEROL (100 MG) TABLET MEPERIDINE HCL X
3 DEMEROL (100 MG/ML) VIAL MEPERIDINE HCL
3 DEMEROL (50 MG/ML) VIAL MEPERIDINE HCL
3 DEMSER METYROSINE
2 DEMULEN 1‐50‐21 ETHYNODIOL D‐ETHINYL ESTRADIOL X
2 DEPAKENE VALPROIC ACID
2 DEPAKOTE DIVALPROEX SODIUM
2 DEPAKOTE ER DIVALPROEX SODIUM
2 DEPAKOTE SPRINKLE DIVALPROEX SODIUM
3 DEPO‐ESTRADIOL ESTRADIOL CYPIONATE
2 DEPO‐PROVERA MEDROXYPROGESTERONE ACETATE X
2 DEPO‐TESTOSTERONE TESTOSTERONE CYPIONATE X X
3 DERMACINRX EMPRICAINE LIDOCAINE/PRILOCAINE
3 DERMACINRX PRIZOPAK LIDOCAINE/PRILOCAINE
3 DERMAGRAFT CULT SKIN SUBST,HUMAN‐BOVINE
Excluded DERMAPAK PLUS
Excluded DERMASORB XM
3 DERMATOP PREDNICARBATE
3 DERMOTIC FLUOCINOLONE ACETONIDE OIL
2 DESCOVY EMTRICITABINE/TENOFOV ALAFENAM X
3 DESFERAL DEFEROXAMINE MESYLATE
3 DESFERAL MESYLATE DEFEROXAMINE MESYLATE
2 DESIPRAMINE TABLET DESIPRAMINE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 DESLORATADINE DESLORATADINE X
2 DESLORATADINE ODT DESLORATADINE X X
1 DESMOPRESSIN (NONREFRIGERATED) DESMOPRESSIN (NONREFRIGERATED)
1 DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE
2 DESOGEN DESOGESTREL‐ETHINYL ESTRADIOL X
3 DESONATE DESONIDE
2 DESONIDE 0.05% CREAM (LOW) DESONIDE
2 DESONIDE 0.05% LOTION (LOW) DESONIDE
2 DESONIDE 0.05% OINTMENT (LOWER‐MID) DESONIDE
2 DESOWEN DESONIDE
2 DESOXIMETASONE 0.05 % CREAM (MEDIUM) DESOXIMETASONE
2 DESOXIMETASONE 0.05 % GEL (HIGH) DESOXIMETASONE
2 DESOXIMETASONE 0.05 % OINTMENT (MEDIUM) DESOXIMETASONE
1 DESOXIMETASONE 0.25 % CREAM (HIGH) DESOXIMETASONE
2 DESOXIMETASONE 0.25 % OINTMENT (HIGH) DESOXIMETASONE
3 DESOXYN METHAMPHETAMINE HCL X
2 DESVENLAFAXINE ER (RANBAXY BRAND) DESVENLAFAXINE X X
3 DESVENLAFAXINE FUMARATE ER DESVENLAFAXINE FUMARATE X X
1 DESVENLAFAXINE SUCCINATE DESVENLAFAXINE SUCCINATE X
2 DETROL TOLTERODINE TARTRATE X
2 DETROL LA TOLTERODINE TARTRATE X
3 DEVILBISS NEBULIZER AND COMPRESSOR
3 DEVILBISS PULMO‐AIDE COMPRESSOR, FOR NEBULIZER
3 DEVILBISS PULMONEB LT COMP‐NEB NEBULIZER AND COMPRESSOR
1 DEXAMETHASONE DEXAMETHASONE
3 DEXAMETHASONE INTENSOL DEXAMETHASONE
1 DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SOD PHOSPHATE
3 DEXCOM G4 BLOOD‐GLUCOSE TRANSMITTER
3 DEXCOM G5 BLOOD‐GLUCOSE METER,CONTINUOUS
3 DEXCOM G5 BLOOD‐GLUCOSE TRANSMITTER
3 DEXCOM G5‐G4 SENSOR BLOOD‐GLUCOSE SENSOR
2 DEXEDRINE (10 MG) CAPSULE ER DEXTROAMPHETAMINE SULFATE X
2 DEXEDRINE (10 MG) TABLET DEXTROAMPHETAMINE SULFATE X
2 DEXEDRINE (15 MG) CAPSULE ER DEXTROAMPHETAMINE SULFATE X
2 DEXEDRINE (5 MG) CAPSULE ER DEXTROAMPHETAMINE SULFATE X
2 DEXEDRINE (5 MG) TABLET DEXTROAMPHETAMINE SULFATE X
3 DEXERYL EMOLLIENT COMBINATION NO.104
3 DEXILANT LANSOPRAZOLE X X
2 DEXMETHYLPHENIDATE ER CAPSULE DEXMETHYLPHENIDATE
2 DEXMETHYLPHENIDATE HCL (10 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
1 DEXMETHYLPHENIDATE HCL (10 MG) TABLET DEXMETHYLPHENIDATE HCL X
2 DEXMETHYLPHENIDATE HCL (15 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
1 DEXMETHYLPHENIDATE HCL (2.5 MG) TABLET DEXMETHYLPHENIDATE HCL X
2 DEXMETHYLPHENIDATE HCL (20 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
1 DEXMETHYLPHENIDATE HCL (25 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
2 DEXMETHYLPHENIDATE HCL (30 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
1 DEXMETHYLPHENIDATE HCL (35 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
2 DEXMETHYLPHENIDATE HCL (40 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
2 DEXMETHYLPHENIDATE HCL (5 MG) (CPBP 50‐50) DEXMETHYLPHENIDATE HCL X
1 DEXMETHYLPHENIDATE IR TABLET DEXMETHYLPHENIDATE HCL
2 DEXPAK DEXAMETHASONE
2 DEXTROAMPHETAMINE ER CAPSULE DEXTROAMPHETAMINE
2 DEXTROAMPHETAMINE TABLET DEXTROAMPHETAMINE
2 DEXTROAMPHETAMINE/AMPHETAMINE ER CAPSULE DEXTROAMPHETAMINE/AMPHETAMINE
3 DIALYVITE 5000 MULTIVIT‐MINS NO.11/FOLIC ACID
3 DIALYVITE SUPREME D MULTIVIT‐MINS 25/FOLIC ACID/D3
2 DIAMOX SEQUELS ACETAZOLAMIDE
2 DIASTAT DIAZEPAM X
1 DIAZEPAM (ANTI‐ANXIETY) DIAZEPAM
1 DIAZEPAM (SIEZURE DISORDER) DIAZEPAM X
3 DICLEGIS DOXYLAMINE/PYRIDOXINE HCL (B6) X
2 DICLOFENAC GEL DICLOFENAC
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 DICLOFENAC SODIUM 1.5% TOPICAL SOLUTION DICLOFENAC SODIUM
1 DICLOFENAC SODIUM 24 HR TABLET DICLOFENAC SODIUM
1
DICLOFENAC SODIUM DELAYED RELEASE 50MG, 75MG
TABLET DICLOFENAC SODIUM
1 DICLOFENAC SODIUM OPTHALMIC SOLUTION DICLOFENAC SODIUM
1 DICLOFENAC SODIUM TABLET & MISOPROSTOL TABLET DICLOFENAC SODIUM & MISOPROSTOL
2
DICLOFENAC SODIUM/MISOPROSTOL COMBINATION
TABLET DICLOFENAC SODIUM/MISOPROSTOL
1 DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM
1 DICYCLOMINE HCL DICYCLOMINE HCL
1 DIDANOSINE (125, 200, 250, 400 MG) CAPSULE DR DIDANOSINE X
2 DIFFERIN ADAPALENE
2 DIFICID FIDAXOMICIN X X
2 DIFLORASONE DIACETATE 0.05% CREAM (HIGH) DIFLORASONE DIACETATE
2 DIFLORASONE DIACETATE 0.05% OINTMENT (HIGH) DIFLORASONE DIACETATE
2 DIFLUCAN FLUCONAZOLE
1 DIFLUNISAL DIFLUNISAL
1 DIGOXIN (125, 250 MCG) TABLET DIGOXIN
2 DIGOXIN (50 MCG/ML) SOLUTION DIGOXIN
1 DIHYDROERGOTAMINE DIHYDROERGOTAMINE X
2 DILANTIN PHENYTOIN
2 DILANTIN‐125 PHENYTOIN
3 DILATRATE‐SR ISOSORBIDE DINITRATE
2 DILAUDID HYDROMORPHONE HCL X
3 DILAUDID HYDROMORPHONE HCL/PF X
1 DILTIAZEM DILTIAZEM
1 DILTIAZEM CD DILTIAZEM
2 DILTIAZEM ER TABLET DILTIAZEM
1 DILTIAZEM ER/IR CAPSULE DILTIAZEM
3 DILUENT FOR ROTARIX DILUENT,LIVE ROTAVIRUS VACC,CA
3 DILUTING MEDIUM FOR NOVOLOG DILUENT, INSULIN ASPART NO.1
2 DIOVAN VALSARTAN
Excluded DIPENTUM
1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE HCL/ATROPINE
2 DIPROLENE BETAMETHASONE/PROPYLENE GLYC
2 DIPROLENE AF BETAMETHASONE/PROPYLENE GLYC
1 DIPYRIDAMOLE DIPYRIDAMOLE
2 DISALCID SALSALATE
3 DISKETS METHADONE HCL X X
1 DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE
1 DISULFIRAM DISULFIRAM
2 DITROPAN XL OXYBUTYNIN CHLORIDE
3 DIURIL CHLOROTHIAZIDE
1 DIVALPROEX SODIUM DIVALPROEX SODIUM
2 DIVIGEL ESTRADIOL
1 DOFETILIDE DOFETILIDE X
3 DOLOPHINE HCL (5, 10 MG) TABLET METHADONE HCL X X
1 DONEPEZIL 10 MG TABLET DONEPEZIL HCL
2 DONEPEZIL 23 MG TABLET DONEPEZIL
1 DONEPEZIL HCL (10 MG) TABLET DONEPEZIL HCL
1 DONEPEZIL HCL (5, 10 MG) TAB RAPDIS DONEPEZIL HCL
2 DONNATAL PHENOBARB/HYOSCY/ATROPINE/SCOP
3 DORAL QUAZEPAM
3 DORYX (50, 200 MG) TABLET DR DOXYCYCLINE HYCLATE X X
3 DORYX MPC DOXYCYCLINE HYCLATE X X
1 DORZOLAMIDE HCL DORZOLAMIDE HCL
3 DOVER ADVANTAGE DRAINAGE BAG
3 DOVER ADVANTAGE DRAINAGE DRAINAGE BAG
3 DOVER COATED LATEX FOLEY URINARY BAG/CATH TRAY
3 DOVER LATEX FOLEY CATHETER CATHETER
3 DOVER PREMIUM DRAINAGE BAG
3 DOVER RED RUBBER ROBIBSON CATH CATHETER
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 DOVER UNIVERSAL CATHETERIZATION TRAY
2 DOVONEX CALCIPOTRIENE X
1 DOXAZOSIN DOXAZOSIN
2 DOXEPIN 5% CREAM DOXEPIN
1 DOXEPIN TABLET (BEHAVIORAL HEALTH) DOXEPIN
2 DOXERCALCIFEROL CAPSULE DOXERCALCIFEROL
1 DOXYCYCLINE HYCLATE 100 MG CAPSULE DOXYCYCLINE HYCLATE
1 DOXYCYCLINE HYCLATE 100 MG TABLET DOXYCYCLINE HYCLATE
2 DOXYCYCLINE HYCLATE 100 MG TABLET DR DOXYCYCLINE HYCLATE
2 DOXYCYCLINE HYCLATE 150 MG TABLET DR DOXYCYCLINE HYCLATE
1 DOXYCYCLINE HYCLATE 20 MG CAPSULE DOXYCYCLINE HYCLATE
2 DOXYCYCLINE HYCLATE 200 MG TABLET DR DOXYCYCLINE HYCLATE
1 DOXYCYCLINE HYCLATE 50 MG CAPSULE DOXYCYCLINE HYCLATE
2 DOXYCYCLINE HYCLATE 50 MG TABLET DR DOXYCYCLINE HYCLATE
2 DOXYCYCLINE HYCLATE 75 MG TABLET DR DOXYCYCLINE HYCLATE
1 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE DOXYCYCLINE MONOHYDRATE
2 DOXYCYCLINE MONOHYDRATE 150 MG CAPSULE DOXYCYCLINE MONOHYDRATE
1 DOXYCYCLINE MONOHYDRATE 150 MG TABLET DOXYCYCLINE MONOHYDRATE
2
DOXYCYCLINE MONOHYDRATE 40MG CAPSULE BIPHASIC
RELEASE DOXYCYCLINE MONOHYDRATE
1 DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE DOXYCYCLINE MONOHYDRATE
1 DOXYCYCLINE MONOHYDRATE 50 MG TABLET DOXYCYCLINE MONOHYDRATE
2 DOXYCYCLINE MONOHYDRATE 75 MG CAPSULE DOXYCYCLINE MONOHYDRATE
1 DOXYCYCLINE MONOHYDRATE 75 MG TABLET DOXYCYCLINE MONOHYDRATE
2 DRITHOCREME HP ANTHRALIN X
2 DRONABINOL CAPSULE DRONABINOL X X
1 DROSPIR/ETH ESTRA/LEVOMEFOL CA DROSPIR/ETH ESTRA/LEVOMEFOL CA X
3 DROXIA HYDROXYUREA
2 DRYSOL ALUMINUM CHLORIDE
3 DUAC CLINDAMYCIN PHOS/BENZOYL PEROX
2 DUAVEE ESTROGENS,CONJ/BAZEDOXIFENE
3 DUET DHA 400 PNV106/IRON/FA/OM3/DHA/EPA
3 DUET DHA BALANCED PNV117/IRON/FA/OM3/DHA/EPA
2 DUETACT PIOGLITAZONE HCL/GLIMEPIRIDE X
Excluded DUEXIS
2 DULERA MOMETASONE/FORMOTEROL X
1 DULOXETINE HCL (30, 60 MG) CAPSULE DR DULOXETINE HCL X
2 DULOXETINE HCL 40 MG CAPSULE DULOXETINE
3 DUODOTE PRALIDOXIME CHLORIDE/ATROPINE
3 DUOPA CARBIDOPA/LEVODOPA X
3 DURACLON CLONIDINE HCL/PF
2 DURAGESIC FENTANYL X X
3 DURAMORPH MORPHINE SULFATE/PF
2 DUREZOL DIFLUPREDNATE
Excluded DURLAZA
1 DUTASTERIDE DUTASTERIDE X
1 DUTASTERIDE/TAMSULOSIN HCL DUTASTERIDE/TAMSULOSIN HCL X
3 DYANAVEL XR AMPHETAMINE X X
2 DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZID
3 DYMISTA AZELASTINE/FLUTICASONE X X
3 DYMISTA ER AZELASTINE/FLUTICASONE X X
3 DYNACRIC CR
3 DYRENIUM TRIAMTERENE
3 DYSPORT ABOBOTULINUMTOXIN A X X X
3 EAR POPPER MIDDLE EAR INFLATION DEVICE
3 EASIVENT INHALER, ASSIST DEVICES
3 EBASE CONTROLLER COMPRESSOR, FOR NEBULIZER
3 ECLIPSE NEEDLE NEEDLES, SAFETY
3 ECLIPSE SYRINGE SYRINGE,SAFETY WITH NEEDLE,3ML
2 EC‐NAPROSYN NAPROXEN
2 ECONAZOLE NITRATE 0.01% CREAM ECONAZOLE NITRATE
3 ECOZA ECONAZOLE NITRATE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 EDARBI AZILSARTAN MEDOXOMIL X
2 EDARBYCLOR AZILSARTAN MED/CHLORTHALIDONE X
3 EDECRIN ETHACRYNIC ACID
3 EDEX ALPROSTADIL X
Excluded EDLUAR
2 EDURANT RILPIVIRINE HCL X
3 EFFER‐K POTASSIUM BICARBONATE/CIT AC
2 EFFEXOR XR VENLAFAXINE HCL
2 EFFIENT PRASUGREL HCL X
2 EFUDEX FLUOROURACIL
2 ELDEPRYL SELEGILINE HCL
3 ELESTAT EPINASTINE HCL
3 ELESTRIN ESTRADIOL
3 ELETONE EMOLLIENT COMBINATION NO. 25
2 ELIDEL PIMECROLIMUS X
2 ELIMITE PERMETHRIN
2 ELIQUIS (2.5 MG) TABLET APIXABAN X
2 ELIQUIS (5 MG) TABLET APIXABAN X
3 ELITE‐OB IRON,CARBONYL/FOLIC ACID/MV‐MN
3 ELLA ULIPRISTAL ACETATE
3 ELLIOTTS B CHEMO THEAPY DILUENT NO.1/PF
2 ELMIRON PENTOSAN POLYSULFATE SODIUM
2 ELOCON MOMETASONE FUROATE
Excluded EMADINE
3 EMBEDA (100MG‐4MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X
3 EMBEDA (20MG‐0.8MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X
3 EMBEDA (30MG‐1.2MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X
3 EMBEDA (50 MG‐2 MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X
3 EMBEDA (60MG‐2.4MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X
3 EMBEDA (80MG‐3.2MG) CAP ER PO MORPHINE SULFATE/NALTREXONE X
2 EMEND (125 MG) CAPSULE APREPITANT X
2 EMEND (125 MG) SUSP RECON APREPITANT X
2 EMEND (125MG‐80MG) CAP DS PK APREPITANT X
2 EMEND (40, 80 MG) CAPSULE APREPITANT X
Excluded EMFLAZA
3 EMSAM SELEGILINE X
2 EMTRIVA (10 MG/ML) SOLUTION EMTRICITABINE X
2 EMTRIVA (200 MG) CAPSULE EMTRICITABINE X
2 EMVERM MEBENDAZOLE X
3 ENABLEX DARIFENACIN HYDROBROMIDE X
1 ENALAPRIL MALEATE ENALAPRIL MALEATE
1 ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL/HYDROCHLOROTHIAZIDE
3 ENBRACE HR PRENATAL #92/IRON/FA #8/PS‐DHA
2 ENBREL ETANERCEPT X X X
3 ENDO‐AVITENE MICROFIBRILLAR COLLAGEN
3 ENDOFORM EXTRACELLULAR MATRIX, OVINE
3 ENJUVIA
3 ENLITE BLOOD‐GLUC TRANSMITTER/SENSOR
3 ENLITE GLUCOSE SENSOR BLOOD‐GLUCOSE SENSOR
3 ENLITE SERTER DIABETIC SUPPLIES,MISCELL
1 ENOXAPARIN SODIUM (100 MG/ML) SYRINGE ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (120MG/.8ML) SYRINGE ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (150 MG/ML) SYRINGE ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (300MG/3ML) VIAL ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (30MG/0.3ML) SYRINGE ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (40MG/0.4ML) SYRINGE ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (60MG/0.6ML) SYRINGE ENOXAPARIN SODIUM X
1 ENOXAPARIN SODIUM (80MG/0.8ML) SYRINGE ENOXAPARIN SODIUM X
3 ENSTILAR CALCIPOTRIENE/BETAMETHASONE X
1 ENTACAPONE ENTACAPONE
3 ENTEREG ALVIMOPAN
2 ENTOCORT EC BUDESONIDE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 ENTRESTO SACUBITRIL/VALSARTAN X
3 ENTYVIO VEDOLIZUMAB X X
3 ENVARSUS XR TACROLIMUS X X
3 EPANED ENALAPRIL MALEATE X X
2 EPCLUSA X
3 EPICERAM EMOLLIENT COMBINATION NO.32
2 EPIDUO ADAPALENE/BENZOYL PEROXIDE X
2 EPIDUO FORTE ADAPALENE/BENZOYL PEROXIDE X
3 EPIFIX AMNIOTIC MEMBRANE HUMAN REGENERATIVE TISSUE MTRX
3 EPIFOAM HYDROCORTISONE/PRAMOXINE
1 EPINASTINE HCL EPINASTINE HCL
1 EPINEPHRINE EPINEPHRINE
2 EPIPEN EPINEPHRINE
2 EPIPEN 2‐PAK EPINEPHRINE
2 EPIPEN JR 2‐PAK EPINEPHRINE
3 EPISIL MUCOSITIS AND STOMATITIS COMB2
2 EPIVIR (10 MG/ML) SOLUTION LAMIVUDINE X
2 EPIVIR (150 MG) TABLET LAMIVUDINE X
2 EPIVIR (300 MG) TABLET LAMIVUDINE X
2 EPIVIR HBV (100 MG) TABLET LAMIVUDINE X
2 EPIVIR HBV (25 MG/5 ML) SOLUTION LAMIVUDINE X
2 EPLERENONE TABLET EPLERENONE
3 EPOGEN EPOETIN X
Excluded EPROSARTAN
2 EPZICOM ABACAVIR SULFATE/LAMIVUDINE X
3 EQUETRO CARBAMAZEPINE
3 ERAPID NEBULIZER NEBULIZER
3 ERAPID NEBULIZER HANDSET NEBULIZER ACCESSORIES
1 ERGOCALCIFEROL (VITAMIN D2) ERGOCALCIFEROL (VITAMIN D2)
1 ERGOLOID MESYLATES ERGOLOID MESYLATES
3 ERGOMAR ERGOTAMINE TARTRATE X
1 ERGOTAMINE/CAFFEINE ERGOTAMINE/CAFFEINE X
3 ERTACZO SERTACONAZOLE NITRATE
2 ERYGEL ERYTHROMYCIN BASE/ETHANOL
2 ERYPED 200, 400 ERYTHROMYCIN ETHYLSUCCINATE
2 ERY‐TAB ERYTHROMYCIN BASE
1 ERYTHROMYCIN BASE ERYTHROMYCIN BASE
1 ERYTHROMYCIN BASE (250 MG) CAPSULE DR ERYTHROMYCIN BASE
1 ERYTHROMYCIN BASE (250 MG) TABLET DR ERYTHROMYCIN BASE
1 ERYTHROMYCIN BASE (500 MG) TABLET ERYTHROMYCIN BASE
1 ERYTHROMYCIN BASE (500 MG) TABLET DR ERYTHROMYCIN BASE
1 ERYTHROMYCIN BASE/ETHANOL (2 %) (MED. SWAB) ERYTHROMYCIN BASE/ETHANOL
2 ERYTHROMYCIN BASE/ETHANOL (2 %) GEL ERYTHROMYCIN BASE/ETHANOL
1 ERYTHROMYCIN BASE/ETHANOL (2 %) SOLUTION ERYTHROMYCIN BASE/ETHANOL
1 ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE
1 ERYTHROMYCIN STEARATE ERYTHROMYCIN STEARATE
2 ERYTHROMYCIN TOPICAL GEL ERYTHROMYCIN
1 ERYTHROMYCIN TOPICAL SOLUTION ERYTHROMYCIN
2 ERYTHROMYCIN/BENZOYL GEL ERYTHROMYCIN/BENZOYL PEROXIDE
3 ESCAVITE PEDI MULTIVIT 47/IRON/FLUORIDE
3 ESCAVITE D PEDI MULTIVIT 78/IRON/FLUORIDE
3 ESCAVITE LQ PEDI MULTIVIT 86/IRON/FLUORIDE
1 ESCITALOPRAM ESCITALOPRAM
3 ESGIC (50‐325‐40) CAPSULE BUTALB/ACETAMINOPHEN/CAFFEINE
2 ESGIC (50‐325‐40) TABLET BUTALB/ACETAMINOPHEN/CAFFEINE
1 ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM X X
1 ESOMEPRAZOLE STRONTIUM ESOMEPRAZOLE STRONTIUM X X
1 ESTAZOLAM ESTAZOLAM
2 ESTRACE ESTRADIOL
1 ESTRADIOL ESTRADIOL
1 ESTRADIOL PATCH ESTRADIOL X
1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL/NORETHINDRONE ACET
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 ESTRING ESTRADIOL X
Excluded ESTROGEL
1 ESTROGEN,ESTER/ME‐TESTOSTERONE ESTROGEN,ESTER/ME‐TESTOSTERONE
1 ESTROPIPATE ESTROPIPATE
3 ESTROSTEP FE NORETHINDRONE‐E.ESTRADIOL‐IRON X
1 ESZOPICLONE ESZOPICLONE X
1 ETHACRYNIC ACID ETHACRYNIC ACID
1 ETHAMBUTOL HCL ETHAMBUTOL HCL
1 ETHOSUXIMIDE ETHOSUXIMIDE
3 ETHYL ACETATE ETHYL ACETATE
1 ETHYL CHLORIDE ETHYL CHLORIDE
2 ETIDRONATE TABLET ETIDRONATE
2 ETODOLAC ER TABLET ETODOLAC
1 ETOPOSIDE ETOPOSIDE
3 EUCRISA CRISABOROLE X
2 EURAX CROTAMITON
3 EVAMIST ESTRADIOL
3 EVARREST FIBRINOGEN/THROMBIN(HUMAN DER)
Excluded EVEKEO AMPHETAMINE SULFATE
3 EVICEL THROMBIN(HUM PLAS)/FIBRINOG/CA
2 EVISTA RALOXIFENE HCL X
2 EVOCLIN CLINDAMYCIN PHOSPHATE
2 EVOTAZ ATAZANAVIR SULFATE/COBICISTAT X
2 EVOXAC CEVIMELINE HCL
Excluded EVZIO
3 EXALGO (8, 12, 16, 32 MG) TAB ER 24H HYDROMORPHONE HCL X X
2 EXELDERM SULCONAZOLE NITRATE
2 EXELON RIVASTIGMINE X
1 EXEMESTANE EXEMESTANE
2 EXFORGE AMLODIPINE/VALSARTAN X
2 EXFORGE HCT AMLODIPINE/VALSARTAN/HCTHIAZID X
Excluded EXONDYS 51 ETEPLIRSEN
Excluded EXTAVIA
3 EXTINA KETOCONAZOLE
3 EYE HOMEOPATHIC DRUGS
3 E‐Z SPACER INHALER, ASSIST DEVICES
1 EZETIMIBE EZETIMIBE X
2 FABIOR TAZAROTENE
3 FACTIVE GEMIFLOXACIN MESYLATE
1 FAMCICLOVIR FAMCICLOVIR
2 FAMOTIDINE ORAL SUSPENSION FAMOTIDINE
1 FAMOTIDINE TABLET FAMOTIDINE
3 FANAPT ILOPERIDONE X X
Excluded FARXIGA
1 FAYOSIM
3 FAZACLO CLOZAPINE X X
1 FELBAMATE (400 MG) TABLET FELBAMATE X X
1 FELBAMATE (600 MG) TABLET FELBAMATE X X
1 FELBAMATE (600 MG/5ML) ORAL SUSP FELBAMATE X X
3 FELBATOL (400 MG) TABLET FELBAMATE X X
3 FELBATOL (600 MG) TABLET FELBAMATE X X
3 FELBATOL (600 MG/5ML) ORAL SUSP FELBAMATE X X
2 FELDENE PIROXICAM
1 FELODIPINE FELODIPINE
3 FEM PH ACETIC ACID/OXYQUINOLINE
3 FEMALE SELF CATHETER CATHETER
2 FEMARA LETROZOLE
3 FEMCAP CERVICAL CAP
3 FEMCON FE NORETH‐ETHINYL ESTRADIOL/IRON X
2 FEMHRT NORETHINDRONE AC‐ETH ESTRADIOL
3 FEMRING ESTRADIOL ACETATE X
3 FEMTRACE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 FENOFIBRATE 150 MG CAPSULE (LIPOFEN) FENOFIBRATE
2 FENOFIBRATE 40 MG, 120 MG TABLET (FENOGLIDE) FENOFIBRATE
1 FENOFIBRATE 50 MG CAPSULE (LIPOFEN) FENOFIBRATE
1 FENOFIBRATE 54 MG, 160 MG TABLET (LOFIBRA) FENOFIBRATE
1 FENOFIBRATE MICRONIZED FENOFIBRATE MICRONIZED
2
FENOFIBRATE MICRONIZED 43 MG, 130 MG CAPSULE
(ANTARA) FENOFIBRATE MICRONIZED
1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE NANOCRYSTALLIZED
1 FENOFIBRIC ACID FENOFIBRIC ACID X
1 FENOFIBRIC ACID FENOFIBRIC ACID
2 FENOGLIDE FENOFIBRATE X
2 FENOPROFEN CAPSULE FENOPROFEN
2 FENORTHO FENOPROFEN CALCIUM
1
FENTANYL TRANSDREMAL PATCH 12MCG/HR, 25MCG/HR,
50MCG/HR, 75MCG/HR FENTANYL
2
FENTANYL TRANSDREMAL PATCH 37.5MCG/HR,
62.5MCG/HR, 87.5MCG/HR FENTANYL
Excluded FENTORA
3 FERIVA IRON/FOLIC ACID/C/B12/BIOTIN
3 FERIVA 21‐7 IRON/FA#1/VIT C/B12/ZN/DSS/SUC
3 FERIVA FA IRON/FA#1/C/B12/BIOT/COPPR/DSS
3 FERRALET 90 IRON CARB,GL/FA/B12/C/DOCUSATE
1 FERRIC SUBSULFATE FERRIC SUBSULFATE
1 FERROUS FUM/FOLIC ACID/BCOMP,C FERROUS FUM/FOLIC ACID/BCOMP,C
1 FERROUS FUM/VIT C/B12/STOMC FERROUS FUM/VIT C/B12/STOMC
1 FERROUS FUM/VIT C/B12‐IF/FOLIC FERROUS FUM/VIT C/B12‐IF/FOLIC
1 FERROUS FUMARATE/FOLIC ACID FERROUS FUMARATE/FOLIC ACID
2 FETZIMA LEVOMILNACIPRAN HCL X X
Excluded FEXMID
2 FEXOFENADINE‐PSE COMBO TABLET (ALLEGRA D 24 HOUR)
3 FIBRICOR FENOFIBRIC ACID
3 FILTER NEEDLE NEEDLES, FILTER
3 FILTER PAD NEBULIZER ACCESSORIES
3 FILTER, VALVE SET FOR LL & LC NEBULIZER ACCESSORIES
3 FILTERED EXTENSION SET INTRAVENOUS EXTEN.SET‐FILTER
3 FINACEA AZELAIC ACID
1 FINASTERIDE FINASTERIDE
3 FIORICET BUTALB/ACETAMINOPHEN/CAFFEINE
3 FIORICET WITH CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE X
2 FIORINAL BUTALBITAL/ASPIRIN/CAFFEINE
2 FIORINAL WITH CODEINE #3 CODEINE/BUTALBITAL/ASA/CAFFEIN X
2 FLAGYL METRONIDAZOLE
2 FLAGYL ER METRONIDAZOLE
2 FLAREX FLUOROMETHOLONE ACETATE
1 FLAVOXATE HCL FLAVOXATE HCL
1 FLECAINIDE ACETATE FLECAINIDE ACETATE
Excluded FLEXEPAX
3 FLEXICHAMBER INHALER, ASSIST DEVICES
3 FLEXI‐SEAL SIGNAL FMS FECAL COLL W‐CHARCOAL/CATH/SYR
2 FLOMAX TAMSULOSIN HCL
3 FLORIVA SODIUM FLUORIDE/VITAMIN D3
3 FLORIVA PEDI MULTIVIT NO.85/FLUORIDE
3 FLORIVA PLUS PEDI MULTIVIT NO.130/FLUORIDE
Excluded FLOVENT DISKUS
Excluded FLOVENT HFA
3 FLOWTUSS GUAIFENESIN/HYDROCODONE X X
2 FLOXIN OFLOXACIN
1 FLUCONAZOLE FLUCONAZOLE
1 FLUCYTOSINE FLUCYTOSINE
1 FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE
3 FLUMADINE RIMANTADINE HCL
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
TherapyExcluded FLUMIST QUAD 2016‐2017 FLU VACC QV LIVE 2016(2‐49 YRS)
1 FLUNISOLIDE FLUNISOLIDE X
1 FLUOCINOLONE ACETONIDE 0.01 % CREAM (LOW) FLUOCINOLONE ACETONIDE
2 FLUOCINOLONE ACETONIDE 0.01 % SOLUTION (LOW) FLUOCINOLONE ACETONIDE
2 FLUOCINOLONE ACETONIDE 0.01% SOLUTION (LOW) FLUOCINOLONE ACETONIDE
1 FLUOCINOLONE ACETONIDE 0.025 % CREAM (LOWER‐MID) FLUOCINOLONE ACETONIDE
1 FLUOCINOLONE ACETONIDE 0.025 % OINTMENT (MEDIUM) FLUOCINOLONE ACETONIDE
1 FLUOCINONIDE 0.05 % CREAM (HIGH) FLUOCINONIDE
1 FLUOCINONIDE 0.05 % EMOLIENT CREAM (HIGH) FLUOCINONIDE
1 FLUOCINONIDE 0.05 % GEL (HIGH) FLUOCINONIDE
2 FLUOCINONIDE 0.05 % OINTMENT (HIGH) FLUOCINONIDE
1 FLUOCINONIDE 0.05 % SOLUTION (HIGH) FLUOCINONIDE
2 FLUOCINONIDE 0.1 % CREAM (SUPER HIGH) FLUOCINONIDE
3 FLUORABON SODIUM FLUORIDE
3 FLUOR‐A‐DAY SODIUM FLUORIDE
3 FLUORESCEIN‐BENOXINATE BENOXINATE HCL/FLUORESCEIN NA
1 FLUORIDE/IRON/VITAMINS A,C,D FLUORIDE/IRON/VITAMINS A,C,D
2 FLUORITAB SODIUM FLUORIDE
1 FLUOROMETHOLONE FLUOROMETHOLONE
3 FLUOROPLEX FLUOROURACIL
1 FLUOROURACIL FLUOROURACIL
1 FLUOXAMINE TABLET FLUOXAMINE
1 FLUOXETINE CAPSULE FLUOXETINE
1 FLUOXETINE ER FLUOXETINE
2 FLUOXETINE HCL CAPSULE DR WEEKLY 90MG FLUOXETINE
1 FLUOXETINE/OLANZAPINE FLUOXETINE/OLANZAPINE X
2 FLUOXYMESTERONE TABLET FLUOXYMESTERONE
2 FLUPHENAZINE HCL TABLET FLUPHENAZINE
2 FLURA‐DROPS SODIUM FLUORIDE
2 FLURANDRENOLIDE 0.05 % CREAM (LOWER‐MID) FLURANDRENOLIDE
1 FLURAZEPAM HCL FLURAZEPAM HCL
1 FLURBIPROFEN FLURBIPROFEN
1 FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM
3 FLUROX BENOXINATE HCL/FLUORESCEIN NA
1 FLUTAMIDE FLUTAMIDE
1 FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE X
1 FLUTICASONE PROPIONATE 0.005 % OINTMENT (HIGH) FLUTICASONE PROPIONATE
1 FLUTICASONE PROPIONATE 0.05 % CREAM (LOWER‐MID) FLUTICASONE PROPIONATE
2 FLUTICASONE PROPIONATE 0.05 % LOTION (LOWER‐MID) FLUTICASONE PROPIONATE
2 FLUVASTATIN CAPSULE FLUVASTATIN X X
2 FLUVASTATIN SODIUM ER 80 MG TABLET FLUVASTATIN SODIUM
2 FLUVOXAMINE ER CAPSULE FLUVOXAMINE MALEATE
1 FLUVOXAMINE TABLET FLUVOXAMINE
2 FML FLUOROMETHOLONE
2 FML FORTE FLUOROMETHOLONE
2 FML S.O.P. FLUOROMETHOLONE
2 FOCALIN DEXMETHYLPHENIDATE HCL X
2 FOCALIN XR DEXMETHYLPHENIDATE HCL X
3 FOLET ONE PNV NO.80/IRON/MFOLATE/DSS/DHA
3 FOLGARD OS CALCIUM/MAG/D3/B12/FA/B6/BORON
2 FOLGARD RX CYANOCOBALAMIN/FOLIC AC/VIT B6
1 FOLIC ACID (1 MG) TABLET FOLIC ACID
1 FOLIC ACID (5 MG/ML) VIAL FOLIC ACID
1 FOLIC ACID/B COMPLEX C NO.17 FOLIC ACID/B COMPLEX C NO.17
1 FOLIC ACID/B CPLX/C/SELEN/ZINC FOLIC ACID/B CPLX/C/SELEN/ZINC
1 FOLIC ACID/VIT B COMPLEX AND C FOLIC ACID/VIT B COMPLEX AND C
1 FOLIC ACID/VIT BCOMP,C/CU/ZINC FOLIC ACID/VIT BCOMP,C/CU/ZINC
3 FOLTRATE CYANOCOBALAMIN/FOLIC ACID
1 FONDAPARINUX SODIUM (10MG/0.8ML) SYRINGE FONDAPARINUX SODIUM X
1 FONDAPARINUX SODIUM (2.5 MG/0.5) SYRINGE FONDAPARINUX SODIUM X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 FONDAPARINUX SODIUM (5MG/0.4ML) SYRINGE FONDAPARINUX SODIUM X
1 FONDAPARINUX SODIUM (7.5MG/0.6) SYRINGE FONDAPARINUX SODIUM X
3 FORADIL FORMOTEROL FUMARATE X X
3 FORANE ISOFLURANE
Excluded FORFIVO XL
1 FORMALDEHYDE FORMALDEHYDE
3 FORMA‐RAY FORMALDEHYDE
3 FORTAMET METFORMIN HCL X
3 FORTAVIT MV,IRON,MINS/DIET.SUP4/DNA/RNA
2 FORTEO TERIPARATIDE X
Excluded FORTESTA
3 FORTICAL
2 FOSAMAX ALENDRONATE SODIUM
2 FOSAMAX PLUS D ALENDRONATE SODIUM/VITAMIN D3
1 FOSINOPRIL SODIUM FOSINOPRIL SODIUM
1 FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL/HYDROCHLOROTHIAZIDE
3 FOSRENOL LANTHANUM CARBONATE
2 FRAGMIN (10000/ML) SYRINGE DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (12500/0.5) SYRINGE DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (15000/0.6) SYRINGE DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (18000/0.72) SYRINGE DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (2500/0.2ML) SYRINGE DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (25000/ML) VIAL DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (5000/0.2ML) SYRINGE DALTEPARIN SODIUM,PORCINE X
2 FRAGMIN (7500/0.3ML) SYRINGE DALTEPARIN SODIUM,PORCINE X
3 FREESTYLE NAVIGATOR BLOOD‐GLUCOSE SENSOR
3 FROVA X X
2 FROVATRIPTAN TABLET FROVATRIPTAN
2 FURADANTIN NITROFURANTOIN
1 FUROSEMIDE (10 MG/ML) SOLUTION FUROSEMIDE
1 FUROSEMIDE (40MG/5ML) SOLUTION FUROSEMIDE
3 FUSION PLUS IRON,FM,PS/FOLIC/B,C18/L.CASEI
3 FUSION SPRINKLES IRON FUM, PS/FA/VIT C/L. CASEI
2 FUZEON ENFUVIRTIDE X
3 FYCOMPA (0.5 MG/ML) ORAL SUSP PERAMPANEL X X
3 FYCOMPA (2, 4, 6, 8, 10, 12 MG) TABLET PERAMPANEL X X
1 GABAPENTIN GABAPENTIN
3 GABITRIL (2, 4, 12, 16 MG) TABLET TIAGABINE HCL X X
3 GABLOFEN BACLOFEN
1 GALANTAMINE HBR (12 MG) TABLET GALANTAMINE HBR X
1 GALANTAMINE HBR (16 MG) CAP24H PEL GALANTAMINE HBR X
1 GALANTAMINE HBR (24 MG) CAP24H PEL GALANTAMINE HBR X
1 GALANTAMINE HBR (4 MG) TABLET GALANTAMINE HBR X
1 GALANTAMINE HBR (4 MG/ML) SOLUTION GALANTAMINE HBR X
1 GALANTAMINE HBR (8 MG) CAP24H PEL GALANTAMINE HBR X
1 GALANTAMINE HBR (8 MG) TABLET GALANTAMINE HBR X
3 GALZIN ZINC ACETATE
3 GASTROCROM CROMOLYN SODIUM
1 GATIFLOXACIN GATIFLOXACIN
3 GELCLAIR POT SOR/HE‐CELLULOS/POV/HYALUR
3 GELFILM GELATIN
3 GELFOAM GELATIN SPONGE,ABSORBABLE
3 GELFOAM COMPRESSED GELATIN SPONGE,ABSORBABLE
3 GELNIQUE OXYBUTYNIN CHLORIDE X
3 GELX POVID/TAUR/ZN/PEG40 CASTOR OIL
1 GEMFIBROZIL GEMFIBROZIL
3 GENADUR CARBIT/EQUIS XT/ETHAN/CHIT/MSM
3 GENERESS FE NORETH‐ETHINYL ESTRADIOL/IRON
Excluded GENOTROPIN
1 GENTAMICIN SULFATE GENTAMICIN SULFATE
1 GENTIAN VIOLET/BRGREEN/PROFLAV GENTIAN VIOLET/BRGREEN/PROFLAV
2 GENVOYA ELVITEG/COBI/EMTRIC/TENOFO ALA X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 GEODON ZIPRASIDONE HCL X
3 GIALAX PEG 3350/SOD CHLOR/POTASS CIT
1 GIANVI, LORYNA, VESTURA X
3 GIAZO BALSALAZIDE DISODIUM X
2 GILENYA X
1 GLATOPA GLITIRAMER X
1 GLIMEPIRIDE TABLET GLIMEPIRIDE
1 GLIPIZIDE TABLET GLIPIZIDE
1 GLIPIZIDE/METFORMIN GLIPIZIDE/METFORMIN
3 GLUCAGEN GLUCAGON,HUMAN RECOMBINANT
2 GLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT
3 GLUCOCOM AUTOLINK DIABETIC SUPPLIES,MISCELL
2 GLUCOPHAGE METFORMIN HCL
2 GLUCOPHAGE XR METFORMIN HCL
2 GLUCOTROL GLIPIZIDE
2 GLUCOTROL XL GLIPIZIDE
2 GLUCOVANCE GLYBURIDE/METFORMIN HCL
Excluded GLUMETZA
3 GLUTATHIONE GLUTATHIONE
3 GLUTATHIONE‐L GLUTATHIONE
1 GLYBURIDE GLYBURIDE
1 GLYBURIDE,MICRONIZED GLYBURIDE,MICRONIZED
1 GLYBURIDE/METFORMIN GLYBURIDE/METFORMIN
1 GLYCINE UROLOGIC SOLUTION GLYCINE UROLOGIC SOLUTION
1 GLYCOPYRROLATE GLYCOPYRROLATE
3 GLYNASE GLYBURIDE,MICRONIZED
3 GLYSET MIGLITOL
2 GLYXAMBI EMPAGLIFLOZIN/LINAGLIPTIN X X
Excluded GOCOVRI AMANTADINE
2 GOLYTELY PEG3350/SOD SULF,BICARB,CL/KCL
Excluded GONITRO
3 GORDO‐UREA UREA
3 GRAFIX CORE HUMAN REGENERATIVE TISSUE MTRX
3 GRAFIX PRIME HUMAN REGENERATIVE TISSUE MTRX
Excluded GRALISE
2 GRANISETRON HCL TABLET GRANISETRON HCL X X
2 GRASTEK GRASS POLLEN‐TIMOTHY, STANDARD X
2 GRISEOFULVIN MICROSIZE TABLET GRISEOFULVIN MICROSIZE
2 GRISEOFULVIN ULTRAMICROSIZE TABLET GRISEOFULVIN ULTRAMICROSIZE
2 GRIS‐PEG GRISEOFULVIN ULTRAMICROSIZE
3 GUAIACOL GUAIACOL
1 GUANFACINE HCL GUANFACINE HCL
1 GUANFACINE HCL (BEHAVIORAL HEALTH ‐ OTHER) GUANFACINE HCL X
1 GUANIDINE HCL GUANIDINE HCL
3 GUARDIAN RT CHARGER DIABETIC SUPPLIES,MISCELL
3 GUARDIAN RT STARTER KIT DIABETIC SUPPLIES,MISCELL
3 GUARDIAN RT SYSTEM DIABETIC SUPPLIES,MISCELL
3 GUARDIAN TEST PLUG DIABETIC SUPPLIES,MISCELL
2 GYNAZOLE 1 BUTOCONAZOLE NITRATE
2 HALCION TRIAZOLAM
1 HALOBETASOL PROPIONATE 0.05% CREAM (SUPER HIGH) HALOBETASOL PROPIONATE
1
HALOBETASOL PROPIONATE 0.05% OINTMENT
(SUPER HIGH) HALOBETASOL PROPIONATE
3 HALOG HALCINONIDE
1 HALOPERIDOL LACTATE HALOPERIDOL LACTATE
1 HALOPERIDOL TABLET HALOPERIDOL
2 HARVONI
1 HC/MINERAL OIL/PETROLAT,WHT HC/MINERAL OIL/PETROLAT,WHT
3 HECTOROL DOXERCALCIFEROL
3 HELIDAC
3 HEMANGEOL PROPRANOLOL HCL X X
3 HEMATRON‐AF IRON/DSS/B12‐IF/FOLIC AC/MV‐MN
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 HEMMOREX‐HC HYDROCORTISONE ACETATE
3 HEMOCYTE PLUS IRON FUM/FOLIC ACID/MV,MIN 15
3 HEMOCYTE‐F FERROUS FUMARATE/FOLIC ACID
1 HEPARIN SOD,PORCINE/0.9 % NACL HEPARIN SOD,PORCINE/0.9 % NACL
1 HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE
1 HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM,PORCINE/D5W
1 HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF
3 HERCEPTIN TRASTUZUMAB X X X
3 HICON SODIUM IODIDE‐131
3 HIPREX METHENAMINE HIPPURATE
3 HISTEX‐AC TRIPROLIDINE/PHENYLEPH/CODEINE X
3 HI‐VOLUME PUMPING CHAMBER TRANSFER SETS
1 HOMATROPINE HBR HOMATROPINE HBR
Excluded HORIZANT
3 HPR EMOLLIENT COMBINATION NO.44
3 HPR PLUS EMOLLIENT COMBINATION NO.53
2 HUMALOG INSULIN LISPRO X
2 HUMALOG MIX 50‐50 INSULIN LISPRO PROTAMIN/LISPRO X
2 HUMALOG MIX 75‐25 INSULIN LISPRO PROTAMIN/LISPRO X
Excluded HUMATROPE
2 HUMIRA ADALIMUMAB X
2 HUMULIN 70‐30 INSULIN NPH HUM/REG INSULIN HM X
2 HUMULIN N INSULIN NPH HUMAN ISOPHANE X
2 HUMULIN R INSULIN REGULAR, HUMAN X
2 HUMULIN R U‐500 INSULIN REGULAR, HUMAN X
2 HYCET HYDROCODONE/ACETAMINOPHEN X
Excluded HYCOFENIX
1 HYDRALAZINE HCL HYDRALAZINE HCL
2 HYDREA HYDROXYUREA
3 HYDRO 35 UREA
3 HYDRO 40 UREA
1 HYDROCHLOROTHIAZIDE (12.5 MG) CAPSULE HYDROCHLOROTHIAZIDE
1 HYDROCHLOROTHIAZIDE (12.5 MG) TABLET HYDROCHLOROTHIAZIDE
1 HYDROCODONE BIT/HOMATROP ME‐BR HYDROCODONE BIT/HOMATROP ME‐BR X
2 HYDROCODONE/APAP 10MG‐300MG TABLET (VICODIN) HYDROCODONE/APAP X
1 HYDROCODONE/APAP 10MG‐325MG TABLET (NORCO) HYDROCODONE/APAP X
2 HYDROCODONE/APAP 5 MG‐300MG TABLET (VICODIN) HYDROCODONE/APAP X
1 HYDROCODONE/APAP 5 MG‐325MG TABLET (NORCO) HYDROCODONE/APAP X
2 HYDROCODONE/APAP 7.5‐300 MG TABLET (VICODIN) HYDROCODONE/APAP X
1 HYDROCODONE/APAP 7.5‐325 MG TABLET (NORCO) HYDROCODONE/APAP X
2 HYDROCORTISONE ACETATE/LIDOCAINE KIT HYDROCORTISONE/LIDOCAINE
1
HYDROCORTISONE ACETATE/LIDOCAINE RECTAL
CREAM 3‐0.5% HYDROCORTISONE/LIDOCAINE
1
HYDROCORTISONE ACETATE/LIDOCAINE/ALOE VERA GEL
(2.8‐9.55%) HYDROCORTISONE/LIDOCAINE
2 HYDROCORTISONE ACETATE/LIDOCAINE/ALOE VERA KIT HYDROCORTISONE/LIDOCAINE
2 HYDROCORTISONE BUTYRATE 0.1% CREAM (LOWER‐MID) HYDROCORTISONE BUTYRATE
2
HYDROCORTISONE BUTYRATE 0.1% LIPO CREAM
(LOWER‐MID) HYDROCORTISONE BUTYRATE
2
HYDROCORTISONE BUTYRATE 0.1% OINTMENT
(LOWER‐MID) HYDROCORTISONE BUTYRATE
2
HYDROCORTISONE BUTYRATE 0.1% SOLUTION
(LOWER‐MID) HYDROCORTISONE BUTYRATE
2 HYDROCORTISONE VALERATE 0.2% CREAM (LOWER‐MID) HYDROCORTISONE VALERATE
2 HYDROCORTISONE VALERATE 0.2% OINTMENT (MEDIUM) HYDROCORTISONE VALERATE
3 HYDROFERA BLUE PVA/GENTIAN VIOLET/METHYL BLUE
1 HYDROMORPHONE HCL (0.5MG/.5ML) SYRINGE HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (1 MG/ML) AMPUL HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (1 MG/ML) LIQUID HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (1 MG/ML) SYRINGE HYDROMORPHONE HCL X
2 HYDROMORPHONE HCL (12 MG) TAB ER 24H HYDROMORPHONE HCL X X
1 HYDROMORPHONE HCL (16 MG) TAB ER 24H HYDROMORPHONE HCL X X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 HYDROMORPHONE HCL (2 MG) TABLET HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (2 MG/ML) AMPUL HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (2 MG/ML) SYRINGE HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (2 MG/ML) VIAL HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (3 MG) SUPP RECT HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (32 MG) TAB ER 24H HYDROMORPHONE HCL X X
1 HYDROMORPHONE HCL (4 MG) TABLET HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (4 MG/ML) AMPUL HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (4 MG/ML) SYRINGE HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL (60 MG/30ML) PCA SYRINGE HYDROMORPHONE HCL X
2 HYDROMORPHONE HCL (8 MG) TAB ER 24H HYDROMORPHONE HCL X X
1 HYDROMORPHONE HCL (8 MG) TABLET HYDROMORPHONE HCL X
1 HYDROMORPHONE HCL/0.9% NACL/PF HYDROMORPHONE HCL/0.9% NACL/PF X
1 HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF X
1 HYDROMORPHONE/BUPIV/0.9NACL/PF HYDROMORPHONE/BUPIV/0.9NACL/PF X
1 HYDROMORPHONE/ROPIV/SOD CHL/PF HYDROMORPHONE/ROPIV/SOD CHL/PF X
1 HYDROXOCOBALAMIN HYDROXOCOBALAMIN
1 HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE
1 HYDROXYUREA HYDROXYUREA
1 HYDROXYZINE HYDROXYZINE
3 HYGEL HYALURONATE SODIUM/HE‐CELL/PEG
3 HYLATOPIC EMOLLIENT COMBINATION NO.44
3 HYLATOPICPLUS EMOLLIENT COMBINATION NO.53
1 HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE
3 HYPER‐SAL (3.5 %) VIAL‐NEB SODIUM CHLORIDE FOR INHALATION
2 HYPER‐SAL (7 %) VIAL‐NEB SODIUM CHLORIDE FOR INHALATION
3 HYPODERMIC NEEDLE NEEDLES, DISPOSABLE
2 HYSINGLA ER HYDROCODONE BITARTRATE X
2 HYZAAR LOSARTAN/HYDROCHLOROTHIAZIDE
1 IBANDRONATE SODIUM IBANDRONATE SODIUM
3 IBUDONE HYDROCODONE/IBUPROFEN X
1 IBUPROFEN TABLET IBUPROFEN
2 ILEVRO NEPAFENAC
1 IMIPRAMINE HCL TABLET IMIPRAMINE
2 IMIPRAMINE PAMOATE CAPSULE (TOFRANIL PM) IMIPRAMINE PAMOATE
1 IMIQUIMOD IMIQUIMOD X X
2 IMITREX SUMATRIPTAN X
2 IMITREX (25, 100 MG) TABLET SUMATRIPTAN SUCCINATE X
2 IMITREX (4 MG/0.5ML) CARTRIDGE SUMATRIPTAN SUCCINATE X
2 IMITREX (4 MG/0.5ML) PEN INJCTR SUMATRIPTAN SUCCINATE X
2 IMITREX (50 MG) TABLET SUMATRIPTAN SUCCINATE X
2 IMITREX (6 MG/0.5ML) CARTRIDGE SUMATRIPTAN SUCCINATE X
2 IMITREX (6 MG/0.5ML) PEN INJCTR SUMATRIPTAN SUCCINATE X
2 IMITREX (6 MG/0.5ML) VIAL SUMATRIPTAN SUCCINATE X
3 IMPAVIDO MILTEFOSINE X
2 IMURAN AZATHIOPRINE
3 INCRUSE ELLIPTA UMECLIDINIUM BROMIDE X X
1 INDAPAMIDE INDAPAMIDE
2 INDERAL LA PROPRANOLOL HCL
3 INDERAL XL PROPRANOLOL HCL X
3 INDICLOR INDIUM‐111 CHLORIDE
2 INDOCIN INDOMETHACIN
1 INDOMETHACIN INDOMETHACIN
3 INFASURF CALFACTANT
3 INFUSION SET INTRAVENOUS ADMINISTRATION SET
3 INNOPRAN XL PROPRANOLOL HCL X
3 INNOSPIRE DELUXE NEBULIZER AND COMPRESSOR
3 INNOSPIRE ELEGANCE NEBULIZER AND COMPRESSOR
3 INNOSPIRE ESSENCE NEBULIZER AND COMPRESSOR
3 INNOSPIRE MINI NEBULIZER AND COMPRESSOR
3 INNOSPIRE REPLACEMENT FILTER NEBULIZER ACCESSORIES
3 INOVA BENZOYL PEROXIDE/VIT E MIX
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 INOVA 4‐1 SALICYLIC AC/BENZOYL PER/VIT E
3 INOVA 8‐2 SALICYLIC AC/BENZOYL PER/VIT E
3 INSET 30 INFUSION SET INFUSION SET FOR INSULIN PUMP
3 INSET 30 TUBING SUB‐Q INFUSION PUMP ACCESSORY
3 INSET INFUSION SET INFUSION SET FOR INSULIN PUMP
3 INSPIRACHAMBER INHALER, ASSIST DEVICES
3 INSPIRATION ELITE FILTER NEBULIZER ACCESSORIES
2 INSPRA EPLERENONE
3 INSUFLON SUB‐Q ADMINISTRATION SET
3 INSYTE AUTOGUARD INTRAVENOUS CATHETER
3 INSYTE IV CATHETER INTRAVENOUS CATHETER
3 INTEGRA F IRON FUM,PS/FOLIC ACID/VITC/B3
3 INTEGRA PLUS IRON FUM,PS/FA/VIT B WITH C #9
3 INTEGRA SYRINGE SYRINGE,SAFETY WITH NEEDLE,3ML
2 INTELENCE (100 MG) TABLET ETRAVIRINE X
2 INTELENCE (200 MG) TABLET ETRAVIRINE X
2 INTELENCE (25 MG) TABLET ETRAVIRINE X
3 INTERLINK SYRINGE W‐CANNULA SYRINGE W‐CANNULA,DISP, 10 ML
Excluded INTERMEZZO ZOLPIDEM
Excluded INTRON‐A INTERFERON ALFA 2B
3 INTUNIV GUANFACINE HCL X
3 INVEGA PALIPERIDONE X X
2 INVIRASE (200 MG) CAPSULE SAQUINAVIR MESYLATE X
2 INVIRASE (500 MG) TABLET SAQUINAVIR MESYLATE X
2 INVOKAMET CANAGLIFLOZIN/METFORMIN HCL X X
2 INVOKAMET XR CANAGLIFLOZIN/METFORMIN HCL X X
2 INVOKANA CANAGLIFLOZIN X X
1 IODINE/POTASSIUM IODIDE IODINE/POTASSIUM IODIDE
3 IODOFLEX CADEXOMER IODINE
3 IODOSORB CADEXOMER IODINE
3 IONSYS FENTANYL HCL
3 IOPIDINE APRACLONIDINE HCL
3 I‐PORT INJECTION PORTS
3 I‐PORT ADVANCE INJECTION PORTS
1 IPRATROPIUM IPRATROPIUM
1 IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM/ALBUTEROL SULFATE
3 IPRIVASK DESIRUDIN X X
1 IRBESARTAN IRBESARTAN
1 IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN/HYDROCHLOROTHIAZIDE
Excluded IRENKA
1 IRON ASPGLY,PS/C/B12/FA/CA/SUC IRON ASPGLY,PS/C/B12/FA/CA/SUC
1 IRON ASPGLY/C/B12/FA/CA‐TH/SUC IRON ASPGLY/C/B12/FA/CA‐TH/SUC
1 IRON BG,PS/VITC/B12/FA/CALCIUM IRON BG,PS/VITC/B12/FA/CALCIUM
1 IRON CARB,GL/FA/B12/C/DOCUSATE IRON CARB,GL/FA/B12/C/DOCUSATE
1 IRON FM,PS NO.1/FOLIC/MV NO.18 IRON FM,PS NO.1/FOLIC/MV NO.18
1 IRON FUM,AG/C/B12/FOLIC/CA/SUC IRON FUM,AG/C/B12/FOLIC/CA/SUC
1 IRON FUM,PS/FA/VIT B WITH C #9 IRON FUM,PS/FA/VIT B WITH C #9
1 IRON FUM,PS/FOLIC ACID/VITC/B3 IRON FUM,PS/FOLIC ACID/VITC/B3
1 IRON FUM/DOCUSAT/FOLIC/BCOMP,C IRON FUM/DOCUSAT/FOLIC/BCOMP,C
1 IRON FUMARATE/VIT C/VIT B12/FA IRON FUMARATE/VIT C/VIT B12/FA
1 IRON POLYSAC/IRON HEME/FA/B12 IRON POLYSAC/IRON HEME/FA/B12
1 IRON PS CMPLX/VIT B12/FA IRON PS CMPLX/VIT B12/FA
1 IRON,CARB/VIT C/VIT B12/FOLIC IRON,CARB/VIT C/VIT B12/FOLIC
1 IRON/C/FOLIC ACD/MV CMB11/CALC IRON/C/FOLIC ACD/MV CMB11/CALC
1 IRON/CALCIUM/E/FOLIC ACID/MVIT IRON/CALCIUM/E/FOLIC ACID/MVIT
1 IRON/DSS/B12‐IF/FOLIC AC/MV‐MN IRON/DSS/B12‐IF/FOLIC AC/MV‐MN
1 IRON/FOLATE 9/VIT C/D3/B6/B12 IRON/FOLATE 9/VIT C/D3/B6/B12
1 IRON/FOLIC AC/VIT BCOMP,C/MIN IRON/FOLIC AC/VIT BCOMP,C/MIN
1 IRON/FOLIC ACID/B12/C/DOCUSATE IRON/FOLIC ACID/B12/C/DOCUSATE
1 IRON/FOLIC ACID/C/B6/B12/ZINC IRON/FOLIC ACID/C/B6/B12/ZINC
3 IROSPAN IRON BG,PS/FOLIC/B,C NO.12/SUC
2 ISENTRESS (100 MG) POWD PACK RALTEGRAVIR POTASSIUM X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 ISENTRESS (25, 100 MG) TAB CHEW RALTEGRAVIR POTASSIUM X
2 ISENTRESS (400 MG) TABLET RALTEGRAVIR POTASSIUM X
2 ISOCHRON ISOSORBIDE DINITRATE
1 ISOFLURANE ISOFLURANE
1 ISOMETHEPT/DICHLPHN/ACETAMINOP ISOMETHEPT/DICHLPHN/ACETAMINOP
1 ISOMETHEPTEN/CAF/ACETAMINOPHEN ISOMETHEPTEN/CAF/ACETAMINOPHEN
1 ISONIAZID ISONIAZID
2 ISOPTO CARPINE PILOCARPINE HCL
2 ISORDIL ISOSORBIDE DINITRATE
2 ISORDIL TITRADOSE ISOSORBIDE DINITRATE
1 ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE
1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE
1 ISOTRETINOIN ISOTRETINOIN
1 ISOXSUPRINE HCL ISOXSUPRINE HCL
1 ISRADIPINE ISRADIPINE
3 ISTALOL TIMOLOL MALEATE
1 ITRACONAZOLE TABLET ITRACONAZOLE
1 IVERMECTIN IVERMECTIN
2 JALYN DUTASTERIDE/TAMSULOSIN HCL X
2 JANUMET SITAGLIPTIN PHOS/METFORMIN HCL X
2 JANUVIA SITAGLIPTIN PHOSPHATE X
2 JARDIANCE EMPAGLIFLOZIN X X
2 JENTADUETO LINAGLIPTIN/METFORMIN HCL X
3 JETCO‐SPRAY CANNULA MEDICAL SUPPLY, MISCELLANEOUS
2 JEVANTIQUE LO NORETHINDRONE AC‐ETH ESTRADIOL
3 JUBLIA EFINACONAZOLE X
2 JUXTABID X
Excluded KADIAN MORPHINE
2 KALETRA (100MG‐25MG) TABLET LOPINAVIR/RITONAVIR X
2 KALETRA (200MG‐50MG) TABLET LOPINAVIR/RITONAVIR X
2 KALETRA (400‐100/5) SOLUTION LOPINAVIR/RITONAVIR X
3 KANGAROO 924 SAFETY SCREW PUMP SET
3 KANGAROO EPUMP SET FEEDER CONTAINER WITH PUMP SET
3 KANGAROO GRAVITY SET FEEDER CONTAINER W‐GRAVITY SET
3 KAPVAY CLONIDINE HCL X
3 KARBINAL ER CARBINOXAMINE MALEATE X X
1 KARIVA
2 KAYEXALATE SODIUM POLYSTYRENE SULFONATE
Excluded KAZANO
2 KEFLEX (250, 500 MG) CAPSULE CEPHALEXIN
3 KEFLEX (750 MG) CAPSULE CEPHALEXIN
2 KENALOG TRIAMCINOLONE ACETONIDE
3 KENDALL DISINFECTANT CAP ALCOHOL SWAB CAP
3 KENGUARD CATHETER
2 KEPPRA LEVETIRACETAM
3 KEPPRA XR LEVETIRACETAM
3 KERAFOAM UREA
3 KERAGEL GEL DRESSING
3 KERAGELT GEL DRESSING
Excluded KERALAC UREA CREAM
3 KERALYT SALICYLIC ACID
3 KERALYT SCALP SALICYLIC ACID
3 KERLIX AMD POLYHEXAM BIGUAN/GAUZE BANDAGE
3 KERYDIN TAVABOROLE X
2 KETEK TELITHROMYCIN
1 KETOCONAZOLE 2 % CREAM KETOCONAZOLE
2 KETOCONAZOLE 2 % FOAM KETOCONAZOLE
1 KETOCONAZOLE 2 % SHAMPOO KETOCONAZOLE
1 KETOCONAZOLE TABLET KETOCONAZOLE
2 KETOCONAZOLE TOPICAL FOAM KETOCONAZOLE
2 KETOPROFEN ER CAPSULE KETOPROFEN
1 KETOROLAC TROMETHAMINE OPTHALMIC DROPS KETOROLAC TROMETHAMINE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
TherapyExcluded KEVZARA SARILUMAB
Excluded KHEDEZLA DESVENLAFAXINE
3 KINERET ANAKINRA X
2 KLARON SULFACETAMIDE SODIUM
2 KLONOPIN CLONAZEPAM
2 KLOR‐CON POTASSIUM CHLORIDE
2 KLOR‐CON 8, 10 POTASSIUM CHLORIDE
2 KLOR‐CON‐EF POTASSIUM BICARBONATE/CIT AC
Excluded KOMBIGLYZE XR
3 K‐PHOS NEUTRAL SOD PHOS DI, MONO/K PHOS MONO
3 K‐PHOS NO.2 SOD PHOS,M‐B/K PHOS,MONOB
3 K‐PHOS ORIGINAL POTASSIUM PHOSPHATE,MONOBASIC
2 KRISTALOSE LACTULOSE
3 KRYSTEXXA PEGLOTICASE X X
2 K‐TAB ER POTASSIUM CHLORIDE
3 KYLEENA LEVONORGESTREL
Excluded KYMRIAH TISAGENLECLEUCEL
2 KYNAMRO X
1 LABETALOL HCL LABETALOL HCL
3 LACRISERT HYDROXYPROPYL CELLULOSE
3 LACTATED RINGERS RINGERS SOLUTION,LACTATED
1 LACTIC ACID LACTIC ACID
1 LACTULOSE LACTULOSE
2 LAMICTAL LAMOTRIGINE
2 LAMICTAL (BLUE) LAMOTRIGINE
2 LAMICTAL (GREEN) LAMOTRIGINE
2 LAMICTAL (ORANGE) LAMOTRIGINE
3 LAMICTAL ODT (100 MG) TAB RAPDIS LAMOTRIGINE X X
3 LAMICTAL ODT (200 MG) TAB RAPDIS LAMOTRIGINE X X
3 LAMICTAL ODT (25 MG) TAB RAPDIS LAMOTRIGINE X X
3 LAMICTAL ODT (50 MG) TAB RAPDIS LAMOTRIGINE X X
3 LAMICTAL ODT (BLUE) LAMOTRIGINE X
3 LAMICTAL ODT (GREEN) LAMOTRIGINE X
3 LAMICTAL ODT (ORANGE) LAMOTRIGINE X
3 LAMICTAL XR (100 MG) TAB ER 24 LAMOTRIGINE X X
3 LAMICTAL XR (200 MG) TAB ER 24 LAMOTRIGINE X X
3 LAMICTAL XR (25 MG) TAB ER 24 LAMOTRIGINE X X
3 LAMICTAL XR (250 MG) TAB ER 24 LAMOTRIGINE X X
3 LAMICTAL XR (300 MG) TAB ER 24 LAMOTRIGINE X X
3 LAMICTAL XR (50 MG) TAB ER 24 LAMOTRIGINE X X
3 LAMICTAL XR (BLUE) LAMOTRIGINE X
3 LAMICTAL XR (GREEN) LAMOTRIGINE X
3 LAMICTAL XR (ORANGE) LAMOTRIGINE X
3 LAMIOFLUR HOMEOPATHIC DRUGS
2 LAMISIL TERBINAFINE HCL
1 LAMIVUDINE LAMIVUDINE X
1 LAMIVUDINE (10 MG/ML) SOLUTION LAMIVUDINE X
1 LAMIVUDINE (150 MG) TABLET LAMIVUDINE X
1 LAMIVUDINE (300 MG) TABLET LAMIVUDINE X
1 LAMIVUDINE/ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE X
2 LAMOTRIGINE (100 MG) TAB ER 24 LAMOTRIGINE X X
1 LAMOTRIGINE (100 MG) TAB RAPDIS LAMOTRIGINE X X
1 LAMOTRIGINE (100 MG) TABLET LAMOTRIGINE
1 LAMOTRIGINE (150 MG) TABLET LAMOTRIGINE
2 LAMOTRIGINE (200 MG) TAB ER 24 LAMOTRIGINE X X
1 LAMOTRIGINE (200 MG) TAB RAPDIS LAMOTRIGINE X X
1 LAMOTRIGINE (200 MG) TABLET LAMOTRIGINE
2 LAMOTRIGINE (25 MG) TAB ER 24 LAMOTRIGINE X X
1 LAMOTRIGINE (25 MG) TAB RAPDIS LAMOTRIGINE X X
1 LAMOTRIGINE (25 MG) TABLET LAMOTRIGINE
1 LAMOTRIGINE (25 MG) TB CHW DSP LAMOTRIGINE
1 LAMOTRIGINE (25(21)‐50) TB RD DSPK LAMOTRIGINE X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 LAMOTRIGINE (250 MG) TAB ER 24 LAMOTRIGINE X X
1 LAMOTRIGINE (25‐50‐100) TB RD DSPK LAMOTRIGINE X
2 LAMOTRIGINE (300 MG) TAB ER 24 LAMOTRIGINE X X
1 LAMOTRIGINE (5 MG) TB CHW DSP LAMOTRIGINE
2 LAMOTRIGINE (50 MG) TAB ER 24 LAMOTRIGINE X X
1 LAMOTRIGINE (50 MG) TAB RAPDIS LAMOTRIGINE X X
1 LAMOTRIGINE (50(42)‐100) TB RD DSPK LAMOTRIGINE X
2 LANOXIN (125 MCG) TABLET DIGOXIN
3 LANOXIN (187.5 MCG) TABLET DIGOXIN
2 LANOXIN (250 MCG) TABLET DIGOXIN
3 LANOXIN (62.5 MCG) TABLET DIGOXIN
3 LANOXIN PEDIATRIC DIGOXIN
1 LANSOPRAZOLE LANSOPRAZOLE
1 LANSOPRAZOLE/AMOXICILN/CLARITH LANSOPRAZOLE/AMOXICILN/CLARITH X
2 LANTUS INSULIN GLARGINE,HUM.REC.ANLOG X
2 LANTUS SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG X
2 LASIX FUROSEMIDE
Excluded LASTACAFT
1 LATANOPROST LATANOPROST
2 LATUDA LURASIDONE HCL X X
Excluded LAZANDA
3 LC D NEBULIZER SET NEBULIZER
3 LC PLUS NEBULIZER
3 LC SPRINT NEBULIZER NEBULIZER
3 LC STAR NEBULIZER
1 LEFLUNOMIDE LEFLUNOMIDE
3 LEMTRADA ALEMTUZUMAB X X X
3 LESCOL XL FLUVASTATIN SODIUM
1 LETROZOLE LETROZOLE
1 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM
3 LEVA SET LIDOCAINE/PRILOCAINE
2 LEVALBUTEROL INHALATION SOLUTION LEVALBUTEROL
2 LEVAQUIN LEVOFLOXACIN
3 LEVATOL PENBUTOLOL SULFATE
2 LEVBID HYOSCYAMINE SULFATE
Excluded LEVEMIR
3 LEVER LOCK CANNULA SYRINGE ACCESSORY
1 LEVETIRACETAM LEVETIRACETAM
Excluded LEVITRA
1 LEVOBUNOLOL HCL LEVOBUNOLOL HCL
1 LEVOCETIRIZINE SOLUTION LEVOCETIRIZINE X X
1 LEVOCETIRIZINE TABS LEVOCETIRIZINE
1 LEVOFLOXACIN LEVOFLOXACIN
1 LEVORA‐28
2 LEVO‐T LEVOTHYROXINE SODIUM
1 LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM
2 LEVOXYL LEVOTHYROXINE SODIUM
2 LEVSIN HYOSCYAMINE SULFATE
2 LEVSIN‐SL HYOSCYAMINE SULFATE
3 LEVULAN AMINOLEVULINIC ACID HCL
2 LEXAPRO ESCITALOPRAM OXALATE
2 LEXIVA (50 MG/ML) ORAL SUSP FOSAMPRENAVIR CALCIUM X
2 LEXIVA (700 MG) TABLET FOSAMPRENAVIR CALCIUM X
2 LIALDA MESALAMINE
2 LIBRAX CHLORDIAZEPOXIDE/CLIDINIUM BR
2 LIDOCAINE CREAM 3% LIDOCAINE
2 LIDOCAINE OINTMENT 5% LIDOCAINE
3 LIDODERM LIDOCAINE
3 LIDO‐K LIDOCAINE HCL
3 LIDOPIN LIDOCAINE HCL
3 LIDOPRIL LIDOCAINE/PRILOCAINE
3 LIDOPRIL XR LIDOCAINE/PRILOCAINE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 LIDO‐PRILO CAINE PACK LIDOCAINE/PRILOCAINE
3 LIDOVEX LIDOCAINE
3 LILETTA LEVONORGESTREL
1 LINDANE LOTION LINDANE
1 LINEZOLID (100 MG/5ML) SUSP RECON LINEZOLID
1 LINEZOLID (600 MG) TABLET LINEZOLID X
2 LINZESS LINACLOTIDE X
3 LIORESAL INTRATHECAL BACLOFEN
1 LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM
2 LIPITOR ATORVASTATIN CALCIUM
3 LIPOCHOL PLUS METHIONINE/INOSI/CHOL/FOLIC AC
3 LIPOFEN FENOFIBRATE X
3 LIPROZONEPAK LIDOCAINE/PRILOCAINE
3 LIPTRUZET X X
1 LISINOPRIL TABLET LISINOPRIL
1 LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE
3 LITEAIRE INHALER, ASSIST DEVICES
3 LITETOUCH INHALER,ASSIST DEVICE,ACCESORY
1 LITHIUM CARBONATE LITHIUM CARBONATE
1 LITHIUM CITRATE LITHIUM CITRATE
2 LITHOBID LITHIUM CARBONATE
3 LITHOSTAT ACETOHYDROXAMIC ACID
2 LIVALO PITAVASTATIN CALCIUM X
3 LIVIXIL PAK LIDOCAINE/PRILOCAINE
2 LO LOESTRIN FE NORETHINDRONE‐E.ESTRADIOL‐IRON X
2 LOCOID (0.1 %) CREAM, OINTMENT, SOLUTION HYDROCORTISONE BUTYRATE
3 LOCOID (0.1 %) LOTION HYDROCORTISONE BUTYRATE
2 LOCOID LIPOCREAM HYDROCORTISONE BUTYRATE/EMOLL
Excluded LOCORT
2 LODINE ETODOLAC
2 LODOSYN CARBIDOPA
2 LOESTRIN NORETHINDRONE AC‐ETH ESTRADIOL X
2 LOESTRIN FE NORETHINDRONE‐E.ESTRADIOL‐IRON X
2 LOMOTIL DIPHENOXYLATE HCL/ATROPINE
1 LOPERAMIDE HCL LOPERAMIDE HCL
2 LOPID GEMFIBROZIL
1 LOPINAVIR/RITONAVIR LOPINAVIR/RITONAVIR X
2 LOPRESSOR METOPROLOL TARTRATE
2 LOPRESSOR HCT METOPROLOL/HYDROCHLOROTHIAZIDE
2 LOPROX CICLOPIROX
3 LOPROX CICLOPIROX/SKIN CLEANSER NO.40
1 LORAZEPAM LORAZEPAM
3 LORTAB (10‐300/15) SOLUTION HYDROCODONE/ACETAMINOPHEN X
2 LORTAB (10MG‐325MG) TABLET HYDROCODONE/ACETAMINOPHEN X
2 LORTAB (5 MG‐325MG) TABLET HYDROCODONE/ACETAMINOPHEN X
2 LORTAB (7.5‐325 MG) TABLET HYDROCODONE/ACETAMINOPHEN X
3 LORZONE CHLORZOXAZONE
1 LOSARTAN TABLET LOSARTAN
1 LOSARTAN/HCTZ COMBO TABLET LOSARTAN/HCTZ
3 LOSEASONIQUE L‐NORGEST/E.ESTRADIOL‐E.ESTRAD X X
2 LOTEMAX LOTEPREDNOL ETABONATE
2 LOTENSIN BENAZEPRIL HCL
2 LOTENSIN HCT BENAZEPRIL/HYDROCHLOROTHIAZIDE
2 LOTREL AMLODIPINE BESYLATE/BENAZEPRIL
2 LOTRISONE CLOTRIMAZOLE/BETAMETHASONE DIP
3 LOTRONEX ALOSETRON HCL
1 LOVASTATIN LOVASTATIN
2 LOVAZA OMEGA‐3 ACID ETHYL ESTERS X
2 LOVENOX (100 MG/ML) SYRINGE ENOXAPARIN SODIUM X
2 LOVENOX (120MG/.8ML) SYRINGE ENOXAPARIN SODIUM X
2 LOVENOX (150 MG/ML) SYRINGE ENOXAPARIN SODIUM X
2 LOVENOX (300MG/3ML) VIAL ENOXAPARIN SODIUM X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 LOVENOX (30MG/0.3ML) SYRINGE ENOXAPARIN SODIUM X
2 LOVENOX (40MG/0.4ML) SYRINGE ENOXAPARIN SODIUM X
2 LOVENOX (60MG/0.6ML) SYRINGE ENOXAPARIN SODIUM X
2 LOVENOX (80MG/0.8ML) SYRINGE ENOXAPARIN SODIUM X
1 LOW‐OGESTREL
1 LOXAPINE SUCCINATE LOXAPINE SUCCINATE
3 LP LITE PAK LIDOCAINE/PRILOCAINE
2 LUDENT FLUORIDE SODIUM FLUORIDE
2 LUMIGAN 0.01% BIMATOPROST X
2 LUNESTA ESZOPICLONE X
3 LUPANETA PACK LEUPROLIDE/NORETHINDRONE ACET
3 LUPRON LUEPROLIDE X X X
3 LUXAMEND EMOLLIENT COMBINATION NO.10
3 LUXIQ BETAMETHASONE VALERATE
3 LUZU LULICONAZOLE X X
2 LYRICA PREGABALIN
3 LYSIPLEX PLUS LYSINE/E/FOLIC ACID/BCOMP,C/ZN
3 LYSTEDA TRANEXAMIC ACID
3 MACI AUTOL CHRONDROCY/COLLAGEN,PORC
2 MACROBID NITROFURANTOIN MONOHYD/M‐CRYST
2 MACRODANTIN NITROFURANTOIN MACROCRYSTAL
3 MACUVEX FA/VIT C/E/ZINC/COPPER/LUT/ZEA
3 MACUZIN FA/VIT C/E/ZINC/COPPER/LUT/ZEA
3 MAGELLAN TUBERCULIN SYRINGE SYRINGE,SAFETY WITH NEEDLE,1ML
3 MALARONE ATOVAQUONE/PROGUANIL HCL
2 MALATHION LOTION MALATHION
1 MANNITOL/SORBITOL SOLUTION MANNITOL/SORBITOL SOLUTION
1 MAPROTILINE HCL MAPROTILINE HCL
2 MARINOL DRONABINOL X X
3 MARPLAN ISOCARBOXAZID
3 MARVONA SUIK BUPIVACAINE/PF/NORFLU/HFC245FA
3 MASK SET WITH Y‐PIECE NEBULIZER ACCESSORIES
3 MATRISTEM EXTRACELL MATRIX,PORCINE,FENES
3 MATRISTEM MICROMATRIX EXTRACELLULAR MATRIX,PORCINE
2 MAVIK TRANDOLAPRIL
2 MAXALT RIZATRIPTAN BENZOATE X
2 MAXALT MLT RIZATRIPTAN BENZOATE X
3 MAXARON FORTE IRON GLY,FUM/C/B12/ME‐THFOLATE
3 MAXFE IRON/MFOLATE/B12/C/BIOT/ZN/DSS
3 MAXIDEX DEXAMETHASONE
3 MAXINATE PNV 3/IRON FUM,GLUC/FOLIC ACID
2 MAXITROL NEOMYCIN/POLYMYXIN B/DEXAMETHA
2 MAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZID
2 MAXZIDE‐25 MG TRIAMTERENE/HYDROCHLOROTHIAZID
3 M‐CLEAR WC CODEINE PHOSPHATE/GUAIFENESIN X
1 MECLIZINE HCL MECLIZINE HCL
2 MECLOFENAMATE SODIUM CAPSULE MECLOFENAMATE SODIUM
3 MEDOLOR PAK LIDOCAINE/PRILOCAINE
2 MEDROL METHYLPREDNISOLONE
3 MEDROLOAN II SUIK ME‐PREDNIS/NORFLURAN/HFC 245FA
3 MEDROLOAN SUIK ME‐PREDNIS/NORFLURAN/HFC 245FA
1 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE X
2 MEFENAMIC ACID CAPSULE MEFENAMIC ACID
1 MEFLOQUINE HCL MEFLOQUINE HCL
2 MEGACE MEGESTROL ACETATE
2 MEGACE ES MEGESTROL ACETATE
1 MEGESTROL SOLUTION MEGESTROL
1 MEGESTROL TABLET MEGESTROL
1 MELOXICAM TABLET MELOXICAM
1 MEMANTINE HCL (10 MG) TABLET MEMANTINE HCL X
1 MEMANTINE HCL (2 MG/ML) SOLUTION MEMANTINE HCL X
1 MEMANTINE HCL (5 MG) TABLET MEMANTINE HCL X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 MEMANTINE HCL (5 MG‐10 MG) TAB DS PK MEMANTINE HCL X
3 M‐END MAX D DEXBROMPHENIRAMINE/PSE/CODEINE X
3 M‐END PE BROMPHENIRAMINE/PE/CODEINE X
2 MENEST ESTROGENS, ESTERIFIED
3 MENOSTAR ESTRADIOL X
3 MENTAX BUTENAFINE HCL
1 MEPERIDINE HCL (10 MG/ML) CARTRIDGE MEPERIDINE HCL
1 MEPERIDINE HCL (100 MG) TABLET MEPERIDINE HCL X
1 MEPERIDINE HCL (50 MG) TABLET MEPERIDINE HCL X
1 MEPERIDINE HCL (50 MG/5 ML) SOLUTION MEPERIDINE HCL X
1 MEPERIDINE HCL/PF MEPERIDINE HCL/PF
2 MEPHYTON PHYTONADIONE (VIT K1)
2 MEPROBAMATE TABLET MEPROBAMATE
3 MEPRON ATOVAQUONE
1 MERCAPTOPURINE MERCAPTOPURINE
1 MESALAMINE 4 G/60 MI ENEMA MESALAMINE
2 MESALAMINE DR TABLET 800MG (ASACOL HD) MESALAMINE
2 MESALAMINE KIT W/CLEANSING WIPES MESALAMINE W/CLEANSING WIPES
3 MESNEX MESNA
2 MESTINON PYRIDOSTIGMINE BROMIDE
2 METADATE CD (10 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X
2 METADATE CD (20 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X
2 METADATE CD (30 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X
2 METADATE CD (40 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X
2 METADATE CD (50 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X
2 METADATE CD (60 MG) (CPBP 30‐70) METHYLPHENIDATE HCL X
1 METAPROTERENOL SULFATE METAPROTERENOL SULFATE
2 METAXALONE TABLET METAXALONE
1 ME‐TESTOSTERONE TESTOSTERONE
1 METFORMIN METFORMIN
2 METFORMIN ER METFORMIN
1 METFORMIN IR METFORMIN
1 METH/MEBLUE/SOD PHOS/PSAL/HYOS METH/MEBLUE/SOD PHOS/PSAL/HYOS
1 METHADONE HCL (10 MG) TABLET METHADONE HCL X X
1 METHADONE HCL (10 MG/5 ML) SOLUTION METHADONE HCL X X
1 METHADONE HCL (10 MG/ML) ORAL CONC METHADONE HCL X X
1 METHADONE HCL (10 MG/ML) VIAL METHADONE HCL X X
1 METHADONE HCL (40 MG) TABLET SOL METHADONE HCL X X
1 METHADONE HCL (5 MG) TABLET METHADONE HCL X X
1 METHADONE HCL (5 MG/5 ML) SOLUTION METHADONE HCL X X
3 METHADOSE METHADONE HCL X X
2 METHAMPHETAMINE TABLET METHAMPHETAMINE
Excluded METHAVER
2 METHAZOLAMIDE TABLET METHAZOLAMIDE
1 METHEN/MBLUE/SAL/SOD PHOS/HYOS METHEN/MBLUE/SAL/SOD PHOS/HYOS
1 METHENAM/M.BLUE/SALICYL/HYOSCY METHENAM/M.BLUE/SALICYL/HYOSCY
1 METHENAM/SOD PHOS/MBLUE/HYOSCY METHENAM/SOD PHOS/MBLUE/HYOSCY
1 METHENAMINE HIPPURATE METHENAMINE HIPPURATE
1 METHENAMINE MANDELATE METHENAMINE MANDELATE
1
METHENAMINE/HYOSCYAMINE 120‐0.12 MG
COMBINATION TABLET (USTELL) METHENAMINE/HYSCYAMINE
2
METHENAMINE/HYOSCYAMINE 120‐40.8MG COMBINATION
TABLET (INDIOMIN MB) METHENAMINE/HYSCYAMINE
1
METHENAMINE/HYOSCYAMINE 81.6‐10.8 MG
COMBINATION TABLET (UTIRA‐C) METHENAMINE/HYSCYAMINE
2
METHENAMINE/HYOSCYAMINE 81‐0.12MG COMBINATION
TABLET (HYOPHEN) METHENAMINE/HYSCYAMINE
2
METHENAMINE/HYOSCYAMINE 81‐0.12MG COMBINATION
TABLET (URELLE) METHENAMINE/HYSCYAMINE
2
METHENAMINE/HYOSCYAMINE 81‐0.12MG COMBINATION
TABLET (UROGESIC‐BLUE) METHENAMINE/HYSCYAMINE
2 METHERGINE METHYLERGONOVINE MALEATE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 METHIMAZOLE METHIMAZOLE
2 METHITEST METHYLTESTOSTERONE X
1 METHOCARBAMOL TABLET METHOCARBAMOL
1 METHOTREXATE METHOTREXATE
1 METHOTREXATE SODIUM/PF METHOTREXATE SODIUM/PF
1 METHOXSALEN METHOXSALEN
1 METHSCOPOLAMINE BROMIDE METHSCOPOLAMINE BROMIDE
1 METHYCLOTHIAZIDE METHYCLOTHIAZIDE
1 METHYLDOPA METHYLDOPA
1 METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE
2 METHYLIN (10 MG) TAB CHEW METHYLPHENIDATE HCL X
2 METHYLIN (10 MG/5 ML) SOLUTION METHYLPHENIDATE HCL
2 METHYLIN (2.5, 5 MG) TAB CHEW METHYLPHENIDATE HCL X
2 METHYLIN (5 MG/5 ML) SOLUTION METHYLPHENIDATE HCL
2 METHYLPHENIDATE ER CAPSULE (METADATE CD) METHYLPHENIDATE
2 METHYLPHENIDATE ER CAPSULE (RITALIN LA) METHYLPHENIDATE
2 METHYLPHENIDATE ER TABLET (CONCERTA) METHYLPHENIDATE
2 METHYLPHENIDATE HCL TABLET ER (METADATE ER) METHYLPHENIDATE HCL
1 METHYLPHENIDATE IR TABLET METHYLPHENIDATE
1 METHYLPREDNISOLONE TABLET METHYLPREDNISOLONE
1 METHYLTESTOSTERONE METHYLTESTOSTERONE X
1 METIPRANOLOL METIPRANOLOL
2 METOCLOPRAMIDE ODT METOCLOPRAMIDE
1 METOCLOPRAMIDE TABLET METOCLOPRAMIDE HCL
1 METOLAZONE METOLAZONE
1 METOPROLOL SUCCINATE 24 HR TABLET METOPROLOL SUCCINATE
1
METOPROLOL SUCCINATE 24 HR TABLET & HCTZ TABLET &
HCTZ METOPROLOL SUCCINATE & HCTZ
2
METOPROLOL SUCCINATE/HCTZ COMBO TABLET
(DUTOPROLOL) METOPROLOL SUCCINATE/HCTZ X
1 METOPROLOL TARTRATE 100 MG TABLET METOPROLOL TARTRATE
2 METOPROLOL TARTRATE 37.5 MG, 75 MG TABLET METOPROLOL TARTRATE
1 METOPROLOL TARTRATE 50 MG TABLET METOPROLOL TARTRATE
1 METOPROLOL TARTRATE/HCTZ COMBO TABLET METOPROLOL TARTRATE/HCTZ
2 METROCREAM METRONIDAZOLE
3 METROGEL METRONIDAZOLE
2 METROGEL‐VAGINAL METRONIDAZOLE
2 METROLOTION METRONIDAZOLE
1 METRONIDAZOLE 0.75 % CREAM METRONIDAZOLE
1 METRONIDAZOLE 0.75 % GEL METRONIDAZOLE
2 METRONIDAZOLE 1 % GEL METRONIDAZOLE
1 METRONIDAZOLE TABLET/CAPSULE METRONIDAZOLE
1 MEXILETINE HCL MEXILETINE HCL
3 MIACALCIN CALCITONIN,SALMON,SYNTHETIC
1 MIBELAS 24 FE
3 MICARDIS TELMISARTAN
3 MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZID
1 MICONAZOLE NITRATE MICONAZOLE NITRATE
3 MICORT‐HC HYDROCORTISONE ACETATE
3 MICROBORE EXTENSION SET INTRAVENOUS EXTENSION SET
3 MICROCHAMBER INHALER, ASSIST DEVICES
3 MICROCRYSTALLINE CELLULOSE CELLULOSE
3 MICROCYN HYPOC ACID/SOD HYPO/NACL/WATER
3 MICROCYN HYDROGEL HOCL/NA HY/NAMGF/NA PH/NACL/WA
1 MICROGESTIN 24 FE NORETHINDRONE‐E.ESTRADIOL‐IRON
3 MICROSPACER INHALER, ASSIST DEVICES
2 MICROZIDE HYDROCHLOROTHIAZIDE
1 MIDAZOLAM HCL MIDAZOLAM HCL
1 MIDODRINE HCL MIDODRINE HCL
3 MIFEPREX MIFEPRISTONE
2 MIGERGOT ERGOTAMINE TARTRATE/CAFFEINE X
2 MIGLITOL TABLET MIGLITOL
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 MIGRANAL DIHYDROERGOTAMINE MESYLATE X
2 MILLIPRED PREDNISOLONE
3 MILLIPRED PREDNISOLONE SOD PHOSPHATE
2 MILLIPRED DP PREDNISOLONE
2 MINASTRIN 24 FE NORETHINDRONE‐E.ESTRADIOL‐IRON
3 MINI PLUS NEBULIZER NEBULIZER
3 MINILINK REAL‐TIME TRANSMITTER BLOOD‐GLUCOSE TRANSMITTER
3 MINIMED INFUSION SET FOR INSULIN PUMP
3 MINIMED 530G SUBCUTANEOUS INSULIN PUMP
3 MINIMED 630G SUBCUTANEOUS INSULIN PUMP
3 MINIMED 630G GUARDIAN START KT BLOOD‐GLUCOSE TRANSMITTER
3 MINIMED PRO‐SET INFUSION SET FOR INSULIN PUMP
2 MINIPRESS PRAZOSIN HCL
2 MINIVELLE ESTRADIOL X
3 MINI‐WRIGHT PEAK FLOW METER PEAK FLOW METER
2 MINOCIN MINOCYCLINE HCL
1 MINOCYCLINE CAPSULE MINOCYCLINE
2 MINOCYCLINE ER TABLET MINOCYCLINE
2 MINOCYCLINE IR TABLET MINOCYCLINE
1 MINOXIDIL MINOXIDIL
3 MIO INFUSION SET INFUSION SET FOR INSULIN PUMP
2 MIRAPEX (0.125 MG) TABLET PRAMIPEXOLE DI‐HCL
2 MIRAPEX (0.25 MG) TABLET PRAMIPEXOLE DI‐HCL
2 MIRAPEX (0.5 MG) TABLET PRAMIPEXOLE DI‐HCL
2 MIRAPEX (0.75 MG) TABLET PRAMIPEXOLE DI‐HCL
2 MIRAPEX (1.5 MG) TABLET PRAMIPEXOLE DI‐HCL
3 MIRAPEX ER PRAMIPEXOLE DI‐HCL X X
3 MIRCERA X
2 MIRCETTE DESOG‐E.ESTRADIOL/E.ESTRADIOL X
1 MIRTAZAPINE/SOLTAB MIRTAZAPINE/SOLTAB
3 MIRVASO BRIMONIDINE TARTRATE
1 MISOPROSTOL MISOPROSTOL
3 MISTASSIST SPIROMETERS AND ACCESSORIES
3 MISTASSIST KIT SPIROMETER/DRUG DELIVERY ADAPT
3 MITIGARE COLCHICINE X
3 MITOSOL MITOMYCIN
2 MOBIC MELOXICAM
2 MODAFINIL MODAFINIL X
3 MODERIBA DOSEPACK RIBAVIRIN X
1 MOEXIPRIL HCL MOEXIPRIL HCL
1 MOEXIPRIL/HYDROCHLOROTHIAZIDE MOEXIPRIL/HYDROCHLOROTHIAZIDE
1 MOLINDONE HCL (10 MG) TABLET MOLINDONE HCL X
1 MOLINDONE HCL (25 MG) TABLET MOLINDONE HCL X
1 MOLINDONE HCL (5 MG) TABLET MOLINDONE HCL
1 MOMETASONE FUROATE 0.1% CREAM (MEDIUM) MOMETASONE FUROATE
1 MOMETASONE FUROATE 0.1% OINTMENT (HIGH) MOMETASONE FUROATE
1 MOMETASONE FUROATE 0.1% SOLUTION (MEDIUM) MOMETASONE FUROATE
2 MOMETASONE NASAL SPRAY MOMETASONE
3 MONAGHAN Z STAT INHALER, ASSIST DEVICES
2 MONDOXYNE NL (100 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X
2 MONDOXYNE NL (50 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X
3 MONDOXYNE NL (75 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X X
2 MONODOX (100 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X
2 MONODOX (50 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X
3 MONODOX (75 MG) CAPSULE DOXYCYCLINE MONOHYDRATE X X
3 MONO‐FLO DRAINAGE BAG
3 MONOJECT SYRINGE W‐NEEDLE,DISPOSAB,6 ML
3 MONOJECT SYRINGE W‐NEEDLE,DISPOSABLE
3 MONOJECT 0.9% SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE
3 MONOJECT BLOOD COLLECTION NEEDLES, BLOOD COLLECTION
3 MONOJECT CONTROL SYRINGE SYRINGE, DISPOSABLE, 12 ML
3 MONOJECT LUER ADAPTER INTRAVENOUS EQUIPMENT
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 MONOJECT LUER LOCK TB SYRINGE SYRINGE, DISPOSABLE, 1 ML
3 MONOJECT MAGELLAN SYRINGE,SAFETY WITH NEEDLE,1ML
3 MONOJECT MAGELLAN SYRINGE,SAFETY WITH NEEDLE,3ML
3 MONOJECT MEGELLAN TB SYRINGE SYRINGE, DISPOSABLE, 1 ML
3 MONOJECT PHARMACY TRAY SYRINGE, DISPOSABLE, 1 ML
3 MONOJECT PREFILL 0.9 % SODIUM CHLORIDE
3 MONOJECT PREFILL ADVANCED 0.9 % SODIUM CHLORIDE
3 MONOJECT SAFETY SYRINGE SYRINGE,SAFETY NEEDLE,12 ML
3 MONOJECT SMARTIP CANNULA SYRINGE W‐CANNULA,DISP, 3 ML
3 MONOJECT SMARTIP CANNULA SYRINGE W‐CANNULA,DISP, 6 ML
3 MONOJECT SMARTIP CANNULA SYRINGE WITH CANNULA,DISP.12ML
3 MONOJECT SYRINGE SYRINGE W‐NEEDLE,DISPOSAB,6 ML
3 MONOJECT SYRINGE SYRINGE, DISPOSABLE, 12 ML
3 MONOJECT SYRINGE SYRINGE, DISPOSABLE, 3 ML
3 MONOJECT SYRINGE SYRINGE, DISPOSABLE, 6 ML
1 MONTELUKAST CHEWABLE TABLET MONTELUKAST
1 MONTELUKAST TABLET MONTELUKAST
3 MONUROL FOSFOMYCIN TROMETHAMINE
2 MORGIDOX DOXYCYCLINE HYCLATE X
1 MORPHINE SULFATE SOLUTION MORPHINE SULFATE
Excluded MOTOFEN DIFENOXIN HCL/ATROPINE SULFATE
3 MOUTHPIECE NEBULIZER ACCESSORIES
2 MOVANTIK NALOXEGOL OXALATE X
3 MOVIPREP PEG3350/SOD SUL/NACL/ASB/C/KCL
3 MOXATAG AMOXICILLIN
2 MOXEZA MOXIFLOXACIN HCL
1 MOXIFLOXACIN HCL MOXIFLOXACIN HCL
2 MS CONTIN MORPHINE SULFATE X
3 MUGARD GLY/CARB H.POLYMR A/POT HYDROX
2 MULTAQ DRONEDARONE HCL
1 MULTIVIT,IRON,MIN 5/FOLIC ACID MULTIVIT,IRON,MIN 5/FOLIC ACID
1 MULTIVIT34/FOLIC AC/NADH/COQ10 MULTIVIT34/FOLIC AC/NADH/COQ10
1 MULTIVIT‐MINS NO.20/IRON/FOLIC MULTIVIT‐MINS NO.20/IRON/FOLIC
1 MULTIVIT‐MINS NO.7/FOLIC ACID MULTIVIT‐MINS NO.7/FOLIC ACID
2 MUPIROCIN CALCIUM CREAM MUPIROCIN CALCIUM
1 MUPIROCIN OINTMENT MUPIROCIN
3 MURI‐LUBE MINERAL OIL MINERAL OIL
3 MUSE ALPROSTADIL X
3 M‐VIT PV W‐O CAL/FERROUS FUM/FOLIC
3 MY MDI PORTABLE NEBULISER NEBULIZER AND COMPRESSOR
2 MYAMBUTOL ETHAMBUTOL HCL
3 MYCOBUTIN RIFABUTIN
1 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL
1 MYCOPHENOLATE SODIUM MYCOPHENOLATE SODIUM
3 MYDRIACYL TROPICAMIDE
3 MYELOGRAM TRAY MYELOGRAM TRAY
3 MYFORTIC MYCOPHENOLATE SODIUM
3 MYOBLOC RIMABOTULINUMTOXIN B X X X
2 MYRBETRIQ MIRABEGRON X
2 MYSOLINE PRIMIDONE
3 MYTESI CROFELEMER X X
1 NABUMETONE TABLET NABUMETONE
2 NADOLOL TABLET NADOLOL
1 NADOLOL/BENDROFLUMETHIAZIDE NADOLOL/BENDROFLUMETHIAZIDE
2 NAFTIFINE CREAM NAFTIFINE
2 NAFTIN NAFTIFINE HCL
1 NALBUPHINE HCL NALBUPHINE HCL
2 NALFON FENOPROFEN CALCIUM
1 NALOXONE HCL NALOXONE HCL
1 NALTREXONE HCL NALTREXONE HCL
2 NAMENDA (10 MG) TABLET MEMANTINE HCL X
2 NAMENDA (2 MG/ML) SOLUTION MEMANTINE HCL X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 NAMENDA (5 MG) TABLET MEMANTINE HCL X
2 NAMENDA (5 MG‐10 MG) TAB DS PK MEMANTINE HCL X
2 NAMENDA XR (14 MG) CAP SPR 24 MEMANTINE HCL X
2 NAMENDA XR (21 MG) CAP SPR 24 MEMANTINE HCL X
2 NAMENDA XR (28 MG) CAP SPR 24 MEMANTINE HCL X
2 NAMENDA XR (7 MG) CAP SPR 24 MEMANTINE HCL X
2 NAMENDA XR (7‐14‐21‐28) CAP24 DSPK MEMANTINE HCL X
2 NAMZARIC (14MG‐10MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X
2 NAMZARIC (21 MG‐10MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X
2 NAMZARIC (28 MG‐10MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X
2 NAMZARIC (7 MG‐10 MG) CAP SPR 24 MEMANTINE HCL/DONEPEZIL HCL X X
2 NAMZARIC (7‐10/14‐10) CAP24 DSPK MEMANTINE HCL/DONEPEZIL HCL X X
Excluded NAPRELAN
2 NAPROSYN NAPROXEN
1 NAPROXEN NAPROXEN
1 NARATRIPTAN NARATRIPTAN X
2 NARCAN NALOXONE HCL X
2 NARDIL PHENELZINE SULFATE
3 NASCOBAL CYANOCOBALAMIN (VITAMIN B‐12)
3 NASONEB NASAL NEBULIZER NEBULIZER
2 NASONEX MOMETASONE FUROATE X
3 NATACHEW PNV 55/IRON FUM,B‐G/FOLIC ACID
3 NATACYN NATAMYCIN
3 NATAZIA ESTRADIOL VALERATE/DIENOGEST X
1 NATEGLINIDE NATEGLINIDE
3 NATELLE ONE PNV WITH CA,NO.70/IRON/FA/DHA
Excluded NATESTO
3 NATROBA SPINOSAD
2 NEBUPENT PENTAMIDINE ISETHIONATE
3 NEBUSAL SODIUM CHLORIDE FOR INHALATION
3 NEEDLE NEEDLES, SAFETY
3 NEEVODHA PRENATAL64/IRON/LMFOLATE/ALGAL
2 NEFAZODONE TABLET NEFAZODONE
1 NEOMYCIN SU/BACITRA/POLYMYXIN NEOMYCIN SU/BACITRA/POLYMYXIN
1 NEOMYCIN SULF/POLYMYXIN B SULF/HC DROPS NEOMYCIN SULF/POLYMYXIN B SULF
1 NEOMYCIN SULFATE NEOMYCIN SULFATE
1 NEOMYCIN/BACIT/P‐MYX/HYDROCORT NEOMYCIN/BACIT/P‐MYX/HYDROCORT
1 NEOMYCIN/POLYMYXIN B/DEXAMETHA NEOMYCIN/POLYMYXIN B/DEXAMETHA
1 NEOMYCIN/POLYMYXIN B/HYDROCORT NEOMYCIN/POLYMYXIN B/HYDROCORT
1 NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN/POLYMYXN B/GRAMICIDIN
2 NEORAL CYCLOSPORINE, MODIFIED
3 NEOSALUS EMOLLIENT COMBINATION NO.38
3 NEOSALUS EMOLLIENT COMBINATION NO.47
3 NEOSALUS CP EMOLLIENT COMBINATION NO.47
2 NEOSPORIN NEOMYCIN/POLYMYXN B/GRAMICIDIN
3 NEOSPORIN G.U. IRRIGANT NEOMYCIN SULF/POLYMYXIN B SULF
3 NEO‐SYNALAR NEOMYCIN SULFATE/FLUOCINOLONE X
3 NEPHROCAPS B COMPLEX W‐C NO.20/FOLIC ACID
3 NEPHROCAPS QT VIT B CPLX C NO.13/FOLIC AC/D3
2 NEPTAZANE METHAZOLAMIDE
Excluded NESINA
3 NESTABS PRENATAL VIT#86/IRON BISGLY/FA
3 NESTABS ABC PNV #86/IRON POLY/FA/DHA/EPA
3 NESTABS DHA PNV #87/IRON BISGLY/FA/DHA
2 NEUPRO ROTIGOTINE X X
2 NEURONTIN GABAPENTIN
3 NEUTRASAL SALIVA SUBSTITUTE COMB NO.10
3 NEUTRASAL SALIVA SUBSTITUTE COMBO NO.5
2 NEVANAC NEPAFENAC
1 NEVIRAPINE (100 MG) TAB ER 24H NEVIRAPINE X
1 NEVIRAPINE (200 MG) TABLET NEVIRAPINE X
1 NEVIRAPINE (400 MG) TAB ER 24H NEVIRAPINE X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 NEVIRAPINE (50 MG/5 ML) ORAL SUSP NEVIRAPINE X
3 NEXA PLUS PNV53/IRON FUM/FA/DOCUSATE/DHA
3 NEXAVIR LIVER EXTRACT (BEEF‐PORK)
2 NEXIUM ESOMEPRAZOLE MAGNESIUM X X
3 NEXIVA INTRAVENOUS CATHETER
1 NIACIN ER NIACIN X
2 NIASPAN NIACIN X
1 NICARDIPINE HCL NICARDIPINE HCL
3 NICOMIDE LMEFOLATE/B3/COPP/ZN/SEL/CHROM
3 NICOMIDE M‐TETRAHYROFOLATE/NIACIN/CU/ZN
1 NIFEDIPINE TABLET (ADALAT CC) NIFEDIPINE
1 NIFEDIPINE TABLET (PROCARDIA XL) NIFEDIPINE
1 NIFEDIPINE TABLET (PROCARDIA) NIFEDIPINE
1 NIMODIPINE NIMODIPINE
2 NISOLDIPINE ER TABLET NISOLDIPINE
2 NITRO‐BID NITROGLYCERIN
2 NITRO‐DUR NITROGLYCERIN
1 NITROFURANTOIN MACROCRYSTAL CAPSULE NITROFURANTOIN MACROCRYSTAL
2 NITROFURANTOIN ORAL SUSPENSION NITROFURANTOIN
1 NITROGLYCERIN SUBLINGUAL TABLET NITROGLYCERIN
2 NITROGLYCERIN TRANSLINGUAL SPRAY NITROGLYCERIN
2 NITROLINGUAL NITROGLYCERIN
3 NITROMIST NITROGLYCERIN
2 NITROSTAT NITROGLYCERIN
3 NIVATOPIC PLUS EMOLLIENT COMBINATION NO.53
2 NIZORAL KETOCONAZOLE
2 NORCO HYDROCODONE/ACETAMINOPHEN X
2 NORDIFLEX X
2 NORDITROPIN FLEXPEN X
1 NORETH‐ETHINYL ESTRADIOL/IRON (0.8‐25(24)) TAB CHEW NORETH‐ETHINYL ESTRADIOL/IRON
1
NORETHINDRONE AC‐ETH ESTRADIOL (HORMONAL
DEFICIENCY) NORETHINDRONE AC‐ETH ESTRADIOL
1 NORETHIN‐ETH ESTRA FERROUS FUM NORETHINDRONE‐E.ESTRADIOL‐IRON
Excluded NORITATE
3 NORM‐JECT SYRINGE W‐NEEDLE,DISPOSABLE
3 NORMLGEL AG SILVER CARBONATE
2 NORPACE DISOPYRAMIDE PHOSPHATE
2 NORPACE CR DISOPYRAMIDE PHOSPHATE
2 NORPRAMIN DESIPRAMINE HCL
1 NORTEL
1 NORTRIPTYLINE NORTRIPTYLINE
2 NORVASC AMLODIPINE BESYLATE
2 NORVIR (100 MG) CAPSULE, TABLET RITONAVIR X
2 NORVIR (80 MG/ML) SOLUTION RITONAVIR X
3 NOSE CLIP NEBULIZER ACCESSORIES
3 NOVACORT HYDROCORTISONE/PRAMOXINE/ALOE
Excluded NOVOLIN
Excluded NOVOLOG
Excluded NOVOLOG FLEXPEN
3 NOXAFIL POSACONAZOLE
3 NUCALA MEPOLIZUMAB X
3 NUCORT HYDROCORTISONE ACETATE/ALOE V
2 NUCYNTA TAPENTADOL HCL X
2 NUCYNTA ER TAPENTADOL HCL X
3 NUEDEXTA DEXTROMETHORPHAN HBR/QUINIDINE X
2 NULEV HYOSCYAMINE SULFATE
2 NULYTELY WITH FLAVOR PACKS SODIUM CHLORIDE/NAHCO3/KCL/PEG
3 NUMBONEX LIDOCAINE HCL
3 NUMOISYN SORBITOL/SAL ST#1/MAL AC/CA PH
3 NUOX BENZOYL PEROXIDE/SULFUR
Excluded NUPLAZID PIMAVANSERIN
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 NUTRESTORE GLUTAMINE
3 NUTRICAP FOLIC ACID/MV,IRON,MIN
Excluded NUTROPIN
3 NUVAIL POLY‐UREAURETHANE
2 NUVARING ETONOGESTREL/ETHINYL ESTRADIOL X
3 NUVESSA METRONIDAZOLE
Excluded NYATA
1 NYSTATIN NYSTATIN
2 NYSTATIN/TRIAMCIN CREAM, OINTMENT NYSTATIN/TRIAMCIN
3 OASIS ULTRA PORCINE ACELL SUBMUCOSA,MESHED
3 OASIS ULTRA PORCINE SUBMUCOSA, FENESTRATED
3 OB COMPLETE IRON,CARBONYL/FOLIC ACID/MV‐MN
3 OB COMPLETE GOLD PNV NO.106/IRON/FOLATE #6/DHA
3 OB COMPLETE ONE PNV 85/IRON/FOLIC/DHA/FISH OIL
3 OB COMPLETE PETITE PRENATAL56/IRON/FOLIC ACID/DHA
3 OB COMPLETE PREMIER PNV83/IRON,CARB/IRON ASP GL/FA
3 OB COMPLETE WITH DHA PNV 30/IRON CARB,AG/FOLIC/OM3
3 OBREDON GUAIFENESIN/HYDROCODONE X X
3 OBSTETRIX EC PV W‐O CAL/IRON/DOCUSATE/FOLIC
3 OBSTETRIX ONE PNV NO.80/IRON/MFOLATE/DSS/DHA
3 OBTREX DHA PNV NO.12/IRON/FOLIC/DSS/OM‐3
1 OCELLA, SYEDA, ZARAH X
Excluded OCREVUS OCRELIZUMAB
2 OCUFEN FLURBIPROFEN SODIUM
2 OCUFLOX OFLOXACIN
2 ODEFSEY EMTRICITAB/RILPIVIRI/TENOF ALA X
1 OFLOXACIN OFLOXACIN
1 OLANZAPINE OLANZAPINE X
2 OLANZAPINE ODT OLANZAPINE
1 OLANZAPINE TABLET OLANZAPINE
1 OLANZAPINE TABLET & FLUOXETINE CAPSULE OLANZAPINE & FLUOXETINE
2 OLANZAPINE/FLUOXETINE OLANZAPINE/FLUOXETINE
3 OLEPTRO X X
1 OLMESARTAN/AMLODIPIN OLMESARTAN/AMLODIPIN
1 OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/AMLODIPIN/HCTHIAZID
1 OLMESARTAN/HYDROCHLOROTHIAZIDE OLMESARTAN/HYDROCHLOROTHIAZIDE
2 OLOPATADINE NASAL SPRAY OLOPATADINE X X
2 OLUX CLOBETASOL PROPIONATE
3 OLUX‐E CLOBETASOL PROPIONATE/EMOLL
3 OLYSIO X
1 OM‐3/DHA/EPA/B12/FA/B6/PHYTOST OM‐3/DHA/EPA/B12/FA/B6/PHYTOST
3 OMECLAMOX‐PAK OMEPRAZOLE/CLARITH/AMOXICILLIN
1 OMEG3/CALCIUM/D3/FOLIC/MVIT 13 OMEG3/CALCIUM/D3/FOLIC/MVIT 13
2 OMEGA‐3 ACID ETHYL ESTERS CAPSULE OMEGA‐3 ACID ETHYL ESTERS X
1 OMEPRAZOLE CAPSULE OMEPRAZOLE
Excluded OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE/SODIUM BICARBONATE
Excluded OMNARIS
3 OMNIPOD SUBCUTANEOUS INSULIN PUMP
2 OMNIPRED PREDNISOLONE ACETATE
2 OMNITROPE X
1 ONDANSETRON HCL (24 MG) TABLET ONDANSETRON HCL
1 ONDANSETRON HCL (4 MG) TABLET ONDANSETRON HCL
1 ONDANSETRON HCL (4 MG/5 ML) SOLUTION ONDANSETRON HCL X
1 ONDANSETRON HCL (8 MG) TABLET ONDANSETRON HCL
1 ONDANSETRON TABLET ONDANSETRON
3 ONETOUCH PING SUBCUTANEOUS INSULIN PUMP
2 ONEXTON CLINDAMYCIN PHOS/BENZOYL PEROX X
3 ONFI (10 MG) TABLET CLOBAZAM X X
3 ONFI (2.5 MG/ML) ORAL SUSP CLOBAZAM X X
3 ONFI (20 MG) TABLET CLOBAZAM X X
Excluded ONGLYZA
3 ONMEL ITRACONAZOLE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
TherapyExcluded ONSOLIS
Excluded ONZETRA
3 OPANA OXYMORPHONE HCL X
3 OPANA ER (5, 7.5, 10, 15, 20, 30, 40 MG) TAB ER 12H OXYMORPHONE HCL X
2 OPIUM TINCTURE OPIUM TINCTURE
1 OPIUM/BELLADONNA ALKALOIDS OPIUM/BELLADONNA ALKALOIDS
3 OPTICHAMBER INHALER,ASSIST DEVICE,ACCESORY
3 OPTICHAMBER DIAMOND INHALER, ASSIST DEVICES
3 ORAFATE SUCRALFATE MALATE, POLYMERIZED
2 ORALAIR (100 IR) TAB SUBL GR POL‐ORC/SW VER/RYE/KENT/TIM X
3 ORALAIR (100‐300 IR) TAB SUBL GR POL‐ORC/SW VER/RYE/KENT/TIM X
2 ORALAIR (300 IR) TAB SUBL GR POL‐ORC/SW VER/RYE/KENT/TIM X
3 ORAMAGICRX POT SORBATE/MALTO/ALOE/MANN PS
3 ORAP PIMOZIDE
3 ORAPRED ODT PREDNISOLONE SOD PHOSPHATE
3 ORAVIG MICONAZOLE
3 ORENCIA ABATACEPT X
1 ORPHENADRINE CITRATE ORPHENADRINE CITRATE
2 ORTHO MICRONOR NORETHINDRONE X
2 ORTHO TRI‐CYCLEN NORGESTIMATE‐ETHINYL ESTRADIOL X
2 ORTHO TRI‐CYCLEN LO NORGESTIMATE‐ETHINYL ESTRADIOL X
2 ORTHO‐CYCLEN NORGESTIMATE‐ETHINYL ESTRADIOL X
2 ORTHO‐NOVUM NORETHINDRONE‐ETHINYL ESTRAD X
1 OSELTAMIVIR PHOSPHATE (30, 45, 75 MG) CAPSULE OSELTAMIVIR PHOSPHATE X
Excluded OSENI
3 OSMOPREP SOD PHOSPHATE MBAS/NA PHOS,DI‐
3 OSPHENA OSPEMIFENE X
2 OTEZLA APREMILAST X
3 OTIPRIO CIPROFLOXACIN
3 OTOVEL CIPROFLOXACIN HCL/FLUOCINOLONE
2 OTREXUP METHOTREXATE X X
3 OVACE SULFACETAMIDE SODIUM
3 OVACE PLUS (10 %) CLEANSR ER, CREAM SULFACETAMIDE SODIUM
2 OVACE PLUS (10 %) SHAMPOO SULFACETAMIDE SODIUM
3 OVACE PLUS (9.8 %) FOAM, LOTION SULFACETAMIDE SODIUM
3 OVACE PLUS WASH SULFACETAMIDE SODIUM
3 OVCON‐35 NORETHINDRONE‐ETHINYL ESTRAD X
2 OVIDE MALATHION
3 OXANDRIN OXANDROLONE X
1 OXANDROLONE OXANDROLONE X
2 OXAPROZIN TABLET OXAPROZIN
3 OXAYDO OXYCODONE HCL X
1 OXAZEPAM OXAZEPAM
1 OXCARBAZEPINE OXCARBAZEPINE
2 OXICONAZOLE NITRATE 1% CREAM OXICONAZOLE NITRATE
3 OXISTAT OXICONAZOLE NITRATE
2 OXSORALEN‐ULTRA METHOXSALEN
3 OXTELLAR XR (150, 300, 600 MG) TAB ER 24H OXCARBAZEPINE X X
1 OXYBUTYNIN ER TABLET OXYBUTYNIN
1 OXYBUTYNIN IR TABLET OXYBUTYNIN
1 OXYCODONE CAPSULE OXYCODONE X
2 OXYCODONE HCL ORAL SOLUTIION 25MG/ML OXYCODONE HCL X
2 OXYCONTIN (10, 15, 20, 30, 40, 60, 80 MG) TAB ER 12H OXYCODONE HCL X
2 OXYMORPHONE HCL (10 MG) TAB ER 12H OXYMORPHONE HCL X
1 OXYMORPHONE HCL (10 MG) TABLET OXYMORPHONE HCL
1 OXYMORPHONE HCL (15, 20, 30 MG) TAB ER 12H OXYMORPHONE HCL X
2 OXYMORPHONE HCL (5 MG) TABLET OXYMORPHONE HCL
2 OXYMORPHONE HCL (5, 40 MG) TAB ER 12H OXYMORPHONE HCL X
1 OXYMORPHONE HCL (7.5 MG) TAB ER 12H OXYMORPHONE HCL X
3 OXYTROL OXYBUTYNIN X
3 PACNEX BENZOYL PEROXIDE
3 PACNEX HP BENZOYL PEROXIDE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 PACNEX LP BENZOYL PEROXIDE
3 PAIN EASE NORFLURANE/PENTAFLUOROPROPANE
1 PALIPERIDONE (1.5, 9 MG) TAB ER 24 PALIPERIDONE X X
2 PALIPERIDONE (6 MG) TAB ER 24 PALIPERIDONE X X
2 PALIPERIDONE ER TABLET PALIPERIDONE
2 PAMELOR NORTRIPTYLINE HCL
Excluded PANCREAZE
2 PANDEL HYDROCORTISONE PROBUTATE
1 PANTOPRAZOLE PANTOPRAZOLE
1 PAPAV/PHENTOLAM/ALPROST/WATER PAPAV/PHENTOLAM/ALPROST/WATER X
1 PAPAVERINE HCL PAPAVERINE HCL
1 PAPAVERINE HCL/ALPROSTAD/WATER PAPAVERINE HCL/ALPROSTAD/WATER X
1 PAPAVERINE/PHENTOLAMINE/WATER PAPAVERINE/PHENTOLAMINE/WATER X
3 PARADIGM INFUSION SUB‐Q INFUSION PUMP ACCESSORY
3 PARADIGM REAL‐TIME BLOOD‐GLUC TRANSMITTER/SENSOR
3 PARADIGM SILHOUETTE SUB‐Q INFUSION PUMP ACCESSORY
2 PARAFON FORTE DSC CHLORZOXAZONE
3 PARAGARD T 380‐A COPPER
1 PAREGORIC PAREGORIC
3 PAREMYD HYDROXYAMPHETAMINE/TROPICAMIDE
3 PARI LC PLUS NEBULIZER NEBULIZER ACCESSORIES
3 PARI LC SPRINT SINUS NEBULIZER
3 PARI SINUS AEROSOL SYSTEM NEBULIZER AND COMPRESSOR
2 PARICALCITOL CAPSULE PARICALCITOL
2 PARLODEL BROMOCRIPTINE MESYLATE
2 PARNATE TRANYLCYPROMINE SULFATE
1 PAROMOMYCIN SULFATE PAROMOMYCIN SULFATE
2 PAROXETINE CR/ER PAROXETINE
1 PAROXETINE IR PAROXETINE
3 PASER AMINOSALICYLIC ACID
2 PATADAY OLOPATADINE HCL X
3 PATANASE OLOPATADINE HCL X X
2 PATANOL OLOPATADINE HCL
2 PAXIL PAROXETINE HCL
3 PAXIL CR PAROXETINE HCL
Excluded PAZEO
3 PCCA ACCUPEN‐15 TOPICAL CREAM METERED‐DOSE DEV
2 PCE ERYTHROMYCIN BASE
1 PED MULTIVIT 142/IRON/FLUORIDE PED MULTIVIT 142/IRON/FLUORIDE
1 PED MVIT A,C,D3 NO.21/FLUORIDE PED MVIT A,C,D3 NO.21/FLUORIDE
1 PEDI MULTIVIT 45/FLUORIDE/IRON PEDI MULTIVIT 45/FLUORIDE/IRON
1 PEDI MULTIVIT 75/FLUORIDE/IRON PEDI MULTIVIT 75/FLUORIDE/IRON
1 PEDI MULTIVIT 84 WITH FLUORIDE PEDI MULTIVIT 84 WITH FLUORIDE
1 PEDI MULTIVIT NO.12 W‐FLUORIDE PEDI MULTIVIT NO.12 W‐FLUORIDE
1 PEDI MULTIVIT NO.16 W‐FLUORIDE PEDI MULTIVIT NO.16 W‐FLUORIDE
1 PEDI MULTIVIT NO.17 W‐FLUORIDE PEDI MULTIVIT NO.17 W‐FLUORIDE
1 PEDI MULTIVIT NO.2 W‐FLUORIDE PEDI MULTIVIT NO.2 W‐FLUORIDE
1 PEDI MULTIVIT NO.63 W‐FLUORIDE PEDI MULTIVIT NO.63 W‐FLUORIDE
1 PEDI MULTIVIT NO.82 W‐FLUORIDE PEDI MULTIVIT NO.82 W‐FLUORIDE
1 PEDI MULTIVIT NO.83 W‐FLUORIDE PEDI MULTIVIT NO.83 W‐FLUORIDE
2 PEDIAPRED PREDNISOLONE SOD PHOSPHATE
3 PEDIATRIC DINOSAUR NEBULIZER NEBULIZER AND COMPRESSOR
3 PEDIATRIC DOG NEBULIZER NEBULIZER AND COMPRESSOR
3 PEDIATRIC FROG NEBULIZER NEBULIZER AND COMPRESSOR
Excluded PEDIPAK
1 PEG3350/SOD SULF,BICARB,CL/KCL PEG3350/SOD SULF,BICARB,CL/KCL
3 PEGANONE ETHOTOIN
2 PEGASYS PEGINTERFERON ALFA 2A X
3 PEG‐PREP BISAC/NACL/NAHCO3/KCL/PEG 3350
1 PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM
2 PENLAC CICLOPIROX
Excluded PENNSAID
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 PENTASA MESALAMINE
1 PENTAZOCINE HCL/NALOXONE HCL PENTAZOCINE HCL/NALOXONE HCL
1 PENTOXIFYLLINE PENTOXIFYLLINE
2 PEPCID FAMOTIDINE
2 PERCOCET OXYCODONE HCL/ACETAMINOPHEN X
2 PERFOROMIST FORMOTEROL FUMARATE X
2 PERIDEX CHLORHEXIDINE GLUCONATE
1 PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE
1 PERMETHRIN 5% CREAM PERMETHRIN
1 PERPHENAZINE PERPHENAZINE
1 PERPHENAZINE/AMITRIPTYLINE HCL PERPHENAZINE/AMITRIPTYLINE HCL
Excluded PERTZYE
Excluded PEXEVA
3 PFLEX TRAINER SPIROMETERS AND ACCESSORIES
3 PHASEAL ADAPTER INFUSION ADAPTER, CLOSED SYSTM
3 PHASEAL ASSEMBLY FIXTURE ASSEMBLY SYS,VIAL TO TRNSF,CLS
3 PHASEAL CONNECTOR LUER CONNECTOR LUER LOCK,CLOSD SYST
3 PHASEAL INFUSION CLAMP, IV TUBING
3 PHASEAL INJECTOR LUER NEEDLE INJECTOR,LUER,CLOSD SYS
3 PHASEAL INJECTOR LUER NEEDLE INJECTR,LUER LOCK,CLOSD
3 PHASEAL PROTECTOR TRANSFER DEVICE, CLOSED SYSTEM
3 PHASEAL SECONDARY SET INTRAVENOUS PIGGYBACK SET
3 PHASEAL Y‐SITE Y‐SITE CONNECTOR, CLOSED SYSTM
1 PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL
1 PHENELZINE TABLET PHENELZINE
3 PHENERGAN (ALLERGY) PROMETHAZINE HCL
2 PHENERGAN (ANTIEMESIS/ANTIVERTIGO) PROMETHAZINE HCL
1 PHENOBARBITAL PHENOBARBITAL
2 PHENOHYTRO PHENOBARB/HYOSCY/ATROPINE/SCOP
1 PHENTOLAMINE/ALPROSTADIL/WATER PHENTOLAMINE/ALPROSTADIL/WATER X
1 PHENYLEPHRINE HCL PHENYLEPHRINE HCL
1 PHENYLEPHRINE HCL/PROMETH HCL PHENYLEPHRINE HCL/PROMETH HCL
2 PHENYTEK PHENYTOIN SODIUM EXTENDED
1 PHENYTOIN PHENYTOIN
1 PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED
3 PHLAG SPRAY PALM OIL/EUCALYPTUS OIL
3 PHOSLYRA CALCIUM ACETATE
2 PHOSPHASAL METH/MEBLUE/SOD PHOS/PSAL/HYOS
3 PHOSPHOLINE IODIDE ECHOTHIOPHATE IODIDE
3 PHOTREXA RIBOFLAVIN 5‐PHOSPHATE SODIUM
3 PHOTREXA VISCOUS RIBOFLAVIN 5‐PHOS/20 % DEXTRAN
3 PHYSIOLYTE PHYSIOLOGICAL IRRIG SOLN NO.1
3 PHYSIOSOL PHYSIOLOGICAL IRRIG SOLN NO.1
1 PHYTONADIONE (VIT K1) PHYTONADIONE (VIT K1)
2 PICATO (0.015 %) GEL INGENOL MEBUTATE X
2 PICATO (0.05 %) GEL INGENOL MEBUTATE X
3 PILLOW MASK FOR CHILDREN NEBULIZER ACCESSORIES
1 PILOCARPINE TABLET PILOCARPINE
1 PIMOZIDE PIMOZIDE
1 PINDOLOL PINDOLOL
1 PIOGLITAZONE PIOGLITAZONE
1 PIOGLITAZONE TABLET & GLIMEPIRIDE TABLET PIOGLITAZONE & METFORMIN
1 PIOGLITAZONE TABLET & METFORMIN TABLET PIOGLITAZONE & METFORMIN
2 PIOGLITAZONE/GLIMEPIRIDE COMBINATION TABLET PIOGLITAZONE/GLIMEPIRIDE X
2 PIOGLITAZONE/METFORMIN COMBINATION TABLET PIOGLITAZONE/METFORMIN X
2 PIROXICAM PIROXICAM
2 PLAN B ONE‐STEP LEVONORGESTREL
3 PLANTAGO‐HOMACCORD HOMEOPATHIC DRUGS
2 PLAQUENIL HYDROXYCHLOROQUINE SULFATE
2 PLAVIX (300 MG) TABLET CLOPIDOGREL BISULFATE X
2 PLAVIX (75 MG) TABLET CLOPIDOGREL BISULFATE
3 PLEGISOL CARDIOPLEGIC SOLUTION NO.1
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 PLEGRIDY X
3 PLEXION SULFACETAMIDE SODIUM/SULFUR
3 PLIAGLIS LIDOCAINE/TETRACAINE
1 PODOFILOX PODOFILOX
1 PODOPHYLLUM RESIN PODOPHYLLUM RESIN
1 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350
3 POLYFIN QR SUB‐Q INFUSION PUMP ACCESSORY
1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SULF/TRIMETHOPRIM
2 POLYTRIM POLYMYXIN B SULF/TRIMETHOPRIM
3 POLY‐TUSSIN AC BROMPHENIRAMINE/PE/CODEINE X
3 POLY‐VI‐FLOR PEDI MULTIVIT NO.33/FLUORIDE
3 POLY‐VI‐FLOR PEDI MULTIVIT NO.37 W‐FLUORIDE
3 POLY‐VI‐FLOR FS PEDI MULTIVIT NO.90 W‐FLUORIDE
3 POLY‐VI‐FLOR WITH IRON PEDI MULTIVIT 33/FLUORIDE/IRON
3 POLY‐VI‐FLOR WITH IRON PEDI MULTIVIT 37/FLUORIDE/IRON
3 PONSTEL MEFENAMIC ACID
3 PONTOCAINE TETRACAINE HCL
3 POPULUS COMPOSITUM HOMEOPATHIC DRUGS
3 PORTABLE NEBULIZER SYSTEM NEBULIZER AND COMPRESSOR
1 POT CHLORIDE/POT BICARB/CIT AC POT CHLORIDE/POT BICARB/CIT AC
3 POTABA POTASSIUM AMINOBENZOATE
1 POTASSIUM BICARBONATE/CIT AC POTASSIUM BICARBONATE/CIT AC
1 POTASSIUM CHLORIDE POTASSIUM CHLORIDE
1 POTASSIUM CITRATE POTASSIUM CITRATE
1 POTASSIUM HYDROXIDE POTASSIUM HYDROXIDE
1 POTASSIUM IODIDE POTASSIUM IODIDE
1 POTASSIUM IODIDE/IODINE POTASSIUM IODIDE/IODINE
2 POTIGA (50, 200, 300, 400 MG) TABLET EZOGABINE X X
3 PRADAXA DABIGATRAN ETEXILATE MESYLATE X X
3 PRALIDOXIME CHLORIDE PRALIDOXIME CHLORIDE
2 PRAMCORT HYDROCORTISONE/PRAMOXINE
1 PRAMIPEXOLE DI‐HCL (0.125 MG) TABLET PRAMIPEXOLE DI‐HCL
1 PRAMIPEXOLE DI‐HCL (0.25 MG) TABLET PRAMIPEXOLE DI‐HCL
1 PRAMIPEXOLE DI‐HCL (0.375 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
1 PRAMIPEXOLE DI‐HCL (0.5 MG) TABLET PRAMIPEXOLE DI‐HCL
1 PRAMIPEXOLE DI‐HCL (0.75 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
1 PRAMIPEXOLE DI‐HCL (0.75 MG) TABLET PRAMIPEXOLE DI‐HCL
1 PRAMIPEXOLE DI‐HCL (1.5 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
1 PRAMIPEXOLE DI‐HCL (1.5 MG) TABLET PRAMIPEXOLE DI‐HCL
1 PRAMIPEXOLE DI‐HCL (2.25 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
1 PRAMIPEXOLE DI‐HCL (3 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
1 PRAMIPEXOLE DI‐HCL (3.75 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
1 PRAMIPEXOLE DI‐HCL (4.5 MG) TAB ER 24H PRAMIPEXOLE DI‐HCL X X
2 PRAMOSONE HYDROCORTISONE/PRAMOXINE
3 PRAMOSONE E HYDROCORTISONE/PRAMOXINE/EMOLL
2 PRANDIN REPAGLINIDE
2 PRAVACHOL PRAVASTATIN SODIUM
1 PRAVASTATIN TABLET PRAVASTATIN SODIUM
1 PRAZOSIN HCL PRAZOSIN HCL
3 PRE‐ATTACHED LTA KIT LIDOCAINE HCL
2 PRECOSE ACARBOSE
2 PRED FORTE PREDNISOLONE ACETATE
2 PRED MILD PREDNISOLONE ACETATE
3 PRED‐G GENTAMICIN SULF/PREDNISOLONE
1 PREDNICARBATE PREDNICARBATE
2
PREDNISOLONE SODIUM PHOSPHATE ODT TABLET
(ORAPRED ODT) PREDNISOLONE SOD PHOSPHATE
1 PREDNISOLONE SODIUM PHOSPHATE SOLUTION (ORAPRED) PREDNISOLONE SOD PHOSPHATE
1 PREDNISONE SOLUTION (PRELONE) PREDNISONE
1 PREDNISONE TABLET PREDNISONE
3 PREFERA OB PNV 21/IRON PS,HEME PPEP/FOLIC
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 PREFERA‐OB ONE PNV 19/IRON PS,HEME/FOLIC/DHA
3 PREFERA‐OB PLUS DHA PNV NO.88/IRON PS,HEME/FA/DHA
3 PREFEST ESTRADIOL/NORGESTIMATE
2 PREMARIN ESTROGENS, CONJUGATED
2 PREMPHASE ESTROGEN,CON/M‐PROGEST ACET
2 PREMPRO ESTROGEN,CON/M‐PROGEST ACET
1 PRENAT VIT 17/IRON/FOLIC/OM3,6 PRENAT VIT 17/IRON/FOLIC/OM3,6
1 PRENAT VIT COMB.10/IRON/FA/DHA PRENAT VIT COMB.10/IRON/FA/DHA
3 PRENATA PRENATAL VIT37/IRON/FOLIC ACID
1 PRENATAL #108/IRON,CARBONYL/FA PRENATAL #108/IRON,CARBONYL/FA
1 PRENATAL #57/IRON/FA/DSS/DHA PRENATAL #57/IRON/FA/DSS/DHA
1 PRENATAL 105/IRON/FOLIC AC/DHA PRENATAL 105/IRON/FOLIC AC/DHA
1 PRENATAL 68/IRON/FOLIC NO1/DHA PRENATAL 68/IRON/FOLIC NO1/DHA
1 PRENATAL COMB NO.42/FOLIC ACID PRENATAL COMB NO.42/FOLIC ACID
1 PRENATAL NO.13/IRON PS/FA CB#1 PRENATAL NO.13/IRON PS/FA CB#1
1 PRENATAL NO.52/IRON/FA/DHA PRENATAL NO.52/IRON/FA/DHA
1 PRENATAL NO.75/IRON/FOLATE #1 PRENATAL NO.75/IRON/FOLATE #1
3 PRENATAL PLUS‐DHA PRENATAL72/IRON FUM/FA/OM3/DHA
1 PRENATAL VIT #76/IRON,CARB/FA PRENATAL VIT #76/IRON,CARB/FA
1 PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL VIT 15/IRON CB/FA/DSS
1 PRENATAL VIT 16/IRON CB/FA/DSS PRENATAL VIT 16/IRON CB/FA/DSS
1 PRENATAL VIT 18/IRON CB/FA/DSS PRENATAL VIT 18/IRON CB/FA/DSS
1 PRENATAL VIT 55/IRON/FOLIC/OM3 PRENATAL VIT 55/IRON/FOLIC/OM3
1 PRENATAL VIT 7‐IRON‐FOLIC‐DHA PRENATAL VIT 7‐IRON‐FOLIC‐DHA
1 PRENATAL VIT NO.109/IRON/FA PRENATAL VIT NO.109/IRON/FA
1 PRENATAL VIT NO.127/IRON/FA PRENATAL VIT NO.127/IRON/FA
1 PRENATAL VIT NO.73/IRON/FA PRENATAL VIT NO.73/IRON/FA
1 PRENATAL VIT NO.78/IRON/FA PRENATAL VIT NO.78/IRON/FA
1 PRENATAL VIT#4/IRON FUM,PS/FA PRENATAL VIT#4/IRON FUM,PS/FA
1 PRENATAL VIT#86/IRON BISGLY/FA PRENATAL VIT#86/IRON BISGLY/FA
1 PRENATAL VIT/IRON BISGLYCIN/FA PRENATAL VIT/IRON BISGLYCIN/FA
1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL VIT/IRON FUMARATE/FA
1 PRENATAL VIT100/IRON/FOLIC/OM3 PRENATAL VIT100/IRON/FOLIC/OM3
1 PRENATAL VIT27,CALCIUM/IRON/FA PRENATAL VIT27,CALCIUM/IRON/FA
1 PRENATAL VITS#4/IRON FUM/FA PRENATAL VITS#4/IRON FUM/FA
1 PRENATAL,CALC NO.65/IRON/FOLIC PRENATAL,CALC NO.65/IRON/FOLIC
1 PRENATAL,CALC.40/IRON/FOLATE 1 PRENATAL,CALC.40/IRON/FOLATE 1
1 PRENATAL64/IRON/LMFOLATE/ALGAL PRENATAL64/IRON/LMFOLATE/ALGAL
1 PRENATAL71/IRON/FOLIC ACID/DHA PRENATAL71/IRON/FOLIC ACID/DHA
3 PRENATE AM PRENATAL VIT NO.114/FA/GINGER
3 PRENATE CHEWABLE PRENATAL VIT NO.112/FOLIC ACID
3 PRENATE DHA PNV #38/IRON FUM/FOLATE/DHA
3 PRENATE ELITE PRENATAL 114/IRON ASP GLY/FA 1
3 PRENATE ENHANCE PRENATAL VIT #68/IRON/FA#6/DHA
3 PRENATE ESSENTIAL PRENATAL NO35/IRON/FOLATE6/DHA
3 PRENATE MINI PRENATAL VIT NO.87/IRON/FA/DHA
3 PRENATE PIXIE PRENATAL VIT#85/IRON/FA#1/DHA
3 PRENATE RESTORE PRENATAL VIT #69/IRON/FA#6/DHA
3 PRENATE STAR PRENATAL NO.77/IRON ASP GLY/FA
3 PREPIDIL DINOPROSTONE
2 PREPOPIK SOD PICOSULF/MAG OX/CITRIC AC
3 PREQUE 10 PRENATAL 18/IRON/FOLIC/DSS/DHA
3 PRESERA EMOLLIENT COMBINATION NO.80
Excluded PRESTALIA
2 PREVACID (15, 30 MG) CAPSULE DR LANSOPRAZOLE
2 PREVACID (15, 30 MG) TAB RAP DR LANSOPRAZOLE X
3 PREVIDENT SODIUM FLUORIDE
3 PREVIDENT 5000 SODIUM FLUORIDE
3 PREVIDENT 5000 ENAMEL PROTECT SODIUM FLUORIDE/POTASSIUM NIT
3 PREVIDENT 5000 PLUS SODIUM FLUORIDE
3 PREVIDENT 5000 SENSITIVE SODIUM FLUORIDE/POTASSIUM NIT
2 PREVPAC LANSOPRAZOLE/AMOXICILN/CLARITH X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 PREZCOBIX DARUNAVIR/COBICISTAT X
2 PREZISTA (100 MG/ML) ORAL SUSP DARUNAVIR ETHANOLATE X
2 PREZISTA (75, 150, 600, 800 MG) TABLET DARUNAVIR ETHANOLATE X
3 PRIALT ZICONOTIDE ACETATE
3 PRIFTIN RIFAPENTINE
3 PRILOLID LIDOCAINE/PRILOCAINE
3 PRILOSEC OMEPRAZOLE MAGNESIUM
3 PRIMACARE PRENATAL VIT#118/IRON/FA#6/DHA
2 PRIMAQUINE PRIMAQUINE PHOSPHATE
3 PRIMEAIRE INHALER, ASSIST DEVICES
1 PRIMIDONE PRIMIDONE
3 PRIMLEV OXYCODONE HCL/ACETAMINOPHEN X
2 PRIMSOL TRIMETHOPRIM
2 PRINIVIL LISINOPRIL
2 PRISTIQ DESVENLAFAXINE SUCCINATE X X
2 PROAIR HFA ALBUTEROL SULFATE
2 PROAIR RESPICLICK ALBUTEROL SULFATE
1 PROBENECID PROBENECID
1 PROBENECID/COLCHICINE PROBENECID/COLCHICINE
3 PROBUPHINE BUPRENORPHINE HCL
2 PROCARDIA NIFEDIPINE
2 PROCARDIA XL NIFEDIPINE
3 PROCENTRA DEXTROAMPHETAMINE SULFATE X
3 PRO‐CEPTION FERTILITY PAK MEDICAL SUPPLY, MISCELLANEOUS
3 PROCHAMBER INHALER, ASSIST DEVICES
1 PROCHLORPERAZINE PROCHLORPERAZINE
1 PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE
3 PROCORT HYDROCORTISONE/PRAMOXINE
2 PROCRIT EPOETIN X
2 PROCTOCORT HYDROCORTISONE
2 PROCTOFOAM‐HC HYDROCORTISONE/PRAMOXINE
3 PRODIGY MINI‐MIST NEBULIZER
3 PROFERRIN‐FORTE IRON HEME POLYPEPTIDE/FOLIC AC
1 PROGESTERONE PROGESTERONE
1 PROGESTERONE, MICRONIZED PROGESTERONE, MICRONIZED
3 PROGLYCEM DIAZOXIDE
2 PROGRAF TACROLIMUS
3 PROLENSA BROMFENAC SODIUM
3 PROLIA DENOSUMAB X X X
1 PROMETHAZINE HCL PROMETHAZINE HCL
1 PROMETHAZINE HCL/CODEINE PROMETHAZINE HCL/CODEINE X
1 PROMETHAZINE/DEXTROMETHORPHAN PROMETHAZINE/DEXTROMETHORPHAN
1 PROMETHAZINE/PHENYLEPH/CODEINE PROMETHAZINE/PHENYLEPH/CODEINE X
2 PROMETRIUM PROGESTERONE, MICRONIZED
3 PROMISEB EMOLLIENT COMBINATION NO.43
3 PROMISEB COMPLETE EMOLLIENT #43/SKIN CLEANSER#27
3 PRONEB ULTRA II NEBULIZER AND COMPRESSOR
1 PROPAFENONE HCL PROPAFENONE HCL
1 PROPANTHELINE BROMIDE PROPANTHELINE BROMIDE
1 PROPARACAINE HCL PROPARACAINE HCL
1 PROPARACAINE/FLUORESCEIN SOD PROPARACAINE/FLUORESCEIN SOD
1 PROPRANOLOL HCL PROPRANOLOL HCL
1 PROPRANOLOL LA PROPRANOLOL
1 PROPRANOLOL/HCTZ COMBO TABLET PROPRANOLOL/HCTZ
3 PROPYLENE GLYCOL PROPYLENE GLYCOL
1 PROPYLTHIOURACIL PROPYLTHIOURACIL
3 PRO‐RED AC DEXCHLORPHEN/PHENYLEPH/CODEINE X
2 PROSCAR FINASTERIDE
3 PROSTIN E2 VAGINAL SUPPOSITORY DINOPROSTONE
1 PROTECT CMB2/CERAMIDE 1,3,6‐11 PROTECT CMB2/CERAMIDE 1,3,6‐11
3 PROTECT IRON MV‐MINS NO.24/IRON/FOLIC ACID
3 PROTHELIAL SUCRALFATE MALATE, POLYMERIZED
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 PROTONIX (40 MG) GRANPKT DR PANTOPRAZOLE SODIUM X
2 PROTONIX (40 MG) TABLET DR PANTOPRAZOLE SODIUM
2 PROTONIX SUSP PANTOPRAZOLE SODIUM
2 PROTOPIC TACROLIMUS
2 PROTRIPTYLINE TABLET PROTRIPTYLINE
3 PROVENT NASAL EXHALATION RESISTANC.DEV
Excluded PROVENTIL HFA
2 PROVERA MEDROXYPROGESTERONE ACETATE
3 PROVIDA DHA PRENATAL#90/IRON FUM,PS/FA/DHA
3 PROVIDA OB PRENATAL VIT#65/IRON FUM,PS/FA
2 PROVIGIL MODAFINIL X
2 PROZAC FLUOXETINE HCL
2 PROZAC WEEKLY FLUOXETINE HCL
3 PRUDOXIN DOXEPIN HCL
1 PSEUDOEPHED/CHLOR‐MAL/BELL ALK PSEUDOEPHED/CHLOR‐MAL/BELL ALK
1 PSEUDOEPHED/COD/CHLORPHENIR PSEUDOEPHED/COD/CHLORPHENIR
1 PSEUDOEPHED/CODEINE/GUAIFEN PSEUDOEPHED/CODEINE/GUAIFEN X
2 PSORCON DIFLORASONE DIACETATE
3 PSORINOHEEL HOMEOPATHIC DRUGS
2 PULMICORT FLEXHALER BUDESONIDE X
2 PULMICORT RESPULES BUDESONIDE X
3 PULMO‐AIDE COMPRESSOR, FOR NEBULIZER
2 PULMOSAL SODIUM CHLORIDE FOR INHALATION
3 PURALOR CI FA7/PC,PE DHA/NAC/PAP/IF/MV46
3 PUREVIT DUALFE PLUS IRON FM,PS NO.1/FOLIC/MV NO.18
1 PV W‐O CAL/IRON PS CPLX/FOLIC PV W‐O CAL/IRON PS CPLX/FOLIC
3 PYLERA BISMUTH/METRONID/TETRACYCLINE
1 PYRAZINAMIDE PYRAZINAMIDE
2 PYRIDIUM PHENAZOPYRIDINE HCL
1 PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE
1 PYRIDOXINE HCL (VITAMIN B6) PYRIDOXINE HCL (VITAMIN B6)
3 PYROGALLIC ACID PYROGALLOL
3 QBRELIS LISINOPRIL X X
3 Q‐CARE RX DENTL SUCTION DEV/CHLORHX/SWB1
2 QNASL BECLOMETHASONE DIPROPIONATE X X
2 QNASL CHILDREN BECLOMETHASONE DIPROPIONATE X X
Excluded QSYMIA
3 QUAKE MUCUS CLEARING DEVICE
2 QUALAQUIN QUININE SULFATE
3 QUARTETTE L‐NORGEST/E.ESTRADIOL‐E.ESTRAD
1 QUAZEPAM QUAZEPAM
3 QUDEXY XR (25, 50, 100, 150, 200 MG) CAP SPR 24 TOPIRAMATE X X
2 QUESTRAN CHOLESTYRAMINE (WITH SUGAR)
2 QUESTRAN LIGHT CHOLESTYRAMINE/ASPARTAME
1 QUETIAPINE IR/XR QUETIAPINE X
3 QUICK RELEASE SOFT TEFLON INTRAVENOUS ADMINISTRATION SET
3 QUICK‐SET PARADIGM INFUSION SET FOR INSULIN PUMP
3 QUILLICHEW ER (20 MG) TAB CBP24H METHYLPHENIDATE HCL X X
3 QUILLICHEW ER (30 MG) TAB CBP24H METHYLPHENIDATE HCL X X
3 QUILLICHEW ER (40 MG) TAB CBP24H METHYLPHENIDATE HCL X X
2 QUILLIVANT XR (5 MG/ML) SU ER RC24 METHYLPHENIDATE HCL X X
1 QUINAPRIL QUINAPRIL
1 QUINAPRIL/HYDROCHLOROTHIAZIDE QUINAPRIL/HYDROCHLOROTHIAZIDE
1 QUINIDINE GLUCONATE QUINIDINE GLUCONATE
1 QUINIDINE SULFATE QUINIDINE SULFATE
1 QUININE SULFATE QUININE SULFATE
3 QUTENZA CAPSAICIN/SKIN CLEANSER X
2 QVAR BECLOMETHASONE DIPROPIONATE X
1 RABEPRAZOLE SODIUM RABEPRAZOLE X
3 RADIAGEL EMOLLIENT BASE
3 RADIAPLEXRX HYALURONATE/ALLANTOIN/ALOE EXT
Excluded RADICAVA EDARAVONE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 RADIGEL ACEMANNAN/ALLANTOIN
3 RADIOGARDASE PRUSSIAN BLUE (INSOLUBLE)
2 RAGWITEK WEED POLLEN‐SHORT RAGWEED X
1 RALOXIFENE HCL RALOXIFENE HCL X
1 RAMIPRIL TABLET RAMIPRIL
2 RANEXA (500, 1000 MG) TAB ER 12H RANOLAZINE X
1 RANITIDINE CAPSULE/TABLET RANITIDINE
1 RANITIDINE SYRUP RANITIDINE HCL
3 RAPAFLO SILODOSIN X
2 RAPAMUNE SIROLIMUS
3 RAPLIXA FIBRINOGEN/THROMBIN(HUMAN DER)
3 RAPLIXA DELIVERY KIT GAS PRESS.HEMOSTATIC SPRAY DEV
3 RAPPORT VACUUM THERAPY VACUUM ERECTION DEVICE SYSTEM
1 RASAGILINE MESYLATE RASAGILINE MESYLATE X
3 RASUVO METHOTREXATE X X X
3 RATE FLOW REGULATOR IV SET INTRAVENOUS ADMINISTRATION SET
2 RAYALDEE CALCIFEDIOL X
Excluded RAYOS
2 RAZADYNE GALANTAMINE HBR X
2 RAZADYNE ER GALANTAMINE HBR X
3 REA LO 39, 40 UREA
2 REBETOL SOLUTION RIBAVIRIN
2 REBIF X
2 REBIF REBIDOSE X
3 RECEDO POLYDIMETHYLSILOXANES/SILICON
3 RECLAST ZOLEDRONIC ACID X X X
3 RECONSTITUBE MEDICAL SUPPLY, MISCELLANEOUS
3 RECOTHROM THROMBIN (RECOMBINANT)
3 RECTIV NITROGLYCERIN
3 REGENECARE LIDOCAINE HCL/COLLAGEN
2 REGLAN METOCLOPRAMIDE HCL
2 REGRANEX BECAPLERMIN
3 RELADOR PAK LIDOCAINE/PRILOCAINE
3 RELADOR PAK PLUS LIDOCAINE/PRILOCAINE
3 RELAGARD ACETIC ACID/OXYQUINOLINE
3 RELENZA ZANAMIVIR X
3 RELISTOR METHYLNALTREXONE BROMIDE X X
3 RELIZORB ENTERAL PUMP ACCESS.HYDROLYSIS
3 RELPAX ELETRIPTAN HBR X X
2 REMERON MIRTAZAPINE
3 REMICADE INFLIXIMAB X
3 RENACIDIN CITRIC AC/GLUCONOLACT/MAG CARB
2 RENAGEL SEVELAMER HCL
3 RENEEL HOMEOPATHIC DRUGS
2 RENVELA SEVELAMER CARBONATE
1 REPAGLINIDE REPAGLINIDE
1 REPAGLINIDE/METFORMIN HCL REPAGLINIDE/METFORMIN HCL
3 REPLICARE HYDROCOLLOID DRESSING
3 REPLICARE THIN HYDROCOLLOID DRESSING
3 REPLICARE ULTRA HYDROCOLLOID DRESSING
3 REPLICARE ULTRA SACRUM HYDROCOLLOID DRESSING
3 REQ49+ MV‐MIN 16/FOLIC ACID/LUT/LYCOP
2 REQUIP ROPINIROLE HCL
2 REQUIP XL ROPINIROLE HCL X X
2 RESCRIPTOR DELAVIRDINE MESYLATE
3 RESECTISOL MANNITOL
1 RESERPINE RESERPINE
2 RESTASIS CYCLOSPORINE X
2 RESTASIS MULTIDOSE CYCLOSPORINE X
3 RESTIZAN EMOLLIENT COMBINATION NO.60
3 RESTORA RX LACTOBACILLUS CASEI/FOLIC ACID
3 RESTORA SPRINKLES LACTOBACILLUS CASEI/FOLIC ACID
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 RESTORE SILVER SULFATE/FOAM BANDAGE
3 RESTORE CALCIUM ALGINATE SILVER/CALCIUM ALGINATE
3 RESTORE CONTACT LAYER SILVER SILVER SULFATE/NON‐ADH BANDAGE
2 RESTORIL TEMAZEPAM
3 RETIN‐A TRETINOIN
3 RETIN‐A MICRO TRETINOIN MICROSPHERES
3 RETIN‐A MICRO PUMP (0.04 %) GEL W/PUMP TRETINOIN MICROSPHERES
3 RETIN‐A MICRO PUMP (0.08 %) GEL W/PUMP TRETINOIN MICROSPHERES X
3 RETIN‐A MICRO PUMP (0.1 %) GEL W/PUMP TRETINOIN MICROSPHERES
2 RETROVIR (10 MG/ML) SYRUP ZIDOVUDINE X
2 RETROVIR (100 MG) CAPSULE ZIDOVUDINE X
3 REUSABLE NEBULIZER KIT NEBULIZER ACCESSORIES
3 REVEL PROGRAMMABLE PUMP SUBCUTANEOUS INSULIN PUMP
2 REVIA NALTREXONE HCL
2 REXULTI BREXPIPRAZOLE X X
2 REYATAZ (150, 200, 300 MG) CAPSULE ATAZANAVIR SULFATE X
2 REYATAZ (50 MG) POWD PACK ATAZANAVIR SULFATE X
3 REZIRA PSEUDOEPHED/HYDROCODONE X
3 RHOFADE OXYMETAZOLINE HCL
3 RIBAPAK X
1 RIBASPHERE 200MG
3 RIBASPHERE 400MG, 600MG X
1 RIBAVIRIN 200MG RIBAVIRIN
1 RIFABUTIN RIFABUTIN
2 RIFADIN RIFAMPIN
2 RIFAMATE RIFAMPIN/ISONIAZID
1 RIFAMPIN RIFAMPIN
3 RIFATER RIFAMP/ISONIAZID/PYRAZINAMIDE
1 RIMANTADINE HCL RIMANTADINE HCL
3 RIMSO‐50 DIMETHYL SULFOXIDE
1 RINGERS SOLUTION RINGERS SOLUTION
2 RIOMET METFORMIN HCL
2 RISEDRONATE TABLET RISEDRONATE
2 RISPERDAL (0.25 MG) TABLET RISPERIDONE X
2 RISPERDAL (0.5 MG) TABLET RISPERIDONE X
2 RISPERDAL (1 MG) TABLET RISPERIDONE X
2 RISPERDAL (1 MG/ML) SOLUTION RISPERIDONE X
2 RISPERDAL (2, 3, 4 MG) TABLET RISPERIDONE X
2 RISPERDAL M‐TAB RISPERIDONE X
2 RISPERIDONE ODT RISPERIDONE
1 RISPERIDONE TABLET RISPERIDONE
2 RITALIN METHYLPHENIDATE HCL X
2 RITALIN LA (10, 20, 30, 40 MG) (CPBP 50‐50) METHYLPHENIDATE HCL X
3 RITEFLO INHALER, ASSIST DEVICES
3 RITUXAN RITUXIMAB X
1 RIVASTIGMINE RIVASTIGMINE X
1 RIVASTIGMINE TARTRATE RIVASTIGMINE TARTRATE
1 RIVELSA
1 RIZATRIPTAN RIZATRIPTAN
1 RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE X
2 ROBAXIN METHOCARBAMOL
2 ROBAXIN‐750 METHOCARBAMOL
3 ROBINSON CLEAR VINYL CATHETER CATHETER
3 ROBINUL GLYCOPYRROLATE
3 ROBINUL FORTE GLYCOPYRROLATE
2 ROCALTROL CALCITRIOL
1 ROPINIROLE HCL (0.25 MG) TABLET ROPINIROLE HCL
1 ROPINIROLE HCL (0.5 MG) TABLET ROPINIROLE HCL
1 ROPINIROLE HCL (1 MG) TABLET ROPINIROLE HCL
1 ROPINIROLE HCL (12 MG) TAB ER 24H ROPINIROLE HCL X X
1 ROPINIROLE HCL (2 MG) TAB ER 24H ROPINIROLE HCL X X
1 ROPINIROLE HCL (2 MG) TABLET ROPINIROLE HCL
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 ROPINIROLE HCL (3 MG) TABLET ROPINIROLE HCL
1 ROPINIROLE HCL (4 MG) TAB ER 24H ROPINIROLE HCL X X
1 ROPINIROLE HCL (4 MG) TABLET ROPINIROLE HCL
1 ROPINIROLE HCL (5 MG) TABLET ROPINIROLE HCL
1 ROPINIROLE HCL (6 MG) TAB ER 24H ROPINIROLE HCL X X
1 ROPINIROLE HCL (8 MG) TAB ER 24H ROPINIROLE HCL X X
1 ROPIVACAINE HCL IN 0.9% NACL/PF ROPIVACAINE HCL IN 0.9%NACL/PF
3 ROSADAN METRONIDAZOLE
3 ROSANIL SULFACETAMIDE SODIUM/SULFUR
3 ROSULA SULFACETAMIDE SODIUM/SULFUR
1 ROSUVASTATIN ROSUVASTATIN
3 ROTARIX ROTAVIRUS VAC,LIVE ATT, 89‐12
3 ROTATEQ ROTAVIRUS VACCINE,LIVE ORAL PV
2 ROWASA MESALAMINE W/CLEANSING WIPES
2 ROWEEPRA LEVETIRACETAM
2 ROXICODONE OXYCODONE HCL X
Excluded ROZEREM
3 RUBBER MOUTHPIECE NEBULIZER ACCESSORIES
3 RYTARY CARBIDOPA/LEVODOPA X X
2 RYTHMOL SR PROPAFENONE HCL
3 RYVENT CARBINOXAMINE MALEATE
3 SABAL‐HOMACCORD HOMEOPATHIC DRUGS
3 SACCHARIN SACCHARIN
3 SAFETY SYRINGE WITH SHIELD SYRINGE,SAFETY WITH NEEDLE,3ML
3 SAFETY SYRINGE‐NEEDLE SYRINGE,SAFETY WITH NEEDLE,3ML
3 SAFETYGLIDE ALLERGY SYRINGE SYRINGE W‐NEEDLE,DISPOSAB,1 ML
3 SAF‐T‐INTIMA IV CATHETER INTRAVENOUS CATHETER KIT
3 SAFYRAL DROSPIR/ETH ESTRA/LEVOMEFOL CA X
Excluded SAIZEN
3 SALACYN SALICYLIC ACID
2 SALAGEN PILOCARPINE HCL
3 SALEX SALICYLIC ACID
1 SALICYLIC ACID GEL SALICYLIC ACID
2 SALICYLIC ACID/CERAMIDES KIT CLEANSER & CREAM SALICYLIC ACID/CERAMIDE
3 SALIVAMAX SALIVA SUBSTITUTE COMB NO.11
3 SALIVATERX SALIVA SUBSTITUTE COMB NO.11
3 SALKERA SALICYLIC ACID/AMMON LACT/ALOE
3 SALVAX DUO PLUS SALICYLIC ACID/UREA
3 SAMI THE SEAL NEBULIZER AND COMPRESSOR
3 SAMI THE SEAL MASK NEBULIZER ACCESSORIES
3 SAMSCA (15, 30 MG) TABLET TOLVAPTAN X
3 SANCUSO GRANISETRON X X
2 SANDIMMUNE CYCLOSPORINE
3 SANTYL COLLAGENASE CLOSTRIDIUM HIST.
2 SAPHRIS ASENAPINE MALEATE X X
3 SARAFEM FLUOXETINE HCL
Excluded SARILUMAB SARILUMAB
3 SAVAYSA EDOXABAN TOSYLATE X X
2 SAVELLA MILNACIPRAN HCL
2 SCALACORT HYDROCORTISONE
2 SCALACORT DK HYDROCORT/SAL ACID/SULF/SHAMP1
3 SCLEROSOL TALC
2 SEASONALE X X
3 SEASONIQUE L‐NORGEST/E.ESTRADIOL‐E.ESTRAD X X
3 SEBUDERM EMOLLIENT COMBINATION NO.60
3 SECONAL SODIUM SECOBARBITAL SODIUM
Excluded SEEBRI NEOHALER
3 SELECT‐OB + DHA PRENATAL VITS #33/IRON/FA/DHA
1 SELEGILINE HCL SELEGILINE HCL
2 SELENIUM SULFIDE 2.25 % SHAMPOO SELENIUM SULFIDE
3 SELRX SELENIUM SULFIDE
2 SELZENTRY (25, 75, 150, 300 MG) TABLET MARAVIROC X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 SEMPREX‐D PSEUDOEPHEDRINE HCL/ACRIVAS
2 SEREVENT DISKUS SALMETEROL XINAFOATE X
3 SERNIVO BETAMETHASONE DIPROPIONATE X
2 SEROQUEL QUETIAPINE FUMARATE X
3 SEROSTIM X
1 SERTRALINE TABLET SERTRALINE
1 SEVOFLURANE SEVOFLURANE
2 SFROWASA MESALAMINE
3 SIDESTREAM NEBULIZER
3 SIDESTREAM MASK NEBULIZER ACCESSORIES
3 SIDESTREAM NEBULIZER NEBULIZER
3 SIDESTREAM PLUS NEBULIZER
1 SILDENAFIL CITRATE SILDENAFIL CITRATE X
3 SILENOR DOXEPIN HCL X X
3 SILHOUETTE SUB‐Q INFUSION PUMP ACCESSORY
3 SILICONE MASK NEBULIZER ACCESSORIES
Excluded SILIQ BRODALUMAB
2 SILVADENE SILVER SULFADIAZINE
1 SILVER NITRATE SILVER NITRATE
1 SILVER NITRATE APPLICATOR SILVER NITRATE APPLICATOR
1 SILVER SULFADIAZINE SILVER SULFADIAZINE
3 SILVERSEAL HYDROGEL SILVER/HYDROCOLLOID DRESSING
3 SILVRSTAT SILVER
2 SIMBRINZA BRINZOLAMIDE/BRIMONIDINE TART
2 SIMCOR X X
Excluded SIMPONI ARIA GOLIMUMAB
1 SIMVASTATIN TABLET SIMVASTATIN X
1 SIMVASTATIN/EZETIMIBE SIMVASTATIN/EZETIMIBE X X
2 SINEMET 10‐100 CARBIDOPA/LEVODOPA
2 SINEMET 25‐100 CARBIDOPA/LEVODOPA
2 SINEMET 25‐250 CARBIDOPA/LEVODOPA
2 SINEMET CR CARBIDOPA/LEVODOPA
2 SINGULAIR MONTELUKAST SODIUM
3 SINUSTAR NEBULIZER
3 SINUSTAR NEBULIZER AND COMPRESSOR
1 SIROLIMUS SIROLIMUS
3 SITAVIG ACYCLOVIR X X
2 SIVEXTRO TEDIZOLID PHOSPHATE X
2 SKELAXIN METAXALONE
3 SKLICE IVERMECTIN
3 SKYLA LEVONORGESTREL
3 SMARTMASK KIDS NEBULIZER ACCESSORIES
Excluded SMARTRX GABA KIT
Excluded SMARTRX GABA ‐V KIT
3 SNAP INSULIN PUMP CONTROLLER INSULIN PUMP CONTROLLER
3 SNAP INSULIN PUMP‐INFUSION SET INFUSION SET‐INSULIN PUMP BODY
1 SOD PHOS DI, MONO/K PHOS MONO SOD PHOS DI, MONO/K PHOS MONO
3 SODIUM CHLORIDE BACTERIOSTATIC SODIUM CHLORIDE
1 SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE 0.45 %
1 SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE FOR INHALATION
1 SODIUM CHLORIDE IRRIG SOLUTION SODIUM CHLORIDE IRRIG SOLUTION
1 SODIUM CHLORIDE/NAHCO3/KCL/PEG SODIUM CHLORIDE/NAHCO3/KCL/PEG
1 SODIUM CITRATE SODIUM CITRATE
1 SODIUM FLUORIDE SODIUM FLUORIDE
1 SODIUM FLUORIDE/POTASSIUM NIT SODIUM FLUORIDE/POTASSIUM NIT
1 SODIUM POLYSTYRENE SULFON/SORB SODIUM POLYSTYRENE SULFON/SORB
1 SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE
3 SODIUM SUCCINATE SODIUM SUCCINATE
1 SODIUM THIOSULFATE/SAL ACID SODIUM THIOSULFATE/SAL ACID
3 SOF‐SENSOR BLOOD‐GLUCOSE SENSOR
3 SOF‐SET INTRAVENOUS ADMINISTRATION SET
3 SOF‐SET MICRO INTRAVENOUS ADMINISTRATION SET
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 SOLARAZE DICLOFENAC SODIUM X X
3 SOLESTA DEXTRANOMER/HYALURONATE/NACL
Excluded SOLIQUA
3 SOLIRIS ECULIZUMAB X X X
3 SOLODYN MINOCYCLINE HCL X X
2 SOLTAMOX TAMOXIFEN CITRATE
3 SOLU‐CORTEF HYDROCORTISONE SODIUM SUCC/PF
2 SOMA CARISOPRODOL
2 SONATA ZALEPLON X
3 SOOLANTRA IVERMECTIN
3 SORBITOL SORBITOL SOLUTION
1 SORBITOL SOLUTION SORBITOL SOLUTION
3 SORILUX CALCIPOTRIENE X
1 SOTALOL HCL SOTALOL HCL
3 SOTYLIZE (5 MG/ML) SOLUTION SOTALOL HCL X X
3 SOVALDI X
3 SP ANTIPRURITIC NA MG FL/NA PHO/NACL/HA/NA HYP
3 SP SCAR MANAGEMENT EMOLLIENT COMBINATION NO.60
3 SPACE CHAMBER PLUS INHALER, ASSIST DEVICES
3 SPECTRACEF CEFDITOREN PIVOXIL
3 SPECTRAGEL GEL DRESSING
3 SPEEDICATH CATHETER
2 SPINOSAD SUSPENSION SPINOSAD
Excluded SPINRAZA
2 SPIRIVA TIOTROPIUM BROMIDE X
2 SPIRIVA RESPIMAT TIOTROPIUM BROMIDE X
1 SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACT/HYDROCHLOROTHIAZID
1 SPIRONOLACTONE TABLET SPIRONOLACTONE
2 SPORANOX ITRACONAZOLE
3 SPRAY AND STRETCH NORFLURANE/PENTAFLUOROPROPANE
1 SPRINTEC
3 SPRITAM (1000 MG) TAB SUSP LEVETIRACETAM X X
3 SPRITAM (250, 500, 750 MG) TAB SUSP LEVETIRACETAM X X
3 SPRIX KETOROLAC TROMETHAMINE X
3 SPS SODIUM POLYSTYRENE SULFON/SORB
3 SS 10‐2 SULFACETAMIDE SODIUM/SULFUR
2 STALEVO 100 CARBIDOPA/LEVODOPA/ENTACAPONE
2 STALEVO 50, 75, 125, 150, 200 CARBIDOPA/LEVODOPA/ENTACAPONE
2 STARLIX NATEGLINIDE
1 STAVUDINE (1 MG/ML) SOLN RECON STAVUDINE X
1 STAVUDINE (15, 20, 30, 40 MG) CAPSULE STAVUDINE X
Excluded STAXYN
STELARA USTEKINUMAB X
Excluded STENDRA
3 STIMATE DESMOPRESSIN ACETATE
2 STIOLTO RESPIMAT TIOTROPIUM BR/OLODATEROL HCL X
2 STRATTERA (10, 18, 25, 40, 60, 80, 100 MG) CAPSULE ATOMOXETINE HCL X
3 STRAVIX HUMAN REGENERATIVE TISSUE MTRX
3 STRIANT TESTOSTERONE X
2 STRIBILD ELVITEG/COBI/EMTRIC/TENOFO DIS X
2 STRIVERDI RESPIMAT OLODATEROL HCL X
3 STROMECTOL IVERMECTIN
3 STROVITE ONE MV,MIN10/FOLIC ACID/D3/ALA/LUT
2 SUBOXONE (2 MG‐0.5MG) FILM BUPRENORPHINE HCL/NALOXONE HCL X X
2 SUBOXONE (4MG‐1MG) FILM BUPRENORPHINE HCL/NALOXONE HCL X X
2 SUBOXONE (8 MG‐2 MG) FILM BUPRENORPHINE HCL/NALOXONE HCL X X
2 SUBOXONE FILM BUPRENORPHINE HCL/NALOXONE HCL X
Excluded SUBSYS
1 SUCRALFATE SUCRALFATE
3 SULAR NISOLDIPINE
2 SULFACETAMIDE SODIU,/SULFER MEDICATED PADS SULFACETAMIDE SODIUM/SULFUR
2 SULFACETAMIDE SODIUM 10% SHAMPOO SULFACETAMIDE SODIUM
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 SULFACETAMIDE SODIUM 10% SOLUTION SULFACETAMIDE SODIUM
1 SULFACETAMIDE SODIUM/SULFUR 10 %‐5 % FOAM SULFACETAMIDE SODIUM/SULFUR
2 SULFACETAMIDE SODIUM/SULFUR LOTION SULFACETAMIDE SODIUM/SULFUR
2 SULFACETAMIDE SODIUM/SULFUR SUSPENSION SULFACETAMIDE SODIUM/SULFUR
1 SULFACT SOD/SULUR/AVOB/OTN/OCT SULFACT SOD/SULUR/AVOB/OTN/OCT
1 SULFADIAZINE SULFADIAZINE
1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM
3 SULFAMYLON MAFENIDE ACETATE
1 SULFASALAZINE 500 MG DR TABLET SULFASALAZINE
1 SULFASALAZINE 500 MG TABLET SULFASALAZINE
1 SULINDAC TABLET SULINDAC
3 SUMADAN SULFACETAMIDE SODIUM/SULFUR
3 SUMADAN XLT SULFACT SOD/SULUR/AVOB/OTN/OCT
1 SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE X
3 SUMAVEL DOSEPRO SUMATRIPTAN SUCCINATE X X
3 SUMAXIN SULFACETAMIDE SODIUM/SULFUR
3 SUMAXIN TS SULFACETAMIDE SODIUM/SULFUR
3 SUNRISE COMPRESSOR‐NEBULIZER COMPRESSOR, FOR NEBULIZER
3 SUPERVITE LYSINE/B COMP/FOLIC ACID/ZINC
3 SUPRANE DESFLURANE
2 SUPRAX CEFIXIME
2 SUPREP SODIUM, POTASSIUM,MAG SULFATES
3 SURE‐T SUB‐Q INFUSION PUMP ACCESSORY
3 SURE‐T PARADIGM INFUSION SET FOR INSULIN PUMP
3 SURFAXIN LUCINACTANT
Excluded SURILIMAB
3 SURMONTIL TRIMIPRAMINE MALEATE
3 SURVANTA BERACTANT
2 SUSTIVA EFAVIRENZ
2 SYMAX HYOSCYAMINE SULFATE
3 SYMAX DUOTAB HYOSCYAMINE SULFATE
2 SYMAX‐SL HYOSCYAMINE SULFATE
2 SYMAX‐SR HYOSCYAMINE SULFATE
2 SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE X
2 SYMBYAX OLANZAPINE/FLUOXETINE HCL X
2 SYMLIN PRAMLINTIDE ACETATE
2 SYMLINPEN 60 PRAMLINTIDE ACETATE
2 SYNALAR FLUOCINOLONE ACETONIDE
3 SYNALAR FLUOCINOLONE/EMOL CMB#65
3 SYNALAR TS FLUOCINOLONE/SKIN CLNSR28
3 SYNALGOS‐DC ASPIRIN/CAFFEIN/DIHYDROCODEINE X
3 SYNERA LIDOCAINE/TETRACAINE
Excluded SYNERDERM
2 SYNJARDY EMPAGLIFLOZIN/METFORMIN HCL X X
2 SYNJARDY XR EMPAGLIFLOZIN/METFORMIN HCL X X
2 SYNTHROID LEVOTHYROXINE SODIUM
3 SYNVEXIA TC LIDOCAINE HCL/MENTHOL
3 SYPRINE TRIENTINE HCL X
3 SYRINGE SYRINGE, DISPOSABLE, 5 ML
3 SYRINGE SYRINGE, DISPOSABLE, 60 ML
3 SYRINGE AVITENE MICROFIBRILLAR COLLAGEN
3 SYRINGE‐NEEDLE SYRINGE,SAFETY WITH NEEDLE,1ML
3 SYZYGIUM COMPOSITUM HOMEOPATHIC DRUGS
3 TACHOSIL FIBRINOGEN/THROMBIN(HUMAN DER)
3 TACLONEX CALCIPOTRIENE/BETAMETHASONE X
1 TACROLIMUS TACROLIMUS
3 TALWIN PENTAZOCINE LACTATE
2 TAMIFLU (30, 45, 75 MG) CAPSULE OSELTAMIVIR PHOSPHATE X
2 TAMIFLU (6 MG/ML) SUSP RECON OSELTAMIVIR PHOSPHATE X
1 TAMOXIFEN CITRATE TAMOXIFEN CITRATE
1 TAMSULOSIN TAMSULOSIN
3 TANDEM PLUS IRON FM,PS NO.1/FOLIC/MV NO.18
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
TherapyExcluded TANZEUM
2 TAPAZOLE METHIMAZOLE
3 TARGADOX DOXYCYCLINE HYCLATE X X
1 TARINA FE
3 TARKA TRANDOLAPRIL/VERAPAMIL HCL
3 TASMAR TOLCAPONE X X
3 TAYTULLA NORETHINDRONE‐E.ESTRADIOL‐IRON
2 TAZORAC TAZAROTENE
2 TECFIDERA X
3 TECHNIVIE X
2 TEGRETOL CARBAMAZEPINE
2 TEGRETOL XR CARBAMAZEPINE
3 TEKAMLO ALISKIREN/AMLODIPINE BESYLATE X
3 TEKTURNA ALISKIREN HEMIFUMARATE X
3 TEKTURNA HCT ALISKIREN/HYDROCHLOROTHIAZIDE X
1 TELMISARTAN TELMISARTAN
1 TELMISARTAN & AMLODIPINE TABLETS TELMISARTAN & AMLODIPINE
2 TELMISARTAN/AMLODIPINE COMBO TABLET TELMISARTAN/AMLODIPINE
2 TELMISARTAN/HCTZ COMBO TABLET TELMISARTAN/HCTZ
2 TEMOVATE CLOBETASOL PROPIONATE
2 TENORETIC 50, 100 ATENOLOL/CHLORTHALIDONE
2 TENORMIN ATENOLOL
3 TENS 502, 504 TENS UNIT
3 TERAZOL 7 TERCONAZOLE
1 TERAZOSIN TERAZOSIN
1 TERBINAFINE TABLET TERBINAFINE
1 TERBUTALINE SULFATE TERBUTALINE SULFATE
1 TERCONAZOLE TERCONAZOLE
3 TERSI FOAM SELENIUM SULFIDE
3 TERUMO SURGUARD2 SYRINGE,SAFETY NEEDLE,10 ML
3 TERUMO SURGUARD2 SYRINGE,SAFETY WITH NEEDLE,1ML
3 TERUMO SURGUARD2 SYRINGE,SAFETY WITH NEEDLE,3ML
3 TERUMO SURGUARD2 SYRINGE,SAFETY WITH NEEDLE,5ML
3 TERUMO SURGUARD2 NEEDLES, SAFETY
3 TESSALON PERLE BENZONATATE
Excluded TESTIM
3 TESTOPEL TESTOSTERONE
1 TESTOSTERONE 1% GEL TESTOSTERONE X
1 TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE X
1 TESTOSTERONE ENANTHATE TESTOSTERONE ENANTHATE X
2 TESTOSTERONE GEL PUMP TESTOSTERONE
2 TESTOSTERONE GEL/GEL PACKET TESTOSTERONE
3 TESTRED METHYLTESTOSTERONE X
3 TETCAINE TETRACAINE HCL
1 TETRACAINE HCL TETRACAINE HCL
1 TETRACAINE HCL/PF TETRACAINE HCL/PF
1 TETRACYCLINE HCL TETRACYCLINE HCL
3 TETRAVISC TETRACAINE HCL
3 TETRAVISC FORTE TETRACAINE HCL
3 TETRIX PROTECTIVES COMBINATION NO.2
2 TEXACORT HYDROCORTISONE
3 TEXAVITE LQ PED MULTIVIT 108/IRON/FLUORIDE
2 THEO‐24 THEOPHYLLINE ANHYDROUS
1 THEOPHYLLINE THEOPHYLLINE
2 THERMAZENE SILVER SULFADIAZINE
1 THIAMINE HCL THIAMINE HCL
1 THIORIDAZINE HCL THIORIDAZINE HCL
1 THIOTHIXENE THIOTHIXENE
3 THRESHOLD IMT SPIROMETERS AND ACCESSORIES
3 THRESHOLD PEP SPIROMETERS AND ACCESSORIES
3 THRIVITE RX PRENATAL VIT #76/IRON,CARB/FA
1 THROMB‐CA‐CELL‐DRESSING, HEMOS THROMB‐CA‐CELL‐DRESSING, HEMOS
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 THROMBIN (BOVINE) THROMBIN (BOVINE)
1 THROMBIN/CA/CMC/GEL/DRESS, HEM THROMBIN/CA/CMC/GEL/DRESS, HEM
1 THYROID,PORK THYROID,PORK
3 THYROLAR‐1 LIOTRIX
3 THYROLAR‐1/2 LIOTRIX
3 THYROLAR‐1/4 LIOTRIX
3 THYROLAR‐2 LIOTRIX
3 THYROLAR‐3 LIOTRIX
1 TIAGABINE HCL TIAGABINE HCL X X
2 TIAZAC DILTIAZEM HCL
Excluded TICALAST
Excluded TICANASE
1 TICLOPIDINE HCL TICLOPIDINE HCL
3 TIGAN TRIMETHOBENZAMIDE HCL
2 TIKOSYN DOFETILIDE X
1 TILIA FE, TRI‐LEGEST FE
1 TIMOLOL TIMOLOL
1 TIMOLOL OPHTHALMIC DROPS TIMOLOL
2 TIMOLOL OPHTHALMIC GEL SOLUTION TIMOLOL
1 TIMOLOL/DORZOLAMIDE TIMOLOL/DORZOLAMIDE
2 TIMOPTIC TIMOLOL MALEATE
3 TIMOPTIC OCUDOSE TIMOLOL MALEATE/PF X X
3 TINDAMAX TINIDAZOLE
2 TINIDAZOLE TABLET TINIDAZOLE
Excluded TIROSINT
3 TISSEEL VHSD THROMBIN(HUM PLAS)/FIB/APRO/CA
3 TIS‐U‐SOL PENTALYTE SOD,POT CHLOR/MAG/SOD,POT PHOS
2 TIVICAY DOLUTEGRAVIR SODIUM X
Excluded TIVORBEX
2 TIZANIDINE CAPSULE TIZANIDINE
1 TIZANIDINE TABLET TIZANIDINE
2 TOBRADEX TOBRAMYCIN/DEXAMETHASONE
3 TOBRADEX ST TOBRAMYCIN/DEXAMETHASONE
1 TOBRAMYCIN TOBRAMYCIN
1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE
2 TOBREX TOBRAMYCIN
2 TOFRANIL IMIPRAMINE HCL
3 TOLAK FLUOROURACIL
2 TOLAZAMIDE TABLET TOLAZAMIDE
1 TOLBUTAMIDE TOLBUTAMIDE
1 TOLCAPONE TOLCAPONE X X
2 TOLMETIN SODIUM TABLET TOLMETIN SODIUM
2 TOLTERODINE ER CAPSULE TOLTERODINE
2 TOLTERODINE TABLET TOLTERODINE
1 TOLTERODINE TARTRATE TOLTERODINE X
3 TOOMEY SYRINGE SYRINGE DISPOSABLE IRRIG,70 ML
2 TOPAMAX TOPIRAMATE
2 TOPICORT (0.05 %) CREAM DESOXIMETASONE
2 TOPICORT (0.05 %) GEL DESOXIMETASONE
2 TOPICORT (0.05 %) OINTMENT DESOXIMETASONE
2 TOPICORT (0.25 %) CREAM DESOXIMETASONE
2 TOPICORT (0.25 %) OINTMENT DESOXIMETASONE
3 TOPICORT (0.25 %) SPRAY DESOXIMETASONE X
1 TOPIRAMATE (100 MG) CAP SPR 24 TOPIRAMATE X X
1 TOPIRAMATE (100 MG) TABLET TOPIRAMATE
1 TOPIRAMATE (15 MG) CAP SPRINK TOPIRAMATE
1 TOPIRAMATE (150 MG) CAP SPR 24 TOPIRAMATE X X
1 TOPIRAMATE (200 MG) CAP SPR 24 TOPIRAMATE X X
1 TOPIRAMATE (200 MG) TABLET TOPIRAMATE
1 TOPIRAMATE (25 MG) CAP SPR 24 TOPIRAMATE X X
1 TOPIRAMATE (25 MG) CAP SPRINK TOPIRAMATE
1 TOPIRAMATE (25 MG) TABLET TOPIRAMATE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy1 TOPIRAMATE (50 MG) CAP SPR 24 TOPIRAMATE X X
1 TOPIRAMATE (50 MG) TABLET TOPIRAMATE
2 TOPROL XL METOPROLOL SUCCINATE
3 TORONOVA II SUIK KETOROLAC/NORFLURANE/HFC 245FA
3 TORONOVA SUIK KETOROLAC/NORFLURANE/HFC 245FA
1 TORSEMIDE TORSEMIDE
3 TOUCH‐TROL CATHETER
2 TOUJEO SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG X
2 TOVIAZ FESOTERODINE FUMARATE X
2 TRADJENTA LINAGLIPTIN X
1 TRAMADOL HCL (100 MG) (CPBP 25‐75) TRAMADOL HCL X X
1 TRAMADOL HCL (100 MG) (TBMP 24HR) TRAMADOL HCL X
2 TRAMADOL HCL (100 MG) TAB ER 24H TRAMADOL HCL X
1 TRAMADOL HCL (150 MG) (CPBP 25‐75) TRAMADOL HCL X X
1 TRAMADOL HCL (200 MG) (CPBP 25‐75) TRAMADOL HCL X X
1 TRAMADOL HCL (200 MG) (TBMP 24HR) TRAMADOL HCL X
2 TRAMADOL HCL (200 MG) TAB ER 24H TRAMADOL HCL X
1 TRAMADOL HCL (300 MG) (CPBP 17‐83) TRAMADOL HCL X X
1 TRAMADOL HCL (300 MG) (TBMP 24HR) TRAMADOL HCL X
1 TRAMADOL HCL (300 MG) TAB ER 24H TRAMADOL HCL X
1 TRAMADOL HCL (50 MG) TABLET TRAMADOL HCL X
1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN X
1 TRANDOLAPRIL TRANDOLAPRIL
1 TRANDOLAPRIL TABLET & VERAPAMIL TABLET TRANDOLAPRIL & VERAPAMIL HCL
2 TRANDOLAPRIL/VERAPAMIL HCL TABLET TRANDOLAPRIL/VERAPAMIL HCL
1 TRANEXAMIC ACID TRANEXAMIC ACID
3 TRANSDERM‐SCOP SCOPOLAMINE
Excluded TRANSLARNA ATALUREN
2 TRANXENE T‐TAB CLORAZEPATE DIPOTASSIUM
2 TRANYLCYPROMINE SULFATE TABLET TRANYLCYPROMINE SULFATE
2 TRAVAPROST DROPS TRAVOPROST
2 TRAVATAN Z TRAVOPROST X
1 TRAVOPROST TRAVOPROST X
1 TRAZODONE HCL TRAZODONE HCL
3 TRECATOR ETHIONAMIDE
3 TREK S COMBO PACK NEBULIZER AND COMPRESSOR
3 TREK S COMPACT COMPRESSOR NEBULIZER AND COMPRESSOR
3 TREK S PORTABLE PWR KIT NEBULIZER ACCESSORIES
Excluded TRESIBA
2 TRETINOIN (0.01 %) GEL TRETINOIN
2 TRETINOIN (0.025 %) CREAM TRETINOIN
2 TRETINOIN (0.025 %) GEL TRETINOIN
2 TRETINOIN (0.05 %) CREAM TRETINOIN
2 TRETINOIN (0.05 %) GEL TRETINOIN
2 TRETINOIN (0.1 %) CREAM TRETINOIN
2 TRETINOIN MICROSPHERES TRETINOIN MICROSPHERES
3 TRETIN‐X TRETINOIN
3 TRETIN‐X TRETINOIN/EMOL CMB9/SKIN CLN1
2 TREXALL METHOTREXATE SODIUM
Excluded TREXIMET
3 TREZIX ACETAMINOPHEN/CAFF/DIHYDROCOD X
2 TRIAMCINOLONE ABSORBASE 0.05% OINTMENT (MEDIUM) TRIAMCINOLONE
1 TRIAMCINOLONE ACETONIDE 0.025 % CREAM (LOW) TRIAMCINOLONE ACETONIDE X
1
TRIAMCINOLONE ACETONIDE 0.025 % LOTION
(LOWER‐MID) TRIAMCINOLONE ACETONIDE X
1
TRIAMCINOLONE ACETONIDE 0.025 % OINTMENT
(LOWER‐MID) TRIAMCINOLONE ACETONIDE X
1 TRIAMCINOLONE ACETONIDE 0.05 % CREAM (HIGH) TRIAMCINOLONE ACETONIDE X
1 TRIAMCINOLONE ACETONIDE 0.1 % LOTION (LOWER‐MID) TRIAMCINOLONE ACETONIDE X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy
1 TRIAMCINOLONE ACETONIDE 0.1 % OINTMENT (MEDIUM) TRIAMCINOLONE ACETONIDE X
1 TRIAMCINOLONE ACETONIDE 0.1% CREAM (MEDIUM) TRIAMCINOLONE ACETONIDE X
1 TRIAMCINOLONE ACETONIDE 0.5 % OINTMENT (HIGH) TRIAMCINOLONE ACETONIDE X
2 TRIAMCINOLONE TOPICAL SPRAY (MEDIUM) TRIAMCINOLONE ACETONIDE X
2 TRIAMCINOLONE/DIMETHICONE 0.1%‐5% (MEDIUM) TRIAMCINOLONE ACETONIDE X
1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID
1 TRIAZOLAM TRIAZOLAM
2 TRIBENZOR OLMESARTAN/AMLODIPIN/HCTHIAZID X
3 TRICARE PRENATAL #103/IRON FUMARATE/FA
3 TRICARE PRENATAL PRENATAL VIT #113/IRON/FOLATE
3 TRICARE PRENATAL DHA ONE PNV20/IRON/FOLIC/DOCUSATE/OM3S
3 TRICARE PRENATAL WITH DHA PRENATAL 113/IRON/LMFOL/OMEG3S
2 TRICOR FENOFIBRATE NANOCRYSTALLIZED
1 TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL
1 TRIFLURIDINE TRIFLURIDINE
2 TRIGLIDE FENOFIBRATE NANOCRYSTALLIZED X
1 TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL
2 TRILEPTAL OXCARBAZEPINE
3 TRILIPIX FENOFIBRIC ACID (CHOLINE)
3 TRILOAN II SUIK TRIAMCIN/NORFLURANE/HFC 245FA
3 TRILOAN SUIK TRIAMCIN/NORFLURANE/HFC 245FA
2 TRIMETHOBENZAMIDE HCL TRIMETHOBENZAMIDE HCL
1 TRIMETHOPRIM TRIMETHOPRIM
1 TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE
3 TRINATAL RX 1 PRENATAL VIT27,CALCIUM/IRON/FA
1 TRINESSA
2 TRI‐NORINYL NORETHINDRONE‐ETHINYL ESTRAD X
2 TRINTELLIX VORTIOXETINE HYDROBROMIDE X X
1 TRI‐SPRINTEC
3 TRISTART DHA PRENATAL NO.93/IRON/FA #9/DHA
2 TRIUMEQ ABACAVIR/DOLUTEGRAVIR/LAMIVUDI X
3 TRI‐VI‐FLOR PED MVIT A,C,D3 NO.38/FLUORIDE
1 TRIVORA‐28
2 TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE X
2 TROKENDI XR (100 MG) CAP ER 24H TOPIRAMATE X X
2 TROKENDI XR (200 MG) CAP ER 24H TOPIRAMATE X X
2 TROKENDI XR (25 MG) CAP ER 24H TOPIRAMATE X X
2 TROKENDI XR (50 MG) CAP ER 24H TOPIRAMATE X X
1 TROPICAMIDE TROPICAMIDE
1 TROSPIUM CHLORIDE TROSPIUM CHLORIDE X
1 TROSPIUM CHLORIDE ER TROSPIUM CHLORIDE X
3 TRULANCE PLECANATIDE X X
2 TRULICITY DULAGLUTIDE X
3 TRUNEB NEBULIZER NEBULIZER
3 TRUSKIN HUMAN REGENERATIVE TISSUE MTRX
2 TRUSOPT DORZOLAMIDE HCL
3 TRUST NATAL DHA PRENATAL 2/IRON/FOLIC ACID/OM3
2 TRUVADA EMTRICITABINE/TENOFOVIR (TDF) X
3 TRUZONE PEAK FLOW METER PEAK FLOW METER
Excluded TUDORZA PRESSAIR
2 TUSNEL C PSEUDOEPHED/CODEINE/GUAIFEN X
3 TUSNEL PEDIATRIC GUAIFENESIN/DM/PSEUDOEPHEDRINE
3 TUSSICAPS HYDROCODONE/CHLORPHEN P‐STIREX X
2 TUSSIGON HYDROCODONE BIT/HOMATROP ME‐BR X
2 TUSSIONEX HYDROCODONE/CHLORPHEN P‐STIREX X
3 TUZISTRA XR CODEINE POLI/CHLORPHENIR POLIS X X
1 TWO DULOXETINE 20MG CAPSULE DULOXETINE
3 TWYNSTA TELMISARTAN/AMLODIPINE
2 TYBOST COBICISTAT X
2 TYLENOL‐CODEINE NO.3, NO. 4 ACETAMINOPHEN WITH CODEINE X
3 TYMLOS X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
TherapyExcluded TYSABRI
3 TYZINE TETRAHYDROZOLINE HCL
3 UCERIS BUDESONIDE X
3 UDAMIN SP MV‐MINS NO.9/FOLIC/SAW PALMETT
3 ULESFIA BENZYL ALCOHOL
2 ULORIC FEBUXOSTAT X X
3 ULTANE SEVOFLURANE
3 ULTICARE SYRINGE W‐NEEDLE,DISPOSAB,1 ML
3 ULTICARE SYRINGE SYRINGE,NDLE,SAFE DISP 1.5 ML
2 ULTRACET TRAMADOL HCL/ACETAMINOPHEN X
3 ULTRAFOAM MICROFIBRILLAR COLLAGEN
2 ULTRAM TRAMADOL HCL X
3 ULTRASAL‐ER SALICYLIC ACID
2 ULTRAVATE (0.05 %) CREAM HALOBETASOL PROPIONATE
3 ULTRAVATE (0.05 %) LOTION HALOBETASOL PROPIONATE
2 ULTRAVATE (0.05 %) OINTMENT HALOBETASOL PROPIONATE
3 UMECTA UREA
3 UMECTA PD UREA
3 UNISTIK 2 NORMAL LANCING DEVICE/LANCETS
2 UNITHROID LEVOTHYROXINE SODIUM
3 URAMAXIN UREA
3 URAMAXIN GT UREA
2 UREA 39%, 40%, 50% CREAM UREA
2 URECHOLINE BETHANECHOL CHLORIDE
Excluded URE‐K
3 URELLE METH/MEBLUE/SOD PHOS/PSAL/HYOS
2 URETRON D‐S METH/MEBLUE/SOD PHOS/PSAL/HYOS
Excluded UREVAZ
3 URIBEL METH/MEBLUE/SOD PHOS/PSAL/HYOS
2 URIN D.S. METH/MEBLUE/SOD PHOS/PSAL/HYOS
3 UROCIT‐K POTASSIUM CITRATE
3 UROQID‐ACID NO.2 METHENAMINE/SOD PHOSPHATE MBAS
2 UROXATRAL ALFUZOSIN HCL
2 URSO URSODIOL
2 URSO FORTE URSODIOL
1 URSODIOL URSODIOL
3 URYL METHENAM/SOD PHOS/MBLUE/HYOSCY
3 UTA METHENAM/SOD PHOS/MBLUE/HYOSCY
Excluded UTIBRON
3 UTIRA‐C METH/MEBLUE/SOD PHOS/PSAL/HYOS
Excluded UTOPIC
3 VACUSTIM BLACK FOAM/GAUZE/LIDOCA/CHLHX/ISOPRO
3 VACUSTIM SILVER SILV/BANDG/LIDOCA/CHLORHEX/ALC
2 VAGIFEM ESTRADIOL
1 VALACYCLOVIR HCL VALACYCLOVIR HCL
3 VALCYTE VALGANCICLOVIR HCL
2 VALGANCICLOVIR HCL (450 MG) TABLET VALGANCICLOVIR HCL
1 VALGANCICLOVIR HCL (50 MG/ML) SOLN RECON VALGANCICLOVIR HCL
2 VALIUM DIAZEPAM
1 VALPROIC ACID VALPROIC ACID
1 VALPROIC ACID (AS SODIUM SALT) VALPROIC ACID (AS SODIUM SALT)
1 VALSARTAN TABLET VALSARTAN
1 VALSARTAN TABLET & AMLODIPINE TABLET VALSARTAN & AMLODIPINE
1 VALSARTAN/HCTZ COMBO T ABLET VALSARTAN/HCTZ
2 VALTREX VALACYCLOVIR HCL
3 VANATOL LQ BUTALB/ACETAMINOPHEN/CAFFEINE
2 VANCOCIN HCL (125 MG) CAPSULE VANCOMYCIN HCL X
2 VANCOCIN HCL (250 MG) CAPSULE VANCOMYCIN HCL X
1 VANCOMYCIN HCL (125 MG) CAPSULE VANCOMYCIN HCL X
1 VANCOMYCIN HCL (125MG/2.5) SYRINGE VANCOMYCIN HCL
1 VANCOMYCIN HCL (250 MG) CAPSULE VANCOMYCIN HCL X
2 VANDAZOLE METRONIDAZOLE
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy2 VANOS FLUOCINONIDE
2 VANOXIDE‐HC BENZOYL PEROXIDE/HYDROCORTISON
3 VAPRO PLUS INTERMITT CATHETER URINARY BAG/CATHETER
3 VARITHENA ADMINISTRATION PACK TRANSFER SET/SYRINGE/BAND/TUBE
3 VARUBI ROLAPITANT HCL X
2 VASCEPA ICOSAPENT ETHYL X
2 VASCEPA (1 G) CAPSULE ICOSAPENT ETHYL X
3 VASCUDERM HYDROGEL WOUND GEL DRESSING
2 VASERETIC ENALAPRIL/HYDROCHLOROTHIAZIDE
3 VASHE WOUND THERAPY SODIUM CHLOR/HYPOCHLOROUS ACID
2 VASOTEC ENALAPRIL MALEATE
3 VAXCHORA ACTIVE COMPONENT CHOLERA VACCINE, LIVE
3 VAXCHORA BUFFER COMPONENT CHOLERA VAC BUFFER COMP 1 OF 2
3 VAXCHORA VACCINE CHOLERA VACCINE, LIVE
3 VECAMYL MECAMYLAMINE HCL X
2 VECTICAL CALCITRIOL X
3 VELPHORO SUCROFERRIC OXYHYDROXIDE
3 VELTASSA PATIROMER CALCIUM SORBITEX X X
Excluded VELTIN
3 VENELEX BALSAM PERU/CASTOR OIL
1 VENLAFAXINE ER CAPSULE VENLAFAXINE
2 VENLAFAXINE ER TABLET VENLAFAXINE
2 VENTOLIN HFA ALBUTEROL SULFATE
1 VERAPAM CAPSULE (VERELAN) VERAPAMIL
1 VERAPAM CAPSULEIL (VERELAN PM) VERAPAMIL
1 VERAPAMIL TABLET (CALAN SR) VERAPAMIL
1 VERAPAMIL TABLET (CALAN) VERAPAMIL
3 VERDESO DESONIDE
3 VERDROCET HYDROCODONE/ACETAMINOPHEN X
3 VEREGEN SINECATECHINS
2 VERELAN VERAPAMIL HCL
2 VERELAN PM VERAPAMIL HCL
3 VERIPRED 20 PREDNISOLONE SOD PHOSPHATE
3 VERSACLOZ CLOZAPINE X X
3 VERTIGOHEEL HOMEOPATHIC DRUGS
2 VESICARE SOLIFENACIN SUCCINATE X
2 VFEND VORICONAZOLE
3 VGO 20 SUB‐Q INSULIN DEVICE, 20 UNIT
3 VGO 30 SUB‐Q INSULIN DEVICE, 30 UNIT
3 VGO 40 SUB‐Q INSULIN DEVICE, 40 UNIT
2 VIAGRA SILDENAFIL CITRATE X
3 VIASPAN BELZER‐UW ORGAN PRESERVATION SOLN‐BELZER
3 VIBERZI ELUXADOLINE X
2 VIBRAMYCIN DOXYCYCLINE CALCIUM
2 VIBRAMYCIN DOXYCYCLINE HYCLATE X
2 VIBRAMYCIN DOXYCYCLINE MONOHYDRATE
2 VICTOZA LIRAGLUTIDE X X
2 VIDEX DIDANOSINE X
2 VIDEX EC (125, 200, 250, 400 MG) CAPSULE DR DIDANOSINE X
Excluded VIEKIRA PAK
2 VIGAMOX MOXIFLOXACIN HCL
2 VIIBRYD VILAZODONE HCL X X
Excluded VIMOVO
2 VIMPAT (10 MG/ML) SOLUTION LACOSAMIDE X X
3 VIMPAT (200MG/20ML) VIAL LACOSAMIDE
2 VIMPAT (50, 100, 150, 200 MG) TABLET LACOSAMIDE X X
3 VIOKACE LIPASE/PROTEASE/AMYLASE
3 VIOS AEROSOL DELIVERY SYSTEM NEBULIZER AND COMPRESSOR
2 VIRACEPT NELFINAVIR MESYLATE
2 VIRAMUNE (200 MG) TABLET NEVIRAPINE X
2 VIRAMUNE (50 MG/5 ML) ORAL SUSP NEVIRAPINE X
2 VIRAMUNE XR (100, 400 MG) TAB ER 24H NEVIRAPINE X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 VIRASAL SALICYLIC ACID
2 VIRAZOLE RIBAVIRIN
2 VIREAD (150, 200, 250, 300 MG) TABLET TENOFOVIR DISOPROXIL FUMARATE X
2 VIREAD (40MG/SCOOP) POWDER TENOFOVIR DISOPROXIL FUMARATE X
2 VIROPTIC TRIFLURIDINE
2 VISTARIL HYDROXYZINE PAMOATE
1 VIT B CMPLX 3/FOLIC AC/C/BIOT VIT B CMPLX 3/FOLIC AC/C/BIOT
1 VIT B CMPLX NO3/FA/C/BIOT/ZINC VIT B CMPLX NO3/FA/C/BIOT/ZINC
1 VIT B CPLX #11/FA/C/BIOT/ZN OX VIT B CPLX #11/FA/C/BIOT/ZN OX
3 VITAFOL FE+ PNV#102/IRON/FOLATE #1/DSS/DHA
3 VITAFOL ULTRA PNV#67/IRON PS/FA CMB#1/DHA
3 VITAFOL‐OB PRENATAL VIT COMB.10/IRON/FA
3 VITAFOL‐ONE PNV#26/IRON POLY/FA/DHA
3 VITAMEDMD ONE RX PRENATAL NO.25/IRON/FA #6/DHA
3 VITAMEDMD REDICHEW RX PRENATAL COMB NO.42/FOLIC ACID
1 VITAMINS B1,B2,B3,B5,AND B6 VITAMINS B1,B2,B3,B5,AND B6
3 VITAPEARL PRENATAL71/IRON/FOLIC ACID/DHA
3 VITA‐RESPA CYANOCOBALAMIN/FOLIC AC/VIT B6
3 VITATRUE PRENATAL 105/IRON/FOLIC AC/DHA
1 VITE AC/GRAPE/HYALURONIC ACID VITE AC/GRAPE/HYALURONIC ACID
3 VITUZ HYDROCODONE/CHLORPHENIRAMINE X
2 VIVELLE‐DOT ESTRADIOL X
1 VIVITROL NALTREXONE X X X
Excluded VIVLODEX
3 VIVOTIF TYPHOID VACC,LIVE,ATTENUATED
3 VIVOTIF BERNA TYPHOID VACC,LIVE,ATTENUATED
3 VIXONE NEBULIZER NEBULIZER
Excluded VOGELXO
2 VOLTAREN GEL DICLOFENAC SODIUM
2 VOLTAREN‐XR DICLOFENAC SODIUM
2 VORICONAZOLE TABLET VORICONAZOLE
3 VORTEX INHALER, ASSIST DEVICES
3 VORTEX VHC FROG MASK INHALER, ASSIST DEVICES
3 VORTEX VHC LADYBUG MASK INHALER, ASSIST DEVICES
2 VRAYLAR CARIPRAZINE HCL X X
3 VUSION MICONAZOLE NITRATE/ZINC OX/PET
3 VYTONE HYDROCORTISONE/IODOQUINOL/ALOE
2 VYTORIN (10 MG‐10MG) TABLET EZETIMIBE/SIMVASTATIN X
2 VYTORIN (10 MG‐20MG) TABLET EZETIMIBE/SIMVASTATIN X
2 VYTORIN (10 MG‐40MG) TABLET EZETIMIBE/SIMVASTATIN X
2 VYTORIN (10 MG‐80MG) TABLET EZETIMIBE/SIMVASTATIN X X
2 VYVANSE LISDEXAMFETAMINE DIMESYLATE X X
1 WARFARIN SODIUM WARFARIN SODIUM
1 WATER FOR IRRIGATION,STERILE WATER FOR IRRIGATION,STERILE
2 WELCHOL COLESEVELAM HCL
2 WELLBUTRIN SR BUPROPION HCL
2 WELLBUTRIN XL BUPROPION HCL
3 WIDE SEAL DIAPHRAGM DIAPHRAGMS, WIDE SEAL
3 WOUND MATRIX PORCINE SUBMUCOSA, FENESTRATED
2 XALATAN LATANOPROST
2 XANAX ALPRAZOLAM
3 XANAX XR ALPRAZOLAM
2 XARELTO (10 MG) TABLET RIVAROXABAN X
2 XARELTO (15 MG) TABLET RIVAROXABAN X
2 XARELTO (15 MG‐20MG) TAB DS PK RIVAROXABAN X
2 XARELTO (20 MG) TABLET RIVAROXABAN X
3 XARTEMIS XR OXYCODONE HCL/ACETAMINOPHEN X
3 XCLAIR HYALURONT/E/EMOL 12/ALLAN/SHEA
2 XELJANZ X
2 XELJANZ XR X
2 XEOMIN INCOBOTULINUMTOXIN A X X X
3 XERESE ACYCLOVIR/HYDROCORTISONE X X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
Therapy3 XEROFORM BISMUTH TRIBROMOPH/PETROLATUM
2 XGEVA DENOSUMAB X X X
3 XIFAXAN (200 MG) TABLET RIFAXIMIN X
2 XIFAXAN (550 MG) TABLET RIFAXIMIN X
Excluded XIGDUO XR
2 XIIDRA LIFITEGRAST X
2 XODOL 10‐300 HYDROCODONE/ACETAMINOPHEN X
3 XODOL 5‐300 HYDROCODONE/ACETAMINOPHEN X
3 XODOL 7.5‐300 HYDROCODONE/ACETAMINOPHEN X
2 XOLAIR OMALIZUMAB X X X
3 XOLEGEL KETOCONAZOLE
3 XOPENEX LEVALBUTEROL HCL
3 XOPENEX CONCENTRATE LEVALBUTEROL HCL
3 XTAMPZA ER (13.5 MG) CAP SPR 12 OXYCODONE MYRISTATE X
3 XTAMPZA ER (18 MG) CAP SPR 12 OXYCODONE MYRISTATE X
3 XTAMPZA ER (27 MG) CAP SPR 12 OXYCODONE MYRISTATE X
3 XTAMPZA ER (36 MG) CAP SPR 12 OXYCODONE MYRISTATE X
3 XTAMPZA ER (9 MG) CAP SPR 12 OXYCODONE MYRISTATE X
1 XULANE PATCH X
Excluded XULTOPHY
3 XYZAL (2.5 MG/5ML) SOLUTION LEVOCETIRIZINE DIHYDROCHLORIDE X X
2 XYZAL (5 MG) TABLET LEVOCETIRIZINE DIHYDROCHLORIDE
2 YASMIN ETHINYL ESTRADIOL/DROSPIRENONE X
2 YAZ ETHINYL ESTRADIOL/DROSPIRENONE X
Excluded YERVOY IPILIMUMAB
Excluded YESCARTA AXICABTAGENE CILOLEUCEL
Excluded YOSPRALA
2 ZAFIRLUKAST TABLET ZAFIRLUKAST
1 ZALEPLON ZALEPLON X
3 ZAMICET HYDROCODONE/ACETAMINOPHEN X
3 ZANABIN EMOLLIENT COMBINATION NO.60
2 ZANAFLEX TIZANIDINE HCL
2 ZANTAC RANITIDINE HCL
2 ZARONTIN ETHOSUXIMIDE
2 ZEBETA BISOPROLOL FUMARATE
3 ZEGERID OMEPRAZOLE/SODIUM BICARBONATE X X
3 ZELAPAR SELEGILINE HCL X
Excluded ZEMBRACE SYMTOUCH
2 ZEMPLAR PARICALCITOL
3 ZENCIA SULFACETAMIDE SODIUM/SULFUR
2 ZENPEP LIPASE/PROTEASE/AMYLASE
2 ZENZEDI (15 MG) TABLET DEXTROAMPHETAMINE SULFATE X
2 ZENZEDI (2.5 MG) TABLET DEXTROAMPHETAMINE SULFATE X X
2 ZENZEDI (20 MG) TABLET DEXTROAMPHETAMINE SULFATE X
2 ZENZEDI (30 MG) TABLET DEXTROAMPHETAMINE SULFATE X
2 ZENZEDI (7.5 MG) TABLET DEXTROAMPHETAMINE SULFATE X X
1 ZEOSA, ZENCHENT FE, WYMZYA FE
3 ZEPATIER X
2 ZERIT (1 MG/ML) SOLN RECON STAVUDINE X
2 ZERIT (15, 20, 30, 40 MG) CAPSULE STAVUDINE X
2 ZESTORETIC LISINOPRIL/HYDROCHLOROTHIAZIDE
2 ZESTRIL LISINOPRIL
2 ZETIA EZETIMIBE X
Excluded ZETONNA
2 ZIAC BISOPROL/HYDROCHLOROTHIAZIDE
2 ZIAGEN (20 MG/ML) SOLUTION ABACAVIR SULFATE X
2 ZIAGEN (300 MG) TABLET ABACAVIR SULFATE X
2 ZIANA CLINDAMYCIN/TRETINOIN
1 ZIDOVUDINE (10 MG/ML) SYRUP ZIDOVUDINE X
1 ZIDOVUDINE (100 MG) CAPSULE ZIDOVUDINE X
1 ZIDOVUDINE (300 MG) TABLET ZIDOVUDINE X
3 ZINBRYTA DACLIZUMAB X X X
TIER BRAND NAME GENERIC NAMEPrior
Authorization
Quantity
Limit
Step
TherapyExcluded ZIOPTAN
1 ZIPRASIDONE ZIPRASIDONE X
Excluded ZIPSOR
2 ZIRGAN GANCICLOVIR
3 ZITHRANOL ANTHRALIN MICRONIZED X
3 ZITHRANOL‐RR ANTHRALIN X
2 ZITHROMAX AZITHROMYCIN
2 ZITHROMAX TRI‐PAK AZITHROMYCIN
2 ZMAX AZITHROMYCIN
2 ZOCOR (10 MG) TABLET SIMVASTATIN
2 ZOCOR (20 MG) TABLET SIMVASTATIN
2 ZOCOR (40 MG) TABLET SIMVASTATIN
2 ZOCOR (5 MG) TABLET SIMVASTATIN
2 ZOCOR (80 MG) TABLET SIMVASTATIN X
2 ZOFRAN (4 MG) TABLET ONDANSETRON HCL
2 ZOFRAN (4 MG/5 ML) SOLUTION ONDANSETRON HCL X
2 ZOFRAN (8 MG) TABLET ONDANSETRON HCL
2 ZOFRAN ODT ONDANSETRON
3 ZOHYDRO ER HYDROCODONE BITARTRATE X
2 ZOLMITRIPTAN ODT ZOLMITRIPTAN X X
2 ZOLMITRIPTAN TABLET ZOLMITRIPTAN
2 ZOLOFT SERTRALINE HCL
1 ZOLPIDEM TARTRATE (10 MG) TABLET ZOLPIDEM TARTRATE X
1 ZOLPIDEM TARTRATE (10MG) TABLET ZOLPIDEM TARTRATE X
2 ZOLPIDEM TARTRATE (12.5 MG) TAB MPHASE ZOLPIDEM TARTRATE X
1 ZOLPIDEM TARTRATE (5 MG) TABLET ZOLPIDEM TARTRATE X
1 ZOLPIDEM TARTRATE (5MG) TABLET ZOLPIDEM TARTRATE X
2 ZOLPIDEM TARTRATE (6.25 MG) TAB MPHASE ZOLPIDEM TARTRATE X
Excluded ZOLPIMIST
Excluded ZOMACTON
ZOMETA ZOLEDRONIC ACID X
2 ZOMIG (2.5 MG) SPRAY ZOLMITRIPTAN X X
2 ZOMIG (2.5 MG) TABLET ZOLMITRIPTAN X X
2 ZOMIG (5 MG) SPRAY ZOLMITRIPTAN X X
2 ZOMIG (5 MG) TABLET ZOLMITRIPTAN X X
2 ZOMIG ZMT ZOLMITRIPTAN X X
Excluded ZONACORT
3 ZONALON DOXEPIN HCL
3 ZONATUSS BENZONATATE
2 ZONEGRAN ZONISAMIDE
1 ZONISAMIDE ZONISAMIDE
3 ZONTIVITY VORAPAXAR SULFATE X
3 ZORBTIVE X
2 ZORTRESS EVEROLIMUS
Excluded ZORVOLEX
2 ZOVIRAX ACYCLOVIR
3 Z‐TUSS AC CHLORPHENIRAMINE/CODEINE PHOS X
2 ZUBSOLV BUPRENORPHINE HCL/NALOXONE HCL X
Excluded ZUPLENZ
2 ZURAMPIC LESINURAD X X
3 ZUTRIPRO HYDROCODONE/CPM/PSEUDOEPHED X
3 ZYCLARA (2.5 %) CRM MD PMP IMIQUIMOD X X
3 ZYCLARA (3.75 %) CREAM PACK IMIQUIMOD X X
3 ZYCLARA (3.75 %) CRM MD PMP IMIQUIMOD X X
3 ZYFLO ZILEUTON
2 ZYLET TOBRAMYCIN/LOTEPRED ETAB
2 ZYLOPRIM ALLOPURINOL
2 ZYMAXID GATIFLOXACIN
3 ZYMOGENETICS SPRAY APPLICATOR SPRAY APPLICATOR KIT, STERILE
3 ZYPRAM HYDROCORT/PRAMOXN/SKN CLNSR#16
2 ZYPREXA OLANZAPINE X
2 ZYPREXA ZYDIS OLANZAPINE X