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CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME of 47

• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 07/01/2018• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1

Drug Class/Drug Name Reference Brand Name Brand OnlyPreferred Drug

Status Prior Authorization TypeStep TherapyRequirements

QuantityLimit QL Days

PYRIDOSTIGMINE BROMIDE SYRUP MESTINON SYRUPABACAVIR SULFATE SOLUTION ZIAGENABACAVIR SULFATE TABLETS ZIAGENABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOMABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIRABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQACAMPROSATE CAMPRALACARBOSE TABLETS PRECOSEACEBUTOLOL HCL CAPSULES SECTRALACETAMINOPHEN CAPSULES VARIOUSACETAMINOPHEN CHEWABLE TABLETS VARIOUSACETAMINOPHEN ELIXIR VARIOUSACETAMINOPHEN LIQUID VARIOUSACETAMINOPHEN SUPPOSITORY FEVERALL INFANTSACETAMINOPHEN SUSPENSION TYLENOL INFANTSACETAMINOPHEN TABLETS VARIOUS

ACETAMINOPHEN W/ CODEINE SOLUTION VARIOUSPA Required for > 2 Short Acting

Narcotics Fill

ACETAMINOPHEN W/ CODEINE TABLETS VARIOUSPA Required for > 2 Short Acting

Narcotics FillACETAZOLAMIDE CAPSULE 12-HOUR DIAMOXACETAZOLAMIDE TABLETS ACETAZOLAMIDEACETIC ACID SOLUTION ACETIC ACIDACYCLOVIR BUCCAL TABLET ZOVIRAXACYCLOVIR CAPSULES ZOVIRAXACYCLOVIR OINTMENT 15G ZOVIRAX 15 GM 30ACYCLOVIR SUSPENSION ZOVIRAXACYCLOVIR TABLETS ZOVIRAXADALIMUMAB HUMIRA Preferred Drug PA RequiredADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredALBENDAZOLE TABLETS ALBENZAALBUMIN (URINE) TEST STRIPS ALBUMIN TEST STRIPSALBUTEROL SULFATE AEROSOL VENTOLIN HFAALBUTEROL SULFATE NEBULIZER ALBUTEROL SULFATEALBUTEROL SULFATE SYRUP ALBUTEROL SULFATEALBUTEROL SULFATE TABLETS ALBUTEROLALCLOMETASONE DIPROPIONATE CREAM ACLOVATE

ALCOHOL SWABS PADSALCOH-GLOVE CONTOURED

WIPEALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM






ALLOPURINOL TABLETS ZYLOPRIMALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA RequiredALPHA-TOCOPHEROL CAPSULES VITAMIN E

ALPRAZOLAM CONC 1 MG/ML ALPRAZOLAM INTENSOLPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 ML 15

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

ALPRAZOLAM TAB 0.25 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

ALPRAZOLAM TAB 0.5 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

ALPRAZOLAM TAB 1 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

ALPRAZOLAM TAB 2 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

ALPRAZOLAM TAB SR 24HR 0.5 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 30 30

ALPRAZOLAM TAB SR 24HR 1 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 30 30



ALUM & MAG HYDROXIDE-SIMETHICONE SUSPENTION MAALOX MAXIMUMALUMINU,M/MAGNESIOUM HYDROXIDE SUSPENSION MYLANTAALUMINUM & MAGNESIOUM HYDROXIDE SUSPENSION MAALOXALUMINUM CHLORIDE SOLUTION DRYSOLAMANTADINE HCL CAPSULES AMANTADINE HCLAMANTADINE HCL SYRUP AMANTADINE HCLAMANTADINE HCL TABLETS AMANTADINE HCLAMBRISENTAN TABLETS LETAIRIS PA RequiredAMILORIDE HCL - HYDROCHLOROTHIAZIDE TABLET MODURETICAMILORIDE HCL TABLET MIDAMORAMINOCAPROIC ACID SYRUP AMICARAMINOCAPROIC ACID TABLETS AMICARAMIODARONE HCL TABLETS 200MG PACERONEAMITRIPTYLINE HCL TABLETS ELAVIL PA Required for ages < 6 years






AMLODIPINE BESYLATE TABLETS NORVASC 30 30AMLODIPINE BESYLATE-BENAZEPRIL HCL CAPSULES LOTRELAMOXAPINE TABLETS ASENDIN PA Required for ages < 6 yearsAMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTINAMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTINAMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLINAMOXICILLIN TABLETS AMOXICILLINAMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR (20mg QL 60/30) ADDERALL XR Brand Only Preferred Drug PA Required for Ages < 6 years 30 30

AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand & Generic Preferred Drug PA Required for Ages < 6 years 60 30AMPICILLIN CAPSULES AMPICILLINAMPICILLIN SUSPENSION AMPICILLINANASTROZOLE TABLETS ARIMIDEX PA RequiredANTIPYRINE-BENZOCAINE SOLUTION AURODEXANTIPYRINE-BENZOCAINE-POLYCOSANOL SOLUTION OTIC CAREAPIXABAN TABLETS ELIQUIS Preferred Drug 60 30APREPITANT CAPSULES EMEND 6 21

ARIPIPRAZOLE LAUROXIL 441MG, 662MG, 882MG ARISTADA Preferred Drug PA Required for Ages < 18 years

ARIPIPRAZOLE LAUROXIL 1064MG ARISTADA Preferred Drug PA Required for Ages < 18 years 1 60

ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Preferred Drug PA Required for Ages < 18 years 1 30

ARIPIPRAZOLE TABLETS ABILIFY Preferred Drug PA Required for Ages < 6 years 30 30ARTEMETHER-LUMEFANTRINE TABLETS COARTEMARTIFICAL TEARS TEARSARTIFICIAL SALIVA ARTIFICIAL SALIVAARTIFICIAL TEARS OINTMENT VARIOUS






ASENAPINE MALEATE SUBLINGUAL SAPHRIS Preferred Drug PA Required for Ages < 6 years 60 30ASPIRIN BUFFERED TABLET ASCRIPTINASPIRIN CHEWABLE TABLETS VARIOUSASPIRIN SUPPOSITORY VARIOUSASPIRIN TABLETS VARIOUSASPIRIN TABLETS CONTROLLED RELEASE ASPIRINASPIRIN TABLETS DELAYED RELEASEATAZANAVIR SULFATE CAPSULES REYATAZATAZANAVIR SULFATE PACKETS REYATAZATAZANAVIR SULFATE-COBICISTAT TABLETS EVOTAZATENOLOL & CHLORTHALIDONE TABLETS TENORETIC 50ATENOLOL TABLETS TENORMINATOMOXETINE HCL CAPSULES STRATTERA Brand Only Preferred Drug PA Required for Ages < 6 years 30 30ATORVASTATIN CALCIUM TABLETS LIPITOR 30 30ATOVAQUONE-PROGUANIL HCL TABLETS MALARONEATROPINE SULFATE OINTMENT ATROPINE SULFATEATROPINE SULFATE SOLUTION ISOPTO ATROPINEAXITINIB TABLETS INLYTA PA RequiredAZATHIOPRINE TABLETS IMURANAZELASTINE HCL SOLUTION 0.1% ASTELINAZITHROMYCIN EXTENDED RELEASE ORAL SUSPENSION ZITHROMAXAZITHROMYCIN PACKETS ZITHROMAXAZITHROMYCIN SUSPENSION ZITHROMAXAZITHROMYCIN TABLETS ZITHROMAXBACITRACIN OINTMENT BACIGUENTBACITRACIN OINTMENT 500 UNIT/GM BACITRACIN 3.5GM 7BACITRACIN ZINC OINTMENT BACITRACINBACITRACIN-POLYMYXIN B OINTMENT POLYSPORINBACITRACIN-POLYMYXIN B OINTMENT POLYCINBACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORINBACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HCBACLOFEN TABLETS BACLOFENBALSALAZIDE DISODIUM CAPSULES COLAZAL 270 30BALSALAZIDE DISODIUM TABLETS GIAZO 270 30BENAZEPRIL HCL TABLETS BENAZEPRIL HCLBENZONATATE CAPSULES TESSALON PERLESBENZOYL PEROXIDE BAR VARIOUSBENZOYL PEROXIDE CREAM VARIOUS






BENZOYL PEROXIDE FOAM VARIOUSBENZOYL PEROXIDE GEL VARIOUSBENZOYL PEROXIDE LIQUID VARIOUSBENZOYL PEROXIDE LOTION VARIOUSBENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATEBETAMETHASONE DIPROPIONATE AUGMENTED CREAM ACLOVATEBETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05% DIPROLENE 50 GM 30BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05% DIPROLENEBETAMETHASONE DIPROPIONATE AUGMENTED OINTMENT 0.05% DIPROLENE 50 GM 30BETAMETHASONE DIPROPRIONATE CREAM 0.05%BETAMETHASONE DIPROPRIONATE LOTION 0.05% 118 ML 30BETAMETHASONE VALERATE CREAM VARIOUSBETAMETHASONE VALERATE LOTION VARIOUSBETAMETHASONE VALERATE OINTMENT 0.1% VARIOUSBETAXOLOL HCL SOLUTION BETAXOLOL HCLBETAXOLOL HCL SUSPENSION BETOPTIC-SBETAXOLOL HCL TABLETS KERLONEBETHANECHOL CHLORIDE TABLETS URECHOLINEBEXAROTENE CAPSULES TARGRETIN PA RequiredBICTEGRAVIR-EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS BIKTARVY 30 30BISACODYL SUPPOSITORY DULCOLAXBISACODYL TABLET DELAYED RELEASE DULCOLAXBISMUTH SUBSALICYLATE CHEW TABLET PEPTO-BISMOLBISMUTH SUBSALICYLATE SUSPENSION PEPTO-BISMOLBISMUTH SUBSALICYLATE TABLET PEPTO-BISMOLBISOPROLOL FUMARATE - HYDROCHLOROTHIAZIDE TABLETS ZIACBISOPROLOL FUMARATE TABLETS ZEBETABLOOD GLUCOSE CALIBRATION LIQUID (HIGH, LOW, NORMAL) TRUE METRIXBLOOD GLUCOSE TEST STRIPS NON INSULIN USERS TRUE METRIX 100 90BLOOD GLUCOSE TEST STRIPS INSULIN USERS TRUE METRIX 150 30BOSENTAN TABLETS TRACLEER PA RequiredBRIMONIDINE TARTRATE SOLUTION ALPHAGAN PBRINZOLAMIDE SUSPENSION AZOPTBROMOCRIPTINE MESYLATE CAPSULES PARLODELBROMOCRIPTINE MESYLATE TABLETS PARLODELBROMPHENIRAMINE & PSEUDOEPHEDRINE CAPSULE VARIOUS

BROMPHENIRAMINE & PSEUDOEPHEDRINE CAPSULE CONTROLLED RELEASE VARIOUSBROMPHENIRAMINE & PSEUDOEPHEDRINE ELIXIR VARIOUSBROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID VARIOUSBROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP VARIOUS 480 ML 30BROMPHENIRAMINE &PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUSBROMPHENIRAMINE MALEATE J-TAN PD

CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME

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BROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE LIQUID/TABLETS VARIOUSBUDESONDIE INHALATION POWDER PULMICORT FLEXHALER Brand Only Preferred Drug

BUDESONIDE (INHALATION) SUSPENSION PULMICORT RESPULES Brand Only Covered for Ages < 4

PA Required Ages > 3

BUDESONIDE CAPSULES ENTOCORT EC

BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL SYMBICORT Preferred Drug Step Therapy

Patient must have tried one steroid inhaler: Budesonide, Fluticasone Propionate, or Mometasone

BUMETANIDE TABLETS BUMETANIDE

BUPRENORPHINE SUBUTEX PA Required unless the member is pregnant- the prescriber must note the following ICD-10 codes on the

prescription:1. O09.91- Supervision of high risk

preganancy, 1st Trimester.2. O09.92- Supervision of high risk

preganancy, 2nd Trimester.3. O09.93- Supervision of high risk

preganancy, 3rd Trimester.4. O09.91- Supervision of high risk preganancy- use for Post-Partum

Nursing Mothers.BUPRENORPHINE PATCH WEEKLY BUTRANS Preferred PA RequiredBUPRENORPHINE/NALOXONE SUBOXONE FILM Brand Only Preferred Drug

BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR BUPROBAN84-daysupply 180

BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for Ages < 6 years 60 30BUPROPION HCL TABLET 24-HOUR 150MG WELLBUTRIN XL PA Required for Ages < 6 years 30 30BUPROPION HCL TABLET 24-HOUR 300MG WELLBUTRIN XL PA Required for Ages < 6 years 30 30BUPROPION HCL TABLETS 75MG, 100MG WELLBUTRIN PA Required for Ages < 6 years 120 30

BUSPIRONE HCL TAB 10 MG BUSPIRONE HCLPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30



BUSPIRONE HCL TAB 7.5 MG BUSPIRONE HCLPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

BUSPIRONE HCL TABLETS 30 MG BUSPIRONE HCLPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME

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BUTALBITAL-ACETAMINOPHEN CAPSULES TENCONBUTALBITAL-ACETAMINOPHEN-CAFFEINE CAPSULES FIORICETBUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS ESGIC

BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES FIORICET/CODEINEPA Required for > 2 Short Acting

Narcotics FillBUTALBITAL-ASPIRIN-CAFFEINE CAPSULES FIORINALBUTALBITAL-ASPIRIN-CAFFEINE TABLETS BUTAL/ASA/CAFF






BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES ASCOMP/CODEINEPA Required for > 2 Short Acting

Narcotics FillCABERGOLINE TABLET CABERGOLINECALAMINE LOTION CALAMINECALCIPOTRIENE CREAM DOVONEXCALCIPOTRIENE FOAM DOVONEXCALCIPOTRIENE OINTMENT DOVONEXCALCIPOTRIENE SOLUTION DOVONEXCALCITONIN (SALMON) SOLUTION MIACALCINCALCITRIOL CAPSULES VARIOUSCALCITRIOL OINTMENT VECTICALCALCIUM CARBONATE CHEW TABLETS TUMSCALCIUM CARBONATE W/ VITAMIN D CAPSULES VARIOUSCALCIUM CARBONATE W/ VITAMIN D CHEW TABLETS VARIOUSCALCIUM CARBONATE W/ VITAMIN D TABLETS VARIOUSCALCIUM CARGONATE TABLRETS TUMSCALCIUM CITRATE TABLETS CITRACALCALCIUM TABLETS VARIOUSCALCIUM W/ VITAMIN D CAPSULES VARIOUSCALCIUM W/ VITAMIN D EFFERVESCENT TABLETS VARIOUSCALCIUM W/ VITAMIN D WAFER VARIOUS

CAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETSCAPTOPRIL/

HYDROCHLOROTHIAZIDECAPTOPRIL TABLETS CAPTOPRILCARBAMAZEPINE CAPSULE 12-HOUR CARBATROLCARBAMAZEPINE CAPSULE 12-HOUR EQUETROCARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINECARBAMAZEPINE SUSPENSION TEGRETOLCARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XRCARBAMAZEPINE TABLETS EPITOLCARBAMIDE PEROXIDE OTIC SOLUTION DEBROXCARBIDOPA-LEVODOPA ORALLY DISINTEGRATING TABLETS VARIOUSCARBIDOPA-LEVODOPA TABLETS SINEMETCARBINOXAMINE - PSEUDOEPHEDRINE SYRUP CYDECCARBOXYMETHYLCELLULOSE SODIUM GEL REFRESHCARBOXYMETHYLCELLULOSE SODIUM SOLUTION REFRESHCARISOPRODOL TABLETS SOMACARTEOLOL HCL SOLUTION CARTEOLOL HCLCARVEDILOL TABLETS COREGCEFACLOR CAPSULES CEFACLOR






CEFACLOR MONOHYDRATE TABLET SR 12 HR CECLORCEFACLOR SUSPENSION CEFACLORCEFADROXIL CAPSULES CEFADROXILCEFADROXIL SUSPENSION CEFADROXILCEFADROXIL TABLETS CEFADROXILCEFDINIR CAPSULES CEFDINIRCEFDINIR SUSPENSION CEFDINIRCEFIXIME CAPSULES SUPRAX 1 30CEFIXIME CHEWABLE TABLETS SUPRAX 1 30CEFIXIME SUSPENSION SUPRAX 1 30CEFIXIME TABLETS SUPRAX 1 30CEFPODOXIME PROXETIL SUSPENSION CEFPODOXIME PROXETILCEFPODOXIME PROXETIL TABLETS CEFPODOXIME PROXETILCEFPROZIL SUSPENSION CEFPROZILCEFPROZIL TABLETS CEFPROZILCEFUROXIME AXETIL SUSPENSION CEFTINCEFUROXIME AXETIL TABLETS CEFTINCELECOXIB CAPSULES CELEBREX PA RequiredCEPHALEXIN CAPSULES KEFLEXCEPHALEXIN SUSPENSION CEPHALEXINCEPHALEXIN TABLETS CEPHALEXINCETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30 30CETIRIZINE HCL CHEWABLE TABLETS VARIOUS 30 30CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS ZYRTEC ALLERGY 30 30CETIRIZINE HCL SYRUP VARIOUS 150 ML 30CETIRIZINE HCL TABLETS VARIOUS 30 30CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30

CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30



CHLORHEXIDINE GLUCONATE SOLUTION PERIOGARDCHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATECHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDECHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS VARIOUSCHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS VARIOUSCHLORPHENIRAMINE MALEAT TABLET CHLORPHENIRAMINE






CHLORPHENIRAMINE MALEATE SYRUP CHLORPHENIRAMINE MALEATECHLORPROMAZINE HCL SOLUTION VARIOUS PA Required for Ages < 6 years

CHLORPROMAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years CHLORPROPAMIDE TABLETS CHLORPROPAMIDECHLORTHALIDONE TABLETS CHLORTHALIDONECHOLECALCIFEROL CAPSULES VITAMIN D3CHOLECALCIFEROL TABLETS VITAMIN D3CHOLESTYRAMINE LIGHT PACKETS PREVALITECHOLESTYRAMINE LIGHT POWDER PREVALITECHOLESTYRAMINE PACKETS QUESTRANCHOLESTYRAMINE POWDER QUESTRANCHOLINE & MAGNESIUM SALICYLATES LIQUID TRILISATECHOLINE & MAGNESIUM SALICYLATES TABLETS TRILISATECICLOPIROX OLAMINE CREAM LOPROXCICLOPIROX SOLUTION PENLACCICLOPIROX SOLUTION - VITAMIN E CICLODAN KITCIDOFOVIR IV VISTIDE PA RequiredCILOSTAZOL TABLETS PLETALCIMETIDINE HCL SOLUTION TAGAMETCIMETIDINE HCL TABLETS TAGAMETCINACALCET HCL TABLETS SENSIPAR PA RequiredCIPROFLOX HCl-CIPROFLOX BETAINE TABLETS SR CIPRO XRCIPROFLOXACIN HCL OINTMENT CILOXANCIPROFLOXACIN HCL SOLUTION CILOXANCIPROFLOXACIN HCL TABLETS CIPROFLOXACIN HCLCIPROFLOXACIN ORAL SUSPENSION CIPROCIPROFLOXACIN-DEXAMETHASONE CIPRODEXCITALOPRAM HBR SOLUTION VARIOUS PA Required for Ages < 6 years 600 ML 30CITALOPRAM HBR TABLETS 10 MG, 20 MG CELEXA PA Required for Ages < 6 years 60 30CITALOPRAM HBR TABLETS 40 MG CELEXA PA Required for Ages < 6 years 30 30CLARITHROMYCIN SUSPENSION CLARITHROMYCINCLARITHROMYCIN TABLET 24-HOUR BIAXIN XLCLARITHROMYCIN TABLETS BIAXINCLEMASTINE FUMARATE SYRUP CLEMASTINE FUMARATECLEMASTINE FUMARATE TABLETS CLEMASTINE FUMARATECLINDAMYCIN HCl CAPSULES CLEOCIN

of 47CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME





CLINDAMYCIN PHOSPHATE FOAM EVOCLINCLINDAMYCIN PHOSPHATE GEL CLEOCIN-TCLINDAMYCIN PHOSPHATE LOTION CLEOCIN-TCLINDAMYCIN PHOSPHATE SOLUTION CLEOCIN-TCLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCINCLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCINCLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE BENZACLINCLOBAZAM SUSPENSION ONFI PA RequiredCLOBAZAM TABLETS ONFI PA RequiredCLOBETASOL PROPIONATE CREAM 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE EMULSION FOAM 0.05% TEMOVATECLOBETASOL PROPIONATE FOAM 0.05% OLUX 100 ML 30CLOBETASOL PROPIONATE GEL 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE LOTION 0.05% CLOBEX 118 ML 30CLOBETASOL PROPIONATE OINTMENT 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE SHAMPOO VARIOUSCLOBETASOL PROPIONATE SOLUTION VARIOUSCLOMIPRAMINE HCL TABLETS ANAFRANIL PA Required for ages < 6 years

CLONAZEPAM 0.5 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

CLONAZEPAM 1.0 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

CLONAZEPAM 2 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

CLONAZEPAM ODT 0.125MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

CLONAZEPAM ODT 0.25MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

CLONAZEPAM ODT 0.5 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

CLONAZEPAM ODT 1MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

CLONAZEPAM ODT 2MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 60 30CLONAZEPAM TAB 0.5 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM TAB 1 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM TAB 2 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 60 30CLONIDINE HCL CATAPRES PA Required for ages < 6 years






CLONIDINE HCl (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for ages < 6 years 120 30CLONIDINE HCL (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for Ages < 6 years 120 30CLONIDINE HCL PATCH-WEEKLY CATAPRES-TTS-1 PA Required for Ages <6 years 4 28CLONIDINE HCL TABLETS CATAPRES PA Required for Ages <6 yearsCLONIDINE HCL TRANSDERMAL PATCH CATAPRES PATCHES PA Required for Ages < 6 years 4 28CLOPIDOGREL BISULFATE TABLETS PLAVIX

CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

CLORAZEPATE DIPOTASSIUM TAB 3.75 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30




CLOTRIMAZOLE CREAM LOTRIMINCLOTRIMAZOLE OINTMENT LOTRIMINCLOTRIMAZOLE SOLUTION VARIOUSCLOTRIMAZOLE TROC CLOTRIMAZOLECLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMINCLOTRIMAZOLE VAGINAL TABLET CLOTRIMAZOLECLOTRIMAZOLE W/ BETAMETHASONE CREAM LOTRISONE

CLOTRIMAZOLE W/ BETAMETHASONE LOTION

CLOTRIMAZOLE/BETAMETHASONE

DIPROPIONATECLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO Preferred Drug PA Required for Ages < 18 years 150 30

CLOZAPINE TABLETS CLOZARIL Preferred Drug PA Required for Ages < 18 years 150 30

COBICISTAT TABLETS TYBOST 30 30COLCHICINE TABLETS COLCRYS PA RequiredCOLESTIPOL HCL GRANULES COLESTIDCOLESTIPOL HCL PACKETS COLESTIDCOLESTIPOL HCL TABLETS COLESTID

CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAMEPage 12 of 47





CONDOMS - FEMALE MISC. FC FEMALE CONDOM

CONDOMS - MALE MISC. LIFESTYLES ASSORTED COLORSCONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPROCRIZOTINIB CAPSULES XALKORI PA RequiredCROMOLYN SODIUM NASAL AEROSOL CROMOLYN SODIUMCROMOLYN SODIUM NEBULIZER CROMOLYN SODIUMCROMOLYN SODIUM ORAL CONCENTATE VARIOUSCROMOLYN SODIUM SOLUTION CROMOLYN SODIUMCROTAMITON CREAM EURAXCROTAMITON LOTION EURAXCYANOCOBALAMIN TABLETS VITAMIN B12

CYCLOBENZAPRINE HCL TABLETS 5MG, 10MG FLEXERILPA Required for dosages other than

5mg and 10mg tabletsCYCLOPENTOLATE HCL SOLUTION CYCLOGYLCYCLOSPORINE CAPSULES SANDIMMUNECYCLOSPORINE EMULSION RESTASIS PA RequiredCYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAFCYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAFCYCLOSPORINE SOLUTION SANDIMMUNECYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCLCYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCLDABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA Preferred Drug 60 30DANAZOL CAPSULES DANAZOLDANTROLENE SODIUM CAPSULES DANTRIUMDAPSONE GEL DAPSONEDAPSONE TABLETS DAPSONEDARUNAVIR ETHANOLATE SUSPENSION PREZISTADARUNAVIR ETHANOLATE TABLETS PREZISTADARUNAVIR-COBICISTAT TABLETS PREZCOBIXDASATINIB TABLETS SPRYCEL PA RequiredDELAVIRDINE MESYLATE TABLETS RESCRIPTORDEMECLOCYCLINE HCL TABLETS DEMECLOCYCLINE HCL PA RequiredDESIPRAMINE HCL TABLETS NORPRAMIN PA Required for ages < 6 yearsDESMOPRESSIN ACETATE NASAL SOLUTION VARIOUSDESMOPRESSIN ACETATE REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY SOLUTION VARIOUSDESMOPRESSIN ACETATE TABLETS VARIOUS PA RequiredDESOGESTREL & ETHINYL ESTRADIOL TABLETS APRIDESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS AZURETTEDESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS CAZIANT






DESONIDE CREAM DESOWENDESONIDE GEL DESONATEDESONIDE LOTION DESOWENDESONIDE OINTMENT DESOWENDESVENLAFAXINE ER TABLETS 100MG PRISTIQ PA Required for Ages < 6 years 120 30DESVENLAFAXINE ER TABLETS 25MG PRISTIQ PA Required for Ages < 6 years 120 30DESVENLAFAXINE ER TABLETS 50MG PRISTIQ PA Required for Ages < 6 years 120 30DEXAMETHASONE CONCENTRATE DEXAMETHASONE INTENSOLDEXAMETHASONE ELIXIR VARIOUS

DEXAMETHASONE SODIUM PHOSPHATE SOLUTIONDEXAMETHASONE SODIUM

PHOSPHATEDEXAMETHASONE SOLUTION DEXAMETHASONEDEXAMETHASONE SUSPENSION MAXIDEXDEXAMETHASONE TABLETS DEXAMETHASONE

DEXCHLORPHENIRAMINE MALEATE SYRUPDEXCHLORPHENIRAMINE

MALEATEDEXMETHYLPHENIDATE HCL ER CAPSULE FOCALIN XR Brand Only Preferred Drug PA Required for ages < 6 years 60 30DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Brand Only Preferred Drug PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE VARIOUS Preferred Drug PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for ages < 6 years 60 30DEXTROMETHORPHAN HBR CAPSULE ROBITUSSINDEXTROMETHORPHAN HBR SYRUP ROBITUSSINDEXTROMETHORPHAN POLISTIREX LIQUID DELSYMDEXTROMETHORPHAN-GUAIFENESIN LIQUID VARIOUS 480 ML 30DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 ML 30DEXTROMETHORPHAN-GUAIFENESIN TABLET VARIOUSDEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DMDIAPHRAGM ARC-SPRING DPRH CAYA

DIAPHRAGM COIL SPRING KITORTHO DIAPHRAGM COIL

SPRING KIT 50

DIAPHRAGM FLAT SPRING KITORTHO DIAPHRAGM FLAT

SPRING KIT 55

DIAPHRAGM WIDE SEAL DPRHWIDE-SEAL SILICONEDIAPHRAGM KIT 60

DIAPHRAGMS - OTHER+A1294 OMNIFLEX DIAPHRAGM

DIAZEPAM CONC 5 MG/ML DIAZEPAM INTENSOLPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 ML 30

DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30

DIAZEPAM SOLN 1 MG/ML VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 300 ML 30






DIAZEPAM TAB 10 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30



DICLOFENAC POTASSIUM CAPSULE VOLTARENDICLOFENAC POTASSIUM PACKET DICLOFENACDICLOFENAC POTASSIUM TABLET CATAFLAMDICLOFENAC SODIUM GEL 1% DICLOFENAC GELDICLOFENAC SODIUM SOLUTION DICLOFENAC SODIUMDICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XRDICLOFENAC SODIUM TABLET ENTERIC COATED VOLTARENDICLOFENAC W/ MISOPROSTOL TABLET DELAYED RELEASE ARTHROTEC 50DICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUMDICLOXACILLIN SODIUM CAPSULESDICYCLOMINE HCL CAPSULES VARIOUSDICYCLOMINE HCL SOLUTION VARIOUSDICYCLOMINE HCL TABLETS VARIOUSDIDANOSINE CAPSULE DELAYED RELEASE VIDEX ECDIDANOSINE SOLUTION VIDEX PEDIATRICDIFLUNISAL TABLETS DIFLUNISALDIGOXIN SOLUTION DIGOXINDIGOXIN TABLETS LANOXINDIHYRDROERGOTAMIN MESYLATE NASAL MIGRANAL 4 28DILTIAZEM HCL CAPSULE 12-HOUR DILTIAZEM HCL ERDILTIAZEM HCL CAPSULE CONTROLLED RELEASE DILTIAZEM HCL ERDILTIAZEM HCL COATED BEADS CAPSULE CONTROLLED RELEASE CARDIZEM CD 30 30DILTIAZEM HCL COATED BEADS TABLET 24-HOUR CARDIZEM LA

DILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULE CONTROLLED RELEASE TAZTIA XT 30 30DILTIAZEM HCL TABLETS CARDIZEMDIMENHYDRINATE CHEW TABLET DRAMAMINEDIMENHYDRINATE TABLET DRAMAMINEDIPHENHYDRAMINE HCL CAPSULES VARIOUSDIPHENHYDRAMINE HCL CHEWABLE TABLETS VARIOUS

DIPHENHYDRAMINE HCL CREAMANTI-ITCH MAXIMUM

STRENGTHDIPHENHYDRAMINE HCl CREAM BENADRYLDIPHENHYDRAMINE HCL ELIXIR VARIOUSDIPHENHYDRAMINE HCL GEL BENADRYL ITCH STOPPINGDIPHENHYDRAMINE HCL LIQUID VARIOUSDIPHENHYDRAMINE HCL SOLUTION VARIOUS






DIPHENHYDRAMINE HCL SOLUTIONBENADRYL MAXIMUM

STRENGTHDIPHENHYDRAMINE HCL SUSPENSION VARIOUSDIPHENHYDRAMINE HCL SYRUP VARIOUSDIPHENHYDRAMINE HCL TABLETS VARIOUSDIPHENOXYLATE W/ ATROPINE LIQUID DIPHENOXYLATE/ATROPINEDIPHENOXYLATE W/ ATROPINE TABLETS LOMOTILDIPYRIDAMOLE TABLETS PERSANTINEDISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR NORPACE CRDISOPYRAMIDE PHOSPHATE CAPSULES NORPACEDISULFIRAM ANTABUSEDIVALPROEX SODIUM SPRINKLE CAPSULES DEPAKOTE SPRINKLESDIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ERDIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTEDOCOSANOL 10% CREAM ABREVADOCUSATE CALCIUM CAPSULE SURFAKDOCUSATE SODIUM CPASULES COLACEDOFETILIDE CAPSULES TIKOSYN PA RequiredDOLASETRON MESYLATE TABLETS ANZEMET PA RequiredDOLUTEGRAVIR TIVICAYDONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TABLETS ARICEPT ODT PA RequiredDONEPEZIL HYDROCHLORIDE TABLETS ARICEPT PA RequiredDORNASE ALFA SOLUTION PULMOZYME PA RequiredDORZOLAMIDE HCL SOLUTION TRUSOPTDORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION COSOPTDOXAZOSIN MESYLATE TABLET 24-HOUR CARDURA XLDOXAZOSIN MESYLATE TABLETS CARDURADOXEPIN HCL CAPSULES DOXEPIN HCL PA Required for ages < 6 years 90 30DOXEPIN HCL CONCENTRATE DOXEPIN HCL PA Required for ages < 6 years 180 ML 30DOXYCYCLINE HYCLATE CAPSULES 50MG, 100MG VIBRAMYCINDOXYCYCLINE HYCLATE SUSPENSION VIBRAMYCINDOXYCYCLINE HYCLATE TABLETS 20MG, 100MG ORAXYLDOXYCYCLINE MONOHYDRATE CAPSULES 50MG, 100MG MONODOXDOXYLAMINE SUCCINATE (SLEEP) TAB SLEEP AIDDRONEDARONE HCL TABLETS MULTAQ PA RequiredDROSPIRENONE-ETHINYL ESTRADIOL TABLETS OCELLADULOXETINE CAPSULES 20MG CYMBALTA PA Required for Ages < 6 years 120 30DULOXETINE CAPSULES 30MG CYMBALTA PA Required for Ages < 6 years 120 30DULOXETINE CAPSULES 60MG CYMBALTA PA Required for Ages < 6 years 60 30ECONAZOLE NITRATE CREAM SPECTAZOLEEFAVIRENZ CAPSULES SUSTIVA






EFAVIRENZ TABLETS SUSTIVAEFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLAELTROMBOPAG OLAMINE TABLETS PROMACTA PA RequiredELVITEGRAVIR TABLETS VITEKTAELVITEGRAVIR-COBICISTATE-EMTRICITABINE-TENOFOVIR ALAFENAMIDE TABLETS GENVOYAELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILDEMPAGLIFLOZIN-LINAGLIPTIN TABLETS GLYXAMBI Preferred Drug PA RequiredEMTRICITABINE CAPSULES EMTRIVAEMTRICITABINE SOLUTION EMTRIVAEMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS DESCOVYEMTRICITABINE-RILPIVIRINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS ODEFSEYEMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS COMPLERAEMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADA PA Required

ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETSENALAPRIL MALEATE/

HYDROCHLOROTHIAZIDEENALAPRIL MALEATE SOLUTION EPANEDENALAPRIL MALEATE TABLETS VASOTECENFUVIRTIDE SOLUTION FUZEON PA Required 1 30ENOXAPARIN SODIUM INJ 100 MG/ML ENOXAPARIN INJ 100MG/ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 120 MG/0.8ML ENOXAPARIN INJ 120/0.8ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 150 MG/ML ENOXAPARIN INJ 150MG/ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 30 MG/0.3ML ENOXAPARIN INJ 30/0.3ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 300 MG/3ML ENOXAPARIN INJ 300/3ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 40 MG/0.4ML ENOXAPARIN INJ 40/0.4ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 60 MG/0.6ML ENOXAPARIN INJ 60/0.6ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 80 MG/0.8ML ENOXAPARIN INJ 80/0.8ML Preferred Drug 60 30ENTACAPONE TABLETS COMTANENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredEPINEPHRINE SELF-INJECTED 0.15 MG EPINEPHRINE AUTO-INJECT MYLAN Preferred Drug PA Required for > 2 Per Month 2 30EPINEPHRINE SELF-INJECTED 0.3 MG EPINEPHRINE AUTO-INJECT MYLAN Preferred Drug PA Required for > 2 Per Month 2 30EPLERENONE TABLETS INSPRA PA RequiredEPOETIN ALFA SOLUTION EPOGEN PA RequiredEPOPROSTENOL SODIUM SOLUTION FLOLAN PA RequiredERGOCALCIFEROL CAPSULES VARIOUSERGOTAMINE W/ CAFFEINE SUPPOSITORY MIGERGOT 12 30ERGOTAMINE W/ CAFFEINE TABLETS CAFERGOTERLOTINIB HCL TABLETS TARCEVA PA RequiredERYTHROMYCIN GEL ERYGELERYTHROMYCIN OINTMENT ILOTYCINERYTHROMYCIN PADS 2% ERYTHROMYCINERYTHROMYCIN SOLUTION ERYTHROMYCINERYTHROMYCIN-SULFISOXAZOLE SUSPENSION E.S.P.






ESCITALOPRAM OXALATE SOLUTION LEXAPRO PA Required for Ages < 6 years 600 ML 30ESCITALOPRAM OXALATE TABLETS 10MG & 20MG LEXAPRO PA Required for Ages < 6 years 30 30ESCITALOPRAM OXALATE TABLETS 5MG LEXAPRO PA Required for Ages < 6 years 60 30ESTERIFIED ESTROGENS TABLETS MENESTESTRADIOL & NORETHINDRONE ACETATE TABLETS VARIOUSESTRADIOL ACETATE VAGINAL RING FEMRINGESTRADIOL PATCH-TWICE WEEKLY ALORAESTRADIOL PATCH-WEEKLY MENOSTARESTRADIOL TABLETS ESTRACEESTRADIOL VAGINAL CREAM ESTRACEESTRADIOL VAGINAL RING ESTRINGESTRADIOL VAGINAL TABLETS VAGIFEMESTRADIOL-LEVONORGESTREL PATCH-WEEKLY CLIMARA PATCHESTROGENS, CONJUGATED SYNTHETIC A TABLETS CENESTINESTROGENS, CONJUGATED TABLETS PREMARINESTROGENS, CONJUGATED VAGINAL CREAM PREMARIN PA RequiredESTROPIPATE TABLETS ORTHO-ESTETANERCEPT ENBREL Preferred Drug PA RequiredETHAMBUTOL HCL TABLETS MYAMBUTOLETHOSUXIMIDE CAPSULES ZARONTINETHOSUXIMIDE SOLUTION ZARONTINETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS KELNOR 1/35ETODOLAC CAPSULES LODINEETODOLAC TABLETS LODINEETODOLAC TABLETS EXTENDED RELEASE ETODOLAC ERETONOGESTREL-ETHINYL ESTRADIOL RING NUVARINGETOPOSIDE CAPSULES ETOPOSIDE PA RequiredETRAVIRINE TABLETS INTELENCEEVEROLIMUS (IMMUNOSUPPOSITORYRESSANT) TABLETS ZORTRESS PA RequiredEVEROLIMUS SOLUBLE TABLET AFINITOR DISPERZ PA RequiredEVEROLIMUS TABLETS AFINITOR PA RequiredEXEMESTANE TABLETS AROMASIN PA RequiredEXENATIDE PEN BYDUREON PEN Preferred Drug PA RequiredEXENATIDE SUSPENSION PEN BYETTA PEN Preferred Drug PA RequiredEXENATIDE VIAL BYDUREON Preferred Drug PA RequiredEZETIMIBE TABLETS ZETIA PA RequiredFAMCICLOVIR TABLETS FAMVIR PA RequiredFAMOTIDINE CHEWABLE TABLETS PEPCID ACFAMOTIDINE SUSPENSION PEPCIDFAMOTIDINE TABLETS PEPCID ACFEBUXOSTAT TABLETS ULORIC PA Required






FELBAMATE SUSPENSION FELBATOLFELBAMATE TABLETS FELBATOLFELODIPINE TABLET 24-HOUR FELODIPINE ERFENOFIBRATE MICRONIZED CAPSULES 43MG, 134MG, 200MG ANTARAFENOFIBRIC ACID TABLETS FIBRICORFENOPROFEN CALCIUM CAPSULES NALFONFENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUM

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

FERROUS FUMARATE TABLETS VARIOUSFERROUS GLUCONATE TABLETS VARIOUSFERROUS SULFATE TABLETS VARIOUS

FEXOFENADINE HCL ORALLY DISINTEGRATING TABLETS ALLEGRA ALLERGY CHILDRENS 30 30

FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS 150 ML 30

FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS 30 30FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS 30 30FILGRASTIM SOLUTION NEUPOGEN Brand Only PA RequiredFINASTERIDE TABLETS 5MG ONLY PROSCARFINGOLIMOD HCL CAPSULES GILENYA PA RequiredFLECAINIDE ACETATE TABLETS TAMBOCORFLUCONAZOLE SUSPENSION DIFLUCAN 600 ML 30FLUCONAZOLE TABLETS DIFLUCAN 60 30FLUCYTOSINE CAPSULES ANCOBON PA RequiredFLUDROCORTISONE ACETATE TABLETS FLORINEFFLUNISOLIDE SOLUTION FLUNISOLIDEFLUOCINOLONE ACETONIDE CREAM FLUOCINOLONE ACETONIDEFLUOCINOLONE ACETONIDE OIL DERMA-SMOOTHE/FS BODYFLUOCINOLONE ACETONIDE OINTMENT SYNALARFLUOCINOLONE ACETONIDE SHAMPOO CAPEXFLUOCINOLONE ACETONIDE SOLUTION SYNALARFLUOCINONIDE CREAM 0.05% VARIOUSFLUOCINONIDE EMULSIFIED BASE CREAM VARIOUSFLUOCINONIDE GEL 0.05% VARIOUS 60 GM 30FLUOCINONIDE OINTMENT 0.05% VARIOUS 60 GM 30FLUOCINONIDE SOLUTION VARIOUSFLUOROMETHOLONE OINTMENT FMLFLUOROMETHOLONE SUSPENSION FML LIQUIFILMFLUOXETINE HCL CAPSULES 10MG PROZAC PA Required for Ages < 6 years 60 30FLUOXETINE HCL CAPSULES 20MG PROZAC PA Required for Ages < 6 years 120 30






FLUOXETINE HCL CAPSULES 40MG PROZAC PA Required for Ages < 6 years 60 30FLUOXETINE HCL DR CAPSULES PROZAC WEEKLY PA RequiredFLUOXETINE HCL SOLUTION PROZAC PA Required for Ages < 6 years 600 ML 30FLUOXYMESTERONE TABLETS ANDROXYFLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE PA Required for Ages < 18 years

FLUPHENAZINE HCL CONCENTRATE VARIOUS PA Required for Ages < 6 years

FLUPHENAZINE HCL ELIXIR VARIOUS PA Required for Ages < 6 years

FLUPHENAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years

FLURANDRENOLIDE CREAM CORDRANFLURANDRENOLIDE LOTION CORDRANFLURANDRENOLIDE OINTMENT CORDRANFLURBIPROFEN SODIUM SOLUTION OCUFENFLURBIPROFEN TABLETS FLURBIPROFENFLUTAMIDE CAPSULES FLUTAMIDEFLUTICASONE PROPIONATE HFA AEROSOL FLOVENT HFA Preferred DrugFLUTICASONE PROPIONATE CREAM VARIOUSFLUTICASONE PROPIONATE LOTION VARIOUSFLUTICASONE PROPIONATE OINTMENT VARIOUSFLUTICASONE PROPIONATE SUSPENSION FLONASE

FLUTICASONE-SALMETEROL AEROSOL ADVAIR HFACovered for Ages

4-12 ONLY Step Therapy







FLUTICASONE-SALMETEROL AEROSOL POWDER BREATH ACTIVATED ADVAIR DISKUS Preferred Drug Step Therapy


FLUVOXAMINE MALEATE ER CAPSULES 100MG LUVOX CR PA Required for Ages < 6 years 90 30FLUVOXAMINE MALEATE ER CAPSULES 150MG LUVOX CR PA Required for Ages < 6 years 60 30FLUVOXAMINE MALEATE TABLETS 100MG LUVOX PA Required for Ages < 6 years 90 30FLUVOXAMINE MALEATE TABLETS 25MG LUVOX PA Required for Ages < 6 years 60 30FLUVOXAMINE MALEATE TABLETS 50MG LUVOX PA Required for Ages < 6 years 180 90FOLIC ACID TABLETS VARIOUSFOSAMPRENAVIR CALCIUM SUSPENSION LEXIVAFOSAMPRENAVIR CALCIUM TABLETS LEXIVAFOSCARNET SODIUM FOSCAVIR PA Required

FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETSFOSINOPRIL SODIUM/

HYDROCHLOROTHIAZIDEFOSINOPRIL SODIUM TABLETS FOSINOPRIL SODIUMFUROSEMIDE SOLUTION FUROSEMIDEFUROSEMIDE TABLETS LASIXGABAPENTIN CAPSULES 100MG, 300MG, 400MG NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN TABLETS 600MG NEURONTINGABAPENTIN TABLETS 800MG NEURONTINGABAPENTIN TABLETS EXTENDED RELEASE GRALISE PA RequiredGABAPENTIN TABLETS EXTENDED RELEASE HORIZANT PA RequiredGALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE RAZADYNE ER PA RequiredGALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA RequiredGANCICLOVIR GEL ZIRGANGANCICLOVIR SODIUM CYTOVENE PA RequiredGEFITINIB TABLETS IRESSA PA RequiredGEMFIBROZIL TABLETS LOPIDGENTAMICIN SULFATE CREAM GENTAMICIN SULFATEGENTAMICIN SULFATE OINTMENT GENTAMICIN SULFATEGENTAMICIN SULFATE OINTMENT GARAMYCINGENTAMICIN SULFATE SOLUTION GARAMYCINGENTAMICIN-PREDNISOLONE ACETATE OINTMENT PRED-G S.O.P.GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION PRED-G






GLATIRAMER ACETATE COPAXONE Brand Only PA RequiredGLECAPREVIR/PIBRENTASVIR MAVYRET Preferred Drug PA RequiredGLIMEPIRIDE TABLETS AMARYLGLIPIZIDE TABLET 24-HOUR GLUCATROL XLGLIPIZIDE TABLETS GLUCOTROLGLIPIZIDE-METFORMIN HCL TABLETS GLIPIZIDE/METFORMIN HCLGLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1 30GLUCAGON CHEW TABLETS VARIOUSGLUCAGON GEL VARIOUSGLYBURIDE MICRONIZED TABLETS GLYNASEGLYBURIDE TABLETS DIABETAGLYBURIDE-METFORMIN HCL TABLETS GLUCOVANCEGLYCOPYRROLATE SOLUTION VARIOUSGLYCOPYRROLATE TABLETS VARIOUSGLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL SOLUTION BEVESPI AEROSPHERE Preferred Drug PA RequiredGRANISETRON HCL SOLUTION VARIOUS PA RequiredGRANISETRON HCL TABLETS VARIOUS PA RequiredGRISEOFULVIN MICROSIZE SUSPENSION GRISEOFULVIN MICROSIZEGRISEOFULVIN MICROSIZE TABLETS GRIFULVIN VGRISEOFULVIN ULTRAMICROSIZE TABLETS GRIS-PEGGUAIFENESIN LIQUID VARIOUS 480 ML 30GUAIFENESIN SYRUP VARIOUS 480 ML 30GUAIFENESIN TABLET 12-HOUR VARIOUSGUAIFENESIN TABLETS VARIOUSGUAIFENESIN-CODEINE SYRUP ROBITUSSIN AC PA Required for < 18 years of age 240 ML 12GUANFACINE HCL TENEX PA Required for ages < 6 yearsGUANFACINE HCL (ADHD) TABLET 12-HOUR GUANFACINE HCL ER Preferred Drug PA Required for ages < 6 years 30 30GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30 30GUANFACINE HCL TABLETS TENEX PA Required for Ages <6 years

HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE 50 PA Required for Ages < 18 years

HALOPERIDOL LACTATE CONCENTRATE VARIOUS PA Required for Ages < 6 yearsHALOPERIDOL TABLETS VARIOUS PA Required for Ages < 6 yearsHEPARIN (PORCINE) IN SODIUM CHLORIDE SOLUTION HEPARIN SODIUM/NACL 0.9%HEPARIN SOD (PORCINE) IN D5W SOLUTION HEPARIN SODIUM/D5WHEPARIN SODIUM SOLUTION HEPARIN SODIUMHEPARIN SODIUM LOCK FLUSH SOLUTION HEPARIN LOCK FLUSH






HOMATROPINE HBR SOLUTION ISOPTO HOMATROPINEHYDRALAZINE HCL TABLETS HYDRALAZINE HCLHYDROCHLOROTHIAZIDE CAPSULES 12.5MG MICROZIDEHYDROCHLOROTHIAZIDE TABLETS 25MG, 50MG HYDROCHLOROTHIAZIDEHYDROCODONE W/ HOMATROPINE SYRUP VARIOUS PA Required for < 18 years of age 240 ML 12HYDROCODONE W/ HOMATROPINE TABLETS VARIOUS PA Required for < 18 years of age

HYDROCODONE-ACETAMINOPHEN CAPSULES HYDROGESICPA Required for > 2 Short Acting

Narcotics Fill

HYDROCODONE-ACETAMINOPHEN SOLUTION HYCETPA Required for > 2 Short Acting

Narcotics Fill

HYDROCODONE-ACETAMINOPHEN TABLETS VERDROCETPA Required for > 2 Short Acting

Narcotics Fill

HYDROCODONE-IBUPROFEN TABLETS REPREXAINPA Required for > 2 Short Acting

Narcotics FillHYDROCORTISONE (INTRARECTAL) ENEMA COLOCORTHYDROCORTISONE (RECTAL) CREAM PROCTOCORTHYDROCORTISONE ACETATE (INTRARECTAL) FOAM CORTIFOAMHYDROCORTISONE ACETATE CREAM ANUSOL-HCHYDROCORTISONE ACETATE OINTMENT ANUSOL-HCHYDROCORTISONE BUTYRATE CREAM VARIOUSHYDROCORTISONE BUTYRATE LOTION VARIOUSHYDROCORTISONE BUTYRATE OINTMENT VARIOUSHYDROCORTISONE BUTYRATE SOLUTION VARIOUSHYDROCORTISONE CREAM VARIOUSHYDROCORTISONE LOTION VARIOUSHYDROCORTISONE OINTMENT VARIOUSHYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE) A-HYDROCORT Long Term Care OnlyHYDROCORTISONE SOLUTION VARIOUSHYDROCORTISONE TABLETS HYDROCORTISONEHYDROCORTISONE VALERATE CREAM VARIOUSHYDROCORTISONE VALERATE OINTMENT VARIOUSHYDROCORTISONE W/ACETIC ACID SOLUTION ACETASOL HCHYDROGEN PEROXIDE SOLUTION HYDROGEN PEROXIDE

HYDROMORPHONE HCL LIQUID DILAUDIDPA Required for > 2 Short Acting

Narcotics Fill

HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCLPA Required for > 2 Short Acting

Narcotics Fill

HYDROMORPHONE HCL TABLETS DILAUDIDPA Required for > 2 Short Acting

Narcotics FillHYDROXYCHLOROQUINE SULFATE TABLETS PLAQUENILHYDROXYPROGESTERONE CAPROATE 1250 MG/5ML VIAL MAKENA PA RequiredHYDROXYPROGESTERONE CAPROATE 250 MG/1ML VIAL MAKENA PA RequiredHYDROXYPROPYL METHYLCELLULOSE GEL LACRI-LUBE






HYDROXYPROPYL METHYLCELLULOSE SOLUTION LACRI-LUBEHYDROXYZINE HCL SYRUP HYDROXYZINE HCL 300 ML 30HYDROXYZINE HCL TABLETS HYDROXYZINE HCL 240 30HYDROXYZINE PAMOATE CAPSULES VISTARIL 120 30HYOSCYAMINE SULFATE CONTROLLED RELEASE TABLET VARIOUSHYOSCYAMINE SULFATE ELIXIR VARIOUSHYOSCYAMINE SULFATE ORALLY DISINTEGRATING TABLETS VARIOUSHYOSCYAMINE SULFATE SOLUTION VARIOUSHYOSCYAMINE SULFATE SUBLINGUAL VARIOUSHYOSCYAMINE SULFATE TABLET 12-HOUR VARIOUSHYOSCYAMINE SULFATE TABLETS VARIOUSIBRUTINIB CAPSULES IMBRUVICA PA RequiredIBUPROFEN CAPSULES ADVILIBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRINIBUPROFEN SUSPENSION CHILDRENS MOTRINIBUPROFEN TABLETS ADVILIDURSULFASE SOLUTION ELAPRASE PA RequiredILOPROST SOLUTION VENTAVIS PA RequiredIMATINIB MESYLATE TABLETS GLEEVEC PA RequiredIMIGLUCERASE SOLUTION CEREZYME PA RequiredIMIPRAMINE HCL CAPSULES TOFRANIL PA Required for ages < 6 yearsIMIPRAMINE HCL TABLETS TOFRANIL PA Required for ages < 6 yearsIMIPRAMINE PAMOATE CAPSULES TOFRANIL PM PA Required for ages < 6 yearsINDAPAMIDE TABLETS INDAPAMIDEINDINAVIR SULFATE CAPSULES CRIXIVANINDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CRINDOMETHACIN CAPSULES VARIOUSINDOMETHACIN SUPPOSITORY INDOCININDOMETHACIN SUSPENSION INDOCININSULIN ASPART NOVOLOG Preferred DrugINSULIN ASPART NOVOLOG CARTRIDGE Preferred DrugINSULIN ASPART NOVOLOG FLEXPEN Preferred DrugINSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART NOVOLOG MIX 70/30 Preferred Drug

INSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART NOVOLOG MIX 70/30 FLEXPEN Preferred DrugINSULIN DETEMIR SOLUTION LEVEMIR Preferred Drug

INSULIN DETEMIR SUSPENSION LEVEMIR FLEXPEN/FLEXTOUCH Preferred DrugINSULIN GLARGINE SOLUTION LANTUS Preferred DrugINSULIN GLARGINE SUSPENSION LANTUS SOLOSTAR Preferred DrugINSULIN INFUSION PUMP SUPPLIES VARIOUSINSULIN LISPRO (HUMAN) SOLUTION HUMALOG Preferred DrugINSULIN LISPRO (HUMAN) SUSPENSION HUMALOG KWIKPEN Preferred Drug






INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSIONHUMALOG MIX 75/25

KWIKPEN Preferred Drug

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSIONHUMALOG MIX 50/50

KWIKPEN Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 50/50 VIAL Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION VIAL HUMALOG MIX 75/25 Preferred DrugINSULIN NEEDLES VARIOUSINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N Preferred DrugINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N KWIKPEN Preferred DrugINSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30 Preferred DrugINSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN PEN 70/30 Preferred DrugINSULIN PEN NEEDLES VARIOUS

INSULIN REGULAR (HUMAN) PENHUMULIN R U-500 PEN

(CONCENTRATED) Preferred Drug PA RequiredINSULIN REGULAR (HUMAN) SOLUTION HUMULIN R Preferred Drug

INSULIN REGULAR (HUMAN) SOLUTIONHUMULIN R U-500(CONCENTRATED) Preferred Drug PA Required

INSULIN SYRINGE VARIOUSINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-N3 SOLUTION ALFERON N PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredINTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA RequiredIODOQUINOL TABLETS YODOXINIPRATROPIUM BROMIDE HFA AEROSOL ATROVENT HFA Preferred DrugIPRATROPIUM BROMIDE NASAL SOLUTION ATROVENT NSIPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDE Preferred DrugIPRATROPIUM BROMIDE SOLUTION ATROVENTIPRATROPIUM-ALBUTEROL AEROSOL COMBIVENT RESPIMAT Preferred DrugIPRATROPIUM-ALBUTEROL NEBULIZER SOLUTION DUONEB Preferred DrugIRBESARTAN TABLETS AVAPROIRBESARTAN-HYDROCHLOROTHIAZIDE TABLETS AVALIDEISOCARBOXAZID TABLET MARPLAN PA Required for Ages < 6 yearsISONIAZID SYRUP ISONIAZIDISONIAZID TABLETS ISONIAZIDISONIAZID-RIFAMPIN-PYRAZINAMIDE TABLETS RIFATERISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE DILATRATE SRISOSORBIDE DINITRATE SUBLINGUAL ISOSORBIDE DINITRATEISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE ISOSORBIDE DINITRATE ERISOSORBIDE DINITRATE TABLETS ISORDIL TITRADOSEISOSORBIDE MONONITRATE TABLET 24-HOUR IMDUR






ISOSORBIDE MONONITRATE TABLETS ISOSORBIDE MONONITRATEISOTRETINOIN CAPSULES AMNESTEEM PA RequiredISRADIPINE CAPSULES ISRADIPINEITRACONAZOLE CAPSULES SPORANOX PA RequiredITRACONAZOLE SOLUTION SPORANOX PA RequiredITRACONAZOLE TABLETS ONMEL PA RequiredIVERMECTIN LOTION SKLICE PA RequiredIVERMECTIN TABLETS STROMECTOLKAOLIN-PECTIN SUSPENSION KAOPECTATEKETOCONAZOLE GEL VARIOUSKETOCONAZOLE CREAM VARIOUSKETOCONAZOLE FOAM VARIOUSKETOCONAZOLE SHAMPOO VARIOUSKETOCONAZOLE TABLETS KETOCONAZOLEKETOPROFEN CAPSULES ORUDISKETOPROFEN CAPSULES SUSTAINED RELEASE ORUDISKETOROLAC TROMETHAMINE SOLUTION ACULAR LS

KETOROLAC TROMETHAMINE TABLETS KETOROLAC TROMETHAMINE 20 30KETOTIFEN FUMARATE SOLUTION ALAWAYLABETALOL HCL TABLETS TRANDATELACOSAMIDE SOLUTION VIMPAT PA RequiredLACOSAMIDE TABLETS VIMPAT PA RequiredLACTIC ACID (AMMONIUM LACTATE) CREAM LAC-HYDRINLACTIC ACID (AMMONIUM LACTATE) LOTION LAC-HYDRINLACTULOSE SOLUTION LACTULOSELAMIVUDINE (HBV) SOLUTION EPIVIR HBVLAMIVUDINE (HBV) TABLETS EPIVIR HBVLAMIVUDINE SOLUTION EPIVIRLAMIVUDINE TABLETS EPIVIRLAMIVUDINE-ZIDOVUDINE TABLETS COMBIVIRLAMOTRIGINE CHEWABLE TABLETS LAMICTAL+B135LAMOTRIGINE ORALLY DISINTEGRATING TABLETS 100MG LAMICTAL ODTLAMOTRIGINE ORALLY DISINTEGRATING TABLETS 200MG LAMICTAL ODTLAMOTRIGINE ORALLY DISINTEGRATING TABLETS 25MG, 50MG LAMICTAL ODTLAMOTRIGINE TABLET 24-HOUR LAMICTAL XRLAMOTRIGINE TABLETS 100MG LAMICTALLAMOTRIGINE TABLETS 150MG 200MG LAMICTALLAMOTRIGINE TABLETS 25MG LAMICTALLANCET DEVICES MISC. VARIOUSLANCETS MISC. VARIOUSLANSOPRAZOLE CAPSULE DELAYED RELEASE PREVACIDLANSOPRAZOLE SUSPENSION FIRST-LANSOPRAZOLE






LANTHANUM CARBONATE CHEWABLE TABLETS FOSRENOL PA RequiredLANTHANUM CARBONATE PACKETS FOSRENOL PA RequiredLAPATINIB DITOSYLATE TABLETS TYKERB PA RequiredLATANOPROST SOLUTION XALATAN 2.5ML 30LEFLUNOMIDE TABLETS ARAVALENALIDOMIDE CAPSULES REVLIMID PA RequiredLEUCOVORIN CALCIUM TABLETS LEUCOVORIN CALCIUM PA RequiredLEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (CPP) (3 MONTH) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE (CPP) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE KIT LUPRON DEPOT PA RequiredLEVALBUTEROL HCL NEBULIZED XOPENEX PA Required for Ages 4 Years and OlderLEVETIRACETAM SOLUTION KEPPRALEVETIRACETAM TABLET 24-HOUR KEPPRA XRLEVETIRACETAM TABLETS KEPPRALEVOBUNOLOL HCL SOLUTION LEVOBUNOLOL HCLLEVOFLOXACIN SOLUTION LEVAQUINLEVOFLOXACIN TABLETS LEVAQUINLEVONORGESTREL & ETHINYL ESTRADIOL TABLETS AUBRALEVONORGESTREL TABLETS PLAN BLEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS AMETHIA LOLEVONORGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ENPRESSE-28LEVOTHYROXINE SODIUM TABLETS LEVO-TLIDOCAINE HCL CREAM 4% ASPERCREME OTCLIDOCAINE HCL GEL XYLOCAINELIDOCAINE HCL LOCAL INJECTION XYLOCAINE PA Required (FOR ESRD ONLY)LIDOCAINE HCl LOCAL INJECTION PRESERVATIVE FREE XYLOCAINE-MPF PA Required (FOR ESRD ONLY)LIDOCAINE HCL SOLUTION VARIOUSLIDOCAINE OINTMENT 5% VARIOUS PA Required 50 GM 30LIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE-PRILOCAINE CREAM EMLALINACLOTIDE CAPSULES LINZESS PA RequiredLINAGLIPTIN TABLET TRADJENTA Preferred Drug PA RequiredLINAGLIPTIN/METFORMIN TABLETS JENTADUETO Preferred Drug PA RequiredLINDANE LOTION KWELLLINDANE SHAMPOO KWELLLINEZOLID SUSPENSION ZYVOX PA RequiredLINEZOLID TABLETS ZYVOX PA RequiredLIOTHYRONINE SODIUM TABLETS CYTOMELLIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE ZENPEP Brand Only Preferred Drug 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 U PANCRELIPASE 5000 U Brand Only Preferred Drug 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE CREON Brand Only Preferred Drug 500 30LIRAGLUTIDE SOLUTION VICTOZA Preferred Drug PA Required






LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for Ages < 6 years 30 30LISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETICLISINOPRIL TABLETS ZESTRILLITHIUM CARBONATE CAPSULES LITHIUM CARBONATE

LITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBIDLITHIUM CARBONATE TABLETS LITHIUM CARBONATELITHIUM SOLUTION LITHIUMLODOXAMIDE TROMETHAMINE SOLUTION ALOMIDELOPERAMIDE HCL CAPSULES LOPERAMIDE HCLLOPERAMIDE HCL CHEWABLE TABLETS IMODIUM A-DLOPERAMIDE HCL LIQUID LOPERAMIDE HCLLOPERAMIDE HCL SUSPENSION IMODIUM A-DLOPERAMIDE HCL TABLETS IMODIUM A-DLOPINAVIR-RITONAVIR SOLUTION KALETRALOPINAVIR-RITONAVIR TABLETS KALETRALORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30 30LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30 30LORATADINE CAPSULES CLARITIN 30 30LORATADINE CHEWABLE TABLETS CLARITIN 30 30LORATADINE ORALLY DISINTEGRATING TABLETS CLARITIN REDITABS 30 30LORATADINE SYRUP CLARITIN 150 ML 30LORATADINE TABLETS ALAVERT 30 30

LORAZEPAM CONC 2 MG/ML LORAZEPAM INTENSOLPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 ML 30

LORAZEPAM TAB 0.5 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

LORAZEPAM TAB 1 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 120 30

LORAZEPAM TAB 2 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30

LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS HYZAARLOSARTAN POTASSIUM TABLETS COZAARLOVASTATIN TABLETS MEVACOR 30 30






LOXAPINE SUCCINATE CAPSULES LOXITANE PA Required for Ages < 6 yearsLUBIPROSTONE CAPSULES AMITIZA PA RequiredLURASIDONE HCL TABS LATUDA Preferred Drug PA Required for Ages < 6 years 30 30

MAGNESIOUN CITRATE SOLUTION MAG CITRATEMAGNESIUM HYDROXIDE SUSPENSION MILK OF MAGNESIAMAGNESIUM HYDROXIDE SUSPENSION CONCENTRATE MILK OF MAGNESIAMAGNESIUM OXIDE CAPSULES VARIOUSMAGNESIUM OXIDE TABLETS VARIOUSMAPROTILINE HCL TABLETS LUDIOMIL PA Required for ages < 6 yearsMARAVIROC TABLETS SELZENTRY PA RequiredMECASERMIN SOLUTION INCRELEX PA RequiredMECLIZINE HCL CHEWABLE TABLETS BONINEMECLIZINE HCL TABLETS BONINEMECLOFENAMATE SODIUM CAPSUL MECLOFENAMATE

MEDROXYPROGESTERONE ACETATE SUSPENSIONDEPO-PROVERACONTRACEPTIVE

MEDROXYPROGESTERONE ACETATE TABLETS PROVERAMEFENAMIC ACID CAPSULE PONSTELMEGESTROL ACETATE SUSPENSION MEGACEMEGESTROL ACETATE TABLETS MEGACEMELOXICAM SUSPENSION MOBICMELOXICAM TABLETS MOBICMEMANTINE HCL SOLUTION NAMENDA PA RequiredMEMANTINE HCL TABLETS NAMENDA PA Required

MEPERIDINE HCL TABLETS DEMEROLPA Required for > 2 Short Acting

Narcotics FillMERCAPTOPURINE SUSPENSION PURIXANMERCAPTOPURINE TABLETS PURINETHOLMESALAMINE CAPSULE CONTROLLED RELEASE PENTASA 270 30MESALAMINE ENEMA MESALAMINE 240 30MESALAMINE TABLET ENTERIC COATED ASACOL HD 120 30MESALAMINE W/ CLEANSER KIT ROWASA 240 30METAPROTERENOL SULFATE TABLETS METAPROTERENOL SULFATE






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

PA Required for Osmotic and Modified

Release ProductsMETFORMIN HCL TABLETS GLUCOPHAGE

METHADONE VARIOUS

Only available at an Opioid Treatment Center

METHAZOLAMIDE TABLETS NEPTAZANEMETHENAMINE MANDELATE SUSPENSION METHENAMINEMETHENAMINE MANDELATE TABLETS HIPREXMETHIMAZOLE TABLETS TAPAZOLEMETHOCARBAMOL TABLETS ROBAXINMETHOTREXATE SODIUM TABLETS RHEUMATREXMETHOTREXATE SODIUM TABLETS METHOTREXATEMETHSCOPOLAMINE BROMIDE TABLETS PAMINEMETHYCLOTHIAZIDE TABLETS AQUATENSENMETHYLDOPA TABLETS METHYLDOPAMETHYLERGONOVINE MALEATE TABLETS METHERGINEMETHYLNALTREXONE BROMICE INJECTION RELISTOR PA RequiredMETHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA 10MG Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE 24-HOUR APTENSIO XR Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Preferred Drug PA Required for Ages < 6 years 90 30METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for ages < 6 years 300ML 30METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for ages < 6 years 150ML 30METHYLPHENIDATE HCL TABLET 24-HOUR METHYLPHENIDATE HCL ER Preferred Drug PA Required for Ages < 6 years 60 30METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPHENIDATE HCL ER Preferred Drug PA Required for Ages < 6 years 60 30METHYLPHENIDATE HCL TABLET SUSTAINED RELEASE RITALIN SR PA Required for ages < 6 years 60 30METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 90 30METHYLPHENIDATE HCL TD PATCH DAYTRANA Brand Only Preferred Drug PA Required for ages < 6 years 30 30METHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE) DEPO-MEDROL Long Term Care OnlyMETHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE) A-METHAPRED Long Term Care OnlyMETHYLPREDNISOLONE TABLETS MEDROLMETIPRANOLOL SOLUTION METIPRANOLOLMETOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS VARIOUSMETOCLOPRAMIDE HCL SOLUTION VARIOUSMETOCLOPRAMIDE HCL TABLETS VARIOUSMETOLAZONE TABLETS ZAROXOLYNMETOPROLOL - HYDROCHLOROTHIAZIDE TABLETS LOPRESSOR HCTMETOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XL






METOPROLOL TARTRATE TABLETS METOPROLOL TARTRATEMETRONIDAZOLE CAPSULE FLAGYLMETRONIDAZOLE CREAM METROCREAMMETRONIDAZOLE GEL METROGELMETRONIDAZOLE LOTION METROLOTIONMETRONIDAZOLE TABLET SR FLAGYL ERMETRONIDAZOLE TABLETS FLAGYLMETRONIDAZOLE VAGINAL GEL 0.75% METROGELMEXILETINE HCL CAPSULES MEXILETINE HCLMICONAZOLE NITRATE LIQUID VARIOUSMICONAZOLE NITRATE CREAM VARIOUSMICONAZOLE NITRATE POWDER VARIOUS

MICONAZOLE NITRATE VAGINALMONISTAT 3 COMBINATION

PACKETSMICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3MIDODRINE HCL TABLETS MIDODRINEMILNACIPRAN HCL TABLETS SAVELLA 60 30MINOCYCLINE HCL CAPSULES MINOCINMINOXIDIL TABLETS MINOXIDILMIRTAZAPINE ORALLY DISINTEGRATING TABLETS 15MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 30MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE TABLETS 30MG MIRTAZAPINE PA Required for Ages < 6 years 30 30MIRTAZAPINE TABLETS 45MG MIRTAZAPINE PA Required for Ages < 6 years 30 30MIRTAZAPINE TABLETS 7.5MG, 15MG MIRTAZAPINE PA Required for Ages < 6 years 30 30MISOPROSTOL TABLETS CYTOTECMOEXIPRIL - HYDROCHLOROTHIAZIDE TABLETS UNIRETICMOEXIPRIL HCL TABLETS UNIVASC

MOMETASONE FUROATE (INHALATION) AEROSOL POWDER BREATH ACTIVATEDASMANEX TWISTHALER 30

METERED DOSES Preferred DrugMOMETASONE FUROATE CREAM ELOCONMOMETASONE FUROATE OINTMENT ELOCONMOMETASONE FUROATE SOLUTION ELOCON

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


MONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR 30 30






MONTELUKAST SODIUM GRANULES SINGULAIR PA Required for Ages 4 Years and Older 30 30MONTELUKAST SODIUM TABLETS SINGULAIR 30 30

MORPHINE SULFATE SOLUTION MORPHINE SULFATEPA Required for > 2 Short Acting

Narcotics Fill

MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATEPA Required for > 2 Short Acting

Narcotics FillMORPHINE SULFATE TABLET CONTROLLED RELEASE MS CONTIN Preferred PA Required

MORPHINE SULFATE TABLETS MORPHINE SULFATEPA Required for > 2 Short Acting

Narcotics FillMORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE RELEASE EMBEDA Preferred PA RequiredMOXIFLOXACIN HCL SOLUTION AVELOXMOXIFLOXACIN HCL SOLUTION VIGAMOXMULTIPLE VITAMIN CAPSULES VARIOUSMULTIPLE VITAMIN TABLETS VARIOUSMULTIPLE VITAMIN W/ MINERALS CAPSULES VARIOUSMULTIPLE VITAMIN W/ MINERALS CHEW TABLETS VARIOUSMULTIPLE VITAMIN W/ MINERALS LIQUID VARIOUSMULTIPLE VITAMIN W/ MINERALS TABLETS VARIOUSMUPIROCIN CALCIUM CREAM BACTROBANMUPIROCIN OINTMENT BACTROBANMYCOPHENOLATE MOFETIL CAPSULES CELLCEPTMYCOPHENOLATE MOFETIL SUSPENSION CELLCEPTMYCOPHENOLATE MOFETIL TABLETS CELLCEPTMYCOPHENOLATE SODIUM TABLET DELAYED RELEASE MYFORTICNABUMETONE TABLETS NABUMETONENADOLOL TABLETS CORGARDNALOXONE NASAL SPRAY NARCAN NASALNALOXONE SYRINGE NALOXONENALOXONE VIAL NALOXONE

NALTREXONE REVIA

NALTREXONE VIVITROLNAPHAZOLINE HCL SOLUTION VASOCLEARNAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-ANAPROXEN SODIUM CAPSULE ALEVE. ANAPROXNAPROXEN SODIUM TABLETS ALEVE. ANAPROXNAPROXEN SUSPENSION NAPROSYNNAPROXEN TABLETS NAPROSYNNAPROXEN TABLETS ENTERIC COATED NAPROSYN ECNAPROXEN TABLETS SUSTAINED RELEASE ANAPROX DSNARATRIPTAN HCL TABLETS AMERGE Preferred 9 30NATAMYCIN SUSPENSION NATACYNNATEGLINIDE TABLETS STARLIX






NEFAZODONE TABLETS 100MG VARIOUS PA Required for Ages < 6 years 60 30NEFAZODONE TABLETS 150MG VARIOUS PA Required for Ages < 6 years 120 30NEFAZODONE TABLETS 200MG VARIOUS PA Required for Ages < 6 years 90 30NEFAZODONE TABLETS 250MG VARIOUS PA Required for Ages < 6 years 60 30NEFAZODONE TABLETS 50MG VARIOUS PA Required for Ages < 6 years 60 30NELFINAVIR MESYLATE TABLETS VIRACEPTNEOMYCIN SULFATE TABLETS NEOMYCIN SULFATENEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT NEO-POLYCINNEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT NEOSPORINNEOMYCIN-POLYMY-DEXAMETH OINTMENT MAXITROLNEOMYCIN-POLYMY-DEXAMETH SUSPENSION MAXITROLNEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION NEOSPORINNEOMYCIN-POLYMYXIN-HC SOLUTION CORTISPORINNEOMYCIN-POLYMYXIN-HC SUSPENSION NEO/POLYMYXIN/HCNEVIRAPINE SUSPENSION VIRAMUNENEVIRAPINE TABLET 24-HOUR VIRAMUNE XRNEVIRAPINE TABLETS VIRAMUNENIACIN (ANTIHYPERLIPIDEMIC) TABLETS NIACORNIACIN CAPSULES NIACIN ERNIACIN TAB CR 250MG, 500MG, 750MG SLO-NIACIN (OTC)NIACIN TABLETS NIACINNIACIN TABLETS CONTROLLED RELEASE NIACIN ERNIACINAMIDE TABLETS VARIOUSNIACINAMIDE TABLETS CR VARIOUSNICARDIPINE HCL CAPSULE 12-HOUR CARDENE SRNICARDIPINE HCL CAPSULES NICARDIPINE HCLNICLOSAMIDE NICLOCIDE

NICOTINE INHA NICOTROL INHALER84-daysupply 180

NICOTINE PATCH NICODERM CQ84-daysupply 180

NICOTINE POLACRILEX GUM NICORETTE GUM84-daysupply 180

NICOTINE POLACRILEX LOZENGE COMMIT84-daysupply 180

NICOTINE SOLUTION NICOTROL NS84-daysupply 180

NIFEDIPINE CAPSULES PROCARDIANIFEDIPINE TABLET 24-HOUR ADALAT CC 60 30NILOTINIB HCL CAPSULES TASIGNA PA RequiredNIMODIPINE CAPSULES NIMODIPINENIMODIPINE SOLUTION NYMALIZENISOLDIPINE TABLET 24-HOUR SULAR






NIT REMOVER – GEL LICEOUTNIT REMOVER – SHAMPOO LICEOUTNITROFURANTOIN CAPSULE MACRODANTINNITROFURANTOIN MACROCRYSTALLINE CAPSULES MACROBIDNITROFURANTOIN SUSPENSION FURADANTINNITROGLYCERIN CAPSULE CONTROLLED RELEASE NITRO-TIMENITROGLYCERIN OINTMENT NITRO-BIDNITROGLYCERIN PATCH 24-HOUR NITRO-DURNITROGLYCERIN SUBLINGUAL NITROSTATNIZATIDINE CAPSULES AXIDNIZATIDINE ORAL SOLUTION AXID

NONOXYNOL-9 FOAMVCF VAGINAL CONTRACEPTIVE

FOAMNONOXYNOL-9 GEL SHUR-SEALNORETHINDRONE & ETHINYL ESTRADIOL TABLETS BALZIVANORETHINDRONE & MESTRANOL TABLETS NECON 1/50-28NORETHINDRONE ACETATE & ETHINYL ESTRADIOL TABLETS GILDESS 1/20NORETHINDRONE ACETATE TABLETS AYGESTINNORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS ESTROSTEP FENORETHINDRONE TABLETS CAMILANORETHINDRONE-ETHINYL ESTRADIO+A894L (TRIPHASIC) TABLETS CYCLAFEM 7/7/7NORETHINDRONE-ETHINYL ESTRADIOL (BIPHASIC) TABLETS NECON 10/11-28NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ORTHO TRI-CYCLENNORGESTIMATE-ETHINYL ESTRADIOL TABLETS ESTARYLLANORGESTREL & ETHINYL ESTRADIOL TABLETS CRYSELLE-28NORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for ages < 6 yearsNORTRYIPTYLINE HCL SOLUTION PAMELOR PA Required for ages < 6 yearsNYSTATIN CREAM VARIOUSNYSTATIN POWDER NYAMYCNYSTATIN CAPSULES BIO-STATINNYSTATIN OINTMENT VARIOUSNYSTATIN POWDER NYSTATINNYSTATIN SUSPENSION MYCOSTATINNYSTATIN TABLETS NYSTATINOFLOXACIN SOLUTION OCUFLOXOFLOXACIN SOLUTION OFLOXACINOFLOXACIN TABLETS OFLOXACINOLANZAPINE ORALLY DISPERSABLE TABLET 5MG ZYPREXA ZYDIS Preferred Drug PA Required for Ages < 6 years 60 30






OLANZAPINE ORALLY DISPERSABLE TABLET 10 MG ZYPREXA ZYDIS Preferred Drug PA Required for Ages < 6 years 60 30

OLANZAPINE ORALLY DISPERSABLE TABLET 15 MG ZYPREXA ZYDIS Preferred Drug PA Required for Ages < 6 years 30 30OLANZAPINE ORALLY DISPERSABLE TABLET 20 MG ZYPREXA ZYDIS Preferred Drug PA Required for Ages < 6 years 30 30

OLANZAPINE TABLETS 2.5 MG ZYPREXA Preferred Drug PA Required for Ages < 6 years 30 30

OLANZAPINE TABLETS 5 MG ZYPREXA Preferred Drug PA Required for Ages < 6 years 60 30




OLMESARTAN MEDOXOMIL – HYDROCHLOROTHIAZIDE TABLETS BENICAR HCT Step Therapy

Member must have

tried Losartan Potassium/HCTZ

& OLMESARTAN MEDOXOMIL TABLETS BENICAROLSALAZINE SODIUM CAPSULES DIPENTUM 120 30OMEGA 3 FATTY ACID CAPSULES FISH OILOMEPRAZOLE CAPSULE DELAYED RELEASE PRILOSECOMEPRAZOLE SUSPENSION FIRST-OMEPRAZOLEONDANSETRON HCL TABLETS ZOFRAN PA Required for tablets > 8mg 30 30ONDANSETRON HCL TABLETS ORALLY DISINTEGRATING ZOFRAN ODT PA Required for tablets > 8mg 30 30






ORIORANOLOL – HYDROCHLOROTHIAZIDE TABLETS INDERIDEOSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20 270OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLUOXAPROZIN TABLETS DAYPRO

OXAZEPAM CAP 10 MG VARIOUSPA Required for Ages < 6 yearsPA Required for > 1 Anxiolytic 60 30



OXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTALOXCARBAZEPINE TABLETS SUSTAINED RELEASE OXTELLAR XR PA RequiredOXYBUTYNIN CHLORIDE SYRUP VARIOUSOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XLOXYBUTYNIN CHLORIDE TABLETS VARIOUSOXYCODONE ER CAPSULES XTAMPZA ER Preferred Drug PA Required

OXYCODONE HCL CAPSULES OXYCODONE HCLPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE HCL CONCENTRATE OXYCODONE HCLPA Required for > 2 Short Acting

Narcotics

OXYCODONE HCL SOLUTION OXYCODONE HCLPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE HCL TABLETS ROXICODONEPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE W/ ACETAMINOPHEN CAPSULESOXYCODONE/

ACETAMINOPHENPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICETPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCETPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE W/ASPIRIN TABLETS PERCODANPA Required for > 2 Short Acting

Narcotics Fill

OXYCODONE-IBUPROFEN TABLETS OXYCODONE/IBUPROFENPA Required for > 2 Short Acting

NarcoticsOYSTER SHELL CALCIUM TABLETS VARIOUSPALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Preferred Drug PA Required for Ages < 18 years 1 30






PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Preferred Drug PA Required for Ages < 18 years 1 90

PALIVIZUMAB SOLUTION INJECTION SYNAGIS

PA Required – if approved the prescriber may be required to buy and

bill a medical claim for the drugPANTOPRAZOLE SODIUM SUSPENSION PACKET DELAYED RELEASE PROTONIXPANTOPRAZOLE SODIUM TABLET ENTERIC COATED PROTONIXPAROXETINE HCL ER TABLETS 12.5 MG PAXIL CR PA Required for Ages < 6 years 90 30PAROXETINE HCL ER TABLETS 25 MG PAXIL CR PA Required for Ages < 6 years 60 30PAROXETINE HCL ER TABLETS 37.5 MG PAXIL CR PA Required for Ages < 6 years 30 30PAROXETINE HCL SUSPENSION PAXIL PA Required for Ages < 6 years 900 ML 30PAROXETINE HCL TABLETS 10MG PAXIL PA Required for Ages < 6 years 30 30PAROXETINE HCL TABLETS 20MG PAXIL PA Required for Ages < 6 years 30 30PAROXETINE HCL TABLETS 30MG PAXIL PA Required for Ages < 6 years 30 30PAROXETINE HCL TABLETS 40MG PAXIL PA Required for Ages < 6 years 45 30PAROXETINE MESYLATE TABLETS PEXEVA PA RequiredPAZOPANIB HCL TABLETS VOTRIENT PA RequiredPEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTEPEGFILGRASTIM SOLUTION NEULASTA PA RequiredPEGINTERFERON ALFA-2A SOLUTION PEGASYS Preferred Drug PA RequiredPEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON Preferred Drug PA RequiredPENICILLAMINE CAPSULES CUPRIMINEPENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUMPENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUMPENTOSAN POLYSULFATE SODIUM CAPSULES ELMIRON PA RequiredPENTOXIFYLLINE TABLET CONTROLLED RELEASE TRENTALPERINDOPRIL ERBUMINE TABLETS ACEONPERMETHRIN CREAM ELIMITEPERMETHRIN CRÈME RINSE NIXPERMETHRIN SPRAY & PYRETHINS-PUPERONYL BUTOXIDE SHAMPOO KIT NIXPERPHENAZINE TABLETS VARIOUS PA Required for Ages < 6 yearsPHENAZOPYRIDINE HCL TABLETS PYRIDIUMPHENELZINE SULFATE TABLET NARDIL PA Required for Ages < 6 yearsPHENOBARBITAL & HYOSCYAMINE SOLUTION LEVSIN-PB






PHENOBARBITAL & HYOSCYAMINE TABLET LEVSIN-PBPHENOBARBITAL SOLUTION PHENOBARBITALPHENOBARBITAL TABLETS PHENOBARBITALPHENYLEPHRINE HCL SOLUTION NEOFRINPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN LIQUIDROBITUSSIN CHILDRENS COUGH

& COLD CF 480 ML 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 ML 30

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR VARIOUSPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLETS VARIOUSPHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN ELIXIR VARIOUS 480 ML 30

PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN LIQUID

DIMETAPPDEXTROMETHORPHAN COLD &

COUGH 480 ML 30PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 ML 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS VARIOUS PA Required for < 6 years oldPHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID VARIOUS 480 ML 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 ML 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS VARIOUSPHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE-GUAIFENESIN LIQUIDTRIAMINIC CHEST/ NASAL

CONGESTION 480 ML 30

PHENYLEPHRINE-GUAIFENESIN SYRUPTRIAMINIC CHEST & NASAL

CONGESTION 480 ML 30PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUSPHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETSPHENYTOIN SODIUM EXTENDED CAPSULES DILANTINPHENYTOIN SUSPENSION DILANTIN-125

PHYTONADIONE TABLET MEPHYTON – VITAMIN K

PILOCARPINE HCL GEL PILOPINE HS

PILOCARPINE HCL SOLUTION ISOPTO CARPINE

PIMOZIDE ORAP PA Required for ages < 6PINDOLOL TABLETS PINDOLOLPIOGLITAZONE HCL TABLETS ACTOSPIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XRPIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS METPIROXICAM CAPSULES FELDENEPODOFILOX SOLUTION CONDYLOXPOLYETHYLENE GLYCOL 3350 ORAL PACKET MIRALAX






POLYETHYLENE GLYCOL-PROPYLENE GLYCOL SOLUTION SYSTANEPOLYMYXIN B-TRIMETHOPRIM SOLUTION POLYTRIMPONATINIB HCL TABLETS ICLUSIG PA Required 60 30POSACONAZOLE SUSPENSION NOXAFIL PA RequiredPOSACONAZOLE TABLET ENTERIC COATED NOXAFIL PA RequiredPOTASSIUM CHLORIDE CAPSULES CONTROLLED RELEASE MICRO-KPOTASSIUM CHLORIDE GRANULES VARIOUSPOTASSIUM CHLORIDE MICROENCAPSULATED CRYSTALS CR VARIOUSPOTASSIUM CHLORIDE ORAL LIQUID K-LORPOTASSIUM CHLORIDE POWDER PACKETS KLOR-CONPOTASSIUM CHLORIDE TABLETS CONTROLLED RELEASE K-TABPOTASSIUM CITRATE & CITRIC ACID SOLUTION K CITRATEPOTASSIUM CITRATE TABLETS CONTROLLED RELEASE UROCIT-KPOTASSIUM TABLETS VARIOUSPRAMIPEXOLE DIHYDROCHLORIDE TABLETS MIRAPEXPRAMIPEXOLE DIHYDROCHLORIDE TABLETS SR 24 HR MIRAPEX ERPRAMLINITIDE SYMLINPEN Preferred Drug PA RequiredPRAMLINTIDE SYMLINPEN 60 Preferred Drug PA RequiredPRAMOXINE-HC FOAM EPIFOAMPRAVASTATIN SODIUM TABLETS PRAVACOL 30 30PRAZIQUANTEL TABLETS BILTRICIDEPRAZOSIN HCL CAPSULES MINIPRESSPREDNISOLONE ACETATE SUSPENSION PRED MILDPREDNISOLONE SODIUM PHOSPHATE ORALLY DISINTEGRATING TABLETS ORAPRED ODTPREDNISOLONE SODIUM PHOSPHATE SOLUTION ORAPRED

PREDNISOLONE SODIUM PHOSPHATE SOLUTIONPREDNISOLONE SODIUM

PHOSPHATEPREDNISOLONE SYRUP PRELONEPREDNISOLONE TABLETS VARIOUSPREDNISONE CONCENTRATE PREDNISONE INTENSOLPREDNISONE SOLUTION PREDNISONEPREDNISONE TABLETS PREDNISONEPREGABALIN CAPSULES LYRICA PA RequiredPREGABALIN SOLUTION LYRICA PA RequiredPRENATAL MULTIVITAMINES WITH MINERAL W/FE-FA VARIOUSPRENATAL MULTIVITAMINS WITH OR WITHOUT MINERALS W/ FOLATE VARIOUSPRENATAL VIT W/IRON CARBONYL-FA TABLET VARIOUSPRIMAQUINE PHOSPHATE TABLETS PRIMAQUINE PHOSPHATEPRIMIDONE TABLETS MYSOLINEPROBENECID TABLETS PROBENECIDPROCAINAMIDE CHL TABLET CONTROLLED RELEASE PROCAN SRPROCAINAMIDE HCL CAPSULE PROCAINAMIDEPROCARBAZINE HCL CAPSULES MATULANE






PROCHLORPERAZINE MALEATE TABLETS COMPAZINEPROCHLORPERAZINE SUPPOSITORY COMPAZINEPROGESTERONE MICRONIZED CAPSULES PROMETRIUMPROGESTERONE VAGINAL GEL CRINONEPROGESTERONE VAGINAL SUPPOSITORY PROGESTERONE

PROMETHAZINE & PHENYLEPHRINE SYRUPPROMETHAZINE/PHENYLEPHRINE 480 ML 30

PROMETHAZINE HCL SUPPOSITORY PHENERGANPROMETHAZINE HCl SYRUP PHENERGANPROMETHAZINE HCL TABLETS PROMETHAZINE HCLPROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE PA Required for < 18 years of age 240 ML 12

PROMETHAZINE-DEXTROMETHORPHAN SYRUPPROMETHAZINE/

DEXTROMETHORPHAN 480 ML 30PROPAFENONE HCL CAPSULE 12-HOUR RYTHMOL SRPROPAFENONE HCL TABLETS RYTHMOLPROPANTHELINE BROMIDE TABLETS VARIOUSPROPRANOLOL HCL CAPSULE CONTROLLED RELEASE INDERAL LAPROPRANOLOL HCL SOLUTION PROPRANOLOL HCLPROPRANOLOL HCL TABLETS INDERALPROPYLTHIOURACIL TABLETS PROPYLTHIOURACILPROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for Ages < 6 yearsPSEUDOEPHED-BROMPHEN-DM ELIXIR VARIOUS 480 ML 30PSEUDOEPHED-BROMPHEN-DM SYRUP VARIOUS 480 ML 30PSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENSPSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINEPSEUDOEPHEDRINE HCL TABLET 12-HOUR NASAL DECONGESTANTPSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOURPSEUDOEPHEDRINE HCL TABLETS SUDAFEDPSEUDOEPHEDRINE W/ CODEINE-GUAIFENESIN SYRUP VARIOUS PA Required for < 18 years of age 240 ML 12PSEUDOEPHEDRINE W/ DM-GG LIQUID VARIOUSPSYLLIUM CAPSULE METAMUCILPSYLLIUM POWDER METAMUCILPYRAZINAMIDE TABLETS PYRAZINAMIDEPYRETHRINS-PIPERONYL BUTOXIDE GEL A-200PYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARCPYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDEPYRIDOSTIGMINE BROMIDE TABLET MESTINONPYRIDOSTIGMINE BROMIDE TABLET CONTROLLED RELEASE MESTINON TIMESPANPYRIDOXINE HCL TABLETS VITAMIN B6PYRIMETHAMINE TABLET DARAPRIM






QUETIAPINE FUMARATE TABLETS SEROQUEL Preferred Drug PA Required for Ages < 6 years 60 30QUINAPRIL – HYDROCHLOROTHIAZIDE TABLETS ACCURETICQUINAPRIL HCL TABLETS ACCUPRILQUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CRQUINIDINE SULFATE TABLET CONTROLLED RELEASE QUINIDINE SULFATE ERQUINIDINE SULFATE TABLETS QUINIDINE SULFATEQUININE SULFATE CAPSULES QUALAQUINRALOXIFENE HCL TABLETS EVISTARALTEGRAVIR POTASSIUM CHEWABLE TABLETS ISENTRESSRALTEGRAVIR POTASSIUM PACKETS ISENTRESSRALTEGRAVIR POTASSIUM TABLETS ISENTRESS

RAMELTEON TABLETS ROZEREM Brand Only Preferred Drug PA Required for < 6 Years of Age

Patient must have tried temazepam and

zolpidem 30 30RAMIPRIL CAPSULES ALTACERANITIDINE HCL CAPSULES RANITIDINE HCLRANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQRANITIDINE HCL SYRUP ZANTACRANITIDINE HCL TABLETS ZANTAC 75RANOLAZINE TABLET 12-HOUR RANEXA PA RequiredREPAGLINIDE TABLETS PRANDINRIBAVIRIN (HEPATITIS C) CAPSULES VARIOUS Preferred Drug PA RequiredRIBAVIRIN (HEPATITIS C) TABLETS VARIOUS Preferred Drug PA RequiredRIFABUTIN CAPSULE MYCOBUTINRIFAMPIN CAPSULES RIFADINRILPIVIRINE HCL TABLETS EDURANTRILUZOLE TABLET RILUTEKRIMANTADINE HYDROCHLORIDE TABLETS FLUMADINERISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Preferred Drug PA Required for Ages < 18 years 2 30

RISPERIDONE ORAL SOLUTION RISPERDAL Preferred Drug PA Required for Ages < 6 years 240 ML 30






RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT Preferred Drug PA Required for Ages < 6 years 60 30

RISPERIDONE TABLETS RISPERDAL Preferred Drug PA Required for Ages < 6 years 60 30RITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIRRIVAROXABAN DOSE PACK XARELTO DOSE PACK Preferred Drug 51 30RIVAROXABAN TABLETS XARELTO Preferred Drug 60 30RIVASTIGMINE PATCH EXELON PA RequiredRIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredRIZATRIPTAN BENZOATE ORALLY DISINTEGRATING TABLETS9 MAXALT-MLT Preferred Drug 9 30RIZATRIPTAN BENZOATE TABLETS MAXALT Preferred Drug 9 30ROPINIROLE HYDROCHLORIDE TABLETS REQUIPROPINIROLE HYDROCHLORIDE TABLETS SR 24 HR REQUIP XLRUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA RequiredRUXOLITINIB PHOSPHATE TABLETS JAKAFI PA RequiredSACROSIDASE SOLUTION SUCRAID PA RequiredSACUBITRIL / VALSARTAN ENTRESTO PA RequiredSALICYLIC ACID CREAM SALACYNSALICYLIC ACID FOAM SALVAXSALICYLIC ACID GEL KERALYTSALICYLIC ACID LIQUID VIRASALSALICYLIC ACID LOTION SALACYNSALICYLIC ACID SHAMPOO SALEXSALICYLIC ACID SOLUTION VARIOUSSALIVA SUBSTITUTE SPRAY SALIVARTSALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED SEREVENT DISKUS PA RequiredSALSALATE TABLETS DISALCIDSAQUINAVIR MESYLATE CAPSULES INVIRASESAQUINAVIR MESYLATE TABLETS INVIRASESAXAGLIPTIN TABLET ONGLYZA Preferred Drug PA RequiredSAXAGLIPTIN/METFORMIN ER TABLETS KOMBLIGLYZE XR Preferred Drug PA RequiredSCOPOLAMINE HBR SOLUTION ISOPTO HYASINESELEGILINE HCL CAPSULES ELDEPRYL






SELEGILINE HCL ORALLY DISINTEGRATING TABLET ELDEPRYLSELEGILINE HCL TABLETS VARIOUSSELEGILINE TD PATCH ENSAM PA RequiredSELENIUM SULFIDE LOTION SELSUN SHAMPOOSELENIUM SULFIDE-PYRITHIONE ZINC IN UREA SHAMPOO SELSUMSELIGILENE EMSAM PA RequiredSENNA TABLES CONCENTRATED SENNA CONCSENNA TABLET SENNASENNOSIDES TABLETS SENOKOTSENNOSIDES-DOCUMSATE SDOIUM TABLET SENOKOT SSERTRALINE HCL CONCENTRATE ZOLOFT PA Required for Ages < 6 years 300 ML 30SERTRALINE HCL TABLETS 100MG ZOLOFT PA Required for Ages < 6 years 60 30SERTRALINE HCL TABLETS 25MG ZOLOFT PA Required for Ages < 6 years 90 30SERTRALINE HCL TABLETS 50MG ZOLOFT PA Required for Ages < 6 years 120 30SEVELAMER CARBONATE TABLETS RENVELA Brand Only Preferred DrugSEVELAMER HCL TABLETS RENAGEL Preferred DrugSILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO PA RequiredSILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS REVATIO PA RequiredSILVER SULFADIAZINE CREAM SILVADENESIMETHICONE CAPSULES MYLICONSIMETHICONE CHEW TABLETS MYLICON

SIMETHICONE SUSPENSION MYLICONSIMVASTATIN TABLETS ZOCOR 30 30

SIROLIMUS SOLUTION RAPAMUNESIROLIMUS TABLETS RAPAMUNESITAGLIPTIN PHOSPHATE TABLETS JANUVIA Preferred Drug PA RequiredSITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR Preferred Drug PA RequiredSITAGLIPTIN-METFORMIN HCL TABLETS JANUMET Preferred Drug PA RequiredSODIUM CHLORIDE NEBULIZER SOLUTION NEBUSAL / HYPERSALSODIUM FLUORIDE CHEWABLE TABLETS LUDENTSODIUM FLUORIDE LOZG LOZI-FLURSODIUM FLUORIDE SOLUTION FLUOR-A-DAYSODIUM FLUORIDE TABLETS SODIUM FLUORIDESODIUM PHOSPHATE - ENEMA FLEET ENEMASODIUM PHOSPHATE - SOLUTION VARIOUSSODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATESODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEXSOMATROPIN NORDITROPIN Preferred Drug PA RequiredSOMATROPIN GENOTROPIN Preferred Drug PA Required






SORAFENIB TOSYLATE TABLETS NEXAVAR PA RequiredSOTALOL HCL SOLUTION SOTYLIZESOTALOL HCL TABLETS BETAPACE

SPACER/AEROSOL-HOLDING CHAMBER SUPPOSITORYLIES - MASKSMASK VORTEX/

BABY WHIRL DUCKLING 2 365

SPACER/AEROSOL-HOLDING CHAMBERS DEVICEAEROCHAMBER

MINI AEROCHAMBER 2 365SPINOSAD SUSPENSION NATROBA PA RequiredSPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDESPIRONOLACTONE SUSPENSION SPIRONOLACTONESPIRONOLACTONE TABLETS ALDACTONESTAVUDINE CAPSULES ZERITSTAVUDINE SOLUTION ZERITSUCRALFATE TABLETS CARAFATESULFACETAMIDE SODIUM LIQUID OVACE WASHSULFACETAMIDE SODIUM LOTION KLARONSULFACETAMIDE SODIUM OINTMENT SULFACETAMIDE SODIUMSULFACETAMIDE SODIUM SOLUTION BLEPH-10SULFACETAMIDE SOD-PREDNISOLONE OINTMENT BLEPHAMIDE S.O.P.

SULFACETAMIDE SOD-PREDNISOLONE SOLUTION

SULFACETAMIDESODIUM/PREDNISOLONE

SODIUM PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE SUSPENSION BLEPHAMIDESULFADIAZINE TABLETS SULFADIAZINESULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION SULFATRIM PEDIATRICSULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS BACTRIMSULFANILAMIDE VAGINAL CREAM AVCSULFASALAZINE TABLET ENTERIC COATED AZULFIDINE EN-TABLETS 240 30SULFASALAZINE TABLETS AZULFIDINE 240 30SULINDAC TABLETS SULINDACSUMATRIPTAN NASAL SPRAY IMITREX Preferred Drug 6 30SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION CARTRIDGE/AUTO INJ IMITREX Preferred Drug 2 30SUMATRIPTAN SUCCINATE TABLETS IMITREX Preferred Drug 9 30SUNITINIB MALATE CAPSULES SUTENT PA RequiredTACROLIMUS CAPSULE CONTROLLED RELEASE ASTAGRAF XLTACROLIMUS CAPSULES HECORIATADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA PA RequiredTAFLUPROST SOLUTION ZIOPTANTAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETAMSULOSIN HCL CAPSULES FLOMAXTELBIVUDINE TABLETS TYZEKA PA RequiredTELBIVUDINE TABLETS TYZEKA PA Required






TEMAZEPAM CAPSULES 15MG, 30MG RESTORILPA Required for Ages <6 years

PA Required for > 1 Hypnotic Drug 30 30TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER VIREADTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREADTERAZOSIN HCL CAPSULES TERAZOSIN HCLTERBINAFINE HCl CREAM LAMISIL AFTERBINAFINE HCL PACKETS LAMISIL 90 365TERBINAFINE HCL TABLETS LAMISIL 90 365TERCONALZOLE BAGINAL CREAM TERAZOLTESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA RequiredTESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA RequiredTESTOSTERONE GEL ANDROGEL PA RequiredTESTOSTERONE PATCH ANDRODERM PA RequiredTESTOSTERONE SOLUTION AXIRON PA RequiredTHALIDOMIDE CAPSULES THALOMID PA RequiredTHEOPHYLINE TABLETS SR 12 HR THEOPHYLLINETHEOPHYLLINE CAPSULE CONTROLLED RELEASE THEOPHYLLINETHEOPHYLLINE CAPSULES SR 12 HR THEOPHYLLINETHEOPHYLLINE CAPSULES SR 24 HR THEOPHYLLINETHIAMINE HCL TABLETS VITAMIN B1THIAMINE MONONITRATE TABLETS VITAMIN B1THIORIDAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 yearsTHIOTHIXENE CAPSULES VARIOUS PA Required for Ages < 6 yearsTHYROID TABLETS ARMOUR THYROIDTIAGABINE HCL TABLETS GABITRIL PA RequiredTICAGRELOR TABLETS BRILINTA PA RequiredTIMOLOL MALEATE SOLUTION TIMOPTIC-XETIMOLOL MALEATE SOLUTION TIMOPTICTIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALER Preferred DrugTIOTROPIUM BROMIDE-OLODATEROL HCL AEROSOL SOLUTION STIOLTO RESPIMAT Preferred Drug PA RequiredTIPRANAVIR CAPSULES APTIVUSTIPRANAVIR SOLUTION APTIVUSTIZANIDINE HCL TABLETS TIZANIDINE HCLTOBRAMYCIN NEBULIZED BETHKIS Preferred Drug PA RequiredTOBRAMYCIN NEBULIZED KITABIS Preferred Drug PA RequiredTOBRAMYCIN OINTMENT TOBREX 3.5GM 7






TOBRAMYCIN SOLUTION TOBREXTOBRAMYCIN-DEXAMETHASONE OINTMENT 0.3-0.1% TOBRADEXTOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX STTOLAZAMIDE TABLETS TOLINASETOLBUTAMIDE TABLETS TOLBUTAMIDETOLMETIN SODIUM CAPSULE TOLMETIN SODIUMTOLNAFTATE CREAM TINACTINTOLNAFTATE SOLUTION TINACTIN

TOLTERODINE TARTRATE CAPSULE CONTROLLED RELEASE DETROL LA STEP THERAPY

Member must havetried oxybutynin & tolterodine

TOLTERODINE TARTRATE TABLETS DETROL STEP THERAPYMember must havetried oxybutynin

TOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLESTOPIRAMATE TABLETS TOPAMAXTOREMIFENE CITRATE TABLETS FARESTON PA RequiredTORSEMIDE TABLETS DEMADEX

TRAMADOL HCL TABLETS ULTRAMPA Required for > 2 Short Acting

Narcotics FillTRAMADOL ER TABLETS ULTRAM ER Preferred Drug PA Required

TRAMADOL-ACETAMINOPHEN TABLETS ULTRACETPA Required for > 2 Short Acting

Narcotics FillTRANDOLAPRIL TABLETS MAVIKTRANYLCYPROMINE SULFATE TABLET PARNATE PA Required for Ages < 6 yearsTRAVOPROST SOLUTION TRAVATAN ZTRAZODONE HCL TABLETS 100MG TRAZODONE HCL PA Required for Ages < 6 years 120 30TRAZODONE HCL TABLETS 150M TRAZODONE HCL PA Required for Ages < 6 years 60 30TRAZODONE HCL TABLETS 300MG TRAZODONE HCL PA Required for Ages < 6 years 30 30TRAZODONE HCL TABLETS 50MG TRAZODONE HCL PA Required for Ages < 6 years 90 30TREPROSTINIL SODIUM SOLUTION REMODULIN PA RequiredTREPROSTINIL SOLUTION TYVASO PA RequiredTRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of AgeTRETINOIN CREAM RETIN-A PA Required FOR > 26 Years of AgeTRETINOIN GEL RETIN-A PA Required FOR > 26 Years of AgeTRIAMCINOLONE ACETONIDE (TOPICAL) AEROSOL VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) CREAM VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) LOTION VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) OINTMENT VARIOUSTRIAMCINOLONE ACETONIDE DENTAL PASTE VARIOUSTRIAMCINOLONE ACETONIDE NASAL NASACORT AQTRIAMCINOLONE ACETONIDE ORAL PASTE ORALONETRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE) KENALOG-10 Long Term Care OnlyTRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE) TRIAMCINOLONE Long Term Care Only






TRIAMCINOLONE HEXACETONIDE SUSPENSION (INJECTABLE)ARISTOSPAN INTRALESIONAL &

INTRA-ARTICULAR Long Term Care OnlyTRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25TRIAMTERENE CAPSULES DYRENIUMTRIFLUOPERAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years

TRIFLURIDINE SOLUTION VIROPTICTRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCLTRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCLTRIMETHOBENZAMIDE HCL CAPSULES TIGANTRIMETHOPRIM TABLET TRIMETHOPRIMTRIMIPRAMINE MALEATE CAPSULES TRIMIPRAMINE PA Required for ages < 6 yearsTROPICAMIDE SOLUTION MYDRIACYLTROSPIUM CHLORIDE TABLETS SANCTURAUREA CREAM CARMOL-40URINE GLUCOSE MONITORING KIT VARIOUSURINE GLUCOSE-KETONES TEST STRIPS VARIOUSURSODIOL CAPSULES ACTIGALLURSODIOL TABLETS URSO 250VALACYCLOVIR HCL TABLETS VALTREX PA RequiredVALGANCICLOVIR HCL SOLUTION VALCYTE PA RequiredVALGANCICLOVIR HCL TABLETS VALCYTE PA RequiredVALPROATE SODIUM SYRUP DEPAKENEVALPROIC ACID CAPSULES DEPAKENEVALPROIC ACID CAPSULES DELAYED RELEASE STAVZORVALSARTAN - HYDROCHLOROTHIAZIDE TABLETS DIOVAN HCTVALSARTAN TABLETS DIOVANVANCOMYCIN HCL CAPSULES VANCOCIN HCL PA Required

VANCOMYCIN HCL SOLUTIONAvailable through a

compounding pharmacy PA RequiredVANDETANIB TABLETS CAPRELSA PA Required

VARENICLINE TARTRATE TABLETS CHANTIX84-daysupply 180

VEMURAFENIB TABLETS ZELBORAF PA RequiredVENLAFAXINE HCL ER CAPSULES 150MG EFFEXOR XR PA Required for Ages < 6 years 30 30VENLAFAXINE HCL ER CAPSULES 37.5 MG VENLAFAXINE PA Required for Ages < 6 years 90 30VENLAFAXINE HCL ER CAPSULES 75MG VENLAFAXINE PA Required for Ages < 6 years 90 30VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 100MG VENLAFAXINE PA Required for Ages < 6 years 90 30






VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 25MG VENLAFAXINE PA Required for Ages < 6 years 120 30VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 37.5MG VENLAFAXINE PA Required for Ages < 6 years 90 30VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 50MG VENLAFAXINE PA Required for Ages < 6 years 90 30VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 75MG VENLAFAXINE PA Required for Ages < 6 years 150 30VERAPAMIL HCL CAPSULE CONTROLLED RELEASE VERELAN PM 30 30VERAPAMIL HCL TABLET CONTROLLED RELEASE CALAN SR 30 30VERAPAMIL HCL TABLETS VERAPAMIL HCLVILAZODONE HCL STARTER KIT VIIBRYD PA RequiredVILAZODONE HCL TABLETS VIIBRYD PA RequiredVITAMIN E CAPSULES VITAMIN EVITAMIN E TABLETS VITAMIN EVORICONAZOLE SUSPENSION VFEND PA RequiredVORICONAZOLE TABLETS VFEND PA RequiredVORINOSTAT CAPSULES ZOLINZA PA RequiredWARFARIN SODIUM TABLETS WARFARIN, JANTOVEN Generic Preferred DrugZAFIRLUKAST TABLETS ACCOLATEZANAMIVIR AEROSOL POWDER BREATH ACTIVATED RELENZA DISKHALER 40 270ZIDOVUDINE CAPSULES RETROVIRZIDOVUDINE SYRUP RETROVIRZIDOVUDINE TABLETS ZIDOVUDINEZINC OXIDE CREAM DESITINZINCE OXIDE OINTMENT DESITINZIPRASIDONE HCL CAPSULES GEODON Preferred Drug PA Required for Ages < 6 years 60 30ZOLMITRIPTAN ORALLY DISINTEGRATING TABLETS ZOMIG ZMT Preferred Drug 9 30ZOLMITRIPTAN TABLETS ZOMIG 9 30

ZOLPIDEM TARTRATE TABLETS 10MG AMBIEN Preferred DrugPA Required for Ages <6 years

PA Required for > 1 Hypnotic Drug 30 30

ZOLPIDEM TARTRATE TABLETS 5MG AMBIEN Preferred DrugPA Required for Ages <6 years

PA Required for > 1 Hypnotic Drug 60 30ZONISAMIDE CAPSULES ZONEGRAN

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