formulary drug list - amerihealth caritas louisiana drug list amerihealth caritas louisiana...
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Formulary Drug List
AmeriHealth Caritas Louisiana PerformRxSM Pharmacy Services:
Phone 1-800-684-5502
Fax 1-855-452-9131
Pharmacy Member Services:
Phone 1-866-452-1040
Providers may request the addition or deletion of a medication to this list.
Requests for additions must include the drug name, rationale for inclusion
on the list, role in therapy and medications that may be replaced by the addition.
Please direct such requests to:
AmeriHealth Caritas
P&T Committee
P.O. Box 40849
Charleston, SC 29423
Members may request changes to the list by calling Pharmacy Member Services.
For the most current formulary, please use the searchable formulary on our
website, www.amerihealthcaritasla.com/pharmacy/formulary.aspx.
Sept. 2018
ACLA-1322-07
www.amerihealthcaritasla.com
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
1
Drug Name Notes Requirements/Limits
Antihistamine Drugs
Ethanolamine Derivatives
diphenhydramine HCl injection solution 50
mg/mL
diphenhydramine HCl injection syringe
diphenhydramine HCl oral capsule
diphenhydramine HCl oral syrup
diphenhydramine HCl oral tablet 25 mg
First Gen. Antihist. Derivatives, Misc.
cyproheptadine
First Generation Antihistamines
chlorpheniramine maleate oral tablet
cyproheptadine
diphenhydramine HCl injection solution 50
mg/mL
diphenhydramine HCl injection syringe
diphenhydramine HCl oral capsule
diphenhydramine HCl oral syrup
diphenhydramine HCl oral tablet 25 mg
ED Chlorped Jr
Phenothiazine Derivatives
promethazine oral
promethazine rectal
promethazine-phenylephrine
Piperazine Derivatives
hydroxyzine pamoate
meclizine oral tablet 12.5 mg, 25 mg
Propylamine Derivatives
chlorpheniramine maleate oral tablet
ED Chlorped Jr
Second Generation Antihistamines
cetirizine oral solution 1 mg/mL
cetirizine oral tablet
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
2
Drug Name Notes Requirements/Limits
cetirizine-pseudoephedrine
fexofenadine oral suspension ST
fexofenadine oral tablet 180 mg ST
levocetirizine oral tablet
loratadine oral solution
loratadine oral tablet
loratadine oral tablet,disintegrating
Loratadine-D
Anti-Infective Agents
1St Generation Cephalosporin
Antibiotics
cefadroxil oral capsule
cefadroxil oral suspension for reconstitution 250
mg/5 mL, 500 mg/5 mL
cefadroxil oral tablet
cefazolin injection recon soln 1 gram, 10 gram,
500 mg Specialty PA
cephalexin oral capsule 250 mg, 500 mg
cephalexin oral suspension for reconstitution
2Nd Generation Cephalosporin
Antibiotics
cefaclor oral capsule
cefotetan Specialty PA
cefotetan in dextrose, iso-osm Specialty PA
cefprozil
cefuroxime axetil oral suspension for
reconstitution 125 mg/5 mL
cefuroxime axetil oral tablet
cefuroxime sodium intravenous recon soln 7.5
gram Specialty PA
3Rd Generation Cephalosporin
Antibiotics
cefdinir QL
cefotaxime Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
3
Drug Name Notes Requirements/Limits
cefpodoxime oral suspension for reconstitution
ceftazidime Specialty PA
ceftriaxone in dextrose,iso-os Specialty PA
ceftriaxone injection recon soln 1 gram, 10 gram,
2 gram, 250 mg, 500 mg Specialty PA
ceftriaxone intravenous Specialty PA
Claforan intravenous recon soln Specialty PA
Suprax oral capsule QL
Suprax oral suspension for reconstitution 100
mg/5 mL, 200 mg/5 mL
TAZICEF intravenous Specialty PA
4Th Generation Cephalosporin
Antibiotics
cefepime Specialty PA
cefepime in dextrose 5 % Specialty PA
cefepime in dextrose,iso-osm Specialty PA
Adamantane Antivirals
amantadine HCl oral capsule
amantadine HCl oral solution
Allylamine Antifungals
terbinafine HCl oral QL
Amebicides
metronidazole in NaCl (iso-os) Specialty PA
metronidazole oral tablet
paromomycin PA; QL
Aminoglycoside Antibiotics
amikacin injection solution 1,000 mg/4 mL, 500
mg/2 mL Specialty PA
gentamicin in NaCl (iso-osm) intravenous
piggyback 100 mg/100 mL, 100 mg/50 mL, 80
mg/100 mL, 80 mg/50 mL
Specialty PA
gentamicin injection Specialty PA
gentamicin sulfate (PF) intravenous solution 100
mg/10 mL, 60 mg/6 mL Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
4
Drug Name Notes Requirements/Limits
Tobi Podhaler Specialty PA
tobramycin in 0.225 % NaCl Specialty PA
tobramycin sulfate Specialty PA
Aminopenicillin Antibiotics
amoxicillin oral capsule
amoxicillin oral suspension for reconstitution
amoxicillin oral tablet
amoxicillin oral tablet,chewable 125 mg, 250 mg
amoxicillin-pot clavulanate oral suspension for
reconstitution
amoxicillin-pot clavulanate oral tablet
amoxicillin-pot clavulanate oral tablet,chewable
ampicillin oral capsule
ampicillin sodium Specialty PA
ampicillin-sulbactam Specialty PA
Anthelmintics
Biltricide
Antifungals, Miscellaneous
griseofulvin microsize
griseofulvin ultramicrosize
SSKI
Antimalarials
atovaquone-proguanil
chloroquine phosphate
Daraprim Specialty PA
hydroxychloroquine
mefloquine
primaquine
quinidine gluconate oral
quinidine sulfate oral tablet
Antimycobacterials, Miscellaneous
dapsone oral
Antiprotozoals, Miscellaneous
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
5
Drug Name Notes Requirements/Limits
atovaquone PA
dapsone oral
metronidazole in NaCl (iso-os) Specialty PA
metronidazole oral tablet
Nebupent Specialty PA
Pentam Specialty PA
Antituberculosis Agents
amikacin injection solution 1,000 mg/4 mL, 500
mg/2 mL Specialty PA
ciprofloxacin
ciprofloxacin (mixture)
ciprofloxacin HCl oral tablet 100 mg
ciprofloxacin HCl oral tablet 250 mg, 500 mg,
750 mg QL
ciprofloxacin in 5 % dextrose intravenous
piggyback 400 mg/200 mL Specialty PA
clarithromycin QL
ethambutol
isoniazid oral
levofloxacin in D5W Specialty PA
levofloxacin oral QL
moxifloxacin oral QL
Mycobutin
pyrazinamide
rifampin intravenous Specialty PA
rifampin oral
Antivirals, Miscellaneous
foscarnet Specialty PA
Azole Antifungals
fluconazole in dextrose(iso-o) intravenous
piggyback 400 mg/200 mL Specialty PA
fluconazole in NaCl (iso-osm) intravenous
piggyback 200 mg/100 mL, 400 mg/200 mL Specialty PA
fluconazole oral suspension for reconstitution
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
6
Drug Name Notes Requirements/Limits
fluconazole oral tablet 100 mg, 200 mg, 50 mg
fluconazole oral tablet 150 mg QL
itraconazole PA
ketoconazole oral
Sporanox oral solution PA
voriconazole intravenous Specialty PA
Carbapenem Antibiotics
doripenem Specialty PA
imipenem-cilastatin intravenous recon soln 250
mg Specialty PA
Invanz Specialty PA
meropenem Specialty PA
Cephamycin Antibiotics
cefotetan Specialty PA
cefotetan in dextrose, iso-osm Specialty PA
Cyclic Lipopeptide Antibiotics
daptomycin Specialty PA
Echinocandin Antifungals
caspofungin Specialty PA
Eraxis(Water Diluent) Specialty PA
Mycamine Specialty PA
Erythromycin Antibiotics
E.E.S. Granules
Ery-Tab
Erythrocin (as stearate) oral tablet 250 mg
erythromycin ethylsuccinate oral tablet
erythromycin oral capsule,delayed
release(DR/EC)
erythromycin oral tablet
Extended-Spectrum Penicillins
piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram Specialty PA
Zosyn in dextrose (iso-osm) Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
7
Drug Name Notes Requirements/Limits
Glycopeptide Antibiotics
vancomycin in dextrose 5 % intravenous
piggyback 1 gram/200 mL, 750 mg/150 mL Specialty PA
vancomycin intravenous Specialty PA
vancomycin oral capsule ST
Vibativ intravenous recon soln 750 mg Specialty PA
Glycylcycline Antibiotics
tigecycline Specialty PA
Hcv Polymerase Inhibitor Antivirals
Epclusa Specialty PA
Harvoni Specialty PA
Sovaldi Specialty PA
Viekira Pak Specialty PA
Viekira XR Specialty PA
Vosevi Specialty PA
Hcv Protease Inhibitor Antivirals
Mavyret Specialty PA
Olysio Specialty PA
Technivie Specialty PA
Viekira Pak Specialty PA
Viekira XR Specialty PA
Zepatier Specialty PA
Hcv Replication Complex Inhibitors
Daklinza Specialty PA
Epclusa Specialty PA
Harvoni Specialty PA
Mavyret Specialty PA
Technivie Specialty PA
Viekira Pak Specialty PA
Viekira XR Specialty PA
Vosevi Specialty PA
Zepatier Specialty PA
Hiv Entry And Fusion Inhibitors
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
8
Drug Name Notes Requirements/Limits
Fuzeon subcutaneous recon soln
Selzentry
Trogarzo
Hiv Integrase Inhibitor Antiretrovirals
Biktarvy
Genvoya
Isentress
Isentress HD
Juluca
Stribild
Tivicay
Triumeq
Hiv Nonnucleoside Rev.Transcrip.
Inhib.
Atripla
Complera
Edurant
efavirenz
Intelence
Juluca
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended release 24 hr 400
mg
Odefsey
Rescriptor
Symfi
Symfi Lo
Viramune XR oral tablet extended release 24 hr
100 mg
Hiv Nucleoside, Nucleotide Rt
Inhibitors
abacavir
abacavir-lamivudine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
9
Drug Name Notes Requirements/Limits
Atripla
Biktarvy
Cimduo
Complera
Descovy
didanosine
Emtriva
Epivir HBV
Epivir oral solution
Genvoya
lamivudine oral tablet 150 mg, 300 mg
lamivudine-zidovudine
Odefsey
Retrovir intravenous
stavudine oral capsule
Stribild
Symfi
Symfi Lo
tenofovir disoproxil fumarate
Triumeq
Trizivir
Truvada
Videx 2 gram Pediatric
Viread oral powder
Viread oral tablet 150 mg, 200 mg, 250 mg
Zerit oral recon soln
zidovudine
Hiv Protease Inhibitor Antiretrovirals
Aptivus
atazanavir
Crixivan oral capsule 200 mg, 400 mg
Evotaz
fosamprenavir
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
10
Drug Name Notes Requirements/Limits
Invirase
Kaletra oral tablet
Lexiva oral suspension
lopinavir-ritonavir
Norvir oral capsule
Norvir oral solution
Prezcobix
Prezista oral suspension
Prezista oral tablet 150 mg, 600 mg, 75 mg, 800
mg
Reyataz oral powder in packet
ritonavir
Technivie Specialty PA
Viekira Pak Specialty PA
Viekira XR Specialty PA
Viracept oral tablet
Interferon Antivirals
Alferon N Specialty PA
Intron A injection Specialty PA
Pegasys Specialty PA
Pegasys ProClick Specialty PA
PegIntron subcutaneous kit 50 mcg/0.5 mL Specialty PA
Sylatron Specialty PA
Lincomycin Antibiotics
clindamycin HCl oral capsule 150 mg, 300 mg
clindamycin in 5 % dextrose Specialty PA
clindamycin palmitate HCl
clindamycin phosphate injection Specialty PA
clindamycin phosphate intravenous solution 900
mg/6 mL Specialty PA
Lincocin Specialty PA
Macrolide Antibiotics
E.E.S. Granules
Ery-Tab
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
11
Drug Name Notes Requirements/Limits
Erythrocin (as stearate) oral tablet 250 mg
erythromycin ethylsuccinate oral tablet
erythromycin oral capsule,delayed
release(DR/EC)
erythromycin oral tablet
Monobactam Antibiotics
Azactam in dextrose (iso-osm) Specialty PA
aztreonam Specialty PA
Cayston Specialty PA
Monoclonal Antibody Antivirals
Synagis Specialty PA
Natural Penicillin Antibiotics
Bicillin L-A
penicillin G potassium Specialty PA
penicillin V potassium
Neuraminidase Inhibitor Antivirals
oseltamivir QL
Relenza Diskhaler QL
Nucleoside And Nucleotide Antivirals
acyclovir oral capsule
acyclovir oral suspension 200 mg/5 mL
acyclovir oral tablet
adefovir Specialty PA
cidofovir Specialty PA
Cytovene Specialty PA
entecavir
Rebetol oral solution Specialty PA
Ribasphere oral tablet 400 mg, 600 mg Specialty PA
Ribasphere RibaPak oral tablets,dose pack 400-
400 mg (28)-mg (28), 600-400 mg (28)-mg (28),
600-600 mg (28)-mg (28)
Specialty PA
ribavirin oral capsule Specialty PA
ribavirin oral tablet 200 mg Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
12
Drug Name Notes Requirements/Limits
valacyclovir
Other Macrolide Antibiotics
azithromycin oral QL
clarithromycin QL
Zmax QL
Oxazolidinone Antibiotics
Zyvox intravenous Specialty PA
Penicillinase-Resistant Penicillins
dicloxacillin
nafcillin in dextrose iso-osm intravenous
piggyback 2 gram/100 mL Specialty PA
nafcillin injection Specialty PA
oxacillin injection Specialty PA
Polyene Antifungals
Abelcet Specialty PA
AmBisome Specialty PA
nystatin oral powder 150 million unit, 500 million
unit
nystatin oral suspension
nystatin oral tablet
Polymyxin Antibiotics
colistin (colistimethate Na) Specialty PA
Quinolone Antibiotics
ciprofloxacin
ciprofloxacin (mixture)
ciprofloxacin HCl oral tablet 100 mg
ciprofloxacin HCl oral tablet 250 mg, 500 mg,
750 mg QL
ciprofloxacin in 5 % dextrose intravenous
piggyback 400 mg/200 mL Specialty PA
levofloxacin in D5W Specialty PA
levofloxacin oral QL
moxifloxacin oral QL
ofloxacin oral tablet 400 mg QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
13
Drug Name Notes Requirements/Limits
Rifamycin Antibiotics
Mycobutin
rifampin intravenous Specialty PA
rifampin oral
Xifaxan oral tablet 550 mg PA
Streptogramin Antibiotics
Synercid Specialty PA
Sulfonamide Antibiotics (Systemic)
sulfadiazine
sulfamethoxazole-trimethoprim intravenous Specialty PA
sulfamethoxazole-trimethoprim oral
sulfasalazine
Tetracycline Antibiotics
Doxy-100 Specialty PA
doxycycline hyclate oral capsule
doxycycline hyclate oral tablet 100 mg
doxycycline monohydrate oral capsule 100 mg,
50 mg
doxycycline monohydrate oral tablet 100 mg, 50
mg, 75 mg
minocycline oral capsule
minocycline oral tablet
tetracycline
Urinary Anti-Infectives
nitrofurantoin
nitrofurantoin macrocrystal
nitrofurantoin monohyd/m-cryst
trimethoprim
Antineoplastic Agents
Antineoplastic Agents
Abraxane Specialty PA
Adcetris Specialty PA
Afinitor Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
14
Drug Name Notes Requirements/Limits
Afinitor Disperz Specialty PA
Alecensa Specialty PA
Alferon N Specialty PA
Alimta Specialty PA
anastrozole
Arranon Specialty PA
Arzerra intravenous solution 100 mg/5 mL Specialty PA
Avastin Specialty PA
bexarotene Specialty PA
bicalutamide
BiCNU Specialty PA
bleomycin Specialty PA
Bosulif Specialty PA
busulfan Specialty PA
Camptosar intravenous solution 300 mg/15 mL Specialty PA
capecitabine Specialty PA
Caprelsa Specialty PA
carboplatin Specialty PA
cisplatin Specialty PA
cladribine Specialty PA
clofarabine Specialty PA
Cometriq Specialty PA
cyclophosphamide intravenous Specialty PA
cytarabine Specialty PA
cytarabine (PF) injection solution Specialty PA
dacarbazine Specialty PA
Dacogen Specialty PA
dactinomycin Specialty PA
daunorubicin intravenous solution Specialty PA
Docefrez Specialty PA
docetaxel intravenous solution 160 mg/16 mL (10
mg/mL), 160 mg/8 mL (20 mg/mL), 20 mg/2 mL
(10 mg/mL), 20 mg/mL (1 mL), 80 mg/4 mL (20
mg/mL), 80 mg/8 mL (10 mg/mL)
Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
15
Drug Name Notes Requirements/Limits
Doxil Specialty PA
doxorubicin intravenous solution Specialty PA
Droxia
Eligard Specialty PA
Eligard (3 month) Specialty PA
Eligard (4 month) Specialty PA
Eligard (6 month) Specialty PA
Emcyt
epirubicin intravenous recon soln 50 mg Specialty PA
epirubicin intravenous solution Specialty PA
Erbitux Specialty PA
Erivedge Specialty PA
Erwinaze Specialty PA
Etopophos Specialty PA
etoposide Specialty PA
exemestane Specialty PA
Fareston PA
Faslodex Specialty PA
Firmagon kit w diluent syringe subcutaneous
recon soln 80 mg Specialty PA
Firmagon subcutaneous recon soln 120 mg Specialty PA
floxuridine Specialty PA
fludarabine Specialty PA
fluorouracil intravenous Specialty PA
flutamide
Folotyn Specialty PA
gemcitabine intravenous recon soln Specialty PA
gemcitabine intravenous solution 1 gram/26.3 mL
(38 mg/mL), 2 gram/52.6 mL (38 mg/mL), 200
mg/5.26 mL (38 mg/mL)
Specialty PA
Gliadel Wafer Specialty PA
Halaven Specialty PA
Herceptin intravenous recon soln 440 mg Specialty PA
Hexalen
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
16
Drug Name Notes Requirements/Limits
Hycamtin oral Specialty PA
hydroxyurea
Ibrance Specialty PA
Iclusig Specialty PA
idarubicin Specialty PA
ifosfamide Specialty PA
ifosfamide-mesna intravenous kit 1-1 gram Specialty PA
imatinib Specialty PA
Inlyta Specialty PA
Intron A injection Specialty PA
irinotecan Specialty PA
Ixempra Specialty PA
Jakafi Specialty PA
Jevtana Specialty PA
Kadcyla Specialty PA
Kyprolis intravenous recon soln 60 mg Specialty PA
letrozole QL
Leukeran
leuprolide subcutaneous kit Specialty PA
Lupron Depot Specialty PA
Lupron Depot (3 month) Specialty PA
Lupron Depot (4 month) Specialty PA
Lupron Depot (6 Month) Specialty PA
Lupron Depot-Ped Specialty PA
Lupron Depot-Ped (3 month) Specialty PA
Lysodren
Matulane
megestrol oral suspension 400 mg/10 mL (40
mg/mL)
megestrol oral suspension 625 mg/5 mL QL
megestrol oral tablet
melphalan
melphalan HCl Specialty PA
mercaptopurine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
17
Drug Name Notes Requirements/Limits
methotrexate sodium
methotrexate sodium (PF)
mitomycin intravenous Specialty PA
mitoxantrone Specialty PA
Mustargen Specialty PA
Myleran
Nexavar Specialty PA
nilutamide Specialty PA
Oncaspar Specialty PA
oxaliplatin Specialty PA
paclitaxel Specialty PA
Perjeta Specialty PA
Photofrin Specialty PA
Pomalyst Specialty PA
Proleukin Specialty PA
Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25
mg, 5 mg Specialty PA
Rituxan Specialty PA
Rituxan Hycela Specialty PA
romidepsin Specialty PA
Sprycel Specialty PA
Stivarga Specialty PA
Supprelin LA Specialty PA
Sutent oral capsule 12.5 mg, 25 mg, 50 mg Specialty PA
Sylatron Specialty PA
Synribo Specialty PA
Tabloid
tamoxifen
Tarceva Specialty PA
Targretin topical Specialty PA
Tasigna Specialty PA
Temodar intravenous Specialty PA
temozolomide Specialty PA
teniposide Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
18
Drug Name Notes Requirements/Limits
thiotepa Specialty PA
Tice BCG Specialty PA
topotecan Specialty PA
Torisel Specialty PA
Treanda intravenous recon soln Specialty PA
Trelstar Specialty PA
tretinoin (chemotherapy) Specialty PA
Trexall oral tablet 7.5 mg
Tykerb Specialty PA
Valstar Specialty PA
Vantas Specialty PA
Vectibix Specialty PA
Velcade Specialty PA
Vidaza Specialty PA
vinblastine intravenous solution Specialty PA
vincristine Specialty PA
vinorelbine Specialty PA
Votrient Specialty PA
Xalkori Specialty PA
Xtandi Specialty PA
Yervoy Specialty PA
Zaltrap Specialty PA
Zanosar Specialty PA
Zelboraf Specialty PA
Zevalin (Y-90) Specialty PA
Zoladex Specialty PA
Zolinza Specialty PA
Zykadia Specialty PA
Zytiga Specialty PA
Antitoxins,Immune
Glob,Toxoids,Vaccines
Antitoxins And Immune Globulins
Carimune NF Nanofiltered intravenous recon soln
12 gram, 6 gram Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
19
Drug Name Notes Requirements/Limits
CytoGam intravenous solution 50 mg/mL Specialty PA
Flebogamma DIF intravenous solution 5 % Specialty PA
GamaSTAN S/D Specialty PA
Gamunex-C injection solution 1 gram/10 mL (10
%), 10 gram/100 mL (10 %), 2.5 gram/25 mL (10
%), 20 gram/200 mL (10 %), 5 gram/50 mL (10
%)
Specialty PA
Hizentra subcutaneous solution 1 gram/5 mL (20
%), 2 gram/10 mL (20 %), 4 gram/20 mL (20 %) Specialty PA
HyperRHO S/D Specialty
MICRhoGAM Ultra-Filtered PLUS Specialty
Privigen Specialty PA
RhoGAM Ultra-Filtered PLUS Specialty
Rhophylac Specialty
WinRho SDF Specialty
Vaccines
Afluria 2017-2018 QL; AL
Afluria 2017-2018 (PF) QL; AL
Afluria Quad 2017-2018 QL; AL
Afluria Quad 2017-2018 (PF) QL; AL
Fluarix Quad 2017-2018 (PF) QL; AL
Flucelvax Quad 2017-2018 QL; AL
Flucelvax Quad 2017-2018 (PF) QL; AL
Flulaval Quad 2017-2018 QL; AL
Flulaval Quad 2017-2018 (PF) QL; AL
Fluvirin 2017-2018 QL; AL
Fluvirin 2017-2018 (PF) QL; AL
Fluzone High-Dose 2017-18 (PF) QL; AL
Fluzone Intraderm Quad 2017-18 QL; AL
Fluzone Quad 2017-2018 QL; AL
Fluzone Quad 2017-2018 (PF) QL; AL
Fluzone Quad Pedi 2017-18 (PF) QL; AL
Tice BCG Specialty PA
Autonomic Drugs
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
20
Drug Name Notes Requirements/Limits
Alpha- And Beta-Adrenergic Agonists
cetirizine-pseudoephedrine
epinephrine injection auto-injector 0.15 mg/0.3
mL, 0.3 mg/0.3 mL QL
epinephrine injection solution
epinephrine injection syringe 0.1 mg/mL
Loratadine-D
Alpha-Adrenergic Agonists
clonidine
clonidine HCl oral tablet
Clorpres
methyldopa
methyldopa-hydrochlorothiazide
midodrine
promethazine-phenylephrine
Antimuscarinics/Antispasmodics
Anoro Ellipta
Atrovent HFA
Combivent Respimat
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine
glycopyrrolate oral tablet 1 mg, 2 mg
hyoscyamine sulfate oral
ipratropium bromide inhalation
ipratropium-albuterol
propantheline
Spiriva Respimat AL
Stiolto Respimat
Antiparkinsonian Agents
benztropine oral
trihexyphenidyl
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
21
Drug Name Notes Requirements/Limits
Autonomic Drugs, Miscellaneous
Chantix QL
Chantix Starting Month Box QL
Nicotrol PA
Nicotrol NS PA; QL
Centrally Acting Skeletal Muscle
Relaxnt
carisoprodol oral tablet 350 mg ST; QL
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5 mg
methocarbamol oral
tizanidine oral tablet
Gaba-Derivative Skeletal Muscle
Relaxant
baclofen
Lioresal Specialty PA
Non-Sel. Beta-Adrenergic Blocking
Agents
carvedilol
labetalol oral
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
Sotalol AF oral tablet 160 mg, 80 mg
sotalol oral tablet 120 mg, 240 mg
timolol maleate oral
Non-Sel.Alpha-1-Adrenergic Blocking
Agts
doxazosin
prazosin
terazosin
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
22
Drug Name Notes Requirements/Limits
Non-Sel.Alpha-Adrenergic Blocking
Agents
dihydroergotamine injection
Ergomar
ergotamine-caffeine
Migranal QL
phenoxybenzamine
Parasympathomimetic (Cholinergic
Agents)
bethanechol chloride
donepezil oral tablet 10 mg, 5 mg QL; AL
donepezil oral tablet 23 mg ST; QL; AL
donepezil oral tablet,disintegrating QL; AL
Mestinon oral syrup
pyridostigmine bromide
rivastigmine tartrate AL
Selective Alpha-1-Adrenergic
Block.Agent
alfuzosin
carvedilol
labetalol oral
tamsulosin
Selective Beta-2-Adrenergic Agonists
albuterol sulfate inhalation solution for
nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
Anoro Ellipta
Breo Ellipta
Combivent Respimat
ipratropium-albuterol
levalbuterol tartrate ST
metaproterenol oral syrup
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
23
Drug Name Notes Requirements/Limits
Serevent Diskus
Stiolto Respimat
terbutaline oral
Ventolin HFA QL
Xopenex HFA ST
Selective Beta-Adrenergic Blocking
Agent
acebutolol
atenolol
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
Skeletal Muscle Relaxants,
Miscellaneous
Botox Specialty PA
Dysport Specialty PA
Myobloc Specialty PA
Xeomin Specialty PA
Blood Formation, Coagulation,
Thrombosis
Coumarin Derivatives
warfarin
Direct Factor Xa Inhibitors
Eliquis
Xarelto
Direct Thrombin Inhibitors
Pradaxa
Hematopoietic Agents
Aranesp (in polysorbate) Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
24
Drug Name Notes Requirements/Limits
Epogen injection solution 10,000 unit/mL, 2,000
unit/mL, 20,000 unit/2 mL, 20,000 unit/mL, 3,000
unit/mL, 4,000 unit/mL
Specialty PA
Granix Specialty PA
Leukine injection recon soln Specialty PA
Mozobil Specialty PA
Neulasta Specialty PA
Neupogen Specialty PA
Nplate Specialty PA
Procrit Specialty PA
Promacta Specialty PA
Zarxio Specialty PA
Hemorrheologic Agents
pentoxifylline
Hemostatics
Advate Specialty PA
Alphanate intravenous recon soln 1,000 (400
vWF) unit/10 mL, 1,500 (600 vWF) unit/10 mL,
250 (100 vWF) unit/5 mL, 500 (200 vWF) unit/5
mL
Specialty PA
AlphaNine SD Specialty PA
Amicar
aminocaproic acid intravenous Specialty PA
BeneFIX Specialty PA
Corifact Specialty PA
DDAVP nasal solution PA
desmopressin nasal spray,non-aerosol PA
desmopressin oral PA
Feiba NF Specialty PA
Hemofil M High Specialty PA
Hemofil M Low Specialty PA
Hemofil M Mid Specialty PA
Hemofil M Super High Specialty PA
Humate-P intravenous recon soln 1,000-2,400
unit Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
25
Drug Name Notes Requirements/Limits
Kogenate FS intravenous recon soln 2,000 (+/-)
unit, 3,000 (+/-) unit Specialty PA
Monoclate-P intravenous recon soln 1,000 (+/-)
unit Specialty PA
Novoseven RT Specialty PA
Profilnine Specialty PA
Recombinate intravenous recon soln 1,000 (+/-)
unit, 1,500 (+/-) unit, 250 (+/-) unit, 500 (+/-) unit Specialty PA
Xyntha Specialty PA
Xyntha Solofuse Specialty PA
Heparins
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe QL
heparin (porcine) in 5 % dex Specialty PA
heparin (porcine) in NaCl (PF) Specialty PA
heparin (porcine) injection solution
heparin, porcine (PF) injection solution 5,000
unit/0.5 mL
Iron Preparations
Atabex EC
Cadeau DHA
Daily Multivitamin with Iron
Daily Prenatal
FE C Plus
Feraheme Specialty PA
Ferrlecit Specialty PA
Infed
Injectafer
Multigen
Multigen Folic
Multigen Plus
Multi-Vit with Fluoride-Iron
Mynatal oral capsule
Mynatal Plus
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
26
Drug Name Notes Requirements/Limits
Mynatal-Z
Obstetrix DHA
Obstetrix EC
O-Cal FA
O-Cal Prenatal
One-A-Day Women's Prenatal 1
Prenatabs FA
Prenatal + DHA oral combo pack 28 mg iron-800
mcg-200 mg
Prenatal 19
Prenatal 19 (with docusate)
Prenatal Low Iron
Prenatal Multi-DHA (algal oil)
Prenatal Multi-DHA oral capsule 27 mg iron-800
mcg-228 mg
Prenatal Plus
Prenatal Plus DHA oral combo pack
prenatal vit-iron fum-folic ac
Se-Natal 19
Se-Natal 19 (with docusate)
TriAdvance
Trinatal Rx 1
Trinate
Triveen-Duo DHA
Tri-Vit with Fluoride and Iron
Venofer
Vinate GT
Vinate One
Vinate Ultra
Vol-Nate
Women's Prenatal + DHA
Platelet-Aggregation Inhibitors
aspirin oral tablet
aspirin oral tablet,chewable
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
27
Drug Name Notes Requirements/Limits
aspirin oral tablet,delayed release (DR/EC) 325
mg, 500 mg, 81 mg
aspirin rectal
aspirin-dipyridamole
butalbital-aspirin-caffeine oral capsule
cilostazol
clopidogrel
dipyridamole oral
prasugrel
Thrombolytic Agents
Activase intravenous recon soln 50 mg Specialty PA
aspirin oral tablet
aspirin oral tablet,chewable
aspirin oral tablet,delayed release (DR/EC) 325
mg, 500 mg, 81 mg
aspirin rectal
butalbital-aspirin-caffeine oral capsule
Cathflo Activase Specialty PA
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
carvedilol
doxazosin
labetalol oral
prazosin
terazosin
Alpha-Adrenergic Blocking
Agt.(Hypoten)
doxazosin
labetalol oral
prazosin
terazosin
Angiotensin Ii Receptor
Antagon.(Hypotn)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
28
Drug Name Notes Requirements/Limits
amlodipine-valsartan ST
Avalide oral tablet 150-12.5 mg ST
irbesartan ST
irbesartan-hydrochlorothiazide ST
losartan
losartan-hydrochlorothiazide
olmesartan ST
olmesartan-hydrochlorothiazide ST
telmisartan ST
valsartan ST
valsartan-hydrochlorothiazide ST
Angiotensin Ii Receptor Antagonists
amlodipine-valsartan ST
Avalide oral tablet 150-12.5 mg ST
Entresto
irbesartan ST
irbesartan-hydrochlorothiazide ST
losartan
losartan-hydrochlorothiazide
olmesartan ST
olmesartan-hydrochlorothiazide ST
telmisartan ST
valsartan ST
valsartan-hydrochlorothiazide ST
Angiotensin-Convert.Enzyme
Inhib(Hypotn)
amlodipine-benazepril
benazepril
benazepril-hydrochlorothiazide
captopril
captopril-hydrochlorothiazide
enalapril maleate
enalapril-hydrochlorothiazide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
29
Drug Name Notes Requirements/Limits
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Angiotensin-Converting Enzyme
Inhibitors
amlodipine-benazepril
benazepril
benazepril-hydrochlorothiazide
captopril
captopril-hydrochlorothiazide
enalapril maleate
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmics, Miscellaneous
Digox
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
30
Drug Name Notes Requirements/Limits
digoxin oral solution
magnesium sulfate injection Specialty PA
Antilipemic Agents, Miscellaneous
Juxtapid Specialty PA
Kynamro Specialty PA
niacin oral capsule, extended release 250 mg
niacin oral tablet 500 mg
niacin oral tablet extended release 24 hr ST
niacin oral tablet extended release 250 mg, 500
mg, 750 mg
Beta-Adrenergic Blocking Agents
acebutolol
atenolol
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
carvedilol
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
Sotalol AF oral tablet 160 mg, 80 mg
sotalol oral tablet 120 mg, 240 mg
timolol maleate oral
Beta-Adrenergic Blocking
Agt.(Hypoten)
acebutolol
atenolol
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
31
Drug Name Notes Requirements/Limits
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
Sotalol AF oral tablet 160 mg, 80 mg
sotalol oral tablet 120 mg, 240 mg
timolol maleate oral
Bile Acid Sequestrants
cholestyramine (with sugar)
Cholestyramine Light oral powder in packet
colestipol
Prevalite oral powder
WelChol
Calcium-Channel
Block.Agt,Misc(Hypoten)
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
diltiazem HCl oral tablet
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Calcium-Channel Blocking Agents
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
32
Drug Name Notes Requirements/Limits
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
diltiazem HCl oral tablet
felodipine
nicardipine oral
nifedipine
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Calcium-Channel Blocking
Agents(Hypoten)
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
diltiazem HCl oral tablet
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Calcium-Channel Blocking Agents,
Misc.
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
diltiazem HCl oral tablet
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
33
Drug Name Notes Requirements/Limits
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Carbonic Anhydrase
Inhibitors(Hypoten)
acetazolamide
Cardiotonic Agents
Digox
digoxin oral solution
Central Alpha-Agonists
clonidine
clonidine HCl oral tablet
Clorpres
guanfacine oral tablet
guanfacine oral tablet extended release 24 hr AL
methyldopa
methyldopa-hydrochlorothiazide
Class Ia Antiarrhythmics
disopyramide phosphate oral capsule
quinidine gluconate oral
quinidine sulfate oral tablet
Class Ib Antiarrhythmics
Dilantin
mexiletine
phenytoin oral suspension
phenytoin oral tablet,chewable
phenytoin sodium extended oral capsule 100 mg
Class Ic Antiarrhythmics
flecainide
propafenone oral tablet
Class Ii Antiarrhythmics
acebutolol
atenolol
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
34
Drug Name Notes Requirements/Limits
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
carvedilol
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
Sotalol AF oral tablet 160 mg, 80 mg
sotalol oral tablet 120 mg, 240 mg
timolol maleate oral
Class Iii Antiarrhythmics
amiodarone oral tablet 200 mg, 400 mg
Pacerone oral tablet 100 mg
Sotalol AF oral tablet 160 mg, 80 mg
sotalol oral tablet 120 mg, 240 mg
Class Iv Antiarrhythmics
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
diltiazem HCl oral tablet
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Dihydropyridines
amlodipine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
35
Drug Name Notes Requirements/Limits
amlodipine-benazepril
amlodipine-valsartan ST
felodipine
nicardipine oral
nifedipine
Dihydropyridines (Antihypertensive)
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
felodipine
nicardipine oral
nifedipine
Direct Vasodilators
BiDil
hydralazine oral
minoxidil oral
Diuretics, Miscellaneous (Hypotensive)
Theo-24
theophylline oral tablet extended release 12 hr
Fibric Acid Derivatives
fenofibrate micronized oral capsule 134 mg, 200
mg, 67 mg
fenofibrate nanocrystallized
fenofibrate oral tablet 160 mg, 54 mg
gemfibrozil
Hmg-Coa Reductase Inhibitors
atorvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5
mg
Hypotensive Agents, Miscellaneous
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
36
Drug Name Notes Requirements/Limits
acebutolol
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
carvedilol
doxazosin
felodipine
nicardipine oral
nifedipine
phenoxybenzamine
pindolol
propranolol oral
Sotalol AF oral tablet 160 mg, 80 mg
sotalol oral tablet 120 mg, 240 mg
terazosin
timolol maleate oral
Loop Diuretics (Hypotensive Agents)
bumetanide oral
furosemide oral
torsemide oral
Mineralocorticoid (Aldosterone)
Antagnts
Aldactazide oral tablet 50-50 mg
spironolactone
spironolacton-hydrochlorothiaz
Mineralocorticoid(Aldoster.)Antag(Hyp
ot)
Aldactazide oral tablet 50-50 mg
spironolactone
spironolacton-hydrochlorothiaz
Nitrates And Nitrites
BiDil
Isordil
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
37
Drug Name Notes Requirements/Limits
isosorbide dinitrate oral
isosorbide mononitrate
Nitro-Bid
Nitro-Dur transdermal patch 24 hour 0.3 mg/hr,
0.8 mg/hr
nitroglycerin oral capsule, extended release 2.5
mg, 6.5 mg
nitroglycerin sublingual tablet 0.4 mg
nitroglycerin transdermal patch 24 hour
Nitrostat sublingual tablet 0.3 mg, 0.6 mg
Nitro-Time oral capsule, extended release 9 mg
Pcsk9 Inhibitors
Praluent Pen Specialty PA
Repatha Pushtronex Specialty PA
Repatha SureClick Specialty PA
Repatha Syringe Specialty PA
Peripheral Adrenergic Inhibitors
reserpine oral tablet 0.25 mg
Phosphodiesterase Type 5 Inhibitors
Adcirca Specialty PA
cilostazol
Revatio intravenous Specialty PA
Revatio oral suspension for reconstitution Specialty PA
sildenafil (antihypertensive) oral Specialty PA
Potassium-Sparing Diuretics (Hypoten)
Aldactazide oral tablet 50-50 mg
amiloride
amiloride-hydrochlorothiazide
spironolactone
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid
Renin-Angioten.-Aldost. Sys. Inhib,
Misc
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
38
Drug Name Notes Requirements/Limits
Entresto
Thiazide Diuretics(Hypotensive Agents)
Aldactazide oral tablet 50-50 mg
amiloride-hydrochlorothiazide
Avalide oral tablet 150-12.5 mg ST
benazepril-hydrochlorothiazide
bisoprolol-hydrochlorothiazide
captopril-hydrochlorothiazide
chlorothiazide
Diuril
enalapril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide
irbesartan-hydrochlorothiazide ST
lisinopril-hydrochlorothiazide
losartan-hydrochlorothiazide
methyclothiazide
methyldopa-hydrochlorothiazide
metoprolol ta-hydrochlorothiaz
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
olmesartan-hydrochlorothiazide ST
propranolol-hydrochlorothiazid
quinapril-hydrochlorothiazide
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid
valsartan-hydrochlorothiazide ST
Thiazide-Like Diuretics(Hypotensive
Agt)
atenolol-chlorthalidone
chlorthalidone oral tablet 25 mg, 50 mg
Clorpres
indapamide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
39
Drug Name Notes Requirements/Limits
metolazone
Vasodilating Agents, Miscellaneous
Adempas Specialty PA
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
aspirin-dipyridamole
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
diltiazem HCl oral tablet
dipyridamole oral
epoprostenol (glycine) Specialty PA
felodipine
Letairis Specialty PA
nicardipine oral
nifedipine
Opsumit Specialty PA
Orenitram Specialty PA
Remodulin Specialty PA
Tracleer Specialty PA
Tyvaso Specialty PA
Tyvaso Refill Kit Specialty PA
Tyvaso Starter Kit Specialty PA
Uptravi Specialty PA
Veletri Specialty PA
Ventavis Specialty PA
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Cellular And Gene Therapy
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
40
Drug Name Notes Requirements/Limits
Cellular And Gene Therapy
Provenge Specialty PA
Cellular Therapy
Provenge Specialty PA
Central Nervous System Agents
Adamantanes (Cns)
amantadine HCl oral capsule
amantadine HCl oral solution
Amphetamines
dextroamphetamine oral capsule, extended release AL
dextroamphetamine oral tablet AL
dextroamphetamine-amphetamine AL
Vyvanse AL
Analgesics And Antipyretics, Misc.
acetaminophen oral elixir
acetaminophen oral liquid 160 mg/5 mL
acetaminophen oral suspension 160 mg/5 mL
acetaminophen oral tablet 500 mg
acetaminophen rectal
acetaminophen-codeine oral solution 120-12 mg/5
mL AL
acetaminophen-codeine oral tablet 300-15 mg,
300-60 mg QL; AL
acetaminophen-codeine oral tablet 300-30 mg AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen oral tablet 50-325 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
gabapentin oral capsule
gabapentin oral solution 250 mg/5 mL
gabapentin oral tablet 600 mg, 800 mg
hydrocodone-acetaminophen oral solution 7.5-
325 mg/15 mL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
41
Drug Name Notes Requirements/Limits
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg QL
Infant's Non-Aspirin oral drops
Non-Aspirin Jr Strength
oxycodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg QL
Prialt Specialty PA
tramadol-acetaminophen QL; AL
Anticholinergic Agents (Cns)
benztropine oral
trihexyphenidyl
Anticonvulsants, Miscellaneous
Banzel ST; AL
carbamazepine oral suspension 100 mg/5 mL
carbamazepine oral tablet
carbamazepine oral tablet extended release 12 hr
carbamazepine oral tablet,chewable
divalproex
gabapentin oral capsule
gabapentin oral solution 250 mg/5 mL
gabapentin oral tablet 600 mg, 800 mg
lamotrigine oral tablet
lamotrigine oral tablet, chewable dispersible
lamotrigine oral tablets,dose pack
levetiracetam intravenous Specialty PA
levetiracetam oral solution 100 mg/mL
levetiracetam oral tablet
magnesium sulfate injection Specialty PA
oxcarbazepine oral tablet
Sabril oral tablet Specialty PA
topiramate oral capsule, sprinkle
topiramate oral tablet
valproic acid
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
42
Drug Name Notes Requirements/Limits
valproic acid (as sodium salt) oral solution 250
mg/5 mL
vigabatrin Specialty PA
zonisamide
Antidepressants, Miscellaneous
bupropion HCl
bupropion HCl (smoking deter) QL
mirtazapine
Antimanic Agents
divalproex
lithium carbonate
lithium citrate oral solution 8 mEq/5 mL
valproic acid
valproic acid (as sodium salt) oral solution 250
mg/5 mL
Antimigraine Agents, Miscellaneous
aspirin oral tablet
aspirin oral tablet,chewable
aspirin oral tablet,delayed release (DR/EC) 325
mg, 500 mg, 81 mg
aspirin rectal
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
butalbital-aspirin-caffeine oral capsule
codeine-butalbital-ASA-caff
dihydroergotamine injection
divalproex
Ergomar
ergotamine-caffeine
Migranal QL
propranolol oral
timolol maleate oral
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
43
Drug Name Notes Requirements/Limits
tramadol-acetaminophen QL; AL
valproic acid
valproic acid (as sodium salt) oral solution 250
mg/5 mL
Antipsychotics, Miscellaneous
loxapine succinate AL
pimozide AL
Anxiolytics,Sedatives,And
Hypnotics,Misc
buspirone
droperidol injection solution AL
eszopiclone ST
hydroxyzine pamoate
meprobamate
promethazine oral
promethazine rectal
zaleplon
zolpidem oral tablet
Atypical Antipsychotics
Abilify Maintena Specialty PA
aripiprazole oral solution AL
aripiprazole oral tablet QL; AL
Aristada Specialty PA
clozapine QL; AL
Geodon intramuscular AL
Invega Sustenna Specialty PA
Invega Trinza Specialty PA
Latuda QL; AL
olanzapine intramuscular AL
olanzapine oral QL; AL
olanzapine-fluoxetine oral capsule 12-25 mg, 12-
50 mg, 3-25 mg, 6-25 mg QL; AL
olanzapine-fluoxetine oral capsule 6-50 mg AL
paliperidone QL; AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
44
Drug Name Notes Requirements/Limits
quetiapine QL; AL
Risperdal Consta Specialty PA
risperidone oral solution QL; AL
risperidone oral tablet QL; AL
risperidone oral tablet,disintegrating QL; AL
ziprasidone HCl QL; AL
Zyprexa Relprevv Specialty PA
Barbiturates (Anticonvulsants)
phenobarbital
primidone
Barbiturates (Anxiolytic, Sedative/Hyp)
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen oral tablet 50-325 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
butalbital-aspirin-caffeine oral capsule
codeine-butalbital-ASA-caff
phenobarbital
Benzodiazepines (Anticonvulsants)
clonazepam oral tablet
clorazepate dipotassium
Diazepam Intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal QL
lorazepam oral
Benzodiazepines
(Anxiolytic,Sedativ/Hyp)
alprazolam oral tablet
amitriptyline-chlordiazepoxide
chlordiazepoxide HCl
clonazepam oral tablet
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
45
Drug Name Notes Requirements/Limits
clorazepate dipotassium
Diazepam Intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal QL
estazolam
lorazepam oral
oxazepam
temazepam oral capsule 15 mg, 30 mg
triazolam
Butyrophenones
haloperidol AL
haloperidol decanoate AL
haloperidol lactate injection AL
haloperidol lactate oral AL
Central Nervous System Agents, Misc.
atomoxetine AL
Austedo Specialty PA
guanfacine oral tablet
guanfacine oral tablet extended release 24 hr AL
Ingrezza Specialty PA
memantine oral tablet AL
memantine oral tablets,dose pack
Radicava Specialty PA
riluzole
Xenazine Specialty PA
Cyclooxygenase-2 (Cox-2) Inhibitors
celecoxib QL
Dopamine Precursors
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet extended release
Ergot-Deriv. Dopamine Receptor
Agonists
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
46
Drug Name Notes Requirements/Limits
bromocriptine
cabergoline ST
Fibromyalgia Agents
duloxetine oral capsule,delayed release(DR/EC)
20 mg, 30 mg
duloxetine oral capsule,delayed release(DR/EC)
60 mg QL
Savella
Hydantoins
Dilantin
phenytoin oral suspension
phenytoin oral tablet,chewable
phenytoin sodium extended oral capsule 100 mg
Monoamine Oxidase B Inhibitors
selegiline HCl
Monoamine Oxidase Inhibitors
phenelzine
selegiline HCl
tranylcypromine
Nonergot-Deriv.Dopamine Receptor
Agonist
APOKYN Specialty PA
pramipexole oral tablet
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
Opiate Agonists
acetaminophen-codeine oral solution 120-12 mg/5
mL AL
acetaminophen-codeine oral tablet 300-15 mg,
300-60 mg QL; AL
acetaminophen-codeine oral tablet 300-30 mg AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
codeine sulfate oral tablet AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
47
Drug Name Notes Requirements/Limits
codeine-butalbital-ASA-caff
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr QL
hydrocodone-acetaminophen oral solution 7.5-
325 mg/15 mL
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg QL
hydromorphone oral liquid
hydromorphone oral tablet QL
hydromorphone rectal
meperidine oral solution
meperidine oral tablet QL
morphine concentrate oral solution
morphine oral solution
morphine oral tablet QL
morphine oral tablet extended release QL
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet QL
oxycodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg QL
tramadol oral tablet QL; AL
tramadol-acetaminophen QL; AL
Opiate Antagonists
naltrexone
Narcan nasal spray,non-aerosol 4 mg/actuation QL
Vivitrol QL
Opiate Partial Agonists
buprenorphine HCl sublingual QL; AL
buprenorphine-naloxone QL; AL
butorphanol tartrate nasal PA; QL
nalbuphine
Other Nonsteroidal Anti-Inflam. Agents
diclofenac potassium
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
48
Drug Name Notes Requirements/Limits
diclofenac sodium oral
diclofenac sodium topical gel 1 % ST
diflunisal
etodolac oral capsule
etodolac oral tablet
fenoprofen oral tablet
Ibuprofen IB oral tablet
ibuprofen oral suspension
ibuprofen oral tablet 100 mg, 400 mg, 600 mg,
800 mg
indomethacin oral capsule
ketoprofen oral capsule
ketorolac oral QL
meclofenamate
meloxicam oral tablet
nabumetone
naproxen
naproxen sodium oral capsule
naproxen sodium oral tablet
oxaprozin
piroxicam
sulindac
Phenothiazines
chlorpromazine AL
fluphenazine decanoate AL
fluphenazine HCl injection AL
fluphenazine HCl oral tablet AL
perphenazine AL
perphenazine-amitriptyline AL
prochlorperazine AL
prochlorperazine Edisylate AL
prochlorperazine maleate AL
thioridazine
trifluoperazine AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
49
Drug Name Notes Requirements/Limits
Respiratory And Cns Stimulants
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
butalbital-aspirin-caffeine oral capsule
caffeine citrate oral
codeine-butalbital-ASA-caff
dexmethylphenidate AL
methylphenidate HCl oral capsule, ER biphasic
30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60
mg
AL
methylphenidate HCl oral solution 10 mg/5 mL AL
methylphenidate HCl oral tablet AL
methylphenidate HCl oral tablet extended release
20 mg AL
methylphenidate HCl oral tablet extended release
24hr 18 mg, 27 mg, 36 mg, 54 mg AL
Salicylates
aspirin oral tablet
aspirin oral tablet,chewable
aspirin oral tablet,delayed release (DR/EC) 325
mg, 500 mg, 81 mg
aspirin rectal
aspirin-dipyridamole
butalbital-aspirin-caffeine oral capsule
choline,magnesium salicylate
codeine-butalbital-ASA-caff
salsalate
Sel.Serotonin,Norepi Reuptake
Inhibitor
duloxetine oral capsule,delayed release(DR/EC)
20 mg, 30 mg, 60 mg QL
Savella
venlafaxine oral capsule,extended release 24hr
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
50
Drug Name Notes Requirements/Limits
venlafaxine oral tablet
Selective Serotonin Agonists
Imitrex nasal spray,non-aerosol 5 mg/actuation QL
naratriptan
rizatriptan QL
sumatriptan nasal spray,non-aerosol 20
mg/actuation QL
sumatriptan succinate oral QL
sumatriptan succinate subcutaneous cartridge QL
sumatriptan succinate subcutaneous pen injector QL
sumatriptan succinate subcutaneous solution QL
Selective-Serotonin Reuptake Inhibitors
citalopram
escitalopram oxalate oral tablet
fluoxetine oral capsule
fluoxetine oral solution
fluvoxamine oral tablet
olanzapine-fluoxetine oral capsule 12-25 mg, 12-
50 mg, 3-25 mg, 6-25 mg QL; AL
olanzapine-fluoxetine oral capsule 6-50 mg AL
paroxetine HCl oral tablet
sertraline oral concentrate
sertraline oral tablet QL
Serotonin Modulators
nefazodone
trazodone
Succinimides
ethosuximide
Thioxanthenes
thiothixene AL
Tricyclics, Other Norepi-Ru Inhibitors
amitriptyline
amitriptyline-chlordiazepoxide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
51
Drug Name Notes Requirements/Limits
amoxapine
clomipramine
desipramine
doxepin oral
imipramine HCl
maprotiline
nortriptyline
perphenazine-amitriptyline AL
Vesicular Monoamine Transport2
Inhibitor
Austedo Specialty PA
Ingrezza Specialty PA
Xenazine Specialty PA
Contraceptives (E.G. Foams, Devices)
Contraceptives (E.G. Foams, Devices)
Vaginal Contraceptive Foam
Devices
Devices
Accu-Chek Aviva Control Soln
Accu-Chek FastClix QL
Accu-Chek FastClix kit
Accu-Chek Guide Glucose Meter QL
Accu-Chek Guide L1-L2 Ctrl Sol
Accu-Chek Multiclix Lancet QL
Accu-Chek Multiclix Lancet kit
Accu-Chek SmartView Contrl Sol
Accu-Chek Soft Dev Lancets
Accu-Chek Softclix Lancet Dev
Accu-Chek Softclix Lancets
Aerochamber Plus Flow-Vu
Euflexxa Specialty PA
Gel-One Specialty PA
Gelsyn-3 Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
52
Drug Name Notes Requirements/Limits
GenVisc 850 Specialty PA
heparin (porcine) in NaCl (PF) Specialty PA
Hyalgan Specialty PA
Insulin Syringe syringe 0.5 mL 29 gauge x 1/2"
lancets
Monovisc Specialty PA
ORTHOVISC Specialty PA
pen needle, diabetic needle 29 gauge x 1/2"
sodium chloride inhalation solution for
nebulization 0.9 % QL
Soft Touch Lancets
Solesta Specialty PA
Supartz FX Specialty PA
Synvisc Specialty PA
Synvisc-One Specialty PA
Diagnostic Agents
Adrenocortical Insufficiency
Acthar H.P. Specialty PA
cosyntropin injection Specialty PA
Diabetes Mellitus
Accu-Chek Aviva Plus test strp QL
Accu-Chek Guide QL
Accu-Chek SmartView Test Strip QL
Thyroid Function
Thyrogen Specialty PA
Electrolytic, Caloric, And Water
Balance
Alkalinizing Agents
Oracit
potassium citrate oral tablet extended release 10
mEq (1,080 mg), 5 mEq (540 mg)
sodium citrate-citric acid
Ammonia Detoxicants
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
53
Drug Name Notes Requirements/Limits
Carbaglu Specialty PA
lactulose oral solution 10 gram/15 mL
Caloric Agents
Clinisol SF 15 % Specialty PA
D5 %-0.45 % sodium chloride Specialty PA
dextrose 70 % in water (D70W) Specialty PA
Intralipid intravenous emulsion 20 % Specialty PA
Liposyn III intravenous emulsion 10 %, 30 % Specialty PA
Prosol 20 % Specialty PA
Travasol 10 % Specialty PA
TrophAmine 10 % Specialty PA
Carbonic Anhydrase Inhibitors
acetazolamide
Diuretics, Miscellaneous
Theo-24
theophylline oral tablet extended release 12 hr
Loop Diuretics
bumetanide oral
furosemide oral
torsemide oral
Phosphate-Removing Agents
calcium acetate oral capsule
sevelamer carbonate oral tablet
Potassium-Removing Agents
sodium polystyrene (sorb free)
SPS (with sorbitol) rectal
Potassium-Sparing Diuretics
Aldactazide oral tablet 50-50 mg
amiloride
amiloride-hydrochlorothiazide
spironolactone
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
54
Drug Name Notes Requirements/Limits
Replacement Preparations
Atabex EC
Daily Prenatal
Klor-Con
Mynatal oral capsule
Mynatal Plus
Mynatal-Z
O-Cal FA
O-Cal Prenatal
One-A-Day Women's Prenatal 1
potassium bicarb-citric acid
potassium chloride oral capsule, extended release
10 mEq
potassium chloride oral liquid
potassium chloride oral tablet extended release 10
mEq, 8 mEq
potassium chloride oral tablet,ER
particles/crystals
Prenatabs FA
Prenatal Low Iron
Prenatal Plus
prenatal vit-iron fum-folic ac
sodium chloride inhalation solution for
nebulization 0.9 % QL
TPN Electrolytes Specialty PA
TPN Electrolytes II Specialty PA
TriAdvance
Trinatal Rx 1
Trinate
Triveen-Duo DHA
Vinate One
Vinate Ultra
Vol-Nate
Thiazide Diuretics
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
55
Drug Name Notes Requirements/Limits
Aldactazide oral tablet 50-50 mg
amiloride-hydrochlorothiazide
Avalide oral tablet 150-12.5 mg ST
benazepril-hydrochlorothiazide
bisoprolol-hydrochlorothiazide
captopril-hydrochlorothiazide
chlorothiazide
Diuril
enalapril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide
irbesartan-hydrochlorothiazide ST
lisinopril-hydrochlorothiazide
losartan-hydrochlorothiazide
methyclothiazide
methyldopa-hydrochlorothiazide
metoprolol ta-hydrochlorothiaz
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
olmesartan-hydrochlorothiazide ST
propranolol-hydrochlorothiazid
quinapril-hydrochlorothiazide
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid
valsartan-hydrochlorothiazide ST
Thiazide-Like Diuretics
atenolol-chlorthalidone
chlorthalidone oral tablet 25 mg, 50 mg
Clorpres
indapamide
metolazone
Uricosuric Agents
probenecid
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
56
Drug Name Notes Requirements/Limits
probenecid-colchicine
Vasopressin Antagonists
Samsca Specialty PA
Enzymes
Enzymes
Activase intravenous recon soln 50 mg Specialty PA
Adagen Specialty PA
Aldurazyme Specialty PA
Cathflo Activase Specialty PA
Cerezyme intravenous recon soln 400 unit Specialty PA
Elaprase Specialty PA
Elelyso Specialty PA
Elitek Specialty PA
Fabrazyme Specialty PA
Lumizyme Specialty PA
Naglazyme Specialty PA
Pulmozyme Specialty PA
Sucraid Specialty PA
Voraxaze Specialty PA
VPRIV Specialty PA
Xiaflex Specialty PA
Eye, Ear, Nose And Throat (Eent)
Preps.
Alpha-Adrenergic Agonists (Eent)
brimonidine
Antiallergic Agents
azelastine nasal
azelastine ophthalmic (eye) ST; QL
cromolyn ophthalmic (eye)
ketotifen fumarate
olopatadine ophthalmic (eye) drops 0.1 % ST; QL
Antibacterials (Eent)
bacitracin-polymyxin B ophthalmic (eye)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
57
Drug Name Notes Requirements/Limits
Ciprodex
ciprofloxacin HCl ophthalmic (eye)
doxycycline hyclate oral tablet 20 mg
erythromycin ophthalmic (eye)
Gentak ophthalmic (eye) ointment
gentamicin ophthalmic (eye) drops
Moxeza
moxifloxacin ophthalmic (eye)
neomycin-bacitracin-poly-HC
neomycin-bacitracin-polymyxin
neomycin-polymyxin B-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-HC
ofloxacin ophthalmic (eye)
ofloxacin otic (ear)
polymyxin B sulf-trimethoprim
sulfacetamide sodium ophthalmic (eye) drops
sulfacetamide-prednisolone
tobramycin
tobramycin-dexamethasone
Tobrex ophthalmic (eye) ointment
Antivirals (Eent)
trifluridine
Beta-Adrenergic Blocking Agents (Eent)
carteolol
dorzolamide-timolol QL
levobunolol ophthalmic (eye) drops 0.5 %
metipranolol
timolol maleate ophthalmic (eye) drops
timolol maleate ophthalmic (eye) gel forming
solution
Carbonic Anhydrase Inhibitors (Eent)
acetazolamide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
58
Drug Name Notes Requirements/Limits
Azopt
dorzolamide
dorzolamide-timolol QL
Corticosteroids (Eent)
Ciprodex
dexamethasone sodium phosphate ophthalmic
(eye)
Flarex
fluorometholone
fluticasone nasal
FML Forte
FML S.O.P.
hydrocortisone-acetic acid
Maxidex
neomycin-bacitracin-poly-HC
neomycin-polymyxin B-dexameth
neomycin-polymyxin-HC ophthalmic (eye)
Ozurdex Specialty PA
Pred Mild
prednisolone acetate
prednisolone sodium phosphate ophthalmic (eye)
Retisert Specialty PA
tobramycin-dexamethasone
Eent Anti-Infectives, Miscellaneous
acetic acid otic (ear)
chlorhexidine gluconate mucous membrane
hydrocortisone-acetic acid
Eent Anti-Inflammatory Agents, Misc.
Restasis ST
Restasis MultiDose ST
Xiidra ST
Eent Drugs, Miscellaneous
apraclonidine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
59
Drug Name Notes Requirements/Limits
Eylea Specialty PA
Iopidine ophthalmic (eye) dropperette
ipratropium bromide nasal
Lucentis intravitreal solution 0.3 mg/0.05 mL Specialty PA
Lucentis intravitreal syringe Specialty PA
Macugen Specialty PA
Visudyne Specialty PA
Eent Nonsteroidal Anti-Inflam. Agents
diclofenac sodium ophthalmic (eye)
flurbiprofen sodium
ketorolac ophthalmic (eye)
Local Anesthetics (Eent)
lidocaine HCl mucous membrane jelly in
applicator
lidocaine HCl mucous membrane solution 4 %
(40 mg/mL)
Lidocaine Viscous
proparacaine
tetracaine HCl
tetracaine HCl (PF) ophthalmic (eye)
Miotics
Phospholine Iodide
pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %,
4 %
Mydriatics
atropine ophthalmic (eye)
cyclopentolate ophthalmic (eye) drops 1 %, 2 %
tropicamide
Prostaglandin Analogs
latanoprost
Vasoconstrictors
phenylephrine HCl ophthalmic (eye)
Gastrointestinal Drugs
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
60
Drug Name Notes Requirements/Limits
5-Ht3 Receptor Antagonists
granisetron (PF) Specialty PA
granisetron HCl intravenous Specialty PA
granisetron HCl oral ST
ondansetron QL
ondansetron HCl (PF) injection solution Specialty PA
ondansetron HCl intravenous Specialty PA
ondansetron HCl oral solution QL
ondansetron HCl oral tablet 4 mg, 8 mg QL
palonosetron Specialty PA
Antidiarrhea Agents
diphenoxylate-atropine
loperamide oral capsule
Antiemetics, Miscellaneous
Diclegis PA
Antihistamines (Gi Drugs)
Diclegis PA
meclizine oral tablet 12.5 mg, 25 mg
prochlorperazine AL
prochlorperazine Edisylate AL
prochlorperazine maleate AL
trimethobenzamide oral
Anti-Inflammatory Agents (Gi Drugs)
balsalazide
Canasa
Delzicol oral capsule (with del rel tablets)
Dipentum
mesalamine oral tablet,delayed release (DR/EC)
1.2 gram
mesalamine rectal
Pentasa
sulfasalazine
Cathartics And Laxatives
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
61
Drug Name Notes Requirements/Limits
Amitiza
Atabex EC
Obstetrix EC
peg 3350-electrolytes
peg-electrolyte soln
polyethylene glycol 3350 oral powder
Se-Natal 19 (with docusate)
Vinate Ultra
Cholelitholytic Agents
ursodiol
Digestants
Creon
Zenpep oral capsule,delayed release(DR/EC)
10,000-32,000 -42,000 unit, 20,000-63,000-
84,000 unit, 25,000-79,000- 105,000 unit, 25,000-
85,000- 136,000 unit, 3,000-10,000- 16,000 unit,
40,000-126,000- 168,000 unit, 5,000-17,000 -
27,000 unit, 5,000-17,000- 24,000 unit
Gi Drugs, Miscellaneous
Cimzia Specialty PA
Cimzia Powder for Reconst Specialty PA
Endari Specialty PA
Entyvio Specialty PA
Gattex 30-Vial Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40
mg/0.4 mL
Specialty PA
Humira Pen Crohn's-UC-HS Start Specialty PA
Humira Pen subcutaneous pen injector kit 40
mg/0.4 mL Specialty PA
Inflectra Specialty PA
Linzess oral capsule 145 mcg, 290 mcg AL
Ocaliva Specialty PA
Remicade Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
62
Drug Name Notes Requirements/Limits
Renflexis Specialty PA
Histamine H2-Antagonists
cimetidine
cimetidine HCl oral
famotidine oral
nizatidine
ranitidine HCl injection solution 50 mg/2 mL (25
mg/mL) Specialty PA
ranitidine HCl oral syrup
ranitidine HCl oral tablet
Neurokinin-1 Receptor Antagonists
aprepitant oral capsule 80 mg
aprepitant oral capsule,dose pack
Emend oral capsule 125 mg
Emend oral capsule 40 mg QL
Prokinetic Agents
metoclopramide HCl oral solution
metoclopramide HCl oral tablet
Prostaglandins
misoprostol
Protectants
sucralfate oral tablet
Proton-Pump Inhibitors
esomeprazole magnesium ST; QL
lansoprazole oral capsule,delayed release(DR/EC) ST; QL
Nexium 24HR oral tablet,delayed release
(DR/EC) ST; QL
omeprazole oral capsule,delayed release(DR/EC) QL
omeprazole-sodium bicarbonate oral capsule 20-
1.1 mg-gram ST; QL
pantoprazole oral QL
Prilosec oral susp,delayed release for recon QL; AL
Gold Compounds
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
63
Drug Name Notes Requirements/Limits
Gold Compounds
Ridaura
Heavy Metal Antagonists
Heavy Metal Antagonists
Chemet
deferoxamine Specialty PA
Exjade Specialty PA
Ferriprox oral tablet Specialty PA
Galzin Specialty PA
Jadenu Specialty PA
Jadenu Sprinkle Specialty PA
trientine Specialty PA
Hormones And Synthetic Substitutes
Adrenals
ArmonAir RespiClick
Arnuity Ellipta
Asmanex HFA
Asmanex Twisthaler QL
Breo Ellipta
budesonide inhalation QL; AL
cortisone
dexamethasone
Dexamethasone Intensol
dexamethasone sodium phos (PF)
dexamethasone sodium phosphate injection
solution
Emflaza Specialty PA
Flovent Diskus QL
Flovent HFA QL
fludrocortisone
hydrocortisone oral
Intrarosa
Medrol oral tablet 2 mg
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
64
Drug Name Notes Requirements/Limits
methylprednisolone
methylprednisolone sodium succ intravenous Specialty PA
prednisolone oral solution 15 mg/5 mL
prednisolone sodium phosphate oral solution 15
mg/5 mL (3 mg/mL), 5 mg base/5 mL (6.7 mg/5
mL)
prednisone
Prednisone Intensol
Pulmicort Flexhaler
Qvar QL
Qvar RediHaler QL
Solu-Cortef (PF) injection recon soln 100 mg/2
mL
Androgens
danazol PA
testosterone PA
testosterone cypionate QL
testosterone enanthate QL
Antidiabetic Agents, Miscellaneous
WelChol
Antiestrogens
anastrozole
exemestane Specialty PA
letrozole QL
Antigonadtropins
Firmagon kit w diluent syringe subcutaneous
recon soln 80 mg Specialty PA
Firmagon subcutaneous recon soln 120 mg Specialty PA
Antiparathyroid Agents
calcitonin (salmon)
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg
propylthiouracil
SSKI
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
65
Drug Name Notes Requirements/Limits
Biguanides
alogliptin-metformin ST
glipizide-metformin
glyburide-metformin
Janumet ST
Janumet XR ST
metformin oral tablet
metformin oral tablet extended release 24 hr
pioglitazone-metformin ST
Segluromet ST
Contraceptives
Aftera
Aranelle (28)
Balziva (28)
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
EContra EZ
Ella
ethynodiol diac-eth estradiol oral tablet 1-50 mg-
mcg
Kyleena
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg, 0.15-0.03 mg
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month
levonorg-eth estrad triphasic
Liletta
Low-Ogestrel (28)
Microgestin 1.5/30 (21)
Microgestin Fe 1.5/30 (28)
Mirena
My Way
Nexplanon
norethindrone (contraceptive)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
66
Drug Name Notes Requirements/Limits
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg
norethindrone-e.estradiol-iron oral tablet 1 mg-20
mcg (21)/75 mg (7)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-
mcg
norgestrel-ethinyl estradiol
Nortrel 0.5/35 (28)
Nortrel 1/35 (21)
Nortrel 7/7/7 (28)
NuvaRing
ParaGard T 380A
Skyla
Velivet Triphasic Regimen (28)
Xulane
Zovia 1/35E (28)
Dipeptidyl Peptidase-4(Dpp-4)
Inhibitors
alogliptin ST
alogliptin-metformin ST
alogliptin-pioglitazone ST
Janumet ST
Janumet XR ST
Januvia ST
Estrogen Agonist-Antagonists
Fareston PA
raloxifene
tamoxifen
Estrogens
estradiol oral
estradiol transdermal patch semiweekly
estradiol transdermal patch weekly 0.025 mg/24
hr, 0.075 mg/24 hr QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
67
Drug Name Notes Requirements/Limits
estradiol transdermal patch weekly 0.0375 mg/24
hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.1 mg/24 hr
estropipate oral tablet 0.75 mg, 1.5 mg
Femhrt Low Dose
Jinteli
Menest oral tablet 0.3 mg, 0.625 mg, 1.25 mg
Premarin oral
Premarin vaginal
Premphase
Prempro
Glycogenolytic Agents
Glucagon Emergency Kit (human) QL
Gonadotropins
Eligard Specialty PA
Eligard (3 month) Specialty PA
Eligard (4 month) Specialty PA
Eligard (6 month) Specialty PA
leuprolide subcutaneous kit Specialty PA
Lupron Depot Specialty PA
Lupron Depot (3 month) Specialty PA
Lupron Depot (4 month) Specialty PA
Lupron Depot (6 Month) Specialty PA
Lupron Depot-Ped Specialty PA
Lupron Depot-Ped (3 month) Specialty PA
Supprelin LA Specialty PA
Synarel Specialty PA
Trelstar Specialty PA
Vantas Specialty PA
Zoladex Specialty PA
Gonadotropins And Antigonadotropins
Eligard Specialty PA
Eligard (3 month) Specialty PA
Eligard (4 month) Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
68
Drug Name Notes Requirements/Limits
Eligard (6 month) Specialty PA
leuprolide subcutaneous kit Specialty PA
Lupron Depot Specialty PA
Lupron Depot (3 month) Specialty PA
Lupron Depot (4 month) Specialty PA
Lupron Depot (6 Month) Specialty PA
Lupron Depot-Ped Specialty PA
Lupron Depot-Ped (3 month) Specialty PA
Supprelin LA Specialty PA
Synarel Specialty PA
Vantas Specialty PA
Zoladex Specialty PA
Incretin Mimetics
Ozempic
Trulicity
Victoza 2-Pak
Victoza 3-Pak
Insulins
Admelog SoloStar U-100 Insulin QL
Admelog U-100 Insulin lispro QL
Basaglar KwikPen U-100 Insulin QL
Humalog Junior KwikPen U-100 QL
Humalog Mix 50-50 Insuln U-100 QL
Humalog Mix 50-50 KwikPen QL
Humalog Mix 75-25 KwikPen QL
Humalog Mix 75-25(U-100)Insuln QL
Humulin 70/30 U-100 Insulin QL
Humulin 70/30 U-100 KwikPen QL
Humulin N NPH Insulin KwikPen QL
Humulin N NPH U-100 Insulin QL
Humulin R Regular U-100 Insuln QL
Humulin R U-500 (Conc) Insulin QL
Novolin 70/30 U-100 Insulin QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
69
Drug Name Notes Requirements/Limits
Novolin N NPH U-100 Insulin QL
Novolin R Regular U-100 Insuln QL
Novolog Mix 70-30 U-100 Insuln QL
Novolog Mix 70-30FlexPen U-100 QL
Parathyroid Agents
Forteo Specialty PA
Tymlos Specialty PA
Parathyroid And Antiparathyroid
Agents
calcitonin (salmon)
Forteo Specialty PA
Tymlos Specialty PA
Pituitary
Acthar H.P. Specialty PA
DDAVP nasal solution PA
desmopressin nasal spray,non-aerosol PA
desmopressin oral PA
Genotropin Specialty PA
Genotropin MiniQuick Specialty PA
Humatrope Specialty PA
Norditropin FlexPro Specialty PA
Nutropin AQ Nuspin Specialty PA
Omnitrope Specialty PA
Saizen click.easy Specialty PA
Saizen subcutaneous recon soln 8.8 mg Specialty PA
Serostim subcutaneous recon soln 4 mg, 5 mg, 6
mg Specialty PA
Progestins
Crinone
Depo-Provera intramuscular suspension 400
mg/mL
Femhrt Low Dose
hydroxyprogesterone capr(bulk)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
70
Drug Name Notes Requirements/Limits
hydroxyprogesterone caproate
Jinteli
Makena
Makena (PF)
medroxyprogesterone
megestrol oral suspension 400 mg/10 mL (40
mg/mL)
megestrol oral suspension 625 mg/5 mL QL
megestrol oral tablet
norethindrone acetate
progesterone micronized
Sodium-Gluc Cotransport 2 (Sglt2)
Inhib
Segluromet ST
Steglatro ST
Somatostatin Agonists
octreotide acetate Specialty PA
Signifor Specialty PA
Somatuline Depot Specialty PA
Somatotropin Agonists
Increlex Specialty PA
Somatotropin Antagonists
Somavert subcutaneous recon soln 15 mg, 20 mg Specialty PA
Sulfonylureas
chlorpropamide
glimepiride
glipizide
glipizide-metformin
glyburide
glyburide micronized
glyburide-metformin
tolazamide
tolbutamide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
71
Drug Name Notes Requirements/Limits
Thiazolidinediones
alogliptin-pioglitazone ST
pioglitazone ST
pioglitazone-metformin ST
Thyroid Agents
Armour Thyroid oral tablet 180 mg, 240 mg, 30
mg, 300 mg, 60 mg, 90 mg
levothyroxine oral
liothyronine oral
Nature-Throid oral tablet 130 mg, 16.25 mg, 195
mg, 32.5 mg, 65 mg
NP Thyroid oral tablet 15 mg
thyroid (pork) oral tablet 120 mg
Thyrolar-1
Thyrolar-1/2
Thyrolar-1/4
Thyrolar-2
Thyrolar-3
Miscellaneous Therapeutic Agents
5-Alpha-Reductase Inhibitors
dutasteride
finasteride oral tablet 5 mg
Alcohol Deterrents
disulfiram
naltrexone
Vivitrol QL
Antidotes
Chemet
deferoxamine Specialty PA
Glucagon Emergency Kit (human) QL
leucovorin calcium injection recon soln Specialty PA
leucovorin calcium oral
levoleucovorin Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
72
Drug Name Notes Requirements/Limits
magnesium sulfate injection Specialty PA
Mephyton
Narcan nasal spray,non-aerosol 4 mg/actuation QL
sevelamer carbonate oral tablet
sodium polystyrene (sorb free)
SPS (with sorbitol) rectal
SSKI
Voraxaze Specialty PA
Antigout Agents
allopurinol
colchicine oral tablet ST; QL
indomethacin oral capsule
Krystexxa Specialty PA
naproxen
naproxen sodium oral capsule
naproxen sodium oral tablet
probenecid
probenecid-colchicine
Antisense Oligonucleotides
Kynamro Specialty PA
Spinraza (PF) Specialty PA
Bone Resorption Inhibitors
alendronate oral tablet
calcitonin (salmon)
etidronate disodium
ibandronate intravenous syringe Specialty PA
pamidronate Specialty PA
Prolia Specialty PA
raloxifene
Xgeva Specialty PA
zoledronic acid Specialty PA
zoledronic acid-mannitol-water Specialty PA
Zometa intravenous piggyback Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
73
Drug Name Notes Requirements/Limits
Cariostatic Agents
fluoride (sodium) oral drops AL
fluoride (sodium) oral tablet,chewable AL
Fluoridex Daily Defense dental paste AL
Multi-Vit with Fluoride-Iron
Multivitamin With Fluoride
Multi-Vitamin With Fluoride oral drops
Multi-Vitamin With Fluoride oral tablet,chewable
0.25 mg, 1 mg
Multivitamins With Fluoride oral tablet,chewable
1 mg
PreviDent dental solution
SF AL
SF 5000 Plus AL
Tri-Vit with Fluoride and Iron
Tri-Vitamin With Fluoride
Complement Inhibitors
Berinert intravenous kit Specialty PA
Cinryze Specialty PA
Firazyr Specialty PA
Haegarda Specialty PA
Kalbitor Specialty PA
Soliris Specialty PA
Disease-Modifying Antirheumatic
Agents
Actemra Specialty PA
azathioprine
Cimzia Specialty PA
Cimzia Powder for Reconst Specialty PA
cyclosporine intravenous Specialty PA
cyclosporine modified oral capsule
cyclosporine oral capsule
Enbrel Specialty PA
Enbrel Mini Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
74
Drug Name Notes Requirements/Limits
Enbrel SureClick Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL Specialty PA
Humira Pen Crohn's-UC-HS Start Specialty PA
Humira Pen subcutaneous pen injector kit 40
mg/0.4 mL Specialty PA
hydroxychloroquine
Inflectra Specialty PA
Kevzara Specialty PA
Kineret Specialty PA
leflunomide
methotrexate sodium
methotrexate sodium (PF)
Orencia Specialty PA
Orencia (with maltose) Specialty PA
Orencia ClickJect Specialty PA
Otezla Specialty PA
Otezla Starter Specialty PA
Remicade Specialty PA
Renflexis Specialty PA
Ridaura
Sandimmune intravenous Specialty PA
Sandimmune oral solution
Simponi Specialty PA
Simponi ARIA Specialty PA
Stelara intravenous Specialty PA
Stelara subcutaneous syringe Specialty PA
sulfasalazine
Trexall oral tablet 7.5 mg
Xeljanz Specialty PA
Xeljanz XR Specialty PA
Gonadotropin-Releasing Hormone
Antagnts
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
75
Drug Name Notes Requirements/Limits
Firmagon kit w diluent syringe subcutaneous
recon soln 80 mg Specialty PA
Firmagon subcutaneous recon soln 120 mg Specialty PA
Immunomodulatory Agents
Actemra Specialty PA
Actimmune Specialty PA
Aubagio Specialty PA
Avonex (with albumin) Specialty PA
Avonex intramuscular pen injector kit Specialty PA
Avonex intramuscular syringe kit Specialty PA
azathioprine
Betaseron Specialty PA
Cimzia Specialty PA
Cimzia Powder for Reconst Specialty PA
Copaxone subcutaneous syringe Specialty PA
cyclosporine intravenous Specialty PA
cyclosporine modified oral capsule
cyclosporine oral capsule
Enbrel Specialty PA
Enbrel Mini Specialty PA
Enbrel SureClick Specialty PA
Entyvio Specialty PA
Extavia Specialty PA
Gilenya Specialty PA
glatiramer Specialty PA
Glatopa subcutaneous syringe 20 mg/mL Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40
mg/0.4 mL
Specialty PA
Humira Pen Crohn's-UC-HS Start Specialty PA
Humira Pen subcutaneous pen injector kit 40
mg/0.4 mL Specialty PA
hydroxychloroquine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
76
Drug Name Notes Requirements/Limits
Inflectra Specialty PA
Intron A injection Specialty PA
Kevzara Specialty PA
Kineret Specialty PA
leflunomide
Lemtrada Specialty PA
methotrexate sodium
methotrexate sodium (PF)
Ocrevus Specialty PA
Orencia Specialty PA
Orencia (with maltose) Specialty PA
Orencia ClickJect Specialty PA
Plegridy Specialty PA
Pomalyst Specialty PA
Proleukin Specialty PA
Rebif (with albumin) Specialty PA
Rebif Titration Pack Specialty PA
Remicade Specialty PA
Renflexis Specialty PA
Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25
mg, 5 mg Specialty PA
Ridaura
Sandimmune intravenous Specialty PA
Sandimmune oral solution
Simponi Specialty PA
Simponi ARIA Specialty PA
Stelara intravenous Specialty PA
Stelara subcutaneous syringe Specialty PA
sulfasalazine
Tecfidera Specialty PA
Thalomid Specialty PA
Trexall oral tablet 7.5 mg
Tysabri Specialty PA
Xeljanz Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
77
Drug Name Notes Requirements/Limits
Xeljanz XR Specialty PA
Immunosuppressive Agents
Atgam Specialty PA
azathioprine
Benlysta intravenous Specialty PA
CellCept oral suspension for reconstitution
cyclophosphamide intravenous Specialty PA
cyclosporine intravenous Specialty PA
cyclosporine modified oral capsule
cyclosporine oral capsule
Elidel PA
mercaptopurine
methotrexate sodium
methotrexate sodium (PF)
mycophenolate mofetil
mycophenolate mofetil HCl Specialty PA
mycophenolate sodium PA
Prograf intravenous Specialty PA
Rapamune oral solution PA
Sandimmune intravenous Specialty PA
Sandimmune oral solution
Simulect Specialty PA
sirolimus PA
tacrolimus oral
Thymoglobulin Specialty PA
Trexall oral tablet 7.5 mg
Zortress Specialty PA
Other Miscellaneous Therapeutic
Agents
acetylcysteine
Ampyra Specialty PA
Arcalyst Specialty PA
Botox Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
78
Drug Name Notes Requirements/Limits
Cerdelga Specialty PA
Demser Specialty PA
Dysport Specialty PA
Endari Specialty PA
Evotaz
Ilaris (PF) subcutaneous solution Specialty PA
Kuvan Specialty PA
levocarnitine (with sugar) Specialty PA
levocarnitine oral tablet
miglustat Specialty PA
Myobloc Specialty PA
octreotide acetate Specialty PA
Orfadin oral capsule 10 mg, 2 mg, 5 mg Specialty PA
Panhematin intravenous recon soln 350 mg Specialty PA
Prezcobix
Remicade Specialty PA
Spinraza (PF) Specialty PA
Tybost
Xeomin Specialty PA
Protective Agents
amifostine crystalline Specialty PA
dexrazoxane HCl Specialty PA
Elmiron QL
mesna Specialty PA
Oxytocics
Oxytocics
Methergine QL
Respiratory Tract Agents
Alpha And Beta Adrenergic
Agonist(Respr)
cetirizine-pseudoephedrine
epinephrine injection auto-injector 0.15 mg/0.3
mL, 0.3 mg/0.3 mL QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
79
Drug Name Notes Requirements/Limits
epinephrine injection solution
epinephrine injection syringe 0.1 mg/mL
Loratadine-D
Anticholinergic Agents (Respir.Tract)
Anoro Ellipta
Atrovent HFA
Combivent Respimat
diphenoxylate-atropine
ipratropium bromide inhalation
ipratropium-albuterol
Spiriva Respimat AL
Antifibrotic Agents
Esbriet Specialty PA
Anti-Inflammatory Agents
(Respiratory)
Nucala Specialty PA
Antitussives
codeine sulfate oral tablet AL
Cystic Fibrosis (Cftr) Correctors
Orkambi Specialty PA
Symdeko Specialty PA
Cystic Fibrosis (Cftr) Potentiators
Kalydeco Specialty PA
Orkambi Specialty PA
Symdeko Specialty PA
Expectorants
SSKI
First Generation Antihist.(Respir Tract)
chlorpheniramine maleate oral tablet
cyproheptadine
Diclegis PA
diphenhydramine HCl injection solution 50
mg/mL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
80
Drug Name Notes Requirements/Limits
diphenhydramine HCl injection syringe
diphenhydramine HCl oral capsule
diphenhydramine HCl oral syrup
diphenhydramine HCl oral tablet 25 mg
ED Chlorped Jr
promethazine oral
promethazine-phenylephrine
Interleukin Antagonists
Cinqair Specialty PA
Fasenra Specialty PA
Leukotriene Modifiers
montelukast oral granules in packet QL; AL
montelukast oral tablet QL
montelukast oral tablet,chewable QL
Mast-Cell Stabilizers
cromolyn inhalation
cromolyn ophthalmic (eye)
Mucolytic Agents
acetylcysteine
Pulmozyme Specialty PA
Nasal Preparations (Steroids)
fluticasone nasal
Orally Inhaled Preparations (Steroids)
ArmonAir RespiClick
Arnuity Ellipta
Asmanex HFA
Asmanex Twisthaler QL
Breo Ellipta
budesonide inhalation QL; AL
Flovent Diskus QL
Flovent HFA QL
Pulmicort Flexhaler
Qvar QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
81
Drug Name Notes Requirements/Limits
Qvar RediHaler QL
Phosphodiesterase Type 4 Inhibitors
Daliresp ST
Respiratory Tract Agents,
Miscellaneous
Aralast NP Specialty PA
Glassia Specialty PA
Prolastin-C intravenous recon soln Specialty PA
Xolair Specialty PA
Zemaira Specialty PA
Second Generation Antihist(Respir
Tract)
cetirizine oral solution 1 mg/mL
cetirizine oral tablet
cetirizine-pseudoephedrine
fexofenadine oral suspension ST
fexofenadine oral tablet 180 mg ST
levocetirizine oral tablet
loratadine oral solution
loratadine oral tablet
loratadine oral tablet,disintegrating
Loratadine-D
Select.Beta-2-Adrenergic
Agonist(Respir)
albuterol sulfate inhalation solution for
nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
Anoro Ellipta
Breo Ellipta
Combivent Respimat
ipratropium-albuterol
levalbuterol tartrate ST
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
82
Drug Name Notes Requirements/Limits
metaproterenol oral syrup
Serevent Diskus
terbutaline oral
Ventolin HFA QL
Xopenex HFA ST
Vasodilating Agents (Respiratory Tract)
Adcirca Specialty PA
Adempas Specialty PA
epoprostenol (glycine) Specialty PA
Letairis Specialty PA
Opsumit Specialty PA
Orenitram Specialty PA
Remodulin Specialty PA
Revatio intravenous Specialty PA
Revatio oral suspension for reconstitution Specialty PA
sildenafil (antihypertensive) oral Specialty PA
Tracleer Specialty PA
Tyvaso Specialty PA
Tyvaso Refill Kit Specialty PA
Tyvaso Starter Kit Specialty PA
Uptravi Specialty PA
Veletri Specialty PA
Ventavis Specialty PA
Xanthine Derivatives
Theo-24
theophylline oral tablet extended release 12 hr
Skin And Mucous Membrane Agents
Antibacterials (Skin, Mucous
Membrane)
Cleocin vaginal suppository
clindamycin phosphate topical gel
clindamycin phosphate topical lotion
clindamycin phosphate topical solution
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
83
Drug Name Notes Requirements/Limits
clindamycin phosphate topical swab
clindamycin phosphate vaginal
Ery Pads
erythromycin with ethanol topical gel
erythromycin with ethanol topical solution
erythromycin-benzoyl peroxide
gentamicin topical
Metrogel topical gel 1 %
metronidazole topical cream
metronidazole topical gel 0.75 %
metronidazole vaginal
mupirocin
Anti-Inflammatory Agents (Skin,
Mucous)
amcinonide topical cream
Anucort-HC
betamethasone dipropionate
betamethasone valerate topical cream
betamethasone valerate topical lotion
betamethasone valerate topical ointment
betamethasone, augmented
clobetasol scalp
clobetasol topical cream
clobetasol topical gel
clobetasol topical ointment
clobetasol-emollient topical cream
clotrimazole-betamethasone
desonide
desoximetasone topical cream
desoximetasone topical gel
desoximetasone topical ointment 0.25 %
diflorasone
fluocinolone topical cream
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
84
Drug Name Notes Requirements/Limits
fluocinolone topical ointment
fluocinolone topical solution
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
Fluocinonide-E
fluticasone topical cream
fluticasone topical ointment
hydrocortisone acetate rectal suppository 25 mg
hydrocortisone butyrate topical cream
hydrocortisone butyrate topical ointment
hydrocortisone butyrate topical solution
hydrocortisone rectal
hydrocortisone topical cream 1 %, 2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1 %, 2.5 %
hydrocortisone valerate
hydrocortisone-min oil-wht pet
hydrocortisone-pramoxine rectal cream 1-1 %
mometasone topical cream QL
mometasone topical ointment QL
mometasone topical solution
Oralone
PramCort
Proctofoam HC
triamcinolone acetonide dental
triamcinolone acetonide topical cream
triamcinolone acetonide topical lotion
triamcinolone acetonide topical ointment 0.025
%, 0.1 %, 0.5 %
Antipruritics And Local Anesthetics
hydrocortisone-pramoxine rectal cream 1-1 %
lidocaine HCl topical cream 3 %
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
85
Drug Name Notes Requirements/Limits
lidocaine-prilocaine topical cream QL
phenazopyridine oral tablet 100 mg, 200 mg
PramCort
Proctofoam HC
Antivirals (Skin And Mucous
Membrane)
Abreva
acyclovir topical PA
Zovirax topical cream PA
Astringents
Drysol
Azoles (Skin And Mucous Membrane)
clotrimazole mucous membrane
clotrimazole topical
clotrimazole-betamethasone
econazole
ketoconazole topical cream
ketoconazole topical shampoo
Miconazole-3 vaginal suppository
terconazole
Basic Lotions And Liniments
ammonium lactate topical lotion
Basic Ointments And Protectants
ammonium lactate topical cream
Cell Stimulants And Proliferants
Kepivance Specialty PA
tretinoin topical cream AL
tretinoin topical gel 0.01 %, 0.025 % AL
Corticosteroids (Skin, Mucous
Membrane)
amcinonide topical cream
Anucort-HC
betamethasone dipropionate
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
86
Drug Name Notes Requirements/Limits
betamethasone valerate topical cream
betamethasone valerate topical lotion
betamethasone valerate topical ointment
betamethasone, augmented
clobetasol scalp
clobetasol topical cream
clobetasol topical gel
clobetasol topical ointment
clobetasol-emollient topical cream
clotrimazole-betamethasone
desonide
desoximetasone topical cream
desoximetasone topical gel
desoximetasone topical ointment 0.25 %
diflorasone
fluocinolone topical cream
fluocinolone topical ointment
fluocinolone topical solution
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
Fluocinonide-E
fluticasone topical cream
fluticasone topical ointment
hydrocortisone acetate rectal suppository 25 mg
hydrocortisone butyrate topical cream
hydrocortisone butyrate topical ointment
hydrocortisone butyrate topical solution
hydrocortisone rectal
hydrocortisone topical cream 1 %, 2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1 %, 2.5 %
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
87
Drug Name Notes Requirements/Limits
hydrocortisone valerate
hydrocortisone-min oil-wht pet
hydrocortisone-pramoxine rectal cream 1-1 %
mometasone topical cream QL
mometasone topical ointment QL
mometasone topical solution
Oralone
PramCort
Proctofoam HC
triamcinolone acetonide dental
triamcinolone acetonide topical cream
triamcinolone acetonide topical lotion
triamcinolone acetonide topical ointment 0.025
%, 0.1 %, 0.5 %
U-Cort
Hydroxypyridones (Skin, Mucous
Membrane)
ciclopirox topical suspension
Keratolytic Agents
sulfacetamide sodium-sulfur topical cleanser 10-5
% (w/w)
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
urea topical cream 40 %, 50 %
urea topical lotion 40 %
Keratoplastic Agents
Drithocreme HP
Local Anti-Infectives, Miscellaneous
silver sulfadiazine
sulfacetamide sodium (acne)
sulfacetamide sodium-sulfur topical cleanser 10-5
% (w/w)
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
88
Drug Name Notes Requirements/Limits
Nonsteroidal Anti-
Inflammat.Agents(Skin)
diclofenac sodium topical gel 1 % ST
Pigmenting Agents
Oxsoralen Ultra Specialty PA
Polyenes (Skin And Mucous Membrane)
nystatin topical
nystatin-triamcinolone
Scabicides And Pediculicides
Cutter Backwoods topical aerosol,spray QL; AL
Cutter Skinsations QL; AL
Lice Killing
Lice Killing (permethrin)
Off Active QL; AL
Off Deep Woods Dry QL; AL
Off Deep Woods topical aerosol,spray QL; AL
Off FamilyCare (with DEET) topical aerosol
powder QL; AL
permethrin topical cream QL
Repel Sportsmen QL; AL
Repel Sportsmen Max topical aerosol,spray QL; AL
Sklice ST
Skin And Mucous Membrane Agents,
Misc.
Cosentyx Specialty PA
Cosentyx (2 Syringes) Specialty PA
Cosentyx Pen Specialty PA
Cosentyx Pen (2 Pens) Specialty PA
Cutter Backwoods topical aerosol,spray QL; AL
Cutter Skinsations QL; AL
diclofenac sodium topical gel 1 % ST
Dupixent Specialty PA
Elidel PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
89
Drug Name Notes Requirements/Limits
imiquimod QL
Insect Repellent (picaridin) QL; AL
Natrapel QL; AL
Off Active QL; AL
Off Deep Woods Dry QL; AL
Off Deep Woods topical aerosol,spray QL; AL
Off FamilyCare (with DEET) topical aerosol
powder QL; AL
podofilox
Repel Sportsmen QL; AL
Repel Sportsmen Max topical aerosol,spray QL; AL
Santyl
Siliq Specialty PA
Stelara intravenous Specialty PA
Stelara subcutaneous syringe Specialty PA
tacrolimus topical PA
Taltz Autoinjector Specialty PA
Taltz Syringe Specialty PA
Targretin topical Specialty PA
Tremfya Specialty PA
Smooth Muscle Relaxants
Antimuscarinics
flavoxate
oxybutynin chloride
Oxytrol For Women
tolterodine
trospium oral tablet
Respiratory Smooth Muscle Relaxants
Theo-24
theophylline oral tablet extended release 12 hr
Vitamins
Multivitamin Preparations
Atabex EC
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
90
Drug Name Notes Requirements/Limits
Cadeau DHA
Children's Chewable Multivitmn
Complete Natal DHA
Daily Multivitamin with Iron
Daily Prenatal
Multi-Vit with Fluoride-Iron
Multivitamin With Fluoride
Multi-Vitamin With Fluoride oral drops
Multi-Vitamin With Fluoride oral tablet,chewable
0.25 mg, 1 mg
Multivitamins With Fluoride oral tablet,chewable
1 mg
Mynatal
Mynatal Plus
Mynatal-Z
Mynate 90 Plus
Obstetrix DHA
Obstetrix EC
O-Cal FA
O-Cal Prenatal
One Daily Essential oral tablet 0.4 mg
One-A-Day Women's Prenatal 1
Prenatabs FA
Prenatal + DHA oral combo pack 28 mg iron-800
mcg-200 mg
Prenatal 19
Prenatal 19 (with docusate)
Prenatal Gummy
Prenatal Low Iron
Prenatal Multi-DHA (algal oil)
Prenatal Multi-DHA oral capsule 27 mg iron-800
mcg-228 mg
Prenatal Plus
Prenatal Plus DHA oral combo pack
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
91
Drug Name Notes Requirements/Limits
prenatal vit-iron fum-folic ac
Prenatal-U
Se-Natal 19
Se-Natal 19 (with docusate)
TriAdvance
Trinatal Rx 1
Trinate
Triveen-Duo DHA
Tri-Vit with Fluoride and Iron
Tri-Vitamin With Fluoride
Vinate GT
Vinate II
Vinate M
Vinate One
Vinate Ultra
Vol-Nate
Women's Prenatal + DHA
Vitamin A
Tri-Vitamin With Fluoride
Vitamin B Complex
Atabex EC
Cadeau DHA
Children's Chewable Multivitmn
cyanocobalamin (vitamin B-12) injection
Daily Multivitamin with Iron
Daily Prenatal
Diclegis PA
FE C Plus
folic acid oral capsule 0.8 mg AL
folic acid oral tablet 1 mg
folic acid oral tablet 400 mcg, 800 mcg AL
Multigen Folic
Multigen Plus
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
92
Drug Name Notes Requirements/Limits
Mynatal oral capsule
Mynatal Plus
Mynatal-Z
Nicomide
Obstetrix DHA
Obstetrix EC
O-Cal FA
O-Cal Prenatal
One Daily Essential oral tablet 0.4 mg
Prenatabs FA
Prenatal + DHA oral combo pack 28 mg iron-800
mcg-200 mg
Prenatal 19
Prenatal 19 (with docusate)
Prenatal Gummy
Prenatal Low Iron
Prenatal Multi-DHA (algal oil)
Prenatal Multi-DHA oral capsule 27 mg iron-800
mcg-228 mg
Prenatal Plus
Prenatal Plus DHA oral combo pack
prenatal vit-iron fum-folic ac
pyridoxine (vitamin B6) oral tablet 100 mg
Se-Natal 19
Se-Natal 19 (with docusate)
TriAdvance
Trinatal Rx 1
Trinate
Triveen-Duo DHA
Vinate GT
Vinate One
Vinate Ultra
Vol-Nate
Women's Prenatal + DHA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
93
Drug Name Notes Requirements/Limits
Vitamin C
FE C Plus
Multigen Folic
Multigen Plus
Tri-Vitamin With Fluoride
Vitamin D
calcitriol intravenous solution 1 mcg/mL
calcitriol oral capsule
cholecalciferol (vitamin D3) oral capsule 400 unit AL
cholecalciferol (vitamin D3) oral tablet 400 unit AL
cholecalciferol (vitamin D3) oral tablet,chewable
400 unit AL
ergocalciferol (vitamin D2) oral capsule
One-A-Day Women's Prenatal 1
Tri-Vitamin With Fluoride
Vitamin K Activity
Mephyton
94
Index
A abacavir .................................... 8
abacavir-lamivudine ................. 8
Abelcet ................................... 12
Abilify Maintena .................... 43
Abraxane ................................ 13
Abreva .................................... 85
Accu-Chek Aviva Control Soln
............................................ 51
Accu-Chek Aviva Plus test strp
............................................ 52
Accu-Chek FastClix ............... 51
Accu-Chek Guide ................... 52
Accu-Chek Guide Glucose
Meter .................................. 51
Accu-Chek Guide L1-L2 Ctrl
Sol....................................... 51
Accu-Chek Multiclix Lancet .. 51
Accu-Chek SmartView Contrl
Sol....................................... 51
Accu-Chek SmartView Test
Strip .................................... 52
Accu-Chek Soft Dev Lancets . 51
Accu-Chek Softclix Lancet Dev
............................................ 51
Accu-Chek Softclix Lancets... 51
acebutolol ............. 23, 30, 33, 36
acetaminophen ........................ 40
acetaminophen-codeine .... 40, 46
acetazolamide ............. 33, 53, 57
acetic acid ............................... 58
acetylcysteine ................... 77, 80
Actemra ............................ 73, 75
Acthar H.P. ....................... 52, 69
Actimmune ............................. 75
Activase ............................ 27, 56
acyclovir ........................... 11, 85
Adagen ................................... 56
Adcetris .................................. 13
Adcirca ............................. 37, 82
adefovir................................... 11
Adempas ........................... 39, 82
Admelog SoloStar U-100
Insulin ................................. 68
Admelog U-100 Insulin lispro 68
Advate .................................... 24
Aerochamber Plus Flow-Vu ... 51
Afinitor ................................... 13
Afinitor Disperz...................... 14
Afluria 2017-2018 .................. 19
Afluria 2017-2018 (PF) .......... 19
Afluria Quad 2017-2018 ........ 19
Afluria Quad 2017-2018 (PF) 19
Aftera ...................................... 65
albuterol sulfate ................ 22, 81
Aldactazide ..... 36, 37, 38, 53, 55
Aldurazyme ............................ 56
Alecensa ................................. 14
alendronate ............................. 72
Alferon N .......................... 10, 14
alfuzosin ................................. 22
Alimta ..................................... 14
allopurinol .............................. 72
alogliptin ................................. 66
alogliptin-metformin ........ 65, 66
alogliptin-pioglitazone...... 66, 71
Alphanate................................ 24
AlphaNine SD ........................ 24
alprazolam .............................. 44
amantadine HCl .................. 3, 40
AmBisome .............................. 12
amcinonide ....................... 83, 85
Amicar .................................... 24
amifostine crystalline ............. 78
amikacin ............................... 3, 5
amiloride ........................... 37, 53
amiloride-hydrochlorothiazide
.......................... 37, 38, 53, 55
aminocaproic acid................... 24
amiodarone ............................. 34
Amitiza ................................... 61
amitriptyline ........................... 50
amitriptyline-chlordiazepoxide
...................................... 44, 50
amlodipine ...... 32, 34, 35, 36, 39
amlodipine-benazepril ..... 28, 29,
32, 35, 36, 39
amlodipine-valsartan . 28, 32, 35,
36, 39
ammonium lactate .................. 85
amoxapine .............................. 51
amoxicillin ................................ 4
amoxicillin-pot clavulanate ...... 4
ampicillin .................................. 4
ampicillin sodium ..................... 4
ampicillin-sulbactam ................ 4
Ampyra ................................... 77
anastrozole ........................ 14, 64
Anoro Ellipta ........ 20, 22, 79, 81
Anucort-HC ...................... 83, 85
APOKYN ............................... 46
apraclonidine .......................... 58
aprepitant ................................ 62
Aptivus ..................................... 9
Aralast NP .............................. 81
Aranelle (28) ........................... 65
Aranesp (in polysorbate) ........ 23
Arcalyst................................... 77
aripiprazole ............................. 43
Aristada................................... 43
ArmonAir RespiClick ....... 63, 80
Armour Thyroid...................... 71
Arnuity Ellipta .................. 63, 80
Arranon ................................... 14
Arzerra .................................... 14
Asmanex HFA .................. 63, 80
Asmanex Twisthaler ......... 63, 80
aspirin ................... 26, 27, 42, 49
aspirin-dipyridamole... 27, 39, 49
Atabex EC ...... 25, 54, 61, 89, 91
atazanavir .................................. 9
atenolol ....................... 23, 30, 33
atenolol-chlorthalidone .... 23, 30,
31, 34, 38, 55
Atgam ..................................... 77
atomoxetine ............................ 45
atorvastatin ............................. 35
atovaquone ................................ 5
atovaquone-proguanil ............... 4
Atripla ................................... 8, 9
atropine ................................... 59
Atrovent HFA ................... 20, 79
Aubagio .................................. 75
Austedo ............................. 45, 51
Avalide ....................... 28, 38, 55
Avastin .................................... 14
Avonex ................................... 75
Avonex (with albumin)........... 75
Azactam in dextrose (iso-osm)
............................................ 11
azathioprine ................ 73, 75, 77
azelastine ................................ 56
azithromycin ........................... 12
Azopt ...................................... 58
aztreonam ............................... 11
B bacitracin-polymyxin B .......... 56
95
baclofen .................................. 21
balsalazide .............................. 60
Balziva (28) ............................ 65
Banzel ..................................... 41
Basaglar KwikPen U-100
Insulin ................................. 68
benazepril ......................... 28, 29
benazepril-hydrochlorothiazide
.......................... 28, 29, 38, 55
BeneFIX ................................. 24
Benlysta .................................. 77
benztropine ....................... 20, 41
Berinert ................................... 73
betamethasone dipropionate .. 83,
85
betamethasone valerate .... 83, 86
betamethasone, augmented.... 83,
86
Betaseron ................................ 75
bethanechol chloride .............. 22
bexarotene .............................. 14
bicalutamide ........................... 14
Bicillin L-A ............................ 11
BiCNU .................................... 14
BiDil ................................. 35, 36
Biktarvy ................................ 8, 9
Biltricide ................................... 4
bisoprolol fumarate ... 23, 30, 31,
34
bisoprolol-hydrochlorothiazide
.............. 23, 30, 31, 34, 38, 55
bleomycin ............................... 14
Bosulif .................................... 14
Botox ................................ 23, 77
Breo Ellipta .......... 22, 63, 80, 81
brimonidine ............................ 56
bromocriptine ......................... 46
budesonide ........................ 63, 80
bumetanide ....................... 36, 53
buprenorphine HCl ................. 47
buprenorphine-naloxone......... 47
bupropion HCl ........................ 42
bupropion HCl (smoking deter)
............................................ 42
buspirone ................................ 43
busulfan .................................. 14
butalbital-acetaminop-caf-cod
.................... 40, 42, 44, 46, 49
butalbital-acetaminophen . 40, 44
butalbital-acetaminophen-caff
.......................... 40, 42, 44, 49
butalbital-aspirin-caffeine 27, 42,
44, 49
butorphanol tartrate ................ 47
C cabergoline ............................. 46
Cadeau DHA .............. 25, 90, 91
caffeine citrate ........................ 49
calcitonin (salmon) ..... 64, 69, 72
calcitriol .................................. 93
calcium acetate ....................... 53
Camptosar ............................... 14
Canasa .................................... 60
capecitabine ............................ 14
Caprelsa .................................. 14
captopril ............................ 28, 29
captopril-hydrochlorothiazide28,
29, 38, 55
Carbaglu ................................. 53
carbamazepine ........................ 41
carbidopa-levodopa ................ 45
carboplatin .............................. 14
Carimune NF Nanofiltered ..... 18
carisoprodol ............................ 21
carteolol .................................. 57
carvedilol .. 21, 22, 27, 30, 34, 36
caspofungin .............................. 6
Cathflo Activase ............... 27, 56
Cayston ................................... 11
cefaclor ..................................... 2
cefadroxil .................................. 2
cefazolin ................................... 2
cefdinir...................................... 2
cefepime ................................... 3
cefepime in dextrose 5 % ......... 3
cefepime in dextrose,iso-osm ... 3
cefotaxime ................................ 2
cefotetan ............................... 2, 6
cefotetan in dextrose, iso-osm . 2,
6
cefpodoxime ............................. 3
cefprozil .................................... 2
ceftazidime ............................... 3
ceftriaxone ................................ 3
ceftriaxone in dextrose,iso-os ... 3
cefuroxime axetil ...................... 2
cefuroxime sodium ................... 2
celecoxib ................................. 45
CellCept .................................. 77
cephalexin ................................. 2
Cerdelga .................................. 78
Cerezyme ................................ 56
cetirizine ............................. 1, 81
cetirizine-pseudoephedrine 2, 20,
78, 81
Chantix ................................... 21
Chantix Starting Month Box .. 21
Chemet .............................. 63, 71
Children's Chewable Multivitmn
...................................... 90, 91
chlordiazepoxide HCl ............. 44
chlorhexidine gluconate.......... 58
chloroquine phosphate .............. 4
chlorothiazide ................... 38, 55
chlorpheniramine maleate .. 1, 79
chlorpromazine ....................... 48
chlorpropamide ....................... 70
chlorthalidone ................... 38, 55
chlorzoxazone ......................... 21
cholecalciferol (vitamin D3)... 93
cholestyramine (with sugar) ... 31
Cholestyramine Light ............. 31
choline,magnesium salicylate . 49
ciclopirox ................................ 87
cidofovir ................................. 11
cilostazol ........................... 27, 37
Cimduo ..................................... 9
cimetidine ............................... 62
cimetidine HCl........................ 62
Cimzia......................... 61, 73, 75
Cimzia Powder for Reconst ... 61,
73, 75
Cinqair .................................... 80
Cinryze ................................... 73
Ciprodex ........................... 57, 58
ciprofloxacin ....................... 5, 12
ciprofloxacin (mixture) ....... 5, 12
ciprofloxacin HCl ......... 5, 12, 57
ciprofloxacin in 5 % dextrose .. 5,
12
cisplatin................................... 14
citalopram ............................... 50
cladribine ................................ 14
Claforan .................................... 3
clarithromycin..................... 5, 12
Cleocin .................................... 82
clindamycin HCl ..................... 10
clindamycin in 5 % dextrose .. 10
clindamycin palmitate HCl ..... 10
96
clindamycin phosphate .... 10, 82,
83
Clinisol SF 15 % .................... 53
clobetasol .......................... 83, 86
clobetasol-emollient ......... 83, 86
clofarabine .............................. 14
clomipramine .......................... 51
clonazepam ............................. 44
clonidine ........................... 20, 33
clonidine HCl ................... 20, 33
clopidogrel .............................. 27
clorazepate dipotassium ... 44, 45
Clorpres ................ 20, 33, 38, 55
clotrimazole ............................ 85
clotrimazole-betamethasone .. 83,
85, 86
clozapine................................. 43
codeine sulfate .................. 46, 79
codeine-butalbital-ASA-caff . 42,
44, 47, 49
colchicine ............................... 72
colestipol ................................ 31
colistin (colistimethate Na) .... 12
Combivent Respimat . 20, 22, 79,
81
Cometriq ................................. 14
Complera .............................. 8, 9
Complete Natal DHA ............. 90
Copaxone ................................ 75
Corifact ................................... 24
cortisone ................................. 63
Cosentyx ................................. 88
Cosentyx (2 Syringes) ............ 88
Cosentyx Pen .......................... 88
Cosentyx Pen (2 Pens)............ 88
cosyntropin ............................. 52
Creon ...................................... 61
Crinone ................................... 69
Crixivan .................................... 9
cromolyn........................... 56, 80
Cutter Backwoods .................. 88
Cutter Skinsations .................. 88
cyanocobalamin (vitamin B-12)
............................................ 91
cyclobenzaprine ...................... 21
cyclopentolate......................... 59
cyclophosphamide ............ 14, 77
cyclosporine ............... 73, 75, 77
cyclosporine modified 73, 75, 77
cyproheptadine ................... 1, 79
cytarabine ............................... 14
cytarabine (PF) ....................... 14
CytoGam ................................ 19
Cytovene ................................. 11
D D5 %-0.45 % sodium chloride53
dacarbazine ............................. 14
Dacogen .................................. 14
dactinomycin .......................... 14
Daily Multivitamin with Iron 25,
90, 91
Daily Prenatal ....... 25, 54, 90, 91
Daklinza.................................... 7
Daliresp .................................. 81
danazol.................................... 64
dapsone ................................. 4, 5
daptomycin ............................... 6
Daraprim ................................... 4
daunorubicin ........................... 14
DDAVP ............................ 24, 69
deferoxamine .................... 63, 71
Delzicol .................................. 60
Demser.................................... 78
Depo-Provera.......................... 69
Descovy .................................... 9
desipramine ............................ 51
desmopressin .................... 24, 69
desog-e.estradiol/e.estradiol ... 65
desogestrel-ethinyl estradiol ... 65
desonide ............................ 83, 86
desoximetasone ................ 83, 86
dexamethasone ....................... 63
Dexamethasone Intensol......... 63
dexamethasone sodium phos
(PF) ..................................... 63
dexamethasone sodium
phosphate ...................... 58, 63
dexmethylphenidate................ 49
dexrazoxane HCl .................... 78
dextroamphetamine ................ 40
dextroamphetamine-
amphetamine ...................... 40
dextrose 70 % in water (D70W)
............................................ 53
diazepam ........................... 44, 45
Diazepam Intensol ............ 44, 45
Diclegis ....................... 60, 79, 91
diclofenac potassium .............. 47
diclofenac sodium....... 48, 59, 88
dicloxacillin ............................ 12
dicyclomine ............................ 20
didanosine ................................. 9
diflorasone ........................ 83, 86
diflunisal ................................. 48
Digox ................................ 29, 33
digoxin .............................. 30, 33
dihydroergotamine ............ 22, 42
Dilantin ............................. 33, 46
diltiazem HCl........ 31, 32, 34, 39
Dipentum ................................ 60
diphenhydramine HCl .. 1, 79, 80
diphenoxylate-atropine .... 20, 60,
79
dipyridamole ..................... 27, 39
disopyramide phosphate ......... 33
disulfiram ................................ 71
Diuril................................. 38, 55
divalproex ......................... 41, 42
Docefrez ................................. 14
docetaxel ................................. 14
donepezil................................. 22
doripenem ................................. 6
dorzolamide ............................ 58
dorzolamide-timolol ......... 57, 58
doxazosin .................... 21, 27, 36
doxepin ................................... 51
Doxil ....................................... 15
doxorubicin ............................. 15
Doxy-100 ................................ 13
doxycycline hyclate .......... 13, 57
doxycycline monohydrate ...... 13
Drithocreme HP ...................... 87
droperidol ............................... 43
Droxia ..................................... 15
Drysol ..................................... 85
duloxetine ......................... 46, 49
Dupixent ................................. 88
dutasteride............................... 71
Dysport ............................. 23, 78
E E.E.S. Granules................... 6, 10
econazole ................................ 85
EContra EZ ............................. 65
ED Chlorped Jr ................... 1, 80
Edurant ..................................... 8
efavirenz ................................... 8
Elaprase .................................. 56
Elelyso .................................... 56
Elidel................................. 77, 88
Eligard .............................. 15, 67
97
Eligard (3 month) ............. 15, 67
Eligard (4 month) ............. 15, 67
Eligard (6 month) ....... 15, 67, 68
Eliquis..................................... 23
Elitek ...................................... 56
Ella ......................................... 65
Elmiron ................................... 78
Emcyt ..................................... 15
Emend..................................... 62
Emflaza................................... 63
Emtriva ..................................... 9
enalapril maleate .............. 28, 29
enalapril-hydrochlorothiazide 28,
29, 38, 55
Enbrel ............................... 73, 75
Enbrel Mini ...................... 73, 75
Enbrel SureClick .............. 74, 75
Endari ............................... 61, 78
enoxaparin .............................. 25
entecavir ................................. 11
Entresto............................. 28, 38
Entyvio ............................. 61, 75
Epclusa ..................................... 7
epinephrine ................. 20, 78, 79
epirubicin ................................ 15
Epivir ........................................ 9
Epivir HBV .............................. 9
Epogen .................................... 24
epoprostenol (glycine) ...... 39, 82
Eraxis(Water Diluent) .............. 6
Erbitux .................................... 15
ergocalciferol (vitamin D2) .... 93
Ergomar ............................ 22, 42
ergotamine-caffeine .......... 22, 42
Erivedge ................................. 15
Erwinaze ................................. 15
Ery Pads.................................. 83
Ery-Tab............................... 6, 10
Erythrocin (as stearate)....... 6, 11
erythromycin ................ 6, 11, 57
erythromycin ethylsuccinate ... 6,
11
erythromycin with ethanol ..... 83
erythromycin-benzoyl peroxide
............................................ 83
Esbriet..................................... 79
escitalopram oxalate ............... 50
esomeprazole magnesium ...... 62
estazolam ................................ 45
estradiol ............................ 66, 67
estropipate .............................. 67
eszopiclone ............................. 43
ethambutol ................................ 5
ethosuximide .......................... 50
ethynodiol diac-eth estradiol .. 65
etidronate disodium ................ 72
etodolac .................................. 48
Etopophos ............................... 15
etoposide ................................. 15
Euflexxa.................................. 51
Evotaz ................................. 9, 78
exemestane ....................... 15, 64
Exjade ..................................... 63
Extavia .................................... 75
Eylea ....................................... 59
F Fabrazyme .............................. 56
famotidine ............................... 62
Fareston ............................ 15, 66
Fasenra.................................... 80
Faslodex.................................. 15
FE C Plus .................... 25, 91, 93
Feiba NF ................................. 24
felodipine .............. 32, 35, 36, 39
Femhrt Low Dose ............. 67, 69
fenofibrate .............................. 35
fenofibrate micronized ........... 35
fenofibrate nanocrystallized ... 35
fenoprofen .............................. 48
fentanyl ................................... 47
Feraheme ................................ 25
Ferriprox ................................. 63
Ferrlecit .................................. 25
fexofenadine ....................... 2, 81
finasteride ............................... 71
Firazyr .................................... 73
Firmagon .................... 15, 64, 75
Firmagon kit w diluent syringe
................................ 15, 64, 75
Flarex ...................................... 58
flavoxate ................................. 89
Flebogamma DIF .................... 19
flecainide ................................ 33
Flovent Diskus .................. 63, 80
Flovent HFA ..................... 63, 80
floxuridine .............................. 15
Fluarix Quad 2017-2018 (PF) 19
Flucelvax Quad 2017-2018 .... 19
Flucelvax Quad 2017-2018 (PF)
............................................ 19
fluconazole ........................... 5, 6
fluconazole in dextrose(iso-o) .. 5
fluconazole in NaCl (iso-osm).. 5
fludarabine .............................. 15
fludrocortisone ........................ 63
Flulaval Quad 2017-2018 ....... 19
Flulaval Quad 2017-2018 (PF)
............................................ 19
fluocinolone ................ 83, 84, 86
fluocinonide ...................... 84, 86
Fluocinonide-E ................. 84, 86
fluoride (sodium) .................... 73
Fluoridex Daily Defense......... 73
fluorometholone ..................... 58
fluorouracil ............................. 15
fluoxetine ................................ 50
fluphenazine decanoate .......... 48
fluphenazine HCl .................... 48
flurbiprofen sodium ................ 59
flutamide ................................. 15
fluticasone............. 58, 80, 84, 86
Fluvirin 2017-2018 ................. 19
Fluvirin 2017-2018 (PF) ......... 19
fluvoxamine ............................ 50
Fluzone High-Dose 2017-18
(PF) ..................................... 19
Fluzone Intraderm Quad 2017-
18 ........................................ 19
Fluzone Quad 2017-2018 ....... 19
Fluzone Quad 2017-2018 (PF)
............................................ 19
Fluzone Quad Pedi 2017-18
(PF) ..................................... 19
FML Forte .............................. 58
FML S.O.P.............................. 58
folic acid ................................. 91
Folotyn .................................... 15
Forteo ...................................... 69
fosamprenavir ........................... 9
foscarnet ................................... 5
fosinopril................................. 29
fosinopril-hydrochlorothiazide
................................ 29, 38, 55
furosemide ........................ 36, 53
Fuzeon ...................................... 8
G gabapentin......................... 40, 41
Galzin ..................................... 63
GamaSTAN S/D ..................... 19
Gamunex-C............................. 19
98
Gattex 30-Vial ........................ 61
Gel-One .................................. 51
Gelsyn-3 ................................. 51
gemcitabine ............................ 15
gemfibrozil ............................. 35
Genotropin .............................. 69
Genotropin MiniQuick ........... 69
Gentak .................................... 57
gentamicin .................... 3, 57, 83
gentamicin in NaCl (iso-osm) .. 3
gentamicin sulfate (PF) ............ 3
GenVisc 850 ........................... 52
Genvoya ............................... 8, 9
Geodon ................................... 43
Gilenya ................................... 75
Glassia .................................... 81
glatiramer ............................... 75
Glatopa ................................... 75
Gliadel Wafer ......................... 15
glimepiride ............................. 70
glipizide .................................. 70
glipizide-metformin .......... 65, 70
Glucagon Emergency Kit
(human) ........................ 67, 71
glyburide................................. 70
glyburide micronized.............. 70
glyburide-metformin ........ 65, 70
glycopyrrolate......................... 20
granisetron (PF) ...................... 60
granisetron HCl ...................... 60
Granix ..................................... 24
griseofulvin microsize .............. 4
griseofulvin ultramicrosize ....... 4
guanfacine ........................ 33, 45
H Haegarda................................. 73
Halaven................................... 15
haloperidol .............................. 45
haloperidol decanoate ............. 45
haloperidol lactate .................. 45
Harvoni ..................................... 7
Hemofil M High ..................... 24
Hemofil M Low ...................... 24
Hemofil M Mid ...................... 24
Hemofil M Super High ........... 24
heparin (porcine) .................... 25
heparin (porcine) in 5 % dex .. 25
heparin (porcine) in NaCl (PF)
...................................... 25, 52
heparin, porcine (PF) .............. 25
Herceptin ................................ 15
Hexalen ................................... 15
Hizentra .................................. 19
Humalog Junior KwikPen U-
100 ...................................... 68
Humalog Mix 50-50 Insuln U-
100 ...................................... 68
Humalog Mix 50-50 KwikPen68
Humalog Mix 75-25 KwikPen68
Humalog Mix 75-25(U-
100)Insuln ........................... 68
Humate-P ................................ 24
Humatrope .............................. 69
Humira ........................ 61, 74, 75
Humira Pediatric Crohn's Start
................................ 61, 74, 75
Humira Pen ................. 61, 74, 75
Humira Pen Crohn's-UC-HS
Start ........................ 61, 74, 75
Humulin 70/30 U-100 Insulin 68
Humulin 70/30 U-100 KwikPen
............................................ 68
Humulin N NPH Insulin
KwikPen ............................. 68
Humulin N NPH U-100 Insulin
............................................ 68
Humulin R Regular U-100
Insuln .................................. 68
Humulin R U-500 (Conc)
Insulin ................................. 68
Hyalgan .................................. 52
Hycamtin ................................ 16
hydralazine ............................. 35
hydrochlorothiazide .......... 38, 55
hydrocodone-acetaminophen . 40,
41, 47
hydrocortisone ............ 63, 84, 86
hydrocortisone acetate ...... 84, 86
hydrocortisone butyrate .... 84, 86
hydrocortisone valerate .... 84, 87
hydrocortisone-acetic acid ...... 58
hydrocortisone-min oil-wht pet
...................................... 84, 87
hydrocortisone-pramoxine 84, 87
hydromorphone ...................... 47
hydroxychloroquine...... 4, 74, 75
hydroxyprogesterone capr(bulk)
............................................ 69
hydroxyprogesterone caproate 70
hydroxyurea ............................ 16
hydroxyzine pamoate.......... 1, 43
hyoscyamine sulfate ............... 20
HyperRHO S/D ...................... 19
I ibandronate ............................. 72
Ibrance .................................... 16
ibuprofen................................. 48
Ibuprofen IB ........................... 48
Iclusig ..................................... 16
idarubicin ................................ 16
ifosfamide ............................... 16
ifosfamide-mesna ................... 16
Ilaris (PF) ................................ 78
imatinib ................................... 16
imipenem-cilastatin .................. 6
imipramine HCl ...................... 51
imiquimod............................... 89
Imitrex .................................... 50
Increlex ................................... 70
indapamide ....................... 38, 55
indomethacin .................... 48, 72
Infant's Non-Aspirin ............... 41
Infed ........................................ 25
Inflectra....................... 61, 74, 76
Ingrezza ............................ 45, 51
Injectafer ................................. 25
Inlyta ....................................... 16
Insect Repellent (picaridin) .... 89
Insulin Syringe........................ 52
Intelence ................................... 8
Intralipid ................................. 53
Intrarosa .................................. 63
Intron A ...................... 10, 16, 76
Invanz ....................................... 6
Invega Sustenna ...................... 43
Invega Trinza .......................... 43
Invirase ................................... 10
Iopidine ................................... 59
ipratropium bromide ... 20, 59, 79
ipratropium-albuterol . 20, 22, 79,
81
irbesartan ................................ 28
irbesartan-hydrochlorothiazide
................................ 28, 38, 55
irinotecan ................................ 16
Isentress .................................... 8
Isentress HD ............................. 8
isoniazid .................................... 5
Isordil ...................................... 36
isosorbide dinitrate ................. 37
99
isosorbide mononitrate ........... 37
itraconazole .............................. 6
Ixempra................................... 16
J Jadenu ..................................... 63
Jadenu Sprinkle ...................... 63
Jakafi ...................................... 16
Janumet............................. 65, 66
Janumet XR ...................... 65, 66
Januvia .................................... 66
Jevtana .................................... 16
Jinteli ................................ 67, 70
Juluca ........................................ 8
Juxtapid .................................. 30
K Kadcyla................................... 16
Kalbitor................................... 73
Kaletra .................................... 10
Kalydeco................................. 79
Kepivance ............................... 85
ketoconazole ....................... 6, 85
ketoprofen............................... 48
ketorolac ........................... 48, 59
ketotifen fumarate .................. 56
Kevzara............................. 74, 76
Kineret .............................. 74, 76
Klor-Con................................. 54
Kogenate FS ........................... 25
Krystexxa ............................... 72
Kuvan ..................................... 78
Kyleena................................... 65
Kynamro ........................... 30, 72
Kyprolis .................................. 16
L labetalol .... 21, 22, 27, 30, 31, 34
lactulose .................................. 53
lamivudine ................................ 9
lamivudine-zidovudine ............. 9
lamotrigine ............................. 41
lancets ..................................... 52
lansoprazole ............................ 62
latanoprost .............................. 59
Latuda ..................................... 43
leflunomide....................... 74, 76
Lemtrada................................. 76
Letairis .............................. 39, 82
letrozole ............................ 16, 64
leucovorin calcium ................. 71
Leukeran ................................. 16
Leukine ................................... 24
leuprolide .................... 16, 67, 68
levalbuterol tartrate........... 22, 81
levetiracetam .......................... 41
levobunolol ............................. 57
levocarnitine ........................... 78
levocarnitine (with sugar) ....... 78
levocetirizine ...................... 2, 81
levofloxacin ........................ 5, 12
levofloxacin in D5W .......... 5, 12
levoleucovorin ........................ 71
levonorgestrel-ethinyl estrad .. 65
levonorg-eth estrad triphasic .. 65
levothyroxine .......................... 71
Lexiva ..................................... 10
Lice Killing............................. 88
Lice Killing (permethrin) ....... 88
lidocaine HCl .................... 59, 84
Lidocaine Viscous .................. 59
lidocaine-prilocaine ................ 85
Liletta...................................... 65
Lincocin .................................. 10
Linzess .................................... 61
Lioresal ................................... 21
liothyronine ............................ 71
Liposyn III .............................. 53
lisinopril.................................. 29
lisinopril-hydrochlorothiazide
................................ 29, 38, 55
lithium carbonate .................... 42
lithium citrate ......................... 42
loperamide .............................. 60
lopinavir-ritonavir .................. 10
loratadine ............................ 2, 81
Loratadine-D .......... 2, 20, 79, 81
lorazepam ......................... 44, 45
losartan ................................... 28
losartan-hydrochlorothiazide . 28,
38, 55
lovastatin ................................ 35
Low-Ogestrel (28) .................. 65
loxapine succinate .................. 43
Lucentis .................................. 59
Lumizyme ............................... 56
Lupron Depot ............. 16, 67, 68
Lupron Depot (3 month).. 16, 67,
68
Lupron Depot (4 month).. 16, 67,
68
Lupron Depot (6 Month) . 16, 67,
68
Lupron Depot-Ped ...... 16, 67, 68
Lupron Depot-Ped (3 month) 16,
67, 68
Lysodren ................................. 16
M Macugen ................................. 59
magnesium sulfate ...... 30, 41, 72
Makena ................................... 70
Makena (PF) ........................... 70
maprotiline .............................. 51
Matulane ................................. 16
Mavyret..................................... 7
Maxidex .................................. 58
meclizine............................. 1, 60
meclofenamate ........................ 48
Medrol .................................... 63
medroxyprogesterone ............. 70
mefloquine ................................ 4
megestrol .......................... 16, 70
meloxicam .............................. 48
melphalan ............................... 16
melphalan HCl ........................ 16
memantine .............................. 45
Menest .................................... 67
meperidine .............................. 47
Mephyton .......................... 72, 93
meprobamate .......................... 43
mercaptopurine ................. 16, 77
meropenem ............................... 6
mesalamine ............................. 60
mesna ...................................... 78
Mestinon ................................. 22
metaproterenol .................. 22, 82
metformin ............................... 65
Methergine .............................. 78
methimazole ........................... 64
methocarbamol ....................... 21
methotrexate sodium . 17, 74, 76,
77
methotrexate sodium (PF)17, 74,
76, 77
methyclothiazide............... 38, 55
methyldopa ....................... 20, 33
methyldopa-hydrochlorothiazide
.......................... 20, 33, 38, 55
methylphenidate HCl .............. 49
methylprednisolone ................ 64
methylprednisolone sodium succ
............................................ 64
metipranolol ............................ 57
100
metoclopramide HCl .............. 62
metolazone ....................... 39, 55
metoprolol succinate . 23, 30, 31,
34
metoprolol ta-hydrochlorothiaz
.............. 23, 30, 31, 34, 38, 55
metoprolol tartrate 23, 30, 31, 34
Metrogel ................................. 83
metronidazole ................. 3, 5, 83
metronidazole in NaCl (iso-os) 3,
5
mexiletine ............................... 33
Miconazole-3 .......................... 85
MICRhoGAM Ultra-Filtered
PLUS .................................. 19
Microgestin 1.5/30 (21) .......... 65
Microgestin Fe 1.5/30 (28) ..... 65
midodrine ............................... 20
miglustat ................................. 78
Migranal ........................... 22, 42
minocycline ............................ 13
minoxidil ................................ 35
Mirena .................................... 65
mirtazapine ............................. 42
misoprostol ............................. 62
mitomycin............................... 17
mitoxantrone........................... 17
moexipril ................................ 29
moexipril-hydrochlorothiazide
................................ 29, 38, 55
mometasone ...................... 84, 87
Monoclate-P ........................... 25
Monovisc ................................ 52
montelukast ............................ 80
morphine................................. 47
morphine concentrate ............. 47
Moxeza ................................... 57
moxifloxacin................. 5, 12, 57
Mozobil .................................. 24
Multigen ................................. 25
Multigen Folic ............ 25, 91, 93
Multigen Plus ............. 25, 91, 93
Multi-Vit with Fluoride-Iron . 25,
73, 90
Multivitamin With Fluoride .. 73,
90
Multi-Vitamin With Fluoride 73,
90
Multivitamins With Fluoride . 73,
90
mupirocin................................ 83
Mustargen ............................... 17
My Way .................................. 65
Mycamine ................................. 6
Mycobutin .......................... 5, 13
mycophenolate mofetil ........... 77
mycophenolate mofetil HCl ... 77
mycophenolate sodium ........... 77
Myleran .................................. 17
Mynatal ................. 25, 54, 90, 92
Mynatal Plus ......... 25, 54, 90, 92
Mynatal-Z ............. 26, 54, 90, 92
Mynate 90 Plus ....................... 90
Myobloc............................ 23, 78
N nabumetone ............................ 48
nadolol .................. 21, 30, 31, 34
nadolol-bendroflumethiazide. 21,
30, 31, 34, 38, 55
nafcillin ................................... 12
nafcillin in dextrose iso-osm .. 12
Naglazyme .............................. 56
nalbuphine .............................. 47
naltrexone ......................... 47, 71
naproxen ........................... 48, 72
naproxen sodium .............. 48, 72
naratriptan ............................... 50
Narcan .............................. 47, 72
Natrapel .................................. 89
Nature-Throid ......................... 71
Nebupent .................................. 5
nefazodone.............................. 50
neomycin-bacitracin-poly-HC
...................................... 57, 58
neomycin-bacitracin-polymyxin
............................................ 57
neomycin-polymyxin B-
dexameth ...................... 57, 58
neomycin-polymyxin-
gramicidin ........................... 57
neomycin-polymyxin-HC . 57, 58
Neulasta .................................. 24
Neupogen................................ 24
nevirapine ................................. 8
Nexavar .................................. 17
Nexium 24HR......................... 62
Nexplanon .............................. 65
niacin ...................................... 30
nicardipine ............ 32, 35, 36, 39
Nicomide ................................ 92
Nicotrol ................................... 21
Nicotrol NS ............................. 21
nifedipine .............. 32, 35, 36, 39
nilutamide ............................... 17
Nitro-Bid................................. 37
Nitro-Dur ................................ 37
nitrofurantoin .......................... 13
nitrofurantoin macrocrystal .... 13
nitrofurantoin monohyd/m-cryst
............................................ 13
nitroglycerin ........................... 37
Nitrostat .................................. 37
Nitro-Time .............................. 37
nizatidine ................................ 62
Non-Aspirin Jr Strength ......... 41
Norditropin FlexPro................ 69
norethindrone (contraceptive) 65
norethindrone acetate .............. 70
norethindrone ac-eth estradiol 66
norethindrone-e.estradiol-iron 66
norgestimate-ethinyl estradiol 66
norgestrel-ethinyl estradiol ..... 66
Nortrel 0.5/35 (28) .................. 66
Nortrel 1/35 (21) ..................... 66
Nortrel 7/7/7 (28) .................... 66
nortriptyline ............................ 51
Norvir ..................................... 10
Novolin 70/30 U-100 Insulin.. 68
Novolin N NPH U-100 Insulin
............................................ 69
Novolin R Regular U-100 Insuln
............................................ 69
Novolog Mix 70-30 U-100
Insuln .................................. 69
Novolog Mix 70-30FlexPen U-
100 ...................................... 69
Novoseven RT ........................ 25
NP Thyroid ............................. 71
Nplate ..................................... 24
Nucala ..................................... 79
Nutropin AQ Nuspin .............. 69
NuvaRing ................................ 66
nystatin ............................. 12, 88
nystatin-triamcinolone ............ 88
O Obstetrix DHA............ 26, 90, 92
Obstetrix EC ......... 26, 61, 90, 92
O-Cal FA .............. 26, 54, 90, 92
O-Cal Prenatal ...... 26, 54, 90, 92
Ocaliva .................................... 61
101
Ocrevus................................... 76
octreotide acetate .............. 70, 78
Odefsey................................. 8, 9
Off Active ......................... 88, 89
Off Deep Woods............... 88, 89
Off Deep Woods Dry ....... 88, 89
Off FamilyCare (with DEET) 88,
89
ofloxacin ........................... 12, 57
olanzapine............................... 43
olanzapine-fluoxetine ....... 43, 50
olmesartan .............................. 28
olmesartan-hydrochlorothiazide
................................ 28, 38, 55
olopatadine ............................. 56
Olysio ....................................... 7
omeprazole ............................. 62
omeprazole-sodium bicarbonate
............................................ 62
Omnitrope............................... 69
Oncaspar ................................. 17
ondansetron ............................ 60
ondansetron HCl ..................... 60
ondansetron HCl (PF)............. 60
One Daily Essential .......... 90, 92
One-A-Day Women's Prenatal 1
.......................... 26, 54, 90, 93
Opsumit ............................ 39, 82
Oracit ...................................... 52
Oralone ............................. 84, 87
Orencia ............................. 74, 76
Orencia (with maltose) ..... 74, 76
Orencia ClickJect ............. 74, 76
Orenitram ......................... 39, 82
Orfadin ................................... 78
Orkambi .................................. 79
ORTHOVISC ......................... 52
oseltamivir .............................. 11
Otezla ..................................... 74
Otezla Starter .......................... 74
oxacillin .................................. 12
oxaliplatin ............................... 17
oxaprozin ................................ 48
oxazepam ................................ 45
oxcarbazepine ......................... 41
Oxsoralen Ultra ...................... 88
oxybutynin chloride................ 89
oxycodone .............................. 47
oxycodone-acetaminophen .... 41,
47
Oxytrol For Women ............... 89
Ozempic.................................. 68
Ozurdex .................................. 58
P Pacerone ................................. 34
paclitaxel ................................ 17
paliperidone ............................ 43
palonosetron ........................... 60
pamidronate ............................ 72
Panhematin ............................. 78
pantoprazole ........................... 62
ParaGard T 380A.................... 66
paromomycin ............................ 3
paroxetine HCl ....................... 50
peg 3350-electrolytes ............. 61
Pegasys ................................... 10
Pegasys ProClick .................... 10
peg-electrolyte soln ................ 61
PegIntron ................................ 10
pen needle, diabetic ................ 52
penicillin G potassium ............ 11
penicillin V potassium ............ 11
Pentam ...................................... 5
Pentasa .................................... 60
pentoxifylline.......................... 24
perindopril erbumine .............. 29
Perjeta ..................................... 17
permethrin .............................. 88
perphenazine ........................... 48
perphenazine-amitriptyline .... 48,
51
phenazopyridine ..................... 85
phenelzine ............................... 46
phenobarbital .......................... 44
phenoxybenzamine ........... 22, 36
phenylephrine HCl ................. 59
phenytoin .......................... 33, 46
phenytoin sodium extended ... 33,
46
Phospholine Iodide ................. 59
Photofrin ................................. 17
pilocarpine HCl ...................... 59
pimozide ................................. 43
pindolol ........... 21, 30, 31, 34, 36
pioglitazone ............................ 71
pioglitazone-metformin .... 65, 71
piperacillin-tazobactam ............ 6
piroxicam ................................ 48
Plegridy .................................. 76
podofilox ................................ 89
polyethylene glycol 3350 ....... 61
polymyxin B sulf-trimethoprim
............................................ 57
Pomalyst ........................... 17, 76
potassium bicarb-citric acid .... 54
potassium chloride .................. 54
potassium citrate ..................... 52
Pradaxa ................................... 23
Praluent Pen ............................ 37
PramCort..................... 84, 85, 87
pramipexole ............................ 46
prasugrel ................................. 27
pravastatin............................... 35
prazosin............................. 21, 27
Pred Mild ................................ 58
prednisolone ........................... 64
prednisolone acetate ............... 58
prednisolone sodium phosphate
...................................... 58, 64
prednisone............................... 64
Prednisone Intensol ................ 64
Premarin ................................. 67
Premphase............................... 67
Prempro .................................. 67
Prenatabs FA ........ 26, 54, 90, 92
Prenatal + DHA .......... 26, 90, 92
Prenatal 19 .................. 26, 90, 92
Prenatal 19 (with docusate) ... 26,
90, 92
Prenatal Gummy ............... 90, 92
Prenatal Low Iron . 26, 54, 90, 92
Prenatal Multi-DHA ... 26, 90, 92
Prenatal Multi-DHA (algal oil)
................................ 26, 90, 92
Prenatal Plus ......... 26, 54, 90, 92
Prenatal Plus DHA ..... 26, 90, 92
prenatal vit-iron fum-folic ac . 26,
54, 91, 92
Prenatal-U ............................... 91
Prevalite .................................. 31
PreviDent ................................ 73
Prezcobix .......................... 10, 78
Prezista ................................... 10
Prialt ....................................... 41
Prilosec ................................... 62
primaquine ................................ 4
primidone ................................ 44
Privigen................................... 19
probenecid ........................ 55, 72
probenecid-colchicine ....... 56, 72
102
prochlorperazine ............... 48, 60
prochlorperazine Edisylate .... 48,
60
prochlorperazine maleate . 48, 60
Procrit ..................................... 24
Proctofoam HC ........... 84, 85, 87
Profilnine ................................ 25
progesterone micronized ........ 70
Prograf .................................... 77
Prolastin-C .............................. 81
Proleukin .......................... 17, 76
Prolia ...................................... 72
Promacta ................................. 24
promethazine ................ 1, 43, 80
promethazine-phenylephrine ... 1,
20, 80
propafenone ............................ 33
propantheline .......................... 20
proparacaine ........................... 59
propranolol 21, 30, 31, 34, 36, 42
propranolol-hydrochlorothiazid
.............. 21, 30, 31, 34, 38, 55
propylthiouracil ...................... 64
Prosol 20 % ............................ 53
Provenge ................................. 40
Pulmicort Flexhaler .......... 64, 80
Pulmozyme ....................... 56, 80
pyrazinamide ............................ 5
pyridostigmine bromide ......... 22
pyridoxine (vitamin B6) ......... 92
Q quetiapine ............................... 44
quinapril ................................. 29
quinapril-hydrochlorothiazide
................................ 29, 38, 55
quinidine gluconate ............ 4, 33
quinidine sulfate ................. 4, 33
Qvar .................................. 64, 80
Qvar RediHaler ................ 64, 81
R Radicava ................................. 45
raloxifene .......................... 66, 72
ramipril ................................... 29
ranitidine HCl ......................... 62
Rapamune ............................... 77
Rebetol ................................... 11
Rebif (with albumin) .............. 76
Rebif Titration Pack ............... 76
Recombinate ........................... 25
Relenza Diskhaler .................. 11
Remicade .............. 61, 74, 76, 78
Remodulin ........................ 39, 82
Renflexis ..................... 62, 74, 76
Repatha Pushtronex ................ 37
Repatha SureClick .................. 37
Repatha Syringe ..................... 37
Repel Sportsmen............... 88, 89
Repel Sportsmen Max ...... 88, 89
Rescriptor ................................. 8
reserpine ................................. 37
Restasis ................................... 58
Restasis MultiDose ................. 58
Retisert.................................... 58
Retrovir ..................................... 9
Revatio.............................. 37, 82
Revlimid ........................... 17, 76
Reyataz ................................... 10
RhoGAM Ultra-Filtered PLUS
............................................ 19
Rhophylac ............................... 19
Ribasphere .............................. 11
Ribasphere RibaPak ............... 11
ribavirin .................................. 11
Ridaura ....................... 63, 74, 76
rifampin .............................. 5, 13
riluzole .................................... 45
Risperdal Consta..................... 44
risperidone .............................. 44
ritonavir .................................. 10
Rituxan ................................... 17
Rituxan Hycela ....................... 17
rivastigmine tartrate ................ 22
rizatriptan................................ 50
romidepsin .............................. 17
ropinirole ................................ 46
rosuvastatin ............................. 35
S Sabril ...................................... 41
Saizen ..................................... 69
Saizen click.easy .................... 69
salsalate .................................. 49
Samsca .................................... 56
Sandimmune ............... 74, 76, 77
Santyl ...................................... 89
Savella .............................. 46, 49
Segluromet........................ 65, 70
selegiline HCl ......................... 46
Selzentry ................................... 8
Se-Natal 19 ................. 26, 91, 92
Se-Natal 19 (with docusate) .. 26,
61, 91, 92
Serevent Diskus ................ 23, 82
Serostim .................................. 69
sertraline ................................. 50
sevelamer carbonate ......... 53, 72
SF ............................................ 73
SF 5000 Plus ........................... 73
Signifor ................................... 70
sildenafil (antihypertensive) .. 37,
82
Siliq......................................... 89
silver sulfadiazine ................... 87
Simponi............................. 74, 76
Simponi ARIA .................. 74, 76
Simulect .................................. 77
simvastatin .............................. 35
sirolimus ................................. 77
Sklice ...................................... 88
Skyla ....................................... 66
sodium chloride ................ 52, 54
sodium citrate-citric acid ........ 52
sodium polystyrene (sorb free)
...................................... 53, 72
Soft Touch Lancets ................. 52
Solesta..................................... 52
Soliris ...................................... 73
Solu-Cortef (PF) ..................... 64
Somatuline Depot ................... 70
Somavert ................................. 70
sotalol ............. 21, 30, 31, 34, 36
Sotalol AF ....... 21, 30, 31, 34, 36
Sovaldi ...................................... 7
Spinraza (PF) .................... 72, 78
Spiriva Respimat .............. 20, 79
spironolactone............. 36, 37, 53
spironolacton-hydrochlorothiaz
.................... 36, 37, 38, 53, 55
Sporanox ................................... 6
Sprycel .................................... 17
SPS (with sorbitol) ........... 53, 72
SSKI ....................... 4, 64, 72, 79
stavudine ................................... 9
Steglatro .................................. 70
Stelara ......................... 74, 76, 89
Stiolto Respimat ............... 20, 23
Stivarga ................................... 17
Stribild .................................. 8, 9
Sucraid .................................... 56
sucralfate................................. 62
103
sulfacetamide sodium ............. 57
sulfacetamide sodium (acne) .. 87
sulfacetamide sodium-sulfur .. 87
sulfacetamide-prednisolone .... 57
sulfadiazine............................. 13
sulfamethoxazole-trimethoprim
............................................ 13
sulfasalazine ......... 13, 60, 74, 76
sulindac................................... 48
sumatriptan ............................. 50
sumatriptan succinate ............. 50
Supartz FX.............................. 52
Supprelin LA .............. 17, 67, 68
Suprax....................................... 3
Sutent ...................................... 17
Sylatron ............................ 10, 17
Symdeko ................................. 79
Symfi .................................... 8, 9
Symfi Lo ............................... 8, 9
Synagis ................................... 11
Synarel .............................. 67, 68
Synercid .................................. 13
Synribo ................................... 17
Synvisc ................................... 52
Synvisc-One ........................... 52
T Tabloid ................................... 17
tacrolimus ......................... 77, 89
Taltz Autoinjector .................. 89
Taltz Syringe .......................... 89
tamoxifen .......................... 17, 66
tamsulosin............................... 22
Tarceva ................................... 17
Targretin ........................... 17, 89
Tasigna ................................... 17
TAZICEF ................................. 3
Tecfidera................................. 76
Technivie ............................ 7, 10
telmisartan .............................. 28
temazepam .............................. 45
Temodar ................................. 17
temozolomide ......................... 17
teniposide ............................... 17
tenofovir disoproxil fumarate ... 9
terazosin ..................... 21, 27, 36
terbinafine HCl ......................... 3
terbutaline ......................... 23, 82
terconazole ............................. 85
testosterone ............................. 64
testosterone cypionate ............ 64
testosterone enanthate............. 64
tetracaine HCl ......................... 59
tetracaine HCl (PF) ................. 59
tetracycline ............................. 13
Thalomid ................................ 76
Theo-24 ................ 35, 53, 82, 89
theophylline .......... 35, 53, 82, 89
thioridazine ............................. 48
thiotepa ................................... 18
thiothixene .............................. 50
Thymoglobulin ....................... 77
Thyrogen ................................ 52
thyroid (pork) ......................... 71
Thyrolar-1 ............................... 71
Thyrolar-1/2............................ 71
Thyrolar-1/4............................ 71
Thyrolar-2 ............................... 71
Thyrolar-3 ............................... 71
Tice BCG .......................... 18, 19
tigecycline ................................ 7
timolol maleate .... 21, 30, 31, 34,
36, 42, 57
Tivicay ...................................... 8
tizanidine ................................ 21
Tobi Podhaler ........................... 4
tobramycin .............................. 57
tobramycin in 0.225 % NaCl .... 4
tobramycin sulfate .................... 4
tobramycin-dexamethasone ... 57,
58
Tobrex .................................... 57
tolazamide .............................. 70
tolbutamide ............................. 70
tolterodine ............................... 89
topiramate ............................... 41
topotecan ................................ 18
Torisel ..................................... 18
torsemide .......................... 36, 53
TPN Electrolytes .................... 54
TPN Electrolytes II ................. 54
Tracleer ............................. 39, 82
tramadol .................................. 47
tramadol-acetaminophen . 41, 43,
47
trandolapril ............................. 29
tranylcypromine...................... 46
Travasol 10 % ......................... 53
trazodone ................................ 50
Treanda ................................... 18
Trelstar.............................. 18, 67
Tremfya .................................. 89
tretinoin................................... 85
tretinoin (chemotherapy) ........ 18
Trexall................... 18, 74, 76, 77
TriAdvance ........... 26, 54, 91, 92
triamcinolone acetonide.... 84, 87
triamterene-hydrochlorothiazid
.......................... 37, 38, 53, 55
triazolam ................................. 45
trientine ................................... 63
trifluoperazine......................... 48
trifluridine ............................... 57
trihexyphenidyl ................. 20, 41
trimethobenzamide ................. 60
trimethoprim ........................... 13
Trinatal Rx 1 ......... 26, 54, 91, 92
Trinate................... 26, 54, 91, 92
Triumeq ................................ 8, 9
Triveen-Duo DHA 26, 54, 91, 92
Tri-Vit with Fluoride and Iron
................................ 26, 73, 91
Tri-Vitamin With Fluoride .... 73,
91, 93
Trizivir ...................................... 9
Trogarzo ................................... 8
TrophAmine 10 % .................. 53
tropicamide ............................. 59
trospium .................................. 89
Trulicity .................................. 68
Truvada ..................................... 9
Tybost ..................................... 78
Tykerb..................................... 18
Tymlos .................................... 69
Tysabri .................................... 76
Tyvaso .............................. 39, 82
Tyvaso Refill Kit .............. 39, 82
Tyvaso Starter Kit............. 39, 82
U U-Cort ..................................... 87
Uptravi .............................. 39, 82
urea ......................................... 87
ursodiol ................................... 61
V Vaginal Contraceptive Foam .. 51
valacyclovir ............................ 12
valproic acid ............... 41, 42, 43
valproic acid (as sodium salt) 42,
43
valsartan .................................. 28
104
valsartan-hydrochlorothiazide
................................ 28, 38, 55
Valstar .................................... 18
vancomycin .............................. 7
vancomycin in dextrose 5 % .... 7
Vantas ......................... 18, 67, 68
Vectibix .................................. 18
Velcade ................................... 18
Veletri ............................... 39, 82
Velivet Triphasic Regimen (28)
............................................ 66
venlafaxine ....................... 49, 50
Venofer ................................... 26
Ventavis ............................ 39, 82
Ventolin HFA ................... 23, 82
verapamil ........ 31, 32, 33, 34, 39
Vibativ ...................................... 7
Victoza 2-Pak ......................... 68
Victoza 3-Pak ......................... 68
Vidaza..................................... 18
Videx 2 gram Pediatric ............. 9
Viekira Pak ......................... 7, 10
Viekira XR ......................... 7, 10
vigabatrin ................................ 42
Vinate GT ................... 26, 91, 92
Vinate II.................................. 91
Vinate M ................................. 91
Vinate One............ 26, 54, 91, 92
Vinate Ultra .... 26, 54, 61, 91, 92
vinblastine .............................. 18
vincristine ............................... 18
vinorelbine .............................. 18
Viracept .................................. 10
Viramune XR ........................... 8
Viread ....................................... 9
Visudyne ................................. 59
Vivitrol ............................. 47, 71
Vol-Nate ............... 26, 54, 91, 92
Voraxaze ........................... 56, 72
voriconazole ............................. 6
Vosevi ....................................... 7
Votrient ................................... 18
VPRIV .................................... 56
Vyvanse .................................. 40
W warfarin .................................. 23
WelChol............................ 31, 64
WinRho SDF .......................... 19
Women's Prenatal + DHA ..... 26,
91, 92
X Xalkori .................................... 18
Xarelto .................................... 23
Xeljanz.............................. 74, 76
Xeljanz XR ....................... 74, 77
Xenazine ........................... 45, 51
Xeomin ............................. 23, 78
Xgeva...................................... 72
Xiaflex .................................... 56
Xifaxan ................................... 13
Xiidra ...................................... 58
Xolair ...................................... 81
Xopenex HFA................... 23, 82
Xtandi ..................................... 18
Xulane .................................... 66
Xyntha .................................... 25
Xyntha Solofuse ..................... 25
Y Yervoy .................................... 18
Z zaleplon................................... 43
Zaltrap..................................... 18
Zanosar ................................... 18
Zarxio ..................................... 24
Zelboraf .................................. 18
Zemaira ................................... 81
Zenpep .................................... 61
Zepatier ..................................... 7
Zerit .......................................... 9
Zevalin (Y-90) ........................ 18
zidovudine ................................ 9
ziprasidone HCl ...................... 44
Zmax ....................................... 12
Zoladex ....................... 18, 67, 68
zoledronic acid........................ 72
zoledronic acid-mannitol-water
............................................ 72
Zolinza .................................... 18
zolpidem ................................. 43
Zometa .................................... 72
zonisamide .............................. 42
Zortress ................................... 77
Zosyn in dextrose (iso-osm) ..... 6
Zovia 1/35E (28)..................... 66
Zovirax ................................... 85
Zykadia ................................... 18
Zyprexa Relprevv ................... 44
Zytiga ...................................... 18
Zyvox ...................................... 12