illinois medicaid preferred drug list...illinois medicaid preferred drug list effective january 1,...

Illinois Medicaid Preferred Drug List

Effective January 1, 2020

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

and PDL status

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

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

years of age and older

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

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

� Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those

participants with a diagnosis of epilepsy or seizure disorder in Department records

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

residents

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

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DRUG CLASS DRUG NAME DOSAGE FORM

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

DYANAVEL XR SUER NON_PREFERRED

ADZENYS XR-ODT TBED NON_PREFERRED

AMPHETAMINE SULFATE TABS NON_PREFERRED

EVEKEO TABS NON_PREFERRED

EVEKEO ODT TBDP NON_PREFERRED

DEXEDRINE CP24 NON_PREFERRED

DEXTROAMPHETAMINE SULFATE CP24 NON_PREFERRED

DEXTROAMPHETAMINE SULFATE SOLN NON_PREFERRED

PROCENTRA SOLN NON_PREFERRED

DEXTROAMPHETAMINE SULFATE TABS NON_PREFERRED

ZENZEDI TABS NON_PREFERRED

VYVANSE CAPS PREFERRED

VYVANSE CHEW PREFERRED

DESOXYN TABS NON_PREFERRED

METHAMPHETAMINE HCL TABS NON_PREFERRED

ADDERALL XR CP24 NON_PREFERRED

AMPHETAMINE/DEXTROAMPHETA CP24 PREFERRED

MYDAYIS CP24 NON_PREFERRED

ADDERALL TABS NON_PREFERRED

AMPHETAMINE/DEXTROAMPHETA TABS PREFERRED

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

CLONIDINE HYDROCHLORIDE TB12 PREFERRED

CLONIDINE HYDROCHLORIDE E TB12 PREFERRED

GUANFACINE ER TB24 PREFERRED

GUANFACINE HYDROCHLORIDE TB24 PREFERRED

INTUNIV TB24 NON_PREFERRED

ATOMOXETINE CAPS NON_PREFERRED

ATOMOXETINE HYDROCHLORIDE CAPS NON_PREFERRED

STRATTERA CAPS NON_PREFERRED

SUNOSI TABS NON_PREFERRED

ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTS ARMODAFINIL TABS NON_PREFERRED

NUVIGIL TABS NON_PREFERRED

DEXMETHYLPHENIDATE HCL ER CP24 NON_PREFERRED

DEXMETHYLPHENIDATE HYDROC CP24 NON_PREFERRED

FOCALIN XR CP24 PREFERRED

DEXMETHYLPHENIDATE HCL TABS PREFERRED

DEXMETHYLPHENIDATE HYDROC TABS PREFERRED

FOCALIN TABS NON_PREFERRED

DAYTRANA PTCH NON_PREFERRED

COTEMPLA XR-ODT TBED NON_PREFERRED

QUILLICHEW ER CHER NON_PREFERRED

METHYLPHENIDATE HYDROCHLO CHEW NON_PREFERRED

PDL STATUS

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DRUG CLASS DRUG NAME DOSAGE FORM PDL STATUS

APTENSIO XR CP24 NON_PREFERRED

JORNAY PM CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLO CP24 NON_PREFERRED

RITALIN LA CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLO CPCR NON_PREFERRED

METHYLIN SOLN NON_PREFERRED

METHYLPHENIDATE HYDROCHLO SOLN NON_PREFERRED

QUILLIVANT XR SUSR NON_PREFERRED

METHYLPHENIDATE HYDROCHLO TABS PREFERRED

RITALIN TABS NON_PREFERRED

METHYLPHENIDATE HYDROCHLO TB24 NON_PREFERRED

METADATE ER TBCR PREFERRED

METHYLPHENID TAB 10MG ER TBCR PREFERRED

METHYLPHENID TAB 20MG ER TBCR PREFERRED

CONCERTA TBCR PREFERRED

METHYLPHENID TAB 18MG ER TBCR NON_PREFERRED





RELEXXII TBCR NON_PREFERRED

MODAFINIL TABS NON_PREFERRED

PROVIGIL TABS NON_PREFERRED

ANALGESICS - ANTI-INFLAMMATORY : MISC RIDAURA CAPS PREFERRED

OTREXUP SOAJ NON_PREFERRED

RASUVO SOAJ NON_PREFERRED

METHOTREXATE TABS PREFERRED

ARAVA TABS NON_PREFERRED

LEFLUNOMIDE TABS PREFERRED

ANALGESICS - ANTI-INFLAMMATORY : NONSTEROIDAL ANTI-

INFLAMMATORY AGENTS (NSAIDs) ZORVOLEX CAPS NON_PREFERRED

ZIPSOR CAPS NON_PREFERRED

DICLOFENAC POTASSIUM TABS PREFERRED

DICLOFENAC SODIUM ER TB24 PREFERRED

DICLOFENAC SODIUM DR TBEC PREFERRED

ETODOLAC CAPS PREFERRED

ETODOLAC TABS PREFERRED

ETODOLAC ER TB24 PREFERRED

FENOPROFEN CALCIUM CAPS NON_PREFERRED

NALFON CAPS NON_PREFERRED

FENOPROFEN CALCIUM TABS NON_PREFERRED

NALFON TABS NON_PREFERRED

FLURBIPROFEN TABS PREFERRED

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IBUPROFEN SUSP NON_PREFERRED

IBU TABS PREFERRED

IBUPROFEN TABS PREFERRED

INDOMETHACIN CAPS PREFERRED

TIVORBEX CAPS NON_PREFERRED

INDOMETHACIN ER CPCR PREFERRED

INDOCIN SUPP NON_PREFERRED

INDOCIN SUSP NON_PREFERRED

KETOPROFEN ER CP24 NON_PREFERRED

SPRIX SOLN NON_PREFERRED

KETOROLAC TROMETHAMINE TABS PREFERRED

MECLOFENAMATE SODIUM CAPS NON_PREFERRED

MEFENAMIC ACID CAPS NON_PREFERRED

VIVLODEX CAPS NON_PREFERRED

MELOXICAM TABS PREFERRED

MOBIC TABS NON_PREFERRED

QMIIZ ODT TBDP NON_PREFERRED

NABUMETONE TABS PREFERRED

RELAFEN DS TABS NON_PREFERRED

NAPROXEN SUSP PREFERRED

NAPROXEN TABS PREFERRED

EC-NAPROXEN TBEC NON_PREFERRED

NAPROXEN DR TBEC PREFERRED

NAPROXEN SODIUM TABS PREFERRED

NAPRELAN TB24 NON_PREFERRED

NAPROXEN SODIUM TB24 NON_PREFERRED

NAPROXEN SODIUM CR TB24 NON_PREFERRED

NAPROXEN SODIUM ER TB24 NON_PREFERRED

DAYPRO TABS NON_PREFERRED

OXAPROZIN TABS NON_PREFERRED

FELDENE CAPS NON_PREFERRED

PIROXICAM CAPS NON_PREFERRED

SULINDAC TABS PREFERRED

TOLMETIN SODIUM CAPS NON_PREFERRED

TOLMETIN SODIUM TABS NON_PREFERRED

CELEBREX CAPS NON_PREFERRED

CELECOXIB CAPS PREFERRED

INFLAMMACIN THPK NON_PREFERRED

ARTHROTEC 50 TBEC NON_PREFERRED

ARTHROTEC 75 TBEC NON_PREFERRED

DICLOFENAC SODIUM/MISOPRO TBEC NON_PREFERRED

DUEXIS TABS NON_PREFERRED

VIMOVO TBEC NON_PREFERRED

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ANALGESICS - NONNARCOTIC DIFLUNISAL TABS PREFERRED

SALSALATE TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN CAPS NON_PREFERRED

ALLZITAL TABS NON_PREFERRED

BUPAP TABS NON_PREFERRED

BUTALBITAL/ACETAMINOPHEN TABS PREFERRED

BUT/APAP/CAF CAP CAPS PREFERRED

ESGIC CAPS PREFERRED

FIORICET CAPS NON_PREFERRED

ZEBUTAL CAPS PREFERRED

VANATOL LQ SOLN NON_PREFERRED

VANATOL S SOLN NON_PREFERRED

BUTALBITAL/ACETAMINOPHEN/ TABS PREFERRED

ESGIC TABS NON_PREFERRED

BUTALBITAL/ASPIRIN/CAFFEI CAPS PREFERRED

FIORINAL CAPS NON_PREFERRED

BUTALBITAL/ASPIRIN/CAFFEI TABS PREFERRED

ANALGESICS : OPIOID CODEINE SULFATE TABS PREFERRED

SUBSYS LIQD NON_PREFERRED

DURAGESIC PT72 NON_PREFERRED

FENTANYL PT72 NON_PREFERRED

ACTIQ LPOP NON_PREFERRED

FENTANYL CITRATE ORAL TRA LPOP NON_PREFERRED

LAZANDA SOLN NON_PREFERRED

ABSTRAL SUBL NON_PREFERRED

FENTANYL CITRATE TABS NON_PREFERRED

FENTORA TABS NON_PREFERRED

ZOHYDRO ER C12A NON_PREFERRED

HYSINGLA ER T24A NON_PREFERRED

DILAUDID LIQD NON_PREFERRED

HYDROMORPHONE HCL LIQD PREFERRED

HYDROMORPHONE HCL SUPP PREFERRED

HYDROMORPHONE HCL ER T24A NON_PREFERRED

HYDROMORPHONE HYDROCHLORI T24A NON_PREFERRED

DILAUDID TABS NON_PREFERRED

HYDROMORPHONE HCL TABS PREFERRED

LEVORPHANOL TARTRATE TABS NON_PREFERRED

MEPERIDINE HCL SOLN NON_PREFERRED

MEPERIDINE HCL TABS NON_PREFERRED

METHADONE HCL CONC NON_PREFERRED

METHADONE HCL INTENSOL CONC NON_PREFERRED

METHADOSE CONC NON_PREFERRED

METHADOSE SUGAR-FREE CONC NON_PREFERRED

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METHADONE HCL SOLN NON_PREFERRED

DOLOPHINE TABS NON_PREFERRED

METHADONE HCL TABS NON_PREFERRED

METHADONE HYDROCHLORIDE TABS NON_PREFERRED

METHADONE HCL TBSO NON_PREFERRED

METHADOSE TBSO NON_PREFERRED

KADIAN CP24 NON_PREFERRED

MORPHINE SULFATE ER CP24 NON_PREFERRED

MORPHINE SULFATE SOLN PREFERRED

MORPHINE SULFATE SUPP PREFERRED

MORPHABOND ER T12A NON_PREFERRED

MORPHINE SULFATE TABS PREFERRED

MORPHINE SULFATE ER TBCR PREFERRED_WITH_PA

MS CONTIN TBCR NON_PREFERRED

ARYMO ER TBEA NON_PREFERRED

MORPHINE SULFATE ER CP24 NON_PREFERRED

EMBEDA CPCR PREFERRED_WITH_PA

XTAMPZA ER C12A NON_PREFERRED

OXYCODONE HCL CAPS PREFERRED

OXYCODONE HYDROCHLORIDE CAPS PREFERRED

OXYCODONE HCL CONC PREFERRED

OXYCODONE HYDROCHLORIDE CONC PREFERRED

OXYCODONE HCL SOLN PREFERRED

OXYCODONE HYDROCHLORIDE SOLN PREFERRED

OXYCODONE HCL ER T12A NON_PREFERRED

OXYCODONE HYDROCHLORIDE E T12A NON_PREFERRED

OXYCONTIN T12A NON_PREFERRED

OXAYDO TABA NON_PREFERRED

ROXYBOND TABA NON_PREFERRED

OXYCODONE HCL TABS PREFERRED

OXYCODONE HYDROCHLORIDE TABS PREFERRED

ROXICODONE TABS NON_PREFERRED

OPANA TABS NON_PREFERRED

OXYMORPHONE HYDROCHLORIDE TABS NON_PREFERRED

OXYMORPHONE HYDROCHLORIDE TB12 NON_PREFERRED

NUCYNTA TABS NON_PREFERRED

NUCYNTA ER TB12 NON_PREFERRED

CONZIP CP24 NON_PREFERRED

TRAMADOL HCL ER CP24 NON_PREFERRED

TRAMADOL HCL TABS PREFERRED

ULTRAM TABS NON_PREFERRED

TRAMADOL HCL ER TB24 NON_PREFERRED

BUPRENORPHINE PTWK NON_PREFERRED

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BUTRANS PTWK NON_PREFERRED

BELBUCA FILM NON_PREFERRED

BUTORPHANOL TARTRATE SOLN NON_PREFERRED

PENTAZOCINE/NALOXONE HCL TABS NON_PREFERRED

ANALGESICS : OPIOID COMBINATIONS APADAZ TABS NON_PREFERRED

BENZHYDROCODONE/ACETAMINO TABS NON_PREFERRED

ENDOCET TABS PREFERRED

NALOCET TABS NON_PREFERRED

OXYCODONE/ACETAMINOPHEN TABS PREFERRED

PERCOCET TABS NON_PREFERRED

PRIMLEV TABS NON_PREFERRED

OXYCODONE/ASPIRIN TABS NON_PREFERRED

OXYCODONE/IBUPROFEN TABS NON_PREFERRED

ACETAMINOPHEN/CODEINE SOLN PREFERRED

ACETAMINOPHEN/CODEINE TABS PREFERRED

ACETAMINOPHEN/CODEINE PHO TABS PREFERRED

TYLENOL/CODEINE #3 TABS NON_PREFERRED

TYLENOL/CODEINE #4 TABS NON_PREFERRED

BUTALBITAL/ACETAMINOPHEN/ CAPS NON_PREFERRED

ASCOMP/CODEINE CAPS PREFERRED

BUTALBITAL/ASPIRIN/CAFFEI CAPS PREFERRED

FIORINAL/CODEINE #3 CAPS NON_PREFERRED

ACETAMINOPHEN/CAFFEINE/DI CAPS NON_PREFERRED

DVORAH TABS NON_PREFERRED

LORTAB ELIX NON_PREFERRED

HYDROCODONE BITARTRATE/AC SOLN PREFERRED

HYDROCODONE BITARTRATE/AC TABS PREFERRED

HYDROCODONE/ACETAMINOPHEN TABS PREFERRED

LORCET TABS PREFERRED

LORCET HD TABS PREFERRED

LORCET PLUS TABS PREFERRED

NORCO TABS NON_PREFERRED

VICODIN ES TABS PREFERRED

VICODIN HP TABS PREFERRED

HYDROCODONE/IBUPROFEN TABS PREFERRED

TRAMADOL HYDROCHLORIDE/AC TABS NON_PREFERRED

ULTRACET TABS NON_PREFERRED

ANAPHYLAXIS THERAPY AGENTS EPINEPHRINE SOAJ PREFERRED

EPIPEN 2-PAK SOAJ NON_PREFERRED

EPIPEN-JR 2-PAK SOAJ NON_PREFERRED

ADRENALIN SOLN PREFERRED

SYMJEPI SOSY NON_PREFERRED

ANDROGENS - ANABOLIC DANAZOL CAPS PREFERRED

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METHYLTESTOSTERONE CAPS NON_PREFERRED

METHITEST TABS NON_PREFERRED

ANDROGEL GEL NON_PREFERRED

ANDROGEL PUMP GEL NON_PREFERRED

FORTESTA GEL NON_PREFERRED

TESTIM GEL NON_PREFERRED

TESTOSTERONE GEL NON_PREFERRED

TESTOSTERONE PUMP GEL NON_PREFERRED

VOGELXO GEL NON_PREFERRED

VOGELXO PUMP GEL NON_PREFERRED

STRIANT MISC NON_PREFERRED

ANDRODERM PT24 NON_PREFERRED

TESTOSTERONE SOLN NON_PREFERRED

TESTOSTERONE TOPICAL SOLU SOLN NON_PREFERRED

DEPO-TESTOSTERONE SOLN NON_PREFERRED

TESTOSTERONE CYPIONATE SOLN NON_PREFERRED

XYOSTED SOAJ NON_PREFERRED

TESTOSTERONE ENANTHATE SOLN NON_PREFERRED

AVEED SOLN NON_PREFERRED

OXANDROLONE TABS NON_PREFERRED

ANADROL-50 TABS PREFERRED

ANORECTAL AGENTS ANUSOL-HC CREA NON_PREFERRED

HYDROCORTISONE CREA PREFERRED

PROCTO-MED HC CREA PREFERRED

PROCTO-PAK CREA PREFERRED

PROCTOSOL HC CREA PREFERRED

PROCTOZONE-HC CREA PREFERRED

UCERIS FOAM NON_PREFERRED

COLOCORT ENEM PREFERRED

CORTENEMA ENEM NON_PREFERRED

HYDROCORTISONE ENEM PREFERRED

CORTIFOAM FOAM PREFERRED

RECTIV OINT NON_PREFERRED

LIDOCAINE HCL/HYDROCORTIS CREA NON_PREFERRED

LIDOCAINE HCL-HYDROCORTIS GEL NON_PREFERRED

ANA-LEX KIT NON_PREFERRED

LIDOCAINE HCL/HYDROCORTIS KIT NON_PREFERRED

PROCTOFOAM HC FOAM NON_PREFERRED

ANTIANXIETY AGENTS : BENZODIAZEPINES ALPRAZOLAM INTENSOL CONC PREFERRED

ALPRAZOLAM TABS PREFERRED

XANAX TABS NON_PREFERRED

ALPRAZOLAM ER TB24 NON_PREFERRED

ALPRAZOLAM XR TB24 NON_PREFERRED

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XANAX XR TB24 NON_PREFERRED

ALPRAZOLAM ODT TBDP NON_PREFERRED

CHLORDIAZEPOXIDE HCL CAPS PREFERRED

CLORAZEPATE DIPOTASSIUM TABS PREFERRED

TRANXENE T TABS NON_PREFERRED

DIAZEPAM CONC PREFERRED

DIAZEPAM INTENSOL CONC PREFERRED

DIAZEPAM SOLN PREFERRED

DIAZEPAM TABS PREFERRED

LORAZEPAM CONC PREFERRED

LORAZEPAM INTENSOL CONC PREFERRED

ATIVAN TABS NON_PREFERRED

LORAZEPAM TABS PREFERRED

OXAZEPAM CAPS PREFERRED

ANTIANXIETY AGENTS : MISC BUSPIRONE HCL TABS PREFERRED

BUSPIRONE HYDROCHLORIDE TABS PREFERRED

HYDROXYZINE HCL SYRP PREFERRED

HYDROXYZINE HCL TABS PREFERRED

HYDROXYZINE HYDROCHLORIDE TABS PREFERRED

HYDROXYZINE PAMOATE CAPS PREFERRED

VISTARIL CAPS NON_PREFERRED

MEPROBAMATE TABS NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS :

ADRENERGIC COMBINATIONS COMBIVENT RESPIMAT AERS NON_PREFERRED

IPRATROPIUM BROMIDE/ALBUT SOLN PREFERRED

DUAKLIR PRESSAIR AEPB NON_PREFERRED

SYMBICORT AERO PREFERRED

BEVESPI AEROSPHERE AERO PREFERRED

UTIBRON NEOHALER CAPS NON_PREFERRED

ADVAIR DISKUS AEPB NON_PREFERRED

AIRDUO RESPICLICK 113/14 AEPB NON_PREFERRED



FLUTICASONE PROPIONATE/SA AEPB NON_PREFERRED

WIXELA INHUB AEPB PREFERRED

ADVAIR HFA AERO NON_PREFERRED

BREO ELLIPTA AEPB NON_PREFERRED

DULERA AERO PREFERRED

STIOLTO RESPIMAT AERS NON_PREFERRED

ANORO ELLIPTA AEPB NON_PREFERRED

TRELEGY ELLIPTA AEPB NON_PREFERRED


ANTICHOLINERGICS SEEBRI NEOHALER CAPS NON_PREFERRED

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LONHALA MAGNAIR REFILL KI SOLN NON_PREFERRED

LONHALA MAGNAIR STARTER K SOLN NON_PREFERRED

IPRATROPIUM BROMIDE SOLN PREFERRED

ATROVENT HFA AERS PREFERRED

YUPELRI SOLN NON_PREFERRED

SPIRIVA AER 1.25MCG AERS PREFERRED

SPIRIVA SPR 2.5MCG AERS NON_PREFERRED

SPIRIVA HANDIHALER CAPS PREFERRED

INCRUSE ELLIPTA AEPB NON_PREFERRED

CROMOLYN SODIUM NEBU PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : BETA

ADRENERGICS PROAIR DIGIHALER AEPB NON_PREFERRED

PROAIR RESPICLICK AEPB NON_PREFERRED

ALBUTEROL SULFATE HFA AERS NON_PREFERRED

PROAIR HFA AERS PREFERRED

PROVENTIL HFA AERS PREFERRED

VENTOLIN HFA AERS NON_PREFERRED

ALBUTEROL SULFATE NEBU PREFERRED

ALBUTEROL SULFATE SYRP PREFERRED

ALBUTEROL TABS NON_PREFERRED

ALBUTEROL SULFATE TABS NON_PREFERRED

ALBUTEROL SULFATE ER TB12 NON_PREFERRED

BROVANA NEBU NON_PREFERRED

PERFOROMIST NEBU NON_PREFERRED

ARCAPTA NEOHALER CAPS NON_PREFERRED

LEVALBUTEROL NEBU NON_PREFERRED

LEVALBUTEROL HCL NEBU NON_PREFERRED

LEVALBUTEROL HYDROCHLORID NEBU NON_PREFERRED

XOPENEX NEBU NON_PREFERRED

XOPENEX CONCENTRATE NEBU NON_PREFERRED

LEVALBUTEROL TARTRATE HFA AERO NON_PREFERRED

XOPENEX HFA AERO NON_PREFERRED

METAPROTERENOL SULFATE SYRP NON_PREFERRED

STRIVERDI RESPIMAT AERS NON_PREFERRED

SEREVENT DISKUS AEPB PREFERRED

TERBUTALINE SULFATE TABS PREFERRED


LEUKOTRIENE MODULATORS ZYFLO TABS NON_PREFERRED

ZILEUTON ER TB12 NON_PREFERRED

MONTELUKAST SODIUM CHEW PREFERRED

SINGULAIR CHEW NON_PREFERRED

MONTELUKAST SODIUM PACK PREFERRED

SINGULAIR PACK NON_PREFERRED

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MONTELUKAST SODIUM TABS PREFERRED

SINGULAIR TABS NON_PREFERRED

ACCOLATE TABS NON_PREFERRED

ZAFIRLUKAST TABS PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MISC THEO-24 CP24 PREFERRED

ELIXOPHYLLIN ELIX PREFERRED

THEOPHYLLINE SOLN PREFERRED

THEOPHYLLINE ER TB12 PREFERRED

THEOPHYLLINE ER TB24 PREFERRED

DALIRESP TABS NON_PREFERRED


MONOCLONAL ANTIBODIES XOLAIR SOLR NON_PREFERRED

XOLAIR SOSY NON_PREFERRED

FASENRA PEN SOAJ NON_PREFERRED

FASENRA SOSY NON_PREFERRED

NUCALA SOAJ NON_PREFERRED

NUCALA SOLR PREFERRED_WITH_PA

NUCALA SOSY NON_PREFERRED

CINQAIR SOLN NON_PREFERRED

DUPIXENT INJ 200/1.14 SOSY PREFERRED_WITH_PA

DUPIXENT INJ 300/2ML SOSY NON_PREFERRED

INHALANTS QVAR REDIHALER AERB NON_PREFERRED

PULMICORT FLEXHALER AEPB NON_PREFERRED

BUDESONIDE SUSP PREFERRED

PULMICORT SUSP NON_PREFERRED

ALVESCO AERS NON_PREFERRED

ARNUITY ELLIPTA AEPB NON_PREFERRED

FLOVENT DISKUS AEPB PREFERRED

FLOVENT HFA AERO PREFERRED

ASMANEX TWISTHALER 120 ME AEPB PREFERRED

ASMANEX TWISTHALER 14 MET AEPB PREFERRED



ASMANEX HFA AERO NON_PREFERRED

ANTIBIOITCS : FLUOROQUINOLONES CIPRO SUSR NON_PREFERRED

CIPROFLOXACIN SUSR PREFERRED

CIPRO TABS NON_PREFERRED

CIPROFLOXACIN HCL TABS PREFERRED

CIPROFLOXACIN HYDROCHLORI TABS PREFERRED

BAXDELA TABS NON_PREFERRED

LEVOFLOXACIN SOLN PREFERRED

LEVAQUIN TABS NON_PREFERRED

LEVOFLOXACIN TABS PREFERRED

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MOXIFLOXACIN HYDROCHLORID TABS NON_PREFERRED

OFLOXACIN TABS NON_PREFERRED

ANTIBIOTICS : AMINOGLYCOSIDES NEOMYCIN SULFATE TABS PREFERRED

PAROMOMYCIN SULFATE CAPS PREFERRED

ANTIBIOTICS : AMINOGLYCOSIDES - INHALED ARIKAYCE SUSP NON_PREFERRED

TOBI PODHALER CAPS NON_PREFERRED

BETHKIS NEBU NON_PREFERRED

KITABIS PAK NEBU PREFERRED

TOBI NEBU NON_PREFERRED

TOBRAMYCIN NEBU NON_PREFERRED

ANTIBIOTICS : ANTI-INFECTIVE AGENTS SULFADIAZINE TABS PREFERRED

SOLOSEC PACK NON_PREFERRED

FLAGYL CAPS NON_PREFERRED

METRONIDAZOLE CAPS NON_PREFERRED

FLAGYL TABS NON_PREFERRED

METRONIDAZOLE TABS PREFERRED

NEBUPENT SOLR PREFERRED

XIFAXAN TABS NON_PREFERRED

TINIDAZOLE TABS NON_PREFERRED

TRIMETHOPRIM TABS PREFERRED

CAYSTON SOLR NON_PREFERRED

CLEOCIN CAPS NON_PREFERRED

CLINDAMYCIN HCL CAPS PREFERRED

CLINDAMYCIN HYDROCHLORIDE CAPS PREFERRED

CLEOCIN PEDIATRIC GRANULE SOLR NON_PREFERRED

CLINDAMYCIN PALMITATE HCL SOLR PREFERRED

CLINDAMYCIN PALMITATE HYD SOLR PREFERRED

LINEZOLID SUSR NON_PREFERRED

ZYVOX SUSR NON_PREFERRED

LINEZOLID TABS NON_PREFERRED

ZYVOX TABS NON_PREFERRED

SIVEXTRO TABS NON_PREFERRED

VANCOCIN HCL CAPS NON_PREFERRED

VANCOMYCIN HCL CAPS PREFERRED

VANCOMYCIN HYDROCHLORIDE CAPS PREFERRED

FIRST-VANCOMYCIN 25 SOLN NON_PREFERRED

FIRST-VANCOMYCIN 50 SOLN NON_PREFERRED

FIRVANQ SOLR NON_PREFERRED

VANCOMYCIN HYDROCHLORIDE SOLR PREFERRED

DAPSONE TABS PREFERRED

ATOVAQUONE SUSP PREFERRED

MEPRON SUSP NON_PREFERRED

SULFAMETHOXAZOLE/TRIMETHO SUSP PREFERRED

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SULFATRIM PEDIATRIC SUSP PREFERRED

BACTRIM TABS NON_PREFERRED

BACTRIM DS TABS NON_PREFERRED

SULFAMETHOXAZOLE/TRIMETHO TABS PREFERRED

ANTIBIOTICS : ANTIMYCOBACTERIAL AGENTS PASER PACK NON_PREFERRED

SIRTURO TABS NON_PREFERRED

CYCLOSERINE CAPS PREFERRED

ETHAMBUTOL HCL TABS PREFERRED

ETHAMBUTOL HYDROCHLORIDE TABS PREFERRED

MYAMBUTOL TABS NON_PREFERRED

TRECATOR TABS PREFERRED

ISONIAZID SYRP PREFERRED

ISONIAZID TABS PREFERRED

PYRAZINAMIDE TABS PREFERRED

MYCOBUTIN CAPS NON_PREFERRED

RIFABUTIN CAPS PREFERRED

RIFADIN CAPS NON_PREFERRED

RIFAMPIN CAPS PREFERRED

PRIFTIN TABS NON_PREFERRED

RIFAMATE CAPS PREFERRED

RIFATER TABS PREFERRED

ANTIBIOTICS : CEPHALOSPORINS CEFADROXIL CAPS PREFERRED

CEFADROXIL SUSR PREFERRED

CEFADROXIL TABS PREFERRED

CEPHALEXIN CAPS PREFERRED

KEFLEX CAPS NON_PREFERRED

CEPHALEXIN SUSR PREFERRED

CEPHALEXIN TABS PREFERRED

CEFACLOR CAPS PREFERRED

CEFACLOR SUSR PREFERRED

CEFACLOR ER TB12 NON_PREFERRED

CEFPROZIL SUSR PREFERRED

CEFPROZIL TABS NON_PREFERRED

CEFUROXIME AXETIL TABS PREFERRED

CEFDINIR CAPS PREFERRED

CEFDINIR SUSR PREFERRED

CEFIXIME CAPS PREFERRED

SUPRAX CAPS PREFERRED

SUPRAX CHEW NON_PREFERRED

CEFIXIME SUSR NON_PREFERRED

SUPRAX SUSR NON_PREFERRED

CEFPODOXIME PROXETIL SUSR NON_PREFERRED

CEFPODOXIME PROXETIL TABS NON_PREFERRED

of 98


ANTIBIOTICS : MACROLIDES ERYTHROMYCIN CPEP PREFERRED

ERYTHROMYCIN BASE TABS PREFERRED

ERY-TAB TBEC PREFERRED

ERYTHROMYCIN DR TBEC PREFERRED

ERYTHROCIN STEARATE TABS PREFERRED

E.E.S. GRANULES SUSR PREFERRED

ERYPED 200 SUSR PREFERRED

ERYPED 400 SUSR PREFERRED

ERYTHROMYCIN ETHYLSUCCINA SUSR PREFERRED

E.E.S. 400 TABS PREFERRED

ERYTHROMYCIN ETHYLSUCCINA TABS PREFERRED

AZITHROMYCIN PACK PREFERRED

ZITHROMAX PACK PREFERRED

AZITHROMYCIN SUSR PREFERRED

ZITHROMAX SUSR NON_PREFERRED

AZITHROMYCIN TABS PREFERRED

ZITHROMAX TABS NON_PREFERRED

ZITHROMAX TRI-PAK TABS NON_PREFERRED

ZITHROMAX Z-PAK TABS NON_PREFERRED

CLARITHROMYCIN SUSR PREFERRED

CLARITHROMYCIN TABS PREFERRED

CLARITHROMYCIN ER TB24 PREFERRED

DIFICID TABS NON_PREFERRED

ANTIBIOTICS : PENICILLINS PENICILLIN V POTASSIUM SOLR PREFERRED

PENICILLIN V POTASSIUM TABS PREFERRED

AMOXICILLIN CAPS PREFERRED

AMOXICILLIN CHEW PREFERRED

AMOXICILLIN SUSR PREFERRED

AMOXICILLIN TABS PREFERRED

AMPICILLIN CAPS PREFERRED

DICLOXACILLIN SODIUM CAPS PREFERRED

AMOXICILLIN/CLAVULANATE P CHEW PREFERRED

AMOXICILLIN/CLAVULANATE P SUSR PREFERRED

AUGMENTIN SUSR PREFERRED

AMOXICILLIN/CLAVULANATE P TABS PREFERRED

AMOXICILLIN/CLAVULANATE P TB12 NON_PREFERRED

ANTIBIOTICS : TETRACYCLINES DEMECLOCYCLINE HCL TABS PREFERRED

DEMECLOCYCLINE HYDROCHLOR TABS PREFERRED

DOXYCYCLINE MONOHYDRATE CAPS PREFERRED

DOXYCYCLINE SUSR PREFERRED

VIBRAMYCIN SUSR NON_PREFERRED

DOXYCYCLINE TABS PREFERRED

DOXYCYCLINE MONOHYDRATE TABS PREFERRED

of 98


DOXYCYCLINE HYCLATE CAPS PREFERRED

MORGIDOX 1X100MG CAPS PREFERRED



VIBRAMYCIN CAPS NON_PREFERRED

DOXYCYCLINE HYCLATE TABS PREFERRED

DORYX TBEC NON_PREFERRED

DORYX MPC TBEC NON_PREFERRED

DOXYCYCLINE HYCLATE DR TBEC NON_PREFERRED

VIBRAMYCIN SYRP PREFERRED

MORGIDOX 1X100MG KIT NON_PREFERRED

MORGIDOX 1X50MG KIT KIT NON_PREFERRED

MORGIDOX 2X100MG KIT NON_PREFERRED

MINOCIN CAPS NON_PREFERRED

MINOCYCLINE HCL CAPS PREFERRED

MINOCYCLINE HYDROCHLORIDE CAPS PREFERRED

XIMINO CP24 NON_PREFERRED

MINOCYCLINE HCL TABS PREFERRED

MINOCYCLINE HYDROCHLORIDE TABS PREFERRED

MINOCYCLINE HCL ER TB24 NON_PREFERRED

MINOCYCLINE HYDROCHLORIDE TB24 NON_PREFERRED

SOLODYN TB24 NON_PREFERRED

TETRACYCLINE HYDROCHLORID CAPS PREFERRED

ANTICOAGULANTS : COUMARIN COUMADIN TABS NON_PREFERRED

JANTOVEN TABS PREFERRED

WARFARIN SODIUM TABS PREFERRED

ANTICOAGULANTS : DIRECT FACTOR XA INHIBITORS & MISC PRADAXA CAPS NON_PREFERRED

ELIQUIS TABS PREFERRED_WITH_PA

ELIQUIS STARTER PACK TABS PREFERRED_WITH_PA

BEVYXXA CAPS NON_PREFERRED

SAVAYSA TABS NON_PREFERRED

XARELTO TABS PREFERRED_WITH_PA

XARELTO STARTER PACK TBPK PREFERRED_WITH_PA

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

HEPARIN SODIUM DCU SOLN PREFERRED

HEPARIN SODIUM SOSY PREFERRED

FRAGMIN SOLN PREFERRED

ENOXAPARIN SODIUM SOLN PREFERRED

LOVENOX SOLN NON_PREFERRED

ARIXTRA SOLN NON_PREFERRED

FONDAPARINUX SODIUM SOLN PREFERRED

of 98


ANTICONVULSANTS SYMPAZAN FILM NON_PREFERRED

CLOBAZAM SUSP NON_PREFERRED

ONFI SUSP NON_PREFERRED

CLOBAZAM TABS NON_PREFERRED

ONFI TABS NON_PREFERRED

CLONAZEPAM TABS PREFERRED

KLONOPIN TABS NON_PREFERRED

CLONAZEPAM ODT TBDP NON_PREFERRED

DIASTAT ACUDIAL GEL PREFERRED

DIASTAT PEDIATRIC GEL PREFERRED

DIAZEPAM RECTAL GEL GEL PREFERRED

NAYZILAM SOLN NON_PREFERRED

FELBAMATE SUSP NON_PREFERRED

FELBATOL SUSP NON_PREFERRED

FELBAMATE TABS NON_PREFERRED

FELBATOL TABS NON_PREFERRED

GABITRIL TABS NON_PREFERRED

TIAGABINE HYDROCHLORIDE TABS NON_PREFERRED

SABRIL PACK NON_PREFERRED

VIGABATRIN PACK NON_PREFERRED

VIGADRONE PACK NON_PREFERRED

SABRIL TABS NON_PREFERRED

VIGABATRIN TABS NON_PREFERRED

PEGANONE TABS NON_PREFERRED

DILANTIN INFATABS CHEW NON_PREFERRED

PHENYTOIN CHEW PREFERRED

PHENYTOIN INFATABS CHEW PREFERRED

DILANTIN-125 SUSP NON_PREFERRED

PHENYTOIN SUSP PREFERRED

DILANTIN CAPS NON_PREFERRED

PHENYTEK CAPS NON_PREFERRED

PHENYTOIN SODIUM EXTENDED CAPS PREFERRED

ETHOSUXIMIDE CAPS PREFERRED

ZARONTIN CAPS NON_PREFERRED

ETHOSUXIMIDE SOLN PREFERRED

ZARONTIN SOLN NON_PREFERRED

CELONTIN CAPS NON_PREFERRED

DEPAKOTE SPRINKLES CSDR NON_PREFERRED

DIVALPROEX SODIUM CSDR PREFERRED

DEPAKOTE ER TB24 NON_PREFERRED

DIVALPROEX SODIUM ER TB24 PREFERRED

DEPAKOTE TBEC NON_PREFERRED

DIVALPROEX SODIUM DR TBEC PREFERRED

of 98


VALPROIC ACID SOLN PREFERRED

DEPAKENE CAPS NON_PREFERRED

VALPROIC ACID CAPS PREFERRED

FYCOMPA SUSP NON_PREFERRED

FYCOMPA TABS NON_PREFERRED

BRIVIACT SOLN NON_PREFERRED

BRIVIACT TABS NON_PREFERRED

EPIDIOLEX SOLN NON_PREFERRED

CARBAMAZEPINE CHEW PREFERRED

CARBAMAZEPINE ER CP12 NON_PREFERRED

CARBATROL CP12 NON_PREFERRED

CARBAMAZEPINE SUSP PREFERRED

TEGRETOL SUSP NON_PREFERRED

CARBAMAZEPINE TABS PREFERRED

EPITOL TABS PREFERRED

TEGRETOL TABS NON_PREFERRED

CARBAMAZEPINE ER TB12 PREFERRED

TEGRETOL-XR TB12 NON_PREFERRED

APTIOM TABS NON_PREFERRED

GABAPENTIN CAPS PREFERRED

NEURONTIN CAPS NON_PREFERRED

GABAPENTIN SOLN PREFERRED

NEURONTIN SOLN NON_PREFERRED

GABAPENTIN TABS PREFERRED

NEURONTIN TABS NON_PREFERRED

VIMPAT SOLN NON_PREFERRED

VIMPAT TABS NON_PREFERRED

LAMICTAL CHEWABLE DISPERS CHEW NON_PREFERRED

LAMOTRIGINE CHEW PREFERRED

LAMICTAL ODT KIT NON_PREFERRED

LAMICTAL STARTER/NOT TAKI KIT NON_PREFERRED

LAMICTAL STARTER/TAKING C KIT NON_PREFERRED

LAMICTAL STARTER/TAKING V KIT NON_PREFERRED

LAMICTAL XR KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/B KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/G KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/O KIT NON_PREFERRED

SUBVENITE STARTER KIT/BLU KIT NON_PREFERRED

SUBVENITE STARTER KIT/GRE KIT NON_PREFERRED

SUBVENITE STARTER KIT/ORA KIT NON_PREFERRED

LAMICTAL TABS NON_PREFERRED

LAMOTRIGINE TABS PREFERRED

SUBVENITE TABS PREFERRED

of 98


LAMICTAL XR TB24 NON_PREFERRED

LAMOTRIGINE ER TB24 NON_PREFERRED

LAMICTAL ODT TBDP NON_PREFERRED

LAMOTRIGINE ODT TBDP NON_PREFERRED

KEPPRA SOLN NON_PREFERRED

LEVETIRACETAM SOLN PREFERRED

KEPPRA TABS NON_PREFERRED

LEVETIRACETAM TABS PREFERRED

ROWEEPRA TABS PREFERRED

KEPPRA XR TB24 NON_PREFERRED

LEVETIRACETAM ER TB24 PREFERRED

ROWEEPRA XR TB24 PREFERRED

OXCARBAZEPINE SUSP PREFERRED

TRILEPTAL SUSP NON_PREFERRED

OXCARBAZEPINE TABS PREFERRED

TRILEPTAL TABS NON_PREFERRED

OXTELLAR XR TB24 NON_PREFERRED

LYRICA CAPS NON_PREFERRED

PREGABALIN CAPS PREFERRED

LYRICA SOLN NON_PREFERRED

PREGABALIN SOLN PREFERRED

MYSOLINE TABS NON_PREFERRED

PRIMIDONE TABS PREFERRED

BANZEL SUSP NON_PREFERRED

BANZEL TABS NON_PREFERRED

DIACOMIT CAPS NON_PREFERRED

DIACOMIT PACK NON_PREFERRED

TROKENDI XR CP24 NON_PREFERRED

TOPAMAX SPRINKLE CPSP NON_PREFERRED

TOPIRAMATE CPSP PREFERRED

QUDEXY XR CS24 NON_PREFERRED

TOPIRAMATE ER CS24 NON_PREFERRED

TOPAMAX TABS NON_PREFERRED

TOPIRAMATE TABS PREFERRED

ZONISAMIDE CAPS PREFERRED

ANTIDEPRESSANTS : MISC MIRTAZAPINE TABS PREFERRED

REMERON TABS NON_PREFERRED

MIRTAZAPINE ODT TBDP PREFERRED

REMERON SOLTAB TBDP NON_PREFERRED

MARPLAN TABS NON_PREFERRED

NARDIL TABS NON_PREFERRED

PHENELZINE SULFATE TABS PREFERRED

EMSAM PT24 NON_PREFERRED

of 98


TRANYLCYPROMINE SULFATE TABS PREFERRED

SPRAVATO 56MG DOSE SOPK NON_PREFERRED

SPRAVATO 84MG DOSE SOPK NON_PREFERRED

NEFAZODONE HCL TABS NON_PREFERRED

NEFAZODONE HYDROCHLORIDE TABS NON_PREFERRED

TRAZODONE HYDROCHLORIDE TABS PREFERRED

VIIBRYD STARTER PACK KIT NON_PREFERRED

VIIBRYD TABS NON_PREFERRED

TRINTELLIX TABS NON_PREFERRED

AMITRIPTYLINE HCL TABS PREFERRED

AMITRIPTYLINE HYDROCHLORI TABS PREFERRED

AMOXAPINE TABS NON_PREFERRED

ANAFRANIL CAPS NON_PREFERRED

CLOMIPRAMINE HCL CAPS PREFERRED

CLOMIPRAMINE HYDROCHLORID CAPS PREFERRED

DESIPRAMINE HCL TABS PREFERRED

DESIPRAMINE HYDROCHLORIDE TABS PREFERRED

NORPRAMIN TABS NON_PREFERRED

DOXEPIN HCL CAPS PREFERRED

DOXEPIN HYDROCHLORIDE CAPS PREFERRED

DOXEPIN HCL CONC PREFERRED

IMIPRAMINE HCL TABS PREFERRED

IMIPRAMINE HYDROCHLORIDE TABS PREFERRED

TOFRANIL TABS NON_PREFERRED

IMIPRAMINE PAMOATE CAPS NON_PREFERRED

NORTRIPTYLINE HCL CAPS PREFERRED

PAMELOR CAPS NON_PREFERRED

NORTRIPTYLINE HCL SOLN PREFERRED

PROTRIPTYLINE HCL TABS PREFERRED

TRIMIPRAMINE MALEATE CAPS NON_PREFERRED

MAPROTILINE HCL TABS PREFERRED

BUPROPION HCL TABS PREFERRED

BUPROPION HYDROCHLORIDE TABS PREFERRED

BUPROPION HYDROCHLORIDE E TB12 PREFERRED

WELLBUTRIN SR TB12 NON_PREFERRED

BUPROPION HYDROCHLORIDE E TB24 PREFERRED

FORFIVO XL TB24 NON_PREFERRED

WELLBUTRIN XL TB24 NON_PREFERRED

APLENZIN TB24 NON_PREFERRED

ANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE

INHIBITOR (SSRIs) CITALOPRAM SOLN PREFERRED

CITALOPRAM HYDROBROMIDE SOLN PREFERRED

CELEXA TABS NON_PREFERRED

of 98


CITALOPRAM TABS PREFERRED

CITALOPRAM HYDROBROMIDE TABS PREFERRED

ESCITALOPRAM OXALATE SOLN PREFERRED

ESCITALOPRAM OXALATE TABS PREFERRED

LEXAPRO TABS NON_PREFERRED

FLUOXETINE HCL CAPS PREFERRED

FLUOXETINE HYDROCHLORIDE CAPS PREFERRED

PROZAC CAPS NON_PREFERRED

FLUOXETINE DR CPDR NON_PREFERRED

FLUOXETINE HCL SOLN PREFERRED

FLUOXETINE HYDROCHLORIDE SOLN PREFERRED

FLUOXETINE HYDROCHLORIDE TABS PREFERRED

FLUVOXAMINE MALEATE ER CP24 NON_PREFERRED

FLUVOXAMINE MALEATE TABS PREFERRED

PAXIL SUSP NON_PREFERRED

PAROXETINE HCL TABS PREFERRED

PAROXETINE HYDROCHLORIDE TABS PREFERRED

PAXIL TABS NON_PREFERRED

PAROXETINE HCL ER TB24 NON_PREFERRED

PAROXETINE HYDROCHLORIDE TB24 NON_PREFERRED

PAXIL CR TB24 NON_PREFERRED

PEXEVA TABS NON_PREFERRED

SERTRALINE HCL CONC PREFERRED

SERTRALINE HYDROCHLORIDE CONC PREFERRED

SERTRALINE HCL TABS PREFERRED

SERTRALINE HYDROCHLORIDE TABS PREFERRED

ZOLOFT TABS NON_PREFERRED

DULOXETINE HYDROCHLORIDE CPEP PREFERRED

ANTIDEPRESSANTS : SELECTIVE SEROTONIN-

NOREPINEPHRINE REUPTAKE INHIBITOR (SNRIs) DESVENLAFAXINE ER TB24 NON_PREFERRED

KHEDEZLA TB24 NON_PREFERRED

DESVENLAFAXINE ER TB24 NON_PREFERRED

PRISTIQ TB24 NON_PREFERRED

CYMBALTA CPEP NON_PREFERRED

DULOXETINE HCL CPEP PREFERRED

DULOXETINE HYDROCHLORIDE CPEP PREFERRED

DRIZALMA SPRINKLE CSDR NON_PREFERRED

FETZIMA TITRATION PACK C4PK NON_PREFERRED

FETZIMA CP24 NON_PREFERRED

EFFEXOR XR CP24 NON_PREFERRED

VENLAFAXINE HCL ER CP24 PREFERRED

VENLAFAXINE HCL TABS PREFERRED

VENLAFAXINE HYDROCHLORIDE TABS PREFERRED

of 98


VENLAFAXINE HCL ER TB24 NON_PREFERRED

VENLAFAXINE HYDROCHLORIDE TB24 NON_PREFERRED

ANTIDIABETICS : COMBINATIONS XULTOPHY 100/3.6 SOPN NON_PREFERRED

SOLIQUA 100/33 SOPN NON_PREFERRED

ALOGLIPTIN/METFORMIN HCL TABS NON_PREFERRED

KAZANO TABS NON_PREFERRED

JENTADUETO TABS NON_PREFERRED

JENTADUETO XR TB24 NON_PREFERRED

KOMBIGLYZE XR TB24 NON_PREFERRED

JANUMET TABS NON_PREFERRED

JANUMET XR TB24 NON_PREFERRED

ALOGLIPTIN/PIOGLITAZONE TABS NON_PREFERRED

OSENI TABS NON_PREFERRED

REPAGLINIDE/METFORMIN HYD TABS NON_PREFERRED

INVOKAMET TABS NON_PREFERRED

INVOKAMET XR TB24 NON_PREFERRED

XIGDUO XR TB24 NON_PREFERRED

SYNJARDY TABS NON_PREFERRED

SYNJARDY XR TB24 NON_PREFERRED

SEGLUROMET TABS NON_PREFERRED

QTERN TABS NON_PREFERRED

GLYXAMBI TABS NON_PREFERRED

STEGLUJAN TABS NON_PREFERRED

GLIPIZIDE/METFORMIN HYDRO TABS PREFERRED

GLYBURIDE/METFORMIN HYDRO TABS PREFERRED

DUETACT TABS NON_PREFERRED

PIOGLITAZONE HCL-GLIMEPIR TABS NON_PREFERRED

ACTOPLUS MET TABS NON_PREFERRED

PIOGLITAZONE HCL/METFORMI TABS NON_PREFERRED

ANTIDIABETICS : DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITORS ALOGLIPTIN TABS NON_PREFERRED

NESINA TABS NON_PREFERRED

TRADJENTA TABS PREFERRED

ONGLYZA TABS NON_PREFERRED

JANUVIA TABS PREFERRED

ANTIDIABETICS : INCRETIN MIMETIC AGENTS (GLP-1

RECEPTOR AGONISTS) TRULICITY SOPN NON_PREFERRED

BYDUREON BCISE AUIJ NON_PREFERRED

BYDUREON PEN PEN NON_PREFERRED

BYETTA SOPN PREFERRED

VICTOZA SOPN PREFERRED

ADLYXIN STARTER PACK PNKT NON_PREFERRED

ADLYXIN SOPN NON_PREFERRED

of 98


OZEMPIC SOPN NON_PREFERRED

RYBELSUS TABS NON_PREFERRED

ANTIDIABETICS : INSULIN NOVOLOG PENFILL SOCT NON_PREFERRED

NOVOLOG SOLN NON_PREFERRED

NOVOLOG FLEXPEN SOPN NON_PREFERRED

FIASP PENFILL SOCT NON_PREFERRED

FIASP SOLN NON_PREFERRED

LANTUS SOLN PREFERRED

BASAGLAR KWIKPEN SOPN NON_PREFERRED

LANTUS SOLOSTAR SOPN PREFERRED

TOUJEO MAX SOLOSTAR SOPN NON_PREFERRED

TOUJEO SOLOSTAR SOPN NON_PREFERRED

APIDRA SOLN NON_PREFERRED

APIDRA SOLOSTAR SOPN NON_PREFERRED

HUMALOG SOCT PREFERRED

ADMELOG SOLN NON_PREFERRED

HUMALOG SOLN PREFERRED

INSULIN LISPRO SOLN PREFERRED

ADMELOG SOLOSTAR SOPN NON_PREFERRED

HUMALOG JUNIOR KWIKPEN SOPN PREFERRED

HUMALOG KWIKPEN SOPN PREFERRED

INSULIN LISPRO KWIKPEN SOPN PREFERRED

LEVEMIR SOLN PREFERRED

LEVEMIR FLEXTOUCH SOPN PREFERRED

TRESIBA SOLN NON_PREFERRED

TRESIBA FLEXTOUCH SOPN NON_PREFERRED

AFREZZA POWD NON_PREFERRED

HUMULIN R SOLN PREFERRED

HUMULIN R U-500 (CONCENTR SOLN PREFERRED

NOVOLIN R SOLN NON_PREFERRED

NOVOLIN R RELION SOLN NON_PREFERRED

HUMULIN R U-500 KWIKPEN SOPN PREFERRED

HUMULIN N KWIKPEN SUPN PREFERRED

HUMULIN N SUSP PREFERRED

NOVOLIN N SUSP NON_PREFERRED

NOVOLIN N RELION SUSP NON_PREFERRED

NOVOLOG MIX 70/30 PREFILL SUPN NON_PREFERRED

NOVOLOG MIX 70/30 SUSP NON_PREFERRED

HUMALOG MIX 50/50 KWIKPEN SUPN PREFERRED

HUMALOG MIX 75/25 KWIKPEN SUPN PREFERRED

HUMALOG MIX 50/50 SUSP PREFERRED

HUMALOG MIX 75/25 SUSP PREFERRED

HUMULIN 70/30 KWIKPEN SUPN PREFERRED

of 98


NOVOLIN 70/30 FLEXPEN SUPN NON_PREFERRED

NOVOLIN 70/30 FLEXPEN REL SUPN NON_PREFERRED

HUMULIN 70/30 SUSP PREFERRED

NOVOLIN 70/30 SUSP NON_PREFERRED

NOVOLIN 70/30 RELION SUSP NON_PREFERRED

ANTIDIABETICS : MISC SYMLINPEN 120 SOPN NON_PREFERRED

SYMLINPEN 60 SOPN NON_PREFERRED

AMARYL TABS NON_PREFERRED

GLIMEPIRIDE TABS PREFERRED

GLIPIZIDE TABS PREFERRED

GLUCOTROL TABS NON_PREFERRED

GLIPIZIDE ER TB24 PREFERRED

GLIPIZIDE XL TB24 PREFERRED

GLUCOTROL XL TB24 NON_PREFERRED

GLYBURIDE TABS PREFERRED

GLYBURIDE TABS PREFERRED

GLYBURIDE MICRONIZED TABS PREFERRED

GLYNASE TABS NON_PREFERRED

TOLBUTAMIDE TABS PREFERRED

RIOMET SOLN NON_PREFERRED

GLUCOPHAGE TABS NON_PREFERRED

METFORMIN HYDROCHLORIDE TABS PREFERRED

FORTAMET TB24 NON_PREFERRED

GLUCOPHAGE XR TB24 NON_PREFERRED

GLUMETZA TB24 NON_PREFERRED

METFORMIN HYDROCHLORIDE E TB24 PREFERRED

NATEGLINIDE TABS PREFERRED

STARLIX TABS NON_PREFERRED

REPAGLINIDE TABS NON_PREFERRED

BAQSIMI ONE PACK POWD NON_PREFERRED

BAQSIMI TWO PACK POWD NON_PREFERRED

GLUCAGON EMERGENCY KIT KIT PREFERRED

GLUCAGEN HYPOKIT SOLR PREFERRED

PROGLYCEM SUSP PREFERRED

KORLYM TABS NON_PREFERRED

ACARBOSE TABS PREFERRED

PRECOSE TABS NON_PREFERRED

GLYSET TABS NON_PREFERRED

MIGLITOL TABS PREFERRED

CYCLOSET TABS NON_PREFERRED

ACTOS TABS NON_PREFERRED

PIOGLITAZONE HCL TABS PREFERRED

PIOGLITAZONE HYDROCHLORID TABS PREFERRED

of 98


AVANDIA TABS PREFERRED

ANTIDIABETICS : SODIUM-GLUCOSE CO-TRANSPORTER 2

(SGLT2) INHIBITORS INVOKANA TABS PREFERRED

FARXIGA TABS NON_PREFERRED

JARDIANCE TABS PREFERRED

STEGLATRO TABS NON_PREFERRED

CHELATING AGENTS JADENU SPRINKLE PACK NON_PREFERRED

JADENU TABS NON_PREFERRED

DEFERASIROX TBSO NON_PREFERRED

EXJADE TBSO NON_PREFERRED

FERRIPROX SOLN NON_PREFERRED

FERRIPROX TABS NON_PREFERRED

CHEMET CAPS PREFERRED

ANTIEMETICS : 5-HT3 RECEPTOR ANTAGONISTS ANZEMET TABS NON_PREFERRED

SANCUSO PTCH NON_PREFERRED

GRANISETRON HCL TABS NON_PREFERRED

ZUPLENZ FILM NON_PREFERRED

ONDANSETRON ODT TBDP PREFERRED

ONDANSETRON HCL SOLN PREFERRED

ONDANSETRON HYDROCHLORIDE SOLN PREFERRED

ONDANSETRON HYDROCHLORIDE TABS PREFERRED

ZOFRAN TABS NON_PREFERRED

ANTIEMETICS : MISC MECLIZINE HCL TABS PREFERRED

MECLIZINE HYDROCHLORIDE TABS PREFERRED

SCOPOLAMINE PT72 PREFERRED

TRANSDERM SCOP PT72 PREFERRED

TRANSDERM-SCOP PT72 PREFERRED

TIGAN CAPS NON_PREFERRED

TRIMETHOBENZAMIDE HCL CAPS NON_PREFERRED

DRONABINOL CAPS NON_PREFERRED

MARINOL CAPS NON_PREFERRED

SYNDROS SOLN NON_PREFERRED

BONJESTA TBCR NON_PREFERRED

DICLEGIS TBEC NON_PREFERRED

DOXYLAMINE SUCCINATE/PYRI TBEC NON_PREFERRED

AKYNZEO CAPS NON_PREFERRED

ANTIEMETICS : SUBSTANCE P/NEUROKININ 1 (NK1)

RECEPTOR ANTAGONISTS APREPITANT CAPS PREFERRED

EMEND CAPS NON_PREFERRED

EMEND TRIPACK CAPS NON_PREFERRED

EMEND SUSR NON_PREFERRED

VARUBI TABS NON_PREFERRED

ANTIFUNGALS ANCOBON CAPS NON_PREFERRED

of 98


FLUCYTOSINE CAPS NON_PREFERRED

GRISEOFULVIN MICROSIZE SUSP PREFERRED

GRISEOFULVIN MICROSIZE TABS PREFERRED

GRISEOFULVIN ULTRAMICROSI TABS PREFERRED

NYSTATIN TABS PREFERRED

TERBINAFINE HCL TABS PREFERRED

TERBINAFINE HYDROCHLORIDE TABS PREFERRED

KETOCONAZOLE TABS PREFERRED

DIFLUCAN SUSR NON_PREFERRED

FLUCONAZOLE SUSR PREFERRED

DIFLUCAN TABS NON_PREFERRED

FLUCONAZOLE TABS PREFERRED

CRESEMBA CAPS NON_PREFERRED

ITRACONAZOLE CAPS NON_PREFERRED

SPORANOX CAPS NON_PREFERRED

SPORANOX PULSEPAK CAPS NON_PREFERRED

TOLSURA CAPS NON_PREFERRED

ITRACONAZOLE SOLN NON_PREFERRED

SPORANOX SOLN NON_PREFERRED

NOXAFIL SUSP NON_PREFERRED

NOXAFIL TBEC NON_PREFERRED

POSACONAZOLE DR TBEC NON_PREFERRED

VFEND SUSR NON_PREFERRED

VORICONAZOLE SUSR NON_PREFERRED

VFEND TABS NON_PREFERRED

VORICONAZOLE TABS NON_PREFERRED

ANTIHYPERLIPIDEMICS CHOLESTYRAMINE PACK PREFERRED

QUESTRAN PACK NON_PREFERRED

CHOLESTYRAMINE POWD PREFERRED

QUESTRAN POWD NON_PREFERRED

CHOLESTYRAMINE LIGHT PACK PREFERRED

PREVALITE PACK PREFERRED

CHOLESTYRAMINE LIGHT POWD PREFERRED

PREVALITE POWD PREFERRED

QUESTRAN LIGHT POWD NON_PREFERRED

COLESEVELAM HYDROCHLORIDE PACK NON_PREFERRED

WELCHOL PACK NON_PREFERRED

COLESEVELAM HYDROCHLORIDE TABS NON_PREFERRED

WELCHOL TABS NON_PREFERRED

COLESTID GRAN NON_PREFERRED

COLESTID FLAVORED GRAN NON_PREFERRED

COLESTIPOL HCL GRAN NON_PREFERRED

COLESTID PACK NON_PREFERRED

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COLESTID FLAVORED PACK NON_PREFERRED

COLESTIPOL HCL PACK NON_PREFERRED

COLESTID TABS NON_PREFERRED

COLESTIPOL HCL TABS NON_PREFERRED

FENOFIBRIC ACID DR CPDR PREFERRED

TRILIPIX CPDR NON_PREFERRED

FENOFIBRATE CAPS PREFERRED

LIPOFEN CAPS NON_PREFERRED

FENOFIBRATE TABS PREFERRED

FENOGLIDE TABS NON_PREFERRED

TRICOR TABS NON_PREFERRED

TRIGLIDE TABS NON_PREFERRED

ANTARA CAPS NON_PREFERRED

FENOFIBRATE CAPS PREFERRED

FENOFIBRATE MICRONIZED CAPS PREFERRED

GEMFIBROZIL TABS PREFERRED

LOPID TABS NON_PREFERRED

EZETIMIBE TABS PREFERRED

ZETIA TABS NON_PREFERRED

PRALUENT SOAJ NON_PREFERRED

REPATHA SURECLICK SOAJ NON_PREFERRED

REPATHA PUSHTRONEX SYSTEM SOCT NON_PREFERRED

REPATHA SOSY NON_PREFERRED

ATORVASTATIN CALCIUM TABS PREFERRED

LIPITOR TABS NON_PREFERRED

FLUVASTATIN CAPS NON_PREFERRED

FLUVASTATIN SODIUM ER TB24 NON_PREFERRED

LESCOL XL TB24 NON_PREFERRED

LOVASTATIN TABS PREFERRED

ALTOPREV TB24 NON_PREFERRED

LIVALO TABS NON_PREFERRED

ZYPITAMAG TABS NON_PREFERRED

EZALLOR SPRINKLE CPSP NON_PREFERRED

CRESTOR TABS NON_PREFERRED

ROSUVASTATIN CALCIUM TABS PREFERRED

PRAVACHOL TABS NON_PREFERRED

PRAVASTATIN SODIUM TABS PREFERRED

SIMVASTATIN TABS PREFERRED

ZOCOR TABS NON_PREFERRED

NIACIN ER TBCR NON_PREFERRED

NIASPAN TBCR NON_PREFERRED

JUXTAPID CAPS NON_PREFERRED

VASCEPA CAPS NON_PREFERRED

of 98


LOVAZA CAPS NON_PREFERRED

OMEGA-3-ACID ETHYL ESTERS CAPS NON_PREFERRED

EZETIMIBE/SIMVASTATIN TABS NON_PREFERRED

VYTORIN TABS NON_PREFERRED

ANTIMYASTHENIC AGENTS RUZURGI TABS NON_PREFERRED

FIRDAPSE TABS NON_PREFERRED

GUANIDINE HCL TABS NON_PREFERRED

MESTINON SOLN NON_PREFERRED

PYRIDOSTIGMINE BROMIDE SOLN PREFERRED

MESTINON TABS NON_PREFERRED

PYRIDOSTIGMINE BROMIDE TABS PREFERRED

MESTINON TIMESPAN TBCR NON_PREFERRED

PYRIDOSTIGMINE BROMIDE ER TBCR PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES :

ALKYLATING AGENTS MYLERAN TABS PREFERRED

LEUKERAN TABS PREFERRED

CYCLOPHOSPHAMIDE CAPS PREFERRED

ALKERAN TABS NON_PREFERRED

MELPHALAN TABS PREFERRED

GLEOSTINE CAPS PREFERRED

TEMODAR CAPS NON_PREFERRED

TEMOZOLOMIDE CAPS PREFERRED


ANTIMETABOLITES CAPECITABINE TABS NON_PREFERRED

XELODA TABS NON_PREFERRED

PURIXAN SUSP NON_PREFERRED

MERCAPTOPURINE TABS PREFERRED

XATMEP SOLN NON_PREFERRED

METHOTREXATE TABS PREFERRED

TREXALL TABS PREFERRED

TABLOID TABS PREFERRED


ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS LYSODREN TABS PREFERRED

ERLEADA TABS NON_PREFERRED

BICALUTAMIDE TABS PREFERRED

CASODEX TABS NON_PREFERRED

NUBEQA TABS NON_PREFERRED

XTANDI CAPS NON_PREFERRED

FLUTAMIDE CAPS PREFERRED

NILUTAMIDE TABS PREFERRED

SOLTAMOX SOLN PREFERRED

TAMOXIFEN CITRATE TABS PREFERRED

FARESTON TABS NON_PREFERRED

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TOREMIFENE CITRATE TABS PREFERRED

ANASTROZOLE TABS PREFERRED

ARIMIDEX TABS NON_PREFERRED

AROMASIN TABS NON_PREFERRED

EXEMESTANE TABS PREFERRED

FEMARA TABS NON_PREFERRED

LETROZOLE TABS PREFERRED

EMCYT CAPS PREFERRED

MEGESTROL ACETATE SUSP PREFERRED

MEGESTROL ACETATE TABS PREFERRED

ABIRATERONE ACETATE TABS PREFERRED

YONSA TABS NON_PREFERRED

ZYTIGA TABS NON_PREFERRED


ANTINEOPLASTIC ENZYME INHIBITORS VERZENIO TABS NON_PREFERRED

IBRANCE CAPS NON_PREFERRED

KISQALI TBPK NON_PREFERRED

FARYDAK CAPS NON_PREFERRED

ZOLINZA CAPS NON_PREFERRED

TAFINLAR CAPS NON_PREFERRED

BRAFTOVI CAPS NON_PREFERRED

ZELBORAF TABS NON_PREFERRED

BALVERSA TABS NON_PREFERRED

AFINITOR TABS NON_PREFERRED

AFINITOR DISPERZ TBSO NON_PREFERRED

RYDAPT CAPS NON_PREFERRED

STIVARGA TABS NON_PREFERRED

NEXAVAR TABS PREFERRED

SUTENT CAPS PREFERRED

MEKTOVI TABS NON_PREFERRED

COTELLIC TABS NON_PREFERRED

MEKINIST TABS NON_PREFERRED

VITRAKVI CAPS NON_PREFERRED

VITRAKVI SOLN NON_PREFERRED

CALQUENCE CAPS NON_PREFERRED

GILOTRIF TABS NON_PREFERRED

ALECENSA CAPS NON_PREFERRED

INLYTA TABS NON_PREFERRED

ALUNBRIG TABS NON_PREFERRED

ALUNBRIG TBPK NON_PREFERRED

BOSULIF TABS NON_PREFERRED

COMETRIQ KIT NON_PREFERRED

CABOMETYX TABS NON_PREFERRED

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ZYKADIA CAPS NON_PREFERRED

ZYKADIA TABS NON_PREFERRED

XALKORI CAPS NON_PREFERRED

VIZIMPRO TABS NON_PREFERRED

SPRYCEL TABS NON_PREFERRED

ERLOTINIB HYDROCHLORIDE TABS PREFERRED

TARCEVA TABS NON_PREFERRED

IRESSA TABS PREFERRED

XOSPATA TABS NON_PREFERRED

IMBRUVICA CAPS NON_PREFERRED

IMBRUVICA TABS NON_PREFERRED

GLEEVEC TABS NON_PREFERRED

IMATINIB MESYLATE TABS NON_PREFERRED

TYKERB TABS NON_PREFERRED

LENVIMA 10 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 12MG DAILY DOSE CPPK NON_PREFERRED







LORBRENA TABS NON_PREFERRED

NERLYNX TABS NON_PREFERRED

TASIGNA CAPS NON_PREFERRED

TAGRISSO TABS NON_PREFERRED

VOTRIENT TABS PREFERRED

TURALIO CAPS NON_PREFERRED

ICLUSIG TABS NON_PREFERRED

CAPRELSA TABS PREFERRED

TIBSOVO TABS NON_PREFERRED

IDHIFA TABS NON_PREFERRED

ZEJULA CAPS NON_PREFERRED

LYNPARZA TABS NON_PREFERRED

RUBRACA TABS NON_PREFERRED

TALZENNA CAPS NON_PREFERRED

NINLARO CAPS NON_PREFERRED

JAKAFI TABS PREFERRED

PIQRAY 200MG DAILY DOSE TBPK NON_PREFERRED



COPIKTRA CAPS NON_PREFERRED

ZYDELIG TABS NON_PREFERRED

of 98



CHEMOTHERAPY RESCUE / ANTIDOTE AGENTS LEUCOVORIN CALCIUM TABS PREFERRED

MESNEX TABS PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MISC DAURISMO TABS NON_PREFERRED

ODOMZO CAPS NON_PREFERRED

ERIVEDGE CAPS PREFERRED

POMALYST CAPS NON_PREFERRED

VENCLEXTA TABS NON_PREFERRED

VENCLEXTA STARTING PACK TBPK NON_PREFERRED

HYCAMTIN CAPS PREFERRED

XPOVIO 100 MG ONCE WEEKLY TBPK NON_PREFERRED



XPOVIO 80 MG TWICE WEEKLY TBPK NON_PREFERRED

HYDREA CAPS NON_PREFERRED

HYDROXYUREA CAPS PREFERRED

MATULANE CAPS PREFERRED

TRETINOIN CAPS PREFERRED

BEXAROTENE CAPS PREFERRED

TARGRETIN CAPS NON_PREFERRED

KISQALI FEMARA 200 DOSE TBPK NON_PREFERRED



LONSURF TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MITOTIC

INHIBITORS ETOPOSIDE CAPS PREFERRED

ANTIPARASITICS : ANTHELMINTICS ALBENDAZOLE TABS NON_PREFERRED

ALBENZA TABS NON_PREFERRED

BENZNIDAZOLE TABS NON_PREFERRED

IVERMECTIN TABS NON_PREFERRED

STROMECTOL TABS NON_PREFERRED

EMVERM CHEW NON_PREFERRED

BILTRICIDE TABS NON_PREFERRED

PRAZIQUANTEL TABS PREFERRED

EGATEN TABS NON_PREFERRED

ANTIPARASITICS : ANTIMALARIALS CHLOROQUINE PHOSPHATE TABS PREFERRED

HYDROXYCHLOROQUINE SULFAT TABS PREFERRED

MEFLOQUINE HCL TABS PREFERRED

PRIMAQUINE PHOSPHATE TABS PREFERRED

DARAPRIM TABS NON_PREFERRED

QUALAQUIN CAPS NON_PREFERRED

QUININE SULFATE CAPS NON_PREFERRED

KRINTAFEL TABS NON_PREFERRED

of 98


COARTEM TABS NON_PREFERRED

ATOVAQUONE/PROGUANIL HCL TABS PREFERRED

MALARONE TABS NON_PREFERRED

ANTIPARKINSON AND RELATED THERAPY AGENTS BENZTROPINE MESYLATE TABS PREFERRED

TRIHEXYPHENIDYL HCL ELIX PREFERRED

TRIHEXYPHENIDYL HYDROCHLO TABS PREFERRED

TASMAR TABS NON_PREFERRED

TOLCAPONE TABS NON_PREFERRED

COMTAN TABS NON_PREFERRED

ENTACAPONE TABS PREFERRED

AMANTADINE HCL CAPS PREFERRED

AMANTADINE HYDROCHLORIDE CAPS PREFERRED

GOCOVRI CP24 NON_PREFERRED

AMANTADINE HCL SYRP PREFERRED

AMANTADINE HCL TABS PREFERRED

AMANTADINE HYDROCHLORIDE TABS PREFERRED

OSMOLEX ER TB24 NON_PREFERRED

BROMOCRIPTINE MESYLATE CAPS PREFERRED

PARLODEL CAPS NON_PREFERRED

BROMOCRIPTINE MESYLATE TABS PREFERRED

PARLODEL TABS NON_PREFERRED

INBRIJA CAPS NON_PREFERRED

APOKYN SOCT NON_PREFERRED

MIRAPEX TABS NON_PREFERRED

PRAMIPEXOLE DIHYDROCHLORI TABS PREFERRED

MIRAPEX ER TB24 NON_PREFERRED

PRAMIPEXOLE DIHYDROCHLORI TB24 NON_PREFERRED

ROPINIROLE HCL TABS PREFERRED

ROPINIROLE HYDROCHLORIDE TABS PREFERRED

REQUIP XL TB24 NON_PREFERRED

ROPINIROLE ER TB24 NON_PREFERRED

NEUPRO PT24 NON_PREFERRED

RYTARY CPCR NON_PREFERRED

CARBIDOPA/LEVODOPA TABS PREFERRED

SINEMET TABS NON_PREFERRED

CARBIDOPA/LEVODOPA ER TBCR PREFERRED

SINEMET CR TBCR NON_PREFERRED

CARBIDOPA/LEVODOPA ODT TBDP NON_PREFERRED

CARBIDOPA/LEVODOPA/ENTACA TABS NON_PREFERRED

STALEVO 100 TABS NON_PREFERRED




of 98




AZILECT TABS NON_PREFERRED

RASAGILINE MESYLATE TABS NON_PREFERRED

XADAGO TABS NON_PREFERRED

SELEGILINE HCL CAPS PREFERRED

SELEGILINE HCL TABS PREFERRED

ZELAPAR TBDP NON_PREFERRED

NOURIANZ TABS NON_PREFERRED

CARBIDOPA TABS PREFERRED

LODOSYN TABS NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : BENZISOXAZOLES FANAPT TABS NON_PREFERRED

FANAPT TITRATION PACK TABS NON_PREFERRED

INVEGA TB24 NON_PREFERRED

PALIPERIDONE ER TB24 NON_PREFERRED

INVEGA SUSTENNA SUSY PREFERRED_WITH_PA

INVEGA TRINZA SUSY PREFERRED_WITH_PA

PERSERIS PRSY NON_PREFERRED

RISPERDAL SOLN NON_PREFERRED

RISPERIDONE SOLN PREFERRED

RISPERDAL TABS NON_PREFERRED

RISPERIDONE TABS PREFERRED

RISPERIDONE ODT TBDP NON_PREFERRED

RISPERDAL CONSTA SRER NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : DIBENZAPINES VERSACLOZ SUSP NON_PREFERRED

CLOZAPINE TABS PREFERRED

CLOZARIL TABS NON_PREFERRED

CLOZAPINE ODT TBDP NON_PREFERRED

FAZACLO TBDP NON_PREFERRED

QUETIAPINE FUMARATE TABS PREFERRED

SEROQUEL TABS NON_PREFERRED

QUETIAPINE FUMARATE ER TB24 PREFERRED

SEROQUEL XR TB24 NON_PREFERRED

ADASUVE AEPB NON_PREFERRED

LOXAPINE CAPS PREFERRED

LOXAPINE SUCCINATE CAPS PREFERRED

SAPHRIS SUBL NON_PREFERRED

OLANZAPINE SOLR NON_PREFERRED

ZYPREXA SOLR NON_PREFERRED

OLANZAPINE TABS PREFERRED

ZYPREXA TABS NON_PREFERRED

OLANZAPINE ODT TBDP PREFERRED

of 98


ZYPREXA ZYDIS TBDP NON_PREFERRED

ZYPREXA RELPREVV SUSR NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : MISC HALOPERIDOL TABS PREFERRED

HALOPERIDOL CONC PREFERRED

MOLINDONE HYDROCHLORIDE TABS NON_PREFERRED

CHLORPROMAZINE HCL TABS PREFERRED

CHLORPROMAZINE HYDROCHLOR TABS PREFERRED

FLUPHENAZINE HCL CONC PREFERRED

FLUPHENAZINE HCL ELIX PREFERRED

FLUPHENAZINE HCL TABS PREFERRED

PERPHENAZINE TABS PREFERRED

COMPRO SUPP PREFERRED

PROCHLORPERAZINE SUPP PREFERRED

PROCHLORPERAZINE MALEATE TABS PREFERRED

THIORIDAZINE HCL TABS PREFERRED

TRIFLUOPERAZINE HCL TABS PREFERRED

TRIFLUOPERAZINE HYDROCHLO TABS PREFERRED

THIOTHIXENE CAPS PREFERRED

EQUETRO CP12 NON_PREFERRED

VRAYLAR CAPS NON_PREFERRED

VRAYLAR CPPK NON_PREFERRED

LATUDA TABS NON_PREFERRED

NUPLAZID CAPS NON_PREFERRED

NUPLAZID TABS NON_PREFERRED

GEODON CAPS NON_PREFERRED

ZIPRASIDONE HCL CAPS PREFERRED

ZIPRASIDONE HYDROCHLORIDE CAPS PREFERRED

GEODON SOLR NON_PREFERRED

LITHIUM SOLN PREFERRED

LITHIUM CARBONATE CAPS PREFERRED

LITHIUM CARBONATE TABS PREFERRED

LITHIUM CARBONATE ER TBCR PREFERRED

LITHOBID TBCR NON_PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS : QUINOLINONE

DERIVATIVES ABILIFY MAINTENA PRSY PREFERRED_WITH_PA

ARIPIPRAZOLE SOLN NON_PREFERRED

ABILIFY MAINTENA SRER PREFERRED_WITH_PA

ABILIFY TABS NON_PREFERRED

ABILIFY MYCITE TABS NON_PREFERRED

ARIPIPRAZOLE TABS PREFERRED

ARIPIPRAZOLE ODT TBDP NON_PREFERRED

ARISTADA PRSY PREFERRED_WITH_PA

ARISTADA INITIO PRSY PREFERRED_WITH_PA

of 98


REXULTI TABS NON_PREFERRED

ANTIVIRALS : ANTIRETROVIRALS (HIV) SELZENTRY SOLN NON_PREFERRED

SELZENTRY TABS NON_PREFERRED

TROGARZO SOLN PREFERRED_WITH_PA

FUZEON SOLR NON_PREFERRED

TIVICAY TABS PREFERRED

ISENTRESS CHEW PREFERRED

ISENTRESS PACK PREFERRED

ISENTRESS TABS PREFERRED

ISENTRESS HD TABS PREFERRED

ATAZANAVIR CAPS PREFERRED

ATAZANAVIR SULFATE CAPS PREFERRED

REYATAZ CAPS PREFERRED

REYATAZ PACK PREFERRED

PREZISTA SUSP PREFERRED

PREZISTA TABS PREFERRED

LEXIVA SUSP PREFERRED

FOSAMPRENAVIR CALCIUM TABS PREFERRED

LEXIVA TABS PREFERRED

CRIXIVAN CAPS PREFERRED

VIRACEPT TABS PREFERRED

NORVIR PACK PREFERRED

NORVIR SOLN PREFERRED

NORVIR TABS PREFERRED

RITONAVIR TABS PREFERRED

INVIRASE TABS PREFERRED

APTIVUS CAPS PREFERRED

APTIVUS SOLN PREFERRED

ABACAVIR SOLN PREFERRED

ZIAGEN SOLN PREFERRED

ABACAVIR TABS PREFERRED

ABACAVIR SULFATE TABS PREFERRED

ZIAGEN TABS NON_PREFERRED

DIDANOSINE CPDR PREFERRED

VIDEX EC CPDR NON_PREFERRED

VIDEX SOLR PREFERRED

EMTRIVA CAPS PREFERRED

EMTRIVA SOLN PREFERRED

EPIVIR SOLN NON_PREFERRED

LAMIVUDINE SOLN PREFERRED

EPIVIR TABS NON_PREFERRED

LAMIVUDINE TABS PREFERRED

STAVUDINE CAPS PREFERRED

of 98


RETROVIR CAPS NON_PREFERRED

ZIDOVUDINE CAPS PREFERRED

RETROVIR SYRP NON_PREFERRED

ZIDOVUDINE SYRP PREFERRED

ZIDOVUDINE TABS PREFERRED

VIREAD POWD PREFERRED

TENOFOVIR DISOPROXIL FUMA TABS PREFERRED

VIREAD TABS PREFERRED

RESCRIPTOR TABS PREFERRED

PIFELTRO TABS NON_PREFERRED

EFAVIRENZ CAPS PREFERRED

SUSTIVA CAPS PREFERRED

EFAVIRENZ TABS PREFERRED

SUSTIVA TABS PREFERRED

INTELENCE TABS PREFERRED

NEVIRAPINE SUSP PREFERRED

VIRAMUNE SUSP PREFERRED

NEVIRAPINE TABS PREFERRED

VIRAMUNE TABS NON_PREFERRED

NEVIRAPINE ER TB24 PREFERRED

VIRAMUNE XR TB24 NON_PREFERRED

EDURANT TABS PREFERRED

TYBOST TABS NON_PREFERRED

ABACAVIR SULFATE/LAMIVUDI TABS PREFERRED

EPZICOM TABS NON_PREFERRED

EVOTAZ TABS NON_PREFERRED

DOVATO TABS PREFERRED

PREZCOBIX TABS NON_PREFERRED

JULUCA TABS NON_PREFERRED

DESCOVY TABS PREFERRED

TRUVADA TABS PREFERRED

CIMDUO TABS NON_PREFERRED

TEMIXYS TABS NON_PREFERRED

COMBIVIR TABS NON_PREFERRED

LAMIVUDINE/ZIDOVUDINE TABS PREFERRED

KALETRA SOLN NON_PREFERRED

LOPINAVIR/RITONAVIR SOLN PREFERRED

KALETRA TABS PREFERRED

TRIUMEQ TABS PREFERRED

ABACAVIR SULFATE/LAMIVUDI TABS PREFERRED

TRIZIVIR TABS NON_PREFERRED

BIKTARVY TABS PREFERRED

DELSTRIGO TABS PREFERRED

of 98


ATRIPLA TABS PREFERRED

SYMFI TABS PREFERRED

SYMFI LO TABS PREFERRED

ODEFSEY TABS PREFERRED

COMPLERA TABS PREFERRED

SYMTUZA TABS NON_PREFERRED

GENVOYA TABS PREFERRED

STRIBILD TABS NON_PREFERRED

ANTIVIRALS : HEPATITIS B AGENTS ADEFOVIR DIPIVOXIL TABS NON_PREFERRED

HEPSERA TABS NON_PREFERRED

BARACLUDE SOLN NON_PREFERRED

BARACLUDE TABS NON_PREFERRED

ENTECAVIR TABS PREFERRED

EPIVIR HBV SOLN NON_PREFERRED

EPIVIR HBV TABS NON_PREFERRED

LAMIVUDINE TABS NON_PREFERRED

VEMLIDY TABS NON_PREFERRED

ANTIVIRALS : HEPATITIS C AGENTS PEGASYS SOLN NON_PREFERRED

PEGASYS PROCLICK SOLN NON_PREFERRED

PEGINTRON KIT PREFERRED_WITH_PA

RIBASPHERE CAPS PREFERRED

RIBAVIRIN CAPS PREFERRED

RIBASPHERE TABS PREFERRED

RIBAVIRIN TABS PREFERRED

MODERIBA 1200 DOSE PACK TBPK NON_PREFERRED

MODERIBA 800 DOSE PACK TBPK NON_PREFERRED

RIBASPHERE RIBAPAK TBPK NON_PREFERRED

SOVALDI TABS NON_PREFERRED

ZEPATIER TABS NON_PREFERRED

MAVYRET TABS PREFERRED_WITH_PA

HARVONI TABS NON_PREFERRED

LEDIPASVIR/SOFOSBUVIR TABS NON_PREFERRED

EPCLUSA TABS NON_PREFERRED

SOFOSBUVIR/VELPATASVIR TABS PREFERRED_WITH_PA

VOSEVI TABS NON_PREFERRED

VIEKIRA PAK TBPK NON_PREFERRED

ANTIVIRALS : MISC PREVYMIS TABS NON_PREFERRED

VALCYTE SOLR NON_PREFERRED

VALGANCICLOVIR HYDROCHLOR SOLR NON_PREFERRED

VALCYTE TABS NON_PREFERRED

VALGANCICLOVIR TABS PREFERRED

ACYCLOVIR CAPS PREFERRED

ZOVIRAX CAPS NON_PREFERRED

of 98


ACYCLOVIR SUSP PREFERRED

ZOVIRAX SUSP NON_PREFERRED

ACYCLOVIR TABS PREFERRED

SITAVIG TABS NON_PREFERRED

ZOVIRAX TABS NON_PREFERRED

VALACYCLOVIR HCL TABS PREFERRED

VALACYCLOVIR HYDROCHLORID TABS PREFERRED

VALTREX TABS NON_PREFERRED

FAMCICLOVIR TABS NON_PREFERRED

FLUMADINE TABS NON_PREFERRED

RIMANTADINE HCL TABS NON_PREFERRED

XOFLUZA TBPK NON_PREFERRED

OSELTAMIVIR PHOSPHATE CAPS PREFERRED

TAMIFLU CAPS NON_PREFERRED

OSELTAMIVIR PHOSPHATE SUSR PREFERRED

TAMIFLU SUSR NON_PREFERRED

RELENZA DISKHALER AEPB PREFERRED

RIBAVIRIN SOLR PREFERRED

VIRAZOLE SOLR NON_PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE

INHIBITOR COMBINATIONS AMLODIPINE BESYLATE/BENAZ CAPS PREFERRED

LOTREL CAPS NON_PREFERRED

TARKA TBCR NON_PREFERRED

TRANDOLAPRIL/VERAPAMIL HC TBCR PREFERRED

BENAZEPRIL HCL/HYDROCHLOR TABS PREFERRED

BENAZEPRIL HYDROCHLORIDE/ TABS PREFERRED

LOTENSIN HCT TABS NON_PREFERRED

CAPTOPRIL/HYDROCHLOROTHIA TABS PREFERRED

ENALAPRIL MALEATE/HYDROCH TABS PREFERRED

VASERETIC TABS NON_PREFERRED

FOSINOPRIL SODIUM/HYDROCH TABS PREFERRED

LISINOPRIL/HYDROCHLOROTHI TABS PREFERRED

ZESTORETIC TABS NON_PREFERRED

ACCURETIC TABS NON_PREFERRED

QUINAPRIL/HYDROCHLOROTHIA TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE

INHIBITORS BENAZEPRIL HCL TABS PREFERRED

LOTENSIN TABS NON_PREFERRED

CAPTOPRIL TABS PREFERRED

EPANED SOLN NON_PREFERRED

ENALAPRIL MALEATE TABS PREFERRED

VASOTEC TABS NON_PREFERRED

FOSINOPRIL SODIUM TABS PREFERRED

of 98


QBRELIS SOLN NON_PREFERRED

LISINOPRIL TABS PREFERRED

PRINIVIL TABS NON_PREFERRED

ZESTRIL TABS NON_PREFERRED

MOEXIPRIL HCL TABS PREFERRED

PERINDOPRIL ERBUMINE TABS NON_PREFERRED

ACCUPRIL TABS NON_PREFERRED

QUINAPRIL HCL TABS PREFERRED

QUINAPRIL HYDROCHLORIDE TABS PREFERRED

ALTACE CAPS NON_PREFERRED

RAMIPRIL CAPS PREFERRED

TRANDOLAPRIL TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES :

ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS AMLODIPINE/OLMESARTAN MED TABS NON_PREFERRED

AZOR TABS NON_PREFERRED

AMLODIPINE BESYLATE/VALSA TABS NON_PREFERRED

EXFORGE TABS NON_PREFERRED

TELMISARTAN/AMLODIPINE TABS NON_PREFERRED

TWYNSTA TABS NON_PREFERRED

EDARBYCLOR TABS NON_PREFERRED

ATACAND HCT TABS NON_PREFERRED

CANDESARTAN CILEXETIL/HYD TABS NON_PREFERRED

AVALIDE TABS NON_PREFERRED

IRBESARTAN/HYDROCHLOROTHI TABS PREFERRED

HYZAAR TABS NON_PREFERRED

LOSARTAN POTASSIUM/HYDROC TABS PREFERRED

BENICAR HCT TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL/HYDR TABS NON_PREFERRED

MICARDIS HCT TABS NON_PREFERRED

TELMISARTAN/HYDROCHLOROTH TABS NON_PREFERRED

DIOVAN HCT TABS NON_PREFERRED

VALSARTAN/HYDROCHLOROTHIA TABS PREFERRED

AMLODIPINE/VALSARTAN/HCTZ TABS NON_PREFERRED

AMLODIPINE/VALSARTAN/HYDR TABS NON_PREFERRED

EXFORGE HCT TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL/AMLO TABS NON_PREFERRED

TRIBENZOR TABS NON_PREFERRED


ANGIOTENSIN II RECEPTOR BLOCKERS EDARBI TABS NON_PREFERRED

ATACAND TABS NON_PREFERRED

CANDESARTAN CILEXETIL TABS NON_PREFERRED

EPROSARTAN MESYLATE TABS NON_PREFERRED

AVAPRO TABS NON_PREFERRED

of 98


IRBESARTAN TABS PREFERRED

COZAAR TABS NON_PREFERRED

LOSARTAN POTASSIUM TABS PREFERRED

BENICAR TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL TABS NON_PREFERRED

MICARDIS TABS NON_PREFERRED

TELMISARTAN TABS NON_PREFERRED

DIOVAN TABS NON_PREFERRED

VALSARTAN TABS PREFERRED


ANTIADRENERGICS CATAPRES-TTS-1 PTWK NON_PREFERRED

CATAPRES-TTS-2 PTWK NON_PREFERRED

CATAPRES-TTS-3 PTWK NON_PREFERRED

CLONIDINE HCL PTWK PREFERRED

CATAPRES TABS NON_PREFERRED

CLONIDINE HCL TABS PREFERRED

CLONIDINE HYDROCHLORIDE TABS PREFERRED

GUANFACINE HCL TABS PREFERRED

GUANFACINE HYDROCHLORIDE TABS PREFERRED

METHYLDOPA TABS PREFERRED

CARDURA TABS NON_PREFERRED

DOXAZOSIN TABS PREFERRED

DOXAZOSIN MESYLATE TABS PREFERRED

MINIPRESS CAPS NON_PREFERRED

PRAZOSIN HCL CAPS PREFERRED

PRAZOSIN HYDROCHLORIDE CAPS PREFERRED

TERAZOSIN HCL CAPS PREFERRED

TERAZOSIN HYDROCHLORIDE CAPS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-

BLOCKER COMBINATIONS ATENOLOL/CHLORTHALIDONE TABS PREFERRED

TENORETIC 100 TABS NON_PREFERRED

TENORETIC 50 TABS NON_PREFERRED

BISOPROLOL FUMARATE/HYDRO TABS PREFERRED

ZIAC TABS NON_PREFERRED

METOPROLOL/HYDROCHLOROTHI TABS PREFERRED

PROPRANOLOL/HYDROCHLOROTH TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-

BLOCKERS CORGARD TABS NON_PREFERRED

NADOLOL TABS PREFERRED

PINDOLOL TABS PREFERRED

INDERAL LA CP24 NON_PREFERRED

PROPRANOLOL HCL ER CP24 PREFERRED

HEMANGEOL SOLN PREFERRED_WITH_PA

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PROPRANOLOL HCL SOLN PREFERRED

PROPRANOLOL HCL TABS PREFERRED

PROPRANOLOL HYDROCHLORIDE TABS PREFERRED

INDERAL XL CP24 NON_PREFERRED

INNOPRAN XL CP24 NON_PREFERRED

SOTYLIZE SOLN NON_PREFERRED

BETAPACE TABS NON_PREFERRED

SORINE TABS PREFERRED

SOTALOL HCL TABS PREFERRED

SOTALOL HYDROCHLORIDE TABS PREFERRED

SOTALOL HYDROCHOLRIDE TABS PREFERRED

BETAPACE AF TABS NON_PREFERRED

SOTALOL HCL (AF) TABS NON_PREFERRED

SOTALOL HCL AF TABS NON_PREFERRED

SOTALOL HYDROCHLORIDE (AF TABS NON_PREFERRED

SOTALOL HYDROCHLORIDE AF TABS NON_PREFERRED

TIMOLOL MALEATE TABS PREFERRED

ACEBUTOLOL HCL CAPS PREFERRED

ACEBUTOLOL HYDROCHLORIDE CAPS PREFERRED

FIRST-ATENOLOL SOLN NON_PREFERRED

ATENOLOL TABS PREFERRED

TENORMIN TABS NON_PREFERRED

BETAXOLOL HCL TABS PREFERRED

BISOPROLOL FUMARATE TABS PREFERRED

KAPSPARGO SPRINKLE CS24 NON_PREFERRED

METOPROLOL SUCCINATE ER TB24 PREFERRED

TOPROL XL TB24 NON_PREFERRED

FIRST - METOPROLOL SOLN NON_PREFERRED

LOPRESSOR TABS NON_PREFERRED

METOPROLOL TARTRATE TABS PREFERRED

BYSTOLIC TABS NON_PREFERRED

CARVEDILOL TABS PREFERRED

COREG TABS NON_PREFERRED

CARVEDILOL PHOSPHATE CP24 NON_PREFERRED

COREG CR CP24 NON_PREFERRED

LABETALOL HCL TABS PREFERRED

LABETALOL HYDROCHLORIDE TABS PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM

CHANNEL BLOCKERS KATERZIA SUSP NON_PREFERRED

AMLODIPINE BESYLATE TABS PREFERRED

NORVASC TABS NON_PREFERRED

DILTIAZEM HCL ER CP12 PREFERRED

DILT-XR CP24 PREFERRED

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CARDIZEM TABS NON_PREFERRED

DILTIAZEM HCL TABS PREFERRED


TAZTIA XT CP24 PREFERRED

TIAZAC CP24 NON_PREFERRED

CARDIZEM CD CP24 NON_PREFERRED

CARTIA XT CP24 PREFERRED

DILTIAZEM HCL CD CP24 PREFERRED


DILTIAZEM HYDROCHLORIDE E CP24 PREFERRED

CARDIZEM LA TB24 NON_PREFERRED

DILTIAZEM HCL ER TB24 PREFERRED

MATZIM LA TB24 PREFERRED

FELODIPINE ER TB24 PREFERRED

ISRADIPINE CAPS NON_PREFERRED

NICARDIPINE HCL CAPS NON_PREFERRED

NIFEDIPINE CAPS PREFERRED

PROCARDIA CAPS NON_PREFERRED

ADALAT CC TB24 NON_PREFERRED

NIFEDIPINE ER TB24 PREFERRED

PROCARDIA XL TB24 NON_PREFERRED

NIMODIPINE CAPS PREFERRED

NYMALIZE SOLN NON_PREFERRED

NISOLDIPINE ER TB24 NON_PREFERRED

SULAR TB24 NON_PREFERRED

VERAPAMIL HCL ER CP24 PREFERRED

VERAPAMIL HCL SR CP24 PREFERRED

VERELAN CP24 NON_PREFERRED

VERELAN PM CP24 NON_PREFERRED

CALAN TABS NON_PREFERRED

VERAPAMIL HCL TABS PREFERRED

VERAPAMIL HYDROCHLORIDE TABS PREFERRED

CALAN SR TBCR NON_PREFERRED

VERAPAMIL HCL ER TBCR PREFERRED

VERAPAMIL HYDROCHLORIDE E TBCR PREFERRED

CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : MISC ALISKIREN TABS NON_PREFERRED

TEKTURNA TABS NON_PREFERRED

EPLERENONE TABS NON_PREFERRED

INSPRA TABS NON_PREFERRED

PHENOXYBENZAMINE HYDROCHL CAPS NON_PREFERRED

DEMSER CAPS PREFERRED

HYDRALAZINE HCL TABS PREFERRED

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HYDRALAZINE HYDROCHLORIDE TABS PREFERRED

MINOXIDIL TABS PREFERRED

VECAMYL TABS NON_PREFERRED

METHYLDOPA/HYDROCHLOROTHI TABS PREFERRED

TEKTURNA HCT TABS NON_PREFERRED

CARDIOVASCULAR AGENTS - CARDIOTONICS : CARDIAC

GLYCOSIDES DIGOXIN SOLN PREFERRED

DIGITEK TABS PREFERRED

DIGOX TABS PREFERRED

DIGOXIN TABS PREFERRED

CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS DILATRATE SR CPCR PREFERRED

ISORDIL TITRADOSE TABS NON_PREFERRED

ISOSORBIDE DINITRATE TABS PREFERRED

ISOSORBIDE MONONITRATE TABS PREFERRED

ISOSORBIDE MONONITRATE ER TB24 PREFERRED

NITROMIST AERS NON_PREFERRED

NITRO-BID OINT PREFERRED

GONITRO PACK NON_PREFERRED

MINITRAN PT24 PREFERRED

NITRO-DUR PT24 NON_PREFERRED

NITROGLYCERIN TRANSDERMAL PT24 PREFERRED

NITROGLYCERIN LINGUAL SOLN NON_PREFERRED

NITROLINGUAL PUMPSPRAY SOLN NON_PREFERRED

NITROGLYCERIN SUBL PREFERRED

NITROSTAT SUBL NON_PREFERRED

RANEXA TB12 NON_PREFERRED

RANOLAZINE ER TB12 NON_PREFERRED

CARDIOVASCULAR AGENTS : ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAPS PREFERRED

NORPACE CAPS NON_PREFERRED

NORPACE CR CP12 PREFERRED

QUINIDINE GLUCONATE CR TBCR PREFERRED

QUINIDINE SULFATE TABS PREFERRED

MEXILETINE HCL CAPS PREFERRED

FLECAINIDE ACETATE TABS PREFERRED

PROPAFENONE HCL ER CP12 NON_PREFERRED

PROPAFENONE HYDROCHLORIDE CP12 NON_PREFERRED

RYTHMOL SR CP12 NON_PREFERRED

PROPAFENONE HCL TABS PREFERRED

AMIODARONE HCL TABS PREFERRED

AMIODARONE HYDROCHLORIDE TABS PREFERRED

PACERONE TABS PREFERRED

DOFETILIDE CAPS PREFERRED

TIKOSYN CAPS NON_PREFERRED

of 98


MULTAQ TABS NON_PREFERRED

CARDIOVASCULAR AGENTS : DIURETICS ACETAZOLAMIDE ER CP12 PREFERRED

ACETAZOLAMIDE TABS PREFERRED

KEVEYIS TABS NON_PREFERRED

METHAZOLAMIDE TABS PREFERRED

BUMETANIDE TABS PREFERRED

BUMEX TABS NON_PREFERRED

EDECRIN TABS NON_PREFERRED

ETHACRYNIC ACID TABS PREFERRED

FUROSEMIDE SOLN PREFERRED

FUROSEMIDE TABS PREFERRED

LASIX TABS NON_PREFERRED

TORSEMIDE TABS PREFERRED

AMILORIDE HCL TABS PREFERRED

CAROSPIR SUSP NON_PREFERRED

ALDACTONE TABS NON_PREFERRED

SPIRONOLACTONE TABS PREFERRED

TRIAMTERENE CAPS PREFERRED

DIURIL SUSP PREFERRED

CHLOROTHIAZIDE TABS PREFERRED

CHLORTHALIDONE TABS PREFERRED

HYDROCHLOROTHIAZIDE CAPS PREFERRED

HYDROCHLOROTHIAZIDE TABS PREFERRED

INDAPAMIDE TABS PREFERRED

METOLAZONE TABS PREFERRED

AMILORIDE/HYDROCHLOROTHIA TABS PREFERRED

ALDACTAZIDE TABS NON_PREFERRED

SPIRONOLACTONE/HYDROCHLOR TABS PREFERRED

DYAZIDE CAPS NON_PREFERRED

TRIAMTERENE/HYDROCHLOROTH CAPS PREFERRED

MAXZIDE TABS NON_PREFERRED

MAXZIDE-25 TABS NON_PREFERRED

TRIAMTERENE/HYDROCHLOROTH TABS PREFERRED

CARDIOVASCULAR AGENTS : MISC MIDODRINE HCL TABS PREFERRED

MIDODRINE HYDROCHLORIDE TABS PREFERRED

NORTHERA CAPS NON_PREFERRED

CIALIS TABS NON_PREFERRED

TADALAFIL TABS NON_PREFERRED

VYNDAMAX CAPS NON_PREFERRED

VYNDAQEL CAPS NON_PREFERRED

CORLANOR SOLN NON_PREFERRED

CORLANOR TABS NON_PREFERRED

ENTRESTO TABS NON_PREFERRED

of 98


AMLODIPINE BESYLATE/ATORV TABS NON_PREFERRED

CADUET TABS NON_PREFERRED

BIDIL TABS PREFERRED

CARDIOVASCULAR AGENTS : PULMONARY HYPERTENSION UPTRAVI TABS NON_PREFERRED

UPTRAVI TBPK NON_PREFERRED

ADEMPAS TABS NON_PREFERRED

REVATIO SOLN NON_PREFERRED

SILDENAFIL SOLN NON_PREFERRED

REVATIO SUSR PREFERRED_WITH_PA

SILDENAFIL CITRATE SUSR NON_PREFERRED

REVATIO TABS NON_PREFERRED

SILDENAFIL CITRATE TABS PREFERRED_WITH_PA

ADCIRCA TABS PREFERRED_WITH_PA

ALYQ TABS PREFERRED_WITH_PA

TADALAFIL TABS PREFERRED_WITH_PA

AMBRISENTAN TABS NON_PREFERRED

LETAIRIS TABS PREFERRED_WITH_PA

BOSENTAN TABS NON_PREFERRED

TRACLEER TABS PREFERRED_WITH_PA

TRACLEER TBSO PREFERRED_WITH_PA

OPSUMIT TABS NON_PREFERRED

EPOPROSTENOL SODIUM SOLR PREFERRED_WITH_PA

FLOLAN SOLR PREFERRED_WITH_PA

VELETRI SOLR NON_PREFERRED

VENTAVIS SOLN NON_PREFERRED

REMODULIN SOLN NON_PREFERRED

TREPROSTINIL SOLN NON_PREFERRED

TYVASO SOLN NON_PREFERRED

TYVASO REFILL SOLN NON_PREFERRED

TYVASO STARTER SOLN NON_PREFERRED

ORENITRAM TBCR NON_PREFERRED

CHELATING AGENTS SYPRINE CAPS NON_PREFERRED

TRIENTINE HYDROCHLORIDE CAPS PREFERRED

CUPRIMINE CAPS NON_PREFERRED

PENICILLAMINE CAPS PREFERRED

D-PENAMINE TABS PREFERRED

DEPEN TITRATABS TABS PREFERRED

CONTRACEPTIVES : COMBINATION CONTRACEPTIVES XULANE PTWK PREFERRED

NUVARING RING PREFERRED

APRI TABS PREFERRED

CYRED TABS PREFERRED

CYRED EQ TABS PREFERRED

DESOGESTREL/ETHINYL ESTRA TABS PREFERRED

of 98


EMOQUETTE TABS PREFERRED

ENSKYCE TABS PREFERRED

ISIBLOOM TABS PREFERRED

JULEBER TABS PREFERRED

KALLIGA TABS PREFERRED

RECLIPSEN TABS PREFERRED

DROSPIRENONE/ETHINYL ESTR TABS PREFERRED

GIANVI TABS PREFERRED

JASMIEL TABS PREFERRED

LO-ZUMANDIMINE TABS PREFERRED

LORYNA TABS PREFERRED

NIKKI TABS PREFERRED

OCELLA TABS PREFERRED

SYEDA TABS PREFERRED

YASMIN 28 TABS PREFERRED

YAZ TABS PREFERRED

ZARAH TABS PREFERRED

ZUMANDIMINE TABS PREFERRED

ETHYNODIOL DIACETATE/ETHI TABS PREFERRED

KELNOR 1/35 TABS PREFERRED

KELNOR 1/50 TABS PREFERRED

ZOVIA 1/35E TABS PREFERRED

AFIRMELLE TABS PREFERRED

ALTAVERA TABS PREFERRED

AUBRA TABS PREFERRED

AUBRA EQ TABS PREFERRED

AVIANE TABS PREFERRED

AYUNA TABS PREFERRED

CHATEAL TABS PREFERRED

CHATEAL EQ TABS PREFERRED

FALMINA TABS PREFERRED

KURVELO TABS PREFERRED

LARISSIA TABS PREFERRED

LESSINA TABS PREFERRED

LEVONORGESTREL/ETHINYL ES TABS PREFERRED

LEVORA 0.15/30-28 TABS PREFERRED

LILLOW TABS PREFERRED

LUTERA TABS PREFERRED

MARLISSA TABS PREFERRED

ORSYTHIA TABS PREFERRED

PORTIA-28 TABS PREFERRED

SRONYX TABS PREFERRED

VIENVA TABS PREFERRED

of 98


ALYACEN 1/35 TABS PREFERRED

BALZIVA TABS PREFERRED

BRIELLYN TABS PREFERRED

CYCLAFEM 1/35 TABS PREFERRED

DASETTA 1/35 TABS PREFERRED

NECON 0.5/35-28 TABS PREFERRED

NORTREL 0.5/35 (28) TABS PREFERRED

NORTREL 1/35 TABS PREFERRED

ORTHO-NOVUM 1/35 TABS PREFERRED

PHILITH TABS PREFERRED

PIRMELLA 1/35 TABS PREFERRED

VYFEMLA TABS PREFERRED

WERA TABS PREFERRED

AUROVELA 1.5/30 TABS PREFERRED

AUROVELA 1/20 TABS PREFERRED

HAILEY 1.5/30 TABS PREFERRED

JUNEL 1.5/30 TABS PREFERRED

JUNEL 1/20 TABS PREFERRED

LARIN 1.5/30 TABS PREFERRED

LARIN 1/20 TABS PREFERRED

LOESTRIN 1.5/30-21 TABS PREFERRED

LOESTRIN 1/20-21 TABS PREFERRED

MICROGESTIN 1.5/30 TABS PREFERRED

MICROGESTIN 1/20 TABS PREFERRED

NORETHINDRONE ACETATE/ETH TABS PREFERRED

CRYSELLE-28 TABS PREFERRED

ELINEST TABS PREFERRED

LOW-OGESTREL TABS PREFERRED

OGESTREL TABS PREFERRED

ESTARYLLA TABS PREFERRED

FEMYNOR TABS PREFERRED

MILI TABS PREFERRED

MONO-LINYAH TABS PREFERRED

NORGESTIMATE/ETHINYL ESTR TABS PREFERRED

PREVIFEM TABS PREFERRED

SPRINTEC 28 TABS PREFERRED

VYLIBRA TABS PREFERRED

BEYAZ TABS PREFERRED

DROSPIRENONE/ETHINYL ESTR TABS PREFERRED

SAFYRAL TABS PREFERRED

TYDEMY TABS PREFERRED

BALCOLTRA TABS PREFERRED

FALESSA KIT PREFERRED

of 98


GENERESS FE CHEW PREFERRED

KAITLIB FE CHEW PREFERRED

LAYOLIS FE CHEW PREFERRED

NORETHINDRONE & ETHINYL E CHEW PREFERRED

NORETHINDRONE/ETHINYL EST CHEW PREFERRED

WYMZYA FE CHEW PREFERRED

TAYTULLA CAPS PREFERRED

MELODETTA 24 FE CHEW PREFERRED

MIBELAS 24 FE CHEW PREFERRED

MINASTRIN 24 FE CHEW PREFERRED

NORETHINDRONE ACETATE/ETH CHEW PREFERRED

AUROVELA 24 FE TABS PREFERRED

AUROVELA FE 1.5/30 TABS PREFERRED

AUROVELA FE 1/20 TABS PREFERRED

BLISOVI 24 FE TABS PREFERRED

BLISOVI FE 1.5/30 TABS PREFERRED

BLISOVI FE 1/20 TABS PREFERRED

HAILEY 24 FE TABS PREFERRED

JUNEL FE 1.5/30 TABS PREFERRED

JUNEL FE 1/20 TABS PREFERRED

JUNEL FE 24 TABS PREFERRED

LARIN 24 FE TABS PREFERRED

LARIN FE 1.5/30 TABS PREFERRED

LARIN FE 1/20 TABS PREFERRED

LOESTRIN FE 1.5/30 TABS PREFERRED

LOESTRIN FE 1/20 TABS PREFERRED

MICROGESTIN FE TABS PREFERRED

MICROGESTIN FE 1.5/30 TABS PREFERRED

NORETHINDRONE ACETATE/ETH TABS PREFERRED

TARINA 24 FE TABS PREFERRED

TARINA FE 1/20 TABS PREFERRED

TARINA FE 1/20 EQ TABS PREFERRED

AZURETTE TABS PREFERRED

BEKYREE TABS PREFERRED

DESOGESTREL/ETHINYL ESTRA TABS PREFERRED

KARIVA TABS PREFERRED

MIRCETTE TABS PREFERRED

PIMTREA TABS PREFERRED

SIMLIYA TABS PREFERRED

VIORELE TABS PREFERRED

LO LOESTRIN FE TABS PREFERRED

CAZIANT TABS PREFERRED

VELIVET TABS PREFERRED

of 98


ENPRESSE-28 TABS PREFERRED

LEVONEST TABS PREFERRED


TRIVORA-28 TABS PREFERRED

ALYACEN 7/7/7 TABS PREFERRED

ARANELLE TABS PREFERRED

CYCLAFEM 7/7/7 TABS PREFERRED

DASETTA 7/7/7 TABS PREFERRED

LEENA TABS PREFERRED

NORTREL 7/7/7 TABS PREFERRED

ORTHO-NOVUM 7/7/7 TABS PREFERRED

PIRMELLA 7/7/7 TABS PREFERRED

NORGESTIMATE/ETHINYL ESTR TABS PREFERRED

ORTHO TRI-CYCLEN LO TABS PREFERRED

TRI FEMYNOR TABS PREFERRED

TRI-ESTARYLLA TABS PREFERRED

TRI-LINYAH TABS PREFERRED

TRI-LO-ESTARYLLA TABS PREFERRED

TRI-LO-MARZIA TABS PREFERRED

TRI-LO-MILI TABS PREFERRED

TRI-LO-SPRINTEC TABS PREFERRED

TRI-MILI TABS PREFERRED

TRI-PREVIFEM TABS PREFERRED

TRI-SPRINTEC TABS PREFERRED

TRI-VYLIBRA TABS PREFERRED

TRI-VYLIBRA LO TABS PREFERRED

ESTROSTEP FE TABS PREFERRED

TILIA FE TABS PREFERRED

TRI-LEGEST FE TABS PREFERRED

NATAZIA TABS PREFERRED

AMETHIA TABS PREFERRED

AMETHIA LO TABS PREFERRED

ASHLYNA TABS PREFERRED

CAMRESE TABS PREFERRED

CAMRESE LO TABS PREFERRED

DAYSEE TABS PREFERRED

FAYOSIM TABS PREFERRED

INTROVALE TABS PREFERRED

JOLESSA TABS PREFERRED

LEVONORGESTREL AND ETHINY TABS PREFERRED


LOSEASONIQUE TABS PREFERRED

QUARTETTE TABS PREFERRED

of 98


RIVELSA TABS PREFERRED

SEASONIQUE TABS PREFERRED

SETLAKIN TABS PREFERRED

SIMPESSE TABS PREFERRED

AMETHYST TABS PREFERRED

LEVONORGESTREL AND ETHINY TABS PREFERRED

CONTRACEPTIVES : EMERGENCY CONTRACEPTIVES AFTERA TABS PREFERRED

ECONTRA EZ TABS PREFERRED

ECONTRA ONE-STEP TABS PREFERRED

LEVONORGESTREL TABS PREFERRED

MY CHOICE TABS PREFERRED

MY WAY TABS PREFERRED

NEW DAY TABS PREFERRED

OPCICON ONE-STEP TABS PREFERRED

OPTION 2 TABS PREFERRED

PLAN B ONE-STEP TABS PREFERRED

TAKE ACTION TABS PREFERRED

ELLA TABS PREFERRED

CONTRACEPTIVES : PROGESTIN CONTRACEPTIVES CAMILA TABS PREFERRED

DEBLITANE TABS PREFERRED

ERRIN TABS PREFERRED

HEATHER TABS PREFERRED

INCASSIA TABS PREFERRED

JENCYCLA TABS PREFERRED

LYZA TABS PREFERRED

NORA-BE TABS PREFERRED

NORETHINDRONE TABS PREFERRED

NORLYDA TABS PREFERRED

ORTHO MICRONOR TABS PREFERRED

SHAROBEL TABS PREFERRED

TULANA TABS PREFERRED

SLYND TABS PREFERRED

DEPO-PROVERA CONTRACEPTIV SUSP PREFERRED

MEDROXYPROGESTERONE ACETA SUSP PREFERRED

DEPO-PROVERA CONTRACEPTIV SUSY PREFERRED

DEPO-SUBQ PROVERA 104 SUSY PREFERRED

MEDROXYPROGESTERONE ACETA SUSY PREFERRED

CORTICOSTEROIDS BUDESONIDE CPEP NON_PREFERRED

ENTOCORT EC CPEP NON_PREFERRED

BUDESONIDE ER TB24 NON_PREFERRED

UCERIS TB24 NON_PREFERRED

CORTISONE ACETATE TABS NON_PREFERRED

EMFLAZA SUSP NON_PREFERRED

of 98


EMFLAZA TABS NON_PREFERRED

DEXAMETHASONE INTENSOL CONC PREFERRED

DECADRON ELIX PREFERRED

DEXAMETHASONE ELIX PREFERRED

DEXAMETHASONE SOLN PREFERRED

DECADRON TABS PREFERRED

DEXAMETHASONE TABS PREFERRED

DEXAMETHASONE 10-DAY DOSE TBPK PREFERRED



DEXPAK 10 DAY TBPK NON_PREFERRED



DXEVO 11-DAY TBPK NON_PREFERRED

TAPERDEX 12-DAY TBPK NON_PREFERRED



CORTEF TABS NON_PREFERRED

HYDROCORTISONE TABS PREFERRED

MEDROL TABS NON_PREFERRED

METHYLPREDNISOLONE TABS PREFERRED

MEDROL DOSEPAK TBPK NON_PREFERRED

METHYLPREDNISOLONE DOSE P TBPK PREFERRED

PREDNISOLONE SOLN PREFERRED

MILLIPRED TABS PREFERRED

MILLIPRED DP TBPK PREFERRED

PREDNISOLONE SODIUM PHOSP SOLN PREFERRED

PREDNISOLONE SODIUM PHOSP TBDP NON_PREFERRED

PREDNISONE INTENSOL CONC PREFERRED

PREDNISONE SOLN PREFERRED

PREDNISONE TABS PREFERRED

RAYOS TBEC NON_PREFERRED

PREDNISONE TBPK PREFERRED

FLUDROCORTISONE ACETATE TABS PREFERRED

DERMATOLOGICALS : ACNE PRODUCTS ADAPALENE CREA NON_PREFERRED

DIFFERIN CREA NON_PREFERRED

ADAPALENE GEL NON_PREFERRED

ADAPALENE PUMP GEL NON_PREFERRED

DIFFERIN GEL NON_PREFERRED

DIFFERIN LOTN NON_PREFERRED

ADAPALENE SOLN NON_PREFERRED

AZELEX CREA NON_PREFERRED

BPO GEL NON_PREFERRED

of 98


ABSORICA CAPS NON_PREFERRED

AMNESTEEM CAPS NON_PREFERRED

CLARAVIS CAPS NON_PREFERRED

ISOTRETINOIN CAPS NON_PREFERRED

MYORISAN CAPS NON_PREFERRED

ZENATANE CAPS NON_PREFERRED

FABIOR FOAM NON_PREFERRED

AVITA CREA PREFERRED

RETIN-A CREA NON_PREFERRED

TRETINOIN CREA PREFERRED

ATRALIN GEL NON_PREFERRED

AVITA GEL PREFERRED

RETIN-A GEL NON_PREFERRED

TRETINOIN GEL PREFERRED

ALTRENO LOTN NON_PREFERRED

RETIN-A MICRO GEL NON_PREFERRED

RETIN-A MICRO PUMP GEL NON_PREFERRED

TRETINOIN MICROSPHERE GEL NON_PREFERRED

TRETINOIN MICROSPHERE PUM GEL NON_PREFERRED

AKLIEF CREA NON_PREFERRED

CLINDAMYCIN PHOSPHATE FOAM NON_PREFERRED

EVOCLIN FOAM NON_PREFERRED

CLEOCIN-T GEL NON_PREFERRED

CLINDAGEL GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE GEL PREFERRED

CLEOCIN-T LOTN NON_PREFERRED

CLINDAMYCIN PHOSPHATE LOTN PREFERRED

CLINDAMYCIN PHOSPHATE SOLN PREFERRED

CLINDACIN ETZ PLEDGETS SWAB PREFERRED

CLINDACIN-P SWAB PREFERRED

CLINDAMYCIN PHOSPHATE SWAB PREFERRED

ACZONE GEL NON_PREFERRED

DAPSONE GEL NON_PREFERRED

ERYGEL GEL NON_PREFERRED

ERYTHROMYCIN GEL PREFERRED

ERY PADS NON_PREFERRED

ERYTHROMYCIN PADS NON_PREFERRED

ERYTHROMYCIN SOLN PREFERRED

KLARON LOTN NON_PREFERRED

SODIUM SULFACETAMIDE LOTN NON_PREFERRED

SULFACETAMIDE SODIUM LOTN NON_PREFERRED

ADAPALENE/BENZOYL PEROXID GEL NON_PREFERRED

EPIDUO GEL NON_PREFERRED

of 98


EPIDUO FORTE GEL NON_PREFERRED

BENZAMYCIN GEL NON_PREFERRED

ERYTHROMYCIN/BENZOYL PERO GEL PREFERRED

ACANYA GEL NON_PREFERRED

BENZACLIN GEL NON_PREFERRED

BENZACLIN WITH PUMP GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE/BEN GEL NON_PREFERRED

CLINDAMYCIN/BENZOYL PEROX GEL NON_PREFERRED

ONEXTON GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE/BEN GEL NON_PREFERRED

DUAC GEL NON_PREFERRED

NEUAC GEL NON_PREFERRED

CLINDACIN ETZ KIT NON_PREFERRED

CLINDACIN PAC KIT NON_PREFERRED

CLINDAMYCIN PHOSPHATE/TRE GEL NON_PREFERRED

ZIANA GEL NON_PREFERRED

SODIUM SULFACETAMIDE/SULF CREA NON_PREFERRED

SSS 10%-5% CREA NON_PREFERRED

BP 10-1 EMUL NON_PREFERRED

SULFACETAMIDE SODIUM/SULF EMUL NON_PREFERRED

SSS 10-5 FOAM NON_PREFERRED

SODIUM SULFACETAMIDE/SULF LIQD NON_PREFERRED

SUMADAN WASH LIQD NON_PREFERRED

SUMAXIN WASH LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULF PADS NON_PREFERRED

SUMAXIN PADS NON_PREFERRED

SODIUM SULFACETAMIDE/SULF SUSP NON_PREFERRED

BP CLEANSING WASH EMUL NON_PREFERRED

SODIUM SULFACETAMIDE/SULF EMUL NON_PREFERRED

SUMADAN KIT KIT NON_PREFERRED

SUMAXIN CP KIT KIT NON_PREFERRED

SUMADAN XLT KIT NON_PREFERRED

NEUAC KIT KIT NON_PREFERRED

DERMATOLOGICALS : ANTIBIOTICS GENTAMICIN SULFATE CREA PREFERRED

GENTAMICIN SULFATE OINT PREFERRED

CENTANY AT KIT NON_PREFERRED

CENTANY OINT NON_PREFERRED

MUPIROCIN OINT PREFERRED

MUPIROCIN CREA NON_PREFERRED

NEO-SYNALAR CREA NON_PREFERRED

CORTISPORIN CREA NON_PREFERRED

NEO-SYNALAR KIT KIT NON_PREFERRED

CORTISPORIN OINT PREFERRED

of 98


DERMATOLOGICALS : ANTIFUNGALS MENTAX CREA NON_PREFERRED

CICLOPIROX GEL NON_PREFERRED

CICLODAN SOLUTION KIT KIT NON_PREFERRED

CICLOPIROX TREATMENT KIT NON_PREFERRED

CICLOPIROX SHAM NON_PREFERRED

LOPROX SHAMPOO SHAM NON_PREFERRED

CICLODAN SOLN NON_PREFERRED

CICLOPIROX NAIL LACQUER SOLN NON_PREFERRED

PENLAC NAIL LACQUER SOLN NON_PREFERRED

CICLOPIROX OLAMINE CREA NON_PREFERRED

LOPROX CREA NON_PREFERRED

CICLOPIROX SUSP NON_PREFERRED

LOPROX SUSP NON_PREFERRED

LOPROX KIT NON_PREFERRED

LOPROX KIT KIT NON_PREFERRED

NAFTIFINE HCL CREA NON_PREFERRED

NAFTIFINE HYDROCHLORIDE CREA NON_PREFERRED

NAFTIN CREA NON_PREFERRED

NAFTIN GEL NON_PREFERRED

NYSTATIN CREA PREFERRED

NYSTATIN OINT PREFERRED

NYAMYC POWD PREFERRED

NYSTATIN POWD PREFERRED

NYSTOP POWD PREFERRED

CLOTRIMAZOLE CREA PREFERRED

CLOTRIMAZOLE SOLN NON_PREFERRED

ECONAZOLE NITRATE CREA PREFERRED

JUBLIA SOLN NON_PREFERRED

KETOCONAZOLE CREA PREFERRED

EXTINA FOAM NON_PREFERRED

KETOCONAZOLE FOAM NON_PREFERRED

KETOCONAZOLE SHAM PREFERRED

NIZORAL SHAM NON_PREFERRED

LULICONAZOLE CREA NON_PREFERRED

LUZU CREA NON_PREFERRED

OXICONAZOLE NITRATE CREA NON_PREFERRED

OXISTAT CREA NON_PREFERRED

OXISTAT LOTN NON_PREFERRED

ERTACZO CREA NON_PREFERRED

EXELDERM CREA NON_PREFERRED

EXELDERM SOLN NON_PREFERRED

KERYDIN SOLN NON_PREFERRED

CLOTRIMAZOLE/BETAMETHASON CREA NON_PREFERRED

of 98


LOTRISONE CREA NON_PREFERRED

CLOTRIMAZOLE/BETAMETHASON LOTN NON_PREFERRED

NYSTATIN/TRIAMCINOLONE CREA NON_PREFERRED

NYSTATIN/TRIAMCINOLONE AC CREA NON_PREFERRED

NYSTATIN/TRIAMCINOLONE OINT NON_PREFERRED

NYSTATIN/TRIAMCINOLONE AC OINT NON_PREFERRED

DERMACINRX THERAZOLE PAK THPK NON_PREFERRED

MICONAZOLE NITRATE/ZINC O OINT NON_PREFERRED

VUSION OINT NON_PREFERRED

DERMATOLOGICALS : ANTIPSORIATICS CALCIPOTRIENE CREA PREFERRED

DOVONEX CREA NON_PREFERRED

SORILUX FOAM NON_PREFERRED

CALCIPOTRIENE OINT PREFERRED

CALCITRENE OINT PREFERRED

CALCIPOTRIENE SOLN PREFERRED

CALCITRIOL OINT NON_PREFERRED

VECTICAL OINT NON_PREFERRED

TAZAROTENE CREA NON_PREFERRED

TAZORAC CREA NON_PREFERRED

TAZORAC GEL NON_PREFERRED

ACITRETIN CAPS NON_PREFERRED

SORIATANE CAPS NON_PREFERRED

SILIQ SOSY NON_PREFERRED

TREMFYA SOPN NON_PREFERRED

TREMFYA SOSY NON_PREFERRED

TALTZ SOAJ NON_PREFERRED

TALTZ SOSY NON_PREFERRED

METHOXSALEN CAPS NON_PREFERRED

OXSORALEN ULTRA CAPS NON_PREFERRED

SKYRIZI PSKT NON_PREFERRED

COSENTYX SENSOREADY PEN SOAJ NON_PREFERRED

COSENTYX SOSY NON_PREFERRED

ILUMYA SOSY NON_PREFERRED

STELARA SOLN NON_PREFERRED

STELARA SOSY NON_PREFERRED

DERMATOLOGICALS : CORTICOSTEROIDS - TOPICAL ALCLOMETASONE DIPROPIONAT CREA PREFERRED

ALCLOMETASONE DIPROPIONAT OINT PREFERRED

AMCINONIDE CREA NON_PREFERRED

AMCINONIDE LOTN NON_PREFERRED

BETAMETHASONE DIPROPIONAT CREA NON_PREFERRED

SERNIVO EMUL NON_PREFERRED

BETAMETHASONE DIPROPIONAT LOTN NON_PREFERRED

BETAMETHASONE DIPROPIONAT OINT NON_PREFERRED

of 98


AUGMENTED BETAMETHASONE D CREA NON_PREFERRED

AUGMENTED BETAMETHASONE D GEL NON_PREFERRED

AUGMENTED BETAMETHASONE D LOTN NON_PREFERRED

AUGMENTED BETAMETHASONE D OINT NON_PREFERRED

DIPROLENE OINT NON_PREFERRED

BETAMETHASONE VALERATE CREA PREFERRED

BETAMETHASONE VALERATE FOAM NON_PREFERRED

LUXIQ FOAM NON_PREFERRED

BETAMETHASONE VALERATE LOTN PREFERRED

BETAMETHASONE VALERATE OINT PREFERRED

CLOBETASOL PROPIONATE CREA PREFERRED

TEMOVATE CREA NON_PREFERRED

CLOBETASOL PROPIONATE FOAM NON_PREFERRED

OLUX FOAM NON_PREFERRED

CLOBETASOL PROPIONATE GEL PREFERRED

CLOBETASOL PROPIONATE LIQD NON_PREFERRED

CLOBEX LIQD NON_PREFERRED

CLOBETASOL PROPIONATE LOTN NON_PREFERRED

CLOBEX LOTN NON_PREFERRED

CLOBETASOL PROPIONATE OINT PREFERRED

TEMOVATE OINT NON_PREFERRED

CLOBETASOL PROPIONATE SHAM NON_PREFERRED

CLOBEX SHAM NON_PREFERRED

CLODAN SHAM NON_PREFERRED

CLOBETASOL PROPIONATE SOLN PREFERRED

CLOBETASOL PROPIONATE E CREA PREFERRED

CLOBETASOL PROPIONATE EMO CREA PREFERRED

CLOBETASOL PROPIONATE FOAM NON_PREFERRED

CLOBETASOL PROPIONATE EMO FOAM NON_PREFERRED

OLUX-E FOAM NON_PREFERRED

TOVET FOAM NON_PREFERRED

TOVET KIT KIT NON_PREFERRED

CLODERM CREA NON_PREFERRED

DESONIDE CREA PREFERRED

DESOWEN CREA NON_PREFERRED

DESONIDE LOTN NON_PREFERRED

DESONIDE OINT PREFERRED

DESOXIMETASONE CREA NON_PREFERRED

TOPICORT CREA NON_PREFERRED

DESOXIMETASONE GEL NON_PREFERRED

TOPICORT GEL NON_PREFERRED

DESOXIMETASONE LIQD NON_PREFERRED

TOPICORT LIQD NON_PREFERRED

of 98


DESOXIMETASONE OINT NON_PREFERRED

TOPICORT OINT NON_PREFERRED

DIFLORASONE DIACETATE CREA PREFERRED

PSORCON CREA NON_PREFERRED

DIFLORASONE DIACETATE OINT PREFERRED

APEXICON E CREA NON_PREFERRED

FLUOCINOLONE ACETONIDE CREA PREFERRED

SYNALAR CREA NON_PREFERRED

DERMA-SMOOTHE/FS BODY OIL NON_PREFERRED

DERMA-SMOOTHE/FS SCALP OIL NON_PREFERRED

FLUOCINOLONE ACETONIDE BO OIL PREFERRED

FLUOCINOLONE ACETONIDE SC OIL PREFERRED

FLUOCINOLONE ACETONIDE OINT PREFERRED

SYNALAR OINT NON_PREFERRED

CAPEX SHAM NON_PREFERRED

FLUOCINOLONE ACETONIDE SOLN PREFERRED

SYNALAR SOLN NON_PREFERRED

FLUOCINONIDE CREA PREFERRED

VANOS CREA NON_PREFERRED

FLUOCINONIDE GEL PREFERRED

FLUOCINONIDE OINT PREFERRED

FLUOCINONIDE SOLN PREFERRED

FLUOCINONIDE EMULSIFIED CREA PREFERRED

FLUOCINONIDE EMULSIFIED B CREA PREFERRED

FLURANDRENOLIDE CREA NON_PREFERRED

FLURANDRENOLIDE LOTN NON_PREFERRED

FLURANDRENOLIDE OINT NON_PREFERRED

CORDRAN TAPE NON_PREFERRED

FLUTICASONE PROPIONATE CREA PREFERRED

BESER LOTN NON_PREFERRED

CUTIVATE LOTN NON_PREFERRED

FLUTICASONE PROPIONATE LOTN NON_PREFERRED

FLUTICASONE PROPIONATE OINT PREFERRED

HALCINONIDE CREA NON_PREFERRED

HALOG CREA NON_PREFERRED

HALOG OINT NON_PREFERRED

HALOBETASOL PROPIONATE CREA PREFERRED

HALOBETASOL PROPIONATE FOAM NON_PREFERRED

LEXETTE FOAM NON_PREFERRED

BRYHALI LOTN NON_PREFERRED

ULTRAVATE LOTN NON_PREFERRED

HALOBETASOL PROPIONATE OINT PREFERRED

ALA-CORT CREA PREFERRED

of 98


HYDROCORTISONE CREA PREFERRED

ALA SCALP LOTN NON_PREFERRED

HYDROCORTISONE LOTN PREFERRED

HYDROCORTISONE OINT PREFERRED

TEXACORT SOLN NON_PREFERRED

MICORT-HC CREA NON_PREFERRED

HYDROCORTISONE OINT PREFERRED

HYDROCORTISONE VALERATE CREA PREFERRED

HYDROCORTISONE VALERATE OINT PREFERRED

PANDEL CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE CREA NON_PREFERRED

LOCOID CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE LOTN NON_PREFERRED

LOCOID LOTN NON_PREFERRED

HYDROCORTISONE BUTYRATE OINT NON_PREFERRED

HYDROCORTISONE BUTYRATE SOLN NON_PREFERRED

LOCOID SOLN NON_PREFERRED

HYDROCORTISONE BUTYRATE ( CREA NON_PREFERRED

LOCOID LIPOCREAM CREA NON_PREFERRED

ELOCON CREA NON_PREFERRED

MOMETASONE FUROATE CREA PREFERRED

MOMETASONE FUROATE OINT PREFERRED

MOMETASONE FUROATE SOLN PREFERRED

PREDNICARBATE CREA NON_PREFERRED

PREDNICARBATE OINT NON_PREFERRED

KENALOG AERS NON_PREFERRED

TRIAMCINOLONE ACETONIDE AERS NON_PREFERRED

TRIAMCINOLONE ACETONIDE CREA PREFERRED

TRIDERM CREA PREFERRED

TRIAMCINOLONE ACETONIDE LOTN PREFERRED

TRIAMCINOLONE ACETONIDE OINT PREFERRED

TRIANEX OINT NON_PREFERRED

EPIFOAM FOAM NON_PREFERRED

ENSTILAR FOAM NON_PREFERRED

CALCIPOTRIENE/BETAMETHASO OINT NON_PREFERRED

TACLONEX OINT NON_PREFERRED

TACLONEX SUSP NON_PREFERRED

CLODAN KIT KIT NON_PREFERRED

SYNALAR TS KIT NON_PREFERRED

SYNALAR CREAM KIT KIT NON_PREFERRED

SYNALAR OINTMENT KIT KIT NON_PREFERRED

BESER KIT NON_PREFERRED

DUOBRII LOTN NON_PREFERRED

of 98


ELLZIA PAK THPK NON_PREFERRED

DERMATOLOGICALS : MISC FINACEA FOAM NON_PREFERRED

AZELAIC ACID GEL NON_PREFERRED

FINACEA GEL NON_PREFERRED

MIRVASO GEL NON_PREFERRED

DOXYCYCLINE CPDR NON_PREFERRED

ORACEA CPDR NON_PREFERRED

IVERMECTIN CREA NON_PREFERRED

SOOLANTRA CREA NON_PREFERRED

METROCREAM CREA NON_PREFERRED

METRONIDAZOLE CREA PREFERRED

NORITATE CREA NON_PREFERRED

ROSADAN CREA PREFERRED

METROGEL GEL NON_PREFERRED

METRONIDAZOLE GEL PREFERRED

ROSADAN GEL PREFERRED

METROLOTION LOTN NON_PREFERRED

METRONIDAZOLE LOTN PREFERRED

ROSADAN KIT KIT NON_PREFERRED

RHOFADE CREA NON_PREFERRED

DICLOFENAC EPOLAMINE PTCH NON_PREFERRED

FLECTOR PTCH NON_PREFERRED

DICLOFENAC SODIUM GEL NON_PREFERRED

VOLTAREN GEL NON_PREFERRED

DICLOFENAC SODIUM SOLN NON_PREFERRED

PENNSAID SOLN NON_PREFERRED

DYNABAC 5.0 THPK NON_PREFERRED

DICLOFEX DC THPK NON_PREFERRED

DOXEPIN HYDROCHLORIDE CREA NON_PREFERRED

PRUDOXIN CREA NON_PREFERRED

ZONALON CREA NON_PREFERRED

EUCRISA OINT PREFERRED_WITH_PA

SELENIUM SULFIDE LOTN PREFERRED

SELENIUM SULFIDE SHAM NON_PREFERRED

SELENIUM SULFIDE SHAMPOO SHAM NON_PREFERRED

SODIUM SULFACETAMIDE GEL NON_PREFERRED

SODIUM SULFACETAMIDE WASH LIQD NON_PREFERRED

ACYCLOVIR CREA NON_PREFERRED

ZOVIRAX CREA NON_PREFERRED

ACYCLOVIR OINT NON_PREFERRED

ZOVIRAX OINT NON_PREFERRED

DENAVIR CREA NON_PREFERRED

XERESE CREA NON_PREFERRED

of 98


VALCHLOR GEL NON_PREFERRED

CARAC CREA NON_PREFERRED

EFUDEX CREA NON_PREFERRED

FLUOROURACIL CREA NON_PREFERRED

TOLAK CREA NON_PREFERRED

FLUOROURACIL SOLN NON_PREFERRED

DICLOFENAC SODIUM GEL NON_PREFERRED

AMELUZ GEL NON_PREFERRED

LEVULAN KERASTICK SOLR PREFERRED

PANRETIN GEL PREFERRED

TARGRETIN GEL PREFERRED

PICATO GEL NON_PREFERRED

ORMECA KIT NON_PREFERRED

SULFAMYLON CREA PREFERRED

MAFENIDE ACETATE PACK PREFERRED

SULFAMYLON PACK NON_PREFERRED

SILVADENE CREA NON_PREFERRED

SILVER SULFADIAZINE CREA PREFERRED

SSD CREA PREFERRED

SILVER NITRATE SOLN NON_PREFERRED

ARZOL SILVER NITRATE APP MISC NON_PREFERRED

GRAFCO SILVER NITRATE APP MISC NON_PREFERRED

AMMONIUM LACTATE CREA NON_PREFERRED

AMMONIUM LACTATE LOTN PREFERRED

UREA CREA PREFERRED

UMECTA MOUSSE FOAM NON_PREFERRED

UREA LOTN PREFERRED

UREA HYDRATING FOAM NON_PREFERRED

UREA IN ZINC UNDECYLENATE EMUL PREFERRED

SANTYL OINT NON_PREFERRED

CONDYLOX GEL PREFERRED

PODOFILOX SOLN PREFERRED

PODOCON 25 IN BENZOIN TIN SOLN NON_PREFERRED

SALICYLIC ACID FOAM NON_PREFERRED

SALICYLIC ACID GEL PREFERRED

SALICYLIC ACID WART REMOV LIQD PREFERRED

SALEX SHAM NON_PREFERRED

BENSAL HP OINT NON_PREFERRED

VEREGEN OINT NON_PREFERRED

ALDARA CREA NON_PREFERRED

IMIQUIMOD CREA PREFERRED

IMIQUIMOD PUMP CREA NON_PREFERRED

ZYCLARA CREA NON_PREFERRED

of 98


ZYCLARA PUMP CREA NON_PREFERRED

ELIDEL CREA PREFERRED_WITH_PA

PIMECROLIMUS CREA PREFERRED_WITH_PA

PROTOPIC OINT PREFERRED_WITH_PA

TACROLIMUS OINT PREFERRED_WITH_PA

QUTENZA KIT NON_PREFERRED

LIDOCAINE OINT PREFERRED

LIDOCAINE PTCH NON_PREFERRED

LIDODERM PTCH NON_PREFERRED

ZTLIDO PTCH NON_PREFERRED

LIDOCAINE CREA PREFERRED

LIDOCAINE HYDROCHLORIDE CREA NON_PREFERRED

LIDOTRAL CREA NON_PREFERRED

LIDOCAINE HCL JELLY GEL PREFERRED

LIDOZION LOTN NON_PREFERRED

GLYDO PRSY PREFERRED

LIDOCAINE HCL PRSY PREFERRED

LIDOCAINE HCL JELLY PRSY PREFERRED

LIDOCAINE HCL SOLN PREFERRED

LIDOPURE PATCH KIT NON_PREFERRED

ZILACAINE PATCH THPK NON_PREFERRED

PLIAGLIS CREA NON_PREFERRED

SYNERA PTCH NON_PREFERRED

LIDOCAINE/PRILOCAINE CREA NON_PREFERRED

DERMACINRX EMPRICAINE KIT NON_PREFERRED

LIDOCAINE/PRILOCAINE KIT NON_PREFERRED

NUVAKAAN KIT NON_PREFERRED

PRILOXX LP KIT NON_PREFERRED

PRIZOTRAL KIT NON_PREFERRED

DERMACINRX NEUROTRAL PHAR THPK NON_PREFERRED

APRIZIO PAK KIT NON_PREFERRED

DERMACINRX DUOPATCH PHARM THPK NON_PREFERRED

REGRANEX GEL NON_PREFERRED

QBREXZA PADS NON_PREFERRED

XERAC AC SOLN NON_PREFERRED

HYCLODEX SOLN NON_PREFERRED

HYPOCYN SOLN NON_PREFERRED

DERMACINRX CLORHEXACIN KIT NON_PREFERRED

NUVAIL SOLN NON_PREFERRED

DERMATOLOGICALS : SCABICIDES & PEDICULICIDES EURAX CREA PREFERRED

CROTAN LOTN PREFERRED

EURAX LOTN NON_PREFERRED

SKLICE LOTN NON_PREFERRED

of 98


LINDANE SHAM NON_PREFERRED

MALATHION LOTN NON_PREFERRED

OVIDE LOTN NON_PREFERRED

ELIMITE CREA NON_PREFERRED

PERMETHRIN CREA PREFERRED

GNP LICE TREATMENT LIQD PREFERRED

HM LICE TREATMENT LIQD PREFERRED

LICE TREATMENT LOTN PREFERRED

SM LICE TREATMENT LOTN PREFERRED

NATROBA SUSP PREFERRED

SPINOSAD SUSP NON_PREFERRED

GNP LICE TREATMENT SHAM PREFERRED

HM LICE KILLING MAXIMUM S SHAM PREFERRED

LICE KILLING MAXIMUM STRE SHAM PREFERRED

LICE KILLING SHAMPOO SHAM PREFERRED

SM LICE KILLING MAXIMUM S SHAM PREFERRED

SM LICE SOLUTION KIT KIT PREFERRED

DIGESTIVE ENZYMES CREON CPEP PREFERRED

PANCREAZE CPEP PREFERRED

PERTZYE CPEP NON_PREFERRED

ZENPEP CPEP PREFERRED

VIOKACE TABS NON_PREFERRED

REGULATORS ALENDRONATE SODIUM SOLN PREFERRED

ALENDRONATE SODIUM TABS PREFERRED

FOSAMAX TABS NON_PREFERRED

BINOSTO TBEF NON_PREFERRED

FOSAMAX PLUS D TABS NON_PREFERRED

ETIDRONATE DISODIUM TABS NON_PREFERRED

BONIVA TABS NON_PREFERRED

IBANDRONATE SODIUM TABS NON_PREFERRED

ACTONEL TABS NON_PREFERRED

RISEDRONATE SODIUM TABS NON_PREFERRED

ATELVIA TBEC NON_PREFERRED

RISEDRONATE SODIUM DR TBEC NON_PREFERRED

CALCITONIN SALMON SOLN PREFERRED

CALCITONIN-SALMON SOLN PREFERRED

HORMONES NORDITROPIN FLEXPRO SOLN NON_PREFERRED

NUTROPIN AQ NUSPIN 10 SOLN NON_PREFERRED



OMNITROPE SOLN NON_PREFERRED

GENOTROPIN SOLR PREFERRED_WITH_PA

GENOTROPIN MINIQUICK SOLR PREFERRED_WITH_PA

of 98


HUMATROPE SOLR NON_PREFERRED

HUMATROPE COMBO PACK SOLR NON_PREFERRED

OMNITROPE SOLR NON_PREFERRED

ZOMACTON SOLR NON_PREFERRED

SAIZEN SOLR NON_PREFERRED

SAIZENPREP RECONSTITUTION SOLR NON_PREFERRED

SEROSTIM SOLR NON_PREFERRED

ZORBTIVE SOLR NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS : MISC OSPHENA TABS NON_PREFERRED

EVISTA TABS NON_PREFERRED

RALOXIFENE HYDROCHLORIDE TABS NON_PREFERRED

SYNAREL SOLN NON_PREFERRED

ORILISSA TABS PREFERRED_WITH_PA

EGRIFTA SOLR NON_PREFERRED

INCRELEX SOLN NON_PREFERRED

SOMATULINE DEPOT SOLN NON_PREFERRED

SANDOSTATIN LAR DEPOT KIT NON_PREFERRED

OCTREOTIDE ACETATE SOLN NON_PREFERRED

SANDOSTATIN SOLN NON_PREFERRED

SIGNIFOR SOLN NON_PREFERRED

SIGNIFOR LAR SRER NON_PREFERRED

NOCTIVA EMUL NON_PREFERRED

STIMATE SOLN PREFERRED

NOCDURNA SUBL NON_PREFERRED

DDAVP TABS NON_PREFERRED

DESMOPRESSIN ACETATE TABS PREFERRED

DDAVP SOLN NON_PREFERRED

DESMOPRESSIN ACETATE SOLN PREFERRED

DDAVP SOLN NON_PREFERRED

DESMOPRESSIN ACETATE SOLN PREFERRED

CABERGOLINE TABS PREFERRED

JYNARQUE TABS NON_PREFERRED

SAMSCA TABS NON_PREFERRED

JYNARQUE TBPK NON_PREFERRED

MIFEPREX TABS NON_PREFERRED

MIFEPRISTONE TABS NON_PREFERRED

CARNITOR SOLN NON_PREFERRED

CARNITOR SF SOLN NON_PREFERRED

LEVOCARNITINE SOLN NON_PREFERRED

LEVOCARNITINE SF SOLN NON_PREFERRED

CARNITOR TABS NON_PREFERRED

LEVOCARNITINE TABS NON_PREFERRED

GALAFOLD CAPS NON_PREFERRED

of 98


NITISINONE CAPS PREFERRED

ORFADIN CAPS PREFERRED

ORFADIN SUSP NON_PREFERRED

NITYR TABS NON_PREFERRED

CYSTADANE POWD NON_PREFERRED

CINACALCET HYDROCHLORIDE TABS NON_PREFERRED

SENSIPAR TABS NON_PREFERRED

RAVICTI LIQD NON_PREFERRED

BUPHENYL POWD NON_PREFERRED

SODIUM PHENYLBUTYRATE POWD NON_PREFERRED

BUPHENYL TABS NON_PREFERRED

SODIUM PHENYLBUTYRATE TABS NON_PREFERRED

CARBAGLU TABS NON_PREFERRED

KUVAN PACK NON_PREFERRED

KUVAN TBSO NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS : VITAMIN D ANALOGS RAYALDEE CPCR NON_PREFERRED

CALCITRIOL CAPS PREFERRED

ROCALTROL CAPS NON_PREFERRED

CALCITRIOL SOLN PREFERRED

ROCALTROL SOLN NON_PREFERRED

DOXERCALCIFEROL CAPS PREFERRED

PARICALCITOL CAPS NON_PREFERRED

ZEMPLAR CAPS NON_PREFERRED

ESTROGENS PREMARIN TABS PREFERRED

MENEST TABS PREFERRED

DIVIGEL GEL NON_PREFERRED

ELESTRIN GEL NON_PREFERRED

ALORA PTTW NON_PREFERRED

DOTTI PTTW PREFERRED

ESTRADIOL PTTW PREFERRED

MINIVELLE PTTW NON_PREFERRED

VIVELLE-DOT PTTW NON_PREFERRED

CLIMARA PTWK NON_PREFERRED

ESTRADIOL PTWK PREFERRED

MENOSTAR PTWK NON_PREFERRED

EVAMIST SOLN NON_PREFERRED

ESTRACE TABS NON_PREFERRED

ESTRADIOL TABS PREFERRED

PREMPHASE TABS PREFERRED

PREMPRO TABS PREFERRED

COMBIPATCH PTTW PREFERRED

ACTIVELLA TABS NON_PREFERRED

AMABELZ TABS PREFERRED

of 98


ESTRADIOL/NORETHINDRONE A TABS PREFERRED

LOPREEZA TABS PREFERRED

MIMVEY TABS PREFERRED

MIMVEY LO TABS PREFERRED

FEMHRT LOW DOSE TABS NON_PREFERRED

FYAVOLV TABS NON_PREFERRED

JINTELI TABS NON_PREFERRED

NORETHINDRONE ACETATE/ETH TABS NON_PREFERRED

ANGELIQ TABS NON_PREFERRED

CLIMARA PRO PTWK NON_PREFERRED

PREFEST TABS NON_PREFERRED

DUAVEE TABS NON_PREFERRED

AGENTS BALSALAZIDE DISODIUM CAPS PREFERRED

COLAZAL CAPS NON_PREFERRED

APRISO CP24 NON_PREFERRED

PENTASA CPCR PREFERRED

DELZICOL CPDR NON_PREFERRED

MESALAMINE DR CPDR NON_PREFERRED

MESALAMINE ENEM PREFERRED

SFROWASA ENEM PREFERRED

CANASA SUPP NON_PREFERRED

MESALAMINE SUPP PREFERRED

ASACOL HD TBEC NON_PREFERRED

LIALDA TBEC NON_PREFERRED

MESALAMINE DR TBEC NON_PREFERRED

MESALAMINE KIT NON_PREFERRED

ROWASA KIT NON_PREFERRED

DIPENTUM CAPS NON_PREFERRED

AZULFIDINE TABS NON_PREFERRED

SULFASALAZINE TABS PREFERRED

AZULFIDINE EN-TABS TBEC NON_PREFERRED

SULFASALAZINE TBEC PREFERRED

GASTROINTESTINAL AGENTS : MISC CHENODAL TABS NON_PREFERRED

ACTIGALL CAPS NON_PREFERRED

URSODIOL CAPS PREFERRED

URSO 250 TABS NON_PREFERRED

URSO FORTE TABS NON_PREFERRED

URSODIOL TABS NON_PREFERRED

CROMOLYN SODIUM CONC PREFERRED

GASTROCROM CONC NON_PREFERRED

METOCLOPRAMIDE HCL SOLN PREFERRED

METOCLOPRAMIDE HCL TABS PREFERRED

METOCLOPRAMIDE HYDROCHLOR TABS PREFERRED

of 98


REGLAN TABS NON_PREFERRED

METOCLOPRAMIDE ODT TBDP NON_PREFERRED

ENULOSE SOLN PREFERRED

GENERLAC SOLN PREFERRED

LACTULOSE SOLN PREFERRED

AMITIZA CAPS NON_PREFERRED

GATTEX KIT NON_PREFERRED

TRULANCE TABS NON_PREFERRED

ALOSETRON HYDROCHLORIDE TABS NON_PREFERRED

LOTRONEX TABS NON_PREFERRED

ZELNORM TABS NON_PREFERRED

LINZESS CAPS NON_PREFERRED

VIBERZI TABS NON_PREFERRED

MOTEGRITY TABS NON_PREFERRED

XERMELO TABS NON_PREFERRED

ENTEREG CAPS NON_PREFERRED

RELISTOR SOLN NON_PREFERRED

RELISTOR TABS NON_PREFERRED

SYMPROIC TABS NON_PREFERRED

MOVANTIK TABS NON_PREFERRED

CHOLBAM CAPS NON_PREFERRED

OCALIVA TABS NON_PREFERRED

GASTROINTESTINAL AGENTS : PHOSPHATE BINDER AGENTS CALCIUM ACETATE CAPS PREFERRED

PHOSLYRA SOLN NON_PREFERRED

CALCIUM ACETATE TABS PREFERRED

AURYXIA TABS NON_PREFERRED

FOSRENOL CHEW NON_PREFERRED

LANTHANUM CARBONATE CHEW PREFERRED

FOSRENOL PACK PREFERRED

RENVELA PACK NON_PREFERRED

SEVELAMER CARBONATE PACK NON_PREFERRED

RENVELA TABS NON_PREFERRED

SEVELAMER CARBONATE TABS NON_PREFERRED

RENAGEL TABS NON_PREFERRED

SEVELAMER HYDROCHLORIDE TABS PREFERRED

VELPHORO CHEW NON_PREFERRED

GENITOURINARY AGENTS : MISC K-PHOS NO 2 TABS NON_PREFERRED

POTASSIUM CITRATE ER TBCR NON_PREFERRED

UROCIT-K 10 TBCR NON_PREFERRED



ORACIT SOLN PREFERRED

SODIUM CITRATE/CITRIC ACI SOLN PREFERRED

of 98


CYTRA K CRYSTALS PACK NON_PREFERRED

TARON-CRYSTALS PACK NON_PREFERRED

POTASSIUM CITRATE/CITRIC SOLN NON_PREFERRED

POTASSIUM CITRATE/SODIUM SOLN NON_PREFERRED

TRICITRATES SOLN NON_PREFERRED

PHENAZOPYRIDINE HCL TABS PREFERRED

PHENAZOPYRIDINE HYDROCHLO TABS PREFERRED

PYRIDIUM TABS NON_PREFERRED

CYSTAGON CAPS PREFERRED

PROCYSBI CPDR NON_PREFERRED

ELMIRON CAPS NON_PREFERRED

LITHOSTAT TABS NON_PREFERRED

THIOLA TABS NON_PREFERRED

THIOLA EC TBEC NON_PREFERRED

AGENTS AVODART CAPS NON_PREFERRED

DUTASTERIDE CAPS NON_PREFERRED

FINASTERIDE TABS PREFERRED

PROSCAR TABS NON_PREFERRED

ALFUZOSIN HCL ER TB24 PREFERRED

CARDURA XL TB24 NON_PREFERRED

RAPAFLO CAPS NON_PREFERRED

SILODOSIN CAPS NON_PREFERRED

FLOMAX CAPS NON_PREFERRED

TAMSULOSIN HCL CAPS PREFERRED

TAMSULOSIN HYDROCHLORIDE CAPS PREFERRED

DUTASTERIDE/TAMSULOSIN HC CAPS NON_PREFERRED

DUTASTERIDE/TAMSULOSIN HY CAPS NON_PREFERRED

JALYN CAPS NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : CGMs GUARDIAN REAL-TIME STARTE KIT NON_PREFERRED

GUARDIAN REAL-TIME SYSTEM KIT NON_PREFERRED

GUARDIAN RT STARTER KIT KIT NON_PREFERRED

GUARDIAN RT SYSTEM KIT NON_PREFERRED

PARADIGM REAL-TIME STARTE KIT NON_PREFERRED

DEXCOM G4 PLATINUM PEDIAT DEVI NON_PREFERRED

DEXCOM G4 PLATINUM RECEIV DEVI NON_PREFERRED

DEXCOM G5 MOBILE RECEIVER DEVI NON_PREFERRED

DEXCOM G6 RECEIVER DEVI PREFERRED_WITH_PA

DEXCOM RECEIVER KIT DEVI NON_PREFERRED

FREESTYLE LIBRE 14 DAY/RE DEVI NON_PREFERRED

FREESTYLE LIBRE/READER/FL DEVI NON_PREFERRED

GUARDIAN REAL-TIME REPLAC DEVI NON_PREFERRED

DEXCOM G4 SENSOR KIT MISC NON_PREFERRED

DEXCOM G5 MOBILE/G4 PLATI MISC NON_PREFERRED

of 98


DEXCOM G6 SENSOR MISC PREFERRED_WITH_PA

ENLITE GLUCOSE SENSOR MISC NON_PREFERRED

EVERSENSE SENSOR/HOLDER MISC NON_PREFERRED

FREESTYLE LIBRE 14 DAY/SE MISC NON_PREFERRED

FREESTYLE LIBRE/SENSOR/FL MISC NON_PREFERRED

GUARDIAN SENSOR (3) MISC NON_PREFERRED

MINIMED GUARDIAN SENSOR 3 MISC NON_PREFERRED

SOF-SENSOR MISC NON_PREFERRED

DEXCOM G4 PLATINUM TRANSM MISC NON_PREFERRED

DEXCOM G5 MOBILE TRANSMIT MISC NON_PREFERRED

DEXCOM G6 TRANSMITTER MISC PREFERRED_WITH_PA

EVERSENSE SMART TRANSMITT MISC NON_PREFERRED

GUARDIAN CONNECT TRANSMIT MISC NON_PREFERRED

GUARDIAN LINK 3 MISC NON_PREFERRED

GUARDIAN TRANSMITTER MISC NON_PREFERRED

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

ADVANCE INTUITION BLOOD G DEVI NON_PREFERRED

ADVANCE MICRO-DRAW METER DEVI NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MO DEVI NON_PREFERRED

ADVOCATE REDI-CODE DEVI NON_PREFERRED

ADVOCATE REDI-CODE+ BLOOD DEVI NON_PREFERRED

AGAMATRIX AMP NO CODE ADV DEVI NON_PREFERRED

AGAMATRIX PRESTO PRO METE DEVI NON_PREFERRED

ASSURE 4 BLOOD GLUCOSE ME DEVI NON_PREFERRED

ASSURE PLATINUM BLOOD GLU DEVI NON_PREFERRED

ASSURE PRISM MULTI BLOOD DEVI NON_PREFERRED

ASSURE PRO BLOOD GLUCOSE DEVI NON_PREFERRED

CARESENS N GLUCOSE MONITO DEVI NON_PREFERRED

CARESENS N VOICE BLOOD GL DEVI NON_PREFERRED

CLEVER CHEK AUTO CODE VOI DEVI NON_PREFERRED

CLEVER CHEK AUTO-CODE BLO DEVI NON_PREFERRED

CLEVER CHEK AUTO-CODE VOI DEVI NON_PREFERRED

CLEVER CHOICE AUTO-CODE P DEVI NON_PREFERRED

CLEVER CHOICE MINI BLOOD DEVI NON_PREFERRED

CLEVER CHOICE TALK BLOOD DEVI NON_PREFERRED

CONTOUR BLOOD GLUCOSE MON DEVI NON_PREFERRED

COOL BLOOD GLUCOSE MONITO DEVI NON_PREFERRED

DIATHRIVE BLOOD GLUCOSE M DEVI NON_PREFERRED

DIATRUE PLUS BLOOD GLUCOS DEVI NON_PREFERRED

EASY PLUS II BLOOD GLUCOS DEVI NON_PREFERRED

EASY STEP BLOOD GLUCOSE M DEVI NON_PREFERRED

EASY TALK BLOOD GLUCOSE M DEVI NON_PREFERRED

EASY TRAK BLOOD GLUCOSE M DEVI NON_PREFERRED

of 98


EASYMAX L BLOOD GLUCOSE S DEVI NON_PREFERRED

EASYMAX N BLOOD GLUCOSE S DEVI NON_PREFERRED

EASYMAX NG SELF-MONITORIN DEVI NON_PREFERRED

EASYMAX V BLOOD GLUCOSE S DEVI NON_PREFERRED

EASYMAX V2 SELF-MONITORIN DEVI NON_PREFERRED

ELEMENT COMPACT BLOOD GLU DEVI NON_PREFERRED

ELEMENT COMPACT V BLOOD DEVI NON_PREFERRED

ELEMENT PLUS BLOOD GLUCOS DEVI NON_PREFERRED

EMBRACE BLOOD GLUCOSE MON DEVI NON_PREFERRED

EMBRACE PRO BLOOD GLUCOSE DEVI NON_PREFERRED

EMBRACE TALK BLOOD GLUCOS DEVI NON_PREFERRED

EVENCARE G2 BLOOD GLUCOSE DEVI NON_PREFERRED

EVENCARE G3 BLOOD GLUCOSE DEVI NON_PREFERRED

EVENCARE MINI BLOOD GLUCO DEVI NON_PREFERRED

EVOLUTION AUTOCODE DEVI NON_PREFERRED

EZ SMART DIABETES MONITOR DEVI NON_PREFERRED

EZ SMART PLUS DIABETES MO DEVI NON_PREFERRED

FORA G30A BLOOD GLUCOSE M DEVI NON_PREFERRED

FORA GD20 BLOOD GLUCOSE M DEVI NON_PREFERRED

FORA GD50 BLOOD GLUCOSE M DEVI NON_PREFERRED

FORA GTEL BLOOD GLUCOSE M DEVI NON_PREFERRED

FORA PREMIUM V10 BLE BLOO DEVI NON_PREFERRED

FORA TEST N' GO VOICE BLO DEVI NON_PREFERRED

FORA V10 BLOOD GLUCOSE MO DEVI NON_PREFERRED



FORA V30A BLOOD GLUCOSE M DEVI NON_PREFERRED

FORACARE GD40 BLOOD GLUCO DEVI NON_PREFERRED

FORACARE PREMIUM V10 BLOO DEVI NON_PREFERRED

FORACARE TEST N GO BLOOD DEVI NON_PREFERRED

FREESTYLE LITE BLOOD GLUC DEVI NON_PREFERRED

GE100 BLOOD GLUCOSE MONIT DEVI NON_PREFERRED

GLUCO PERFECT 3 BLOOD GLU DEVI NON_PREFERRED

GLUCOCARD 01 BLOOD GLUCOS DEVI NON_PREFERRED

GLUCOCARD SHINE DEVI NON_PREFERRED

GLUCOCARD SHINE XL DEVI NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MO DEVI NON_PREFERRED

GNP EASY TOUCH GLUCOSE MO DEVI NON_PREFERRED

HW EMBRACE PRO BLOOD GLUC DEVI NON_PREFERRED

HW EMBRACE TALK BLOOD GLU DEVI NON_PREFERRED

IN TOUCH DEVI NON_PREFERRED

LIBERTY BLOOD GLUCOSE MET DEVI NON_PREFERRED

LIBERTY NEXT GENERATION B DEVI NON_PREFERRED

of 98


NOVA MAX BLOOD GLUCOSE MO DEVI NON_PREFERRED

ON CALL EXPRESS BLOOD GLU DEVI NON_PREFERRED

ON CALL PLUS BLOOD GLUCOS DEVI NON_PREFERRED

ON CALL VIVID BLOOD GLUCO DEVI NON_PREFERRED

ON CALL VIVID PAL BLOOD G DEVI NON_PREFERRED

OPTIUM BLOOD GLUCOSE MONI DEVI NON_PREFERRED

PHARMACIST CHOICE MINI BL DEVI NON_PREFERRED

PRECISION QID MONITOR DEVI NON_PREFERRED

PRECISION SOF-TACT MONITO DEVI NON_PREFERRED

PRECISION XTRA DEVI NON_PREFERRED

PRECISION XTRA MONITOR DEVI NON_PREFERRED

PRO VOICE V8 BLOOD GLUCOS DEVI NON_PREFERRED

PRO VOICE V9 BLOOD GLUCOS DEVI NON_PREFERRED

PRODIGY AUTOCODE BLOOD GL DEVI NON_PREFERRED

QUINTET AC BLOOD GLUCOSE DEVI NON_PREFERRED

QUINTET BLOOD GLUCOSE MON DEVI NON_PREFERRED

RA BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

RELION PREMIER BLU BLOOD DEVI NON_PREFERRED

RELION PREMIER CLASSIC BL DEVI NON_PREFERRED

RELION PREMIER VOICE BLOO DEVI NON_PREFERRED

RELION PRIME BLOOD GLUCOS DEVI NON_PREFERRED

SMARTEST EJECT BLOOD GLUC DEVI NON_PREFERRED

SMARTEST PROTEGE BLOOD GL DEVI NON_PREFERRED

SOLUS V2 AUDIBLE BLOOD GL DEVI NON_PREFERRED

SURE EDGE BLOOD GLUCOSE M DEVI NON_PREFERRED

SURE-TEST EASYPLUS MINI S DEVI NON_PREFERRED

SURECHEK BLOOD GLUCOSE MO DEVI NON_PREFERRED

TRUE FOCUS BLOOD GLUCOSE DEVI NON_PREFERRED

TRUE METRIX DEVI NON_PREFERRED

TRUE METRIX AIR BLOOD GLU DEVI NON_PREFERRED

TRUETRACK BLOOD GLUCOSE M DEVI NON_PREFERRED

ULTRATRAK ACTIVE DEVI NON_PREFERRED

ULTRATRAK PRO DEVI NON_PREFERRED

ULTRATRAK ULTIMATE MONITO DEVI NON_PREFERRED

VERASENS BLOOD GLUCOSE MO DEVI NON_PREFERRED

VICTORY BLOOD GLUCOSE MON DEVI NON_PREFERRED

VIVAGUARD INO BLOOD GLUCO DEVI NON_PREFERRED

VOCAL POINT BLOOD GLUCOSE DEVI NON_PREFERRED

WAVESENSE KEYNOTE PRO MET DEVI NON_PREFERRED

ACCU-CHEK AVIVA CONNECT KIT NON_PREFERRED

ACCU-CHEK AVIVA PLUS KIT NON_PREFERRED

ACCU-CHEK COMPACT PLUS CA KIT NON_PREFERRED

ACCU-CHEK GUIDE KIT NON_PREFERRED

of 98


ACCU-CHEK GUIDE ME KIT NON_PREFERRED

ACCU-CHEK NANO SMARTVIEW KIT NON_PREFERRED

ADVANCE INTUITION BLOOD G KIT NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MO KIT NON_PREFERRED

ADVOCATE REDI-CODE+/ TALK KIT NON_PREFERRED

ADVOCATE REDI-CODE/TALKIN KIT NON_PREFERRED

AGAMATRIX JAZZ WIRELESS 2 KIT NON_PREFERRED

AGAMATRIX PRESTO KIT NON_PREFERRED

ASSURE 3 METER KIT NON_PREFERRED

BAYER CONTOUR LINK 2.4 BL KIT NON_PREFERRED

BD LATITUDE DIABETES MANA KIT NON_PREFERRED

BD LOGIC BLOOD GLUCOSE MO KIT NON_PREFERRED

BIOTEL CARE CONNECTED BLO KIT NON_PREFERRED

BLOOD GLUCOSE MONITORING KIT NON_PREFERRED

BLOOD GLUCOSE SYSTEM PAK KIT NON_PREFERRED

CAREONE BLOOD GLUCOSE MON KIT NON_PREFERRED

CARETOUCH BLOOD GLUCOSE M KIT NON_PREFERRED

CHOICE DM DIABETES RISK I KIT NON_PREFERRED

CLEVER CHEK BLOOD GLUCOSE KIT NON_PREFERRED

CLEVER CHOICE MICRO BLOOD KIT NON_PREFERRED

CONTOUR BLOOD GLUCOSE MON KIT NON_PREFERRED

CONTOUR NEXT BLOOD GLUCOS KIT NON_PREFERRED

CONTOUR NEXT EZ BLOOD GLU KIT NON_PREFERRED

CONTOUR NEXT LINK BLOOD G KIT NON_PREFERRED

CONTOUR NEXT LINK WIRELES KIT NON_PREFERRED

CONTOUR NEXT ONE BLOOD GL KIT NON_PREFERRED

COOL BLOOD GLUCOSE MONITO KIT NON_PREFERRED

CVS ADVANCED GLUCOSE METE KIT NON_PREFERRED

D-CARE GLUCOMETER KIT/GLU KIT NON_PREFERRED

EASY TOUCH GLUCOSE MONITO KIT NON_PREFERRED

EASY TOUCH HEALTHPRO GLUC KIT NON_PREFERRED

EASYGLUCO KIT NON_PREFERRED

EASYGLUCO STARTER KIT KIT NON_PREFERRED

EASYMAX L BLOOD GLUCOSE S KIT NON_PREFERRED

EASYMAX N BLOOD GLUCOSE S KIT NON_PREFERRED

EASYMAX NG SELF-MONITORIN KIT NON_PREFERRED

EASYMAX V BLOOD GLUCOSE S KIT NON_PREFERRED

EASYMAX V2 SELF-MONITORIN KIT NON_PREFERRED

EASYPLUS R13N SELF-MONITO KIT NON_PREFERRED

EASYPLUS V SELF-MONITORIN KIT NON_PREFERRED

EASYPRO BLOOD GLUCOSE MON KIT NON_PREFERRED

EASYPRO PLUS KIT NON_PREFERRED

ELEMENT AUTOCODE SYSTEM KIT NON_PREFERRED

of 98


EMBRACE EVO BLOOD GLUCOSE KIT NON_PREFERRED

EMBRACE TALK BLOOD GLUCOS KIT NON_PREFERRED

EVENCARE BLOOD GLUCOSE MO KIT NON_PREFERRED

FIFTY50 GLUCOSE METER 2.0 KIT NON_PREFERRED

FORA G20 BLOOD GLUCOSE MO KIT NON_PREFERRED

FORA TN'G VOICE BLOOD GLU KIT NON_PREFERRED

FORA V10/V12/D10/D20 BLOO KIT NON_PREFERRED

FORA V30A BLOOD GLUCOSE M KIT NON_PREFERRED

FORTISCARE SELF-MONITORIN KIT NON_PREFERRED

FREESTYLE FLASH SYSTEM KIT NON_PREFERRED

FREESTYLE FREEDOM KIT NON_PREFERRED

FREESTYLE FREEDOM LITE KIT NON_PREFERRED

FREESTYLE INSULINX BLOOD KIT NON_PREFERRED

FREESTYLE PRECISION NEO B KIT NON_PREFERRED

FREESTYLE SIDEKICK II VAL KIT NON_PREFERRED

FREESTYLE SYSTEM KIT KIT NON_PREFERRED

GE100 BLOOD GLUCOSE MONIT KIT NON_PREFERRED

GHT BLOOD GLUCOSE MONITO KIT NON_PREFERRED

GLUCOCARD 01 BLOOD GLUCOS KIT NON_PREFERRED

GLUCOCARD 01-MINI BLOOD G KIT NON_PREFERRED

GLUCOCARD EXPRESSION AUDI KIT NON_PREFERRED

GLUCOCARD SHINE KIT NON_PREFERRED

GLUCOCARD SHINE CONNEX BL KIT NON_PREFERRED

GLUCOCARD SHINE EXPRESS B KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLU KIT NON_PREFERRED

GLUCOCARD X-METER KIT NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MO KIT NON_PREFERRED

GLUCONAVII BLOOD GLUCOSE KIT NON_PREFERRED

GOODSENSE PREMIUM BLOOD KIT NON_PREFERRED

HW EMBRACE TALK BLOOD GLU KIT NON_PREFERRED

IBG STAR BLOOD GLUCOSE MO KIT NON_PREFERRED

IGLUCOSE BLOOD GLUCOSE MO KIT NON_PREFERRED

INFINITY BLOOD GLUCOSE MO KIT NON_PREFERRED

INFINITY VOICE KIT NON_PREFERRED

KROGER BLOOD GLUCOSE MONI KIT NON_PREFERRED

KROGER PREMIUM BLOOD GLUC KIT NON_PREFERRED

LDR BLOOD GLUCOSE TRUETES KIT NON_PREFERRED

MEIJER BLOOD GLUCOSE MONI KIT NON_PREFERRED

MEIJER ESSENTIAL BLOOD GL KIT NON_PREFERRED

MEIJER PREMIUM BLOOD GLUC KIT NON_PREFERRED

MEIJER TRUE2GO BLOOD GLUC KIT NON_PREFERRED

MEIJER TRUERESULT BLOOD G KIT NON_PREFERRED

MEIJER TRUETRACK BLOOD GL KIT NON_PREFERRED

of 98


MICRODOT BLOOD GLUCOSE MO KIT NON_PREFERRED

MM EASY TOUCH BLOOD GLUCO KIT NON_PREFERRED

MYGLUCOHEALTH BLOOD GLUCO KIT NON_PREFERRED

NOVA MAX BLOOD GLUCOSE MO KIT NON_PREFERRED

ON CALL EXPRESS BLOOD GLU KIT NON_PREFERRED

ON CALL PLUS BLOOD GLUCOS KIT NON_PREFERRED

ON CALL VIVID BLOOD GLUCO KIT NON_PREFERRED

ON CALL VIVID PAL BLOOD G KIT NON_PREFERRED

ONE DROP BLOOD GLUCOSE MO KIT NON_PREFERRED

ONETOUCH ULTRA 2 KIT PREFERRED

ONETOUCH ULTRA MINI KIT PREFERRED

ONETOUCH ULTRALINK SYSTEM KIT NON_PREFERRED

ONETOUCH VERIO KIT PREFERRED

ONETOUCH VERIO FLEX BLOOD KIT PREFERRED

ONETOUCH VERIO IQ BLOOD G KIT PREFERRED

ONETOUCH VERIO SYNC BLOOD KIT NON_PREFERRED

OPTIUM BLOOD GLUCOSE MONI KIT NON_PREFERRED

OPTUMRX BLOOD GLUCOSE MET KIT NON_PREFERRED

OPTUMRX BLOOD GLUCOSE MON KIT NON_PREFERRED

PARADIGM LINK BLOOD GLUCO KIT NON_PREFERRED

PHARMACIST CHOICE AUTOCOD KIT NON_PREFERRED

POCKETCHEM EZ BLOOD GLUCO KIT NON_PREFERRED

PRECISION LINK KIT NON_PREFERRED

PRECISION XTRA KIT NON_PREFERRED

PRODIGY AUTOCODE BLOOD GL KIT NON_PREFERRED

PRODIGY NO CODING BLOOD G KIT NON_PREFERRED

PRODIGY POCKET BLOOD GLUC KIT NON_PREFERRED

PRODIGY VOICE BLOOD GLUCO KIT NON_PREFERRED

QUICKTEK KIT NON_PREFERRED

RA TRUE2GO BLOOD GLUCOSE KIT NON_PREFERRED

RA TRUERESULT BLOOD GLUCO KIT NON_PREFERRED

REFUAH PLUS BLOOD GLUCOSE KIT NON_PREFERRED

RELION CONFIRM BLOOD GLUC KIT NON_PREFERRED

RELION MICRO BLOOD GLUCOS KIT NON_PREFERRED

RELION PREMIER COMPACT BL KIT NON_PREFERRED

RELION ULTIMA BLOOD GLUCO KIT NON_PREFERRED

REVEAL BLOOD GLUCOSE MONI KIT NON_PREFERRED

REXALL BLOOD GLUCOSE MONI KIT NON_PREFERRED

RIGHTEST GM100 BLOOD GLUC KIT NON_PREFERRED



SMART SENSE PREMIUM BLOOD KIT NON_PREFERRED

SMART SENSE VALUE BLOOD KIT NON_PREFERRED

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SMARTEST EJECT STARTER KI KIT NON_PREFERRED

SMARTEST PERSONA STARTER KIT NON_PREFERRED

SMARTEST PRONTO STARTER KIT NON_PREFERRED

SMARTEST PROTEGE STARTER KIT NON_PREFERRED

SOLUS V2 AUDIBLE BLOOD GL KIT NON_PREFERRED

SURECHEK BLOOD GLUCOSE MO KIT NON_PREFERRED

TELCARE BLOOD GLUCOSE MON KIT NON_PREFERRED

TGT BLOOD GLUCOSE METER M KIT NON_PREFERRED

TGT BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

TRUE METRIX AIR BLOOD GLU KIT NON_PREFERRED

TRUE METRIX AIR W/BLUETOO KIT NON_PREFERRED

TRUE METRIX BLOOD GLUCOSE KIT NON_PREFERRED

TRUE METRIX GO BLOOD GLUC KIT NON_PREFERRED

TRUERESULT BLOOD GLUCOSE KIT NON_PREFERRED

TRUETRACK BLOOD GLUCOSE M KIT NON_PREFERRED

TRUETRACK SMART SYSTEM KIT NON_PREFERRED

ULTIMA KIT NON_PREFERRED

ULTRA TRAK PRO BLOOD GLUC KIT NON_PREFERRED

VERASENS BLOOD GLUCOSE MO KIT NON_PREFERRED

WAVESENSE AMP KIT NON_PREFERRED

WAVESENSE KEYNOTE KIT NON_PREFERRED

RELION ALL-IN-ONE COMPACT DEVI NON_PREFERRED

SIDEKICK BLOOD GLUCOSE SY DEVI NON_PREFERRED

DISPOSABLE PUMP OMNIPOD DASH SYSTEM KIT PREFERRED_WITH_PA

OMNIPOD STARTER KIT KIT PREFERRED_WITH_PA

V-GO 20 KIT NON_PREFERRED



OMNIPOD 5 PACK MISC PREFERRED_WITH_PA

OMNIPOD DASH 5 PACK MISC PREFERRED_WITH_PA

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

ACCU-CHEK COMPACT PLUS STRP NON_PREFERRED

ACCU-CHEK GUIDE STRP NON_PREFERRED

ACCU-CHEK SMARTVIEW STRIP STRP NON_PREFERRED

ACCUTREND GLUCOSE STRP NON_PREFERRED

ADVANCE INTUITION TEST ST STRP NON_PREFERRED

ADVANCE MICRO-DRAW TEST S STRP NON_PREFERRED

ADVOCATE REDI-CODE STRP NON_PREFERRED

ADVOCATE REDI-CODE+ TEST STRP NON_PREFERRED

ADVOCATE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX AMP NO CODE TES STRP NON_PREFERRED

AGAMATRIX JAZZ TEST STRIP STRP NON_PREFERRED

AGAMATRIX KEYNOTE TEST ST STRP NON_PREFERRED

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AGAMATRIX PRESTO TEST STR STRP NON_PREFERRED

ASSURE 3 TEST STRIPS STRP NON_PREFERRED

ASSURE 4 TEST STRIPS STRP NON_PREFERRED

ASSURE II STRP NON_PREFERRED

ASSURE II CHECK STRIP STRP NON_PREFERRED

ASSURE II TEST STRIPS STRP NON_PREFERRED

ASSURE PLATINUM TEST STRI STRP NON_PREFERRED

ASSURE PRISM MULTI TEST S STRP NON_PREFERRED

ASSURE PRO TEST STRIPS STRP NON_PREFERRED

BIOSCANNER GLUCOSE TEST S STRP NON_PREFERRED

BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CAREONE BLOOD GLUCOSE TES STRP NON_PREFERRED

CARESENS N BLOOD GLUCOSE STRP NON_PREFERRED

CARETOUCH BLOOD GLUCOSE T STRP NON_PREFERRED

CLEVER CHEK AUTO-CODE TES STRP NON_PREFERRED

CLEVER CHEK AUTO-CODE VOI STRP NON_PREFERRED

CLEVER CHEK TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE AUTO-CODE P STRP NON_PREFERRED

CLEVER CHOICE MICRO TEST STRP NON_PREFERRED

CLEVER CHOICE NO CODING T STRP NON_PREFERRED

CLEVER CHOICE TALK NO COD STRP NON_PREFERRED

CONTOUR BLOOD GLUCOSE TES STRP NON_PREFERRED

CONTOUR NEXT BLOOD GLUCOS STRP NON_PREFERRED

COOL BLOOD GLUCOSE TEST S STRP NON_PREFERRED

CVS ADVANCED GLUCOSE METE STRP NON_PREFERRED

D-CARE BLOOD GLUCOSE STRP NON_PREFERRED

DIATHRIVE BLOOD GLUCOSE T STRP NON_PREFERRED

DIATRUE PLUS BLOOD GLUCOS STRP NON_PREFERRED

DUO-CARE TEST STRIPS STRP NON_PREFERRED

EASY PLUS II BLOOD GLUCOS STRP NON_PREFERRED

EASY STEP TEST STRIPS STRP NON_PREFERRED

EASY TALK BLOOD GLUCOSE T STRP NON_PREFERRED

EASY TOUCH GLUCOSE TEST S STRP NON_PREFERRED

EASY TOUCH HEALTHPRO GLUC STRP NON_PREFERRED

EASY TRAK BLOOD GLUCOSE T STRP NON_PREFERRED

EASYGLUCO STRP NON_PREFERRED

EASYGLUCO PLUS STRP NON_PREFERRED

EASYMAX 15 TEST STRIPS STRP NON_PREFERRED

EASYMAX TEST STRIPS STRP NON_PREFERRED

EASYPLUS BLOOD GLUCOSE TE STRP NON_PREFERRED

EASYPRO BLOOD GLUCOSE TES STRP NON_PREFERRED

EASYPRO PLUS STRP NON_PREFERRED

ELEMENT COMPACT TEST STRI STRP NON_PREFERRED

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ELEMENT TEST STRIPS STRP NON_PREFERRED

EMBRACE BLOOD GLUCOSE TES STRP NON_PREFERRED

EMBRACE EVO BLOOD GLUCOSE STRP NON_PREFERRED

EMBRACE PRO BLOOD GLUCOSE STRP NON_PREFERRED

EMBRACE TALK BLOOD GLUCOS STRP NON_PREFERRED

EQ BLOOD GLUCOSE TEST STR STRP NON_PREFERRED

EVENCARE + BLOOD GLUCOSE STRP NON_PREFERRED

EVENCARE BLOOD GLUCOSE TE STRP NON_PREFERRED

EVENCARE G2 TEST STRIPS STRP NON_PREFERRED

EVENCARE G3 TEST STRIPS STRP NON_PREFERRED

EVENCARE MINI BLOOD GLUCO STRP NON_PREFERRED

EVOLUTION AUTOCODE STRP NON_PREFERRED

EXACTECH R-S-G TEST STRIP STRP NON_PREFERRED

EXACTECH TEST STRIPS STRP NON_PREFERRED

EZ SMART BLOOD GLUCOSE TE STRP NON_PREFERRED

EZ SMART PLUS BLOOD GLUCO STRP NON_PREFERRED

FIFTY50 GLUCOSE TEST STRI STRP NON_PREFERRED

FORA BLOOD GLUCOSE TEST S STRP NON_PREFERRED

FORA D15G BLOOD GLUCOSE T STRP NON_PREFERRED

FORA D20 BLOOD GLUCOSE TE STRP NON_PREFERRED

FORA D40/G31 BLOOD GLUCOS STRP NON_PREFERRED

FORA G20 BLOOD GLUCOSE TE STRP NON_PREFERRED

FORA G30/PREMIUM V10 BLOO STRP NON_PREFERRED

FORA GD20 TEST STRIPS STRP NON_PREFERRED

FORA GD50 BLOOD GLUCOSE T STRP NON_PREFERRED

FORA GTEL BLOOD GLUCOSE T STRP NON_PREFERRED

FORA TN'G/TN'G VOICE BLOO STRP NON_PREFERRED

FORA V10 BLOOD GLUCOSE TE STRP NON_PREFERRED



FORA V30A BLOOD GLUCOSE T STRP NON_PREFERRED

FORACARE GD40 STRP NON_PREFERRED

FORACARE PREMIUM V10 TEST STRP NON_PREFERRED

FORACARE TEST N GO TEST S STRP NON_PREFERRED

FORTISCARE BLOOD GLUCOSE STRP NON_PREFERRED

FREESTYLE INSULINX BLOOD STRP NON_PREFERRED

FREESTYLE LITE TEST STRIP STRP NON_PREFERRED

FREESTYLE PRECISION NEO B STRP NON_PREFERRED

FREESTYLE TEST STRIPS STRP NON_PREFERRED

GE100 BLOOD GLUCOSE TEST STRP NON_PREFERRED

GENSTRIP 50 STRP NON_PREFERRED

GENULTIMATE TEST STRIPS STRP NON_PREFERRED

GHT TEST STRIPS STRP NON_PREFERRED

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GLUCO PERFECT 3 TEST STRI STRP NON_PREFERRED

GLUCOCARD 01 SENSOR PLUS STRP NON_PREFERRED

GLUCOCARD EXPRESSION BLOO STRP NON_PREFERRED

GLUCOCARD SHINE TEST STRI STRP NON_PREFERRED

GLUCOCARD VITAL TEST STRI STRP NON_PREFERRED

GLUCOCARD X-SENSOR STRP NON_PREFERRED

GLUCOCOM TEST STRIPS STRP NON_PREFERRED

GLUCONAVII BLOOD GLUCOSE STRP NON_PREFERRED

GLUCOSE METER TEST STRIPS STRP NON_PREFERRED

GNP EASY TOUCH GLUCOSE TE STRP NON_PREFERRED

GOODSENSE PREMIUM BLOOD G STRP NON_PREFERRED

HW EMBRACE PRO BLOOD GLUC STRP NON_PREFERRED

HW EMBRACE TALK BLOOD GLU STRP NON_PREFERRED

IGLUCOSE BLOOD GLUCOSE TE STRP NON_PREFERRED

IN TOUCH BLOOD GLUCOSE TE STRP NON_PREFERRED

INFINITY BLOOD GLUCOSE TE STRP NON_PREFERRED

INFINITY VOICE STRP NON_PREFERRED

KROGER BLOOD GLUCOSE TEST STRP NON_PREFERRED

KROGER PREMIUM BLOOD GLUC STRP NON_PREFERRED

KROGER TEST STRIPS STRP NON_PREFERRED

LIBERTY NEXT GENERATION B STRP NON_PREFERRED

LIBERTY TEST STRIPS STRP NON_PREFERRED

MEIJER BLOOD GLUCOSE TEST STRP NON_PREFERRED

MEIJER ESSENTIAL BLOOD GL STRP NON_PREFERRED

MEIJER PREMIUM BLOOD GLUC STRP NON_PREFERRED

MEIJER TRUETEST BLOOD GLU STRP NON_PREFERRED

MEIJER TRUETRACK BLOOD GL STRP NON_PREFERRED

MICRODOT TEST STRIPS STRP NON_PREFERRED

MM EASY TOUCH GLUCOSE TES STRP NON_PREFERRED

MYGLUCOHEALTH BLOOD GLUCO STRP NON_PREFERRED

NEUTEK 2TEK TEST STRIPS STRP NON_PREFERRED

NOVA MAX GLUCOSE TEST STR STRP NON_PREFERRED

ON CALL EXPRESS BLOOD GLU STRP NON_PREFERRED

ON CALL PLUS BLOOD GLUCOS STRP NON_PREFERRED

ON CALL VIVID BLOOD GLUCO STRP NON_PREFERRED

ONE DROP BLOOD GLUCOSE TE STRP NON_PREFERRED

ONETOUCH ULTRA BLUE STRP PREFERRED

ONETOUCH VERIO TEST STRIP STRP PREFERRED

OPTIUM TEST STRIPS STRP NON_PREFERRED

OPTIUMEZ TEST STRIPS STRP NON_PREFERRED

OPTUMRX BLOOD GLUCOSE TES STRP NON_PREFERRED

PHARMACIST CHOICE AUTOCOD STRP NON_PREFERRED

PHARMACIST CHOICE NO CODI STRP NON_PREFERRED

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POCKETCHEM EZ BLOOD GLUCO STRP NON_PREFERRED

PRECISION PCX STRP NON_PREFERRED

PRECISION PCX PLUS TEST S STRP NON_PREFERRED

PRECISION POINT OF CARE T STRP NON_PREFERRED

PRECISION QID TEST STRIPS STRP NON_PREFERRED

PRECISION SOF-TACT TEST S STRP NON_PREFERRED

PRECISION XTRA BLOOD GLUC STRP NON_PREFERRED

PREMIUM BLOOD GLUCOSE TES STRP NON_PREFERRED

PRO VOICE V8/V9 BLOOD GLU STRP NON_PREFERRED

PRODIGY NO CODING BLOOD G STRP NON_PREFERRED

PTS PANELS GLUCOSE TEST STRP NON_PREFERRED

QUICKTEK TEST STRIPS STRP NON_PREFERRED

QUINTET AC BLOOD GLUCOSE STRP NON_PREFERRED

QUINTET BLOOD GLUCOSE TES STRP NON_PREFERRED

RA TRUETEST STRIPS STRP NON_PREFERRED

REFUAH PLUS BLOOD GLUCOSE STRP NON_PREFERRED

RELION BLOOD GLUCOSE TEST STRP NON_PREFERRED

RELION CONFIRM/MICRO TEST STRP NON_PREFERRED

RELION PREMIER BLOOD GLUC STRP NON_PREFERRED

RELION PRIME BLOOD GLUCOS STRP NON_PREFERRED

RELION ULTIMA BLOOD GLUCO STRP NON_PREFERRED

RELION ULTIMA TEST STRIPS STRP NON_PREFERRED

REVEAL BLOOD GLUCOSE TEST STRP NON_PREFERRED

REXALL BLOOD GLUCOSE TEST STRP NON_PREFERRED

RIGHTEST GS100 BLOOD GLUC STRP NON_PREFERRED



SMART SENSE PREMIUM BLOOD STRP NON_PREFERRED

SMART SENSE VALUE BLOOD G STRP NON_PREFERRED

SMARTEST BLOOD GLUCOSE TE STRP NON_PREFERRED

SOLUS V2 AUDIBLE TEST STRP NON_PREFERRED

SUPREME TEST STRIPS STRP NON_PREFERRED

SURE EDGE BLOOD GLUCOSE T STRP NON_PREFERRED

SURE-TEST EASYPLUS MINI B STRP NON_PREFERRED

SURECHEK BLOOD GLUCOSE TE STRP NON_PREFERRED

TELCARE BLOOD GLUCOSE TES STRP NON_PREFERRED

TGT BLOOD GLUCOSE TEST ST STRP NON_PREFERRED

TRUE FOCUS SELF MONITORIN STRP NON_PREFERRED

TRUE METRIX BLOOD GLUCOSE STRP NON_PREFERRED

TRUE METRIX SELF MONITORI STRP NON_PREFERRED

TRUETEST STRIPS STRP NON_PREFERRED

TRUETRACK BLOOD GLUCOSE T STRP NON_PREFERRED

TRUETRACK TEST STRP NON_PREFERRED

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ULTIMA TEST STRIPS STRP NON_PREFERRED

ULTRATRAK PRO TEST STRIPS STRP NON_PREFERRED

ULTRATRAK ULTIMATE TEST S STRP NON_PREFERRED

UNISTRIP1 GENERIC STRP NON_PREFERRED

VERASENS BLOOD GLUCOSE TE STRP NON_PREFERRED

VICTORY AGM-4000 TEST STR STRP NON_PREFERRED

VIVAGUARD INO BLOOD GLUCO STRP NON_PREFERRED

VOCAL POINT BLOOD GLUCOSE STRP NON_PREFERRED

WAVESENSE PRESTO TEST STR STRP NON_PREFERRED

GOUT AGENTS ALLOPURINOL TABS PREFERRED

ZYLOPRIM TABS NON_PREFERRED

COLCHICINE CAPS NON_PREFERRED

MITIGARE CAPS NON_PREFERRED

COLCHICINE TABS NON_PREFERRED

COLCRYS TABS NON_PREFERRED

FEBUXOSTAT TABS NON_PREFERRED

ULORIC TABS NON_PREFERRED

PROBENECID TABS PREFERRED

PROBENECID/COLCHICINE TABS PREFERRED

HEMATOLOGICAL AGENTS : ANTIHEMOPHILIC PRODUCTS HEMOFIL M SOLR PREFERRED_WITH_PA

KOATE SOLR PREFERRED_WITH_PA

KOATE-DVI SOLR PREFERRED_WITH_PA

KOGENATE FS KIT PREFERRED_WITH_PA

KOVALTRY SOLR PREFERRED_WITH_PA

NOVOEIGHT SOLR PREFERRED_WITH_PA

RECOMBINATE SOLR PREFERRED_WITH_PA

NUWIQ KIT PREFERRED_WITH_PA

NUWIQ SOLR PREFERRED_WITH_PA

ADVATE SOLR PREFERRED_WITH_PA

XYNTHA KIT PREFERRED_WITH_PA

XYNTHA SOLOFUSE KIT PREFERRED_WITH_PA

ELOCTATE SOLR PREFERRED_WITH_PA

ADYNOVATE SOLR PREFERRED_WITH_PA

JIVI SOLR PREFERRED_WITH_PA

OBIZUR SOLR PREFERRED_WITH_PA

AFSTYLA KIT PREFERRED_WITH_PA

WILATE KIT PREFERRED_WITH_PA

ALPHANATE/VON WILLEBRAND SOLR PREFERRED_WITH_PA

HUMATE-P SOLR PREFERRED_WITH_PA

FEIBA SOLR PREFERRED_WITH_PA

NOVOSEVEN RT SOLR PREFERRED_WITH_PA

ALPHANINE SD SOLR PREFERRED_WITH_PA

MONONINE SOLR PREFERRED_WITH_PA

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BENEFIX KIT PREFERRED_WITH_PA

IXINITY SOLR PREFERRED_WITH_PA

RIXUBIS SOLR PREFERRED_WITH_PA

IDELVION SOLR PREFERRED_WITH_PA

ALPROLIX SOLR PREFERRED_WITH_PA

REBINYN SOLR PREFERRED_WITH_PA

PROFILNINE SOLR PREFERRED_WITH_PA

PROFILNINE SD SOLR PREFERRED_WITH_PA

COAGADEX SOLR PREFERRED_WITH_PA

TRETTEN SOLR PREFERRED_WITH_PA

CORIFACT KIT PREFERRED_WITH_PA

VONVENDI SOLR PREFERRED_WITH_PA

HEMLIBRA SOLN PREFERRED_WITH_PA

HEMATOLOGICAL AGENTS : MISC PENTOXIFYLLINE ER TBCR PREFERRED

TAVALISSE TABS NON_PREFERRED

HAEGARDA SOLR NON_PREFERRED

FIRAZYR SOLN NON_PREFERRED

ICATIBANT ACETATE SOLN NON_PREFERRED

KALBITOR SOLN NON_PREFERRED

TAKHZYRO SOLN NON_PREFERRED

HEMATOLOGICAL AGENTS : PLATELET AGGREGATION

INHIBITORS DIPYRIDAMOLE TABS PREFERRED

CILOSTAZOL TABS NON_PREFERRED

ZONTIVITY TABS NON_PREFERRED

AGRYLIN CAPS NON_PREFERRED

ANAGRELIDE HYDROCHLORIDE CAPS PREFERRED

CLOPIDOGREL TABS PREFERRED

PLAVIX TABS NON_PREFERRED

EFFIENT TABS NON_PREFERRED

PRASUGREL TABS NON_PREFERRED

BRILINTA TABS PREFERRED

AGGRENOX CP12 NON_PREFERRED

ASPIRIN/DIPYRIDAMOLE CP12 PREFERRED

ASPIRIN/DIPYRIDAMOLE ER CP12 PREFERRED

HEMATOPOIETIC AGENTS : HEMATOPOIETIC GROWTH

FACTORS ARANESP ALBUMIN FREE SOLN NON_PREFERRED

ARANESP ALBUMIN FREE SOSY NON_PREFERRED

EPOGEN SOLN PREFERRED_WITH_PA

PROCRIT SOLN PREFERRED_WITH_PA

RETACRIT SOLN NON_PREFERRED

MIRCERA SOSY NON_PREFERRED

NEUPOGEN SOLN PREFERRED

NEUPOGEN SOSY PREFERRED

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NIVESTYM SOLN NON_PREFERRED

NIVESTYM SOSY NON_PREFERRED

ZARXIO SOSY NON_PREFERRED

GRANIX SOLN NON_PREFERRED

GRANIX SOSY NON_PREFERRED

NEULASTA ONPRO KIT PSKT NON_PREFERRED

NEULASTA SOSY NON_PREFERRED

UDENYCA SOSY NON_PREFERRED

FULPHILA SOSY NON_PREFERRED

LEUKINE SOLR PREFERRED

DOPTELET TABS NON_PREFERRED

PROMACTA PACK NON_PREFERRED

PROMACTA TABS NON_PREFERRED

MULPLETA TABS NON_PREFERRED

NPLATE SOLR NON_PREFERRED

HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS :

BENZODIAZEPINE HYPNOTICS ESTAZOLAM TABS PREFERRED

FLURAZEPAM HCL CAPS NON_PREFERRED

MIDAZOLAM HCL SYRP NON_PREFERRED

RESTORIL CAPS NON_PREFERRED

TEMAZEPAM CAPS PREFERRED

HALCION TABS NON_PREFERRED

TRIAZOLAM TABS PREFERRED

HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : MISC BUTISOL SODIUM TABS NON_PREFERRED

PHENOBARBITAL ELIX PREFERRED

PHENOBARBITAL SOLN PREFERRED

PHENOBARBITAL TABS PREFERRED

SECONAL SODIUM CAPS NON_PREFERRED

RAMELTEON TABS NON_PREFERRED

ROZEREM TABS NON_PREFERRED

HETLIOZ CAPS NON_PREFERRED

SILENOR TABS NON_PREFERRED

BELSOMRA TABS NON_PREFERRED

HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : NON -

BENZODIAZEPINE HYPNOTICS ESZOPICLONE TABS NON_PREFERRED

LUNESTA TABS NON_PREFERRED

ZALEPLON CAPS NON_PREFERRED

ZOLPIMIST SOLN NON_PREFERRED

EDLUAR SUBL NON_PREFERRED

INTERMEZZO SUBL NON_PREFERRED

ZOLPIDEM TARTRATE SUBL NON_PREFERRED

AMBIEN TABS NON_PREFERRED

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ZOLPIDEM TARTRATE TABS PREFERRED

AMBIEN CR TBCR NON_PREFERRED

ZOLPIDEM TARTRATE ER TBCR NON_PREFERRED

IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAPS PREFERRED

SANDIMMUNE CAPS NON_PREFERRED

SANDIMMUNE SOLN PREFERRED

CYCLOSPORINE MODIFIED CAPS PREFERRED

GENGRAF CAPS PREFERRED

NEORAL CAPS NON_PREFERRED

CYCLOSPORINE MODIFIED SOLN PREFERRED

GENGRAF SOLN PREFERRED

NEORAL SOLN NON_PREFERRED

CELLCEPT CAPS NON_PREFERRED

MYCOPHENOLATE MOFETIL CAPS PREFERRED

CELLCEPT SUSR NON_PREFERRED

MYCOPHENOLATE MOFETIL SUSR PREFERRED

CELLCEPT TABS NON_PREFERRED

MYCOPHENOLATE MOFETIL TABS PREFERRED

MYCOPHENOLIC ACID DR TBEC PREFERRED

MYFORTIC TBEC NON_PREFERRED

ZORTRESS TABS NON_PREFERRED

RAPAMUNE SOLN NON_PREFERRED

SIROLIMUS SOLN PREFERRED

RAPAMUNE TABS NON_PREFERRED

SIROLIMUS TABS PREFERRED

PROGRAF CAPS NON_PREFERRED

TACROLIMUS CAPS PREFERRED

ASTAGRAF XL CP24 NON_PREFERRED

PROGRAF PACK NON_PREFERRED

ENVARSUS XR TB24 NON_PREFERRED

AZASAN TABS NON_PREFERRED

AZATHIOPRINE TABS PREFERRED

IMURAN TABS NON_PREFERRED

MIGRAINE PRODUCTS : MISC ERGOMAR SUBL NON_PREFERRED

DIHYDROERGOTAMINE MESYLAT SOLN NON_PREFERRED

MIGRANAL SOLN NON_PREFERRED

CAMBIA PACK NON_PREFERRED

MIGRANOW THPK NON_PREFERRED

MIGERGOT SUPP PREFERRED

CAFERGOT TABS NON_PREFERRED

SUMATRIPTAN/NAPROXEN SODI TABS NON_PREFERRED

TREXIMET TABS NON_PREFERRED

MIGRAINE PRODUCTS : MONOCLONAL ANTIBODIES AIMOVIG SOAJ PREFERRED_WITH_PA

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AJOVY SOSY NON_PREFERRED

EMGALITY INJ 120MG/ML SOAJ PREFERRED_WITH_PA

EMGALITY INJ 100MG/ML SOSY NON_PREFERRED

EMGALITY INJ 120MG/ML SOSY PREFERRED_WITH_PA

HT(1) ALMOTRIPTAN TABS NON_PREFERRED

ALMOTRIPTAN MALATE TABS NON_PREFERRED

ELETRIPTAN HYDROBROMIDE TABS NON_PREFERRED

RELPAX TABS NON_PREFERRED

FROVA TABS NON_PREFERRED

FROVATRIPTAN SUCCINATE TABS NON_PREFERRED

AMERGE TABS NON_PREFERRED

NARATRIPTAN HCL TABS NON_PREFERRED

MAXALT TABS NON_PREFERRED

RIZATRIPTAN BENZOATE TABS PREFERRED

MAXALT-MLT TBDP NON_PREFERRED

RIZATRIPTAN BENZOATE ODT TBDP PREFERRED

IMITREX SOLN NON_PREFERRED

SUMATRIPTAN SOLN PREFERRED

TOSYMRA SOLN NON_PREFERRED

ONZETRA XSAIL EXHP NON_PREFERRED

IMITREX STATDOSE SYSTEM SOAJ NON_PREFERRED

SUMATRIPTAN SUCCINATE SOAJ PREFERRED

ZEMBRACE SYMTOUCH SOAJ NON_PREFERRED

IMITREX STATDOSE REFILL SOCT NON_PREFERRED

SUMATRIPTAN SUCCINATE REF SOCT PREFERRED

IMITREX SOLN NON_PREFERRED

SUMATRIPTAN SUCCINATE SOLN PREFERRED

SUMATRIPTAN SUCCINATE SOSY PREFERRED

IMITREX TABS NON_PREFERRED

SUMATRIPTAN SUCCINATE TABS PREFERRED

ZOMIG SOLN NON_PREFERRED

ZOLMITRIPTAN TABS NON_PREFERRED

ZOMIG TABS NON_PREFERRED

ZOLMITRIPTAN ODT TBDP NON_PREFERRED

ZOMIG ZMT TBDP NON_PREFERRED

MISCELLANEOUS THERAPEUTIC CLASSES THALOMID CAPS NON_PREFERRED

REVLIMID CAPS NON_PREFERRED

BENLYSTA SOAJ NON_PREFERRED

BENLYSTA SOSY NON_PREFERRED

SODIUM POLYSTYRENE SULFON POWD PREFERRED

KIONEX SUSP PREFERRED

SODIUM POLYSTYRENE SULFON SUSP PREFERRED

SPS SUSP PREFERRED

of 98


LOKELMA PACK NON_PREFERRED

VELTASSA PACK NON_PREFERRED

MOUTH / THROAT / DENTAL AGENTS NYSTATIN SUSP PREFERRED

CLOTRIMAZOLE LOZG PREFERRED

CLOTRIMAZOLE TROC PREFERRED

ORAVIG TABS NON_PREFERRED

CHLORHEXIDINE GLUCONATE SOLN PREFERRED

PAROEX SOLN PREFERRED

ORALONE DENTAL PASTE PSTE PREFERRED

TRIAMCINOLONE ACETONIDE D PSTE PREFERRED

LIDOCAINE HCL SOLN PREFERRED

LIDOCAINE VISCOUS SOLN PREFERRED

DENTA 5000 PLUS CREA NON_PREFERRED

SF 5000 PLUS CREA NON_PREFERRED

SODIUM FLUORIDE 5000 PLUS CREA NON_PREFERRED

DENTAGEL GEL NON_PREFERRED

SF GEL NON_PREFERRED

SODIUM FLUORIDE GEL NON_PREFERRED

AQUORAL SOLN NON_PREFERRED

CEVIMELINE HCL CAPS NON_PREFERRED

EVOXAC CAPS NON_PREFERRED

PILOCARPINE HCL TABS PREFERRED

PILOCARPINE HYDROCHLORIDE TABS PREFERRED

SALAGEN TABS NON_PREFERRED

MULTIVITAMINS : PRENATAL VITAMINS VITAFOL STRIPS FILM NON_PREFERRED

PREMESISRX TABS NON_PREFERRED

PRENATE AM TABS NON_PREFERRED

PRENATE CHEW NON_PREFERRED

VITAFOL GUMMIES CHEW NON_PREFERRED

ENBRACE HR CAPS NON_PREFERRED

ELITE-OB TABS PREFERRED

OB COMPLETE TABS PREFERRED

PNV TABS 29-1 TABS PREFERRED

THRIVITE RX TABS PREFERRED

VOL-TAB RX TABS PREFERRED

PRENATE ELITE TABS NON_PREFERRED

OB COMPLETE/DHA CAPS NON_PREFERRED

OB COMPLETE PREMIER TABS NON_PREFERRED

COMPLETENATE CHEW PREFERRED

SE-NATAL 19 CHEW PREFERRED

M-NATAL PLUS TABS PREFERRED

NIVA-PLUS TABS PREFERRED

PRENATAL TABS PREFERRED

of 98


PRENATAL VITAMINS PLUS LO TABS PREFERRED

PREPLUS TABS PREFERRED

PRETAB TABS PREFERRED

TRICARE TABS PREFERRED

TRINATAL RX 1 TABS PREFERRED

VITAFOL-OB TABS PREFERRED

VOL-PLUS TABS PREFERRED

C-NATE DHA CAPS NON_PREFERRED

RELNATE DHA CAPS NON_PREFERRED

VIRT-NATE DHA CAPS NON_PREFERRED

VP-PNV-DHA CAPS NON_PREFERRED

PNV-SELECT TABS NON_PREFERRED

SELECT-OB CHEW NON_PREFERRED

SELECT-OB CHEW NON_PREFERRED

VITAFOL-NANO TABS NON_PREFERRED

CITRANATAL RX TABS NON_PREFERRED

CONCEPT OB CAPS NON_PREFERRED

FOLIVANE-OB CAPS NON_PREFERRED

PROVIDA OB CAPS NON_PREFERRED

PNV-OMEGA CAPS NON_PREFERRED

VIRT-PN PLUS CAPS NON_PREFERRED

ZATEAN-PN PLUS CAPS NON_PREFERRED

NESTABS TABS NON_PREFERRED

NESTABS DHA MISC NON_PREFERRED

TRI-TABS DHA MISC NON_PREFERRED

SE-NATAL 19 TABS PREFERRED

THRIVITE 19 TABS PREFERRED

CITRANATAL B-CALM MISC NON_PREFERRED

OB COMPLETE ONE CAPS NON_PREFERRED

OB COMPLETE PETITE CAPS NON_PREFERRED

VINATE DHA RF CAPS NON_PREFERRED

PRIMACARE CAPS NON_PREFERRED

CITRANATAL BLOOM TABS NON_PREFERRED

CONCEPT DHA CAPS NON_PREFERRED

TARON-C DHA CAPS NON_PREFERRED

VIRT-C DHA CAPS NON_PREFERRED

TRICARE PRENATAL DHA ONE CAPS NON_PREFERRED

COMPLETE NATAL DHA MISC NON_PREFERRED

TRIVEEN-DUO DHA MISC NON_PREFERRED

PRENATAL + DHA THPK NON_PREFERRED

VITAFOL-OB+DHA MISC NON_PREFERRED

TRISTART DHA CAPS NON_PREFERRED

TRISTART ONE CAPS NON_PREFERRED

of 98


PNV-DHA CAPS NON_PREFERRED

PRENATE ENHANCE CAPS NON_PREFERRED

PRENATE RESTORE CAPS NON_PREFERRED

VIRT-PN DHA CAPS NON_PREFERRED

ZATEAN-PN DHA CAPS NON_PREFERRED

PRENATE DHA CAPS NON_PREFERRED

PRENATE ESSENTIAL CAPS NON_PREFERRED

PRENATE PIXIE CAPS NON_PREFERRED

VITAFOL-ONE CAPS NON_PREFERRED

SELECT-OB+DHA MISC NON_PREFERRED

PRENAISSANCE PLUS CAPS NON_PREFERRED

PNV-DHA+DOCUSATE CAPS NON_PREFERRED

PRENAISSANCE CAPS NON_PREFERRED

TARON-PREX CAPS NON_PREFERRED

CITRANATAL 90 DHA MISC NON_PREFERRED

CITRANATAL ASSURE MISC NON_PREFERRED

CITRANATAL BLOOM DHA MISC NON_PREFERRED

CITRANATAL DHA MISC NON_PREFERRED

PRENATE MINI CAPS NON_PREFERRED

CITRANATAL HARMONY CAPS NON_PREFERRED

CITRANATAL MEDLEY CAPS NON_PREFERRED

VITAFOL ULTRA CAPS NON_PREFERRED

NESTABS ONE CAPS NON_PREFERRED

PROVIDA DHA CAPS NON_PREFERRED

VITAFOL FE+ CPPK NON_PREFERRED

MUSCULOSKELETAL THERAPY AGENTS BACLOFEN TABS PREFERRED

CARISOPRODOL TABS NON_PREFERRED

SOMA TABS NON_PREFERRED

CHLORZOXAZONE TABS PREFERRED

LORZONE TABS NON_PREFERRED

AMRIX CP24 NON_PREFERRED

CYCLOBENZAPRINE HYDROCHLO CP24 NON_PREFERRED

CYCLOBENZAPRINE HYDROCHLO TABS PREFERRED

FEXMID TABS NON_PREFERRED

METAXALONE TABS NON_PREFERRED

SKELAXIN TABS NON_PREFERRED

METHOCARBAMOL TABS PREFERRED

ROBAXIN-750 TABS NON_PREFERRED

ORPHENADRINE CITRATE ER TB12 PREFERRED

TIZANIDINE HCL CAPS NON_PREFERRED

TIZANIDINE HYDROCHLORIDE CAPS NON_PREFERRED

ZANAFLEX CAPS NON_PREFERRED

TIZANIDINE HCL TABS PREFERRED

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TIZANIDINE HYDROCHLORIDE TABS PREFERRED

ZANAFLEX TABS NON_PREFERRED

DANTRIUM CAPS NON_PREFERRED

DANTROLENE SODIUM CAPS PREFERRED

CARISOPRODOL/ASPIRIN TABS NON_PREFERRED

METAXALL CP KIT NON_PREFERRED

CARISOPRODOL/ASPIRIN/CODE TABS NON_PREFERRED

NORGESIC FORTE TABS NON_PREFERRED

NASAL AGENTS - SYSTEMIC AND TOPICAL : MISC QNASL AERS NON_PREFERRED

QNASL CHILDRENS AERS NON_PREFERRED

BECONASE AQ SUSP NON_PREFERRED

ZETONNA AERS NON_PREFERRED

OMNARIS SUSP NON_PREFERRED

FLUNISOLIDE SOLN PREFERRED

XHANCE EXHU NON_PREFERRED

FLUTICASONE PROPIONATE SUSP PREFERRED

SINUVA IMPL NON_PREFERRED

MOMETASONE FUROATE SUSP NON_PREFERRED

NASONEX SUSP NON_PREFERRED

COCAINE HYDROCHLORIDE SOLN NON_PREFERRED

GOPRELTO SOLN NON_PREFERRED

IPRATROPIUM BROMIDE SOLN NON_PREFERRED

ASTEPRO SOLN NON_PREFERRED

AZELASTINE HCL SOLN PREFERRED

AZELASTINE HYDROCHLORIDE SOLN PREFERRED

OLOPATADINE HCL SOLN PREFERRED

PATANASE SOLN NON_PREFERRED

DERMACINRX TICANASE PAK THPK NON_PREFERRED

DYMISTA SUSP NON_PREFERRED

DERMACINRX AZENASE PAK THPK NON_PREFERRED

NEUROMUSCULAR AGENTS TIGLUTIK SUSP NON_PREFERRED

RILUTEK TABS NON_PREFERRED

RILUZOLE TABS PREFERRED

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

BETOPTIC-S SUSP NON_PREFERRED

CARTEOLOL HCL SOLN PREFERRED

LEVOBUNOLOL HCL SOLN PREFERRED

TIMOLOL MALEATE OPHTHALMI SOLG PREFERRED

TIMOPTIC-XE SOLG NON_PREFERRED

ISTALOL SOLN NON_PREFERRED

TIMOLOL MALEATE SOLN PREFERRED

TIMOPTIC SOLN NON_PREFERRED

TIMOPTIC OCUDOSE SOLN NON_PREFERRED

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COMBIGAN SOLN NON_PREFERRED

COSOPT SOLN NON_PREFERRED

COSOPT PF SOLN NON_PREFERRED

DORZOLAMIDE HCL/TIMOLOL M SOLN PREFERRED

DORZOLAMIDE HYDROCHLORIDE SOLN NON_PREFERRED

OPHTHALMIC AGENTS : MISC LACRISERT INST PREFERRED

BIMATOPROST SOLN NON_PREFERRED

LUMIGAN SOLN NON_PREFERRED

XELPROS EMUL NON_PREFERRED

LATANOPROST SOLN PREFERRED

XALATAN SOLN NON_PREFERRED

VYZULTA SOLN NON_PREFERRED

ZIOPTAN SOLN NON_PREFERRED

TRAVATAN Z SOLN NON_PREFERRED

ATROPINE SULFATE OINT PREFERRED

ATROPINE SULFATE SOLN PREFERRED

ISOPTO ATROPINE SOLN NON_PREFERRED

CYCLOGYL SOLN NON_PREFERRED

CYCLOPENTOLATE HCL SOLN PREFERRED

CYCLOPENTOLATE HYDROCHLOR SOLN PREFERRED

PHENYLEPHRINE HCL SOLN NON_PREFERRED

MYDRIACYL SOLN NON_PREFERRED

TROPICAMIDE SOLN PREFERRED

CYCLOMYDRIL SOLN PREFERRED

ISOPTO CARPINE SOLN NON_PREFERRED

PILOCARPINE HCL SOLN PREFERRED

PHOSPHOLINE IODIDE SOLR PREFERRED

RHOPRESSA SOLN NON_PREFERRED

ROCKLATAN SOLN NON_PREFERRED

APRACLONIDINE SOLN NON_PREFERRED

IOPIDINE SOLN NON_PREFERRED

ALPHAGAN P SOLN PREFERRED

BRIMONIDINE TARTRATE SOLN PREFERRED

SIMBRINZA SUSP NON_PREFERRED

RESTASIS EMUL NON_PREFERRED

RESTASIS MULTIDOSE EMUL NON_PREFERRED

CEQUA SOLN NON_PREFERRED

XIIDRA SOLN NON_PREFERRED

AKTEN GEL NON_PREFERRED

ALCAINE SOLN NON_PREFERRED

PROPARACAINE HCL SOLN NON_PREFERRED

TETRACAINE HYDROCHLORIDE SOLN NON_PREFERRED

OXERVATE SOLN NON_PREFERRED

of 98


AZOPT SUSP NON_PREFERRED

DORZOLAMIDE HCL SOLN PREFERRED

TRUSOPT SOLN NON_PREFERRED

BROMFENAC SOLN NON_PREFERRED

BROMSITE SOLN NON_PREFERRED

PROLENSA SOLN NON_PREFERRED

DICLOFENAC SODIUM SOLN PREFERRED

FLURBIPROFEN SODIUM SOLN PREFERRED

ACULAR SOLN NON_PREFERRED

ACULAR LS SOLN NON_PREFERRED

ACUVAIL SOLN NON_PREFERRED

KETOROLAC TROMETHAMINE SOLN PREFERRED

ILEVRO SUSP NON_PREFERRED

NEVANAC SUSP NON_PREFERRED

CYSTARAN SOLN NON_PREFERRED

GLOSTRIPS STRP NON_PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC ANTI-INFECTIVES AZASITE SOLN NON_PREFERRED

BACITRACIN OINT PREFERRED

BESIVANCE SUSP NON_PREFERRED

CILOXAN OINT PREFERRED

CILOXAN SOLN NON_PREFERRED

CIPROFLOXACIN HCL SOLN PREFERRED

CIPROFLOXACIN HYDROCHLORI SOLN PREFERRED

ERYTHROMYCIN OINT PREFERRED

GATIFLOXACIN SOLN NON_PREFERRED

ZYMAXID SOLN NON_PREFERRED

GENTAK OINT PREFERRED

GENTAMICIN SULFATE SOLN PREFERRED

LEVOFLOXACIN SOLN PREFERRED

MOXEZA SOLN NON_PREFERRED

MOXIFLOXACIN HYDROCHLORID SOLN NON_PREFERRED

VIGAMOX SOLN NON_PREFERRED

OCUFLOX SOLN NON_PREFERRED

OFLOXACIN SOLN PREFERRED

TOBREX OINT PREFERRED

TOBRAMYCIN SOLN PREFERRED

TOBRAMYCIN SULFATE SOLN PREFERRED

TOBREX SOLN NON_PREFERRED

SULFACETAMIDE SODIUM OINT PREFERRED

BLEPH-10 SOLN NON_PREFERRED

SODIUM SULFACETAMIDE SOLN PREFERRED

SULFACETAMIDE SODIUM SOLN PREFERRED

ZIRGAN GEL PREFERRED

of 98


TRIFLURIDINE SOLN PREFERRED

NATACYN SUSP PREFERRED

BETADINE OPHTHALMIC PREP SOLN NON_PREFERRED

AK-POLY-BAC OINT PREFERRED

BACITRACIN/POLYMYXIN B OINT PREFERRED

POLYCIN OINT PREFERRED

POLYMYXIN B SULFATE/TRIME SOLN PREFERRED

POLYTRIM SOLN NON_PREFERRED

TRIMETHOPRIM SULFATE/POLY SOLN PREFERRED

NEO-POLYCIN OINT PREFERRED

NEOMYCIN/BACITRACIN/POLYM OINT PREFERRED

NEOMYCIN/POLYMYXIN/BACITR OINT PREFERRED

NEOMYCIN/POLYMYXIN/GRAMIC SOLN PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC ANTIALLERGIC LASTACAFT SOLN NON_PREFERRED

AZELASTINE HCL SOLN PREFERRED

AZELASTINE HYDROCHLORIDE SOLN PREFERRED

BEPREVE SOLN NON_PREFERRED

CROMOLYN SODIUM SOLN PREFERRED

EPINASTINE HCL SOLN NON_PREFERRED

ALOMIDE SOLN NON_PREFERRED

ALOCRIL SOLN NON_PREFERRED

OLOPATADINE HCL SOLN NON_PREFERRED

OLOPATADINE HYDROCHLORIDE SOLN NON_PREFERRED

PATADAY SOLN NON_PREFERRED

PATANOL SOLN NON_PREFERRED

PAZEO SOLN PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC STEROIDS DEXTENZA INST NON_PREFERRED

MAXIDEX SUSP PREFERRED

DEXAMETHASONE SODIUM PHOS SOLN PREFERRED

DUREZOL EMUL NON_PREFERRED

FML OINT PREFERRED

FLUOROMETHOLONE SUSP PREFERRED

FML FORTE SUSP PREFERRED

FML LIQUIFILM SUSP NON_PREFERRED

FLAREX SUSP PREFERRED

LOTEMAX GEL NON_PREFERRED

LOTEMAX SM GEL NON_PREFERRED

LOTEMAX OINT NON_PREFERRED

ALREX SUSP PREFERRED

INVELTYS SUSP NON_PREFERRED

LOTEMAX SUSP NON_PREFERRED

LOTEPREDNOL ETABONATE SUSP PREFERRED

PRED FORTE SUSP NON_PREFERRED

of 98


PRED MILD SUSP PREFERRED

PREDNISOLONE ACETATE SUSP PREFERRED

PREDNISOLONE SODIUM PHOSP SOLN PREFERRED

PRED-G S.O.P. OINT NON_PREFERRED

PRED-G SUSP NON_PREFERRED

ZYLET SUSP NON_PREFERRED

BLEPHAMIDE S.O.P. OINT NON_PREFERRED

SULFACETAMIDE SODIUM/PRED SOLN NON_PREFERRED

BLEPHAMIDE SUSP NON_PREFERRED

TOBRADEX OINT NON_PREFERRED

TOBRADEX SUSP NON_PREFERRED

TOBRADEX ST SUSP NON_PREFERRED

TOBRAMYCIN/DEXAMETHASONE SUSP PREFERRED

MAXITROL OINT NON_PREFERRED

NEOMYCIN/POLYMYXIN/DEXAME OINT PREFERRED

MAXITROL SUSP NON_PREFERRED

NEOMYCIN/POLYMYXIN/DEXAME SUSP PREFERRED

NEOMYCIN/POLYMYXIN/HYDROC SUSP PREFERRED

NEO-POLYCIN HC OINT PREFERRED

NEOMYCIN/POLYMYXIN/BACITR OINT PREFERRED

OTIC AGENTS CIPROFLOXACIN SOLN NON_PREFERRED

FLOXIN OTIC SOLN NON_PREFERRED

OFLOXACIN SOLN PREFERRED

DERMOTIC OIL NON_PREFERRED

FLAC OIL NON_PREFERRED

FLUOCINOLONE ACETONIDE OIL NON_PREFERRED

HYDROCORTISONE/ACETIC ACI SOLN NON_PREFERRED

ACETIC ACID SOLN PREFERRED

OTIC AGENTS : OTIC COMBINATIONS CIPRODEX SUSP PREFERRED

OTOVEL SOLN NON_PREFERRED

CIPRO HC SUSP NON_PREFERRED

NEOMYCIN/POLYMYXIN/HC SOLN PREFERRED

NEOMYCIN/POLYMYXIN/HYDROC SOLN PREFERRED

NEOMYCIN/POLYMYXIN/HYDROC SUSP PREFERRED

COLY-MYCIN S SUSP NON_PREFERRED

CORTISPORIN-TC SUSP NON_PREFERRED

PROGESTINS HYDROXYPROGESTERONE CAPRO OIL NON_PREFERRED

MAKENA OIL PREFERRED_WITH_PA

MAKENA SOAJ PREFERRED_WITH_PA

MEDROXYPROGESTERONE ACETA TABS PREFERRED

PROVERA TABS NON_PREFERRED

MEGESTROL ACETATE SUSP NON_PREFERRED

AYGESTIN TABS NON_PREFERRED

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NORETHINDRONE ACETATE TABS NON_PREFERRED

PROGESTERONE OIL PREFERRED

PROGESTERONE CAPS PREFERRED

PROMETRIUM CAPS NON_PREFERRED

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS :

ANTIDEMENTIA AGENTS ARICEPT TABS NON_PREFERRED

DONEPEZIL HCL TABS PREFERRED

DONEPEZIL HYDROCHLORIDE TABS PREFERRED

DONEPEZIL HCL TBDP PREFERRED

DONEPEZIL HYDROCHLORIDE O TBDP PREFERRED

GALANTAMINE HYDROBROMIDE CP24 NON_PREFERRED

RAZADYNE ER CP24 NON_PREFERRED

GALANTAMINE HYDROBROMIDE SOLN NON_PREFERRED

GALANTAMINE HYDROBROMIDE TABS NON_PREFERRED

RAZADYNE TABS NON_PREFERRED

EXELON PT24 NON_PREFERRED

RIVASTIGMINE TRANSDERMAL PT24 NON_PREFERRED

RIVASTIGMINE TARTRATE CAPS NON_PREFERRED

MEMANTINE HYDROCHLORIDE E CP24 NON_PREFERRED

NAMENDA XR CP24 NON_PREFERRED

NAMENDA XR TITRATION PACK CP24 NON_PREFERRED

MEMANTINE HYDROCHLORIDE SOLN NON_PREFERRED

MEMANTINE HCL TABS PREFERRED

MEMANTINE HCL TITRATION P TABS NON_PREFERRED

MEMANTINE HYDROCHLORIDE TABS PREFERRED

NAMENDA TABS NON_PREFERRED

NAMENDA TITRATION PAK TABS NON_PREFERRED

NAMZARIC C4PK NON_PREFERRED

NAMZARIC CP24 NON_PREFERRED

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MISC ERGOLOID MESYLATES TABS PREFERRED

PIMOZIDE TABS PREFERRED

VYLEESI SOAJ NON_PREFERRED

FLUOXETINE CAPS PREFERRED

FLUOXETINE HYDROCHLORIDE TABS NON_PREFERRED

SARAFEM TABS NON_PREFERRED

BRISDELLE CAPS NON_PREFERRED

PAROXETINE CAPS NON_PREFERRED

AUSTEDO TABS NON_PREFERRED

TETRABENAZINE TABS NON_PREFERRED

XENAZINE TABS NON_PREFERRED

INGREZZA CAPS NON_PREFERRED

INGREZZA CPPK NON_PREFERRED

of 98


XYREM SOLN NON_PREFERRED

SAVELLA TITRATION PACK MISC NON_PREFERRED

SAVELLA TABS NON_PREFERRED

GRALISE TABS NON_PREFERRED

LYRICA CR TB24 NON_PREFERRED

HORIZANT TBCR NON_PREFERRED

NUEDEXTA CAPS NON_PREFERRED

TEGSEDI SOSY NON_PREFERRED

CHLORDIAZEPOXIDE/AMITRIPT TABS PREFERRED

PERPHENAZINE/AMITRIPTYLIN TABS PREFERRED

OLANZAPINE/FLUOXETINE CAPS NON_PREFERRED

SYMBYAX CAPS NON_PREFERRED


MULTIPLE SCLEROSIS AGENTS COPAXONE INJ 20MG/ML SOSY PREFERRED

COPAXONE INJ 40MG/ML SOSY NON_PREFERRED

GLATIRAMER ACETATE SOSY NON_PREFERRED

GLATOPA SOSY NON_PREFERRED

MAVENCLAD TBPK NON_PREFERRED

AVONEX PEN AJKT NON_PREFERRED

AVONEX PSKT NON_PREFERRED

REBIF REBIDOSE SOAJ PREFERRED

REBIF REBIDOSE TITRATION SOAJ PREFERRED

REBIF SOSY PREFERRED

REBIF TITRATION PACK SOSY PREFERRED

BETASERON KIT PREFERRED

EXTAVIA KIT NON_PREFERRED

PLEGRIDY SOPN NON_PREFERRED

PLEGRIDY STARTER PACK SOPN NON_PREFERRED

PLEGRIDY SOSY NON_PREFERRED

PLEGRIDY STARTER PACK SOSY NON_PREFERRED

AUBAGIO TABS NON_PREFERRED

LEMTRADA SOLN NON_PREFERRED

TYSABRI CONC NON_PREFERRED

OCREVUS SOLN NON_PREFERRED

TECFIDERA CPDR PREFERRED_WITH_PA

TECFIDERA STARTER PACK MISC PREFERRED_WITH_PA

AMPYRA TB12 NON_PREFERRED

DALFAMPRIDINE ER TB12 NON_PREFERRED

GILENYA CAPS NON_PREFERRED

MAYZENT TABS NON_PREFERRED

MAYZENT STARTER PACK TBPK NON_PREFERRED


SMOKING DETERRENTS BUPROPION HYDROCHLORIDE E TB12 PREFERRED

of 98


NICOTROL INHALER INHA PREFERRED

NICOTINE TRANSDERMAL SYST KIT PREFERRED

GNP NICOTINE TRANSDERMAL PT24 PREFERRED

HM NICOTINE TRANSDERMAL PT24 PREFERRED

HM NICOTINE TRANSDERMAL S PT24 PREFERRED

NICODERM CQ PT24 PREFERRED

NICOTINE TRANSDERMAL SYST PT24 PREFERRED

SM NICOTINE TRANSDERMAL S PT24 PREFERRED

NICOTROL NS SOLN PREFERRED

GNP NICOTINE POLACRILEX GUM PREFERRED

GOODSENSE NICOTINE GUM GUM PREFERRED

HM NICOTINE POLACRILEX GUM PREFERRED

NICORELIEF GUM PREFERRED

NICORETTE GUM PREFERRED

NICORETTE STARTER KIT GUM PREFERRED

NICOTINE POLACRILEX GUM PREFERRED

SM NICOTINE GUM PREFERRED

SM NICOTINE POLACRILEX GUM PREFERRED

GNP NICOTINE MINI LOZENGE LOZG PREFERRED

GNP NICOTINE POLACRILEX LOZG PREFERRED

GNP NICOTINE POLACRILEX M LOZG PREFERRED

GOODSENSE NICOTINE LOZG PREFERRED

GOODSENSE NICOTINE POLACR LOZG PREFERRED

HM NICOTINE POLACRILEX LOZG PREFERRED

NICORETTE LOZG PREFERRED

NICORETTE MINI LOZG PREFERRED

NICOTINE POLACRILEX LOZG PREFERRED

SM NICOTINE LOZG PREFERRED

SM NICOTINE POLACRILEX LOZG PREFERRED

CHANTIX TABS PREFERRED

CHANTIX CONTINUING MONTH TABS PREFERRED

CHANTIX STARTING MONTH PA TABS PREFERRED

RESPIRATORY AGENTS : CYSTIC FIBROSIS AGENTS KALYDECO PACK NON_PREFERRED

KALYDECO TABS NON_PREFERRED

PULMOZYME SOLN PREFERRED

ORKAMBI PACK NON_PREFERRED

ORKAMBI TABS NON_PREFERRED

SYMDEKO TBPK NON_PREFERRED

RESPIRATORY AGENTS : MISC ESBRIET CAPS NON_PREFERRED

ESBRIET TABS NON_PREFERRED

OFEV CAPS NON_PREFERRED

SUBSTANCE USE DISORDER AGENTS ACAMPROSATE CALCIUM DR TBEC PREFERRED

ANTABUSE TABS PREFERRED

of 98


DISULFIRAM TABS PREFERRED

LUCEMYRA TABS PREFERRED

SUBLOCADE SOSY PREFERRED

PROBUPHINE IMPLANT KIT IMPL PREFERRED

BUPRENORPHINE HCL SUBL PREFERRED

BUNAVAIL FILM PREFERRED

BUPRENORPHINE HYDROCHLORI FILM PREFERRED

SUBOXONE FILM PREFERRED

BUPRENORPHINE HCL/NALOXON SUBL PREFERRED

BUPRENORPHINE HYDROCHLORI SUBL PREFERRED

ZUBSOLV SUBL PREFERRED

NARCAN LIQD PREFERRED

NALOXONE HCL SOCT PREFERRED

NALOXONE HCL SOLN PREFERRED

NALOXONE HCL SOSY PREFERRED

VIVITROL SUSR PREFERRED

NALTREXONE HCL TABS PREFERRED

THYROID AGENTS TIROSINT CAPS NON_PREFERRED

TIROSINT-SOL SOLN NON_PREFERRED

EUTHYROX TABS PREFERRED

LEVO-T TABS PREFERRED

LEVOTHYROXINE SODIUM TABS PREFERRED

LEVOXYL TABS PREFERRED

SYNTHROID TABS NON_PREFERRED

UNITHROID TABS PREFERRED

CYTOMEL TABS NON_PREFERRED

LIOTHYRONINE SODIUM TABS PREFERRED

ARMOUR THYROID TABS PREFERRED

LEVOTHYROXINE/LIOTHYRONIN TABS PREFERRED

NP THYROID 120 TABS PREFERRED





METHIMAZOLE TABS PREFERRED

TAPAZOLE TABS NON_PREFERRED

PROPYLTHIOURACIL TABS PREFERRED

TUMOR NECROSIS FACTOR ALPHA INHIBITORS AND MISC

IMMUNOSUPPRESSIVES ENTYVIO SOLR NON_PREFERRED

STELARA SOLN NON_PREFERRED

CIMZIA KIT KIT NON_PREFERRED

CIMZIA PREFL KIT 200MG/ML KIT PREFERRED_WITH_PA

CIMZIA STARTER KIT KIT PREFERRED_WITH_PA

of 98


REMICADE SOLR NON_PREFERRED

RENFLEXIS SOLR NON_PREFERRED

INFLECTRA SOLR NON_PREFERRED

KINERET SOSY NON_PREFERRED

HUMIRA PEN PNKT PREFERRED_WITH_PA

HUMIRA PEN-CD/UC/HS START PNKT PREFERRED_WITH_PA

HUMIRA PEN-PS/UV STARTER PNKT PREFERRED_WITH_PA

HUMIRA PSKT PREFERRED_WITH_PA

HUMIRA PEDIATRIC CROHNS D PSKT PREFERRED_WITH_PA

SIMPONI SOAJ NON_PREFERRED

SIMPONI ARIA SOLN NON_PREFERRED

SIMPONI SOSY NON_PREFERRED

ENBREL SURECLICK SOAJ PREFERRED_WITH_PA

ENBREL MINI SOCT PREFERRED_WITH_PA

ENBREL SOLR PREFERRED_WITH_PA

ENBREL SOSY PREFERRED_WITH_PA

ORENCIA CLICKJECT SOAJ NON_PREFERRED

ORENCIA SOLR NON_PREFERRED

ORENCIA SOSY NON_PREFERRED

ARCALYST SOLR NON_PREFERRED

ILARIS SOLN NON_PREFERRED

KEVZARA SOAJ NON_PREFERRED

KEVZARA SOSY NON_PREFERRED

ACTEMRA ACTPEN SOAJ NON_PREFERRED

ACTEMRA SOLN NON_PREFERRED

ACTEMRA SOSY NON_PREFERRED

OLUMIANT TABS NON_PREFERRED

XELJANZ TABS PREFERRED_WITH_PA

XELJANZ XR TB24 PREFERRED_WITH_PA

RINVOQ TB24 NON_PREFERRED

OTEZLA TABS NON_PREFERRED

OTEZLA TBPK NON_PREFERRED

ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : H-2

ANTAGONISTS CIMETIDINE TABS PREFERRED

CIMETIDINE HCL SOLN PREFERRED

RANITIDINE HYDROCHLORIDE CAPS PREFERRED

RANITIDINE HCL SYRP PREFERRED

RANITIDINE HYDROCHLORIDE SYRP PREFERRED

RANITIDINE HCL TABS PREFERRED

RANITIDINE HYDROCHLORIDE TABS PREFERRED

FAMOTIDINE SUSR PREFERRED

FAMOTIDINE TABS PREFERRED

PEPCID TABS NON_PREFERRED

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NIZATIDINE CAPS PREFERRED

NIZATIDINE SOLN PREFERRED

MISC HYOSCYAMINE SULFATE ELIX PREFERRED

HYOSCYAMINE SULFATE SOLN PREFERRED

HYOSCYAMINE SULFATE SUBL PREFERRED

LEVSIN/SL SUBL NON_PREFERRED

OSCIMIN SUBL PREFERRED

HYOSCYAMINE SULFATE TABS PREFERRED

LEVSIN TABS NON_PREFERRED

OSCIMIN TABS PREFERRED

OSCIMIN SR TB12 PREFERRED

ANASPAZ TBDP NON_PREFERRED

ED-SPAZ TBDP PREFERRED

HYOSCYAMINE SULFATE TBDP PREFERRED

NULEV TBDP PREFERRED

OSCIMIN TBDP PREFERRED

CUVPOSA SOLN NON_PREFERRED

GLYCATE TABS NON_PREFERRED

GLYCOPYRROLATE TABS PREFERRED

METHSCOPOLAMINE BROMIDE TABS NON_PREFERRED

PROPANTHELINE BROMIDE TABS PREFERRED

DICYCLOMINE HYDROCHLORIDE CAPS PREFERRED

DICYCLOMINE HCL SOLN PREFERRED

DICYCLOMINE HYDROCHLORIDE TABS PREFERRED

BELLADONNA/OPIUM SUPP PREFERRED

CHLORDIAZEPOXIDE HCL/CLID CAPS NON_PREFERRED

LIBRAX CAPS NON_PREFERRED

CYTOTEC TABS NON_PREFERRED

MISOPROSTOL TABS PREFERRED

CARAFATE SUSP PREFERRED

SUCRALFATE SUSP PREFERRED

CARAFATE TABS NON_PREFERRED

SUCRALFATE TABS PREFERRED

PYLERA CAPS NON_PREFERRED

LANSOPRAZOLE/AMOXICILLIN/ MISC NON_PREFERRED

OMECLAMOX-PAK MISC NON_PREFERRED

OMEPRAZOLE/SODIUM BICARBO CAPS NON_PREFERRED

ZEGERID CAPS NON_PREFERRED

OMEPRAZOLE/SODIUM BICARBO PACK NON_PREFERRED

ZEGERID PACK NON_PREFERRED

PROTON PUMP INHIBITORS DEXILANT CPDR NON_PREFERRED

ESOMEPRAZOLE MAGNESIUM CPDR NON_PREFERRED

NEXIUM CPDR NON_PREFERRED

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ESOMEP-EZS KIT NON_PREFERRED

NEXIUM PACK NON_PREFERRED

ESOMEPRAZOLE STRONTIUM CPDR NON_PREFERRED

LANSOPRAZOLE CPDR NON_PREFERRED

PREVACID CPDR NON_PREFERRED

LANSOPRAZOLE TBDD PREFERRED

LANSOPRAZOLE ODT TBDD PREFERRED

PREVACID SOLUTAB TBDD NON_PREFERRED

OMEPRAZOLE CPDR PREFERRED

OMEPRAZOLE DR CPDR PREFERRED

PRILOSEC PACK NON_PREFERRED

PROTONIX PACK NON_PREFERRED

PANTOPRAZOLE SODIUM TBEC PREFERRED

PANTOPRAZOLE SODIUM DR TBEC PREFERRED

PROTONIX TBEC NON_PREFERRED

ACIPHEX SPRINKLE CPSP NON_PREFERRED

ACIPHEX TBEC NON_PREFERRED

RABEPRAZOLE SODIUM TBEC NON_PREFERRED

URINARY ANTI-INFECTIVES MONUROL PACK PREFERRED

METHENAMINE MANDELATE TABS PREFERRED

HIPREX TABS NON_PREFERRED

METHENAMINE HIPPURATE TABS PREFERRED

FURADANTIN SUSP NON_PREFERRED

NITROFURANTOIN SUSP PREFERRED

MACRODANTIN CAPS NON_PREFERRED

NITROFURANTOIN MACROCRYST CAPS PREFERRED

MACROBID CAPS NON_PREFERRED

NITROFURANTOIN MONOHYDRAT CAPS PREFERRED

ME/NAPHOS/MB/HYO 1 TABS NON_PREFERRED

UROGESIC-BLUE TABS NON_PREFERRED

URIBEL CAPS NON_PREFERRED

USTELL CAPS NON_PREFERRED

PHOSPHASAL TABS NON_PREFERRED

URIMAR-T TABS NON_PREFERRED

URIN D/S TABS NON_PREFERRED

URO-458 TABS NON_PREFERRED

URINARY ANTISPASMODICS DARIFENACIN HYDROBROMIDE TB24 NON_PREFERRED

ENABLEX TB24 NON_PREFERRED

TOVIAZ TB24 NON_PREFERRED

OXYTROL PTTW NON_PREFERRED

GELNIQUE GEL NON_PREFERRED

GELNIQUE PUMP GEL NON_PREFERRED

OXYBUTYNIN CHLORIDE SYRP PREFERRED

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OXYBUTYNIN CHLORIDE TABS PREFERRED

DITROPAN XL TB24 NON_PREFERRED

OXYBUTYNIN CHLORIDE ER TB24 PREFERRED

SOLIFENACIN SUCCINATE TABS PREFERRED

VESICARE TABS NON_PREFERRED

DETROL LA CP24 NON_PREFERRED

TOLTERODINE TARTRATE ER CP24 NON_PREFERRED

DETROL TABS NON_PREFERRED

TOLTERODINE TARTRATE TABS NON_PREFERRED

TROSPIUM CHLORIDE ER CP24 NON_PREFERRED

TROSPIUM CHLORIDE TABS NON_PREFERRED

MYRBETRIQ TB24 NON_PREFERRED

BETHANECHOL CHLORIDE TABS PREFERRED

URECHOLINE TABS NON_PREFERRED

FLAVOXATE HCL TABS NON_PREFERRED

VAGINAL PRODUCTS CLEOCIN CREA NON_PREFERRED

CLINDAMYCIN PHOSPHATE CREA PREFERRED

CLEOCIN SUPP PREFERRED

CLINDESSE CREA NON_PREFERRED

METRONIDAZOLE VAGINAL GEL PREFERRED

NUVESSA GEL NON_PREFERRED

VANDAZOLE GEL PREFERRED

AVC CREA PREFERRED

GYNAZOLE-1 CREA NON_PREFERRED

MICONAZOLE 3 SUPP PREFERRED

TERCONAZOLE CREA PREFERRED

TERCONAZOLE SUPP PREFERRED

ESTRACE CREA NON_PREFERRED

ESTRADIOL CREA PREFERRED

ESTRING RING NON_PREFERRED

ESTRADIOL TABS NON_PREFERRED

VAGIFEM TABS NON_PREFERRED

YUVAFEM TABS NON_PREFERRED

FEMRING RING NON_PREFERRED

PREMARIN CREA PREFERRED

CRINONE GEL NON_PREFERRED

ENDOMETRIN INST PREFERRED

INTRAROSA INST NON_PREFERRED

TRIMO-SAN GEL NON_PREFERRED

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illinois medicaid preferred drug list...illinois medicaid preferred drug list effective january 1,...

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