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