CENPATICO INTEGRATED CARE COMPREHENSIVE … · ketoprofen capsules sustained release orudis...

Drug Class/Drug Name Reference Brand Name Brand Only

Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days

PYRIDOSTIGMINE BROMIDE SYRUP MESTINON SYRUP

PYRIDOSTIGMINE BROMIDE TABLET MESTINON

PYRIDOSTIGMINE BROMIDE TABLET CONTROLLED RELEASE MESTINON TIMESPAN

ADHD/ANTI-NARCOLEPSY

AMPHETAMINES

AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE CONTROLLED RELEASE ADDERALL XR BRAND Preferred Drug PA Required for ages < 6 years 60 30

AMPHETAMINE-DEXTROAMPHETAMINE TABLETS 5MG, 7.5MG, 10MG, 12.5MG ADDERALL BRAND Preferred Drug PA Required for ages < 6 years 90 30

AMPHETAMINE-DEXTROPHETAMINE TABLETS 15MG, 20MG, 30MG ADDERALL BRAND Preferred Drug PA Required for ages < 6 years 60 30

LISDEXAMFETAMINE ER CAPSULES 10MG, 20MG VYVANSE BRAND Preferred Drug PA Required for ages < 6 years 90 30

LISDEXAMFETAMINE ER CAPSULES 30MG VYVANSE BRAND Preferred Drug PA Required for ages < 6 years 60 30

LISDEXAMFETAMINE ER CAPSULES 40MG, 50MG, 60MG, 70MG VYVANSE BRAND Preferred Drug PA Required for ages < 6 years 30 30

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

ATOMOXETINE HCL CAPSULES 10MG, 18MG, 25MG, 40MG STRATTERA BRAND Preferred Drug PA Required for ages < 6 years 60 30

ATOMOXETINE HCL CAPSULES 60MG, 80MG, 100MG STRATTERA BRAND Preferred Drug PA Required for ages < 6 years 30 30

CENTRAL ACTING ALPHA-AGONISTS

CLONIDINE HCl TABLET SR KAPVAY BRAND Preferred Drug PA Required for ages < 6 years

GUANFACINE HCL TABLET ER GUANFACINE HCL ER Preferred Drug PA Required for ages < 6 years

STIMULANTS - MISC.

DEXMETHYLPHENIDATE HCL ER CAPSULE 5MG, 10MG, 15MG, 20MG FOCALIN XR BRAND Preferred Drug PA Required for ages < 6 years 60 30

DEXMETHYLPHENIDATE HCL ER CAPSULE 25MG, 30MG, 35MG, 40MG FOXALIN XR BRAND Preferred Drug PA Required for ages < 6 years 30 30

DEXMETHYLPHENIDATE HCL TABLETS FOCALIN BRAND Preferred Drug PA Required for ages < 6 years 60 30

METHYLPEHNIDATE HCL CHEWABLET TABLET QUILLICHEW BRAND Preferred Drug PA Required for ages < 6 years

METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN BRAND Preferred Drug PA Required for ages < 6 years 120 30

METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 10MG RITALIN LA BRAND Preferred Drug PA Required for ages < 6 years 120 30

METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 20MG METHYLPHENIDATE LA Preferred Drug PA Required for ages < 6 years 90 30

METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 30MG METHYLPHENIDATE LA Preferred Drug PA Required for ages < 6 years 60 30

METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 40MG, 60MG METHYLPHENIDATE LA Preferred Drug PA Required for ages < 6 years 30 30

METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 10MG METADATE CD BRAND Preferred Drug PA Required for ages < 6 years 120 30



METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 40MG, 50MG, 60MG METADATE CD BRAND Preferred Drug PA Required for ages < 6 years 30 30

METHYLPHENIDATE HCL TD PATCH DAYTRANA BRAND Preferred Drug PA Required for ages < 6 years 30 30

METHYLPHENIDATE HCL SOLUTION METHYLIN BRAND Preferred Drug PA Required for ages < 6 years 300ML 30

METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR BRAND Preferred Drug PA Required for ages < 6 years 150ML 30

METHYLPHENIDATE HCL TABLETS RITALIN Preferred Drug PA Required for ages < 6 years 120 30

METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE 18MG METHYLPEHNIDATE ER Preferred Drug PA Required for ages < 6 years 120 30

CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG CLASS

• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/1/2016

• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-2

ACETYLCHOLINESTERASE INHIBITORS

Page 1 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE 27MG, 36MG METHYLPEHNIDATE ER Preferred Drug PA Required for ages < 6 years 60 30

METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE 54MG METHYLPHENIDATE ER Preferred Drug PA Required for ages < 6 years 30 30

METHYLPHENIDATE HCL TABLET ER 20MG METHYLPHENIDATE ER Preferred Drug PA Required for ages < 6 years 90 30

METHYLPHENIDATE HCL TABLET ER 30MG METHYLPHENIDATE ER Preferred Drug PA Required for ages < 6 years

METHYLPHENIDATE HCL TABLET ER 40MG METHYLPHENIDATE ER Preferred Drug PA Required for ages < 6 years

METHYLPHENIDATE HCL TABLET SUSTAINED RELEASE RITALIN SR PA Required for ages < 6 years 60 30

AMINOGLYCOSIDES

AMINOGLYCOSIDES

NEOMYCIN SULFATE TABLETS NEOMYCIN SULFATE

INHALED ANTIBIOTICS

TOBRAMYCIN NEBULIZED BETHKIS Preferred Drug PA Required

TOBRAMYCIN NEBULIZED KITABIS Preferred Drug PA Required

ANALGESICS - ANTI-INFLAMMATORY

ANTIRHEUMATIC ANTIMETABOLITES

METHOTREXATE SODIUM TABLETS RHEUMATREX

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)

CELECOXIB CAPSULES CELEBREX PA Required 60 30

CHOLINE & MAGNESIUM SALICYLATES LIQUID TRILISATE

CHOLINE & MAGNESIUM SALICYLATES TABLETS TRILISATE

DICLOFENAC POTASSIUM CAPSULE VOLTAREN

DICLOFENAC POTASSIUM PACKET DICLOFENAC

DICLOFENAC POTASSIUM TABLET CATAFLAM

DICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XR

DICLOFENAC SODIUM TABLET DELAYED RELEASE VOLTAREN-XR

DICLOFENAC SODIUM TABLET ENTERIC COATED VOLTAREN

DICLOFENAC W/ MISOPROSTOL TABLET DELAYED RELEASE ARTHROTEC 50

ETODOLAC CAPSULES LODINE

ETODOLAC TABLETS LODINE

ETODOLAC TABLETS EXTENDED RELEASE ETODOLAC ER

FENOPROFEN CALCIUM CAPSULES NALFON

FENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUM

FLURBIPROFEN TABLETS FLURBIPROFEN

IBUPROFEN CAPSULES ADVIL

IBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRIN

IBUPROFEN SUSPENSION CHILDRENS MOTRIN

IBUPROFEN TABLETS ADVIL

INDOMETHACIN CAPSULES VARIOUS

INDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CR

Page 2 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




INDOMETHACIN SUPPOSITORY INDOCIN

INDOMETHACIN SUSPENSION INDOCIN

KETOPROFEN CAPSULES ORUDIS

KETOPROFEN CAPSULES SUSTAINED RELEASE ORUDIS

KETOROLAC TROMETHAMINE TABLETS KETOROLAC TROMETHAMINE 20 30

MECLOFENAMATE SODIUM CAPSUL MECLOFENAMATE

MEFENAMIC ACID CAPSULE PONSTEL

MELOXICAM SUSPENSION MOBIC

MELOXICAM TABLETS MOBIC

NABUMETONE TABLETS NABUMETONE

NAPROXEN SODIUM CAPSULE ALEVE. ANAPROX

NAPROXEN SODIUM TABLETS ALEVE. ANAPROX

NAPROXEN SUSPENSION NAPROSYN

NAPROXEN TABLETS NAPROSYN

NAPROXEN TABLETS ENTERIC COATED NAPROSYN EC

NAPROXEN TABLETS SUSTAINED RELEASE ANAPROX DS

OXAPROZIN TABLETS DAYPRO

PIROXICAM CAPSULES FELDENE

SULINDAC TABLETS SULINDAC

TOLMETIN SODIUM CAPSULE TOLMETIN SODIUM

PYRIMIDINE SYNTHESIS INHIBITORS

LEFLUNOMIDE TABLETS ARAVA

CYTOKINE & CAM ANTAGONIST AGENTS

ADALIMUMAB HUMIRA Preferred Drug PA Required

ETANERCEPT ENBREL Preferred Drug PA Required

ANALGESICS - NONNARCOTIC

ANALGESIC COMBINATIONS

BUTALBITAL-ACETAMINOPHEN CAPSULES TENCON 180 30

BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAPSULES FIORICET 180 30

BUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS ESGIC 180 30

BUTALBITAL-ASPIRIN-CAFFEINE CAPSULES FIORINAL 180 30

BUTALBITAL-ASPIRIN-CAFFEINE TABLETS BUTAL/ASA/CAFF 180 30

ANALGESICS OTHER

ACETAMINOPHEN CAPSULES VARIOUS

ACETAMINOPHEN CHEWABLE TABLETS VARIOUS

ACETAMINOPHEN ELIXIR VARIOUS

ACETAMINOPHEN LIQUID VARIOUS

ACETAMINOPHEN SUPPOSITORY FEVERALL INFANTS

Page 3 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




ACETAMINOPHEN SUSPENSION TYLENOL INFANTS

ACETAMINOPHEN TABLETS VARIOUS

SALICYLATES

ASPIRIN BUFFERED TABLET ASCRIPTIN

ASPIRIN CHEWABLE TABLETS VARIOUS

ASPIRIN SUPPOSITORY VARIOUS

ASPIRIN TABLETS VARIOUS

ASPIRIN TABLETS CONTROLLED RELEASE ASPIRIN

ASPIRIN TABLETS DELAYED RELEASE

DIFLUNISAL TABLETS DIFLUNISAL

SALSALATE TABLETS DISALCID

ANALGESICS - OPIOID

OPIOID AGONISTS

CODEINE SULFATE TABLETS CODEINE PA Required

FENTANYL PATCH DURAGESIC PA Required 10 30

HYDROMORPHONE HCL LIQUID DILAUDID

PA Required for > 2 Short Acting

Narcotics Fill 480 ML 30

HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCL


Narcotics Fill 12 30

HYDROMORPHONE HCL TABLETS DILAUDID



MEPERIDINE HCL TABLETS DEMEROL



METHADONE HCL CONCENTRATE METHADONE HCL INTENSOL

PA Required for > 1 Long Acting


METHADONE HCL SOLUTION METHADONE HCL



METHADONE HCL TABLETS DOLOPHINE



MORPHINE SULFATE CAPSULES SUSTAINED RELEASE KADIAN



MORPHINE SULFATE SOLUTION MORPHINE SULFATE



MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATE



MORPHINE SULFATE TABLETS MORPHINE SULFATE



Page 4 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




MORPHINE SULFATE TABLET CONTROLLED RELEASE MS CONTIN


Narcotic Fill 90 30

OXYCODONE HCL CAPSULES OXYCODONE HCL



OXYCODONE HCL CONCENTRATE OXYCODONE HCL



OXYCODONE HCL SOLUTION OXYCODONE HCL



OXYCODONE HCL TABLET ABUSE DETERRANT 12-HOUR OXYCONTIN PA Required 90 30

OXYCODONE HCL TABLETS ROXICODONE



OXYCODONE HCL TABLETS EXTENDED RELEASE OXYCONTIN PA Required 90 30

TRAMADOL-ACETAMINOPHEN TABLETS ULTRACET



TRAMADOL HCL TABLETS ULTRAM



TRAMADOL HCL TABLET 24-HOUR TRAMADOL HCL ER


Narcotic Fill 30 30

OPIOID COMBINATIONS

ACETAMINOPHEN W/ CODEINE SOLUTION VARIOUS



ACETAMINOPHEN W/ CODEINE TABLETS VARIOUS



BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES FIORICET/CODEINE



BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES FIORINAL/CODEINE



HYDROCODONE-ACETAMINOPHEN CAPSULES VARIOUS



HYDROCODONE-ACETAMINOPHEN SOLUTION VARIOUS



HYDROCODONE-ACETAMINOPHEN TABLETS VARIOUS



HYDROCODONE-IBUPROFEN TABLETS VARIOUS



OXYCODONE W/ ACETAMINOPHEN CAPSULES VARIOUS



Page 5 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICET



OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCET



OXYCODONE W/ASPIRIN TABLETS PERCODAN



ANDROGENS-ANABOLIC

ANDROGENS

DANAZOL CAPSULES DANAZOL

FLUOXYMESTERONE TABLETS ANDROXY

TESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA Required

TESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA Required

TESTOSTERONE GEL ANDROGEL PA Required

TESTOSTERONE PATCH ANDRODERM PA Required

TESTOSTERONE SOLUTION AXIRON PA Required

ANORECTAL AGENTS

INTRARECTAL STEROIDS

HYDROCORTISONE (INTRARECTAL) ENEMA COLOCORT

HYDROCORTISONE ACETATE (INTRARECTAL) FOAM CORTIFOAM

RECTAL STEROIDS

HYDROCORTISONE ACETATE CREAM ANUSOL-HC

HYDROCORTISONE ACETATE OINTMENT ANUSOL-HC

HYDROCORTISONE (RECTAL) CREAM PROCTOCORT

ANTACIDS & MISCELLANEOUS

ALUM & MAG HYDROXIDE-SIMETHICONE SUSPENTION MAALOX MAXIMUM

ALUMINUM & MAGNESIOUM HYDROXIDE SUSPENSION MAALOX

ALUMINU,M/MAGNESIOUM HYDROXIDE SUSPENSION MYLANTA

BISMUTH SUBSALICYLATE CHEW TABLET PEPTO-BISMOL

BISMUTH SUBSALICYLATE SUSPENSION PEPTO-BISMOL

BISMUTH SUBSALICYLATE TABLET PEPTO-BISMOL

CALCIUM CARBONATE CHEW TABLETS TUMS

CALCIUM CARGONATE TABLRETS TUMS

CROMOLYN SODIUM ORAL CONCENTATE VARIOUS

MAGNESIUM HYDROXIDE SUSPENSION MILK OF MAGNESIA

MAGNESIUM HYDROXIDE SUSPENSION CONCENTRATE MILK OF MAGNESIA

METHSCOPOLAMINE BROMIDE TABLETS PAMINE

MISOPROSTOL TABLETS CYTOTEC

SIMETHICONE CAPSULES MYLICON

Page 6 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




SIMETHICONE CHEW TABLETS MYLICON

SIMETHICONE SUSPENSION MYLICON

ANTHELMINTICS

ANTHELMINTICS

ALBENDAZOLE TABLETS ALBENZA PA Required

IVERMECTIN TABLETS STROMECTOL PA Required

PRAZIQUANTEL TABLETS BILTRICIDE

ANTIANGINAL AGENTS

ANTIANGINALS-OTHER

RANOLAZINE TABLET 12-HOUR RANEXA PA Required

NITRATES

ISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE DILATRATE SR

ISOSORBIDE DINITRATE SUBLINGUAL ISOSORBIDE DINITRATE

ISOSORBIDE DINITRATE TABLETS ISORDIL TITRADOSE

ISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE ISOSORBIDE DINITRATE ER

ISOSORBIDE MONONITRATE TABLETS ISOSORBIDE MONONITRATE

ISOSORBIDE MONONITRATE TABLET 24-HOUR IMDUR

NITROGLYCERIN AEROSOL NITROMIST

NITROGLYCERIN CAPSULE CONTROLLED RELEASE NITRO-TIME

NITROGLYCERIN OINTMENT NITRO-BID

NITROGLYCERIN PATCH MINITRAN

NITROGLYCERIN SOLUTION NITROLINGUAL PUMPSPRAY

NITROGLYCERIN SUBLINGUAL NITROSTAT

ANTIANXIETY AGENTS

ANTIANXIETY AGENTS - MISC.

BUSPIRONE HCL TABLETS 5 MG, 7.5 MG, 10 MG, 15 MG BUSPIRONE HCL 120 30

BUSPIRONE HCL TABLETS 30 MG BUSPIRONE HCL 60 30

HYDROXYZINE HCL SYRUP HYDROXYZINE HCL

HYDROXYZINE HCL TABLETS HYDROXYZINE HCL

HYDROXYZINE PAMOATE CAPSULES VISTARIL

BENZODIAZEPINES

ALPRAZOLAM CONCENTRATE ALPRAZOLAM INTENSOL PA Required for > 1 Anxiolytics Fill 60ML 15

ALPRAZOLAM ER TABLET XANAX ER PA Required for > 1 Anxiolytics Fill 30 30

ALPRAZOLAM ODT TABLET 0.25MG, 0.5MG, 1MG NIRAVAM PA Required for > 1 Anxiolytics Fill 120 30

ALPRAZOLAM ODT TABLET 2MG NIRAVAM PA Required for > 1 Anxiolytics Fill 60 30

ALPRAZOLAM TABLET 0.25MG, 0.5MG, 1MG XANAX PA Required for > 1 Anxiolytics Fill 120 30

ALPRAZOLAM TABLET 2MG XANAX PA Required for > 1 Anxiolytics Fill 60 30

CHLORDIAZEPOXIDE HCL CAPSULES LIBRIUM PA Required for > 1 Anxiolytics Fill 60 30

Page 7 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CLONAZEPAM ODT TABLET 0.125MG, 0.25 MG, 0.5MG, 1MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30

CLONAZEPAM ODT TABLET 2MG KLONOPIN PA Required for > 1 Anxiolytics Fill 60 30

CLONAZEPAM TABLETS 0.5MG, 1MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30

CLONAZEPAM TABLETS 2MG KLONOPIN PA Required for > 1 Anxiolytics Fill 60 30

CLORAZEPATE DIPOTASSIUM 3.75 MG, 7.5 MG, TRANXENE-T PA Required for > 1 Anxiolytics Fill 120 30

CLORAZEPATE DIPOTASSIUM 15 MG TRANXENE-T PA Required for > 1 Anxiolytics Fill 60 30

DIAZEPAM CONCENTRATE 5 MG/ML DIAZEPAM INTENSOL PA Required for > 1 Anxiolytics Fill 60ML 30

DIAZEPAM SOLUTION 1 MG/ML DIAZEPAM PA Required for > 1 Anxiolytics Fill 300 ML 30

DIAZEPAM SOLUTION 5 MG/5ML DIAZEPAM PA Required for > 1 Anxiolytics Fill 300 ML 30

DIAZEPAM TABLETS VALIUM PA Required for > 1 Anxiolytics Fill 90 30

LORAZEPAM CONCENTRATE LORAZEPAM INTENSOL PA Required for > 1 Anxiolytics Fill 60ML 30

LORAZEPAM ORAL SOLUTION PA Required for > 1 Anxiolytics Fill 60ML 30

LORAZEPAM TABLETS 0.5MG, 1MG ATIVAN PA Required for > 1 Anxiolytics Fill 120 30

LORAZEPAM TABLETS 2MG ATIVAN PA Required for > 1 Anxiolytics Fill 90 30

OXAZEPAM CAPSULES OXAZEPAM PA Required for > 1 Anxiolytics Fill 60 30

MEPROBAMATE TABLETS VARIOUS PA Required for > 1 Anxiolytics Fill

ANTIARRHYTHMICS

ANTIARRHYTHMICS TYPE I-A

DISOPYRAMIDE PHOSPHATE CAPSULES NORPACE

DISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR NORPACE CR

QUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CR

QUINIDINE SULFATE TABLETS QUINIDINE SULFATE

QUINIDINE SULFATE TABLET CONTROLLED RELEASE QUINIDINE SULFATE ER

ANTIARRHYTHMICS TYPE I-B

MEXILETINE HCL CAPSULES MEXILETINE HCL

ANTIARRHYTHMICS TYPE I-C

FLECAINIDE ACETATE TABLETS TAMBOCOR

PROCAINAMIDE HCL CAPSULE PROCAINAMIDE

PROCAINAMIDE CHL TABLET CONTROLLED RELEASE PROCAN SR

PROPAFENONE HCL CAPSULE 12-HOUR RYTHMOL SR

PROPAFENONE HCL TABLETS RYTHMOL

ANTIARRHYTHMICS TYPE III

AMIODARONE HCL TABLETS PACERONE

DOFETILIDE CAPSULES TIKOSYN PA Required

DRONEDARONE HCL TABLETS MULTAQ PA Required

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ANTI-INFLAMMATORY AGENTS

NON-BENZODIAZEPINE

Page 8 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CROMOLYN SODIUM NASAL AEROSOL CROMOLYN SODIUM

CROMOLYN SODIUM NEBULIZER CROMOLYN SODIUM

BRONCHODILATORS - ANTICHOLINERGICS

IPRATROPIUM BROMIDE HFA AEROSOL ATROVENT HFA Preferred Drug

IPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDE Preferred Drug

TIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALER Preferred Drug

LEUKOTRIENE MODULATORS

MONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR 30 30

MONTELUKAST SODIUM GRANULES SINGULAIR 30 30

MONTELUKAST SODIUM TABLETS SINGULAIR 30 30

ZAFIRLUKAST TABLETS ACCOLATE

STEROID INHALANTS

BECLOMETHASONE DIPROPIONATE INHALER QVAR Preferred Drug

BUDESONIDE (INHALATION) SUSPENSION PULMICORT RESPULES BRAND Preferred Drug PA Required

BUDESONDIE INHALATION POWDER PULMICORT FLEXHALER BRAND Preferred Drug PA Required

FLUTICASONE PROPIONATE HFA AEROSOL FLOVENT HFA Preferred Drug

MOMETASONE FUROATE (INHALATION) AEROSOL POWDER BREATH ACTIVATED

ASMANEX TWISTHALER 30

METERED DOSES Preferred Drug

SYMPATHOMIMETICS

ALBUTEROL SULFATE AEROSOL PROAIR HFA

ALBUTEROL SULFATE NEBULIZER ALBUTEROL SULFATE

ALBUTEROL SULFATE SYRUP ALBUTEROL SULFATE

ALBUTEROL SULFATE TABLETS ALBUTEROL

BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL SYMBICORT Preferred Drug Step Therapy

Patient must have tried

one steroid inhaler:

Beclomethasone

Dipropionate, Budesonide,

Fluticasone Propionate, or

Mometasone

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



Beclomethasone



Mometasone

Page 9 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




FLUTICASONE-SALMETEROL AEROSOL ADVAIR HFA

Covered for

Ages 4-12 ONLY Step Therapy



Beclomethasone



Mometasone

FORMOTEROL FUMARATE CAPSULES FORADIL AEROSOLLIZER PA Required

IPRATROPIUM-ALBUTEROL AEROSOL COMBIVENT RESPIMAT Preferred Drug

METAPROTERENOL SULFATE TABLETS METAPROTERENOL SULFATE PA Required

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



Beclomethasone



Mometasone

SALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED SEREVENT DISKUS PA Required

ANTICOAGULANTS

COUMARIN ANTICOAGULANTS

WARFARIN SODIUM TABLETS JANTOVEN Preferred Drug

WARFARIN SODIUM TABLETS WARFARIN Preferred Drug

DIRECT FACTOR XA INHIBITORS

APIXABAN TABLETS ELIQUIS Preferred Drug 60 30

RIVAROXABAN TABLETS XARELTO Preferred Drug 30 30

HEPARINS AND HEPARINOID-LIKE AGENTS

ENOXAPARIN SODIUM SOLUTION LOVENOX BRAND Preferred Drug PA Required for > 10-day supply 6 10

HEPARIN SODIUM LOCK FLUSH SOLUTION HEPARIN LOCK FLUSH

HEPARIN SODIUM SOLUTION HEPARIN SODIUM

THROMBIN INHIBITORS

DABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA Preferred Drug 60 30

ANTICONVULSANTS

ANTICONVULSANTS - BENZODIAZEPINES

CLOBAZAM SUSPENSION ONFI PA Required

CLOBAZAM TABLETS ONFI PA Required

CLONAZEPAM ORALLY DISINTEGRATING TABLETS 0.125MG, 0.25 MGM 0.5MG, 1MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30

CLONAZEPAM ORALLY DISINTEGRATING TABLETS 2MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 60 30

Page 10 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CLONAZEPAM TABLETS 0.5MG, 1MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30

CLONAZEPAM TABLETS 2MG KLONOPIN PA Required for > 1 Anxiolytics Fill 60 30

DIAZEPAM RECTAL GEL DIASTAT ACUDIAL

DIAZEPAM (ANTICONVULSANT) RECTAL GEL DIASTAT PEDIATRIC

ANTICONVULSANTS - MISC.

CARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINE

CARBAMAZEPINE CAPSULE 12-HOUR CARBATROL 90 30

CARBAMAZEPINE SUSPENSION TEGRETOL

CARBAMAZEPINE TABLETS EPITOL

CARBAMAZEPINE CAPSULE 12-HOUR EQUETRO 90 30

CARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XR

GABAPENTIN CAPSULES 100MG, 300MG, 400MG NEURONTIN 180 30

GABAPENTIN SOLUTION NEURONTIN 1440ML 30

GABAPENTIN TABLETS 600MG NEURONTIN 120 30

GABAPENTIN TABLETS 800MG NEURONTIN 90 30

GABAPENTIN TABLETS EXTENDED RELEASE GRALISE PA Required

GABAPENTIN TABLETS EXTENDED RELEASE HORIZANT PA Required

LACOSAMIDE SOLUTION VIMPAT PA Required

LACOSAMIDE TABLETS VIMPAT PA Required

LAMOTRIGINE CHEWABLE TABLETS LAMICTAL+B135 120 30

LAMOTRIGINE TABLETS 25MG LAMICTAL 120 30

LAMOTRIGINE TABLETS 100MG LAMICTAL 90 30

LAMOTRIGINE TABLETS 150MG 200MG LAMICTAL 60 30

LAMOTRIGINE TABLET 24-HOUR LAMICTAL XR PA Required

LAMOTRIGINE ORALLY DISINTEGRATING TABLETS 25MG, 50MG LAMICTAL ODT 120 30

LAMOTRIGINE ORALLY DISINTEGRATING TABLETS 100MG LAMICTAL ODT 60 30

LAMOTRIGINE ORALLY DISINTEGRATING TABLETS 200MG LAMICTAL ODT 30 30

LEVETIRACETAM SOLUTION KEPPRA

LEVETIRACETAM TABLETS KEPPRA

LEVETIRACETAM TABLET 24-HOUR KEPPRA XR

OXCARBAZEPINE SUSPENSION TRILEPTAL 1050ML 30

OXCARBAZEPINE TABLETS TRILEPTAL 90 30

OXCARBAZEPINE TABLETS SUSTAINED RELEASE OXTELLAR XR PA Required

PREGABALIN CAPSULES LYRICA PA Required

PREGABALIN SOLUTION LYRICA PA Required

PRIMIDONE TABLETS MYSOLINE

RUFINAMIDE SUSPENSION BANZEL PA Required

RUFINAMIDE TABLETS BANZEL PA Required

Page 11 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




TOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLES

TOPIRAMATE TABLETS TOPAMAX

ZONISAMIDE CAPSULES ZONEGRAN

CARBAMATES

FELBAMATE SUSPENSION FELBATOL

FELBAMATE TABLETS FELBATOL

GABA MODULATORS

TIAGABINE HCL TABLETS GABITRIL PA Required

HYDANTOINS

PHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETS

PHENYTOIN SODIUM EXTENDED CAPSULES DILANTIN

PHENYTOIN SUSPENSION DILANTIN-125

SUCCINIMIDES

ETHOSUXIMIDE CAPSULES ZARONTIN

ETHOSUXIMIDE SOLUTION ZARONTIN

VALPROIC ACID

DIVALPROEX SODIUM SPRINKLE CAPSULES DEPAKOTE SPRINKLES

DIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ER

DIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTE

VALPROATE SODIUM SYRUP DEPAKENE

VALPROIC ACID CAPSULES DEPAKENE

VALPROIC ACID CAPSULES DELAYED RELEASE STAVZOR

ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

MIRTAZAPINE TABLETS 7.5MG, 15MG MIRTAZAPINE 90 30

MIRTAZAPINE TABLETS 30MG MIRTAZAPINE 45 30

MIRTAZAPINE TABLETS 45MG MIRTAZAPINE 30 30

MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 15MG REMERON SOLTAB 90 30



ANTIDEPRESSANTS - MISC.

BUPROPION HBR TABLETS EXTENDED RELEASE APLENZIN PA Required

BUPROPION HCL TABLETS 75MG, 100MG WELLBUTRIN 120 30

BUPROPION HCL TABLET 12-HOUR BUDEPRION SR 60 30

BUPROPION HCL TABLET 24-HOUR 150MG WELLBUTRIN XL 90 30

BUPROPION HCL TABLET 24-HOUR 300MG WELLBUTRIN XL 30 30

ISOCARBOXAZID TABLET MARPLAN

MONOAMINE OXIDASE INHIBITORS (MAOIs)

Page 12 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PHENELZINE SULFATE TABLET NARDIL

TRANYLCYPROMINE SULFATE TABLET PARNATE

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

CITALOPRAM HBR SOLUTION VARIOUS 900ML 30

CITALOPRAM HBR TABLETS 10 MG, 20 MG CELEXA 60 30

CITALOPRAM HBR TABLETS 40 MG CELEXA 30 30

ESCITALOPRAM OXALATE SOLUTION LEXAPRO 600 ML 30

ESCITALOPRAM OXALATE TABLETS 5 MG, 10 MG LEXAPRO 60 30

ESCITALOPRAM OXALATE TABLETS 20 MG LEXAPRO 30 30

FLUOXETINE HCL CAPSULES 10 MG, 20 MG PROZAC 120 30

FLUOXETINE HCL CAPSULES 40 MG PROZAC 60 30

FLUOXETINE HCL SOLUTION PROZAC 240 ML 30

FLUOXETINE HCL TABLETS 10 MG, 20 MG PROZAC 120 30

FLUOXETINE HCL TABLET 60MG PROZAC 30 30

FLUOXETINE HCL DR CAPSULES PROZAC WEEKLY PA Required

FLUVOXAMINE MALEATE ER CAPSULES 100 MG LUVOX CR 90 30

FLUVOXAMINE MALEATE ER CAPSULES 150 MG LUVOX CR 60 30

FLUVOXAMINE MALEATE TABLETS 25 MG, 50 MG LUVOX 180 30

FLUVOXAMINE MALEATE TABLETS 100 MG LUVOX 90 30

PAROXETINE HCL SUSPENSION PAXIL 900 ML 30

PAROXETINE HCL ER TABLETS 12.5 MG PAXIL CR 90 30

PAROXETINE HCL ER TABLETS 25 MG PAXIL CR 60 30

PAROXETINE HCL ER TABLETS 37.5 MG PAXIL CR 30 30

PAROXETINE HCL TABLETS 10 MG, 20 MG PAXIL 90 30

PAROXETINE HCL TABLETS 30 MG PAXIL 60 30

PAROXETINE HCL TABLETS 45 MG PAXIL 45 30

PAROXETINE MESYLATE TABLETS PEXEVA PA Required

SERTRALINE HCL CONCENTRATE ZOLOFT 300 ML 30

SERTRALINE HCL TABLETS 25 MG, 50 MG ZOLOFT 120 30

SERTRALINE HCL TABLETS 100 MG ZOLOFT 60 30

VILAZODONE HCL STARTER KIT VIIBRYD PA Required

VILAZODONE HCL TABLETS VIIBRYD PA RequiredSEROTONIN MODULATORS

NEFAZODONE TABLETS VARIOUS

TRAZODONE HCL TABLETS TRAZODONE HCL

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

DESVENLAFAXINE ER TABLETS 25 MG PRISTIQ 90 30

Page 13 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days






DULOXETINE CAPSULES 20 MG, 30 MG CYMBALTA 120 30

DULOXETINE CAPSULES 40 MG CYMBALTA 90 30

DULOXETINE CAPSULES 60 MG CYMBALTA 60 30

VENLAFAXINE HCL ER CAPSULES 37.5 MG EFFEXOR XR 120 30

VENLAFAXINE HCL ER CAPSULES 75 MG EFFEXOR XR 150 30

VENLAFAXINE HCL ER CAPSULES 150 MG EFFEXOR XR 60 30

VENLAFAXINE HCL ER TABLETS 37.5 MG EFFEXOR XR 120 30

VENLAFAXINE HCL ER TABLETS 75 MG EFFEXOR XR 150 30

VENLAFAXINE HCL ER TABLETS 150 MG EFFEXOR XR 60 30

VENLAFAXINE HCL ER TABLETS 225 MG WELLBUTRIN 30 30

VENLAFAXINE HCL TABLETS WELLBUTRIN 90 30TRICYCLIC AGENTS

AMITRIPTYLINE HCL TABLETS ELAVIL

AMOXAPINE TABLETS ASENDIN

CLOMIPRAMINE HCL TABLETS ANAFRANIL

DESIPRAMINE HCL TABLETS NORPRAMIN

DOXEPIN HCL CAPSULES SINEQUAN

DOXEPIN HCL CONCENTRATE SINEQUAN

DOXEPIN HCL TABLETS SILENOR PA Required

IMIPRAMINE HCL CAPSULES TOFRANIL

IMIPRAMINE HCL TABLETS TOFRANIL

IMIPRAMINE PAMOATE CAPSULES TOFRANIL PM

MAPROTILINE HCL TABLETS LUDIOMIL

NORTRIPTYLINE HCL CAPSULES PAMELOR

NORTRYIPTYLINE HCL SOLUTION PAMELOR

PROTRIPTYLINE HCL TABLETS VIVACTIL

TRIMIPRAMINE MALEATE CAPSULES TRIMIPRAMINEANTIDIABETICS

ALPHA-GLUCOSIDASE INHIBITORS

ACARBOSE TABLETS PRECOSE

PRAMLINTIDE SYMLINPEN INJECTOR Preferred Drug PA Required

ANTIDIABETIC COMBINATIONS

GLIPIZIDE-METFORMIN HCL TABLETS GLIPIZIDE/METFORMIN HCL

GLYBURIDE-METFORMIN HCL TABLETS GLUCOVANCE

AMYLINOMIMETIC

Page 14 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS MET

PIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XR

SITAGLIPTIN-METFORMIN HCL TABLETS JANUMET Preferred Drug PA Required

SITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR Preferred Drug PA Required

BIGUANIDES

LINAGLIPTIN/METFORMIN TABLETS JENTADUETO Preferred Drug PA Required

METFORMIN HCL SOLUTION RIOMET

METFORMIN HCL TABLETS GLUCOPHAGE

METFORMIN HCL TABLET 24-HOUR GLUCOPHAGE XR

DIABETIC OTHER

GLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1 30

GLUCAGON CHEW TABLETS VARIOUS

GLUCAGON GEL VARIOUS

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

LINAGLIPTIN TABLET TRADJENTA Preferred Drug PA Required

SITAGLIPTIN PHOSPHATE TABLETS JANUVIA Preferred Drug PA Required

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

EXENATIDE SUSPENSION BYETTA Preferred Drug PA Required

LIRAGLUTIDE SOLUTION VICTOZA Preferred Drug PA Required

INSULIN SENSITIZING AGENTS

PIOGLITAZONE HCL TABLETS ACTOS

INSULIN

INSULIN DETEMIR SOLUTION LEVEMIR Preferred Drug

INSULIN DETEMIR SUSPENSION LEVEMIR FLEXPEN/FLEXTOUCH Preferred Drug

INSULIN GLARGINE SOLUTION LANTUS Preferred Drug

INSULIN GLARGINE SUSPENSION LANTUS SOLOSTAR Preferred Drug

INSULIN LISPRO (HUMAN) SOLUTION HUMALOG Preferred Drug

INSULIN LISPRO (HUMAN) SUSPENSION HUMALOG KWIKPEN Preferred Drug

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION

HUMALOG MIX 75/25

KWIKPEN Preferred Drug

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION VIAL HUMALOG MIX 75/25 Preferred Drug

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION

HUMALOG MIX 50/50

KWIKPEN

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 50/50 VIAL

INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N Preferred Drug

INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N KWIKPEN Preferred Drug

INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30 Preferred Drug

Page 15 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN PEN 70/30 Preferred Drug

INSULIN REGULAR (HUMAN) SOLUTION HUMULIN R Preferred Drug

INSULIN REGULAR (HUMAN) SOLUTION

HUMULIN R U-500

(CONCENTRATED) Preferred Drug PA Required

INSULIN REGULAR (HUMAN) PEN

HUMULIN R U-500 PEN

(CONCENTRATED) Preferred Drug PA Required

MEGLITINIDE ANALOGUES

NATEGLINIDE TABLETS STARLIX

REPAGLINIDE TABLETS PRANDIN

SULFONYLUREAS

CHLORPROPAMIDE TABLETS CHLORPROPAMIDE

GLIMEPIRIDE TABLETS AMARYL

GLIPIZIDE TABLETS GLUCOTROL

GLIPIZIDE TABLET 24-HOUR GLUCATROL XL

GLYBURIDE MICRONIZED TABLETS GLYNASE

GLYBURIDE TABLETS DIABETA

TOLAZAMIDE TABLETS TOLINASE

TOLBUTAMIDE TABLETS TOLBUTAMIDE

ANTIDIARRHEALS

ANTIPERISTALTIC AGENTS

DIPHENOXYLATE W/ ATROPINE LIQUID DIPHENOXYLATE/ATROPINE

DIPHENOXYLATE W/ ATROPINE TABLETS LOMOTIL

LOPERAMIDE HCL CAPSULES LOPERAMIDE HCL

LOPERAMIDE HCL CHEWABLE TABLETS IMODIUM A-D

LOPERAMIDE HCL LIQUID LOPERAMIDE HCL

LOPERAMIDE HCL SUSPENSION IMODIUM A-D

LOPERAMIDE HCL TABLETS IMODIUM A-D

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

DOLASETRON MESYLATE TABLETS ANZEMET PA Required

GRANISETRON HCL SOLUTION VARIOUS PA Required

GRANISETRON HCL TABLETS VARIOUS PA Required

ONDANSETRON HCL TABLETS ORALLY DISINTEGRATING ZOFRAN ODT PA Required for tablets > 8mg 30 30

ONDANSETRON HCL TABLETS ZOFRAN PA Required for tablets > 8mg 30 30

TRIMETHOBENZAMIDE HCL CAPSULES TIGAN

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONIST

APREPITANT CAPSULES EMEND 6 21

ANTIFUNGALS

Page 16 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




ANTIFUNGALS

FLUCYTOSINE CAPSULES ANCOBON PA Required

GRISEOFULVIN MICROSIZE SUSPENSION GRISEOFULVIN MICROSIZE

GRISEOFULVIN MICROSIZE TABLETS GRIFULVIN V

GRISEOFULVIN ULTRAMICROSIZE TABLETS GRIS-PEG

NYSTATIN CAPSULES BIO-STATIN

NYSTATIN POWDER NYSTATIN

NYSTATIN SUSPENSION MYCOSTATIN

NYSTATIN TABLETS NYSTATIN

TERBINAFINE HCL PACKETS LAMISIL 90 365

TERBINAFINE HCL TABLETS LAMISIL 90 365

IMIDAZOLE-RELATED ANTIFUNGALS

FLUCONAZOLE SUSPENSION DIFLUCAN 600 ML 30

FLUCONAZOLE TABLETS DIFLUCAN 60 30

ITRACONAZOLE CAPSULES SPORANOX PA Required

ITRACONAZOLE SOLUTION SPORANOX PA Required

ITRACONAZOLE TABLETS ONMEL PA Required

KETOCONAZOLE TABLETS KETOCONAZOLE

POSACONAZOLE SUSPENSION NOXAFIL PA Required

POSACONAZOLE TABLET ENTERIC COATED NOXAFIL PA Required

VORICONAZOLE SUSPENSION VFEND PA Required

VORICONAZOLE TABLETS VFEND PA Required

ANTIHISTAMINES

ANTIHISTAMINES - ALKYLAMINES

BROMPHENIRAMINE MALEATE J-TAN PD

CARBINOXAMINE - PSEUDOEPHEDRINE SYRUP CYDEC

CHLORPHENIRAMINE MALEATE SYRUP CHLORPHENIRAMINE MALEATE

CHLORPHENIRAMINE MALEAT TABLET CHLORPHENIRAMINE

DEXCHLORPHENIRAMINE MALEATE SYRUP

DEXCHLORPHENIRAMINE

MALEATE

ANTIHISTAMINES - ETHANOLAMINES

CLEMASTINE FUMARATE SYRUP CLEMASTINE FUMARATE

CLEMASTINE FUMARATE TABLETS CLEMASTINE FUMARATE

DIMENHYDRINATE CHEW TABLET DRAMAMINE

DIMENHYDRINATE TABLET DRAMAMINE

DIPHENHYDRAMINE HCL CAPSULES VARIOUS

DIPHENHYDRAMINE HCL CHEWABLE TABLETS VARIOUS

Page 17 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




DIPHENHYDRAMINE HCL ELIXIR VARIOUS

DIPHENHYDRAMINE HCL LIQUID VARIOUS

DIPHENHYDRAMINE HCL SOLUTION VARIOUS

DIPHENHYDRAMINE HCL SUSPENSION VARIOUS

DIPHENHYDRAMINE HCL SYRUP VARIOUS

DIPHENHYDRAMINE HCL TABLETS VARIOUS

MECLIZINE HCL CHEWABLE TABLETS BONINE

MECLIZINE HCL TABLETS BONINE

ANTIHISTAMINES - NON-SEDATING

CETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30 30

CETIRIZINE HCL CHEWABLE TABLETS VARIOUS 30 30

CETIRIZINE HCL SYRUP VARIOUS 150ML 30

CETIRIZINE HCL TABLETS VARIOUS 30 30

CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS ZYRTEC ALLERGY 30 30

FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS 150ML 30

FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS 30 30

FEXOFENADINE HCL ORALLY DISINTEGRATING TABLETS ALLEGRA ALLERGY CHILDRENS 30 30

LORATADINE CAPSULES CLARITIN 30 30

LORATADINE CHEWABLE TABLETS CLARITIN 30 30

LORATADINE SYRUP CLARITIN 150ML 30

LORATADINE TABLETS ALAVERT 30 30

LORATADINE ORALLY DISINTEGRATING TABLETS CLARITIN REDITABS 30 30

ANTIHISTAMINES - PHENOTHIAZINES

PROMETHAZINE HCL SUPPOSITORY PHENERGAN

PROMETHAZINE HCl SYRUP PHENERGAN

PROMETHAZINE HCL TABLETS PROMETHAZINE HCL

ANTIHISTAMINES - PIPERIDINES

CYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCL

CYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCL

ANTIHYPERLIPIDEMICS

BILE ACID SEQUESTRANTS

CHOLESTYRAMINE LIGHT PACKETS PREVALITE

CHOLESTYRAMINE LIGHT POWDER PREVALITE

CHOLESTYRAMINE PACKETS QUESTRAN

CHOLESTYRAMINE POWDER QUESTRAN

COLESTIPOL HCL GRANULES COLESTID

COLESTIPOL HCL PACKETS COLESTID

COLESTIPOL HCL TABLETS COLESTID

Page 18 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




FIBRIC ACID DERIVATIVES

FENOFIBRATE CAPSULES LIPOFEN

FENOFIBRATE MICRONIZED CAPSULES ANTARA

FENOFIBRATE TABLETS FENOGLIDE

FENOFIBRIC ACID TABLETS FIBRICOR

GEMFIBROZIL TABLETS LOPID

HMG COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM TABLETS LIPITOR 30 30

LOVASTATIN TABLETS MEVACOR 30 30

PRAVASTATIN SODIUM TABLETS PRAVACOL 30 30

SIMVASTATIN TABLETS ZOCOR 30 30

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBE TABLETS ZETIA PA Required

NICOTINIC ACID DERIVATIVES

NIACIN (ANTIHYPERLIPIDEMIC) TABLETS NIACOR

NIACIN (ANTIHYPERLIPIDEMIC) CAPSULE CONTROLLED RELEASE NIASPAN

ANTIHYPERTENSIVES

ACE INHIBITORS

BENAZEPRIL HCL TABLETS BENAZEPRIL HCL

CAPTOPRIL TABLETS CAPTOPRIL

ENALAPRIL MALEATE SOLUTION EPANED

ENALAPRIL MALEATE TABLETS VASOTEC

FOSINOPRIL SODIUM TABLETS FOSINOPRIL SODIUM

LISINOPRIL TABLETS ZESTRIL

MOEXIPRIL HCL TABLETS UNIVASC

PERINDOPRIL ERBUMINE TABLETS ACEON

QUINAPRIL HCL TABLETS ACCUPRIL

RAMIPRIL CAPSULES ALTACE

TRANDOLAPRIL TABLETS MAVIK

ANGIOTENSIN II RECEPTOR ANTAGONISTS

IRBESARTAN TABLETS AVAPRO

LOSARTAN POTASSIUM TABLETS COZAAR

OLMESARTAN MEDOXOMIL TABLETS

VALSARTAN TABLETS DIOVAN Step Therapy

Member must have tried

losartan & irbesartan

ANTIADRENERGIC ANTIHYPERTENSIVES

CLONIDINE HCL PATCH-WEEKLY CATAPRES-TTS-1

CLONIDINE HCL TABLETS CATAPRES

Page 19 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




DOXAZOSIN MESYLATE TABLETS CARDURA

GUANFACINE HCL TABLETS TENEX

METHYLDOPA TABLETS METHYLDOPA

PRAZOSIN HCL CAPSULES MINIPRESS

TERAZOSIN HCL CAPSULES TERAZOSIN HCL

ANTIHYPERTENSIVE COMBINATIONS

AMLODIPINE BESYLATE-BENAZEPRIL HCL CAPSULES LOTREL

ATENOLOL & CHLORTHALIDONE TABLETS TENORETIC 50

BENAZEPRIL & HYDROCHLOROTHIAZIDE TABLETS

BENAZEPRIL

HCL/HYDROCHLOROTHIAZIDE

BISOPROLOL FUMARATE - HYDROCHLOROTHIAZIDE TABLETS ZIAC

CAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETS

CAPTOPRIL/

HYDROCHLOROTHIAZIDE

ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETS

ENALAPRIL MALEATE/

HYDROCHLOROTHIAZIDE

FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETS

FOSINOPRIL SODIUM/

HYDROCHLOROTHIAZIDE

IRBESARTAN-HYDROCHLOROTHIAZIDE TABLETS AVALIDE

LISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETIC

LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS HYZAAR

METOPROLOL - HYDROCHLOROTHIAZIDE TABLETS LOPRESSOR HCT

MOEXIPRIL - HYDROCHLOROTHIAZIDE TABLETS UNIRETIC

OLMESARTAN MEDOXOMIL - HYDROCHLOROTHIAZIDE TABLETS BENICAR HCT Step Therapy


Losartan Potassium/HCTZ

& Irbesartan/HCTZ

ORIORANOLOL - HYDROCHLOROTHIAZIDE TABLETS INDERIDE

QUINAPRIL - HYDROCHLOROTHIAZIDE TABLETS ACCURETIC

VALSARTAN - HYDROCHLOROTHIAZIDE TABLETS DIOVAN HCT

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

EPLERENONE TABLETS INSPRA PA Required

VASODILATORS

HYDRALAZINE HCL TABLETS HYDRALAZINE HCL

MIDODRINE HCL TABLETS MIDODRINE

MINOXIDIL TABLETS MINOXIDIL

ANTI-INFECTIVE AGENTS - MISC.

Page 20 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




ANTI-INFECTIVE AGENTS - MISC.

VANCOMYCIN HCL CAPSULES VANCOCIN HCL

VANCOMYCIN HCL SOLUTION FIRST-VANCOMYCIN 25ANTI-INFECTIVE MISC. - COMBINATIONSERYTHROMYCIN-SULFISOXAZOLE SUSPENSION E.S.P.

SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION SULFATRIM PEDIATRIC

SULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS BACTRIM

LEPROSTATICS

DAPSONE GEL DAPSONE

DAPSONE TABLETS DAPSONE

OXAZOLIDINONES

LINEZOLID SUSPENSION ZYVOX PA Required

LINEZOLID TABLETS ZYVOX PA Required

ANTIMALARIALS

ANTIMALARIAL COMBINATIONS

ARTEMETHER-LUMEFANTRINE TABLETS COARTEM

ATOVAQUONE-PROGUANIL HCL TABLETS MALARONE

ANTIMALARIALS

CHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATE

HYDROXYCHLOROQUINE SULFATE TABLETS PLAQUENIL

PRIMAQUINE PHOSPHATE TABLETS PRIMAQUINE PHOSPHATE

QUININE SULFATE CAPSULES QUALAQUIN

ANTIMYCOBACTERIAL AGENTS

ETHAMBUTOL HCL TABLETS MYAMBUTOL

ISONIAZID SYRUP ISONIAZID

ISONIAZID TABLETS ISONIAZID

ISONIAZID-RIFAMPIN-PYRAZINAMIDE TABLETS RIFATER

PYRAZINAMIDE TABLETS PYRAZINAMIDE

RIFABUTIN CAPSULE MYCOBUTIN

RIFAMPIN CAPSULES RIFADIN

ANTIMETABOLITES

MERCAPTOPURINE SUSPENSION PURIXAN

MERCAPTOPURINE TABLETS PURINETHOL

METHOTREXATE SODIUM TABLETS METHOTREXATE

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS

ANASTROZOLE TABLETS ARIMIDEX PA Required

EXEMESTANE TABLETS AROMASIN PA Required

FLUTAMIDE CAPSULES FLUTAMIDE

Page 21 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




LEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA Required

LEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA Required

LEUPROLIDE ACETATE KIT LUPRON DEPOT PA Required

TAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATE

TOREMIFENE CITRATE TABLETS FARESTON PA Required

ANTINEOPLASTIC ENZYME INHIBITORS

AXITINIB TABLETS INLYTA PA Required

CRIZOTINIB CAPSULES XALKORI PA Required

DASATINIB TABLETS SPRYCEL PA Required

ERLOTINIB HCL TABLETS TARCEVA PA Required

EVEROLIMUS TABLETS AFINITOR PA Required

EVEROLIMUS SOLUBLE TABLET AFINITOR DISPERZ PA Required

GEFITINIB TABLETS IRESSA PA Required

IBRUTINIB CAPSULES IMBRUVICA PA Required

IMATINIB MESYLATE TABLETS GLEEVEC PA Required

LAPATINIB DITOSYLATE TABLETS TYKERB PA Required

NILOTINIB HCL CAPSULES TASIGNA PA Required

PAZOPANIB HCL TABLETS VOTRIENT PA Required

PONATINIB HCL TABLETS ICLUSIG PA Required 60 30

RUXOLITINIB PHOSPHATE TABLETS JAKAFI PA Required

SORAFENIB TOSYLATE TABLETS NEXAVAR PA Required

SUNITINIB MALATE CAPSULES SUTENT PA Required

VANDETANIB TABLETS CAPRELSA PA Required

VEMURAFENIB TABLETS ZELBORAF PA Required

VORINOSTAT CAPSULES ZOLINZA PA Required

ANTINEOPLASTICS - MISC.

ALTRETAMINE CAPSULE HEXALEN

BELINOSTAT BELEODAQ PA Required

BEXAROTENE CAPSULES TARGRETIN PA Required

BICALUTAMIDE TABLET CASODEX

BUSULFAN TABLET MYLERAN

CHLORAMBUCIL TABLET LEUKERAN

ENZALUTAMIDE CAPSULE XTANDI PA Required 120 30

HYDROXYUREA CAPSULES HYDREA

IMIQUIMOD CREAM ALDARA

INTERFERON ALFA-2B SOLUTION INTRON A PA Required

INTERFERON ALFA-2B SOLUTION INTRON A PA Required

INTERFERON ALFA-N3 SOLUTION ALFERON N PA Required

Page 22 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




INTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA Required

IXAZOMIB NINLARO PA Required

LETROZOLE TABLET WELLCOVORIN

MEGESTROL ACETATE SUSPENSION MEGACE

MEGESTROL ACETATE TABLETS MEGACE

PEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA Required

PROCARBAZINE HCL CAPSULES MATULANE

THIOGUANINE TABLET TABLOID

TRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of Age

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS

LEUCOVORIN CALCIUM TABLETS LEUCOVORIN CALCIUM PA Required

ALECTINIB ALECENSA PA Required

COBIMETINIB COTELLIC PA Required

MITOTIC INHIBITORS

ETOPOSIDE CAPSULES ETOPOSIDE PA Required

ANTIPARKINSON AGENTS

ANTIPARKINSON ANTICHOLINERGICS

BENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATE

TRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCL

TRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCL

ANTIPARKINSON COMT INHIBITORS

ENTACAPONE TABLETS COMTAN

ANTIPARKINSON DOPAMINERGICS

AMANTADINE HCL CAPSULES AMANTADINE HCL

AMANTADINE HCL SYRUP AMANTADINE HCL

AMANTADINE HCL TABLETS AMANTADINE HCL

BROMOCRIPTINE MESYLATE CAPSULES PARLODEL

BROMOCRIPTINE MESYLATE TABLETS PARLODEL

CARBIDOPA-LEVODOPA ORALLY DISINTEGRATING TABLETS VARIOUS

CARBIDOPA-LEVODOPA TABLETS SINEMET

CARBIDOPA-LEVODOPA TABLETS CONTROLLED RELEASE SINEMET CR

CARBIDOPA TABLET CARBIDOPA

PRAMIPEXOLE DIHYDROCHLORIDE TABLETS MIRAPEX

PRAMIPEXOLE DIHYDROCHLORIDE TABLETS SR 24 HR MIRAPEX ER

ROPINIROLE HYDROCHLORIDE TABLETS REQUIP

ROPINIROLE HYDROCHLORIDE TABLETS SR 24 HR REQUIP XL

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

KINASE INHIBITORS

Page 23 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




SELEGILINE HCL CAPSULES ELDEPRYL

SELEGILINE HCL ORALLY DISINTEGRATING TABLET ELDEPRYL

SELEGILINE HCL TABLETS VARIOUS

SELEGILINE TD PATCH ENSAM PA Required

ANTIMANIC AGENTS

LITHIUM CARBONATE CAPSULES LITHIUM CARBONATE PA Required for ages < 6 years Written by BHMP Only

LITHIUM CARBONATE TABLETS LITHIUM CARBONATE PA Required for ages < 6 years Written by BHMP Only

LITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBID PA Required for ages < 6 years Written by BHMP Only

LITHIUM SOLUTION LITHIUM PA Required for ages < 6 years Written by BHMP OnlyANTIPSYCHOTICS - MISC.

ZIPRASIDONE HCL CAPSULES 20MG, 40MG, 60MG ZIPRASIDONE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 90 30

ZIPRASIDONE HCL CAPSULES 80MG ZIPRASIDONE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

LURASIDONE TABLETS LATUDA Preferred Drug PA Required for ages < 6 years Written by BHMP Only 30 30

BENZISOXAZOLES

PALIPERIDONE LA INJECTION INVEGA SUSTENNA Preferred Drug PA Required for ages < 18 years Written by BHMP Only 1 30

PALIPERIDONE PALMITATE INJECTION INVEGA TRINZA Preferred Drug PA Required for ages < 18 years Written by BHMP Only 1 90

RISPERIDONE SOLUTION RISPERIDONE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60ML 30

RISPERIDONE TABLETS 0.25MG, 0.5MG RISPERIDONE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 120 30

RISPERIDONE TABLETS 1MG, 2MG RISPERIDONE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 90 30

RISPERIDONE TABLETS 3MG, 4MG RISPERIDONE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

RISPERIDONE MICROSPHERES INJECTION RISPERDAL CONSTA Preferred Drug PA Required for ages < 6 years Written by BHMP Only 2 28

RISPERIDONE ORALLY DISINTEGRATING TABLETS 0.25 MG, 0.5MG RISPERIDONE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 120 30

RISPERIDONE ORALLY DISINTEGRATING TABLETS 1MG, 2MG RISPERIDONE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 90 30

RISPERIDONE ORALLY DISINTEGRATING TABLETS 3MG, 4MG RISPERIDONE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

BUTYROPHENONES

HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE 50 PA Required for ages < 6 years Written by BHMP Only

HALOPERIDOL LACTATE CONCENTRATE HALOPERIDOL PA Required for ages < 6 years Written by BHMP Only

HALOPERIDOL TABLETS HALOPERIDOL PA Required for ages < 6 years Written by BHMP OnlyDIBENZAPINES

CLOZAPINE TABLETS CLOZAPINE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 270 30

CLOZAPINE ORALLY DISINTEGRATING TABLETS CLOZAPINE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 270 30

LOXAPINE SUCCINATE CAPSULES LOXITANE PA Required for ages < 6 years Written by BHMP Only

OLANZAPINE TABLETS 2.5MG, 5MG OLANZAPINE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 120 30

OLANZAPINE TABLETS 7.5MG, 10MG OLANZAPINE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

OLANZAPINE TABLETS 15MG, 20MG OLANZAPINE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 30 30

BENZISOTHIAZOLES

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Page 24 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




OLANZAPINE ORALLY DISINTEGRATING TABLETS 5MG OLANZAPINE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 120 30

OLANZAPINE ORALLY DISINTEGRATING TABLETS 10MG OLANZAPINE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

OLANZAPINE ORALLY DISINTEGRATING TABLETS 15MG, 20MG OLANZAPINE ODT Preferred Drug PA Required for ages < 6 years Written by BHMP Only 30 30

QUETIAPINE FUMARATE TABLETS 25MG, 50MG, 100MG, 150MG, 200MG QUETIAPINE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 120 30

QUETIAPINE FUMARATE TABLETS 300MG, 400MG QUETIAPINE Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

LOXAPINE SUCCINATE CAPSULES LOXITANE PA Required for ages < 6 years Written by BHMP Only

ASENAPINE MALEATE TABLETS SUBLINGUAL SAPHRIS Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

PIMOZIDE ORAP PA Required for ages < 6 years Written by BHMP OnlyPHENOTHIAZINES

CHLORPROMAZINE HCL SOLUTION CHLORPROMAZINE HCL PA Required for ages < 6 years

CHLORPROMAZINE HCL TABLETS CHLORPROMAZINE HCL PA Required for ages < 6 years

FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE PA Required for ages < 6 years Written by BHMP Only

FLUPHENAZINE HCL CONCENTRATE FLUPHENAZINE HCL PA Required for ages < 6 years Written by BHMP Only

FLUPHENAZINE HCL ELIXIR FLUPHENAZINE HCL PA Required for ages < 6 years Written by BHMP Only

FLUPHENAZINE HCL TABLETS FLUPHENAZINE HCL PA Required for ages < 6 years Written by BHMP Only

PERPHENAZINE TABLETS PERPHENAZINE PA Required for ages < 6 years Written by BHMP Only

PROCHLORPERAZINE MALEATE TABLETS COMPAZINE PA Required for ages < 6 years Written by BHMP Only

PROCHLORPERAZINE SUPPOSITORY COMPAZINE PA Required for ages < 6 years Written by BHMP Only

THIORIDAZINE HCL TABLETS THIORIDAZINE HCL PA Required for ages < 6 years Written by BHMP Only

TRIFLUOPERAZINE HCL TABLETS TRIFLUOPERAZINE HCL PA Required for ages < 6 years Written by BHMP OnlyQUINOLINONE DERIVATIVES

ARIPIPRAZOLE LA INJECTION ABILIFY MAINTENA BRAND Preferred Drug PA Required for ages < 18 years Written by BHMP Only 1 30

ARIPIPRAZOLE LAUROXIL ARISTADA BRAND Preferred Drug PA Required for ages < 18 years Written by BHMP Only 1 30

ARIPIPRAZOLE TABLETS 2MG, 5MG, 10MG, 15MG ABILIFY BRAND Preferred Drug PA Required for ages < 6 years Written by BHMP Only 60 30

ARIPIPRAZOLE TABLETS 20MG ABILIFY BRAND Preferred Drug PA Required for ages < 6 years Written by BHMP Only 45 30

ARIPIPRAZOLE TABLETS 30MG ABILIFY BRAND Preferred Drug PA Required for ages < 6 years Written by BHMP Only 30 30

THIOXANTHENES

THIOTHIXENE CAPSULES THIOTHIXENE PA Required for ages < 6 years Written by BHMP Only

THIOTHIXENE HCL CONCENTRATED SOLUTION NAVANE PA Required for ages < 6 years Written by BHMP OnlyANTIVIRALS

ANTIRETROVIRALS

ABACAVIR SULFATE SOLUTION ZIAGEN

ABACAVIR SULFATE TABLETS ZIAGEN

ABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOM

DIPHENYL-BUTYLPIPERIDINES

DIBENZOXAPINES

DIBENZOOXEPINO PYRROLES

Page 25 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIR

ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQ

ATAZANAVIR SULFATE CAPSULES REYATAZ

ATAZANAVIR SULFATE PACKETS REYATAZ

ATAZANAVIR SULFATE-COBICISTAT TABLETS EVOTAZ

COBICISTAT TABLETS TYBOST PA Required 30 30

DARUNAVIR ETHANOLATE SUSPENSION PREZISTA

DARUNAVIR ETHANOLATE TABLETS PREZISTA

DARUNAVIR-COBICISTAT TABLETS PREZCOBIX

DELAVIRDINE MESYLATE TABLETS RESCRIPTOR

DIDANOSINE CAPSULE DELAYED RELEASE VIDEX EC

DIDANOSINE SOLUTION VIDEX PEDIATRIC

DOLUTEGRAVIR TIVICAY PA Required

EFAVIRENZ CAPSULES SUSTIVA

EFAVIRENZ TABLETS SUSTIVA

EFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLA

ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILD PA Required

EMTRICITABINE CAPSULES EMTRIVA

EMTRICITABINE SOLUTION EMTRIVA

EMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS COMPLERA

EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADA PA Required

ENFUVIRTIDE SOLUTION FUZEON PA Required 1 30

ETRAVIRINE TABLETS INTELENCE

FOSAMPRENAVIR CALCIUM SUSPENSION LEXIVA

FOSAMPRENAVIR CALCIUM TABLETS LEXIVA

INDINAVIR SULFATE CAPSULES CRIXIVAN

LAMIVUDINE SOLUTION EPIVIR

LAMIVUDINE TABLETS EPIVIR

LAMIVUDINE-ZIDOVUDINE TABLETS COMBIVIR

LOPINAVIR-RITONAVIR SOLUTION KALETRA

LOPINAVIR-RITONAVIR TABLETS KALETRA

MARAVIROC TABLETS SELZENTRY PA Required

NELFINAVIR MESYLATE TABLETS VIRACEPT

NEVIRAPINE SUSPENSION VIRAMUNE

NEVIRAPINE TABLETS VIRAMUNE

NEVIRAPINE TABLET 24-HOUR VIRAMUNE XR

RALTEGRAVIR POTASSIUM CHEWABLE TABLETS ISENTRESS

RALTEGRAVIR POTASSIUM PACKETS ISENTRESS

Page 26 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




RALTEGRAVIR POTASSIUM TABLETS ISENTRESS

RILPIVIRINE HCL TABLETS EDURANT

RITONAVIR CAPSULES NORVIR

RITONAVIR SOLUTION NORVIR

RITONAVIR TABLETS NORVIR

SAQUINAVIR MESYLATE CAPSULES INVIRASE

SAQUINAVIR MESYLATE TABLETS INVIRASE

STAVUDINE CAPSULES ZERIT

STAVUDINE SOLUTION ZERIT

TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER VIREAD

TENOFOVIR DISOPROXIL FUMARATE TABLETS VIREAD

TIPRANAVIR CAPSULES APTIVUS

TIPRANAVIR SOLUTION APTIVUS

ZIDOVUDINE CAPSULES RETROVIR

ZIDOVUDINE SYRUP RETROVIR

ZIDOVUDINE TABLETS ZIDOVUDINE

CMV AGENTS

CIDOFOVIR IV VISTIDE PA Required

FOSCARNET SODIUM FOSCAVIR PA Required

GANCICLOVIR SODIUM CYTOVENE PA Required

VALGANCICLOVIR HCL SOLUTION VALCYTE PA Required

VALGANCICLOVIR HCL TABLETS VALCYTE PA Required

HEPATITIS B AGENTS

ADEFOVIR DIPIVOXIL TABLETS HEPSERA PA Required

ENTECAVIR SOLUTION BARACLUDE PA Required

ENTECAVIR TABLETS BARACLUDE PA Required

TELBIVUDINE TABLETS TYZEKA PA Required

HEPATITIS C AGENTS

ELBASVIR/GRAZOPREVIR TABLET ZEPATIER Preferred Drug PA Required

LEDIPASVIR-SOFOSBUVIR TABLETS HARVONI Preferred Drug PA Required

OMBITASVIR/PARITAPREVIR/RITONAVIR TECHNIVIE Preferred Drug PA Required

OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABUVIR TABLETS VIEKIRA Preferred Drug PA Required

OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABUVIR VIEKIRA PAK PA Required

PEGINTERFERON ALFA-2A SOLUTION PEGASYS PROCLICK Preferred Drug PA Required

PEGINTERFERON ALFA-2A SOLUTION PEGASYS SYRINGE Preferred Drug PA Required

PEGINTERFERON ALFA-2A SOLUTION PEGASYS VIAL Preferred Drug PA Required

PEGINTERFERON ALFA-2B KIT PEGINTRON Preferred Drug PA Required

RIBAVIRIN CAPSULES VARIOUS Preferred Drug PA Required

Page 27 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




RIBAVIRIN SOLUTION REBATROL PA Required

RIBAVIRIN TABLETS VARIOUS Preferred Drug PA Required

SOFOSBUVIR/VELPATASVIR TABLET EPCLUSA Preferred Drug PA Required

HERPES AGENTS

ACYCLOVIR BUCCAL TABLET ZOVIRAX

ACYCLOVIR CAPSULES ZOVIRAX

ACYCLOVIR CREAM ZOVIRAX

ACYCLOVIR SUSPENSION ZOVIRAX

ACYCLOVIR TABLETS ZOVIRAX

FAMCICLOVIR TABLETS FAMVIR PA Required

VALACYCLOVIR HCL TABLETS VALTREX PA Required

INFLUENZA AGENTS

OSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20 270

OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLU

RIMANTADINE HYDROCHLORIDE TABLETS FLUMADINE

ZANAMIVIR AEROSOL POWDER BREATH ACTIVATED RELENZA DISKHALER 40 270

ASSORTED CLASSES

CHELATING AGENTS

PENICILLAMINE CAPSULES CUPRIMINE

IMMUNOMODULATORS

LENALIDOMIDE CAPSULES REVLIMID PA Required

POMALIDOMIDE CAPSULES POMALYST PA Required 21 28

THALIDOMIDE CAPSULES THALOMID PA Required

IMMUNOSUPPRESSIVE AGENTS

AZATHIOPRINE TABLETS IMURAN

CYCLOSPORINE CAPSULES SANDIMMUNE

CYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAF

CYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAF

CYCLOSPORINE SOLUTION SANDIMMUNE

EVEROLIMUS (IMMUNOSUPPOSITORYRESSANT) TABLETS ZORTRESS PA Required

MYCOPHENOLATE MOFETIL CAPSULES CELLCEPT

MYCOPHENOLATE MOFETIL SUSPENSION CELLCEPT

MYCOPHENOLATE MOFETIL TABLETS CELLCEPT

MYCOPHENOLATE SODIUM TABLET DELAYED RELEASE MYFORTIC

SIROLIMUS SOLUTION RAPAMUNE

SIROLIMUS TABLETS RAPAMUNE

TACROLIMUS CAPSULES HECORIA

TACROLIMUS CAPSULE CONTROLLED RELEASE ASTAGRAF XL

Page 28 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




POTASSIUM REMOVING RESINS

SODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATE

SODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEX

CALCIPOTRIENE CREAM DOVONEX

CALCIPOTRIENE FOAM DOVONEX

CALCIPOTRIENE OINTMENT DOVONEX

CALCIPOTRIENE SOLUTION DOVONEX

BETHANEHOL CHLORIDE TABLETS URECHOLINE

BETA BLOCKERS

ALPHA-BETA BLOCKERS

ACEBUTOLOL HCL CAPSULES SECTRAL

BETAXOLOL HCL TABLETS KERLONE

BISOPROLOL FUMARATE TABLETS ZEBETA

CARVEDILOL TABLETS COREG

LABETALOL HCL TABLETS TRANDATE

BETA BLOCKERS CARDIO-SELECTIVE

ATENOLOL TABLETS TENORMIN

METOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XL

METOPROLOL TARTRATE TABLETS METOPROLOL TARTRATE

BETA BLOCKERS NON-SELECTIVE

NADOLOL TABLETS CORGARD

PINDOLOL TABLETS PINDOLOL

PROPRANOLOL HCL CAPSULE CONTROLLED RELEASE INDERAL LA

PROPRANOLOL HCL SOLUTION PROPRANOLOL HCL

PROPRANOLOL HCL TABLETS INDERAL

SOTALOL HCL SOLUTION SOTYLIZE

SOTALOL HCL TABLETS BETAPACE

CALCIUM CHANNEL BLOCKERS

CALCIUM CHANNEL BLOCKERS

AMLODIPINE BESYLATE TABLETS NORVASC 30 30

DILTIAZEM HCL COATED BEADS CAPSULE CONTROLLED RELEASE CARDIZEM CD 30 30

DILTIAZEM HCL COATED BEADS TABLET 24-HOUR CARDIZEM LA 30 30

DILTIAZEM HCL CAPSULE 12-HOUR DILTIAZEM HCL ER 60 30

DILTIAZEM HCL CAPSULE CONTROLLED RELEASE DILTIAZEM HCL ER

DILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULE CONTROLLED RELEASE TAZTIA XT 30 30

DILTIAZEM HCL TABLETS CARDIZEM

AUTOIMMUNE DISORDERS

AUTONOMIC AGENTS

Page 29 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




FELODIPINE TABLET 24-HOUR FELODIPINE ER

ISRADIPINE CAPSULES ISRADIPINE

NICARDIPINE HCL CAPSULES NICARDIPINE HCL

NICARDIPINE HCL CAPSULE 12-HOUR CARDENE SR

NIFEDIPINE CAPSULES PROCARDIA

NIFEDIPINE TABLET 24-HOUR ADALAT CC 60 30

NIMODIPINE CAPSULES NIMODIPINE

NIMODIPINE SOLUTION NYMALIZE

NISOLDIPINE TABLET 24-HOUR SULAR

VERAPAMIL HCL CAPSULE CONTROLLED RELEASE VERELAN PM

VERAPAMIL HCL TABLETS VERAPAMIL HCL

VERAPAMIL HCL TABLET CONTROLLED RELEASE CALAN SR

CARDIOTONICS

CARDIAC GLYCOSIDES

DIGOXIN SOLUTION DIGOXIN

DIGOXIN TABLETS LANOXIN

CARDIOVASCULAR AGENTS - MISC.

PROSTAGLANDIN VASODILATORS

EPOPROSTENOL SODIUM SOLUTION FLOLAN PA Required

ILOPROST SOLUTION VENTAVIS PA Required

TREPROSTINIL SODIUM SOLUTION REMODULIN PA Required

TREPROSTINIL SOLUTION TYVASO PA Required

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

AMBRISENTAN TABLETS LETAIRIS PA Required

BOSENTAN TABLETS TRACLEER PA Required

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

SILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO PA Required

SILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS REVATIO PA Required

TADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA PA Required

CEPHALOSPORINS

CEPHALOSPORINS - 1ST GENERATION

CEFADROXIL CAPSULES CEFADROXIL

CEFADROXIL SUSPENSION CEFADROXIL

CEFADROXIL TABLETS CEFADROXIL

CEPHALEXIN CAPSULES KEFLEX

CEPHALEXIN SUSPENSION CEPHALEXIN

CEPHALEXIN TABLETS CEPHALEXIN

CEPHALOSPORINS - 2ND GENERATION

Page 30 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CEFACLOR CAPSULES CEFACLOR

CEFACLOR SUSPENSION CEFACLOR

CEFACLOR MONOHYDRATE TABLET SR 12 HR CECLOR

CEFPROZIL SUSPENSION CEFPROZIL

CEFPROZIL TABLETS CEFPROZIL

CEFUROXIME AXETIL SUSPENSION CEFTIN

CEFUROXIME AXETIL TABLETS CEFTIN

CEPHALOSPORINS - 3RD GENERATION

CEFDINIR CAPSULES CEFDINIR

CEFDINIR SUSPENSION CEFDINIR

CEFIXIME CAPSULES SUPRAX 1 30

CEFIXIME CHEWABLE TABLETS SUPRAX 1 30

CEFIXIME SUSPENSION SUPRAX 1 30

CEFIXIME TABLETS SUPRAX 1 30

CEFPODOXIME PROXETIL SUSPENSION CEFPODOXIME PROXETIL

CEFPODOXIME PROXETIL TABLETS CEFPODOXIME PROXETIL

CONTRACEPTIVES

COMBINATION CONTRACEPTIVES - ORAL

DESOGESTREL & ETHINYL ESTRADIOL TABLETS APRI

DESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS AZURETTE

DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS CAZIANT

DROSPIRENONE-ETHINYL ESTRADIOL TABLETS OCELLA

ETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS KELNOR 1/35

LEVONORGESTREL & ETHINYL ESTRADIOL TABLETS AUBRA

LEVONORGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ENPRESSE-28

LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS AMETHIA LO

NORETHINDRONE & ETHINYL ESTRADIOL TABLETS BALZIVA

NORETHINDRONE & MESTRANOL TABLETS NECON 1/50-28

NORETHINDRONE ACETATE & ETHINYL ESTRADIOL TABLETS GILDESS 1/20

NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS ESTROSTEP FE

NORETHINDRONE-ETHINYL ESTRADIOL (BIPHASIC) TABLETS NECON 10/11-28

NORETHINDRONE-ETHINYL ESTRADIO+A894L (TRIPHASIC) TABLETS CYCLAFEM 7/7/7

NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ORTHO TRI-CYCLEN

NORGESTIMATE-ETHINYL ESTRADIOL TABLETS ESTARYLLA

NORGESTREL & ETHINYL ESTRADIOL TABLETS CRYSELLE-28

COMBINATION CONTRACEPTIVES - VAGINAL

ETONOGESTREL-ETHINYL ESTRADIOL RING NUVARING

EMERGENCY CONTRACEPTIVES

Page 31 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




LEVONORGESTREL TABLETS PLAN B

PROGESTIN CONTRACEPTIVES - INJECTABLE

MEDROXYPROGESTERONE ACETATE SUSPENSION

DEPO-PROVERA

CONTRACEPTIVE

PROGESTIN CONTRACEPTIVES - ORAL

NORETHINDRONE TABLETS CAMILA

CORTICOSTEROIDS

GLUCOCORTICOSTEROIDS

DEXAMETHASONE CONCENTRATE DEXAMETHASONE INTENSOL

DEXAMETHASONE ELIXIR VARIOUS

DEXAMETHASONE SOLUTION DEXAMETHASONE

DEXAMETHASONE TABLETS DEXAMETHASONE

HYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE) A-HYDROCORT Long Term Care Only

HYDROCORTISONE TABLETS HYDROCORTISONE

METHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE) DEPO-MEDROL Long Term Care Only

METHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE) A-METHAPRED Long Term Care Only

METHYLPREDNISOLONE TABLETS MEDROL

PREDNISOLONE SODIUM PHOSPHATE SOLUTION ORAPRED

PREDNISOLONE SODIUM PHOSPHATE ORALLY DISINTEGRATING TABLETS ORAPRED ODT

PREDNISOLONE SYRUP PRELONE

PREDNISOLONE TABLETS VARIOUS

PREDNISONE CONCENTRATE PREDNISONE INTENSOL

PREDNISONE SOLUTION PREDNISONE

PREDNISONE TABLETS PREDNISONE

TRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE) KENALOG-10 Long Term Care Only

TRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE) TRIAMCINOLONE Long Term Care Only

TRIAMCINOLONE HEXACETONIDE SUSPENSION (INJECTABLE)

ARISTOSPAN INTRALESIONAL &

INTRA-ARTICULAR Long Term Care Only

MINERALOCORTICOIDS

FLUDROCORTISONE ACETATE TABLETS FLORINEF

COUGH/COLD/ALLERGY

ANTITUSSIVES

BENZONATATE CAPSULES TESSALON PERLES

HYDROCODONE W/ HOMATROPINE SYRUP VARIOUS 240ML 12

HYDROCODONE W/ HOMATROPINE TABLETS VARIOUS

COUGH/COLD/ALLERGY COMBINATIONS

BROMPHENIRAMINE & PSEUDOEPHEDRINE CAPSULE VARIOUS

BROMPHENIRAMINE & PSEUDOEPHEDRINE CAPSULE CONTROLLED RELEASE VARIOUS

Page 32 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




BROMPHENIRAMINE & PSEUDOEPHEDRINE ELIXIR VARIOUS

BROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID VARIOUS

BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP VARIOUS 480ML 30

BROMPHENIRAMINE &PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS

BROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE LIQUID/TABLETS VARIOUS

CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30

CHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS VARIOUS

CHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID VARIOUS 480ML 30

CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION VARIOUS 480ML 30

CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP VARIOUS 480ML 30

CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS VARIOUS

DEXTROMETHORPHAN HBR CAPSULE ROBITUSSIN

DEXTROMETHORPHAN HBR SYRUP ROBITUSSIN

DEXTROMETHORPHAN-GUAIFENESIN TABLET VARIOUS

DEXTROMETHORPHAN-GUAIFENESIN LIQUID VARIOUS 480ML 30

DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480ML 30

DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DM

DEXTROMETHORPHAN POLISTIREX LIQUID DELSYM

FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30

FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS 30 30

GUAIFENESIN-CODEINE SYRUP ROBITUSSIN AC 240ML 12

LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30 30

LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30 30

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN LIQUID

ROBITUSSIN CHILDRENS COUGH

& COLD CF 480ML 30

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480ML 30

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLETS VARIOUS

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR VARIOUS

PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN ELIXIR VARIOUS 480ML 30

PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN LIQUID

DIMETAPP

DEXTROMETHORPHAN COLD &

COUGH 480ML 30

PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480ML 30

PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID VARIOUS 480ML 30

PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS VARIOUS PA Required for < 6 years old

PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480ML 30

PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS VARIOUS

Page 33 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE-GUAIFENESIN LIQUID

TRIAMINIC CHEST/ NASAL

CONGESTION 480ML 30

PHENYLEPHRINE-GUAIFENESIN SYRUP

TRIAMINIC CHEST & NASAL

CONGESTION 480ML 30

PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUS

PROMETHAZINE & PHENYLEPHRINE SYRUP

PROMETHAZINE/

PHENYLEPHRINE 480ML 30

PROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE 240ML 12

PROMETHAZINE-DEXTROMETHORPHAN SYRUP

PROMETHAZINE/

DEXTROMETHORPHAN 480ML 30

PSEUDOEPHED-BROMPHEN-DM ELIXIR VARIOUS 480ML 30

PSEUDOEPHED-BROMPHEN-DM SYRUP VARIOUS 480ML 30

PSEUDOEPHEDRINE W/ DM-GG LIQUID VARIOUS

PSEUDOEPHEDRINE W/ CODEINE-GUAIFENESIN SYRUP VARIOUS 240ML 12

EXPECTORANTS

GUAIFENESIN LIQUID VARIOUS 480ML 30

GUAIFENESIN SYRUP VARIOUS 480ML 30

GUAIFENESIN TABLETS VARIOUS

GUAIFENESIN TABLET 12-HOUR VARIOUS

DERMATOLOGICALS

ACNE PRODUCTS

BENZOYL PEROXIDE BAR VARIOUS

BENZOYL PEROXIDE CREAM VARIOUS

BENZOYL PEROXIDE FOAM VARIOUS

BENZOYL PEROXIDE GEL VARIOUS

BENZOYL PEROXIDE LIQUID VARIOUS

BENZOYL PEROXIDE LOTION VARIOUS

CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE BENZACLIN

CLINDAMYCIN PHOSPHATE FOAM EVOCLIN

CLINDAMYCIN PHOSPHATE GEL CLEOCIN-T

CLINDAMYCIN PHOSPHATE LOTION CLEOCIN-T

CLINDAMYCIN PHOSPHATE SOLUTION CLEOCIN-T

ERYTHROMYCIN GEL ERYGEL

ERYTHROMYCIN SOLUTION ERYTHROMYCIN

ERYTHROMYCIN PADS 2% ERYTHROMYCIN

ISOTRETINOIN CAPSULES AMNESTEEM PA Required

SULFACETAMIDE SODIUM LIQUID OVACE WASH

Page 34 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




SULFACETAMIDE SODIUM LOTION KLARON

TRETINOIN CREAM RETIN-A PA Required FOR > 26 Years of Age

TRETINOIN GEL RETIN-A PA Required FOR > 26 Years of Age

ANTIBIOTICS / ANTI-INFECTIVES TOPICAL

BACITRACIN OINTMENT BACIGUENT

BACITRACIN ZINC OINTMENT BACITRACIN

BACITRACIN-POLYMYXIN B OINTMENT POLYSPORIN

BACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORIN

GENTAMICIN SULFATE CREAM GENTAMICIN SULFATE

GENTAMICIN SULFATE OINTMENT GENTAMICIN SULFATE

MUPIROCIN CALCIUM CREAM BACTROBAN

MUPIROCIN OINTMENT BACTROBAN

NEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT NEOSPORIN

UREA CREAM CARMOL-40

ZINC OXIDE CREAM DESITIN

ZINCE OXIDE OINTMENT DESITIN

ANTIFUNGALS - TOPICAL

CICLOPIROX OLAMINE CREAM LOPROX

CICLOPIROX SOLUTION PENLAC

CICLOPIROX SOLUTION - VITAMIN E CICLODAN KIT

CLOTRIMAZOLE CREAM LOTRIMIN

CLOTRIMAZOLE OINTMENT LOTRIMIN

CLOTRIMAZOLE SOLUTION VARIOUS

CLOTRIMAZOLE W/ BETAMETHASONE CREAM LOTRISONE

CLOTRIMAZOLE W/ BETAMETHASONE LOTION

CLOTRIMAZOLE/

BETAMETHASONE

DIPROPIONATE

KETOCONAZOLE CREAM VARIOUS

KETOCONAZOLE FOAM VARIOUS

KETOCONAZOLE GEL VARIOUS

KETOCONAZOLE SHAMPOO VARIOUS

MICONAZOLE NITRATE CREAM VARIOUS

MICONAZOLE NITRATE LIQUID VARIOUS

MICONAZOLE NITRATE POWDER VARIOUS

NYSTATIN CREAM VARIOUS

NYSTATIN OINTMENT VARIOUS

NYSTATIN POWDER NYAMYC

PODOFILOX SOLUTION CONDYLOX

Page 35 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




TERBINAFINE HCl CREAM LAMISIL AF

TOLNAFTATE CREAM TINACTIN

TOLNAFTATE SOLUTION TINACTIN

ANTIHISTAMINES-TOPICAL

DIPHENHYDRAMINE HCL CREAM

ANTI-ITCH MAXIMUM

STRENGTH

DIPHENHYDRAMINE HCL GEL BENADRYL ITCH STOPPING

DIPHENHYDRAMINE HCL SOLUTION

BENADRYL MAXIMUM

STRENGTH

ANTISEBORRHEIC TOPICAL PRODUCTS

SELENIUM SULFIDE LOTION SELSUN SHAMPOO

SELENIUM SULFIDE-PYRITHIONE ZINC IN UREA SHAMPOO SELSUM

ANTIVIRALS - TOPICAL

DOCOSANOL 10% CREAM ABREVA

GANCICLOVIR GEL ZIRGAN

PENCICLOVIR CREAM DENAVIR

BURN PRODUCTS

SILVER SULFADIAZINE CREAM SILVADENE

CORTICOSTEROIDS - TOPICAL

ALCLOMETASONE DIPROPIONATE CREAM ACLOVATE

ALCLOMETASONE DIPROPIONATE OINTMENT ACLOVATE

BETAMETHASONE DIPROPIONATE AUGMENTED CREAM DIPROLENE AF

BETAMETHASONE DIPROPIONATE AUGMENTED GEL DIPROLENE AF

BETAMETHASONE DIPROPIONATE AUGMENTED LOTION DIPROLENE

BETAMETHASONE DIPROPIONATE AUGMENTED OINTMENT DIPROLENE

BETAMETHASONE VALERATE CREAM VARIOUS

BETAMETHASONE VALERATE LOTION VARIOUS

BETAMETHASONE VALERATE OINTMENT VARIOUS

CLOBETASOL PROPIONATE CREAM VARIOUS

CLOBETASOL PROPIONATE EMULSION FOAM VARIOUS

CLOBETASOL PROPIONATE FOAM VARIOUS

CLOBETASOL PROPIONATE GEL VARIOUS

CLOBETASOL PROPIONATE LOTION VARIOUS

CLOBETASOL PROPIONATE OINTMENT VARIOUS

CLOBETASOL PROPIONATE SHAMPOO VARIOUS

CLOBETASOL PROPIONATE SOLUTION VARIOUS

DESONIDE CREAM DESOWEN

DESONIDE GEL DESONATE

Page 36 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




DESONIDE LOTION DESOWEN

DESONIDE OINTMENT DESOWEN

DICLOFENAC SODIUM GEL 1% DICLOFENAC GEL

DIFLORASONE DIACETATE EMOLLIENT BASE CREAM APEXICON E

DIFLORASONE DIACETATE OINTMENT PSORCON

FLUOCINOLONE ACETONIDE CREAM FLUOCINOLONE ACETONIDE

FLUOCINOLONE ACETONIDE OIL DERMA-SMOOTHE/FS BODY

FLUOCINOLONE ACETONIDE OINTMENT SYNALAR

FLUOCINOLONE ACETONIDE SHAMPOO CAPEX

FLUOCINOLONE ACETONIDE SOLUTION SYNALAR

FLUOCINONIDE CREAM VARIOUS

FLUOCINONIDE EMULSIFIED BASE CREAM VARIOUS

FLUOCINONIDE GEL VARIOUS

FLUOCINONIDE OINTMENT VARIOUS

FLUOCINONIDE SOLUTION VARIOUS

FLURANDRENOLIDE CREAM CORDRAN

FLURANDRENOLIDE LOTION CORDRAN

FLURANDRENOLIDE OINTMENT CORDRAN

FLURANDRENOLIDE TAPE CORDRAN TAPE

FLUTICASONE PROPIONATE CREAM VARIOUS

FLUTICASONE PROPIONATE LOTION VARIOUS

FLUTICASONE PROPIONATE OINTMENT VARIOUS

HYDROCORTISONE CREAM VARIOUS

HYDROCORTISONE LOTION VARIOUS

HYDROCORTISONE OINTMENT VARIOUS

HYDROCORTISONE SOLUTION VARIOUS

HYDROCORTISONE BUTYRATE CREAM VARIOUS

HYDROCORTISONE BUTYRATE LOTION VARIOUS

HYDROCORTISONE BUTYRATE OINTMENT VARIOUS

HYDROCORTISONE BUTYRATE SOLUTION VARIOUS

HYDROCORTISONE VALERATE CREAM VARIOUS

HYDROCORTISONE VALERATE OINTMENT VARIOUS

MOMETASONE FUROATE CREAM ELOCON

MOMETASONE FUROATE OINTMENT ELOCON

MOMETASONE FUROATE SOLUTION ELOCON

PRAMOXINE-HC FOAM EPIFOAM

TRIAMCINOLONE ACETONIDE (TOPICAL) AEROSOL VARIOUS

TRIAMCINOLONE ACETONIDE (TOPICAL) CREAM VARIOUS

Page 37 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




TRIAMCINOLONE ACETONIDE (TOPICAL) LOTION VARIOUS

TRIAMCINOLONE ACETONIDE (TOPICAL) OINTMENT VARIOUS

KERATOLYTIC/ANTIMITOTIC AGENTS

SALICYLIC ACID CREAM SALACYN

SALICYLIC ACID FOAM SALVAX

SALICYLIC ACID GEL KERALYT

SALICYLIC ACID LIQUID VIRASAL

SALICYLIC ACID LOTION SALACYN

SALICYLIC ACID SHAMPOO SALEX

SALICYLIC ACID SOLUTION VARIOUS

LOCAL ANESTHETICS - TOPICAL

CALAMINE LOTION CALAMINE

DIPHENHYDRAMINE HCl CREAM BENADRYL

LIDOCAINE HCL CREAM VARIOUS

LIDOCAINE HCL GEL XYLOCAINE

LIDOCAINE HCL LOCAL INJECTION XYLOCAINE PA Required (FOR ESRD ONLY)

LIDOCAINE HCl LOCAL INJECTION PRESERVATIVE FREE XYLOCAINE-MPF PA Required (FOR ESRD ONLY)

LIDOCAINE HCL SOLUTION VARIOUS

LIDOCAINE OINTMENT VARIOUS

LIDOCAINE PATCH LIDODERM

LIDOCAINE-PRILOCAINE CREAM EMLA

TOPICAL - MISC.

ALUMINUM CHLORIDE SOLUTION DRYSOL

HYDROGEN PEROXIDE SOLUTION HYDROGEN PEROXIDE

LACTIC ACID (AMMONIUM LACTATE) CREAM LAC-HYDRIN

LACTIC ACID (AMMONIUM LACTATE) LOTION LAC-HYDRIN

ROSACEA TOPICAL AGENTS

METRONIDAZOLE CREAM METROCREAM

METRONIDAZOLE GEL METROGEL

METRONIDAZOLE LOTION METROLOTION

SCABICIDES & PEDICULICIDES TOPICAl AGENTS+A1106

CROTAMITON CREAM EURAX

CROTAMITON LOTION EURAX

IVERMECTIN LOTION SKLICE PA Required

LINDANE LOTION KWELL

LINDANE SHAMPOO KWELL

NIT REMOVER - GEL LICEOUT

NIT REMOVER - SHAMPOO LICEOUT

Page 38 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PERMETHRIN CREAM ELIMITE

PERMETHRIN CRÈME RINSE NIX

PERMETHRIN SPRAY & PYRETHINS-PUPERONYL BUTOXIDE SHAMPOO KIT NIX

PYRETHRINS-PIPERONYL BUTOXIDE GEL A-200

PYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARC

PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDE

SPINOSAD SUSPENSION NATROBA PA Required

DIAGNOSTIC PRODUCTS

DIAGNOSTIC TESTS

ALBUMIN (URINE) TEST STRIPS ALBUMIN TEST STRIPS

BLOOD GLUCOSE CALIBRATION LIQUID (HIGH, LOW, NORMAL) VARIOUS

BLOOD GLUCOSE MONITORS & TEST STRIPS VARIOUS

INSULIN INFUSION PUMP SUPPLIES VARIOUS

INSULIN NEEDLES VARIOUS

INSULIN PEN NEEDLES VARIOUS

INSULIN SYRINGE VARIOUS

URINE GLUCOSE-KETONES TEST STRIPS VARIOUS

URINE GLUCOSE MONITORING KIT VARIOUS

DIGESTIVE AIDS

DIGESTIVE ENZYMES

PANCRELIPASE DR 5,000 UNIT CAPSULE PANCRELIPASE Preferred Drug

PANCRELIPASE (LIPASE-PROTEASE-AMYLASE) CAP DR ENTERIC COATED CREON BRAND Preferred Drug 500 30

PANCRELIPASE (LIPASE-PROTEASE-AMYLASE) CAP DR ENTERIC COATED ZENPEP DR BRAND Preferred Drug

DIURETICS

CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE CAPSULE 12-HOUR DIAMOX

ACETAZOLAMIDE TABLETS ACETAZOLAMIDE

METHAZOLAMIDE TABLETS NEPTAZANE

DIURETIC COMBINATIONS

AMILORIDE HCL - HYDROCHLOROTHIAZIDE TABLET MODURETIC

SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDE

TRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDE

TRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25

LOOP DIURETICS

BUMETANIDE TABLETS BUMETANIDE

FUROSEMIDE SOLUTION FUROSEMIDE

FUROSEMIDE TABLETS LASIX

TORSEMIDE TABLETS DEMADEX

Page 39 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




POTASSIUM SPARING DIURETICS

AMILORIDE HCL TABLET MIDAMOR

SPIRONOLACTONE SUSPENSION SPIRONOLACTONE

SPIRONOLACTONE TABLETS ALDACTONE

TRIAMTERENE CAPSULES DYRENIUM

THIAZIDES AND THIAZIDE-LIKE DIURETICS

CHLOROTHIAZIDE SUSPENSION DIURIL

CHLOROTHIAZIDE TABLETS CHLOROTHIAZIDE

CHLORTHALIDONE TABLETS CHLORTHALIDONE

HYDROCHLOROTHIAZIDE CAPSULES MICROZIDE

HYDROCHLOROTHIAZIDE TABLETS HYDROCHLOROTHIAZIDE

INDAPAMIDE TABLETS INDAPAMIDE

METHYCLOTHIAZIDE TABLETS AQUATENSEN

METOLAZONE TABLETS ZAROXOLYN

ENDOCRINE AND METABOLIC AGENTS - MISC.

BONE DENSITY REGULATORS

ALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM

CALCITONIN (SALMON) SOLUTION MIACALCIN

CALCITRIOL OINTMENT VECTICAL

GROWTH HORMONES

SOMATROPIN NORDITROPIN Preferred Drug PA Required

SOMATROPIN NUTROPIN AQ Preferred Drug PA Required

SOMATROPIN GENOTROPIN Preferred Drug PA Required

HORMONE RECEPTOR MODULATORS

RALOXIFENE HCL TABLETS EVISTA

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

MECASERMIN SOLUTION INCRELEX PA Required

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

LEUPROLIDE ACETATE (CPP) (3 MONTH) KIT LUPRON DEPOT-PED PA Required

LEUPROLIDE ACETATE (CPP) KIT LUPRON DEPOT-PED PA Required

METABOLIC MODIFIERS

CINACALCET HCL TABLETS SENSIPAR PA Required

IDURSULFASE SOLUTION ELAPRASE PA Required

POSTERIOR PITUITARY HORMONES

CABERGOLINE TABLET CABERGOLINE

DESMOPRESSIN ACETATE NASAL SOLUTION VARIOUS

DESMOPRESSIN ACETATE REFRIGERATED SOLUTION VARIOUS

DESMOPRESSIN ACETATE SOLUTION VARIOUS

Page 40 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




DESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION VARIOUS

DESMOPRESSIN ACETATE SPRAY SOLUTION VARIOUS

DESMOPRESSIN ACETATE TABLETS VARIOUS PA Required

ESTROGENS

ESTROGEN COMBINATIONS

CONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPRO

ESTRADIOL-LEVONORGESTREL PATCH-WEEKLY CLIMARA PATCH

ESTROGENS

ESTERIFIED ESTROGENS TABLETS MENEST

ESTRADIOL PATCH-TWICE WEEKLY ALORA

ESTRADIOL PATCH-WEEKLY MENOSTAR

ESTRADIOL TABLETS ESTRACE

ESTROGENS, CONJUGATED SYNTHETIC A TABLETS CENESTIN

ESTROGENS, CONJUGATED TABLETS PREMARIN

ESTROPIPATE TABLETS ORTHO-EST

MILNACIPRAN HCL TABLETS SAVELLA 60 30

FLUOROQUINOLONES

FLUOROQUINOLONES

CIPROFLOXACIN ORAL SUSPENSION CIPRO

CIPROFLOXACIN HCL TABLETS CIPROFLOXACIN HCL

CIPROFLOX HCl-CIPROFLOX BETAINE TABLETS SR CIPRO XR

LEVOFLOXACIN SOLUTION LEVAQUIN

LEVOFLOXACIN TABLETS LEVAQUIN

MOXIFLOXACIN HCL SOLUTION AVELOX

OFLOXACIN TABLETS OFLOXACIN

GASTROINTMENTESTINAL AGENTS - MISC.

GALLSTONE SOLUBILIZING AGENTS

URSODIOL CAPSULES ACTIGALL

URSODIOL TABLETS URSO 250

GASTROINTMENTESTINAL CHLORIDE CHANNEL ACTIVATORS

LUBIPROSTONE CAPSULES AMITIZA PA Required

GASTROINTMENTESTINAL STIMULANTS

METOCLOPRAMIDE HCL SOLUTION VARIOUS

METOCLOPRAMIDE HCL TABLETS VARIOUS

METOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS VARIOUS

INFLAMMATORY BOWEL AGENTS

BALSALAZIDE DISODIUM CAPSULES COLAZAL 270 30

FIBROMYALGIA

Page 41 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




BALSALAZIDE DISODIUM TABLETS GIAZO 270 30

BUDESONIDE CAPSULES ENTOCORT EC

MESALAMINE CAPSULE CONTROLLED RELEASE PENTASA 270 30

MESALAMINE ENEMA MESALAMINE 240 30

MESALAMINE TABLET ENTERIC COATED ASACOL HD 120 30

MESALAMINE W/ CLEANSER KIT ROWASA 240 30

OLSALAZINE SODIUM CAPSULES DIPENTUM 120 30

SULFASALAZINE TABLETS AZULFIDINE 240 30

SULFASALAZINE TABLET ENTERIC COATED AZULFIDINE EN-TABLETS 240 30

IRRITABLE BOWEL SYNDROME (IBS) AGENTS

LINACLOTIDE CAPSULES LINZESS PA Required

MISCELLANEOUS

KAOLIN-PECTIN SUSPENSION KAOPECTATE

PHOSPHATE BINDER AGENTS

CALCIUM ACETATE (PHOSPHATE BINDER) CAPSULES PHOSLO

CALCIUM ACETATE (PHOSPHATE BINDER) SOLUTION PHOSLYRA

CALCIUM ACETATE (PHOSPHATE BINDER) TABLETS ELIPHOS

LANTHANUM CARBONATE CHEWABLE TABLETS FOSRENOL PA Required

LANTHANUM CARBONATE PACKETS FOSRENOL PA Required

SEVELAMER CARBONATE PACKETS RENVELA PA Required

SEVELAMER CARBONATE TABLETS RENVELA PA Required

SEVELAMER HCL TABLETS RENAGEL PA Required

GENITOURINARY AGENTS - MISC.

INTERSTITIAL CYSTITIS AGENTS

PENTOSAN POLYSULFATE SODIUM CAPSULES ELMIRON PA Required

PROSTATIC HYPERTROPHY AGENTS

DOXAZOSIN MESYLATE TABLET 24-HOUR CARDURA XL

FINASTERIDE TABLETS 5MG ONLY PROSCAR

TAMSULOSIN HCL CAPSULES FLOMAX

URINARY ANALGESICS

PHENAZOPYRIDINE HCL TABLETS PYRIDIUM

GOUT AGENTS

GOUT AGENTS

ALLOPURINOL TABLETS ZYLOPRIM

COLCHICINE TABLETS COLCRYS PA Required

FEBUXOSTAT TABLETS ULORIC PA Required

URICOSURICS

PROBENECID TABLETS PROBENECID

Page 42 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




HEMATOLOGICAL AGENTS - MISC.

PLATELET AGGREGATION INHIBITORS

CILOSTAZOL TABLETS PLETAL

CLOPIDOGREL BISULFATE TABLETS PLAVIX

DIPYRIDAMOLE TABLETS PERSANTINE

TICAGRELOR TABLETS BRILINTA PA Required

HEMATOPOIETIC AGENTS

AGENTS FOR GAUCHER DISEASE

IMIGLUCERASE SOLUTION CEREZYME PA Required

HEMATOPOIETIC GROWTH FACTORS

ELTROMBOPAG OLAMINE TABLETS PROMACTA PA Required

EPOETIN ALFA SOLUTION EPOGEN PA Required

FILGRASTIM SOLUTION NEUPOGEN BRAND PA Required

PEGFILGRASTIM SOLUTION NEULASTA PA Required

HEMORRHEOLOGIC AGENTS

PENTOXIFYLLINE TABLET CONTROLLED RELEASE TRENTAL

HEMOSTATICS

HEMOSTATICS - SYSTEMIC

AMINOCAPROIC ACID SYRUP AMICAR

AMINOCAPROIC ACID TABLETS AMICAR

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

BARBITURATE HYPNOTICS

PHENOBARBITAL SOLUTION PHENOBARBITAL

PHENOBARBITAL TABLETS PHENOBARBITAL

NON-BARBITURATE HYPNOTICS

ESTAZOLAM TABLETS ESTAZOLAM PA Required for > 1 Hypnotic Fill 30 30

ESZOPICLONE TABLETS LUNESTA PA Required for > 1 Hypnotic Fill 30 30

FLURAZEPAM HCL CAPSULES FLURAZEPAM HCL PA Required for > 1 Hypnotic Fill 30 30

TEMAZEPAM CAPSULES RESTORIL PA Required for > 1 Hypnotic Fill 30 30

TRIAZOLAM TABLETS HALCION PA Required for > 1 Hypnotic Fill 30 30

ZALEPLON CAPSULES SONATA PA Required for > 1 Hypnotic Fill 30 30

ZOLPIDEM TARTRATE SOLUTION ZOLPIMIST

PA Required PA

also Required for > 1 Hypnotic Fill

ZOLPIDEM TARTRATE TABLETS AMBIEN PA Required for > 1 Hypnotic Fill

60: 5MG

30: 10MG

30

30

ZOLPIDEM TARTRATE TABLETS CONTROLLED RELEASE AMBIEN CR

PA Required PA

also Required for > 1 Hypnotic Fill 30 30

Page 43 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




ZOLPIDEM TARTRATE TABLETS SUBLINGUAL INTERMEZZO

PA Required PA


ZOLPIDEM TARTRATE TABLETS SUBLINGUAL EDLUAR

PA Required PA


SELECTIVE MELATONIN RECEPTOR AGONISTS

RAMELTEON TABLETS ROZEREM

PA Required PA


LAXATIVES

LAXATIVE COMBINATIONS

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTE

POLYETHYLENE GLYCOL 3350 ORAL PACKET MIRALAX

SENNOSIDES-DOCUMSATE SDOIUM TABLET SENOKOT S

LAXATIVES - MISC.

BISACODYL SUPPOSITORY DULCOLAX

BISACODYL TABLET DELAYED RELEASE DULCOLAX

DOCUSATE CALCIUM CAPSULE SURFAK

DOCUSATE SODIUM CPASULES COLACE

LACTULOSE SOLUTION LACTULOSE

MAGNESIOUN CITRATE SOLUTION MAG CITRATE

METHYLNALTREXONE BROMICE INJECTION RELISTOR PA Required

PSYLLIUM CAPSULE METAMUCIL

PSYLLIUM POWDER METAMUCIL

SENNA TABLET SENNA

SENNA TABLES CONCENTRATED SENNA CONC

SENNOSIDES TABLETS SENOKOT

SODIUM PHOSPHATE - ENEMA FLEET ENEMA

SODIUM PHOSPHATE - SOLUTION VARIOUS

MACROLIDES

AZITHROMYCIN

AZITHROMYCIN PACKETS ZITHROMAX

AZITHROMYCIN EXTENDED RELEASE ORAL SUSPENSION ZITHROMAX

AZITHROMYCIN SUSPENSION ZITHROMAX

AZITHROMYCIN TABLETS ZITHROMAX

CLARITHROMYCIN

CLARITHROMYCIN SUSPENSION CLARITHROMYCIN

Page 44 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CLARITHROMYCIN TABLETS BIAXIN

CLARITHROMYCIN TABLET 24-HOUR BIAXIN XL

ERYTHROMYCINS

ERYTHROMYCIN BASE (COATED) TABLET ENTERIC COATED PCE

ERYTHROMYCIN BASE CPEP ERYTHROMYCIN

ERYTHROMYCIN BASE TABLETS ERYTHROMYCIN BASE

ERYTHROMYCIN BASE TABLET ENTERIC COATED ERY-TAB

ERYTHROMYCIN ESTOLATE SUSPENSION VARIOUS

ERYTHROMYCIN ETHYLSUCCINATE SUSPENSION E.E.S. GRANULESULES

ERYTHROMYCIN ETHYLSUCCINATE TABLETS E.E.S. 400

ERYTHROMYCIN STEARATE TABLETS ERYTHROCIN STEARATE

ERYTHROMYCIN TABLET DELAYED RELEASE ERY-TAB

LINCOMYCINS

CLINDAMYCIN HCl CAPSULES CLEOCIN

IODOQUINOL TABLETS YODOXIN

METHENAMINE MANDELATE SUSPENSION METHENAMINE

METHENAMINE MANDELATE TABLETS HIPREX

METRONIDAZOLE CAPSULE FLAGYL

METRONIDAZOLE TABLETS FLAGYL

METRONIDAZOLE TABLET SR FLAGYL ER

NICLOSAMIDE NICLOCIDE

NITROFURANTOIN CAPSULE MACRODANTIN

NITROFURANTOIN MACROCRYSTALLINE CAPSULES MACROBID

NITROFURANTOIN SUSPENSION FURADANTIN

PYRIMETHAMINE TABLET DARAPRIM

TRIMETHOPRIM TABLET TRIMETHOPRIM

MEDICAL DEVICES

CONTRACEPTIVES

CONDOMS - FEMALE MISC. FC FEMALE CONDOM

CONDOMS - MALE MISC. LIFESTYLES ASSORTED COLORS

DIAPHRAGM ARC-SPRING DPRH CAYA

DIAPHRAGM COIL SPRING KIT

ORTHO DIAPHRAGM COIL

SPRING KIT 50

DIAPHRAGM FLAT SPRING KIT

ORTHO DIAPHRAGM FLAT

SPRING KIT 55

MISCELLANEOUS

Page 45 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




DIAPHRAGM WIDE SEAL DPRH

WIDE-SEAL SILICONE

DIAPHRAGM KIT 60

DIAPHRAGMS - OTHER+A1294 OMNIFLEX DIAPHRAGM

DIABETIC SUPPLIES

BLOOD GLUCOSE MONITORING KIT W/ DEVICE VARIOUS

BLOOD GLUCOSE MONITORING DEVICES VARIOUS

LANCET DEVICES MISC. VARIOUS

LANCETS MISC. VARIOUS

DEVICES - MISC.

ALCOHOL SWABS PADS

ALCOH-GLOVE CONTOURED

WIPE

RESPIRATORY THERAPY SUPPLIES

SODIUM CHLORIDE NEBULIZER SOLUTION NEBUSAL / HYPERSAL

SPACER/AEROSOL-HOLDING CHAMBER SUPPOSITORYLIES - MASKS

MASK VORTEX/

BABY WHIRL DUCKLING 2 365

SPACER/AEROSOL-HOLDING CHAMBERS DEVICE

AEROCHAMBER

MINI AEROCHAMBER 2 365

MIGRAINE PRODUCTS

MIGRAINE COMBINATIONS

DIHYRDROERGOTAMIN MESYLATE NASAL MIGRANAL 4 28

ERGOTAMINE W/ CAFFEINE SUPPOSITORY MIGERGOT 12 30

ERGOTAMINE W/ CAFFEINE TABLETS CAFERGOT

SEROTONIN AGONISTS

NARATRIPTAN HCL TABLETS AMERGE 9 30

RIZATRIPTAN BENZOATE ORALLY DISINTEGRATING TABLETS MAXALT-MLT 18 28

RIZATRIPTAN BENZOATE TABLETS MAXALT-MLT 18 28

SUMATRIPTAN NASAL SOLUTION IMITREX 6 30

SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION IMITREX 2 30

SUMATRIPTAN SUCCINATE TABLETS IMITREX 9 30

ZOLMITRIPTAN ORALLY DISINTEGRATING TABLETS ZOMIG ZMT 12 28

ZOLMITRIPTAN TABLETS ZOMIG 12 28

MOUTH/THROAT/DENTAL AGENTS

ANTI-INFECTIVES - THROAT

CHLORHEXIDINE GLUCONATE SOLUTION PERIOGARD

CLOTRIMAZOLE TROC CLOTRIMAZOLE

SODIUM FLUORIDE SOLUTION LURIDE

TRIAMCINOLONE ACETONIDE DENTAL PASTE VARIOUS

Page 46 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




MISCELLANEOUS

ARTIFICIAL SALIVA ARTIFICIAL SALIVA

SALIVA SUBSTITUTE SPRAY SALIVART

STEROIDS - MOUTH/THROAT

TRIAMCINOLONE ACETONIDE ORAL PASTE ORALONE

MUSCULOSKELETAL THERAPY AGENTS

CENTRAL MUSCLE RELAXANTS

BACLOFEN TABLETS BACLOFEN

CARISOPRODOL TABLETS SOMA

CYCLOBENZAPRINE HCL TABLETS FLEXERIL

PA Required for dosages other than

5mg and 10mg tablets

METHOCARBAMOL TABLETS ROBAXIN

TIZANIDINE HCL CAPSULES ZANAFLEX

TIZANIDINE HCL TABLETS TIZANIDINE HCL

DIRECT MUSCLE RELAXANTS

DANTROLENE SODIUM CAPSULES DANTRIUM

NASAL AGENTS - SYSTEMIC AND TOPICAL

NASAL ANTIALLERGY

AZELASTINE HCL SOLUTION ASTELIN

NASAL ANTICHOLINERGICS

IPRATROPIUM BROMIDE SOLUTION ATROVENT

NASAL STEROIDS

FLUNISOLIDE SOLUTION FLUNISOLIDE

FLUTICASONE PROPIONATE SUSPENSION FLONASE

IPRATROPIUM BROMIDE NASAL SOLUTION ATROVENT NS

TRIAMCINOLONE ACETONIDE NASAL NASACORT AQ

SYMPATHOMIMETIC DECONGESTANTS

PSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENS

PSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINE

PSEUDOEPHEDRINE HCL TABLETS SUDAFED

PSEUDOEPHEDRINE HCL TABLET 12-HOUR NASAL DECONGESTANT

PSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOUR

RILUZOLE TABLET RILUTEK

OPHTHALMIC AGENTS

OPHTHALMIC - BETA-BLOCKERS & MISCELLANOUS

BETAXOLOL HCL SOLUTION BETAXOLOL HCL

BETAXOLOL HCL SUSPENSION BETOPTIC-S

NEUROMUSCULAR DISORDERS

Page 47 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




BRIMONIDINE TARTRATE SOLUTION ALPHAGAN P

CARTEOLOL HCL SOLUTION CARTEOLOL HCL

DORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION COSOPT

LEVOBUNOLOL HCL SOLUTION LEVOBUNOLOL HCL

METIPRANOLOL SOLUTION METIPRANOLOL

TIMOLOL MALEATE SOLUTION TIMOPTIC-XE

TIMOLOL MALEATE SOLUTION TIMOPTIC

OPHTHALMIC - CYCLOPLEGIC MYDRIATICS

ATROPINE SULFATE OINTMENT ATROPINE SULFATE

ATROPINE SULFATE SOLUTION ISOPTO ATROPINE

CYCLOPENTOLATE HCL SOLUTION CYCLOGYL

HOMATROPINE HBR SOLUTION ISOPTO HOMATROPINE

OPHTHALMIC - MIOTICS

PILOCARPINE HCL GEL PILOPINE HS

PILOCARPINE HCL SOLUTION ISOPTO CARPINE

OPHTHALMIC - ANTI-INFECTIVES

BACITRACIN OINTMENT BACITRACIN

BACITRACIN-POLYMYXIN B OINTMENT POLYCIN

CIPROFLOXACIN HCL OINTMENT CILOXAN

CIPROFLOXACIN HCL SOLUTION CILOXAN

ERYTHROMYCIN OINTMENT ILOTYCIN

GENTAMICIN SULFATE OINTMENT GARAMYCIN

GENTAMICIN SULFATE SOLUTION GARAMYCIN

MOXIFLOXACIN HCL SOLUTION VIGAMOX

NATAMYCIN SUSPENSION NATACYN

NEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT NEO-POLYCIN

NEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION NEOSPORIN

OFLOXACIN SOLUTION OCUFLOX

POLYMYXIN B-TRIMETHOPRIM SOLUTION POLYTRIM

SULFACETAMIDE SODIUM OINTMENT SULFACETAMIDE SODIUM

SULFACETAMIDE SODIUM SOLUTION BLEPH-10

TOBRAMYCIN OINTMENT TOBREX

TOBRAMYCIN SOLUTION TOBREX

TRIFLURIDINE SOLUTION VIROPTIC

OPHTHALMIC - DECONGESTANTS

NAPHAZOLINE HCL SOLUTION VASOCLEAR

NAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-A

OPHTHALMIC - IMMUNOMODULATORS

Page 48 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CYCLOSPORINE EMULSION RESTASIS PA Required

OPHTHALMIC - STEROIDS

BACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HC

DEXAMETHASONE SUSPENSION MAXIDEX

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION

DEXAMETHASONE SODIUM

PHOSPHATE

FLUOROMETHOLONE OINTMENT FML

FLUOROMETHOLONE SUSPENSION FML LIQUIFILM

GENTAMICIN-PREDNISOLONE ACETATE OINTMENT PRED-G S.O.P.

GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION PRED-G

NEOMYCIN-POLYMY-DEXAMETH OINTMENT MAXITROL

NEOMYCIN-POLYMY-DEXAMETH SUSPENSION MAXITROL

PREDNISOLONE ACETATE SUSPENSION PRED MILD

PREDNISOLONE SODIUM PHOSPHATE SOLUTION

PREDNISOLONE SODIUM

PHOSPHATE

SULFACETAMIDE SOD-PREDNISOLONE OINTMENT BLEPHAMIDE S.O.P.

SULFACETAMIDE SOD-PREDNISOLONE SOLUTION

SULFACETAMIDE

SODIUM/PREDNISOLONE

SODIUM PHOSPHATE

SULFACETAMIDE SOD-PREDNISOLONE SUSPENSION BLEPHAMIDE

TOBRAMYCIN-DEXAMETHASONE OINTMENT TOBRADEX

TOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX ST

OPHTHALMICS - MISC.

ARTIFICAL TEARS TEARS

ARTIFICIAL TEARS OINTMENT VARIOUS

BRINZOLAMIDE SUSPENSION AZOPT PA Required

CARBOXYMETHYLCELLULOSE SODIUM GEL REFRESH

CARBOXYMETHYLCELLULOSE SODIUM SOLUTION REFRESH

CROMOLYN SODIUM SOLUTION CROMOLYN SODIUM

DICLOFENAC SODIUM SOLUTION DICLOFENAC SODIUM

DORZOLAMIDE HCL SOLUTION TRUSOPT

FLURBIPROFEN SODIUM SOLUTION OCUFEN

HYDROXYPROPYL METHYLCELLULOSE GEL LACRI-LUBE

HYDROXYPROPYL METHYLCELLULOSE SOLUTION LACRI-LUBE

KETOROLAC TROMETHAMINE SOLUTION ACULAR LS

KETOTIFEN FUMARATE SOLUTION ALAWAY

LODOXAMIDE TROMETHAMINE SOLUTION ALOMIDE

OLOPATADINE HCL SOLUTION PATANOL

Page 49 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PHENYLEPHRINE HCL SOLUTION NEOFRIN

POLYETHYLENE GLYCOL-PROPYLENE GLYCOL SOLUTION SYSTANE

SCOPOLAMINE HBR SOLUTION ISOPTO HYASINE

TROPICAMIDE SOLUTION MYDRIACYL

OPHTHALMIC - PROSTAGLANDINS

LATANOPROST SOLUTION XALATAN 2.5ML 30

TAFLUPROST SOLUTION ZIOPTAN PA Required

TRAVOPROST SOLUTION TRAVATAN Z PA Required

NALOXONE NASAL NARCAN NASAL SPRAY Preferred Drug

NALOXONE SYRINGE VARIOUS Preferred Drug

NALOXONE VIAL VARIOUS Preferred Drug

OTIC AGENTS

OTIC AGENTS - MISCELLANEOUS

ACETIC ACID SOLUTION ACETIC ACID

CARBAMIDE PEROXIDE OTIC SOLUTION DEBROX

OTIC ANTI-INFECTIVES

OFLOXACIN SOLUTION OFLOXACIN

OTIC COMBINATIONS

ANTIPYRINE-BENZOCAINE SOLUTION AURODEX

ANTIPYRINE-BENZOCAINE-POLYCOSANOL SOLUTION OTIC CARE

CIPROFLOXACIN-DEXAMETHASONE CIPRODEX

NEOMYCIN-POLYMYXIN-HC SOLUTION CORTISPORIN

NEOMYCIN-POLYMYXIN-HC SUSPENSION NEO/POLYMYXIN/HC

OTIC STEROIDS

HYDROCORTISONE W/ACETIC ACID SOLUTION ACETASOL HC

OXYTOCICS

OXYTOCICS

METHYLERGONOVINE MALEATE TABLETS METHERGINE

PASSIVE IMMUNIZING AGENTS

MONOCLONAL ANTIBODIES

OPIOID ANTAGONISTS

Page 50 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PALIVIZUMAB SOLUTION INJECTION SYNAGIS

PA Required - if approved the

prescriber may be required to buy and

bill a medical claim for the drug

PENICILLINS

AMINOPENICILLINS

AMOXICILLIN CAPSULES AMOXICILLIN

AMOXICILLIN CHEWABLE TABLETS AMOXICILLIN

AMOXICILLIN SUSPENSION AMOXICILLIN

AMOXICILLIN TABLETS AMOXICILLIN

AMPICILLIN CAPSULES AMPICILLIN

AMPICILLIN SUSPENSION AMPICILLIN

NATURAL PENICILLINS

PENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUM

PENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUM

PENICILLIN COMBINATIONS

AMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTIN

AMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTIN

AMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XR

PENICILLINASE-RESISTANT PENICILLINS

DICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUM

POTASSIUM CHLORIDE CAPSULES CONTROLLED RELEASE MICRO-K

POTASSIUM CHLORIDE GRANULES VARIOUS

POTASSIUM CHLORIDE MICROENCAPSULATED CRYSTALS CR VARIOUS

POTASSIUM CHLORIDE ORAL LIQUID K-LOR

POTASSIUM CHLORIDE POWDER PACKETS KLOR-CON

POTASSIUM CHLORIDE TABLETS CONTROLLED RELEASE K-TAB

POTASSIUM CITRATE & CITRIC ACID SOLUTION K CITRATE

POTASSIUM CITRATE TABLETS CONTROLLED RELEASE UROCIT-K

POTASSIUM TABLETS VARIOUS

PROGESTINS

PROGESTINS

MEDROXYPROGESTERONE ACETATE TABLETS PROVERA

NORETHINDRONE ACETATE TABLETS AYGESTIN

PROGESTERONE MICRONIZED CAPSULES PROMETRIUM

PROGESTERONE VAGINAL GEL CRINONE

PROGESTERONE VAGINAL SUPPOSITORY PROGESTERONE

POTASSIUM SUPPLEMENTS

Page 51 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS

ANTIDEMENTIA AGENTS

DONEPEZIL HYDROCHLORIDE TABLETS ARICEPT PA Required

DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TABLETS ARICEPT ODT PA Required

GALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE RAZADYNE ER PA Required

GALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA Required

GALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA Required

MEMANTINE HCL SOLUTION NAMENDA PA Required

MEMANTINE HCL TABLETS NAMENDA PA Required

RIVASTIGMINE PATCH EXELON PA Required

RIVASTIGMINE TARTRATE CAPSULES EXELON PA Required

RIVASTIGMINE TARTRATE SOLUTION EXELON PA Required

MULTIPLE SCLEROSIS AGENTS

FINGOLIMOD HCL CAPSULES GILENYA PA Required

GLATIRAMER ACETATE COPAXONE BRAND PA Required

INTERFERON BETA-1A KIT AVONEX PA Required

INTERFERON BETA-1A SOLUTION REBIF REBIDOSE PA Required

INTERFERON BETA-1B KIT BETASERON PA Required

SMOKING DETERRENTS

BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR BUPROBAN

84-day

supply 180

NICOTINE INHA NICOTROL INHALER

84-day

supply 180

NICOTINE POLACRILEX GUM NICORETTE GUM

84-day

supply 180

NICOTINE POLACRILEX LOZENGE COMMIT

84-day

supply 180

NICOTINE PATCH NICODERM CQ

84-day

supply 180

NICOTINE SOLUTION NICOTROL NS

84-day

supply 180

VARENICLINE TARTRATE TABLETS CHANTIX

84-day

supply 180

RESPIRATORY AGENTS - MISC.

ALPHA-PROTEINASE INHIBITOR (HUMAN)

ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA Required

THEOPHYLLINE CAPSULE CONTROLLED RELEASE THEOPHYLLINE

THEOPHYLLINE CAPSULES SR 12 HR THEOPHYLLINE

Page 52 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




THEOPHYLLINE CAPSULES SR 24 HR THEOPHYLLINE

THEOPHYLINE TABLETS SR 12 HR THEOPHYLLINE

CYSTIC FIBROSIS AGENTS

DORNASE ALFA SOLUTION PULMOZYME PA Required

SULFONAMIDES

SULFONAMIDES

SULFADIAZINE TABLETS SULFADIAZINE

TETRACYCLINES

TETRACYCLINES

DEMECLOCYCLINE HCL TABLETS DEMECLOCYCLINE HCL PA Required

DOXYCYCLINE HYCLATE CAPSULES ORAXYL

DOXYCYCLINE HYCLATE SUSPENSION VIBRAMYCIN

DOXYCYCLINE HYCLATE TABLETS DOXYCYCLINE HYCLATE

DOXYCYCLINE HYCLATE TABLET ENTERIC COATED DORYX

MINOCYCLINE HCL CAPSULES MINOCIN

MINOCYCLINE HCL TABLETS DYNACIN

TETRACYCLINE HCL CAPSULES TETRACYCLINE HCL

THYROID AGENTS

ANTITHYROID AGENTS

METHIMAZOLE TABLETS TAPAZOLE

PROPYLTHIOURACIL TABLETS PROPYLTHIOURACIL

THYROID HORMONES

LEVOTHYROXINE SODIUM TABLETS LEVO-T

LIOTHYRONINE SODIUM TABLETS CYTOMEL

THYROID TABLETS ARMOUR THYROID

ULCER DRUGS

ANTISPASMODICS

DICYCLOMINE HCL CAPSULES VARIOUS

DICYCLOMINE HCL SOLUTION VARIOUS

DICYCLOMINE HCL TABLETS VARIOUS

GLYCOPYRROLATE SOLUTION VARIOUS

GLYCOPYRROLATE TABLETS VARIOUS

HYOSCYAMINE SULFATE ELIXIR VARIOUS

HYOSCYAMINE SULFATE SOLUTION VARIOUS

HYOSCYAMINE SULFATE SUBLINGUAL VARIOUS

HYOSCYAMINE SULFATE TABLETS VARIOUS

HYOSCYAMINE SULFATE TABLET 12-HOUR VARIOUS

HYOSCYAMINE SULFATE CONTROLLED RELEASE TABLET VARIOUS

Page 53 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




HYOSCYAMINE SULFATE ORALLY DISINTEGRATING TABLETS VARIOUS

PHENOBARBITAL & HYOSCYAMINE SOLUTION LEVSIN-PB

PHENOBARBITAL & HYOSCYAMINE TABLET LEVSIN-PB

PROPANTHELINE BROMIDE TABLETS VARIOUS

H-2 ANTAGONISTS

CIMETIDINE HCL SOLUTION TAGAMET

CIMETIDINE HCL TABLETS TAGAMET

FAMOTIDINE CHEWABLE TABLETS PEPCID AC

FAMOTIDINE SUSPENSION PEPCID

FAMOTIDINE TABLETS PEPCID AC

NIZATIDINE CAPSULES AXID

NIZATIDINE ORAL SOLUTION AXID

RANITIDINE HCL CAPSULES RANITIDINE HCL

RANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQ

RANITIDINE HCL SYRUP ZANTAC

RANITIDINE HCL TABLETS ZANTAC 75

ANTI-ULCER - MISC.

SUCRALFATE TABLETS CARAFATE

PROTON PUMP INHIBITORS

LANSOPRAZOLE CAPSULE DELAYED RELEASE PREVACID

LANSOPRAZOLE SUSPENSION FIRST-LANSOPRAZOLE

OMEPRAZOLE CAPSULE DELAYED RELEASE PRILOSEC

OMEPRAZOLE SUSPENSION FIRST-OMEPRAZOLE

PANTOPRAZOLE SODIUM TABLET ENTERIC COATED PROTONIX

PANTOPRAZOLE SODIUM SUSPENSION PACKET DELAYED RELEASE PROTONIX

URINARY ANTISPASMODICS

URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLI)

OXYBUTYNIN CHLORIDE SYRUP VARIOUS

OXYBUTYNIN CHLORIDE TABLETS VARIOUS

OXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XL

TOLTERODINE TARTRATE CAPSULE CONTROLLED RELEASE DETROL LA STEP THERAPY


oxybutynin & tolterodine

TOLTERODINE TARTRATE TABLETS DETROL STEP THERAPY


oxybutynin

TROSPIUM CHLORIDE TABLETS SANCTURA

VAGINAL PRODUCTS

SPERMICIDES

Page 54 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




NONOXYNOL-9 FOAM

VCF VAGINAL CONTRACEPTIVE

FOAM

NONOXYNOL-9 GEL SHUR-SEAL

VAGINAL ANTI-INFECTIVES

CLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCIN

CLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCIN

CLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMIN

CLOTRIMAZOLE VAGINAL TABLET CLOTRIMAZOLE

ECONAZOLE NITRATE CREAM SPECTAZOLE

METRONIDAZOLE VAGINAL GEL METROGEL-VAGINAL

MICONAZOLE NITRATE VAGINAL

MONISTAT 3 COMBINATION

PACKETS

MICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3

SULFANILAMIDE VAGINAL CREAM AVC

TERCONALZOLE BAGINAL CREAM TERAZOL

VAGINAL ESTROGENS

ESTRADIOL ACETATE VAGINAL RING FEMRING PA Required

ESTRADIOL VAGINAL CREAM ESTRACE

ESTRADIOL VAGINAL RING ESTRING

ESTRADIOL VAGINAL TABLETS VAGIFEM

ESTROGENS, CONJUGATED VAGINAL CREAM PREMARIN PA Required

VASOPRESSORS

ANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE SELF-INJECTED EPIPEN-JR 2-PAK Preferred Drug PA Required for > 2 Per Month 2 30

EPINEPHRINE SELF-INJECTED EPIPEN 2-PAK Preferred Drug PA Required for > 2 Per Month 2 30

VITAMINS, MINERALS AND OTHER MISCELLANEOUS AGENTS

ALPHA-TOCOPHEROL CAPSULES VITAMIN E

CALCIUM TABLETS VARIOUS

CALCIUM CARBONATE W/ VITAMIN D CAPSULES VARIOUS

CALCIUM CARBONATE W/ VITAMIN D CHEW TABLETS VARIOUS

CALCIUM CARBONATE W/ VITAMIN D TABLETS VARIOUS

CALCIUM CITRATE TABLETS CITRACAL

CALCIUM W/ VITAMIN D CAPSULES VARIOUS

CALCIUM W/ VITAMIN D EFFERVESCENT TABLETS VARIOUS

CALCIUM W/ VITAMIN D WAFER VARIOUS

CALCITRIOL CAPSULES VARIOUS

CHOLECALCIFEROL CAPSULES VITAMIN D3

CHOLECALCIFEROL TABLETS VITAMIN D3

Page 55 of 56


Preferred Drug

Status PA Type

Step Therapy

Requirements

Quantity

Limit

QL

Days




CYANOCOBALAMIN TABLETS VITAMIN B12

DICLOXACILLIN SODIUM CAPSULES

DOXYLAMINE SUCCINATE (SLEEP) TAB SLEEP AID

ERGOCALCIFEROL CAPSULES VARIOUS

FERROUS FUMARATE TABLETS VARIOUS

FERROUS GLUCONATE TABLETS VARIOUS

FERROUS SULFATE TABLETS VARIOUS

FOLIC ACID TABLETS VARIOUS

MAGNESIUM OXIDE CAPSULES VARIOUS

MAGNESIUM OXIDE TABLETS VARIOUS

MULTIPLE VITAMIN CAPSULES VARIOUS

MULTIPLE VITAMIN TABLETS VARIOUS

MULTIPLE VITAMIN W/ MINERALS CAPSULES VARIOUS

MULTIPLE VITAMIN W/ MINERALS CHEW TABLETS VARIOUS

MULTIPLE VITAMIN W/ MINERALS LIQUID VARIOUS

MULTIPLE VITAMIN W/ MINERALS TABLETS VARIOUS

NIACIN CAPSULES NIACIN ER

NIACIN TABLETS NIACIN

NIACIN TABLETS CONTROLLED RELEASE NIACIN ER

NIACINAMIDE TABLETS VARIOUS

NIACINAMIDE TABLETS CR VARIOUS

OMEGA 3 FATTY ACID CAPSULES FISH OIL

OYSTER SHELL CALCIUM TABLETS VARIOUS

PHYTONADIONE TABLET MEPHYTON - VITAMIN K

PRENATAL VIT W/IRON CARBONYL-FA TABLET VARIOUS

PRENATAL MULTIVITAMINS WITH OR WITHOUT MINERALS W/ FOLATE VARIOUS

PRENATAL MULTIVITAMINES WITH MINERAL W/FE-FA VARIOUS

PYRIDOXINE HCL TABLETS VITAMIN B6

THIAMINE HCL TABLETS VITAMIN B1

THIAMINE MONONITRATE TABLETS VITAMIN B1

VITAMIN E CAPSULES VITAMIN E

VITAMIN E TABLETS VITAMIN E

Page 56 of 56

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