Illinois Medicaid Preferred Drug List Effective January 1, 2021
▪ The Preferred Drug List (PDL) has products listed in groups by drug class, drug name, dosage form, and PDL status
▪ Multi-source drugs are listed by both brand and generic names when applicable
▪ ADHD Agents: Prior authorization required for participants under 6 years of age and participants 19 years of age and older
▪ Spiriva AER 1.25mcg: Prior authorization NOT required for participants ages 6-17 years
▪ Budesonide: Prior authorization NOT required for participants age 7 years and under
▪ Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those participants with a diagnosis of epilepsy or seizure disorder in Department records
▪ Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents
▪ Proton Pump Inhibitors, oral: Prior authorization required for participants age 21 and over. Adults with non-complicated GERD have to pay out of pocket for a PPI or use a prescribed H2 blocker. PA is needed for coverage of indications requiring longer term use.
▪ Lansoprazole ODT: Prior authorization NOT required for participants age 10 years and under.
▪ For drugs not found on this list, go to the drug search engine at: www.ilpriorauth.com
Page 1 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORM
ADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINES ADZENYS ER SUER NON_PREFERRED
AMPHETAMINE ER SUER NON_PREFERRED
DYANAVEL XR SUER NON_PREFERRED
ADZENYS XR-ODT TBED NON_PREFERRED
AMPHETAMINE SULFATE TABS NON_PREFERRED
EVEKEO TABS NON_PREFERRED
EVEKEO ODT TBDP NON_PREFERRED
DEXEDRINE CP24 NON_PREFERRED
DEXTROAMPHETAMINE SULFATE ER CP24 NON_PREFERRED
DEXTROAMPHETAMINE SULFATE SOLN NON_PREFERRED
PROCENTRA SOLN NON_PREFERRED
DEXEDRINE TABS NON_PREFERRED
DEXTROAMPHETAMINE SULFATE TABS NON_PREFERRED
ZENZEDI TABS NON_PREFERRED
VYVANSE CAPS PREFERRED
VYVANSE CHEW PREFERRED
DESOXYN TABS NON_PREFERRED
METHAMPHETAMINE HCL TABS NON_PREFERRED
ADDERALL XR CP24 NON_PREFERRED
AMPHETAMINE/DEXTROAMPHETAMINE CP24 PREFERRED
MYDAYIS CP24 NON_PREFERRED
ADDERALL TABS NON_PREFERRED
AMPHETAMINE/DEXTROAMPHETAMINE TABS PREFERRED
ADHD / ANTI-NARCOLEPSY AGENTS : MISC CLONIDINE HCL ER TB12 PREFERRED
CLONIDINE HYDROCHLORIDE ER TB12 PREFERRED
GUANFACINE ER TB24 PREFERRED
GUANFACINE HYDROCHLORIDE TB24 PREFERRED
INTUNIV TB24 NON_PREFERRED
ATOMOXETINE CAPS NON_PREFERRED
ATOMOXETINE HYDROCHLORIDE CAPS NON_PREFERRED
STRATTERA CAPS NON_PREFERRED
SUNOSI TABS NON_PREFERRED
WAKIX TABS NON_PREFERRED
ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTS ARMODAFINIL TABS NON_PREFERRED
NUVIGIL TABS NON_PREFERRED
DEXMETHYLPHENIDATE HCL ER CP24 NON_PREFERRED
DEXMETHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED
FOCALIN XR CP24 PREFERRED
DEXMETHYLPHENIDATE HCL TABS PREFERRED
DEXMETHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED
FOCALIN TABS NON_PREFERRED
DAYTRANA PTCH NON_PREFERRED
COTEMPLA XR-ODT TBED NON_PREFERRED
QUILLICHEW ER CHER NON_PREFERRED
PDL STATUS
Page 2 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
METHYLPHENIDATE HYDROCHLORIDE CHEW NON_PREFERRED
ADHANSIA XR CP24 NON_PREFERRED
APTENSIO XR CP24 NON_PREFERRED
JORNAY PM CP24 NON_PREFERRED
METHYLPEHNIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24 NON_PREFERRED
RITALIN LA CP24 NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE CD CPCR NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE ER CPCR NON_PREFERRED
METHYLIN SOLN NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE SOLN NON_PREFERRED
QUILLIVANT XR SRER NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED
RITALIN TABS NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE ER TB24 NON_PREFERRED
METHYLPHENID TAB 10MG ER TBCR PREFERRED
METHYLPHENID TAB 20MG ER TBCR PREFERRED
CONCERTA TBCR PREFERRED
METHYLPHENID TAB 18MG ER TBCR NON_PREFERRED
METHYLPHENID TAB 27MG ER TBCR NON_PREFERRED
METHYLPHENID TAB 36MG ER TBCR NON_PREFERRED
METHYLPHENID TAB 54MG ER TBCR NON_PREFERRED
METHYLPHENID TAB 72MG ER TBCR NON_PREFERRED
METHYLPHENIDATE HYDROCHLORIDE ER TBCR NON_PREFERRED
RELEXXII TBCR NON_PREFERRED
MODAFINIL TABS NON_PREFERRED
PROVIGIL TABS NON_PREFERRED
ANALGESICS - ANTI-INFLAMMATORY : MISC RIDAURA CAPS NON_PREFERRED
OTREXUP SOAJ NON_PREFERRED
RASUVO SOAJ NON_PREFERRED
REDITREX SOSY NON_PREFERRED
ARAVA TABS NON_PREFERRED
LEFLUNOMIDE TABS PREFERRED
ANALGESICS - ANTI-INFLAMMATORY : NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS (NSAIDs) ZORVOLEX CAPS NON_PREFERRED
ZIPSOR CAPS NON_PREFERRED
DICLOFENAC POTASSIUM TABS PREFERRED
DICLOFENAC SODIUM ER TB24 PREFERRED
DICLOFENAC SODIUM DR TBEC PREFERRED
ETODOLAC CAPS PREFERRED
ETODOLAC TABS PREFERRED
ETODOLAC ER TB24 PREFERRED
FENOPROFEN CALCIUM CAPS NON_PREFERRED
Page 3 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
NALFON CAPS NON_PREFERRED
FENOPROFEN CALCIUM TABS NON_PREFERRED
NALFON TABS NON_PREFERRED
FLURBIPROFEN TABS PREFERRED
IBUPAK KIT NON_PREFERRED
IBUPROFEN SUSP NON_PREFERRED
IBU TABS PREFERRED
IBUPROFEN TABS PREFERRED
INDOMETHACIN CAPS PREFERRED
TIVORBEX CAPS NON_PREFERRED
INDOMETHACIN ER CPCR PREFERRED
INDOCIN SUPP NON_PREFERRED
INDOCIN SUSP NON_PREFERRED
KETOPROFEN CAPS PREFERRED
KETOPROFEN ER CP24 NON_PREFERRED
KETOROLAC TROMETHAMINE SOLN NON_PREFERRED
SPRIX SOLN NON_PREFERRED
KETOROLAC TROMETHAMINE TABS PREFERRED
MECLOFENAMATE SODIUM CAPS NON_PREFERRED
MEFENAMIC ACID CAPS NON_PREFERRED
VIVLODEX CAPS NON_PREFERRED
MELOXICAM TABS PREFERRED
MOBIC TABS NON_PREFERRED
QMIIZ ODT TBDP NON_PREFERRED
NABUMETONE TABS PREFERRED
RELAFEN DS TABS NON_PREFERRED
NAPROXEN SUSP PREFERRED
NAPROXEN TABS PREFERRED
EC-NAPROXEN TBEC PREFERRED
NAPROXEN DR TBEC PREFERRED
NAPROXEN SODIUM TABS PREFERRED
NAPRELAN TB24 NON_PREFERRED
NAPROXEN SODIUM TB24 NON_PREFERRED
NAPROXEN SODIUM CR TB24 NON_PREFERRED
NAPROXEN SODIUM ER TB24 NON_PREFERRED
DAYPRO TABS NON_PREFERRED
OXAPROZIN TABS NON_PREFERRED
FELDENE CAPS NON_PREFERRED
PIROXICAM CAPS NON_PREFERRED
SULINDAC TABS PREFERRED
TOLMETIN SODIUM CAPS NON_PREFERRED
TOLMETIN SODIUM TABS NON_PREFERRED
CELEBREX CAPS NON_PREFERRED
CELECOXIB CAPS PREFERRED
Page 4 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ARTHROTEC 50 TBEC NON_PREFERRED
ARTHROTEC 75 TBEC NON_PREFERRED
DICLOFENAC SODIUM/MISOPROSTOL TBEC NON_PREFERRED
DUEXIS TABS NON_PREFERRED
NAPROXEN/ESOMEPRAZOLE MAGNESIUM TBEC NON_PREFERRED
VIMOVO TBEC NON_PREFERRED
ANALGESICS - NONNARCOTIC DIFLUNISAL TABS PREFERRED
SALSALATE TABS PREFERRED
BUTALBITAL/ACETAMINOPHEN CAPS NON_PREFERRED
ALLZITAL TABS NON_PREFERRED
BUPAP TABS PREFERRED
BUTALBITAL/ACETAMINOPHEN TABS PREFERRED
MARTEN-TAB TABS PREFERRED
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPS PREFERRED
ESGIC CAPS PREFERRED
FIORICET CAPS NON_PREFERRED
ZEBUTAL CAPS PREFERRED
VANATOL LQ SOLN NON_PREFERRED
VANATOL S SOLN NON_PREFERRED
VTOL LQ SOLN NON_PREFERRED
BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS PREFERRED
ESGIC TABS NON_PREFERRED
BUTALBITAL/ASPIRIN/CAFFEINE CAPS PREFERRED
FIORINAL CAPS NON_PREFERRED
BUTALBITAL/ASPIRIN/CAFFEINE TABS PREFERRED
ANALGESICS : OPIOID CODEINE SULFATE TABS PREFERRED
DURAGESIC PT72 NON_PREFERRED
FENTANYL PT72 NON_PREFERRED
ACTIQ LPOP NON_PREFERRED
FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP NON_PREFERRED
ABSTRAL SUBL NON_PREFERRED
FENTANYL CITRATE TABS NON_PREFERRED
FENTORA TABS NON_PREFERRED
HYDROCODONE BITARTRATE ER CP12 NON_PREFERRED
ZOHYDRO ER CP12 NON_PREFERRED
HYSINGLA ER T24A NON_PREFERRED
DILAUDID LIQD NON_PREFERRED
HYDROMORPHONE HCL LIQD PREFERRED
HYDROMORPHONE HCL SUPP PREFERRED
DILAUDID TABS NON_PREFERRED
HYDROMORPHONE HCL TABS PREFERRED
HYDROMORPHONE HCL ER TB24 NON_PREFERRED
HYDROMORPHONE HYDROCHLORIDE ER TB24 NON_PREFERRED
LEVORPHANOL TARTRATE TABS NON_PREFERRED
Page 5 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
MEPERIDINE HCL SOLN NON_PREFERRED
MEPERIDINE HCL TABS NON_PREFERRED
METHADONE HCL CONC NON_PREFERRED
METHADONE HCL INTENSOL CONC NON_PREFERRED
METHADOSE CONC NON_PREFERRED
METHADOSE SUGAR-FREE CONC NON_PREFERRED
METHADONE HCL SOLN NON_PREFERRED
METHADONE HCL TABS NON_PREFERRED
METHADONE HYDROCHLORIDE TABS NON_PREFERRED
METHADONE HCL TBSO NON_PREFERRED
METHADOSE TBSO NON_PREFERRED
KADIAN CP24 NON_PREFERRED
MORPHINE SULFATE ER CP24 NON_PREFERRED
MORPHINE SULFATE SOLN PREFERRED
MORPHINE SULFATE SUPP PREFERRED
MORPHABOND ER T12A NON_PREFERRED
MORPHINE SULFATE TABS PREFERRED
MORPHINE SULFATE ER TBCR PREFERRED_WITH_PA
MS CONTIN TBCR NON_PREFERRED
ARYMO ER TBEA NON_PREFERRED
MORPHINE SULFATE ER CP24 NON_PREFERRED
XTAMPZA ER C12A NON_PREFERRED
OXYCODONE HCL CAPS PREFERRED
OXYCODONE HYDROCHLORIDE CAPS PREFERRED
OXYCODONE HCL CONC PREFERRED
OXYCODONE HYDROCHLORIDE CONC PREFERRED
OXYCODONE HYDROCHLORIDE SOLN PREFERRED
OXYCODONE HCL ER T12A NON_PREFERRED
OXYCODONE HYDROCHLORIDE ER T12A NON_PREFERRED
OXYCONTIN T12A NON_PREFERRED
OXAYDO TABS NON_PREFERRED
OXYCODONE HCL TABS PREFERRED
OXYCODONE HYDROCHLORIDE TABS PREFERRED
ROXICODONE TABS NON_PREFERRED
OXYMORPHONE HYDROCHLORIDE TABS NON_PREFERRED
OXYMORPHONE HYDROCHLORIDE ER TB12 NON_PREFERRED
OXYMORPHONE HYDROCHLORIDEER TB12 NON_PREFERRED
NUCYNTA TABS NON_PREFERRED
NUCYNTA ER TB12 NON_PREFERRED
CONZIP CP24 NON_PREFERRED
TRAMADOL HCL ER CP24 NON_PREFERRED
TRAMADOL HCL TABS PREFERRED
TRAMADOL HYDROCHLORIDE TABS NON_PREFERRED
TRAMADOL HYDROCHLORIDE TABS PREFERRED
Page 6 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ULTRAM TABS NON_PREFERRED
TRAMADOL HCL ER TB24 NON_PREFERRED
BUPRENORPHINE PTWK NON_PREFERRED
BUTRANS PTWK NON_PREFERRED
BELBUCA FILM NON_PREFERRED
BUTORPHANOL TARTRATE SOLN NON_PREFERRED
PENTAZOCINE/NALOXONE HCL TABS NON_PREFERRED
ANALGESICS : OPIOID COMBINATIONS APADAZ TABS NON_PREFERRED
BENZHYDROCODONE/ACETAMINOPHEN TABS NON_PREFERRED
ENDOCET TABS PREFERRED
NALOCET TABS NON_PREFERRED
OXYCODONE/ACETAMINOPHEN TABS PREFERRED
PERCOCET TABS NON_PREFERRED
PRIMLEV TABS NON_PREFERRED
PROLATE TABS NON_PREFERRED
OXYCODONE/ASPIRIN TABS NON_PREFERRED
OXYCODONE/IBUPROFEN TABS NON_PREFERRED
ACETAMINOPHEN/CODEINE SOLN PREFERRED
ACETAMINOPHEN/CODEINE TABS PREFERRED
ACETAMINOPHEN/CODEINE PHOSPHATE TABS PREFERRED
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE CAPS NON_PREFERRED
ASCOMP/CODEINE CAPS PREFERRED
BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS PREFERRED
FIORINAL/CODEINE #3 CAPS NON_PREFERRED
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPS NON_PREFERRED
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE TABS NON_PREFERRED
PANLOR TABS NON_PREFERRED
LORTAB ELIX NON_PREFERRED
HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN PREFERRED
HYDROCODONE BITARTRATE/ACETAMINOPHEN TABS PREFERRED
HYDROCODONE/ACETAMINOPHEN TABS PREFERRED
LORCET TABS PREFERRED
LORCET HD TABS PREFERRED
LORCET PLUS TABS PREFERRED
NORCO TABS NON_PREFERRED
VERDROCET TABS NON_PREFERRED
HYDROCODONE/IBUPROFEN TABS PREFERRED
REPREXAIN TABS NON_PREFERRED
REPREXAIN TABS PREFERRED
XYLON TABS PREFERRED
TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN TABS NON_PREFERRED
ULTRACET TABS NON_PREFERRED
ANAPHYLAXIS THERAPY AGENTS ADRENACLICK SOAJ PREFERRED
EPINEPHRINE SOAJ PREFERRED
Page 7 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
EPIPEN 2-PAK SOAJ NON_PREFERRED
EPIPEN-JR 2-PAK SOAJ NON_PREFERRED
SYMJEPI SOSY NON_PREFERRED
ANORECTAL AGENTS ANUSOL-HC CREA NON_PREFERRED
HYDROCORTISONE CREA PREFERRED
PROCTO-MED HC CREA PREFERRED
PROCTOSOL HC CREA PREFERRED
PROCTOZONE-HC CREA PREFERRED
UCERIS FOAM NON_PREFERRED
CORTENEMA ENEM NON_PREFERRED
HYDROCORTISONE ENEM PREFERRED
CORTIFOAM FOAM NON_PREFERRED
RECTIV OINT NON_PREFERRED
LIDOCAINE HCL/HYDROCORTISONE ACETATE CREA NON_PREFERRED
LIDOCORT CREA NON_PREFERRED
LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE GEL NON_PREFERRED
ANA-LEX KIT NON_PREFERRED
LIDOCAINE HCL/HYDROCORTISONE ACETATE KIT NON_PREFERRED
PROCTOFOAM HC FOAM NON_PREFERRED
ANTIANXIETY AGENTS : BENZODIAZEPINES ALPRAZOLAM INTENSOL CONC PREFERRED
ALPRAZOLAM TABS PREFERRED
XANAX TABS NON_PREFERRED
ALPRAZOLAM ER TB24 NON_PREFERRED
ALPRAZOLAM XR TB24 NON_PREFERRED
XANAX XR TB24 NON_PREFERRED
ALPRAZOLAM ODT TBDP NON_PREFERRED
CHLORDIAZEPOXIDE HCL CAPS PREFERRED
CHLORDIAZEPOXIDE HYDROCHLORIDE CAPS PREFERRED
CLORAZEPATE DIPOTASSIUM TABS PREFERRED
TRANXENE T TABS NON_PREFERRED
DIAZEPAM CONC PREFERRED
DIAZEPAM INTENSOL CONC PREFERRED
DIAZEPAM SOLN PREFERRED
DIAZEPAM TABS PREFERRED
LORAZEPAM CONC PREFERRED
LORAZEPAM INTENSOL CONC PREFERRED
ATIVAN TABS NON_PREFERRED
LORAZEPAM TABS PREFERRED
OXAZEPAM CAPS PREFERRED
ANTIANXIETY AGENTS : MISC BUSPIRONE HCL TABS PREFERRED
BUSPIRONE HYDROCHLORIDE TABS PREFERRED
HYDROXYZINE HCL SYRP PREFERRED
HYDROXYZINE HCL TABS PREFERRED
HYDROXYZINE HYDROCHLORIDE TABS PREFERRED
Page 8 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
HYDROXYZINE PAMOATE CAPS PREFERRED
VISTARIL CAPS NON_PREFERRED
MEPROBAMATE TABS NON_PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : ADRENERGIC
COMBINATIONS COMBIVENT RESPIMAT AERS NON_PREFERRED
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE SOLN PREFERRED
DUAKLIR PRESSAIR AEPB NON_PREFERRED
BUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE AERO NON_PREFERRED
SYMBICORT AERO PREFERRED
BEVESPI AEROSPHERE AERO PREFERRED
UTIBRON NEOHALER CAPS NON_PREFERRED
ADVAIR DISKUS AEPB NON_PREFERRED
AIRDUO DIGIHALER 113/14 AEPB NON_PREFERRED
AIRDUO DIGIHALER 232/14 AEPB NON_PREFERRED
AIRDUO DIGIHALER 55/14 AEPB NON_PREFERRED
AIRDUO RESPICLICK 113/14 AEPB NON_PREFERRED
AIRDUO RESPICLICK 232/14 AEPB NON_PREFERRED
AIRDUO RESPICLICK 55/14 AEPB NON_PREFERRED
FLUTICASONE PROPIONATE/SALMETEROL AEPB NON_PREFERRED
FLUTICASONE PROPIONATE/SALMETEROL DISKUS AEPB NON_PREFERRED
WIXELA INHUB AEPB PREFERRED
ADVAIR HFA AERO NON_PREFERRED
BREO ELLIPTA AEPB NON_PREFERRED
DULERA AERO PREFERRED
STIOLTO RESPIMAT AERS NON_PREFERRED
ANORO ELLIPTA AEPB NON_PREFERRED
BREZTRI AEROSPHERE AERO NON_PREFERRED
TRELEGY ELLIPTA AEPB NON_PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS :
ANTICHOLINERGICS TUDORZA PRESSAIR AEPB NON_PREFERRED
SEEBRI NEOHALER CAPS NON_PREFERRED
LONHALA MAGNAIR REFILL KIT SOLN NON_PREFERRED
LONHALA MAGNAIR STARTER KIT SOLN NON_PREFERRED
IPRATROPIUM BROMIDE SOLN PREFERRED
ATROVENT HFA AERS PREFERRED
YUPELRI SOLN NON_PREFERRED
SPIRIVA AER 1.25MCG AERS PREFERRED
SPIRIVA SPR 2.5MCG AERS NON_PREFERRED
SPIRIVA HANDIHALER CAPS PREFERRED
INCRUSE ELLIPTA AEPB NON_PREFERRED
CROMOLYN SODIUM NEBU PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : BETA
ADRENERGICS PROAIR DIGIHALER AEPB NON_PREFERRED
PROAIR RESPICLICK AEPB NON_PREFERRED
Page 9 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ALBUTEROL SULFATE HFA AERS PREFERRED
PROAIR HFA AERS PREFERRED
PROVENTIL HFA AERS PREFERRED
VENTOLIN HFA AERS PREFERRED
ALBUTEROL SULFATE NEBU PREFERRED
ALBUTEROL SULFATE SYRP PREFERRED
ALBUTEROL TABS NON_PREFERRED
ALBUTEROL SULFATE TABS NON_PREFERRED
ALBUTEROL SULFATE ER TB12 NON_PREFERRED
BROVANA NEBU NON_PREFERRED
PERFOROMIST NEBU NON_PREFERRED
ARCAPTA NEOHALER CAPS NON_PREFERRED
LEVALBUTEROL NEBU PREFERRED
LEVALBUTEROL HCL NEBU PREFERRED
LEVALBUTEROL HYDROCHLORIDE NEBU PREFERRED
XOPENEX NEBU NON_PREFERRED
XOPENEX CONCENTRATE NEBU NON_PREFERRED
LEVALBUTEROL TARTRATE HFA AERO PREFERRED
XOPENEX HFA AERO PREFERRED
METAPROTERENOL SULFATE SYRP NON_PREFERRED
STRIVERDI RESPIMAT AERS NON_PREFERRED
SEREVENT DISKUS AEPB PREFERRED
TERBUTALINE SULFATE TABS PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : LEUKOTRIENE
MODULATORS ZYFLO TABS NON_PREFERRED
ZILEUTON ER TB12 NON_PREFERRED
MONTELUKAST SODIUM CHEW PREFERRED
SINGULAIR CHEW NON_PREFERRED
MONTELUKAST SODIUM PACK PREFERRED
SINGULAIR PACK NON_PREFERRED
MONTELUKAST SODIUM TABS PREFERRED
SINGULAIR TABS NON_PREFERRED
ACCOLATE TABS NON_PREFERRED
ZAFIRLUKAST TABS PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MISC THEO-24 CP24 PREFERRED
THEOPHYLLINE SOLN PREFERRED
THEOPHYLLINE ER TB12 PREFERRED
THEOPHYLLINE ER TB24 PREFERRED
DALIRESP TABS NON_PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MONOCLONAL
ANTIBODIES XOLAIR SOLR NON_PREFERRED
XOLAIR SOSY NON_PREFERRED
FASENRA PEN SOAJ NON_PREFERRED
FASENRA SOSY NON_PREFERRED
Page 10 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
NUCALA SOAJ NON_PREFERRED
NUCALA SOLR PREFERRED_WITH_PA
NUCALA SOSY NON_PREFERRED
CINQAIR SOLN NON_PREFERRED
DUPIXENT SOPN NON_PREFERRED
DUPIXENT INJ 200/1.14 SOSY PREFERRED_WITH_PA
DUPIXENT INJ 300/2ML SOSY NON_PREFERRED
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : STEROID
INHALANTS QVAR REDIHALER AERB NON_PREFERRED
PULMICORT FLEXHALER AEPB NON_PREFERRED
BUDESONIDE SUSP PREFERRED
PULMICORT SUSP NON_PREFERRED
ALVESCO AERS NON_PREFERRED
ARNUITY ELLIPTA AEPB NON_PREFERRED
ARMONAIR DIGIHALER AEPB NON_PREFERRED
FLOVENT DISKUS AEPB PREFERRED
FLOVENT HFA AERO PREFERRED
ASMANEX TWISTHALER 120 METERED DOSES AEPB PREFERRED
ASMANEX TWISTHALER 14 METERED DOSES AEPB PREFERRED
ASMANEX TWISTHALER 30 METERED DOSES AEPB PREFERRED
ASMANEX TWISTHALER 60 METERED DOSES AEPB PREFERRED
ASMANEX HFA AERO NON_PREFERRED
ANTIBIOITCS : FLUOROQUINOLONES CIPRO SUSR NON_PREFERRED
CIPROFLOXACIN SUSR PREFERRED
CIPRO XR TB24 NON_PREFERRED
CIPRO TABS NON_PREFERRED
CIPROFLOXACIN HCL TABS PREFERRED
CIPROFLOXACIN HYDROCHLORIDE TABS PREFERRED
BAXDELA TABS NON_PREFERRED
LEVOFLOXACIN SOLN PREFERRED
LEVOFLOXACIN TABS PREFERRED
AVELOX TABS NON_PREFERRED
MOXIFLOXACIN HYDROCHLORIDE TABS NON_PREFERRED
OFLOXACIN TABS NON_PREFERRED
ANTIBIOTICS : AMINOGLYCOSIDES NEOMYCIN SULFATE TABS PREFERRED
PAROMOMYCIN SULFATE CAPS PREFERRED
ANTIBIOTICS : AMINOGLYCOSIDES - INHALED ARIKAYCE SUSP NON_PREFERRED
TOBI PODHALER CAPS NON_PREFERRED
BETHKIS NEBU NON_PREFERRED
KITABIS PAK NEBU PREFERRED
TOBI NEBU NON_PREFERRED
TOBRAMYCIN NEBU NON_PREFERRED
ANTIBIOTICS : ANTI-INFECTIVE AGENTS SULFADIAZINE TABS PREFERRED
SOLOSEC PACK NON_PREFERRED
Page 11 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
FLAGYL CAPS NON_PREFERRED
METRONIDAZOLE CAPS NON_PREFERRED
FLAGYL TABS NON_PREFERRED
METRONIDAZOLE TABS PREFERRED
NEBUPENT SOLR PREFERRED
PENTAMIDINE ISETHIONATE SOLR PREFERRED
XIFAXAN TABS NON_PREFERRED
TINIDAZOLE TABS NON_PREFERRED
TRIMETHOPRIM TABS PREFERRED
CAYSTON SOLR NON_PREFERRED
CLEOCIN CAPS NON_PREFERRED
CLINDAMYCIN HCL CAPS PREFERRED
CLINDAMYCIN HYDROCHLORIDE CAPS PREFERRED
CLEOCIN PEDIATRIC GRANULES SOLR NON_PREFERRED
CLINDAMYCIN PALMITATE HCL SOLR PREFERRED
CLINDAMYCIN PALMITATE HYDROCHLORIDE SOLR PREFERRED
LINEZOLID SUSR NON_PREFERRED
ZYVOX SUSR NON_PREFERRED
LINEZOLID TABS NON_PREFERRED
ZYVOX TABS NON_PREFERRED
SIVEXTRO TABS NON_PREFERRED
XENLETA TABS NON_PREFERRED
VANCOCIN CAPS NON_PREFERRED
VANCOCIN HCL CAPS NON_PREFERRED
VANCOMYCIN HYDROCHLORIDE CAPS PREFERRED
FIRST-VANCOMYCIN 25 SOLN NON_PREFERRED
FIRST-VANCOMYCIN 50 SOLN NON_PREFERRED
FIRVANQ SOLR NON_PREFERRED
VANCOMYCIN HYDROCHLORIDE SOLR PREFERRED
DAPSONE TABS PREFERRED
ATOVAQUONE SUSP PREFERRED
MEPRON SUSP NON_PREFERRED
LAMPIT TABS NON_PREFERRED
FOSFOMYCIN TROMETHAMINE PACK PREFERRED
MONUROL PACK PREFERRED
METHENAMINE MANDELATE TABS PREFERRED
HIPREX TABS NON_PREFERRED
METHENAMINE HIPPURATE TABS PREFERRED
NITROFURANTOIN SUSP PREFERRED
MACRODANTIN CAPS NON_PREFERRED
NITROFURANTOIN MACROCRYSTALS CAPS PREFERRED
MACROBID CAPS NON_PREFERRED
NITROFURANTOIN MONOHYDRATE CAPS PREFERRED
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS CAPS PREFERRED
Page 12 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP PREFERRED
SULFATRIM PEDIATRIC SUSP PREFERRED
BACTRIM TABS NON_PREFERRED
BACTRIM DS TABS NON_PREFERRED
SULFAMETHOXAZOLE/TRIMETHOPRIM TABS PREFERRED
SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS PREFERRED
ME/NAPHOS/MB/HYO 1 TABS NON_PREFERRED
UROGESIC-BLUE TABS NON_PREFERRED
HYOPHEN TABS NON_PREFERRED
URAMIT MB CAPS NON_PREFERRED
URO-MP CAPS NON_PREFERRED
USTELL CAPS NON_PREFERRED
HYOLEV MB TABS NON_PREFERRED
PHOSPHASAL TABS NON_PREFERRED
URIMAR-T TABS NON_PREFERRED
URIN D/S TABS NON_PREFERRED
URO-458 TABS NON_PREFERRED
ANTIBIOTICS : ANTIMYCOBACTERIAL AGENTS PASER PACK NON_PREFERRED
SIRTURO TABS NON_PREFERRED
CYCLOSERINE CAPS PREFERRED
ETHAMBUTOL HCL TABS PREFERRED
ETHAMBUTOL HYDROCHLORIDE TABS PREFERRED
MYAMBUTOL TABS NON_PREFERRED
TRECATOR TABS PREFERRED
ISONIAZID SYRP PREFERRED
ISONIAZID TABS PREFERRED
PRETOMANID TABS NON_PREFERRED
PYRAZINAMIDE TABS PREFERRED
MYCOBUTIN CAPS NON_PREFERRED
RIFABUTIN CAPS PREFERRED
RIFAMPIN CAPS PREFERRED
PRIFTIN TABS NON_PREFERRED
ANTIBIOTICS : CEPHALOSPORINS CEFADROXIL CAPS PREFERRED
CEFADROXIL SUSR PREFERRED
CEFADROXIL TABS PREFERRED
CEPHALEXIN CAPS PREFERRED
KEFLEX CAPS NON_PREFERRED
CEPHALEXIN SUSR PREFERRED
CEPHALEXIN TABS PREFERRED
CEFACLOR CAPS PREFERRED
CEFACLOR SUSR PREFERRED
CEFACLOR ER TB12 NON_PREFERRED
CEFPROZIL SUSR PREFERRED
CEFPROZIL TABS NON_PREFERRED
Page 13 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CEFUROXIME AXETIL TABS PREFERRED
CEFDINIR CAPS PREFERRED
CEFDINIR SUSR PREFERRED
CEFIXIME CAPS PREFERRED
SUPRAX CAPS PREFERRED
SUPRAX CHEW NON_PREFERRED
CEFIXIME SUSR NON_PREFERRED
SUPRAX SUSR NON_PREFERRED
CEFPODOXIME PROXETIL SUSR NON_PREFERRED
CEFPODOXIME PROXETIL TABS NON_PREFERRED
ANTIBIOTICS : MACROLIDES ERYTHROMYCIN CPEP PREFERRED
ERYTHROMYCIN BASE TABS PREFERRED
ERY-TAB TBEC PREFERRED
ERYTHROMYCIN DR TBEC PREFERRED
PCE TBEC PREFERRED
ERYTHROCIN STEARATE TABS PREFERRED
E.E.S. GRANULES SUSR PREFERRED
ERYPED 200 SUSR PREFERRED
ERYPED 400 SUSR PREFERRED
ERYTHROMYCIN ETHYLSUCCINATE SUSR PREFERRED
E.E.S. 400 TABS PREFERRED
ERYTHROMYCIN ETHYLSUCCINATE TABS PREFERRED
AZITHROMYCIN PACK PREFERRED
ZITHROMAX PACK PREFERRED
AZITHROMYCIN SUSR PREFERRED
ZITHROMAX SUSR NON_PREFERRED
AZITHROMYCIN TABS PREFERRED
ZITHROMAX TABS NON_PREFERRED
ZITHROMAX TRI-PAK TABS NON_PREFERRED
ZITHROMAX Z-PAK TABS NON_PREFERRED
CLARITHROMYCIN SUSR PREFERRED
CLARITHROMYCIN TABS PREFERRED
CLARITHROMYCIN ER TB24 PREFERRED
DIFICID TABS NON_PREFERRED
ANTIBIOTICS : PENICILLINS PENICILLIN V POTASSIUM SOLR PREFERRED
PENICILLIN V POTASSIUM TABS PREFERRED
AMOXICILLIN CAPS PREFERRED
AMOXICILLIN CHEW PREFERRED
AMOXICILLIN SUSR PREFERRED
AMOXICILLIN TABS PREFERRED
AMPICILLIN CAPS PREFERRED
DICLOXACILLIN SODIUM CAPS PREFERRED
AMOXICILLIN/CLAVULANATE POTASSIUM CHEW PREFERRED
AMOXICILLIN/CLAVULANATE POTASSIUM SUSR PREFERRED
Page 14 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
AUGMENTIN SUSR PREFERRED
AMOXICILLIN/CLAVULANATE POTASSIUM TABS PREFERRED
AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 NON_PREFERRED
ANTIBIOTICS : TETRACYCLINES DEMECLOCYCLINE HCL TABS PREFERRED
DEMECLOCYCLINE HYDROCHLORIDE TABS PREFERRED
DOXYCYCLINE MONOHYDRATE CAPS PREFERRED
DOXYCYCLINE SUSR PREFERRED
VIBRAMYCIN SUSR NON_PREFERRED
DOXYCYCLINE TABS PREFERRED
DOXYCYCLINE MONOHYDRATE TABS PREFERRED
DOXYCYCLINE HYCLATE CAPS PREFERRED
MORGIDOX 1X100MG CAPS PREFERRED
MORGIDOX 1X50MG CAPS PREFERRED
MORGIDOX 2X100MG CAPS PREFERRED
VIBRAMYCIN CAPS NON_PREFERRED
DOXYCYCLINE HYCLATE TABS PREFERRED
DORYX TBEC NON_PREFERRED
DORYX MPC TBEC NON_PREFERRED
DOXYCYCLINE HYCLATE TBEC NON_PREFERRED
DOXYCYCLINE HYCLATE DR TBEC NON_PREFERRED
VIBRAMYCIN SYRP PREFERRED
MORGIDOX 1X100MG KIT NON_PREFERRED
MORGIDOX 1X50MG KIT KIT NON_PREFERRED
MORGIDOX 2X100MG KIT NON_PREFERRED
MINOCIN CAPS NON_PREFERRED
MINOCYCLINE HCL CAPS PREFERRED
MINOCYCLINE HYDROCHLORIDE CAPS PREFERRED
XIMINO CP24 NON_PREFERRED
MINOCYCLINE HCL TABS PREFERRED
MINOCYCLINE HYDROCHLORIDE TABS PREFERRED
MINOCYCLINE HCL ER TB24 NON_PREFERRED
MINOCYCLINE HYDROCHLORIDE ER TB24 NON_PREFERRED
MINOCYCLINE HYDROCHLORIDEER TB24 NON_PREFERRED
MINOLIRA TB24 NON_PREFERRED
SOLODYN TB24 NON_PREFERRED
TETRACYCLINE HYDROCHLORIDE CAPS PREFERRED
NUZYRA TABS NON_PREFERRED
ANTICOAGULANTS : COUMARIN COUMADIN TABS NON_PREFERRED
JANTOVEN TABS PREFERRED
WARFARIN SODIUM TABS PREFERRED
ANTICOAGULANTS : DIRECT FACTOR XA INHIBITORS & MISC PRADAXA CAPS NON_PREFERRED
ELIQUIS TABS PREFERRED_WITH_PA
ELIQUIS STARTER PACK TBPK PREFERRED_WITH_PA
BEVYXXA CAPS NON_PREFERRED
Page 15 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SAVAYSA TABS NON_PREFERRED
XARELTO TABS PREFERRED_WITH_PA
XARELTO STARTER PACK TBPK PREFERRED_WITH_PA
ANTICOAGULANTS : HEPARIN AND HEPARINOID-LIKE AGENTS HEPARIN SODIUM SOLN PREFERRED
HEPARIN SODIUM DCU SOLN PREFERRED
HEPARIN SODIUM SOSY PREFERRED
FRAGMIN SOLN PREFERRED
ENOXAPARIN SODIUM SOLN PREFERRED
LOVENOX SOLN NON_PREFERRED
ARIXTRA SOLN NON_PREFERRED
FONDAPARINUX SODIUM SOLN PREFERRED
ANTICONVULSANTS SYMPAZAN FILM NON_PREFERRED
CLOBAZAM SUSP NON_PREFERRED
ONFI SUSP NON_PREFERRED
CLOBAZAM TABS NON_PREFERRED
ONFI TABS NON_PREFERRED
CLONAZEPAM TABS PREFERRED
KLONOPIN TABS NON_PREFERRED
CLONAZEPAM ODT TBDP NON_PREFERRED
DIASTAT ACUDIAL GEL PREFERRED
DIASTAT PEDIATRIC GEL PREFERRED
DIAZEPAM GEL PREFERRED
DIAZEPAM RECTAL GEL GEL PREFERRED
VALTOCO LIQD NON_PREFERRED
VALTOCO LQPK NON_PREFERRED
NAYZILAM SOLN NON_PREFERRED
XCOPRI TABS NON_PREFERRED
XCOPRI TBPK NON_PREFERRED
FELBAMATE SUSP NON_PREFERRED
FELBATOL SUSP NON_PREFERRED
FELBAMATE TABS NON_PREFERRED
FELBATOL TABS NON_PREFERRED
GABITRIL TABS NON_PREFERRED
TIAGABINE HYDROCHLORIDE TABS NON_PREFERRED
SABRIL PACK NON_PREFERRED
VIGABATRIN PACK NON_PREFERRED
VIGADRONE PACK NON_PREFERRED
SABRIL TABS NON_PREFERRED
VIGABATRIN TABS NON_PREFERRED
PEGANONE TABS NON_PREFERRED
DILANTIN INFATABS CHEW NON_PREFERRED
PHENYTOIN CHEW PREFERRED
PHENYTOIN INFATABS CHEW PREFERRED
Page 16 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
DILANTIN-125 SUSP NON_PREFERRED
PHENYTOIN SUSP PREFERRED
DILANTIN CAPS NON_PREFERRED
PHENYTEK CAPS NON_PREFERRED
PHENYTOIN SODIUM EXTENDED CAPS PREFERRED
ETHOSUXIMIDE CAPS PREFERRED
ZARONTIN CAPS NON_PREFERRED
ETHOSUXIMIDE SOLN PREFERRED
ZARONTIN SOLN NON_PREFERRED
CELONTIN CAPS NON_PREFERRED
DEPAKOTE SPRINKLES CSDR NON_PREFERRED
DIVALPROEX SODIUM CSDR PREFERRED
DEPAKOTE ER TB24 NON_PREFERRED
DIVALPROEX SODIUM ER TB24 PREFERRED
DEPAKOTE TBEC NON_PREFERRED
DIVALPROEX SODIUM DR TBEC PREFERRED
VALPROIC ACID SOLN PREFERRED
VALPROIC ACID CAPS PREFERRED
FYCOMPA SUSP NON_PREFERRED
FYCOMPA TABS NON_PREFERRED
BRIVIACT SOLN NON_PREFERRED
BRIVIACT TABS NON_PREFERRED
EPIDIOLEX SOLN NON_PREFERRED
CARBAMAZEPINE CHEW PREFERRED
CARBAMAZEPINE ER CP12 NON_PREFERRED
CARBATROL CP12 NON_PREFERRED
CARBAMAZEPINE SUSP PREFERRED
TEGRETOL SUSP NON_PREFERRED
CARBAMAZEPINE TABS PREFERRED
EPITOL TABS PREFERRED
TEGRETOL TABS NON_PREFERRED
CARBAMAZEPINE ER TB12 PREFERRED
TEGRETOL-XR TB12 NON_PREFERRED
APTIOM TABS NON_PREFERRED
FINTEPLA SOLN NON_PREFERRED
GABAPENTIN CAPS PREFERRED
NEURONTIN CAPS NON_PREFERRED
GABAPENTIN SOLN PREFERRED
NEURONTIN SOLN NON_PREFERRED
GABAPENTIN TABS PREFERRED
NEURONTIN TABS NON_PREFERRED
VIMPAT SOLN NON_PREFERRED
VIMPAT TABS NON_PREFERRED
LAMICTAL CHEWABLE DISPERSIBLE CHEW NON_PREFERRED
Page 17 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
LAMOTRIGINE CHEW PREFERRED
LAMICTAL ODT KIT NON_PREFERRED
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT NON_PREFERRED
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE KIT NON_PREFERRED
LAMICTAL STARTER/TAKING VALPROATE KIT NON_PREFERRED
LAMICTAL XR KIT NON_PREFERRED
LAMOTRIGINE STARTER KIT/BLUE KIT NON_PREFERRED
LAMOTRIGINE STARTER KIT/GREEN KIT NON_PREFERRED
LAMOTRIGINE STARTER KIT/ORANGE KIT NON_PREFERRED
LAMOTRIGINE TITRATION KIT NON_PREFERRED
SUBVENITE STARTER KIT/BLUE KIT NON_PREFERRED
SUBVENITE STARTER KIT/GREEN KIT NON_PREFERRED
SUBVENITE STARTER KIT/ORANGE KIT NON_PREFERRED
LAMICTAL TABS NON_PREFERRED
LAMOTRIGINE TABS PREFERRED
SUBVENITE TABS PREFERRED
LAMICTAL XR TB24 NON_PREFERRED
LAMOTRIGINE ER TB24 NON_PREFERRED
LAMICTAL ODT TBDP NON_PREFERRED
LAMOTRIGINE ODT TBDP NON_PREFERRED
KEPPRA SOLN NON_PREFERRED
LEVETIRACETAM SOLN PREFERRED
KEPPRA TABS NON_PREFERRED
LEVETIRACETAM TABS PREFERRED
ROWEEPRA TABS PREFERRED
KEPPRA XR TB24 NON_PREFERRED
LEVETIRACETAM ER TB24 PREFERRED
SPRITAM TB3D NON_PREFERRED
OXCARBAZEPINE SUSP PREFERRED
TRILEPTAL SUSP NON_PREFERRED
OXCARBAZEPINE TABS PREFERRED
TRILEPTAL TABS NON_PREFERRED
OXTELLAR XR TB24 NON_PREFERRED
LYRICA CAPS NON_PREFERRED
PREGABALIN CAPS PREFERRED
LYRICA SOLN NON_PREFERRED
PREGABALIN SOLN PREFERRED
MYSOLINE TABS NON_PREFERRED
PRIMIDONE TABS PREFERRED
BANZEL SUSP NON_PREFERRED
RUFINAMIDE SUSP NON_PREFERRED
BANZEL TABS NON_PREFERRED
DIACOMIT CAPS NON_PREFERRED
DIACOMIT PACK NON_PREFERRED
Page 18 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
TROKENDI XR CP24 NON_PREFERRED
TOPAMAX SPRINKLE CPSP NON_PREFERRED
TOPIRAMATE CPSP PREFERRED
QUDEXY XR CS24 NON_PREFERRED
TOPIRAMATE ER CS24 NON_PREFERRED
TOPAMAX TABS NON_PREFERRED
TOPIRAMATE TABS PREFERRED
ZONISAMIDE CAPS PREFERRED
ANTIDEPRESSANTS : MISC MIRTAZAPINE TABS PREFERRED
REMERON TABS NON_PREFERRED
MIRTAZAPINE ODT TBDP PREFERRED
REMERON SOLTAB TBDP NON_PREFERRED
MARPLAN TABS NON_PREFERRED
NARDIL TABS NON_PREFERRED
PHENELZINE SULFATE TABS PREFERRED
EMSAM PT24 NON_PREFERRED
TRANYLCYPROMINE SULFATE TABS PREFERRED
SPRAVATO 56MG DOSE SOPK NON_PREFERRED
SPRAVATO 84MG DOSE SOPK NON_PREFERRED
NEFAZODONE HCL TABS NON_PREFERRED
NEFAZODONE HYDROCHLORIDE TABS NON_PREFERRED
TRAZODONE HYDROCHLORIDE TABS PREFERRED
VIIBRYD STARTER PACK KIT NON_PREFERRED
VIIBRYD TABS NON_PREFERRED
TRINTELLIX TABS NON_PREFERRED
AMITRIPTYLINE HCL TABS PREFERRED
AMITRIPTYLINE HYDROCHLORIDE TABS PREFERRED
AMOXAPINE TABS NON_PREFERRED
ANAFRANIL CAPS NON_PREFERRED
CLOMIPRAMINE HCL CAPS PREFERRED
CLOMIPRAMINE HYDROCHLORIDE CAPS PREFERRED
DESIPRAMINE HCL TABS PREFERRED
DESIPRAMINE HYDROCHLORIDE TABS PREFERRED
NORPRAMIN TABS NON_PREFERRED
DOXEPIN HCL CAPS PREFERRED
DOXEPIN HYDROCHLORIDE CAPS PREFERRED
DOXEPIN HCL CONC PREFERRED
IMIPRAMINE HCL TABS PREFERRED
IMIPRAMINE HYDROCHLORIDE TABS PREFERRED
TOFRANIL TABS NON_PREFERRED
IMIPRAMINE PAMOATE CAPS NON_PREFERRED
NORTRIPTYLINE HCL CAPS PREFERRED
NORTRIPTYLINE HYDROCHLORIDE CAPS PREFERRED
PAMELOR CAPS NON_PREFERRED
Page 19 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
NORTRIPTYLINE HCL SOLN PREFERRED
PROTRIPTYLINE HCL TABS PREFERRED
SURMONTIL CAPS NON_PREFERRED
TRIMIPRAMINE MALEATE CAPS NON_PREFERRED
MAPROTILINE HCL TABS PREFERRED
BUPROPION HCL TABS PREFERRED
BUPROPION HYDROCHLORIDE TABS PREFERRED
BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED
WELLBUTRIN SR TB12 NON_PREFERRED
BUPROPION HYDROCHLORIDE ER (XL) TB24 PREFERRED
FORFIVO XL TB24 NON_PREFERRED
WELLBUTRIN XL TB24 NON_PREFERRED
APLENZIN TB24 NON_PREFERRED
PRAMLYTE THPK NON_PREFERRED
ANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE INHIBITOR
(SSRIs) CITALOPRAM HYDROBROMIDE SOLN PREFERRED
CELEXA TABS NON_PREFERRED
CITALOPRAM TABS PREFERRED
CITALOPRAM HYDROBROMIDE TABS PREFERRED
ESCITALOPRAM OXALATE SOLN PREFERRED
ESCITALOPRAM OXALATE TABS PREFERRED
LEXAPRO TABS NON_PREFERRED
FLUOXETINE HCL CAPS PREFERRED
FLUOXETINE HYDROCHLORIDE CAPS PREFERRED
PROZAC CAPS NON_PREFERRED
FLUOXETINE DR CPDR NON_PREFERRED
FLUOXETINE HCL SOLN PREFERRED
FLUOXETINE HYDROCHLORIDE SOLN PREFERRED
FLUOXETINE HYDROCHLORIDE TABS PREFERRED
FLUVOXAMINE MALEATE ER CP24 NON_PREFERRED
FLUVOXAMINE MALEATE TABS PREFERRED
PAXIL SUSP NON_PREFERRED
PAROXETINE HCL TABS PREFERRED
PAROXETINE HYDROCHLORIDE TABS PREFERRED
PAXIL TABS NON_PREFERRED
PAROXETINE HCL ER TB24 NON_PREFERRED
PAROXETINE HYDROCHLORIDEER TB24 NON_PREFERRED
PAXIL CR TB24 NON_PREFERRED
PEXEVA TABS NON_PREFERRED
SERTRALINE HCL CONC PREFERRED
SERTRALINE HYDROCHLORIDE CONC PREFERRED
ZOLOFT CONC NON_PREFERRED
SERTRALINE HCL TABS PREFERRED
SERTRALINE HYDROCHLORIDE TABS PREFERRED
Page 20 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ZOLOFT TABS NON_PREFERRED
ANTIDEPRESSANTS : SELECTIVE SEROTONIN-NOREPINEPHRINE
REUPTAKE INHIBITOR (SNRIs) DESVENLAFAXINE ER TB24 NON_PREFERRED
DESVENLAFAXINE ER TB24 NON_PREFERRED
DESVENLAFAXINE ER TB24 NON_PREFERRED
PRISTIQ TB24 NON_PREFERRED
CYMBALTA CPEP NON_PREFERRED
DULOXETINE HCL CPEP PREFERRED
DULOXETINE HYDROCHLORIDE CPEP PREFERRED
DRIZALMA SPRINKLE CSDR NON_PREFERRED
FETZIMA TITRATION PACK C4PK NON_PREFERRED
FETZIMA CP24 NON_PREFERRED
EFFEXOR XR CP24 NON_PREFERRED
VENLAFAXINE HCL ER CP24 PREFERRED
VENLAFAXINE HYDROCHLORIDE ER CP24 PREFERRED
VENLAFAXINE HYDROCHLORIDEER CP24 PREFERRED
VENLAFAXINE HCL TABS PREFERRED
VENLAFAXINE HYDROCHLORIDE TABS PREFERRED
VENLAFAXINE HCL ER TB24 NON_PREFERRED
VENLAFAXINE HYDROCHLORIDE ER TB24 NON_PREFERRED
ANTIDIABETICS : COMBINATIONS XULTOPHY 100/3.6 SOPN NON_PREFERRED
SOLIQUA 100/33 SOPN NON_PREFERRED
ALOGLIPTIN/METFORMIN HCL TABS NON_PREFERRED
KAZANO TABS NON_PREFERRED
JENTADUETO TABS NON_PREFERRED
JENTADUETO XR TB24 NON_PREFERRED
KOMBIGLYZE XR TB24 NON_PREFERRED
JANUMET TABS NON_PREFERRED
JANUMET XR TB24 NON_PREFERRED
ALOGLIPTIN/PIOGLITAZONE TABS NON_PREFERRED
OSENI TABS NON_PREFERRED
REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS NON_PREFERRED
INVOKAMET TABS NON_PREFERRED
INVOKAMET XR TB24 NON_PREFERRED
XIGDUO XR TB24 NON_PREFERRED
SYNJARDY TABS NON_PREFERRED
SYNJARDY XR TB24 NON_PREFERRED
SEGLUROMET TABS NON_PREFERRED
QTERN TABS NON_PREFERRED
GLYXAMBI TABS NON_PREFERRED
STEGLUJAN TABS NON_PREFERRED
TRIJARDY XR TB24 NON_PREFERRED
GLIPIZIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED
GLIPIZIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED
Page 21 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
GLYBURIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED
DUETACT TABS NON_PREFERRED
PIOGLITAZONE HCL-GLIMEPIRIDE TABS NON_PREFERRED
ACTOPLUS MET TABS NON_PREFERRED
PIOGLITAZONE HCL/METFORMIN HCL TABS NON_PREFERRED
ANTIDIABETICS : DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS ALOGLIPTIN TABS NON_PREFERRED
NESINA TABS NON_PREFERRED
TRADJENTA TABS PREFERRED
ONGLYZA TABS NON_PREFERRED
JANUVIA TABS PREFERRED
ANTIDIABETICS : INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR
AGONISTS) TRULICITY SOPN NON_PREFERRED
BYDUREON BCISE AUIJ NON_PREFERRED
BYDUREON PEN PEN NON_PREFERRED
BYETTA SOPN PREFERRED
BYDUREON SRER NON_PREFERRED
VICTOZA SOPN PREFERRED
ADLYXIN STARTER PACK PNKT NON_PREFERRED
ADLYXIN SOPN NON_PREFERRED
OZEMPIC SOPN NON_PREFERRED
RYBELSUS TABS NON_PREFERRED
ANTIDIABETICS : INSULIN INSULIN ASPART PENFILL SOCT NON_PREFERRED
NOVOLOG PENFILL SOCT NON_PREFERRED
INSULIN ASPART SOLN NON_PREFERRED
NOVOLOG SOLN NON_PREFERRED
INSULIN ASPART FLEXPEN SOPN NON_PREFERRED
NOVOLOG FLEXPEN SOPN NON_PREFERRED
FIASP PENFILL SOCT NON_PREFERRED
FIASP SOLN NON_PREFERRED
FIASP FLEXTOUCH SOPN NON_PREFERRED
LANTUS SOLN PREFERRED
SEMGLEE SOLN NON_PREFERRED
BASAGLAR KWIKPEN SOPN NON_PREFERRED
LANTUS SOLOSTAR SOPN PREFERRED
SEMGLEE SOPN NON_PREFERRED
TOUJEO MAX SOLOSTAR SOPN NON_PREFERRED
TOUJEO SOLOSTAR SOPN NON_PREFERRED
APIDRA SOLN NON_PREFERRED
APIDRA SOLOSTAR SOPN NON_PREFERRED
HUMALOG SOCT PREFERRED
ADMELOG SOLN NON_PREFERRED
HUMALOG SOLN PREFERRED
INSULIN LISPRO SOLN PREFERRED
Page 22 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ADMELOG SOLOSTAR SOPN NON_PREFERRED
HUMALOG JUNIOR KWIKPEN SOPN PREFERRED
HUMALOG KWIKPEN SOPN PREFERRED
INSULIN LISPRO JUNIOR KWIKPEN SOPN PREFERRED
INSULIN LISPRO KWIKPEN SOPN PREFERRED
LYUMJEV SOLN NON_PREFERRED
LYUMJEV KWIKPEN SOPN NON_PREFERRED
LEVEMIR SOLN PREFERRED
LEVEMIR FLEXTOUCH SOPN PREFERRED
TRESIBA SOLN NON_PREFERRED
TRESIBA FLEXTOUCH SOPN NON_PREFERRED
AFREZZA POWD NON_PREFERRED
HUMULIN R SOLN PREFERRED
HUMULIN R U-500 (CONCENTRATED) SOLN PREFERRED
NOVOLIN R SOLN NON_PREFERRED
NOVOLIN R RELION SOLN NON_PREFERRED
HUMULIN R U-500 KWIKPEN SOPN PREFERRED
NOVOLIN R FLEXPEN SOPN NON_PREFERRED
NOVOLIN R FLEXPEN RELION SOPN NON_PREFERRED
HUMULIN N KWIKPEN SUPN PREFERRED
NOVOLIN N FLEXPEN SUPN NON_PREFERRED
NOVOLIN N FLEXPEN RELION SUPN NON_PREFERRED
HUMULIN N SUSP PREFERRED
NOVOLIN N SUSP NON_PREFERRED
NOVOLIN N RELION SUSP NON_PREFERRED
INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN SUPN NON_PREFERRED
NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN NON_PREFERRED
INSULIN ASPART PROTAMINE/INSULIN ASPART SUSP NON_PREFERRED
NOVOLOG MIX 70/30 SUSP NON_PREFERRED
HUMALOG MIX 50/50 KWIKPEN SUPN PREFERRED
HUMALOG MIX 75/25 KWIKPEN SUPN PREFERRED
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN SUPN PREFERRED
HUMALOG MIX 50/50 SUSP PREFERRED
HUMALOG MIX 75/25 SUSP PREFERRED
HUMULIN 70/30 KWIKPEN SUPN PREFERRED
NOVOLIN 70/30 FLEXPEN SUPN NON_PREFERRED
NOVOLIN 70/30 FLEXPEN RELION SUPN NON_PREFERRED
HUMULIN 70/30 SUSP PREFERRED
NOVOLIN 70/30 SUSP NON_PREFERRED
NOVOLIN 70/30 RELION SUSP NON_PREFERRED
ANTIDIABETICS : MISC SYMLINPEN 120 SOPN NON_PREFERRED
SYMLINPEN 60 SOPN NON_PREFERRED
AMARYL TABS NON_PREFERRED
GLIMEPIRIDE TABS PREFERRED
Page 23 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
GLIPIZIDE TABS PREFERRED
GLUCOTROL TABS NON_PREFERRED
GLIPIZIDE ER TB24 PREFERRED
GLIPIZIDE XL TB24 PREFERRED
GLUCOTROL XL TB24 NON_PREFERRED
GLYBURIDE TABS PREFERRED
GLYBURIDE TABS PREFERRED
GLYBURIDE MICRONIZED TABS PREFERRED
GLYNASE TABS NON_PREFERRED
TOLBUTAMIDE TABS PREFERRED
METFORMIN HYDROCHLORIDE SOLN NON_PREFERRED
RIOMET SOLN NON_PREFERRED
RIOMET ER SRER NON_PREFERRED
METFORMIN HYDROCHLORIDE TABS PREFERRED
FORTAMET TB24 NON_PREFERRED
GLUCOPHAGE XR TB24 NON_PREFERRED
GLUMETZA TB24 NON_PREFERRED
METFORMIN HYDROCHLORIDE ER TB24 PREFERRED
NATEGLINIDE TABS PREFERRED
STARLIX TABS NON_PREFERRED
PRANDIN TABS NON_PREFERRED
REPAGLINIDE TABS NON_PREFERRED
BAQSIMI ONE PACK POWD NON_PREFERRED
BAQSIMI TWO PACK POWD NON_PREFERRED
GVOKE HYPOPEN SOAJ NON_PREFERRED
GVOKE PFS SOSY NON_PREFERRED
GLUCAGON EMERGENCY KIT KIT PREFERRED
GLUCAGEN HYPOKIT SOLR PREFERRED
GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR SOLR PREFERRED
DIAZOXIDE SUSP PREFERRED
PROGLYCEM SUSP PREFERRED
KORLYM TABS NON_PREFERRED
ACARBOSE TABS PREFERRED
PRECOSE TABS NON_PREFERRED
GLYSET TABS NON_PREFERRED
MIGLITOL TABS PREFERRED
CYCLOSET TABS NON_PREFERRED
ACTOS TABS NON_PREFERRED
PIOGLITAZONE HCL TABS PREFERRED
PIOGLITAZONE HYDROCHLORIDE TABS PREFERRED
AVANDIA TABS PREFERRED
ANTIDIABETICS : SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITORS INVOKANA TABS PREFERRED
FARXIGA TABS NON_PREFERRED
Page 24 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
JARDIANCE TABS PREFERRED
STEGLATRO TABS NON_PREFERRED
ANTIDOTES AND SPECIFIC ANTAGONISTS : ANTIDOTES - CHELATING
AGENTS DEFERASIROX PACK NON_PREFERRED
DEFERSIROX PACK NON_PREFERRED
JADENU SPRINKLE PACK NON_PREFERRED
DEFERASIROX TABS NON_PREFERRED
JADENU TABS NON_PREFERRED
DEFERASIROX TBSO NON_PREFERRED
EXJADE TBSO NON_PREFERRED
FERRIPROX SOLN NON_PREFERRED
DEFERIPRONE TABS NON_PREFERRED
FERRIPROX TABS NON_PREFERRED
FERRIPROX TWICE-A-DAY TABS NON_PREFERRED
CHEMET CAPS PREFERRED
CLOVIQUE CAPS PREFERRED
SYPRINE CAPS NON_PREFERRED
TRIENTINE HYDROCHLORIDE CAPS PREFERRED
CUPRIMINE CAPS NON_PREFERRED
PENICILLAMINE CAPS PREFERRED
DEPEN TITRATABS TABS PREFERRED
PENICILLAMINE TABS PREFERRED
ANTIEMETICS : 5-HT3 RECEPTOR ANTAGONISTS ANZEMET TABS NON_PREFERRED
SANCUSO PTCH NON_PREFERRED
GRANISETRON HCL TABS NON_PREFERRED
ZUPLENZ FILM NON_PREFERRED
ONDANSETRON ODT TBDP PREFERRED
ONDANSETRON HCL SOLN PREFERRED
ONDANSETRON HYDROCHLORIDE SOLN PREFERRED
ONDANSETRON HYDROCHLORIDE TABS PREFERRED
ZOFRAN TABS NON_PREFERRED
ANTIEMETICS : MISC MECLIZINE HCL TABS PREFERRED
MECLIZINE HYDROCHLORIDE TABS PREFERRED
SCOPOLAMINE PT72 PREFERRED
TRANSDERM-SCOP PT72 PREFERRED
TIGAN CAPS NON_PREFERRED
TRIMETHOBENZAMIDE HYDROCHLORIDE CAPS NON_PREFERRED
DRONABINOL CAPS NON_PREFERRED
MARINOL CAPS NON_PREFERRED
BONJESTA TBCR NON_PREFERRED
DICLEGIS TBEC NON_PREFERRED
DOXYLAMINE SUCCINATE/PYRIDOXINE HYDROCHLORIDE TBEC NON_PREFERRED
AKYNZEO CAPS NON_PREFERRED
Page 25 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ANTIEMETICS : SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR
ANTAGONISTS APREPITANT CAPS PREFERRED
EMEND CAPS NON_PREFERRED
EMEND TRIPACK CAPS NON_PREFERRED
EMEND SUSR NON_PREFERRED
VARUBI TBPK NON_PREFERRED
ANTIFUNGALS ANCOBON CAPS NON_PREFERRED
FLUCYTOSINE CAPS NON_PREFERRED
GRISEOFULVIN MICROSIZE SUSP PREFERRED
GRISEOFULVIN MICROSIZE TABS PREFERRED
GRISEOFULVIN ULTRAMICROSIZE TABS PREFERRED
NYSTATIN TABS PREFERRED
TERBINAFINE HCL TABS PREFERRED
TERBINAFINE HYDROCHLORIDE TABS PREFERRED
KETOCONAZOLE TABS PREFERRED
DIFLUCAN SUSR NON_PREFERRED
FLUCONAZOLE SUSR PREFERRED
DIFLUCAN TABS NON_PREFERRED
FLUCONAZOLE TABS PREFERRED
CRESEMBA CAPS NON_PREFERRED
ITRACONAZOLE CAPS NON_PREFERRED
SPORANOX CAPS NON_PREFERRED
SPORANOX PULSEPAK CAPS NON_PREFERRED
TOLSURA CAPS NON_PREFERRED
ITRACONAZOLE SOLN NON_PREFERRED
SPORANOX SOLN NON_PREFERRED
ONMEL TABS NON_PREFERRED
NOXAFIL SUSP NON_PREFERRED
NOXAFIL TBEC NON_PREFERRED
POSACONAZOLE DR TBEC NON_PREFERRED
VFEND SUSR NON_PREFERRED
VORICONAZOLE SUSR NON_PREFERRED
VFEND TABS NON_PREFERRED
VORICONAZOLE TABS NON_PREFERRED
ANTIHYPERLIPIDEMICS CHOLESTYRAMINE PACK PREFERRED
QUESTRAN PACK NON_PREFERRED
CHOLESTYRAMINE POWD PREFERRED
QUESTRAN POWD NON_PREFERRED
CHOLESTYRAMINE LIGHT PACK PREFERRED
PREVALITE PACK PREFERRED
CHOLESTYRAMINE LIGHT POWD PREFERRED
PREVALITE POWD PREFERRED
QUESTRAN LIGHT POWD NON_PREFERRED
COLESEVELAM HYDROCHLORIDE PACK NON_PREFERRED
Page 26 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
WELCHOL PACK NON_PREFERRED
COLESEVELAM HYDROCHLORIDE TABS NON_PREFERRED
WELCHOL TABS NON_PREFERRED
COLESTID GRAN NON_PREFERRED
COLESTID FLAVORED GRAN NON_PREFERRED
COLESTIPOL HCL GRAN NON_PREFERRED
COLESTID PACK NON_PREFERRED
COLESTID FLAVORED PACK NON_PREFERRED
COLESTIPOL HCL PACK NON_PREFERRED
COLESTID TABS NON_PREFERRED
COLESTIPOL HCL TABS NON_PREFERRED
FENOFIBRIC ACID DR CPDR PREFERRED
TRILIPIX CPDR NON_PREFERRED
FIBRICOR TABS NON_PREFERRED
FENOFIBRATE CAPS PREFERRED
LIPOFEN CAPS NON_PREFERRED
FENOFIBRATE TABS PREFERRED
FENOGLIDE TABS NON_PREFERRED
TRICOR TABS NON_PREFERRED
ANTARA CAPS NON_PREFERRED
FENOFIBRATE CAPS PREFERRED
FENOFIBRATE MICRONIZED CAPS PREFERRED
GEMFIBROZIL TABS PREFERRED
LOPID TABS NON_PREFERRED
EZETIMIBE TABS PREFERRED
ZETIA TABS NON_PREFERRED
PRALUENT SOAJ NON_PREFERRED
REPATHA SURECLICK SOAJ NON_PREFERRED
REPATHA PUSHTRONEX SYSTEM SOCT NON_PREFERRED
REPATHA SOSY NON_PREFERRED
NEXLETOL TABS NON_PREFERRED
ATORVASTATIN CALCIUM TABS PREFERRED
LIPITOR TABS NON_PREFERRED
FLUVASTATIN CAPS NON_PREFERRED
FLUVASTATIN SODIUM ER TB24 NON_PREFERRED
LESCOL XL TB24 NON_PREFERRED
LOVASTATIN TABS PREFERRED
ALTOPREV TB24 NON_PREFERRED
LIVALO TABS NON_PREFERRED
ZYPITAMAG TABS NON_PREFERRED
EZALLOR SPRINKLE CPSP NON_PREFERRED
CRESTOR TABS NON_PREFERRED
ROSUVASTATIN CALCIUM TABS PREFERRED
PRAVACHOL TABS NON_PREFERRED
Page 27 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
PRAVASTATIN SODIUM TABS PREFERRED
SIMVASTATIN TABS PREFERRED
ZOCOR TABS NON_PREFERRED
NIACIN ER TBCR NON_PREFERRED
NIASPAN TBCR NON_PREFERRED
JUXTAPID CAPS NON_PREFERRED
ICOSAPENT ETHYL CAPS NON_PREFERRED
VASCEPA CAPS NON_PREFERRED
LOVAZA CAPS NON_PREFERRED
OMEGA-3-ACID ETHYL ESTERS CAPS NON_PREFERRED
NEXLIZET TABS NON_PREFERRED
EZETIMIBE/SIMVASTATIN TABS NON_PREFERRED
VYTORIN TABS NON_PREFERRED
ANTIMYASTHENIC AGENTS RUZURGI TABS NON_PREFERRED
FIRDAPSE TABS NON_PREFERRED
GUANIDINE HCL TABS NON_PREFERRED
MESTINON SOLN NON_PREFERRED
PYRIDOSTIGMINE BROMIDE SOLN PREFERRED
MESTINON TABS NON_PREFERRED
PYRIDOSTIGMINE BROMIDE TABS PREFERRED
MESTINON TIMESPAN TBCR NON_PREFERRED
PYRIDOSTIGMINE BROMIDE ER TBCR PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ALKYLATING
AGENTS MYLERAN TABS PREFERRED
LEUKERAN TABS PREFERRED
CYCLOPHOSPHAMIDE CAPS PREFERRED
ALKERAN TABS NON_PREFERRED
MELPHALAN TABS PREFERRED
GLEOSTINE CAPS PREFERRED
TEMODAR CAPS NON_PREFERRED
TEMOZOLOMIDE CAPS PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES :
ANTIMETABOLITES ONUREG TABS NON_PREFERRED
CAPECITABINE TABS NON_PREFERRED
XELODA TABS NON_PREFERRED
PURIXAN SUSP NON_PREFERRED
MERCAPTOPURINE TABS PREFERRED
XATMEP SOLN NON_PREFERRED
METHOTREXATE TABS PREFERRED
METHOTREXATE SODIUM TABS PREFERRED
TREXALL TABS PREFERRED
TABLOID TABS PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC -
HORMONAL AND RELATED AGENTS LYSODREN TABS PREFERRED
Page 28 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ERLEADA TABS NON_PREFERRED
BICALUTAMIDE TABS PREFERRED
CASODEX TABS NON_PREFERRED
NUBEQA TABS NON_PREFERRED
XTANDI CAPS NON_PREFERRED
FLUTAMIDE CAPS PREFERRED
NILUTAMIDE TABS PREFERRED
SOLTAMOX SOLN PREFERRED
TAMOXIFEN CITRATE TABS PREFERRED
FARESTON TABS NON_PREFERRED
TOREMIFENE CITRATE TABS PREFERRED
ANASTROZOLE TABS PREFERRED
ARIMIDEX TABS NON_PREFERRED
AROMASIN TABS NON_PREFERRED
EXEMESTANE TABS PREFERRED
FEMARA TABS NON_PREFERRED
LETROZOLE TABS PREFERRED
EMCYT CAPS PREFERRED
MEGESTROL ACETATE SUSP PREFERRED
MEGESTROL ACETATE TABS PREFERRED
ABIRATERONE ACETATE TABS PREFERRED
YONSA TABS NON_PREFERRED
ZYTIGA TABS NON_PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC
ENZYME INHIBITORS VERZENIO TABS NON_PREFERRED
IBRANCE CAPS NON_PREFERRED
IBRANCE TABS NON_PREFERRED
KISQALI TBPK NON_PREFERRED
FARYDAK CAPS NON_PREFERRED
ZOLINZA CAPS NON_PREFERRED
TAFINLAR CAPS NON_PREFERRED
BRAFTOVI CAPS NON_PREFERRED
ZELBORAF TABS NON_PREFERRED
BALVERSA TABS NON_PREFERRED
PEMAZYRE TABS NON_PREFERRED
AFINITOR TABS NON_PREFERRED
EVEROLIMUS TABS NON_PREFERRED
AFINITOR DISPERZ TBSO NON_PREFERRED
RYDAPT CAPS NON_PREFERRED
STIVARGA TABS NON_PREFERRED
NEXAVAR TABS PREFERRED
SUTENT CAPS PREFERRED
MEKTOVI TABS NON_PREFERRED
COTELLIC TABS NON_PREFERRED
Page 29 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
KOSELUGO CAPS NON_PREFERRED
MEKINIST TABS NON_PREFERRED
TAZVERIK TABS NON_PREFERRED
ROZLYTREK CAPS NON_PREFERRED
VITRAKVI CAPS NON_PREFERRED
VITRAKVI SOLN NON_PREFERRED
CALQUENCE CAPS NON_PREFERRED
GILOTRIF TABS NON_PREFERRED
ALECENSA CAPS NON_PREFERRED
INLYTA TABS NON_PREFERRED
AYVAKIT TABS NON_PREFERRED
ALUNBRIG TABS NON_PREFERRED
ALUNBRIG TBPK NON_PREFERRED
BOSULIF TABS NON_PREFERRED
COMETRIQ KIT NON_PREFERRED
CABOMETYX TABS NON_PREFERRED
ZYKADIA TABS NON_PREFERRED
XALKORI CAPS NON_PREFERRED
TABRECTA TABS NON_PREFERRED
VIZIMPRO TABS NON_PREFERRED
SPRYCEL TABS NON_PREFERRED
ERLOTINIB HYDROCHLORIDE TABS PREFERRED
TARCEVA TABS NON_PREFERRED
IRESSA TABS PREFERRED
XOSPATA TABS NON_PREFERRED
IMBRUVICA CAPS NON_PREFERRED
IMBRUVICA TABS NON_PREFERRED
GLEEVEC TABS NON_PREFERRED
IMATINIB MESYLATE TABS NON_PREFERRED
LAPATINIB DITOSYLATE TABS NON_PREFERRED
TYKERB TABS NON_PREFERRED
LENVIMA 10 MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 12MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 14 MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 18 MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 20 MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 24 MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 4 MG DAILY DOSE CPPK NON_PREFERRED
LENVIMA 8 MG DAILY DOSE CPPK NON_PREFERRED
LORBRENA TABS NON_PREFERRED
NERLYNX TABS NON_PREFERRED
TASIGNA CAPS NON_PREFERRED
TAGRISSO TABS NON_PREFERRED
VOTRIENT TABS PREFERRED
Page 30 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
TURALIO CAPS NON_PREFERRED
ICLUSIG TABS NON_PREFERRED
GAVRETO CAPS NON_PREFERRED
QINLOCK TABS NON_PREFERRED
RETEVMO CAPS NON_PREFERRED
TUKYSA TABS NON_PREFERRED
CAPRELSA TABS PREFERRED
BRUKINSA CAPS NON_PREFERRED
TIBSOVO TABS NON_PREFERRED
IDHIFA TABS NON_PREFERRED
ZEJULA CAPS NON_PREFERRED
LYNPARZA TABS NON_PREFERRED
RUBRACA TABS NON_PREFERRED
TALZENNA CAPS NON_PREFERRED
NINLARO CAPS NON_PREFERRED
INREBIC CAPS NON_PREFERRED
JAKAFI TABS PREFERRED
PIQRAY 200MG DAILY DOSE TBPK NON_PREFERRED
PIQRAY 250MG DAILY DOSE TBPK NON_PREFERRED
PIQRAY 300MG DAILY DOSE TBPK NON_PREFERRED
COPIKTRA CAPS NON_PREFERRED
ZYDELIG TABS NON_PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : CHEMOTHERAPY
RESCUE / ANTIDOTE AGENTS LEUCOVORIN CALCIUM TABS PREFERRED
MESNEX TABS PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MISC DAURISMO TABS NON_PREFERRED
ODOMZO CAPS NON_PREFERRED
ERIVEDGE CAPS PREFERRED
POMALYST CAPS NON_PREFERRED
VENCLEXTA TABS NON_PREFERRED
VENCLEXTA STARTING PACK TBPK NON_PREFERRED
HYCAMTIN CAPS PREFERRED
XPOVIO 100 MG ONCE WEEKLY TBPK NON_PREFERRED
XPOVIO 40 MG ONCE WEEKLY TBPK NON_PREFERRED
XPOVIO 40 MG TWICE WEEKLY TBPK NON_PREFERRED
XPOVIO 60 MG ONCE WEEKLY TBPK NON_PREFERRED
XPOVIO 60 MG TWICE WEEKLY TBPK NON_PREFERRED
XPOVIO 80 MG ONCE WEEKLY TBPK NON_PREFERRED
XPOVIO 80 MG TWICE WEEKLY TBPK NON_PREFERRED
HYDREA CAPS NON_PREFERRED
HYDROXYUREA CAPS PREFERRED
MATULANE CAPS PREFERRED
TRETINOIN CAPS PREFERRED
BEXAROTENE CAPS PREFERRED
Page 31 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
TARGRETIN CAPS NON_PREFERRED
INQOVI TABS NON_PREFERRED
KISQALI FEMARA 200 DOSE TBPK NON_PREFERRED
KISQALI FEMARA 400 DOSE TBPK NON_PREFERRED
KISQALI FEMARA 600 DOSE TBPK NON_PREFERRED
LONSURF TABS NON_PREFERRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MITOTIC
INHIBITORS ETOPOSIDE CAPS PREFERRED
ANTIPARASITICS : ANTHELMINTICS ALBENDAZOLE TABS NON_PREFERRED
ALBENZA TABS NON_PREFERRED
BENZNIDAZOLE TABS NON_PREFERRED
IVERMECTIN TABS NON_PREFERRED
STROMECTOL TABS NON_PREFERRED
EMVERM CHEW NON_PREFERRED
BILTRICIDE TABS NON_PREFERRED
PRAZIQUANTEL TABS PREFERRED
EGATEN TABS NON_PREFERRED
ANTIPARASITICS : ANTIMALARIALS CHLOROQUINE PHOSPHATE TABS PREFERRED
HYDROXYCHLOROQUINE SULFATE TABS PREFERRED
MEFLOQUINE HCL TABS PREFERRED
PRIMAQUINE PHOSPHATE TABS PREFERRED
DARAPRIM TABS NON_PREFERRED
PYRIMETHAMINE TABS NON_PREFERRED
QUALAQUIN CAPS NON_PREFERRED
QUININE SULFATE CAPS NON_PREFERRED
KRINTAFEL TABS NON_PREFERRED
COARTEM TABS NON_PREFERRED
ATOVAQUONE/PROGUANIL HCL TABS PREFERRED
MALARONE TABS NON_PREFERRED
ANTIPARKINSON AND RELATED THERAPY AGENTS BENZTROPINE MESYLATE TABS PREFERRED
TRIHEXYPHENIDYL HCL SOLN PREFERRED
TRIHEXYPHENIDYL HYDROCHLORIDE TABS PREFERRED
TASMAR TABS NON_PREFERRED
TOLCAPONE TABS NON_PREFERRED
COMTAN TABS NON_PREFERRED
ENTACAPONE TABS PREFERRED
ONGENTYS CAPS NON_PREFERRED
AMANTADINE HCL CAPS PREFERRED
AMANTADINE HYDROCHLORIDE CAPS PREFERRED
GOCOVRI CP24 NON_PREFERRED
AMANTADINE HCL SYRP PREFERRED
OSMOLEX ER T4PK NON_PREFERRED
AMANTADINE HCL TABS PREFERRED
AMANTADINE HYDROCHLORIDE TABS PREFERRED
Page 32 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
OSMOLEX ER TB24 NON_PREFERRED
BROMOCRIPTINE MESYLATE CAPS PREFERRED
PARLODEL CAPS NON_PREFERRED
BROMOCRIPTINE MESYLATE TABS PREFERRED
PARLODEL TABS NON_PREFERRED
INBRIJA CAPS NON_PREFERRED
KYNMOBI FILM NON_PREFERRED
KYNMOBI TITRATION KIT KIT NON_PREFERRED
APOKYN SOCT NON_PREFERRED
PRAMIPEXOLE DIHYDROCHLORIDE TABS PREFERRED
MIRAPEX ER TB24 NON_PREFERRED
PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 NON_PREFERRED
ROPINIROLE HCL TABS PREFERRED
ROPINIROLE HYDROCHLORIDE TABS PREFERRED
ROPINIROLE ER TB24 NON_PREFERRED
NEUPRO PT24 NON_PREFERRED
RYTARY CPCR NON_PREFERRED
CARBIDOPA/LEVODOPA TABS PREFERRED
SINEMET TABS NON_PREFERRED
CARBIDOPA/LEVODOPA ER TBCR PREFERRED
CARBIDOPA/LEVODOPA ODT TBDP NON_PREFERRED
CARBIDOPA/LEVODOPA/ENTACAPONE TABS NON_PREFERRED
STALEVO 100 TABS NON_PREFERRED
STALEVO 125 TABS NON_PREFERRED
STALEVO 150 TABS NON_PREFERRED
STALEVO 200 TABS NON_PREFERRED
STALEVO 50 TABS NON_PREFERRED
STALEVO 75 TABS NON_PREFERRED
AZILECT TABS NON_PREFERRED
RASAGILINE MESYLATE TABS NON_PREFERRED
XADAGO TABS NON_PREFERRED
SELEGILINE HCL CAPS PREFERRED
SELEGILINE HYDROCHLORIDE CAPS PREFERRED
SELEGILINE HCL TABS PREFERRED
ZELAPAR TBDP NON_PREFERRED
NOURIANZ TABS NON_PREFERRED
CARBIDOPA TABS PREFERRED
LODOSYN TABS NON_PREFERRED
ANTIPSYCHOTICS / ANTIMANIC AGENTS : BENZISOXAZOLES FANAPT TABS NON_PREFERRED
FANAPT TITRATION PACK TABS NON_PREFERRED
INVEGA TB24 NON_PREFERRED
PALIPERIDONE ER TB24 NON_PREFERRED
INVEGA SUSTENNA SUSY PREFERRED_WITH_PA
INVEGA TRINZA SUSY PREFERRED_WITH_PA
Page 33 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
PERSERIS PRSY NON_PREFERRED
RISPERDAL SOLN NON_PREFERRED
RISPERIDONE SOLN PREFERRED
RISPERDAL TABS NON_PREFERRED
RISPERIDONE TABS PREFERRED
RISPERIDONE ODT TBDP NON_PREFERRED
RISPERDAL CONSTA SRER NON_PREFERRED
ANTIPSYCHOTICS / ANTIMANIC AGENTS : DIBENZAPINES VERSACLOZ SUSP NON_PREFERRED
CLOZAPINE TABS PREFERRED
CLOZARIL TABS NON_PREFERRED
CLOZAPINE ODT TBDP NON_PREFERRED
FAZACLO TBDP NON_PREFERRED
QUETIAPINE FUMARATE TABS PREFERRED
SEROQUEL TABS NON_PREFERRED
QUETIAPINE FUMARATE ER TB24 PREFERRED
SEROQUEL XR TB24 NON_PREFERRED
ADASUVE AEPB NON_PREFERRED
LOXAPINE CAPS PREFERRED
LOXAPINE SUCCINATE CAPS PREFERRED
SECUADO PT24 NON_PREFERRED
SAPHRIS SUBL NON_PREFERRED
OLANZAPINE SOLR NON_PREFERRED
ZYPREXA SOLR NON_PREFERRED
OLANZAPINE TABS PREFERRED
ZYPREXA TABS NON_PREFERRED
OLANZAPINE ODT TBDP PREFERRED
ZYPREXA ZYDIS TBDP NON_PREFERRED
ZYPREXA RELPREVV SUSR NON_PREFERRED
ANTIPSYCHOTICS / ANTIMANIC AGENTS : MISC HALOPERIDOL TABS PREFERRED
HALOPERIDOL CONC PREFERRED
MOLINDONE HYDROCHLORIDE TABS NON_PREFERRED
CHLORPROMAZINE HCL TABS PREFERRED
CHLORPROMAZINE HYDROCHLORIDE TABS PREFERRED
FLUPHENAZINE HCL CONC PREFERRED
FLUPHENAZINE HYDROCHLORIDE ELIX PREFERRED
FLUPHENAZINE HCL TABS PREFERRED
PERPHENAZINE TABS PREFERRED
COMPRO SUPP PREFERRED
PROCHLORPERAZINE SUPP PREFERRED
PROCHLORPERAZINE MALEATE TABS PREFERRED
THIORIDAZINE HCL TABS PREFERRED
TRIFLUOPERAZINE HCL TABS PREFERRED
TRIFLUOPERAZINE HYDROCHLORIDE TABS PREFERRED
THIOTHIXENE CAPS PREFERRED
Page 34 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
EQUETRO CP12 NON_PREFERRED
VRAYLAR CAPS NON_PREFERRED
VRAYLAR CPPK NON_PREFERRED
CAPLYTA CAPS NON_PREFERRED
LATUDA TABS NON_PREFERRED
NUPLAZID CAPS NON_PREFERRED
NUPLAZID TABS NON_PREFERRED
GEODON CAPS NON_PREFERRED
ZIPRASIDONE HCL CAPS PREFERRED
ZIPRASIDONE HYDROCHLORIDE CAPS PREFERRED
GEODON SOLR NON_PREFERRED
ZIPRASIDONE MESYLATE SOLR NON_PREFERRED
LITHIUM SOLN PREFERRED
LITHIUM CARBONATE CAPS PREFERRED
LITHIUM CARBONATE TABS PREFERRED
LITHIUM CARBONATE ER TBCR PREFERRED
LITHOBID TBCR NON_PREFERRED
ANTIPSYCHOTICS / ANTIMANIC AGENTS : QUINOLINONE
DERIVATIVES ABILIFY MAINTENA PRSY PREFERRED_WITH_PA
ARIPIPRAZOLE SOLN NON_PREFERRED
ABILIFY MAINTENA SRER PREFERRED_WITH_PA
ABILIFY TABS NON_PREFERRED
ABILIFY MYCITE TABS NON_PREFERRED
ARIPIPRAZOLE TABS PREFERRED
ARIPIPRAZOLE ODT TBDP NON_PREFERRED
ARISTADA PRSY PREFERRED_WITH_PA
ARISTADA INITIO PRSY PREFERRED_WITH_PA
REXULTI TABS NON_PREFERRED
ANTIVIRALS : ANTIRETROVIRALS (HIV) SELZENTRY SOLN NON_PREFERRED
SELZENTRY TABS NON_PREFERRED
TROGARZO SOLN PREFERRED_WITH_PA
RUKOBIA TB12 NON_PREFERRED
FUZEON SOLR NON_PREFERRED
TIVICAY TABS PREFERRED
TIVICAY PD TBSO PREFERRED
ISENTRESS CHEW PREFERRED
ISENTRESS PACK PREFERRED
ISENTRESS TABS PREFERRED
ISENTRESS HD TABS PREFERRED
ATAZANAVIR CAPS PREFERRED
ATAZANAVIR SULFATE CAPS PREFERRED
REYATAZ CAPS PREFERRED
REYATAZ PACK PREFERRED
PREZISTA SUSP PREFERRED
Page 35 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
PREZISTA TABS PREFERRED
LEXIVA SUSP PREFERRED
FOSAMPRENAVIR CALCIUM TABS PREFERRED
LEXIVA TABS PREFERRED
CRIXIVAN CAPS PREFERRED
VIRACEPT TABS PREFERRED
NORVIR PACK PREFERRED
NORVIR SOLN PREFERRED
NORVIR TABS PREFERRED
RITONAVIR TABS PREFERRED
INVIRASE TABS PREFERRED
APTIVUS CAPS PREFERRED
APTIVUS SOLN PREFERRED
ABACAVIR SOLN PREFERRED
ZIAGEN SOLN PREFERRED
ABACAVIR TABS PREFERRED
ABACAVIR SULFATE TABS PREFERRED
ZIAGEN TABS NON_PREFERRED
DIDANOSINE CPDR PREFERRED
VIDEX EC CPDR NON_PREFERRED
VIDEXPEDIATRIC SOLR PREFERRED
EMTRICITABINE CAPS PREFERRED
EMTRIVA CAPS PREFERRED
EMTRIVA SOLN PREFERRED
EPIVIR SOLN NON_PREFERRED
LAMIVUDINE SOLN PREFERRED
EPIVIR TABS NON_PREFERRED
LAMIVUDINE TABS PREFERRED
STAVUDINE CAPS PREFERRED
RETROVIR CAPS NON_PREFERRED
ZIDOVUDINE CAPS PREFERRED
RETROVIR SYRP NON_PREFERRED
ZIDOVUDINE SYRP PREFERRED
ZIDOVUDINE TABS PREFERRED
VIREAD POWD PREFERRED
TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED
VIREAD TABS PREFERRED
PIFELTRO TABS NON_PREFERRED
EFAVIRENZ CAPS PREFERRED
SUSTIVA CAPS PREFERRED
EFAVIRENZ TABS PREFERRED
SUSTIVA TABS PREFERRED
INTELENCE TABS PREFERRED
NEVIRAPINE SUSP PREFERRED
Page 36 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
VIRAMUNE SUSP PREFERRED
NEVIRAPINE TABS PREFERRED
VIRAMUNE TABS NON_PREFERRED
NEVIRAPINE ER TB24 PREFERRED
VIRAMUNE XR TB24 NON_PREFERRED
EDURANT TABS PREFERRED
TYBOST TABS NON_PREFERRED
ABACAVIR SULFATE/LAMIVUDINE TABS PREFERRED
EPZICOM TABS NON_PREFERRED
EVOTAZ TABS NON_PREFERRED
DOVATO TABS PREFERRED
PREZCOBIX TABS NON_PREFERRED
JULUCA TABS NON_PREFERRED
DESCOVY TABS PREFERRED
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED
TRUVADA TABS PREFERRED
CIMDUO TABS NON_PREFERRED
TEMIXYS TABS NON_PREFERRED
COMBIVIR TABS NON_PREFERRED
LAMIVUDINE/ZIDOVUDINE TABS PREFERRED
KALETRA SOLN NON_PREFERRED
LOPINAVIR/RITONAVIR SOLN PREFERRED
KALETRA TABS PREFERRED
TRIUMEQ TABS PREFERRED
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE TABS PREFERRED
TRIZIVIR TABS NON_PREFERRED
BIKTARVY TABS PREFERRED
DELSTRIGO TABS PREFERRED
ATRIPLA TABS PREFERRED
EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED
EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPROXIL FUMARATE TABS NON_PREFERRED
SYMFI TABS PREFERRED
SYMFI LO TABS PREFERRED
ODEFSEY TABS PREFERRED
COMPLERA TABS PREFERRED
SYMTUZA TABS NON_PREFERRED
GENVOYA TABS PREFERRED
STRIBILD TABS NON_PREFERRED
ANTIVIRALS : HEPATITIS B AGENTS ADEFOVIR DIPIVOXIL TABS NON_PREFERRED
HEPSERA TABS NON_PREFERRED
BARACLUDE SOLN NON_PREFERRED
BARACLUDE TABS NON_PREFERRED
ENTECAVIR TABS PREFERRED
EPIVIR HBV SOLN NON_PREFERRED
Page 37 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
EPIVIR HBV TABS NON_PREFERRED
LAMIVUDINE TABS NON_PREFERRED
VEMLIDY TABS NON_PREFERRED
ANTIVIRALS : HEPATITIS C AGENTS PEGASYS SOLN NON_PREFERRED
PEGINTRON KIT PREFERRED_WITH_PA
RIBASPHERE CAPS PREFERRED
RIBAVIRIN CAPS PREFERRED
RIBASPHERE TABS PREFERRED
RIBAVIRIN TABS PREFERRED
MODERIBA 1200 DOSE PACK TBPK NON_PREFERRED
MODERIBA 800 DOSE PACK TBPK NON_PREFERRED
RIBASPHERE RIBAPAK TBPK NON_PREFERRED
SOVALDI PACK NON_PREFERRED
SOVALDI TABS NON_PREFERRED
ZEPATIER TABS NON_PREFERRED
MAVYRET TABS PREFERRED_WITH_PA
HARVONI PACK NON_PREFERRED
HARVONI TABS NON_PREFERRED
LEDIPASVIR/SOFOSBUVIR TABS NON_PREFERRED
EPCLUSA TABS NON_PREFERRED
SOFOSBUVIR/VELPATASVIR TABS PREFERRED_WITH_PA
VOSEVI TABS NON_PREFERRED
VIEKIRA PAK TBPK NON_PREFERRED
ANTIVIRALS : MISC PREVYMIS TABS NON_PREFERRED
VALCYTE SOLR NON_PREFERRED
VALGANCICLOVIR HYDROCHLORDE SOLR NON_PREFERRED
VALCYTE TABS NON_PREFERRED
VALGANCICLOVIR TABS PREFERRED
ACYCLOVIR CAPS PREFERRED
ACYCLOVIR SUSP PREFERRED
ZOVIRAX SUSP NON_PREFERRED
ACYCLOVIR TABS PREFERRED
SITAVIG TABS NON_PREFERRED
VALACYCLOVIR HCL TABS PREFERRED
VALACYCLOVIR HYDROCHLORIDE TABS PREFERRED
VALTREX TABS NON_PREFERRED
FAMCICLOVIR TABS NON_PREFERRED
FLUMADINE TABS NON_PREFERRED
RIMANTADINE HCL TABS NON_PREFERRED
XOFLUZA TBPK NON_PREFERRED
OSELTAMIVIR PHOSPHATE CAPS PREFERRED
TAMIFLU CAPS NON_PREFERRED
OSELTAMIVIR PHOSPHATE SUSR PREFERRED
TAMIFLU SUSR NON_PREFERRED
Page 38 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
RELENZA DISKHALER AEPB PREFERRED
RIBAVIRIN SOLR PREFERRED
VIRAZOLE SOLR NON_PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITOR
COMBINATIONS AMLODIPINE BESYLATE/BENAZEPRIL HCL CAPS PREFERRED
AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE CAPS PREFERRED
LOTREL CAPS NON_PREFERRED
TARKA TBCR NON_PREFERRED
TRANDOLAPRIL/VERAPAMIL HCL ER TBCR PREFERRED
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS PREFERRED
BENAZEPRIL HYDROCHLORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED
LOTENSIN HCT TABS NON_PREFERRED
CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE TABS PREFERRED
VASERETIC TABS NON_PREFERRED
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED
LISINOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED
ZESTORETIC TABS NON_PREFERRED
ACCURETIC TABS NON_PREFERRED
QUINAPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITORS BENAZEPRIL HCL TABS PREFERRED
BENAZEPRIL HYDROCHLORIDE TABS PREFERRED
LOTENSIN TABS NON_PREFERRED
CAPTOPRIL TABS PREFERRED
EPANED SOLN NON_PREFERRED
ENALAPRIL MALEATE TABS PREFERRED
VASOTEC TABS NON_PREFERRED
FOSINOPRIL SODIUM TABS PREFERRED
QBRELIS SOLN NON_PREFERRED
LISINOPRIL TABS PREFERRED
PRINIVIL TABS NON_PREFERRED
ZESTRIL TABS NON_PREFERRED
MOEXIPRIL HCL TABS PREFERRED
PERINDOPRIL ERBUMINE TABS NON_PREFERRED
ACCUPRIL TABS NON_PREFERRED
QUINAPRIL HCL TABS PREFERRED
QUINAPRIL HYDROCHLORIDE TABS PREFERRED
ALTACE CAPS NON_PREFERRED
RAMIPRIL CAPS PREFERRED
TRANDOLAPRIL TABS PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II
RECEPTOR BLOCKER COMBINATIONS AMLODIPINE/OLMESARTAN MEDOXOMIL TABS NON_PREFERRED
AZOR TABS NON_PREFERRED
Page 39 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
AMLODIPINE BESYLATE/VALSARTAN TABS NON_PREFERRED
EXFORGE TABS NON_PREFERRED
TELMISARTAN/AMLODIPINE TABS NON_PREFERRED
EDARBYCLOR TABS NON_PREFERRED
ATACAND HCT TABS NON_PREFERRED
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED
AVALIDE TABS NON_PREFERRED
IRBESARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED
HYZAAR TABS NON_PREFERRED
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED
BENICAR HCT TABS NON_PREFERRED
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED
MICARDIS HCT TABS NON_PREFERRED
TELMISARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED
DIOVAN HCT TABS NON_PREFERRED
VALSARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED
AMLODIPINE/VALSARTAN/HCTZ TABS NON_PREFERRED
AMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED
EXFORGE HCT TABS NON_PREFERRED
OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED
TRIBENZOR TABS NON_PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II
RECEPTOR BLOCKERS EDARBI TABS NON_PREFERRED
ATACAND TABS NON_PREFERRED
CANDESARTAN CILEXETIL TABS NON_PREFERRED
AVAPRO TABS NON_PREFERRED
IRBESARTAN TABS PREFERRED
COZAAR TABS NON_PREFERRED
LOSARTAN POTASSIUM TABS PREFERRED
BENICAR TABS NON_PREFERRED
OLMESARTAN MEDOXOMIL TABS NON_PREFERRED
MICARDIS TABS NON_PREFERRED
TELMISARTAN TABS NON_PREFERRED
DIOVAN TABS NON_PREFERRED
VALSARTAN TABS PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES :
ANTIADRENERGICS CATAPRES-TTS-1 PTWK NON_PREFERRED
CATAPRES-TTS-2 PTWK NON_PREFERRED
CATAPRES-TTS-3 PTWK NON_PREFERRED
CLONIDINE HCL PTWK PREFERRED
CATAPRES TABS NON_PREFERRED
CLONIDINE HCL TABS PREFERRED
CLONIDINE HYDROCHLORIDE TABS PREFERRED
GUANFACINE HCL TABS PREFERRED
Page 40 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
GUANFACINE HYDROCHLORIDE TABS PREFERRED
METHYLDOPA TABS PREFERRED
CARDURA TABS NON_PREFERRED
DOXAZOSIN TABS PREFERRED
DOXAZOSIN MESYLATE TABS PREFERRED
MINIPRESS CAPS NON_PREFERRED
PRAZOSIN HCL CAPS PREFERRED
PRAZOSIN HYDROCHLORIDE CAPS PREFERRED
TERAZOSIN HCL CAPS PREFERRED
TERAZOSIN HYDROCHLORIDE CAPS PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKER
COMBINATIONS ATENOLOL/CHLORTHALIDONE TABS PREFERRED
TENORETIC 100 TABS NON_PREFERRED
TENORETIC 50 TABS NON_PREFERRED
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TABS PREFERRED
ZIAC TABS NON_PREFERRED
METOPROLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED
NADOLOL/BENDROFLUMETHIAZIDE TABS PREFERRED
PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKERS CORGARD TABS NON_PREFERRED
NADOLOL TABS PREFERRED
PINDOLOL TABS PREFERRED
INDERAL LA CP24 NON_PREFERRED
PROPRANOLOL HCL ER CP24 PREFERRED
PROPRANOLOL HYDROCHLORIDE ER CP24 PREFERRED
HEMANGEOL SOLN PREFERRED_WITH_PA
PROPRANOLOL HCL SOLN PREFERRED
PROPRANOLOL HCL TABS PREFERRED
PROPRANOLOL HYDROCHLORIDE TABS PREFERRED
INDERAL XL CP24 NON_PREFERRED
INNOPRAN XL CP24 NON_PREFERRED
SOTYLIZE SOLN NON_PREFERRED
BETAPACE TABS NON_PREFERRED
SORINE TABS PREFERRED
SOTALOL HCL TABS PREFERRED
SOTALOL HYDROCHLORIDE TABS PREFERRED
SOTALOL HYDROCHOLRIDE TABS PREFERRED
BETAPACE AF TABS NON_PREFERRED
SOTALOL HCL (AF) TABS NON_PREFERRED
SOTALOL HCL AF TABS NON_PREFERRED
SOTALOL HYDROCHLORIDE (AF) TABS NON_PREFERRED
SOTALOL HYDROCHLORIDE AF TABS NON_PREFERRED
TIMOLOL MALEATE TABS PREFERRED
Page 41 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ACEBUTOLOL HCL CAPS PREFERRED
ACEBUTOLOL HYDROCHLORIDE CAPS PREFERRED
FIRST-ATENOLOL SOLN NON_PREFERRED
ATENOLOL TABS PREFERRED
TENORMIN TABS NON_PREFERRED
BETAXOLOL HCL TABS PREFERRED
BISOPROLOL FUMARATE TABS PREFERRED
KAPSPARGO SPRINKLE CS24 NON_PREFERRED
METOPROLOL SUCCINATE ER TB24 PREFERRED
TOPROL XL TB24 NON_PREFERRED
FIRST - METOPROLOL SOLN NON_PREFERRED
LOPRESSOR TABS NON_PREFERRED
METOPROLOL TARTRATE TABS PREFERRED
BYSTOLIC TABS NON_PREFERRED
CARVEDILOL TABS PREFERRED
COREG TABS NON_PREFERRED
CARVEDILOL PHOSPHATE CP24 NON_PREFERRED
COREG CR CP24 NON_PREFERRED
LABETALOL HYDROCHLORIDE TABS PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM
CHANNEL BLOCKERS KATERZIA SUSP NON_PREFERRED
AMLODIPINE BESYLATE TABS PREFERRED
NORVASC TABS NON_PREFERRED
DILTIAZEM HCL ER CP12 PREFERRED
DILT-XR CP24 PREFERRED
DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED
CARDIZEM TABS NON_PREFERRED
DILTIAZEM HCL TABS PREFERRED
DILTIAZEM HYDROCHLORIDE TABS PREFERRED
DILTIAZEM HCL ER CP24 PREFERRED
DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED
TAZTIA XT CP24 PREFERRED
TIADYLT ER CP24 PREFERRED
TIAZAC CP24 NON_PREFERRED
CARDIZEM CD CP24 NON_PREFERRED
CARTIA XT CP24 PREFERRED
DILTIAZEM HCL CD CP24 PREFERRED
DILTIAZEM HCL ER CP24 PREFERRED
DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED
CARDIZEM LA TB24 NON_PREFERRED
DILTIAZEM HCL ER TB24 PREFERRED
MATZIM LA TB24 PREFERRED
FELODIPINE ER TB24 PREFERRED
ISRADIPINE CAPS NON_PREFERRED
Page 42 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
NICARDIPINE HCL CAPS NON_PREFERRED
NIFEDIPINE CAPS PREFERRED
PROCARDIA CAPS NON_PREFERRED
ADALAT CC TB24 NON_PREFERRED
NIFEDIPINE ER TB24 PREFERRED
PROCARDIA XL TB24 NON_PREFERRED
NIMODIPINE CAPS PREFERRED
NYMALIZE SOLN NON_PREFERRED
NISOLDIPINE ER TB24 NON_PREFERRED
SULAR TB24 NON_PREFERRED
VERAPAMIL HCL ER CP24 PREFERRED
VERAPAMIL HCL SR CP24 PREFERRED
VERELAN CP24 NON_PREFERRED
VERELAN PM CP24 NON_PREFERRED
VERAPAMIL HCL TABS PREFERRED
VERAPAMIL HYDROCHLORIDE TABS PREFERRED
CALAN SR TBCR NON_PREFERRED
VERAPAMIL HCL ER TBCR PREFERRED
VERAPAMIL HYDROCHLORIDE ER TBCR PREFERRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : MISC ALISKIREN TABS NON_PREFERRED
TEKTURNA TABS NON_PREFERRED
EPLERENONE TABS NON_PREFERRED
INSPRA TABS NON_PREFERRED
PHENOXYBENZAMINE HYDROCHLORIDE CAPS NON_PREFERRED
DEMSER CAPS PREFERRED
METYROSINE CAPS PREFERRED
HYDRALAZINE HYDROCHLORIDE SOLN PREFERRED
HYDRALAZINE HCL TABS PREFERRED
HYDRALAZINE HYDROCHLORIDE TABS PREFERRED
MINOXIDIL TABS PREFERRED
VECAMYL TABS NON_PREFERRED
METHYLDOPA/HYDROCHLOROTHIAZIDE TABS PREFERRED
TEKTURNA HCT TABS NON_PREFERRED
CARDIOVASCULAR AGENTS - CARDIOTONICS : CARDIAC GLYCOSIDES DIGOXIN SOLN PREFERRED
DIGITEK TABS PREFERRED
DIGOX TABS PREFERRED
DIGOXIN TABS PREFERRED
CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS DILATRATE SR CPCR PREFERRED
ISORDIL TITRADOSE TABS NON_PREFERRED
ISOSORBIDE DINITRATE TABS PREFERRED
ISOSORBIDE MONONITRATE TABS PREFERRED
ISOSORBIDE MONONITRATE ER TB24 PREFERRED
NITROMIST AERS NON_PREFERRED
Page 43 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
NITRO-BID OINT PREFERRED
GONITRO PACK NON_PREFERRED
MINITRAN PT24 PREFERRED
NITRO-DUR PT24 NON_PREFERRED
NITROGLYCERIN TRANSDERMAL PT24 PREFERRED
NITROGLYCERIN LINGUAL SOLN NON_PREFERRED
NITROLINGUAL PUMPSPRAY SOLN NON_PREFERRED
NITROGLYCERIN SUBL PREFERRED
NITROSTAT SUBL NON_PREFERRED
RANEXA TB12 NON_PREFERRED
RANOLAZINE ER TB12 NON_PREFERRED
CARDIOVASCULAR AGENTS : ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE CAPS PREFERRED
NORPACE CAPS NON_PREFERRED
NORPACE CR CP12 PREFERRED
QUINIDINE GLUCONATE CR TBCR PREFERRED
QUINIDINE SULFATE TABS PREFERRED
MEXILETINE HCL CAPS PREFERRED
MEXILETINE HYDROCHLORIDE CAPS PREFERRED
FLECAINIDE ACETATE TABS PREFERRED
PROPAFENONE HYDROCHLORIDE ER CP12 NON_PREFERRED
RYTHMOL SR CP12 NON_PREFERRED
PROPAFENONE HCL TABS PREFERRED
PROPAFENONE HYDROCHLORIDE TABS PREFERRED
AMIODARONE HCL TABS PREFERRED
AMIODARONE HYDROCHLORIDE TABS PREFERRED
PACERONE TABS PREFERRED
DOFETILIDE CAPS PREFERRED
TIKOSYN CAPS NON_PREFERRED
MULTAQ TABS NON_PREFERRED
CARDIOVASCULAR AGENTS : DIURETICS ACETAZOLAMIDE ER CP12 PREFERRED
ACETAZOLAMIDE TABS PREFERRED
KEVEYIS TABS NON_PREFERRED
METHAZOLAMIDE TABS PREFERRED
BUMETANIDE TABS PREFERRED
BUMEX TABS NON_PREFERRED
EDECRIN TABS NON_PREFERRED
ETHACRYNIC ACID TABS PREFERRED
FUROSEMIDE SOLN PREFERRED
FUROSEMIDE TABS PREFERRED
LASIX TABS NON_PREFERRED
TORSEMIDE TABS PREFERRED
AMILORIDE HCL TABS PREFERRED
CAROSPIR SUSP NON_PREFERRED
ALDACTONE TABS NON_PREFERRED
Page 44 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SPIRONOLACTONE TABS PREFERRED
TRIAMTERENE CAPS PREFERRED
DIURIL SUSP PREFERRED
CHLOROTHIAZIDE TABS PREFERRED
CHLORTHALIDONE TABS PREFERRED
HYDROCHLOROTHIAZIDE CAPS PREFERRED
HYDROCHLOROTHIAZIDE TABS PREFERRED
INDAPAMIDE TABS PREFERRED
METOLAZONE TABS PREFERRED
AMILORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED
ALDACTAZIDE TABS NON_PREFERRED
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS PREFERRED
DYAZIDE CAPS NON_PREFERRED
TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS PREFERRED
MAXZIDE TABS NON_PREFERRED
MAXZIDE-25 TABS NON_PREFERRED
TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS PREFERRED
CARDIOVASCULAR AGENTS : MISC MIDODRINE HCL TABS PREFERRED
MIDODRINE HYDROCHLORIDE TABS PREFERRED
NORTHERA CAPS NON_PREFERRED
CIALIS TABS NON_PREFERRED
TADALAFIL TABS NON_PREFERRED
VYNDAMAX CAPS NON_PREFERRED
VYNDAQEL CAPS NON_PREFERRED
CORLANOR SOLN NON_PREFERRED
CORLANOR TABS NON_PREFERRED
ENTRESTO TABS NON_PREFERRED
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS NON_PREFERRED
CADUET TABS NON_PREFERRED
BIDIL TABS PREFERRED
CARDIOVASCULAR AGENTS : PULMONARY HYPERTENSION UPTRAVI TABS NON_PREFERRED
UPTRAVI TBPK NON_PREFERRED
ADEMPAS TABS NON_PREFERRED
REVATIO SOLN NON_PREFERRED
SILDENAFIL SOLN NON_PREFERRED
REVATIO SUSR PREFERRED_WITH_PA
SILDENAFIL CITRATE SUSR NON_PREFERRED
REVATIO TABS NON_PREFERRED
SILDENAFIL CITRATE TABS PREFERRED_WITH_PA
ADCIRCA TABS PREFERRED_WITH_PA
ALYQ TABS PREFERRED_WITH_PA
TADALAFIL TABS PREFERRED_WITH_PA
AMBRISENTAN TABS NON_PREFERRED
LETAIRIS TABS PREFERRED_WITH_PA
Page 45 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
BOSENTAN TABS NON_PREFERRED
TRACLEER TABS PREFERRED_WITH_PA
TRACLEER TBSO PREFERRED_WITH_PA
OPSUMIT TABS NON_PREFERRED
EPOPROSTENOL SODIUM SOLR PREFERRED_WITH_PA
FLOLAN SOLR PREFERRED_WITH_PA
VELETRI SOLR NON_PREFERRED
VENTAVIS SOLN NON_PREFERRED
REMODULIN SOLN NON_PREFERRED
TREPROSTINIL SOLN NON_PREFERRED
TYVASO SOLN NON_PREFERRED
TYVASO REFILL SOLN NON_PREFERRED
TYVASO STARTER SOLN NON_PREFERRED
ORENITRAM TBCR NON_PREFERRED
CONTRACEPTIVES : COMBINATION CONTRACEPTIVES XULANE PTWK PREFERRED
ELURYNG RING PREFERRED
ETONOGESTREL/ETHINYL ESTR RING PREFERRED
NUVARING RING PREFERRED
ANNOVERA RING PREFERRED
APRI TABS PREFERRED
CYRED TABS PREFERRED
CYRED EQ TABS PREFERRED
EMOQUETTE TABS PREFERRED
ENSKYCE TABS PREFERRED
ISIBLOOM TABS PREFERRED
JULEBER TABS PREFERRED
KALLIGA TABS PREFERRED
RECLIPSEN TABS PREFERRED
DROSPIRENONE/ETHINYL ESTRADIOL TABS PREFERRED
GIANVI TABS PREFERRED
JASMIEL TABS PREFERRED
LO-ZUMANDIMINE TABS PREFERRED
LORYNA TABS PREFERRED
NIKKI TABS PREFERRED
OCELLA TABS PREFERRED
SYEDA TABS PREFERRED
YASMIN 28 TABS PREFERRED
YAZ TABS PREFERRED
ZARAH TABS PREFERRED
ZUMANDIMINE TABS PREFERRED
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL TABS PREFERRED
KELNOR 1/35 TABS PREFERRED
KELNOR 1/50 TABS PREFERRED
ZOVIA 1/35E TABS PREFERRED
Page 46 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
AFIRMELLE TABS PREFERRED
ALTAVERA TABS PREFERRED
AUBRA TABS PREFERRED
AUBRA EQ TABS PREFERRED
AVIANE TABS PREFERRED
AYUNA TABS PREFERRED
CHATEAL TABS PREFERRED
CHATEAL EQ TABS PREFERRED
FALMINA TABS PREFERRED
KURVELO TABS PREFERRED
LARISSIA TABS PREFERRED
LESSINA TABS PREFERRED
LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED
LEVORA 0.15/30-28 TABS PREFERRED
LILLOW TABS PREFERRED
LUTERA TABS PREFERRED
MARLISSA TABS PREFERRED
ORSYTHIA TABS PREFERRED
PORTIA-28 TABS PREFERRED
SRONYX TABS PREFERRED
TYBLUME TABS PREFERRED
VIENVA TABS PREFERRED
ALYACEN 1/35 TABS PREFERRED
BALZIVA TABS PREFERRED
BRIELLYN TABS PREFERRED
CYCLAFEM 1/35 TABS PREFERRED
DASETTA 1/35 TABS PREFERRED
NECON 0.5/35-28 TABS PREFERRED
NORTREL 0.5/35 (28) TABS PREFERRED
NORTREL 1/35 TABS PREFERRED
PHILITH TABS PREFERRED
PIRMELLA 1/35 TABS PREFERRED
VYFEMLA TABS PREFERRED
WERA TABS PREFERRED
ZENCHENT TABS PREFERRED
AUROVELA 1.5/30 TABS PREFERRED
AUROVELA 1/20 TABS PREFERRED
HAILEY 1.5/30 TABS PREFERRED
JUNEL 1.5/30 TABS PREFERRED
JUNEL 1/20 TABS PREFERRED
LARIN 1.5/30 TABS PREFERRED
LARIN 1/20 TABS PREFERRED
LOESTRIN 1.5/30-21 TABS PREFERRED
LOESTRIN 1/20-21 TABS PREFERRED
Page 47 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
MICROGESTIN 1.5/30 TABS PREFERRED
MICROGESTIN 1/20 TABS PREFERRED
NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS PREFERRED
CRYSELLE-28 TABS PREFERRED
ELINEST TABS PREFERRED
LOW-OGESTREL TABS PREFERRED
OGESTREL TABS PREFERRED
ESTARYLLA TABS PREFERRED
FEMYNOR TABS PREFERRED
MILI TABS PREFERRED
MONO-LINYAH TABS PREFERRED
NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED
PREVIFEM TABS PREFERRED
SPRINTEC 28 TABS PREFERRED
VYLIBRA TABS PREFERRED
BEYAZ TABS PREFERRED
DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM TABS PREFERRED
SAFYRAL TABS PREFERRED
TYDEMY TABS PREFERRED
BALCOLTRA TABS PREFERRED
FALESSA KIT PREFERRED
GENERESS FE CHEW PREFERRED
KAITLIB FE CHEW PREFERRED
LAYOLIS FE CHEW PREFERRED
NORETHINDRONE & ETHINYL ESTRADIOL FERROUS FUMARATE CHEW PREFERRED
NORETHINDRONE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED
WYMZYA FE CHEW PREFERRED
TAYTULLA CAPS PREFERRED
CHARLOTTE 24 FE CHEW PREFERRED
MELODETTA 24 FE CHEW PREFERRED
MIBELAS 24 FE CHEW PREFERRED
MINASTRIN 24 FE CHEW PREFERRED
NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED
AUROVELA 24 FE TABS PREFERRED
AUROVELA FE 1.5/30 TABS PREFERRED
AUROVELA FE 1/20 TABS PREFERRED
BLISOVI 24 FE TABS PREFERRED
BLISOVI FE 1.5/30 TABS PREFERRED
BLISOVI FE 1/20 TABS PREFERRED
HAILEY 24 FE TABS PREFERRED
HAILEY FE 1.5/30 TABS PREFERRED
HAILEY FE 1/20 TABS PREFERRED
JUNEL FE 1.5/30 TABS PREFERRED
JUNEL FE 1/20 TABS PREFERRED
Page 48 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
JUNEL FE 24 TABS PREFERRED
LARIN 24 FE TABS PREFERRED
LARIN FE 1.5/30 TABS PREFERRED
LARIN FE 1/20 TABS PREFERRED
LOESTRIN FE 1.5/30 TABS PREFERRED
LOESTRIN FE 1/20 TABS PREFERRED
MICROGESTIN 24 FE TABS PREFERRED
MICROGESTIN FE TABS PREFERRED
MICROGESTIN FE 1.5/30 TABS PREFERRED
MICROGESTIN FE 1/20 TABS PREFERRED
NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE TABS PREFERRED
TARINA 24 FE TABS PREFERRED
TARINA FE 1/20 TABS PREFERRED
TARINA FE 1/20 EQ TABS PREFERRED
AZURETTE TABS PREFERRED
BEKYREE TABS PREFERRED
DESOGESTREL/ETHINYL ESTRADIOL TABS PREFERRED
KARIVA TABS PREFERRED
MIRCETTE TABS PREFERRED
PIMTREA TABS PREFERRED
SIMLIYA TABS PREFERRED
VIORELE TABS PREFERRED
VOLNEA TABS PREFERRED
LO LOESTRIN FE TABS PREFERRED
CAZIANT TABS PREFERRED
CYCLESSA TABS PREFERRED
VELIVET TABS PREFERRED
ENPRESSE-28 TABS PREFERRED
LEVONEST TABS PREFERRED
LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED
TRIVORA-28 TABS PREFERRED
ALYACEN 7/7/7 TABS PREFERRED
ARANELLE TABS PREFERRED
CYCLAFEM 7/7/7 TABS PREFERRED
DASETTA 7/7/7 TABS PREFERRED
LEENA TABS PREFERRED
NORTREL 7/7/7 TABS PREFERRED
PIRMELLA 7/7/7 TABS PREFERRED
NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED
TRI FEMYNOR TABS PREFERRED
TRI-ESTARYLLA TABS PREFERRED
TRI-LINYAH TABS PREFERRED
TRI-LO-ESTARYLLA TABS PREFERRED
TRI-LO-MARZIA TABS PREFERRED
Page 49 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
TRI-LO-MILI TABS PREFERRED
TRI-LO-SPRINTEC TABS PREFERRED
TRI-MILI TABS PREFERRED
TRI-PREVIFEM TABS PREFERRED
TRI-SPRINTEC TABS PREFERRED
TRI-VYLIBRA TABS PREFERRED
TRI-VYLIBRA LO TABS PREFERRED
TRINESSA TABS PREFERRED
ESTROSTEP FE TABS PREFERRED
TILIA FE TABS PREFERRED
TRI-LEGEST FE TABS PREFERRED
NATAZIA TABS PREFERRED
AMETHIA TABS PREFERRED
AMETHIA LO TABS PREFERRED
ASHLYNA TABS PREFERRED
CAMRESE TABS PREFERRED
CAMRESE LO TABS PREFERRED
DAYSEE TABS PREFERRED
FAYOSIM TABS PREFERRED
INTROVALE TABS PREFERRED
JAIMIESS TABS PREFERRED
JOLESSA TABS PREFERRED
LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED
LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED
LOJAIMIESS TABS PREFERRED
LOSEASONIQUE TABS PREFERRED
QUARTETTE TABS PREFERRED
RIVELSA TABS PREFERRED
SEASONIQUE TABS PREFERRED
SETLAKIN TABS PREFERRED
SIMPESSE TABS PREFERRED
AMETHYST TABS PREFERRED
LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED
CONTRACEPTIVES : EMERGENCY CONTRACEPTIVES AFTERA TABS PREFERRED
ECONTRA EZ TABS PREFERRED
ECONTRA ONE-STEP TABS PREFERRED
FALLBACK SOLO TABS PREFERRED
LEVONORGESTREL TABS PREFERRED
MY CHOICE TABS PREFERRED
MY WAY TABS PREFERRED
NEW DAY TABS PREFERRED
OPCICON ONE-STEP TABS PREFERRED
OPTION 2 TABS PREFERRED
PLAN B ONE-STEP TABS PREFERRED
Page 50 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
TAKE ACTION TABS PREFERRED
ELLA TABS PREFERRED
CONTRACEPTIVES : PROGESTIN CONTRACEPTIVES CAMILA TABS PREFERRED
DEBLITANE TABS PREFERRED
ERRIN TABS PREFERRED
HEATHER TABS PREFERRED
INCASSIA TABS PREFERRED
JENCYCLA TABS PREFERRED
JOLIVETTE TABS PREFERRED
LYZA TABS PREFERRED
NORA-BE TABS PREFERRED
NORETHINDRONE TABS PREFERRED
NORLYDA TABS PREFERRED
ORTHO MICRONOR TABS PREFERRED
SHAROBEL TABS PREFERRED
TULANA TABS PREFERRED
SLYND TABS PREFERRED
DEPO-PROVERA CONTRACEPTIVE SUSP PREFERRED
MEDROXYPROGESTERONE ACETATE SUSP PREFERRED
DEPO-PROVERA CONTRACEPTIVE SUSY PREFERRED
DEPO-SUBQ PROVERA 104 SUSY PREFERRED
MEDROXYPROGESTERONE ACETATE SUSY PREFERRED
CORTICOSTEROIDS ORTIKOS CP24 NON_PREFERRED
BUDESONIDE CPEP NON_PREFERRED
ENTOCORT EC CPEP NON_PREFERRED
BUDESONIDE ER TB24 NON_PREFERRED
UCERIS TB24 NON_PREFERRED
CORTISONE ACETATE TABS NON_PREFERRED
EMFLAZA SUSP NON_PREFERRED
EMFLAZA TABS NON_PREFERRED
DEXAMETHASONE INTENSOL CONC PREFERRED
DECADRON ELIX PREFERRED
DEXAMETHASONE ELIX PREFERRED
DEXAMETHASONE SOLN PREFERRED
DECADRON TABS PREFERRED
DEXAMETHASONE TABS PREFERRED
HEMADY TABS NON_PREFERRED
DEXAMETHASONE 10-DAY DOSE PACK TBPK PREFERRED
DEXAMETHASONE 13-DAY DOSE PACK TBPK PREFERRED
DEXAMETHASONE 6-DAY DOSEPACK TBPK PREFERRED
DEXAMETHASONE 6-DAY THERAPY PACK TBPK PREFERRED
TAPERDEX 12-DAY TBPK NON_PREFERRED
TAPERDEX 6-DAY TBPK NON_PREFERRED
TAPERDEX 7-DAY TBPK NON_PREFERRED
Page 51 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ALKINDI SPRINKLE CPSP NON_PREFERRED
CORTEF TABS NON_PREFERRED
HYDROCORTISONE TABS PREFERRED
MEDROL TABS NON_PREFERRED
METHYLPREDNISOLONE TABS PREFERRED
MEDROL DOSEPAK TBPK NON_PREFERRED
METHYLPREDNISOLONE DOSE PACK TBPK PREFERRED
PREDNISOLONE SOLN PREFERRED
MILLIPRED TABS PREFERRED
MILLIPRED DP TBPK PREFERRED
PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED
PREDNISOLONE SODIUM PHOSPHATE ODT TBDP NON_PREFERRED
PREDNISONE INTENSOL CONC PREFERRED
PREDNISONE SOLN PREFERRED
PREDNISONE TABS PREFERRED
RAYOS TBEC NON_PREFERRED
PREDNISONE TBPK PREFERRED
FLUDROCORTISONE ACETATE TABS PREFERRED
DERMATOLOGICALS : ACNE PRODUCTS ADAPALENE CREA NON_PREFERRED
DIFFERIN CREA NON_PREFERRED
ADAPALENE GEL NON_PREFERRED
ADAPALENE PUMP GEL NON_PREFERRED
DIFFERIN GEL NON_PREFERRED
DIFFERIN LOTN NON_PREFERRED
ADAPALENE SOLN NON_PREFERRED
AZELEX CREA NON_PREFERRED
ABSORICA CAPS NON_PREFERRED
AMNESTEEM CAPS NON_PREFERRED
CLARAVIS CAPS NON_PREFERRED
ISOTRETINOIN CAPS NON_PREFERRED
MYORISAN CAPS NON_PREFERRED
ZENATANE CAPS NON_PREFERRED
ABSORICA LD CAPS NON_PREFERRED
FABIOR FOAM NON_PREFERRED
ARAZLO LOTN NON_PREFERRED
AVITA CREA PREFERRED
RETIN-A CREA NON_PREFERRED
TRETIN-X CREA NON_PREFERRED
TRETINOIN CREA PREFERRED
ATRALIN GEL NON_PREFERRED
AVITA GEL PREFERRED
RETIN-A GEL NON_PREFERRED
TRETINOIN GEL PREFERRED
ALTRENO LOTN NON_PREFERRED
Page 52 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
RETIN-A MICRO GEL NON_PREFERRED
RETIN-A MICRO PUMP GEL NON_PREFERRED
TRETINOIN MICROSPHERE GEL NON_PREFERRED
TRETINOIN MICROSPHERE PUMP GEL NON_PREFERRED
AKLIEF CREA NON_PREFERRED
CLINDAMYCIN PHOSPHATE FOAM NON_PREFERRED
EVOCLIN FOAM NON_PREFERRED
CLEOCIN-T GEL NON_PREFERRED
CLINDAGEL GEL NON_PREFERRED
CLINDAMYCIN PHOSPHATE GEL PREFERRED
CLEOCIN-T LOTN NON_PREFERRED
CLINDAMYCIN PHOSPHATE LOTN PREFERRED
CLINDAMYCIN PHOSPHATE SOLN PREFERRED
CLINDACIN ETZ PLEDGETS SWAB PREFERRED
CLINDACIN-P SWAB PREFERRED
CLINDAMYCIN PHOSPHATE SWAB PREFERRED
ACZONE GEL NON_PREFERRED
DAPSONE GEL NON_PREFERRED
ERYGEL GEL NON_PREFERRED
ERYTHROMYCIN GEL PREFERRED
ERY PADS NON_PREFERRED
ERYTHROMYCIN PADS NON_PREFERRED
ERYTHROMYCIN SOLN PREFERRED
KLARON LOTN NON_PREFERRED
SODIUM SULFACETAMIDE LOTN NON_PREFERRED
SULFACETAMIDE SODIUM LOTN NON_PREFERRED
AMZEEQ FOAM NON_PREFERRED
ADAPALENE/BENZOYL PEROXIDE GEL NON_PREFERRED
EPIDUO GEL NON_PREFERRED
EPIDUO FORTE GEL NON_PREFERRED
BENZAMYCIN GEL NON_PREFERRED
ERYTHROMYCIN/BENZOYL PEROXIDE GEL PREFERRED
AKTIPAK PACK PREFERRED
ACANYA GEL NON_PREFERRED
BENZACLIN GEL NON_PREFERRED
BENZACLIN WITH PUMP GEL NON_PREFERRED
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED
CLINDAMYCIN/BENZOYL PEROXIDE GEL NON_PREFERRED
ONEXTON GEL NON_PREFERRED
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED
NEUAC GEL NON_PREFERRED
CLINDACIN ETZ KIT NON_PREFERRED
CLINDACIN PAC KIT NON_PREFERRED
CLINDAMYCIN PHOSPHATE/TRETINOIN GEL NON_PREFERRED
Page 53 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ZIANA GEL NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR CREA NON_PREFERRED
SSS 10%-5% CREA NON_PREFERRED
BP 10-1 EMUL NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR CLEANSER EMUL NON_PREFERRED
SULFACETAMIDE SODIUM/SULFUR CLEANSER EMUL NON_PREFERRED
SSS 10-5 FOAM NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR LIQD NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR CLEANSER LIQD NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR WASH LIQD NON_PREFERRED
SUMADAN WASH LIQD NON_PREFERRED
SUMAXIN WASH LIQD NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR PADS NON_PREFERRED
SUMAXIN PADS NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR SUSP NON_PREFERRED
SUMAXIN TS SUSP NON_PREFERRED
BP CLEANSING WASH EMUL NON_PREFERRED
SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA EMUL NON_PREFERRED
SUMADAN KIT KIT NON_PREFERRED
SUMAXIN CP KIT KIT NON_PREFERRED
SUMADAN XLT KIT NON_PREFERRED
NEUAC KIT KIT NON_PREFERRED
DERMATOLOGICALS : ANTIBIOTICS GENTAMICIN SULFATE CREA PREFERRED
GENTAMICIN SULFATE OINT PREFERRED
XEPI CREA NON_PREFERRED
CENTANY AT KIT NON_PREFERRED
CENTANY OINT NON_PREFERRED
MUPIROCIN OINT PREFERRED
MUPIROCIN CREA NON_PREFERRED
NEO-SYNALAR CREA NON_PREFERRED
CORTISPORIN CREA NON_PREFERRED
NEO-SYNALAR KIT KIT NON_PREFERRED
CORTISPORIN OINT PREFERRED
DERMATOLOGICALS : ANTIFUNGALS MENTAX CREA NON_PREFERRED
CICLOPIROX GEL NON_PREFERRED
CICLODAN SOLUTION KIT KIT NON_PREFERRED
CICLOPIROX TREATMENT KIT NON_PREFERRED
CICLOPIROX SHAM NON_PREFERRED
LOPROX SHAMPOO SHAM NON_PREFERRED
CICLODAN SOLN NON_PREFERRED
CICLOPIROX NAIL LACQUER SOLN NON_PREFERRED
CICLODAN CREA NON_PREFERRED
CICLOPIROX OLAMINE CREA NON_PREFERRED
LOPROX CREA NON_PREFERRED
Page 54 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CICLOPIROX SUSP NON_PREFERRED
LOPROX SUSP NON_PREFERRED
CICLODAN CREAM KIT KIT NON_PREFERRED
LOPROX KIT NON_PREFERRED
LOPROX KIT KIT NON_PREFERRED
NAFTIFINE HCL CREA NON_PREFERRED
NAFTIFINE HYDROCHLORIDE CREA NON_PREFERRED
NAFTIN CREA NON_PREFERRED
NAFTIFINE HYDROCHLORIDE GEL NON_PREFERRED
NAFTIN GEL NON_PREFERRED
NYSTATIN CREA PREFERRED
NYSTATIN OINT PREFERRED
NYAMYC POWD PREFERRED
NYSTATIN POWD PREFERRED
NYSTOP POWD PREFERRED
CLOTRIMAZOLE CREA PREFERRED
CLOTRIMAZOLE SOLN NON_PREFERRED
ECONAZOLE NITRATE CREA PREFERRED
JUBLIA SOLN NON_PREFERRED
KETOCONAZOLE CREA PREFERRED
EXTINA FOAM NON_PREFERRED
KETOCONAZOLE FOAM NON_PREFERRED
KETODAN FOAM NON_PREFERRED
KETOCONAZOLE SHAM PREFERRED
KETODAN KIT KIT NON_PREFERRED
LULICONAZOLE CREA NON_PREFERRED
LUZU CREA NON_PREFERRED
OXICONAZOLE NITRATE CREA NON_PREFERRED
OXISTAT CREA NON_PREFERRED
OXISTAT LOTN NON_PREFERRED
ERTACZO CREA NON_PREFERRED
EXELDERM CREA NON_PREFERRED
EXELDERM SOLN NON_PREFERRED
KERYDIN SOLN NON_PREFERRED
TAVABOROLE SOLN NON_PREFERRED
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED
ZOLPAK KIT NON_PREFERRED
NYSTATIN/TRIAMCINOLONE CREA NON_PREFERRED
NYSTATIN/TRIAMCINOLONE ACETONIDE CREA NON_PREFERRED
NYSTATIN/TRIAMCINOLONE OINT NON_PREFERRED
NYSTATIN/TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED
ECONASIL KIT NON_PREFERRED
MICONAZOLE NITRATE/ZINC OXIDE/WHITE PETROLATUM OINT NON_PREFERRED
Page 55 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
VUSION OINT NON_PREFERRED
DERMATOLOGICALS : ANTIPSORIATICS CALCIPOTRIENE CREA PREFERRED
DOVONEX CREA NON_PREFERRED
SORILUX FOAM NON_PREFERRED
CALCIPOTRIENE OINT PREFERRED
CALCIPOTRIENE SOLN PREFERRED
CALCITRIOL OINT NON_PREFERRED
VECTICAL OINT NON_PREFERRED
TAZAROTENE CREA NON_PREFERRED
TAZORAC CREA NON_PREFERRED
TAZORAC GEL NON_PREFERRED
ACITRETIN CAPS NON_PREFERRED
SORIATANE CAPS NON_PREFERRED
SILIQ SOSY NON_PREFERRED
TREMFYA SOPN NON_PREFERRED
TREMFYA SOSY NON_PREFERRED
TALTZ SOAJ NON_PREFERRED
TALTZ SOSY NON_PREFERRED
METHOXSALEN CAPS NON_PREFERRED
OXSORALEN ULTRA CAPS NON_PREFERRED
SKYRIZI PSKT NON_PREFERRED
COSENTYX SENSOREADY PEN SOAJ NON_PREFERRED
COSENTYX SOSY NON_PREFERRED
ILUMYA SOSY NON_PREFERRED
STELARA SOLN NON_PREFERRED
STELARA SOSY NON_PREFERRED
DERMATOLOGICALS : CORTICOSTEROIDS - TOPICAL ALCLOMETASONE DIPROPIONATE CREA PREFERRED
ALCLOMETASONE DIPROPIONATE OINT PREFERRED
AMCINONIDE CREA NON_PREFERRED
AMCINONIDE LOTN NON_PREFERRED
BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED
SERNIVO EMUL NON_PREFERRED
BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED
BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED
AUGMENTED BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED
AUGMENTED BETAMETHASONE DIPROPIONATE GEL NON_PREFERRED
AUGMENTED BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED
AUGMENTED BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED
DIPROLENE OINT NON_PREFERRED
BETAMETHASONE VALERATE CREA PREFERRED
BETAMETHASONE VALERATE FOAM NON_PREFERRED
LUXIQ FOAM NON_PREFERRED
BETAMETHASONE VALERATE LOTN PREFERRED
BETAMETHASONE VALERATE OINT PREFERRED
Page 56 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CLOBETASOL PROPIONATE CREA PREFERRED
TEMOVATE CREA NON_PREFERRED
CLOBETASOL PROPIONATE FOAM NON_PREFERRED
OLUX FOAM NON_PREFERRED
CLOBETASOL PROPIONATE GEL PREFERRED
TASOPROL KIT NON_PREFERRED
CLOBETASOL PROPIONATE LIQD NON_PREFERRED
CLOBEX LIQD NON_PREFERRED
CLOBETASOL PROPIONATE LOTN NON_PREFERRED
CLOBEX LOTN NON_PREFERRED
IMPEKLO LOTN NON_PREFERRED
CLOBETASOL PROPIONATE OINT PREFERRED
TEMOVATE OINT NON_PREFERRED
CLOBETASOL PROPIONATE SHAM NON_PREFERRED
CLOBEX SHAM NON_PREFERRED
CLODAN SHAM NON_PREFERRED
CLOBETASOL PROPIONATE SOLN PREFERRED
CLOBETASOL PROPIONATE E CREA PREFERRED
CLOBETASOL PROPIONATE EMOLLIENT CREA PREFERRED
CLOBETASOL PROPIONATE FOAM NON_PREFERRED
CLOBETASOL PROPIONATE EMOLLIENT FOAM NON_PREFERRED
OLUX-E FOAM NON_PREFERRED
TOVET FOAM NON_PREFERRED
TOVET KIT KIT NON_PREFERRED
CLOCORTOLONE PIVALATE CREA NON_PREFERRED
CLODERM CREA NON_PREFERRED
DESONIDE CREA PREFERRED
DESONATE GEL NON_PREFERRED
DESONIDE LOTN NON_PREFERRED
DESONIDE OINT PREFERRED
DESOXIMETASONE CREA NON_PREFERRED
TOPICORT CREA NON_PREFERRED
DESOXIMETASONE GEL NON_PREFERRED
TOPICORT GEL NON_PREFERRED
DESOXIMETASONE LIQD NON_PREFERRED
TOPICORT LIQD NON_PREFERRED
DESOXIMETASONE OINT NON_PREFERRED
TOPICORT OINT NON_PREFERRED
DIFLORASONE DIACETATE CREA PREFERRED
PSORCON CREA NON_PREFERRED
DIFLORASONE DIACETATE OINT PREFERRED
APEXICON E CREA NON_PREFERRED
FLUOCINOLONE ACETONIDE CREA PREFERRED
SYNALAR CREA NON_PREFERRED
Page 57 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
DERMA-SMOOTHE/FS BODY OIL NON_PREFERRED
DERMA-SMOOTHE/FS SCALP OIL NON_PREFERRED
FLUOCINOLONE ACETONIDE BODY OIL PREFERRED
FLUOCINOLONE ACETONIDE SCALP OIL PREFERRED
FLUOCINOLONE ACETONIDE OINT PREFERRED
SYNALAR OINT NON_PREFERRED
CAPEX SHAM NON_PREFERRED
FLUOCINOLONE ACETONIDE SOLN PREFERRED
SYNALAR SOLN NON_PREFERRED
FLUOCINONIDE CREA PREFERRED
VANOS CREA NON_PREFERRED
FLUOCINONIDE GEL PREFERRED
FLUOCINONIDE OINT PREFERRED
FLUOCINONIDE SOLN PREFERRED
FLUOCINONIDE EMULSIFIED BASE CREA PREFERRED
FLUOCINONIDE EMULSIFIEDBASE CREA PREFERRED
FLURANDRENOLIDE CREA NON_PREFERRED
FLURANDRENOLIDE LOTN NON_PREFERRED
FLURANDRENOLIDE OINT NON_PREFERRED
CORDRAN TAPE NON_PREFERRED
FLUTICASONE PROPIONATE CREA PREFERRED
BESER LOTN NON_PREFERRED
CUTIVATE LOTN NON_PREFERRED
FLUTICASONE PROPIONATE LOTN NON_PREFERRED
FLUTICASONE PROPIONATE OINT PREFERRED
HALCINONIDE CREA NON_PREFERRED
HALOG CREA NON_PREFERRED
HALOG OINT NON_PREFERRED
HALOG SOLN NON_PREFERRED
HALOBETASOL PROPIONATE CREA PREFERRED
ULTRAVATE CREA NON_PREFERRED
HALOBETASOL PROPIONATE FOAM NON_PREFERRED
LEXETTE FOAM NON_PREFERRED
BRYHALI LOTN NON_PREFERRED
ULTRAVATE LOTN NON_PREFERRED
HALOBETASOL PROPIONATE OINT PREFERRED
ULTRAVATE OINT NON_PREFERRED
HYDROCORTISONE CREA PREFERRED
HYDROCORTISONE LOTN PREFERRED
HYDROCORTISONE OINT PREFERRED
HYDROCORTISONE IN ABSORBASE OINT PREFERRED
TEXACORT SOLN NON_PREFERRED
HYDROCORTISONE VALERATE CREA PREFERRED
HYDROCORTISONE VALERATE OINT PREFERRED
Page 58 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
PANDEL CREA NON_PREFERRED
HYDROCORTISONE BUTYRATE CREA NON_PREFERRED
HYDROCORTISONE BUTYRATE LOTN NON_PREFERRED
LOCOID LOTN NON_PREFERRED
HYDROCORTISONE BUTYRATE OINT NON_PREFERRED
HYDROCORTISONE BUTYRATE SOLN NON_PREFERRED
HYDROCORTISONE BUTYRATE CREA NON_PREFERRED
HYDROCORTISONE BUTYRATE (LIPID) CREA NON_PREFERRED
HYDROCORTISONE BUTYRATE (LIPOPHILIC) CREA NON_PREFERRED
LOCOID LIPOCREAM CREA NON_PREFERRED
MOMETASONE FUROATE CREA PREFERRED
MOMETASONE FUROATE OINT PREFERRED
MOMETASONE FUROATE SOLN PREFERRED
PREDNICARBATE CREA NON_PREFERRED
PREDNICARBATE OINT NON_PREFERRED
KENALOG AERS NON_PREFERRED
TRIAMCINOLONE ACETONIDE AERS NON_PREFERRED
TRIAMCINOLONE ACETONIDE CREA PREFERRED
TRIAMCINOLONE ACETONIDE LOTN PREFERRED
TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED
TRIAMCINOLONE ACETONIDE OINT PREFERRED
TRIANEX OINT NON_PREFERRED
EPIFOAM FOAM NON_PREFERRED
ENSTILAR FOAM NON_PREFERRED
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED
TACLONEX OINT NON_PREFERRED
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE SUSP NON_PREFERRED
TACLONEX SUSP NON_PREFERRED
CLODAN KIT KIT NON_PREFERRED
SYNALAR TS KIT NON_PREFERRED
SYNALAR CREAM KIT KIT NON_PREFERRED
SYNALAR OINTMENT KIT KIT NON_PREFERRED
FLUOPAR KIT NON_PREFERRED
BESER KIT NON_PREFERRED
DUOBRII LOTN NON_PREFERRED
ULTRAVATE X KIT NON_PREFERRED
DERMATOLOGICALS : MISC FINACEA FOAM NON_PREFERRED
AZELAIC ACID GEL NON_PREFERRED
FINACEA GEL NON_PREFERRED
MIRVASO GEL NON_PREFERRED
DOXYCYCLINE CPDR NON_PREFERRED
ORACEA CPDR NON_PREFERRED
IVERMECTIN CREA NON_PREFERRED
SOOLANTRA CREA NON_PREFERRED
Page 59 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
METROCREAM CREA NON_PREFERRED
METRONIDAZOLE CREA PREFERRED
NORITATE CREA NON_PREFERRED
ROSADAN CREA PREFERRED
METROGEL GEL NON_PREFERRED
METRONIDAZOLE GEL PREFERRED
ROSADAN GEL PREFERRED
METRONIDAZOLE LOTN PREFERRED
ROSADAN KIT KIT NON_PREFERRED
ZILXI FOAM NON_PREFERRED
RHOFADE CREA NON_PREFERRED
LICART PT24 NON_PREFERRED
DICLOFENAC EPOLAMINE PTCH NON_PREFERRED
FLECTOR PTCH NON_PREFERRED
DICLOFENAC SODIUM GEL NON_PREFERRED
VOLTAREN GEL NON_PREFERRED
VOPAC MDS KIT NON_PREFERRED
DICLOFENAC SODIUM SOLN NON_PREFERRED
PENNSAID SOLN NON_PREFERRED
DYNABAC 5.0 THPK NON_PREFERRED
DICLOFEX DC THPK NON_PREFERRED
DICLOTREX THPK NON_PREFERRED
DOXEPIN HYDROCHLORIDE CREA NON_PREFERRED
PRUDOXIN CREA NON_PREFERRED
ZONALON CREA NON_PREFERRED
EUCRISA OINT PREFERRED_WITH_PA
SELENIUM SULFIDE LOTN PREFERRED
SELENIUM SULFIDE SHAM NON_PREFERRED
SELENIUM SULFIDE SHAMPOO SHAM NON_PREFERRED
SODIUM SULFACETAMIDE GEL NON_PREFERRED
SODIUM SULFACETAMIDE WASH LIQD NON_PREFERRED
OVACE PLUS LOTN NON_PREFERRED
ACYCLOVIR CREA NON_PREFERRED
ZOVIRAX CREA NON_PREFERRED
ACYCLOVIR OINT NON_PREFERRED
ZOVIRAX OINT NON_PREFERRED
DENAVIR CREA NON_PREFERRED
XERESE CREA NON_PREFERRED
VALCHLOR GEL NON_PREFERRED
CARAC CREA NON_PREFERRED
EFUDEX CREA NON_PREFERRED
FLUOROURACIL CREA NON_PREFERRED
TOLAK CREA NON_PREFERRED
FLUOROURACIL SOLN NON_PREFERRED
Page 60 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
DICLOFENAC SODIUM GEL NON_PREFERRED
AMELUZ GEL NON_PREFERRED
LEVULAN KERASTICK SOLR PREFERRED
PANRETIN GEL PREFERRED
TARGRETIN GEL PREFERRED
PICATO GEL NON_PREFERRED
ORMECA KIT NON_PREFERRED
SULFAMYLON CREA PREFERRED
MAFENIDE ACETATE PACK PREFERRED
SULFAMYLON PACK NON_PREFERRED
SILVADENE CREA NON_PREFERRED
SILVER SULFADIAZINE CREA PREFERRED
SSD CREA PREFERRED
SILVER NITRATE SOLN NON_PREFERRED
ARZOL SILVER NITRATE APPLICATORS MISC NON_PREFERRED
GRAFCO SILVER NITRATE APPLICATOR MISC NON_PREFERRED
AMMONIUM LACTATE CREA NON_PREFERRED
AMMONIUM LACTATE LOTN PREFERRED
UREA CREA PREFERRED
UREA LOTN PREFERRED
UREA HYDRATING FOAM NON_PREFERRED
SANTYL OINT NON_PREFERRED
CONDYLOX GEL PREFERRED
PODOFILOX SOLN PREFERRED
PODOCON 25 IN BENZOIN TINCTURE SOLN NON_PREFERRED
SALICYLIC ACID FOAM NON_PREFERRED
SALICYLIC ACID GEL PREFERRED
SALICYLIC ACID WART REMOVER LIQD PREFERRED
SALEX SHAM NON_PREFERRED
SALEX CREAM KIT NON_PREFERRED
SALEX LOTION KIT NON_PREFERRED
BENSAL HP OINT NON_PREFERRED
VEREGEN OINT NON_PREFERRED
ALDARA CREA NON_PREFERRED
IMIQUIMOD CREA PREFERRED
IMIQUIMOD PUMP CREA NON_PREFERRED
ZYCLARA CREA NON_PREFERRED
ZYCLARA PUMP CREA NON_PREFERRED
ELIDEL CREA PREFERRED_WITH_PA
PIMECROLIMUS CREA PREFERRED_WITH_PA
PROTOPIC OINT PREFERRED_WITH_PA
TACROLIMUS OINT PREFERRED_WITH_PA
QUTENZA KIT NON_PREFERRED
LIDOCAINE OINT PREFERRED
Page 61 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
LIDOCAINE PTCH PREFERRED
LIDOCAINE PATCH 5% PTCH PREFERRED
LIDODERM PTCH NON_PREFERRED
ZTLIDO PTCH NON_PREFERRED
LIDOCAINE CREA PREFERRED
LIDOCAINE HYDROCHLORIDE CREA PREFERRED
LYDEXA CREA NON_PREFERRED
LIDOCAINE HCL JELLY GEL PREFERRED
LIDOZION LOTN NON_PREFERRED
GLYDO PRSY PREFERRED
LIDOCAINE HCL PRSY PREFERRED
LIDOCAINE HCL JELLY PRSY PREFERRED
LIDOCAINE HCL SOLN PREFERRED
LIDOCAINE HYDROCHLORIDE SOLN PREFERRED
PLIAGLIS CREA NON_PREFERRED
SYNERA PTCH NON_PREFERRED
LIDOCAINE/PRILOCAINE CREA NON_PREFERRED
LIDOCAINE/PRILOCAINE KIT NON_PREFERRED
PRILOXX LP KIT NON_PREFERRED
PRIZOTRAL II KIT NON_PREFERRED
APRIZIO PAK II KIT NON_PREFERRED
EMPRICAINE II KIT NON_PREFERRED
PRIZOPAK II KIT NON_PREFERRED
NUVAKAAN II KIT NON_PREFERRED
REGRANEX GEL NON_PREFERRED
BPCO OINT NON_PREFERRED
QBREXZA PADS NON_PREFERRED
XERAC AC SOLN NON_PREFERRED
HYCLODEX SOLN NON_PREFERRED
HYPOCYN SOLN NON_PREFERRED
HYLATOPIC PLUS CREA NON_PREFERRED
TETRIX CREA NON_PREFERRED
HYLATOPIC PLUS LOTN NON_PREFERRED
NUVAIL SOLN NON_PREFERRED
DERMATOLOGICALS : SCABICIDES & PEDICULICIDES EURAX CREA PREFERRED
CROTAN LOTN NON_PREFERRED
EURAX LOTN NON_PREFERRED
SKLICE LOTN NON_PREFERRED
LINDANE SHAM NON_PREFERRED
MALATHION LOTN NON_PREFERRED
OVIDE LOTN NON_PREFERRED
ELIMITE CREA NON_PREFERRED
PERMETHRIN CREA PREFERRED
GNP LICE TREATMENT LIQD PREFERRED
Page 62 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
HM LICE TREATMENT LIQD PREFERRED
LICE TREATMENT LOTN PREFERRED
SM LICE TREATMENT LOTN PREFERRED
NATROBA SUSP PREFERRED
SPINOSAD SUSP NON_PREFERRED
GNP LICE TREATMENT SHAM PREFERRED
HM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED
LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED
LICE KILLING SHAMPOO SHAM PREFERRED
SM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED
DIGESTIVE ENZYMES CREON CPEP PREFERRED
PANCREAZE CPEP PREFERRED
PERTZYE CPEP NON_PREFERRED
ZENPEP CPEP PREFERRED
VIOKACE TABS NON_PREFERRED
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY
REGULATORS ALENDRONATE SODIUM SOLN PREFERRED
ALENDRONATE SODIUM TABS PREFERRED
FOSAMAX TABS NON_PREFERRED
BINOSTO TBEF NON_PREFERRED
FOSAMAX PLUS D TABS NON_PREFERRED
BONIVA TABS NON_PREFERRED
IBANDRONATE SODIUM TABS NON_PREFERRED
ACTONEL TABS NON_PREFERRED
RISEDRONATE SODIUM TABS NON_PREFERRED
ATELVIA TBEC NON_PREFERRED
RISEDRONATE SODIUM DR TBEC NON_PREFERRED
CALCITONIN SALMON SOLN PREFERRED
CALCITONIN-SALMON SOLN PREFERRED
ENDOCRINE AND METABOLIC AGENTS : GROWTH HORMONES OMNITROPE SOCT NON_PREFERRED
GENOTROPIN SOLR PREFERRED_WITH_PA
GENOTROPIN MINIQUICK SOLR PREFERRED_WITH_PA
HUMATROPE SOLR NON_PREFERRED
HUMATROPE COMBO PACK SOLR NON_PREFERRED
OMNITROPE SOLR NON_PREFERRED
ZOMACTON SOLR NON_PREFERRED
NORDITROPIN FLEXPRO SOPN NON_PREFERRED
NUTROPIN AQ NUSPIN 10 SOPN NON_PREFERRED
NUTROPIN AQ NUSPIN 20 SOPN NON_PREFERRED
NUTROPIN AQ NUSPIN 5 SOPN NON_PREFERRED
SAIZEN SOLR NON_PREFERRED
SAIZENPREP RECONSTITUTIONKIT SOLR NON_PREFERRED
SEROSTIM SOLR NON_PREFERRED
Page 63 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ZORBTIVE SOLR NON_PREFERRED
ENDOCRINE AND METABOLIC AGENTS : MISC ISTURISA TABS NON_PREFERRED
OSPHENA TABS NON_PREFERRED
EVISTA TABS NON_PREFERRED
RALOXIFENE HYDROCHLORIDE TABS NON_PREFERRED
SYNAREL SOLN NON_PREFERRED
ORILISSA TABS PREFERRED_WITH_PA
EGRIFTA SOLR NON_PREFERRED
EGRIFTA SV SOLR NON_PREFERRED
INCRELEX SOLN NON_PREFERRED
SOMATULINE DEPOT SOLN NON_PREFERRED
MYCAPSSA CPDR NON_PREFERRED
SANDOSTATIN LAR DEPOT KIT NON_PREFERRED
OCTREOTIDE ACETATE SOLN NON_PREFERRED
SANDOSTATIN SOLN NON_PREFERRED
BYNFEZIA PEN SOPN NON_PREFERRED
SIGNIFOR SOLN NON_PREFERRED
SIGNIFOR LAR SRER NON_PREFERRED
STIMATE SOLN PREFERRED
NOCDURNA SUBL NON_PREFERRED
DDAVP TABS NON_PREFERRED
DESMOPRESSIN ACETATE TABS PREFERRED
DDAVP SOLN NON_PREFERRED
DESMOPRESSIN ACETATE SOLN PREFERRED
DDAVP SOLN NON_PREFERRED
DESMOPRESSIN ACETATE SOLN PREFERRED
CABERGOLINE TABS PREFERRED
JYNARQUE TABS NON_PREFERRED
SAMSCA TABS NON_PREFERRED
TOLVAPTAN TABS NON_PREFERRED
JYNARQUE TBPK NON_PREFERRED
MIFEPREX TABS NON_PREFERRED
MIFEPRISTONE TABS NON_PREFERRED
CARNITOR SOLN NON_PREFERRED
CARNITOR SF SOLN NON_PREFERRED
LEVOCARNITINE SOLN NON_PREFERRED
LEVOCARNITINE SF SOLN NON_PREFERRED
CARNITOR TABS NON_PREFERRED
LEVOCARNITINE TABS NON_PREFERRED
GALAFOLD CAPS NON_PREFERRED
NITISINONE CAPS PREFERRED
ORFADIN CAPS PREFERRED
ORFADIN SUSP NON_PREFERRED
NITYR TABS NON_PREFERRED
Page 64 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CYSTADANE POWD NON_PREFERRED
CINACALCET HYDROCHLORIDE TABS NON_PREFERRED
SENSIPAR TABS NON_PREFERRED
RAVICTI LIQD NON_PREFERRED
BUPHENYL POWD NON_PREFERRED
SODIUM PHENYLBUTYRATE POWD NON_PREFERRED
BUPHENYL TABS NON_PREFERRED
SODIUM PHENYLBUTYRATE TABS NON_PREFERRED
CARBAGLU TABS NON_PREFERRED
KUVAN PACK NON_PREFERRED
SAPROPTERIN DIHYDROCHLORIDE PACK NON_PREFERRED
KUVAN TBSO NON_PREFERRED
SAPROPTERIN DIHYDROCHLORIDE TBSO NON_PREFERRED
ENDOCRINE AND METABOLIC AGENTS : VITAMIN D ANALOGS RAYALDEE CPCR NON_PREFERRED
CALCITRIOL CAPS PREFERRED
ROCALTROL CAPS NON_PREFERRED
CALCITRIOL SOLN PREFERRED
ROCALTROL SOLN NON_PREFERRED
DOXERCALCIFEROL CAPS PREFERRED
PARICALCITOL CAPS NON_PREFERRED
ZEMPLAR CAPS NON_PREFERRED
ESTROGENS PREMARIN TABS PREFERRED
MENEST TABS PREFERRED
DIVIGEL GEL NON_PREFERRED
ELESTRIN GEL NON_PREFERRED
ALORA PTTW NON_PREFERRED
DOTTI PTTW PREFERRED
ESTRADIOL PTTW PREFERRED
MINIVELLE PTTW NON_PREFERRED
VIVELLE-DOT PTTW NON_PREFERRED
CLIMARA PTWK NON_PREFERRED
ESTRADIOL PTWK PREFERRED
MENOSTAR PTWK NON_PREFERRED
EVAMIST SOLN NON_PREFERRED
ESTRACE TABS NON_PREFERRED
ESTRADIOL TABS PREFERRED
PREMPHASE TABS PREFERRED
PREMPRO TABS PREFERRED
COMBIPATCH PTTW PREFERRED
ACTIVELLA TABS NON_PREFERRED
AMABELZ TABS PREFERRED
ESTRADIOL/NORETHINDRONE ACETATE TABS PREFERRED
LOPREEZA TABS PREFERRED
Page 65 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
MIMVEY TABS PREFERRED
MIMVEY LO TABS PREFERRED
BIJUVA CAPS NON_PREFERRED
FEMHRT LOW DOSE TABS NON_PREFERRED
FYAVOLV TABS NON_PREFERRED
JINTELI TABS NON_PREFERRED
NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS NON_PREFERRED
ANGELIQ TABS NON_PREFERRED
CLIMARA PRO PTWK NON_PREFERRED
PREFEST TABS NON_PREFERRED
ORIAHNN CPPK NON_PREFERRED
DUAVEE TABS NON_PREFERRED
GASTROINTESTINAL AGENTS : INFLAMMATORY BOWEL AGENTS BALSALAZIDE DISODIUM CAPS PREFERRED
COLAZAL CAPS NON_PREFERRED
APRISO CP24 NON_PREFERRED
MESALAMINE ER CP24 NON_PREFERRED
PENTASA CPCR PREFERRED
DELZICOL CPDR NON_PREFERRED
MESALAMINE DR CPDR NON_PREFERRED
MESALAMINE ENEM PREFERRED
SFROWASA ENEM PREFERRED
CANASA SUPP NON_PREFERRED
MESALAMINE SUPP PREFERRED
ASACOL HD TBEC NON_PREFERRED
LIALDA TBEC NON_PREFERRED
MESALAMINE DR TBEC NON_PREFERRED
MESALAMINE KIT NON_PREFERRED
ROWASA KIT NON_PREFERRED
DIPENTUM CAPS NON_PREFERRED
AZULFIDINE TABS NON_PREFERRED
SULFASALAZINE TABS PREFERRED
AZULFIDINE EN-TABS TBEC NON_PREFERRED
SULFASALAZINE TBEC PREFERRED
GASTROINTESTINAL AGENTS : MISC CHENODAL TABS NON_PREFERRED
ACTIGALL CAPS NON_PREFERRED
URSODIOL CAPS PREFERRED
URSO 250 TABS NON_PREFERRED
URSO FORTE TABS NON_PREFERRED
URSODIOL TABS NON_PREFERRED
CROMOLYN SODIUM CONC PREFERRED
GASTROCROM CONC NON_PREFERRED
METOCLOPRAMIDE HCL SOLN PREFERRED
METOCLOPRAMIDE HCL TABS PREFERRED
Page 66 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
METOCLOPRAMIDE HYDROCHLORIDE TABS PREFERRED
REGLAN TABS NON_PREFERRED
METOCLOPRAMIDE ODT TBDP NON_PREFERRED
ENULOSE SOLN PREFERRED
GENERLAC SOLN PREFERRED
LACTULOSE SOLN PREFERRED
AMITIZA CAPS NON_PREFERRED
GATTEX KIT NON_PREFERRED
TRULANCE TABS NON_PREFERRED
ALOSETRON HYDROCHLORIDE TABS NON_PREFERRED
LOTRONEX TABS NON_PREFERRED
ZELNORM TABS NON_PREFERRED
LINZESS CAPS NON_PREFERRED
VIBERZI TABS NON_PREFERRED
MOTEGRITY TABS NON_PREFERRED
XERMELO TABS NON_PREFERRED
ENTEREG CAPS NON_PREFERRED
RELISTOR SOLN NON_PREFERRED
RELISTOR TABS NON_PREFERRED
SYMPROIC TABS NON_PREFERRED
MOVANTIK TABS NON_PREFERRED
CHOLBAM CAPS NON_PREFERRED
OCALIVA TABS NON_PREFERRED
GASTROINTESTINAL AGENTS : PHOSPHATE BINDER AGENTS CALCIUM ACETATE CAPS PREFERRED
PHOSLYRA SOLN NON_PREFERRED
CALCIUM ACETATE TABS PREFERRED
AURYXIA TABS NON_PREFERRED
FOSRENOL CHEW NON_PREFERRED
LANTHANUM CARBONATE CHEW PREFERRED
FOSRENOL PACK PREFERRED
RENVELA PACK NON_PREFERRED
SEVELAMER CARBONATE PACK NON_PREFERRED
RENVELA TABS NON_PREFERRED
SEVELAMER CARBONATE TABS PREFERRED
RENAGEL TABS NON_PREFERRED
SEVELAMER HYDROCHLORIDE TABS PREFERRED
VELPHORO CHEW NON_PREFERRED
GENITOURINARY AGENTS : MISC K-PHOS NO 2 TABS NON_PREFERRED
POTASSIUM CITRATE ER TBCR NON_PREFERRED
UROCIT-K 10 TBCR NON_PREFERRED
UROCIT-K 15 TBCR NON_PREFERRED
UROCIT-K 5 TBCR NON_PREFERRED
ORACIT SOLN PREFERRED
SODIUM CITRATE/CITRIC ACID SOLN PREFERRED
Page 67 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CYTRA K CRYSTALS PACK NON_PREFERRED
POTASSIUM CITRATE-CITRICACID CRYSTALS PACK NON_PREFERRED
TARON-CRYSTALS PACK NON_PREFERRED
POTASSIUM CITRATE/CITRICACID SOLN NON_PREFERRED
POTASSIUM CITRATE/SODIUMCITRATE/CITRIC ACID SOLN NON_PREFERRED
TRICITRATES SOLN NON_PREFERRED
PHENAZOPYRIDINE HCL TABS PREFERRED
PHENAZOPYRIDINE HYDROCHLORIDE TABS PREFERRED
PYRIDIUM TABS NON_PREFERRED
CYSTAGON CAPS PREFERRED
PROCYSBI CPDR NON_PREFERRED
PROCYSBI PACK NON_PREFERRED
ELMIRON CAPS NON_PREFERRED
LITHOSTAT TABS NON_PREFERRED
THIOLA TABS NON_PREFERRED
THIOLA EC TBEC NON_PREFERRED
GENITOURINARY AGENTS : PROSTATIC HYPERTROPHY AGENTS AVODART CAPS NON_PREFERRED
DUTASTERIDE CAPS NON_PREFERRED
FINASTERIDE TABS PREFERRED
PROSCAR TABS NON_PREFERRED
ALFUZOSIN HCL ER TB24 PREFERRED
CARDURA XL TB24 NON_PREFERRED
RAPAFLO CAPS NON_PREFERRED
SILODOSIN CAPS NON_PREFERRED
FLOMAX CAPS NON_PREFERRED
TAMSULOSIN HYDROCHLORIDE CAPS PREFERRED
DUTASTERIDE/TAMSULOSIN HCL CAPS NON_PREFERRED
DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS NON_PREFERRED
JALYN CAPS NON_PREFERRED
GLUCOSE MONITORING SUPPLIES : CGMs DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT DEVI NON_PREFERRED
DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT/SHARE DEVI NON_PREFERRED
DEXCOM G4 PLATINUM RECEIVER KIT DEVI NON_PREFERRED
DEXCOM G4 PLATINUM RECEIVER KIT/SHARE DEVI NON_PREFERRED
DEXCOM G5 MOBILE RECEIVERKIT DEVI NON_PREFERRED
DEXCOM G6 RECEIVER DEVI PREFERRED_WITH_PA
DEXCOM RECEIVER KIT DEVI NON_PREFERRED
FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED
FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED
GUARDIAN REAL-TIME REPLACEMENT MONITOR DEVI NON_PREFERRED
GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC DEVI NON_PREFERRED
DEXCOM G4 SENSOR KIT MISC NON_PREFERRED
DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT MISC NON_PREFERRED
Page 68 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
DEXCOM G6 SENSOR MISC PREFERRED_WITH_PA
ENLITE GLUCOSE SENSOR MISC NON_PREFERRED
EVERSENSE SENSOR/HOLDER MISC NON_PREFERRED
EVERSENSE SENSOR/HOLDER KIT MISC NON_PREFERRED
FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM MISC NON_PREFERRED
FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED
GUARDIAN SENSOR (3) MISC NON_PREFERRED
MINIMED GUARDIAN SENSOR 3 MISC NON_PREFERRED
SOF-SENSOR MISC NON_PREFERRED
DEXCOM G4 PLATINUM TRANSMITTER KIT MISC NON_PREFERRED
DEXCOM G5 MOBILE TRANSMITTER KIT MISC NON_PREFERRED
DEXCOM G6 TRANSMITTER MISC PREFERRED_WITH_PA
EVERSENSE SMART TRANSMITTER MISC NON_PREFERRED
GUARDIAN CONNECT TRANSMITTER MISC NON_PREFERRED
GUARDIAN CONNECT TRANSMITTER KIT MISC NON_PREFERRED
GUARDIAN LINK 3 MISC NON_PREFERRED
GUARDIAN LINK 3 TRANSMITTER KIT MISC NON_PREFERRED
GUARDIAN TRANSMITTER MISC NON_PREFERRED
GUARDIAN REAL-TIME STARTER KIT KIT NON_PREFERRED
GUARDIAN REAL-TIME SYSTEM KIT NON_PREFERRED
GUARDIAN REAL-TIME SYSTEMPEDIATRIC KIT NON_PREFERRED
GUARDIAN RT STARTER KIT KIT NON_PREFERRED
GUARDIAN RT SYSTEM KIT NON_PREFERRED
PARADIGM REAL-TIME STARTER KIT KIT NON_PREFERRED
GLUCOSE MONITORING SUPPLIES : DEVICES AND KITS ACCU-CHEK AVIVA DEVI NON_PREFERRED
ADVANCE INTUITION BLOOD GLUCOSE METER DEVI NON_PREFERRED
ADVANCE MICRO-DRAW METER DEVI NON_PREFERRED
ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
ADVOCATE REDI-CODE DEVI NON_PREFERRED
ADVOCATE REDI-CODE+ BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED
ADVOCATE REDI-CODE+ BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
AGAMATRIX AMP NO CODE ADVANCED BLOOD GLUCOSE MONITORING SYST DEVI NON_PREFERRED
AGAMATRIX PRESTO PRO METER DEVI NON_PREFERRED
ASSURE 4 BLOOD GLUCOSE METER DEVI NON_PREFERRED
ASSURE PLATINUM BLOOD GLUCOSE METER DEVI NON_PREFERRED
ASSURE PRISM MULTI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
ASSURE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED
BAYER CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CARESENS N GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CARESENS N VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CLEVER CHEK AUTO CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CLEVER CHEK AUTO-CODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CLEVER CHEK AUTO-CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
Page 69 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CLEVER CHOICE AUTO-CODE PRO BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CLEVER CHOICE MINI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CLEVER CHOICE TALK BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
COOL BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
DIATHRIVE BLOOD GLUCOSE METER DEVI NON_PREFERRED
DIATHRIVE+ BLOOD GLUCOSEMONITORING SYSTEM/BLUETOOTH DEVI NON_PREFERRED
DIATRUE PLUS BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
EASY PLUS BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
EASY PLUS II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
EASY STEP BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED
EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
EASY TRAK II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
EASYMAX L BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED
EASYMAX N BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED
EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED
EASYMAX V BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED
EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED
ELEMENT COMPACT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
ELEMENT COMPACT V BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
ELEMENT PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED
EMBRACE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
EMBRACE BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED
EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED
EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
EVENCARE G2 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED
EVENCARE G3 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED
EVENCARE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
EVOLUTION AUTOCODE DEVI NON_PREFERRED
EZ SMART DIABETES MONITORING SYSTEM DEVI NON_PREFERRED
EZ SMART PLUS DIABETES MONITORING SYSTEM DEVI NON_PREFERRED
FORA G30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORA GD20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORA GD50 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORA GTEL BLOOD GLUCOSE MONITORING SYSTEM/MULTI-FUNCTIONAL DEVI NON_PREFERRED
FORA PREMIUM V10 BLE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORA TEST N' GO VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORA V10 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED
FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/NO-CODING DEVI NON_PREFERRED
FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED
FORA V20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORA V30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORACARE GD40 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
Page 70 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
FORACARE PREMIUM V10 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORACARE TEST N GO BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM EMV3.1 DEVI NON_PREFERRED
FORTISCARE T1 SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED
FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
GE100 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
GLUCO PERFECT 3 BLOOD GLUCOSE METER DEVI NON_PREFERRED
GLUCO PERFECT 3 BLOOD GLUCOSE MONITORING SYSTEM/VOICE DEVI NON_PREFERRED
GLUCOCARD 01 BLOOD GLUCOSE METER DEVI NON_PREFERRED
GLUCOCARD SHINE DEVI NON_PREFERRED
GLUCOCARD SHINE XL DEVI NON_PREFERRED
GLUCOCOM BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
GNP EASY TOUCH GLUCOSE MONITORING SYSTEM/NO CODING DEVI NON_PREFERRED
HW EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED
HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
IN TOUCH DEVI NON_PREFERRED
LIBERTY BLOOD GLUCOSE METER DEVI NON_PREFERRED
LIBERTY BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
LIBERTY NEXT GENERATION BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
ON CALL EXPRESS BLOOD GLUCOSE METER DEVI NON_PREFERRED
ON CALL PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED
ON CALL VIVID BLOOD GLUCOSE METER DEVI NON_PREFERRED
ON CALL VIVID PAL BLOOD GLUCOSE METER DEVI NON_PREFERRED
OPTIUM BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
PHARMACIST CHOICE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
PRECISION QID MONITOR DEVI NON_PREFERRED
PRECISION SOF-TACT MONITOR DEVI NON_PREFERRED
PRECISION XTRA DEVI NON_PREFERRED
PRECISION XTRA MONITOR DEVI NON_PREFERRED
PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
QUINTET AC BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED
QUINTET BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
RA BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED
RELION PREMIER BLU BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
RELION PREMIER CLASSIC BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
RELION PREMIER VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
RELION PRIME BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
RIGHTSOURCE BLOOD GLUCOSE METER DEVI NON_PREFERRED
SMARTEST EJECT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
SMARTEST PROTEGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM DEVI NON_PREFERRED
Page 71 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SURE EDGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
SURE-TEST EASYPLUS MINI SELF MONITORING BLOOD GLUCOSE METER DEVI NON_PREFERRED
SURECHEK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
TRUE FOCUS BLOOD GLUCOSESELF MONITORING METER DEVI NON_PREFERRED
TRUE METRIX DEVI NON_PREFERRED
TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH DEVI NON_PREFERRED
TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
ULTRATRAK ACTIVE DEVI NON_PREFERRED
ULTRATRAK PRO DEVI NON_PREFERRED
ULTRATRAK ULTIMATE MONITOR DEVI NON_PREFERRED
VERASENS BLOOD GLUCOSE MONITORING SYSTEM METER KIT DEVI NON_PREFERRED
VICTORY BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
VIVAGUARD INO BLOOD GLUCOSE METER DEVI NON_PREFERRED
VOCAL POINT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED
WAVESENSE KEYNOTE PRO METER DEVI NON_PREFERRED
ACCU-CHEK AVIVA CONNECT KIT NON_PREFERRED
ACCU-CHEK AVIVA PLUS KIT NON_PREFERRED
ACCU-CHEK COMPACT PLUS CARE KIT KIT NON_PREFERRED
ACCU-CHEK GUIDE KIT NON_PREFERRED
ACCU-CHEK GUIDE ME KIT NON_PREFERRED
ACCU-CHEK NANO SMARTVIEW KIT NON_PREFERRED
ACURA BLOOD GLUCOSE MONITORING SYSTEM METER KIT KIT NON_PREFERRED
ACURA BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED
ACURA PLUS BLOOD GLUCOSEMONITORING SYSTEM METER KIT KIT NON_PREFERRED
ACURA PLUS BLOOD GLUCOSEMONITORING SYSTEM STARTER KIT KIT NON_PREFERRED
ADVANCE INTUITION BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT NON_PREFERRED
ADVOCATE REDI-CODE+/ TALKING KIT NON_PREFERRED
ADVOCATE REDI-CODE/TALKING KIT NON_PREFERRED
AGAMATRIX JAZZ WIRELESS 2 KIT NON_PREFERRED
AGAMATRIX PRESTO KIT NON_PREFERRED
ASSURE 3 METER KIT NON_PREFERRED
AT LAST BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED
BAYER BREEZE 2 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
BAYER CONTOUR LINK 2.4 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
BAYER CONTOUR LINK BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
BD LATITUDE DIABETES MANAGEMENT SYSTEM KIT NON_PREFERRED
BD LOGIC BLOOD GLUCOSE MONITOR KIT NON_PREFERRED
BIOTEL CARE CONNECTED BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
BLOOD GLUCOSE MONITORINGSYSTEM KIT NON_PREFERRED
BLOOD GLUCOSE MONITORINGSYSTEM PREMIUM KIT NON_PREFERRED
BLOOD GLUCOSE SYSTEM PAK KIT NON_PREFERRED
CAREONE BLOOD GLUCOSE MONITORING SYSTEM/PREMIUM KIT NON_PREFERRED
Page 72 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CAREONE BLOOD GLUCOSE MONITORING SYSTEM/VALUE KIT NON_PREFERRED
CARETOUCH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CHOICE DM DIABETES RISK IN-HOME TEST KIT KIT NON_PREFERRED
CLEVER CHEK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CLEVER CHOICE MICRO BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTOUR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTOUR NEXT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTOUR NEXT EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTOUR NEXT LINK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTOUR NEXT LINK WIRELESS BLOOD GLUCOSE MONITORING SY KIT NON_PREFERRED
CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTOUR NEXT USB BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
CONTROL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
COOL BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
CVS ADVANCED GLUCOSE METER KIT NON_PREFERRED
D-CARE GLUCOMETER KIT/GLUCOSE TEST STRIPS KIT NON_PREFERRED
EASY PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
EASY STEP BLOOD GLUCOSE MONITOR STARTER KIT KIT NON_PREFERRED
EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT NON_PREFERRED
EASY TOUCH GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
EASY TOUCH HEALTHPRO GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
EASYGLUCO KIT NON_PREFERRED
EASYGLUCO PLUS BLOOD GLUCOSE MONITORING SYSTEM METER KIT KIT NON_PREFERRED
EASYGLUCO PLUS BLOOD GLUCSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED
EASYGLUCO STARTER KIT KIT NON_PREFERRED
EASYMAX L BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED
EASYMAX N BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED
EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED
EASYMAX V BLOOD GLUCOSE SYSTEM/TALKING KIT NON_PREFERRED
EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT NON_PREFERRED
EASYPLUS R13N SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED
EASYPLUS V SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT NON_PREFERRED
EASYPRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
EASYPRO PLUS KIT NON_PREFERRED
ELEMENT AUTOCODE SYSTEM KIT NON_PREFERRED
EMBRACE EVO BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
EVENCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
FIFTY50 GLUCOSE METER 2.0 KIT NON_PREFERRED
FORA G20 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
FORA TN'G VOICE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
FORA V10/V12/D10/D20 BLOOD GLUCOSE TEST STRIPS/LANCETS 30G KIT NON_PREFERRED
FORA V30A BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
Page 73 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED
FREESTYLE FLASH SYSTEM KIT NON_PREFERRED
FREESTYLE FREEDOM KIT NON_PREFERRED
FREESTYLE FREEDOM LITE KIT NON_PREFERRED
FREESTYLE INSULINX BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
FREESTYLE SIDEKICK II VALUEPACK KIT NON_PREFERRED
FREESTYLE SYSTEM KIT KIT NON_PREFERRED
GE100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GHT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCARD 01 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCARD 01-MINI BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCARD EXPRESSION AUDIO-ENABLED BLOOD GLUCOSE MONITORING KIT NON_PREFERRED
GLUCOCARD SHINE KIT NON_PREFERRED
GLUCOCARD SHINE CONNEX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCARD SHINE EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLACK KIT NON_PREFERRED
GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLUE KIT NON_PREFERRED
GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM PINK KIT NON_PREFERRED
GLUCOCARD X-METER KIT NON_PREFERRED
GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM VALUE KIT KIT NON_PREFERRED
GLUCONAVII BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED
GOODSENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
IBG STAR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
IGLUCOSE BLOOD GLUCOSE MOITORING SYSTEM KIT NON_PREFERRED
INFINITY BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
INFINITY BLOOD GLUCOSE MONITORING SYSTEM/STARTER KIT KIT NON_PREFERRED
INFINITY VOICE KIT NON_PREFERRED
KROGER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
KROGER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
LDR BLOOD GLUCOSE TRUETEST KIT KIT NON_PREFERRED
MAXIMA BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
MAXIMA METER KIT KIT NON_PREFERRED
MAXIMA STARTER KIT KIT NON_PREFERRED
MEIJER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
MEIJER ESSENTIAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
MEIJER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
MEIJER TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
MEIJER TRUERESULT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
MEIJER TRUETRACK BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED
MICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
Page 74 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
MM EASY TOUCH BLOOD GLUCOSE METER KIT NON_PREFERRED
MYGLUCOHEALTH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
NEXGEN METER KIT KIT NON_PREFERRED
NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ON CALL EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ON CALL PLUS BLOOD GLUCOSE METER KIT NON_PREFERRED
ON CALL PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ON CALL VIVID BLOOD GLUCOSE METER KIT NON_PREFERRED
ON CALL VIVID BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ON CALL VIVID PAL BLOOD GLUCOSE METER KIT NON_PREFERRED
ONE DROP BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
ONETOUCH ULTRA 2 KIT PREFERRED
ONETOUCH ULTRA MINI KIT PREFERRED
ONETOUCH VERIO KIT PREFERRED
ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED
ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED
ONETOUCH VERIO REFLECT KIT PREFERRED
OPTIUM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
OPTUMRX BLOOD GLUCOSE METER KIT NON_PREFERRED
OPTUMRX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
PARADIGM LINK BLOOD GLUCOSE MONITOR KIT NON_PREFERRED
PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
POCKETCHEM EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
PRECISION LINK KIT NON_PREFERRED
PRECISION XTRA KIT NON_PREFERRED
PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING/TALKING KIT NON_PREFERRED
PRODIGY NO CODING BLOOD GLUCOSE KIT NON_PREFERRED
PRODIGY POCKET BLOOD GLUCOSE METER KIT KIT NON_PREFERRED
PRODIGY VOICE BLOOD GLUCOSE METER KIT KIT NON_PREFERRED
QUICKTEK KIT NON_PREFERRED
RA TRUE2GO BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED
RA TRUERESULT BLOOD GLUCOSE MONITOR KIT NON_PREFERRED
REFUAH PLUS BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED
RELION CONFIRM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
RELION MICRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
RELION PREMIER COMPACT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
RELION ULTIMA BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
REVEAL BLOOD GLUCOSE MONITOR KIT NON_PREFERRED
REXALL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
RIGHTEST GM100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
RIGHTEST GM300 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
RIGHTEST GM550 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
SMART SENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
Page 75 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SMART SENSE VALUE BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
SMARTEST EJECT STARTER KIT KIT NON_PREFERRED
SMARTEST PERSONA STARTERKIT KIT NON_PREFERRED
SMARTEST PRONTO STARTERKIT KIT NON_PREFERRED
SMARTEST PROTEGE STARTERKIT KIT NON_PREFERRED
SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM KIT NON_PREFERRED
SURECHEK BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED
TELCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
TGT BLOOD GLUCOSE METER MONITORING SYSTEM KIT NON_PREFERRED
TGT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
TGT BLOOD GLUCOSE MONITORING SYSTEM PREMIUM KIT NON_PREFERRED
TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH SMART KIT NON_PREFERRED
TRUE METRIX AIR W/BLUETOOTH SMART KIT NON_PREFERRED
TRUE METRIX BLOOD GLUCOSEMETER KIT NON_PREFERRED
TRUE METRIX GO BLOOD GLUCOSE METER KIT NON_PREFERRED
TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED
TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM/NO CODING KIT NON_PREFERRED
TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
TRUETRACK SMART SYSTEM KIT NON_PREFERRED
ULTIMA KIT NON_PREFERRED
ULTRA TRAK PRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
VERASENS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED
WAVESENSE AMP KIT NON_PREFERRED
WAVESENSE KEYNOTE KIT NON_PREFERRED
RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM DEVI NON_PREFERRED
SIDEKICK BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED
GLUCOSE MONITORING SUPPLIES : INSULIN INFUSION DISPOSABLE
PUMP OMNIPOD DASH SYSTEM KIT PREFERRED_WITH_PA
OMNIPOD STARTER KIT KIT PREFERRED_WITH_PA
V-GO 20 KIT NON_PREFERRED
V-GO 30 KIT NON_PREFERRED
V-GO 40 KIT NON_PREFERRED
OMNIPOD 10 PACK MISC PREFERRED_WITH_PA
OMNIPOD 5 PACK MISC PREFERRED_WITH_PA
OMNIPOD DASH 5 PACK MISC PREFERRED_WITH_PA
GLUCOSE MONITORING SUPPLIES : TEST STRIPS ACCU-CHEK AVIVA PLUS STRP NON_PREFERRED
ACCU-CHEK COMPACT PLUS STRP NON_PREFERRED
ACCU-CHEK GUIDE STRP NON_PREFERRED
ACCU-CHEK SMARTVIEW STRIPS STRP NON_PREFERRED
ACCUTREND GLUCOSE STRP NON_PREFERRED
ADVANCE INTUITION TEST STRIPS STRP NON_PREFERRED
ADVANCE MICRO-DRAW TEST STRIPS STRP NON_PREFERRED
ADVOCATE REDI-CODE STRP NON_PREFERRED
Page 76 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ADVOCATE REDI-CODE+ TESTSTRIPS STRP NON_PREFERRED
ADVOCATE TEST STRIPS STRP NON_PREFERRED
AGAMATRIX AMP NO CODE TEST STRIPS STRP NON_PREFERRED
AGAMATRIX JAZZ TEST STRIPS STRP NON_PREFERRED
AGAMATRIX KEYNOTE TEST STRIPS STRP NON_PREFERRED
AGAMATRIX PRESTO TEST STRIPS STRP NON_PREFERRED
ASSURE 3 TEST STRIPS STRP NON_PREFERRED
ASSURE 4 TEST STRIPS STRP NON_PREFERRED
ASSURE II STRP NON_PREFERRED
ASSURE II CHECK STRIP STRP NON_PREFERRED
ASSURE II TEST STRIPS STRP NON_PREFERRED
ASSURE PLATINUM TEST STRIPS STRP NON_PREFERRED
ASSURE PRISM MULTI TEST STRIPS STRP NON_PREFERRED
ASSURE PRO TEST STRIPS STRP NON_PREFERRED
BIOSCANNER GLUCOSE TEST STRIPS STRP NON_PREFERRED
BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED
CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP NON_PREFERRED
CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP NON_PREFERRED
CARESENS N BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
CARETOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
CLEVER CHEK AUTO-CODE TEST STRIPS STRP NON_PREFERRED
CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP NON_PREFERRED
CLEVER CHEK TEST STRIPS STRP NON_PREFERRED
CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP NON_PREFERRED
CLEVER CHOICE MICRO TESTSTRIPS STRP NON_PREFERRED
CLEVER CHOICE NO CODING TEST STRIPS STRP NON_PREFERRED
CLEVER CHOICE TALK NO CODING TEST STRIPS STRP NON_PREFERRED
CONTOUR BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
CONTOUR NEXT BLOOD GLUCOSE TEST STRP NON_PREFERRED
COOL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
CVS ADVANCED GLUCOSE METER TEST STRIPS STRP NON_PREFERRED
CVS GLUCOSE METER TEST STRIPS STRP NON_PREFERRED
D-CARE BLOOD GLUCOSE STRP NON_PREFERRED
DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
DIATHRIVE+ BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
DUO-CARE TEST STRIPS STRP NON_PREFERRED
EASY PLUS II BLOOD GLUCOSE TEST STRP NON_PREFERRED
EASY STEP TEST STRIPS STRP NON_PREFERRED
EASY TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED
EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EASY TRAK II BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
Page 77 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
EASYGLUCO STRP NON_PREFERRED
EASYGLUCO PLUS STRP NON_PREFERRED
EASYMAX 15 TEST STRIPS STRP NON_PREFERRED
EASYMAX TEST STRIPS STRP NON_PREFERRED
EASYPLUS BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED
EASYPRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EASYPRO PLUS STRP NON_PREFERRED
ELEMENT COMPACT TEST STRIPS STRP NON_PREFERRED
ELEMENT TEST STRIPS STRP NON_PREFERRED
EMBRACE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EQ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EVENCARE + BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED
EVENCARE BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED
EVENCARE G2 TEST STRIPS STRP NON_PREFERRED
EVENCARE G3 TEST STRIPS STRP NON_PREFERRED
EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EVENCARE PROVIEW BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EVOLUTION AUTOCODE STRP NON_PREFERRED
EXACTECH R-S-G TEST STRIPS STRP NON_PREFERRED
EXACTECH TEST STRIPS STRP NON_PREFERRED
EZ SMART BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NON_PREFERRED
FORA 6 CONNECT STRP NON_PREFERRED
FORA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA D15G BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA D20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA D40/G31 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA G20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA GD20 TEST STRIPS STRP NON_PREFERRED
FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA GTEL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA V12 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA V20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORA V30A BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FORACARE GD40 STRP NON_PREFERRED
FORACARE PREMIUM V10 TESTSTRIPS STRP NON_PREFERRED
FORACARE TEST N GO TEST STRIPS STRP NON_PREFERRED
Page 78 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
FORTISCARE BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED
FREESTYLE INSULINX BLOODGLUCOSE TEST STRP NON_PREFERRED
FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP NON_PREFERRED
FREESTYLE LITE TEST STRIPS STRP NON_PREFERRED
FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
FREESTYLE TEST STRIPS STRP NON_PREFERRED
GE100 BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED
GENSTRIP 50 STRP NON_PREFERRED
GENULTIMATE TEST STRIPS STRP NON_PREFERRED
GHT TEST STRIPS STRP NON_PREFERRED
GLUCO PERFECT 3 TEST STRIPS STRP NON_PREFERRED
GLUCOCARD 01 SENSOR PLUS STRP NON_PREFERRED
GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP NON_PREFERRED
GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
GLUCOCARD SHINE TEST STRIPS STRP NON_PREFERRED
GLUCOCARD VITAL TEST STRIPS STRP NON_PREFERRED
GLUCOCARD X-SENSOR STRP NON_PREFERRED
GLUCOCOM TEST STRIPS STRP NON_PREFERRED
GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
GLUCOSE METER TEST STRIPS ADVANCED STRP NON_PREFERRED
GNP EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED
GOJJI BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED
GOJJI BLOOD GLUCOSE TESTSTRIPS/GOJJI STERILE LANCETS 30G STRP NON_PREFERRED
GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
HARMONY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
IGLUCOSE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
INFINITY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
INFINITY VOICE STRP NON_PREFERRED
KROGER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED
KROGER HEALTHPRO GLUCOSETEST STRIPS STRP NON_PREFERRED
KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
KROGER TEST STRIPS STRP NON_PREFERRED
LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
LIBERTY TEST STRIPS STRP NON_PREFERRED
MEIJER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED
MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
MICRODOT TEST STRIPS STRP NON_PREFERRED
MICRODOT XTRA TEST STRIPS STRP NON_PREFERRED
Page 79 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
MM EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED
MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP NON_PREFERRED
NEUTEK 2TEK TEST STRIPS STRP NON_PREFERRED
NOVA MAX GLUCOSE TEST STRIPS STRP NON_PREFERRED
ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
ON CALL PLUS BLOOD GLUCOSE TEST STRP NON_PREFERRED
ON CALL VIVID BLOOD GLUCOSE TEST STRP NON_PREFERRED
ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
ONE DROP BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
ONETOUCH ULTRA BLUE STRP PREFERRED
ONETOUCH VERIO TEST STRIPS STRP PREFERRED
OPTIUM TEST STRIPS STRP NON_PREFERRED
OPTIUMEZ TEST STRIPS STRP NON_PREFERRED
OPTUMRX BLOOD GLUCOSE TEST STRP NON_PREFERRED
PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
PRECISION PCX STRP NON_PREFERRED
PRECISION PCX PLUS TEST STRIPS STRP NON_PREFERRED
PRECISION POINT OF CARE TEST STRIPS STRP NON_PREFERRED
PRECISION QID TEST STRIPS STRP NON_PREFERRED
PRECISION SOF-TACT TEST STRIPS STRP NON_PREFERRED
PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
PTS PANELS GLUCOSE TEST STRP NON_PREFERRED
QUICKTEK TEST STRIPS STRP NON_PREFERRED
QUINTET AC BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
QUINTET BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RA TRUETEST STRIPS STRP NON_PREFERRED
REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
RELION BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED
RELION CONFIRM/MICRO TEST STRIPS STRP NON_PREFERRED
RELION PREMIER BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RELION ULTIMA TEST STRIPS STRP NON_PREFERRED
REVEAL BLOOD GLUCOSE TEST STRP NON_PREFERRED
REXALL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP NON_PREFERRED
Page 80 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP NON_PREFERRED
SMARTEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
SOLUS V2 AUDIBLE TEST STRP NON_PREFERRED
SUPREME TEST STRIPS STRP NON_PREFERRED
SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
SURECHEK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
TELCARE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
TGT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED
TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED
TRUE METRIX PRO GLUCOSE TEST STRIPS STRP NON_PREFERRED
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP NON_PREFERRED
TRUETEST STRIPS STRP NON_PREFERRED
TRUETRACK BLOOD GLUCOSE TEST STRP NON_PREFERRED
TRUETRACK TEST STRP NON_PREFERRED
ULTIMA TEST STRIPS STRP NON_PREFERRED
ULTRATRAK PRO TEST STRIPS STRP NON_PREFERRED
ULTRATRAK ULTIMATE TEST STRIPS STRP NON_PREFERRED
UNISTRIP1 GENERIC STRP NON_PREFERRED
VERASENS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
VICTORY AGM-4000 TEST STRIPS STRP NON_PREFERRED
VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED
WAVESENSE PRESTO TEST STRIPS STRP NON_PREFERRED
GOUT AGENTS ALLOPURINOL TABS PREFERRED
ZYLOPRIM TABS NON_PREFERRED
COLCHICINE CAPS NON_PREFERRED
MITIGARE CAPS NON_PREFERRED
GLOPERBA SOLN NON_PREFERRED
COLCHICINE TABS NON_PREFERRED
COLCRYS TABS NON_PREFERRED
FEBUXOSTAT TABS NON_PREFERRED
ULORIC TABS NON_PREFERRED
PROBENECID TABS PREFERRED
PROBENECID/COLCHICINE TABS PREFERRED
HEMATOLOGICAL AGENTS : ANTIHEMOPHILIC PRODUCTS HEMOFIL M SOLR PREFERRED_WITH_PA
KOATE SOLR PREFERRED_WITH_PA
KOATE-DVI SOLR PREFERRED_WITH_PA
KOGENATE FS KIT PREFERRED_WITH_PA
RECOMBINATE SOLR PREFERRED_WITH_PA
NUWIQ KIT PREFERRED_WITH_PA
NUWIQ SOLR PREFERRED_WITH_PA
Page 81 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ADVATE SOLR PREFERRED_WITH_PA
KOVALTRY SOLR PREFERRED_WITH_PA
XYNTHA KIT PREFERRED_WITH_PA
XYNTHA SOLOFUSE KIT PREFERRED_WITH_PA
ELOCTATE SOLR PREFERRED_WITH_PA
NOVOEIGHT SOLR PREFERRED_WITH_PA
ESPEROCT SOLR PREFERRED_WITH_PA
ADYNOVATE SOLR PREFERRED_WITH_PA
JIVI SOLR PREFERRED_WITH_PA
OBIZUR SOLR PREFERRED_WITH_PA
AFSTYLA KIT PREFERRED_WITH_PA
WILATE KIT PREFERRED_WITH_PA
ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN SOLR PREFERRED_WITH_PA
HUMATE-P SOLR PREFERRED_WITH_PA
FEIBA SOLR PREFERRED_WITH_PA
NOVOSEVEN RT SOLR PREFERRED_WITH_PA
ALPHANINE SD SOLR PREFERRED_WITH_PA
MONONINE SOLR PREFERRED_WITH_PA
BENEFIX KIT PREFERRED_WITH_PA
IXINITY SOLR PREFERRED_WITH_PA
RIXUBIS SOLR PREFERRED_WITH_PA
IDELVION SOLR PREFERRED_WITH_PA
ALPROLIX SOLR PREFERRED_WITH_PA
REBINYN SOLR PREFERRED_WITH_PA
PROFILNINE SOLR PREFERRED_WITH_PA
PROFILNINE SD SOLR PREFERRED_WITH_PA
COAGADEX SOLR PREFERRED_WITH_PA
TRETTEN SOLR PREFERRED_WITH_PA
CORIFACT KIT PREFERRED_WITH_PA
VONVENDI SOLR PREFERRED_WITH_PA
HEMLIBRA SOLN PREFERRED_WITH_PA
HEMATOLOGICAL AGENTS : MISC PENTOXIFYLLINE ER TBCR PREFERRED
TAVALISSE TABS NON_PREFERRED
HAEGARDA SOLR NON_PREFERRED
FIRAZYR SOLN NON_PREFERRED
ICATIBANT ACETATE SOLN NON_PREFERRED
KALBITOR SOLN NON_PREFERRED
TAKHZYRO SOLN NON_PREFERRED
HEMATOLOGICAL AGENTS : PLATELET AGGREGATION INHIBITORS DIPYRIDAMOLE TABS PREFERRED
CILOSTAZOL TABS NON_PREFERRED
ZONTIVITY TABS NON_PREFERRED
AGRYLIN CAPS NON_PREFERRED
ANAGRELIDE HYDROCHLORIDE CAPS PREFERRED
Page 82 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CLOPIDOGREL TABS PREFERRED
PLAVIX TABS NON_PREFERRED
EFFIENT TABS NON_PREFERRED
PRASUGREL TABS NON_PREFERRED
BRILINTA TABS PREFERRED
YOSPRALA TBEC NON_PREFERRED
AGGRENOX CP12 NON_PREFERRED
ASPIRIN/DIPYRIDAMOLE CP12 PREFERRED
ASPIRIN/DIPYRIDAMOLE ER CP12 PREFERRED
HEMATOPOIETIC AGENTS : HEMATOPOIETIC GROWTH FACTORS REBLOZYL SOLR NON_PREFERRED
ARANESP ALBUMIN FREE SOLN NON_PREFERRED
ARANESP ALBUMIN FREE SOSY NON_PREFERRED
EPOGEN SOLN PREFERRED_WITH_PA
PROCRIT SOLN PREFERRED_WITH_PA
RETACRIT SOLN NON_PREFERRED
MIRCERA SOSY NON_PREFERRED
NEUPOGEN SOLN PREFERRED
NEUPOGEN SOSY PREFERRED
NIVESTYM SOLN NON_PREFERRED
NIVESTYM SOSY NON_PREFERRED
ZARXIO SOSY NON_PREFERRED
GRANIX SOLN NON_PREFERRED
GRANIX SOSY NON_PREFERRED
NEULASTA ONPRO KIT PSKT NON_PREFERRED
NEULASTA SOSY NON_PREFERRED
ZIEXTENZO SOSY NON_PREFERRED
UDENYCA SOSY NON_PREFERRED
FULPHILA SOSY NON_PREFERRED
LEUKINE SOLR PREFERRED
DOPTELET TABS NON_PREFERRED
PROMACTA PACK NON_PREFERRED
PROMACTA TABS NON_PREFERRED
MULPLETA TABS NON_PREFERRED
NPLATE SOLR NON_PREFERRED
HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS :
BENZODIAZEPINE HYPNOTICS ESTAZOLAM TABS PREFERRED
FLURAZEPAM HCL CAPS NON_PREFERRED
MIDAZOLAM HCL SYRP NON_PREFERRED
RESTORIL CAPS NON_PREFERRED
TEMAZEPAM CAPS PREFERRED
HALCION TABS NON_PREFERRED
TRIAZOLAM TABS PREFERRED
HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : MISC PHENOBARBITAL ELIX PREFERRED
Page 83 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
PHENOBARBITAL TABS PREFERRED
SECONAL SODIUM CAPS NON_PREFERRED
RAMELTEON TABS NON_PREFERRED
ROZEREM TABS NON_PREFERRED
HETLIOZ CAPS NON_PREFERRED
DOXEPIN HYDROCHLORIDE TABS NON_PREFERRED
SILENOR TABS NON_PREFERRED
DAYVIGO TABS NON_PREFERRED
BELSOMRA TABS NON_PREFERRED
HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : NON -
BENZODIAZEPINE HYPNOTICS ESZOPICLONE TABS NON_PREFERRED
LUNESTA TABS NON_PREFERRED
ZALEPLON CAPS NON_PREFERRED
ZOLPIMIST SOLN NON_PREFERRED
EDLUAR SUBL NON_PREFERRED
INTERMEZZO SUBL NON_PREFERRED
ZOLPIDEM TARTRATE SUBL NON_PREFERRED
AMBIEN TABS NON_PREFERRED
ZOLPIDEM TARTRATE TABS PREFERRED
AMBIEN CR TBCR NON_PREFERRED
ZOLPIDEM TARTRATE ER TBCR NON_PREFERRED
IMMUNOSUPPRESSIVE AGENTS CYCLOSPORINE CAPS PREFERRED
SANDIMMUNE CAPS NON_PREFERRED
SANDIMMUNE SOLN PREFERRED
CYCLOSPORINE MODIFIED CAPS PREFERRED
GENGRAF CAPS PREFERRED
NEORAL CAPS NON_PREFERRED
CYCLOSPORINE MODIFIED SOLN PREFERRED
GENGRAF SOLN PREFERRED
NEORAL SOLN NON_PREFERRED
CELLCEPT CAPS NON_PREFERRED
MYCOPHENOLATE MOFETIL CAPS PREFERRED
CELLCEPT SUSR NON_PREFERRED
MYCOPHENOLATE MOFETIL SUSR PREFERRED
CELLCEPT TABS NON_PREFERRED
MYCOPHENOLATE MOFETIL TABS PREFERRED
MYCOPHENOLIC ACID DR TBEC PREFERRED
MYFORTIC TBEC NON_PREFERRED
EVEROLIMUS TABS NON_PREFERRED
ZORTRESS TABS NON_PREFERRED
RAPAMUNE SOLN NON_PREFERRED
SIROLIMUS SOLN PREFERRED
RAPAMUNE TABS NON_PREFERRED
SIROLIMUS TABS PREFERRED
Page 84 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
PROGRAF CAPS NON_PREFERRED
TACROLIMUS CAPS PREFERRED
ASTAGRAF XL CP24 NON_PREFERRED
PROGRAF PACK NON_PREFERRED
ENVARSUS XR TB24 NON_PREFERRED
AZASAN TABS NON_PREFERRED
AZATHIOPRINE TABS PREFERRED
IMURAN TABS NON_PREFERRED
MIGRAINE PRODUCTS : CALCITONIN GENE-RELATED PEPTIDE (CGRP)
RECEPTOR ANTAG NURTEC TBDP NON_PREFERRED
UBRELVY TABS NON_PREFERRED
VYEPTI SOLN NON_PREFERRED
AIMOVIG SOAJ PREFERRED_WITH_PA
AJOVY SOAJ NON_PREFERRED
AJOVY SOSY NON_PREFERRED
EMGALITY SOAJ NON_PREFERRED
EMGALITY SOSY NON_PREFERRED
MIGRAINE PRODUCTS : MISC ERGOMAR SUBL NON_PREFERRED
DIHYDROERGOTAMINE MESYLATE SOLN NON_PREFERRED
MIGRANAL SOLN NON_PREFERRED
CAMBIA PACK NON_PREFERRED
MIGERGOT SUPP PREFERRED
CAFERGOT TABS NON_PREFERRED
SUMATRIPTAN/NAPROXEN SODIUM TABS NON_PREFERRED
TREXIMET TABS NON_PREFERRED
MIGRAINE PRODUCTS : SELECTIVE SEROTONIN AGONISTS 5-HT(1F) ALMOTRIPTAN TABS NON_PREFERRED
ALMOTRIPTAN MALATE TABS NON_PREFERRED
ELETRIPTAN HYDROBROMIDE TABS NON_PREFERRED
RELPAX TABS NON_PREFERRED
FROVA TABS NON_PREFERRED
FROVATRIPTAN SUCCINATE TABS NON_PREFERRED
AMERGE TABS NON_PREFERRED
NARATRIPTAN HCL TABS NON_PREFERRED
MAXALT TABS NON_PREFERRED
RIZATRIPTAN BENZOATE TABS PREFERRED
MAXALT-MLT TBDP NON_PREFERRED
RIZATRIPTAN BENZOATE ODT TBDP PREFERRED
IMITREX SOLN NON_PREFERRED
SUMATRIPTAN SOLN PREFERRED
TOSYMRA SOLN NON_PREFERRED
ONZETRA XSAIL EXHP NON_PREFERRED
IMITREX STATDOSE SYSTEM SOAJ NON_PREFERRED
SUMATRIPTAN SUCCINATE SOAJ PREFERRED
Page 85 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ZEMBRACE SYMTOUCH SOAJ NON_PREFERRED
IMITREX STATDOSE REFILL SOCT NON_PREFERRED
SUMATRIPTAN SUCCINATE REFILL SOCT PREFERRED
IMITREX SOLN NON_PREFERRED
SUMATRIPTAN SUCCINATE SOLN PREFERRED
SUMATRIPTAN SUCCINATE SOSY PREFERRED
IMITREX TABS NON_PREFERRED
SUMATRIPTAN SUCCINATE TABS PREFERRED
ZOMIG SOLN NON_PREFERRED
ZOLMITRIPTAN TABS NON_PREFERRED
ZOMIG TABS NON_PREFERRED
ZOLMITRIPTAN ODT TBDP NON_PREFERRED
ZOMIG ZMT TBDP NON_PREFERRED
REYVOW TABS NON_PREFERRED
MISCELLANEOUS THERAPEUTIC CLASSES THALOMID CAPS NON_PREFERRED
REVLIMID CAPS NON_PREFERRED
BENLYSTA SOAJ NON_PREFERRED
BENLYSTA SOSY NON_PREFERRED
SODIUM POLYSTYRENE SULFONATE POWD PREFERRED
KIONEX SUSP PREFERRED
SODIUM POLYSTYRENE SULFONATE SUSP PREFERRED
SPS SUSP PREFERRED
LOKELMA PACK NON_PREFERRED
VELTASSA PACK NON_PREFERRED
MOUTH / THROAT / DENTAL AGENTS NYSTATIN SUSP PREFERRED
CLOTRIMAZOLE LOZG PREFERRED
CLOTRIMAZOLE TROC PREFERRED
ORAVIG TABS NON_PREFERRED
CHLORHEXIDINE GLUCONATE SOLN PREFERRED
PAROEX SOLN PREFERRED
ORALONE DENTAL PASTE PSTE PREFERRED
TRIAMCINOLONE ACETONIDE DENTAL PASTE PSTE PREFERRED
LIDOCAINE HCL SOLN PREFERRED
LIDOCAINE HCL VISCOUS SOLN PREFERRED
LIDOCAINE VISCOUS SOLN PREFERRED
DENTA 5000 PLUS CREA NON_PREFERRED
SF 5000 PLUS CREA NON_PREFERRED
SODIUM FLUORIDE 5000 PLUS CREA NON_PREFERRED
SODIUM FLUORIDE 5000 PPM CREA NON_PREFERRED
DENTAGEL GEL NON_PREFERRED
SF GEL NON_PREFERRED
SODIUM FLUORIDE GEL NON_PREFERRED
SODIUM FLUORIDE 5000 PPM PSTE NON_PREFERRED
SODIUM FLUORIDE 5000 PPMSENSITIVE PSTE NON_PREFERRED
Page 86 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
AQUORAL SOLN NON_PREFERRED
CEVIMELINE HCL CAPS NON_PREFERRED
CEVIMELINE HYDROCHLORIDE CAPS NON_PREFERRED
EVOXAC CAPS NON_PREFERRED
PILOCARPINE HCL TABS PREFERRED
PILOCARPINE HYDROCHLORIDE TABS PREFERRED
SALAGEN TABS NON_PREFERRED
GELX GEL NON_PREFERRED
MULTIVITAMINS : PRENATAL VITAMINS VITAFOL STRIPS FILM NON_PREFERRED
VP-GGR-B6 PRENATAL TABS NON_PREFERRED
PREMESISRX TABS NON_PREFERRED
PRENATE AM TABS NON_PREFERRED
PRENATE CHEW NON_PREFERRED
TRICARE PRENATAL DHA ONE/FOLATE CAPS NON_PREFERRED
VITAFOL GUMMIES CHEW NON_PREFERRED
ENBRACE HR CAPS NON_PREFERRED
ELITE-OB TABS PREFERRED
OB COMPLETE TABS PREFERRED
PNV TABS 29-1 TABS PREFERRED
THRIVITE RX TABS PREFERRED
PRENATE STAR TABS NON_PREFERRED
PRENATE ELITE TABS NON_PREFERRED
OB COMPLETE/DHA CAPS NON_PREFERRED
OB COMPLETE PREMIER TABS NON_PREFERRED
COMPLETENATE CHEW PREFERRED
SE-NATAL 19 CHEW PREFERRED
M-NATAL PLUS TABS PREFERRED
NIVA-PLUS TABS PREFERRED
PRENATAL TABS PREFERRED
PRENATAL VITAMINS PLUS LOW IRON TABS PREFERRED
PRENATRIX TABS PREFERRED
PREPLUS TABS PREFERRED
PRETAB TABS PREFERRED
TRICARE TABS PREFERRED
TRINATAL RX 1 TABS PREFERRED
VIRT NATE TABS PREFERRED
VITAFOL-OB TABS PREFERRED
VOL-PLUS TABS PREFERRED
WESTAB PLUS TABS PREFERRED
C-NATE DHA CAPS NON_PREFERRED
RELNATE DHA CAPS NON_PREFERRED
VIRT-NATE DHA CAPS NON_PREFERRED
VP-PNV-DHA CAPS NON_PREFERRED
PNV-SELECT TABS NON_PREFERRED
Page 87 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
VIRT-PN TABS NON_PREFERRED
SELECT-OB CHEW NON_PREFERRED
SELECT-OB CHEW NON_PREFERRED
PNV-VP-U CAPS PREFERRED
VITAFOL-NANO TABS NON_PREFERRED
CITRANATAL RX TABS NON_PREFERRED
CONCEPT OB CAPS NON_PREFERRED
FOLIVANE-OB CAPS NON_PREFERRED
PROVIDA OB CAPS NON_PREFERRED
PUREFE OB PLUS CAPS NON_PREFERRED
CALCIUM PNV CAPS NON_PREFERRED
OB COMPLETE ADVANCED CAPS NON_PREFERRED
PNV-OMEGA CAPS NON_PREFERRED
VIRT-PN PLUS CAPS NON_PREFERRED
ZATEAN-PN PLUS CAPS NON_PREFERRED
NESTABS TABS NON_PREFERRED
NESTABS DHA MISC NON_PREFERRED
TRI-TABS DHA MISC NON_PREFERRED
SE-NATAL 19 TABS PREFERRED
CITRANATAL B-CALM MISC NON_PREFERRED
OB COMPLETE ONE CAPS NON_PREFERRED
OB COMPLETE PETITE CAPS NON_PREFERRED
VINATE DHA RF CAPS NON_PREFERRED
PRIMACARE CAPS NON_PREFERRED
CITRANATAL BLOOM TABS NON_PREFERRED
VP-HEME OB TABS NON_PREFERRED
CONCEPT DHA CAPS NON_PREFERRED
TARON-C DHA CAPS NON_PREFERRED
VIRT-C DHA CAPS NON_PREFERRED
TRICARE PRENATAL DHA ONE CAPS NON_PREFERRED
COMPLETE NATAL DHA MISC NON_PREFERRED
VITAFOL-OB+DHA MISC NON_PREFERRED
TRISTART DHA CAPS NON_PREFERRED
TRISTART ONE CAPS NON_PREFERRED
WESTGEL DHA CAPS NON_PREFERRED
PNV-DHA CAPS NON_PREFERRED
PRENATE ENHANCE CAPS NON_PREFERRED
PRENATE RESTORE CAPS NON_PREFERRED
VIRT-PN DHA CAPS NON_PREFERRED
ZATEAN-PN DHA CAPS NON_PREFERRED
PRENATE DHA CAPS NON_PREFERRED
PRENATE ESSENTIAL CAPS NON_PREFERRED
PRENATE PIXIE CAPS NON_PREFERRED
VITAFOL-ONE CAPS NON_PREFERRED
Page 88 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
SELECT-OB+DHA MISC NON_PREFERRED
PRENAISSANCE PLUS CAPS NON_PREFERRED
VP-CH PLUS CAPS NON_PREFERRED
VP-CH-PNV CAPS NON_PREFERRED
PNV-DHA+DOCUSATE CAPS NON_PREFERRED
PRENAISSANCE CAPS NON_PREFERRED
TARON-PREX CAPS NON_PREFERRED
VIRT-SELECT CAPS NON_PREFERRED
VIRTPREX CAPS NON_PREFERRED
CITRANATAL 90 DHA MISC NON_PREFERRED
CITRANATAL ASSURE MISC NON_PREFERRED
CITRANATAL BLOOM DHA MISC NON_PREFERRED
CITRANATAL DHA MISC NON_PREFERRED
PNV OB+DHA MISC NON_PREFERRED
PRENATE MINI CAPS NON_PREFERRED
CITRANATAL HARMONY CAPS NON_PREFERRED
VP-HEME ONE CAPS NON_PREFERRED
VITAFOL FE+ CAPS NON_PREFERRED
VITAFOL ULTRA CAPS NON_PREFERRED
NESTABS ONE CAPS NON_PREFERRED
VITAFOL FE+ CPPK NON_PREFERRED
MUSCULOSKELETAL THERAPY AGENTS BACLOFEN TABS PREFERRED
CARISOPRODOL TABS NON_PREFERRED
SOMA TABS NON_PREFERRED
CHLORZOXAZONE TABS PREFERRED
LORZONE TABS PREFERRED
AMRIX CP24 NON_PREFERRED
CYCLOBENZAPRINE HYDROCHLORIDE ER CP24 NON_PREFERRED
CYCLOBENZAPRINE HYDROCHLORIDE TABS PREFERRED
FEXMID TABS NON_PREFERRED
METAXALL TABS NON_PREFERRED
METAXALONE TABS NON_PREFERRED
SKELAXIN TABS NON_PREFERRED
METHOCARBAMOL TABS PREFERRED
ROBAXIN-750 TABS NON_PREFERRED
ORPHENADRINE CITRATE ER TB12 PREFERRED
TIZANIDINE HCL CAPS NON_PREFERRED
TIZANIDINE HYDROCHLORIDE CAPS NON_PREFERRED
ZANAFLEX CAPS NON_PREFERRED
TIZANIDINE HCL TABS PREFERRED
TIZANIDINE HYDROCHLORIDE TABS PREFERRED
ZANAFLEX TABS NON_PREFERRED
DANTRIUM CAPS NON_PREFERRED
DANTROLENE SODIUM CAPS PREFERRED
Page 89 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
CARISOPRODOL/ASPIRIN/CODEINE TABS NON_PREFERRED
NORGESIC FORTE TABS NON_PREFERRED
NASAL AGENTS - SYSTEMIC AND TOPICAL : MISC QNASL AERS NON_PREFERRED
QNASL CHILDRENS AERS NON_PREFERRED
BECONASE AQ SUSP NON_PREFERRED
ZETONNA AERS NON_PREFERRED
OMNARIS SUSP NON_PREFERRED
FLUNISOLIDE SOLN PREFERRED
XHANCE EXHU NON_PREFERRED
FLUTICASONE PROPIONATE SUSP PREFERRED
SINUVA IMPL NON_PREFERRED
MOMETASONE FUROATE SUSP NON_PREFERRED
NASONEX SUSP NON_PREFERRED
IPRATROPIUM BROMIDE SOLN NON_PREFERRED
ASTEPRO SOLN NON_PREFERRED
AZELASTINE HCL SOLN PREFERRED
AZELASTINE HYDROCHLORIDE SOLN PREFERRED
OLOPATADINE HCL SOLN PREFERRED
OLOPATADINE HYDROCHLORIDE SOLN PREFERRED
PATANASE SOLN NON_PREFERRED
AZELASTINE HYDROCHLORIDE/FLUTICASONE PROPIONATE SUSP NON_PREFERRED
DYMISTA SUSP NON_PREFERRED
NEUROMUSCULAR AGENTS TIGLUTIK SUSP NON_PREFERRED
RILUTEK TABS NON_PREFERRED
RILUZOLE TABS PREFERRED
OPHTHALMIC AGENTS : BETA-BLOCKERS - OPHTHALMIC BETAXOLOL HCL SOLN PREFERRED
BETOPTIC-S SUSP NON_PREFERRED
CARTEOLOL HCL SOLN PREFERRED
LEVOBUNOLOL HCL SOLN PREFERRED
TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG PREFERRED
TIMOPTIC-XE SOLG NON_PREFERRED
ISTALOL SOLN NON_PREFERRED
TIMOLOL MALEATE SOLN PREFERRED
TIMOPTIC SOLN NON_PREFERRED
TIMOPTIC OCUDOSE SOLN NON_PREFERRED
COMBIGAN SOLN NON_PREFERRED
COSOPT SOLN NON_PREFERRED
COSOPT PF SOLN NON_PREFERRED
DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN PREFERRED
DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF SOLN NON_PREFERRED
OPHTHALMIC AGENTS : MISC LACRISERT INST PREFERRED
BIMATOPROST SOLN NON_PREFERRED
LUMIGAN SOLN NON_PREFERRED
XELPROS EMUL NON_PREFERRED
Page 90 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
LATANOPROST SOLN PREFERRED
XALATAN SOLN NON_PREFERRED
VYZULTA SOLN NON_PREFERRED
ZIOPTAN SOLN NON_PREFERRED
TRAVATAN Z SOLN NON_PREFERRED
TRAVOPROST SOLN NON_PREFERRED
ATROPINE SULFATE OINT PREFERRED
ATROPINE SULFATE SOLN PREFERRED
ISOPTO ATROPINE SOLN NON_PREFERRED
CYCLOGYL SOLN NON_PREFERRED
CYCLOPENTOLATE HCL SOLN PREFERRED
CYCLOPENTOLATE HYDROCHLORIDE SOLN PREFERRED
PHENYLEPHRINE HCL SOLN NON_PREFERRED
MYDRIACYL SOLN NON_PREFERRED
TROPICAMIDE SOLN PREFERRED
CYCLOMYDRIL SOLN PREFERRED
ISOPTO CARPINE SOLN NON_PREFERRED
PILOCARPINE HCL SOLN PREFERRED
PILOCARPINE HYDROCHLORIDE SOLN PREFERRED
PHOSPHOLINE IODIDE SOLR PREFERRED
RHOPRESSA SOLN NON_PREFERRED
ROCKLATAN SOLN NON_PREFERRED
APRACLONIDINE SOLN NON_PREFERRED
IOPIDINE SOLN NON_PREFERRED
ALPHAGAN P SOLN PREFERRED
BRIMONIDINE TARTRATE SOLN PREFERRED
SIMBRINZA SUSP NON_PREFERRED
RESTASIS EMUL NON_PREFERRED
RESTASIS MULTIDOSE EMUL NON_PREFERRED
CEQUA SOLN NON_PREFERRED
XIIDRA SOLN NON_PREFERRED
AKTEN GEL NON_PREFERRED
ALCAINE SOLN NON_PREFERRED
PROPARACAINE HCL SOLN NON_PREFERRED
TETRACAINE HCL SOLN NON_PREFERRED
TETRACAINE HYDROCHLORIDE SOLN NON_PREFERRED
OXERVATE SOLN NON_PREFERRED
AZOPT SUSP NON_PREFERRED
DORZOLAMIDE HCL SOLN PREFERRED
DORZOLAMIDE HYDROCHLORIDE SOLN PREFERRED
TRUSOPT SOLN NON_PREFERRED
BROMFENAC SOLN NON_PREFERRED
BROMSITE SOLN NON_PREFERRED
PROLENSA SOLN NON_PREFERRED
Page 91 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
DICLOFENAC SODIUM SOLN PREFERRED
FLURBIPROFEN SODIUM SOLN PREFERRED
ACULAR SOLN NON_PREFERRED
ACULAR LS SOLN NON_PREFERRED
ACUVAIL SOLN NON_PREFERRED
KETOROLAC TROMETHAMINE SOLN PREFERRED
ILEVRO SUSP NON_PREFERRED
NEVANAC SUSP NON_PREFERRED
CYSTADROPS SOLN NON_PREFERRED
CYSTARAN SOLN NON_PREFERRED
GLOSTRIPS STRP NON_PREFERRED
OPHTHALMIC AGENTS : OPHTHALMIC ANTI-INFECTIVES AZASITE SOLN NON_PREFERRED
BACITRACIN OINT PREFERRED
BESIVANCE SUSP NON_PREFERRED
CILOXAN OINT PREFERRED
CILOXAN SOLN NON_PREFERRED
CIPROFLOXACIN HYDROCHLORIDE SOLN PREFERRED
ERYTHROMYCIN OINT PREFERRED
GATIFLOXACIN SOLN NON_PREFERRED
ZYMAXID SOLN NON_PREFERRED
GENTAK OINT PREFERRED
GENTAMICIN SULFATE SOLN PREFERRED
LEVOFLOXACIN SOLN PREFERRED
MOXEZA SOLN NON_PREFERRED
MOXIFLOXACIN HYDROCHLORIDE SOLN NON_PREFERRED
VIGAMOX SOLN NON_PREFERRED
OCUFLOX SOLN NON_PREFERRED
OFLOXACIN SOLN PREFERRED
TOBREX OINT PREFERRED
TOBRAMYCIN SOLN PREFERRED
TOBRAMYCIN SULFATE SOLN PREFERRED
TOBREX SOLN NON_PREFERRED
SULFACETAMIDE SODIUM OINT PREFERRED
BLEPH-10 SOLN NON_PREFERRED
SODIUM SULFACETAMIDE SOLN PREFERRED
SULFACETAMIDE SODIUM SOLN PREFERRED
ZIRGAN GEL PREFERRED
TRIFLURIDINE SOLN PREFERRED
NATACYN SUSP PREFERRED
BETADINE OPHTHALMIC PREP SOLN NON_PREFERRED
AK-POLY-BAC OINT PREFERRED
BACITRACIN/POLYMYXIN B OINT PREFERRED
POLYCIN OINT PREFERRED
POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN PREFERRED
Page 92 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
POLYTRIM SOLN NON_PREFERRED
TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE SOLN PREFERRED
NEO-POLYCIN OINT PREFERRED
NEOMYCIN/BACITRACIN/POLYMYXIN OINT PREFERRED
NEOMYCIN/POLYMYXIN/BACITRACIN ZINC OINT PREFERRED
NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN PREFERRED
OPHTHALMIC AGENTS : OPHTHALMIC ANTIALLERGIC LASTACAFT SOLN NON_PREFERRED
AZELASTINE HCL SOLN PREFERRED
AZELASTINE HYDROCHLORIDE SOLN PREFERRED
BEPREVE SOLN NON_PREFERRED
ZERVIATE SOLN NON_PREFERRED
CROMOLYN SODIUM SOLN PREFERRED
EPINASTINE HCL SOLN NON_PREFERRED
ALOMIDE SOLN NON_PREFERRED
ALOCRIL SOLN NON_PREFERRED
OLOPATADINE HCL SOLN NON_PREFERRED
OLOPATADINE HYDROCHLORIDE SOLN NON_PREFERRED
PATADAY SOLN NON_PREFERRED
PATANOL SOLN NON_PREFERRED
PAZEO SOLN PREFERRED
OPHTHALMIC AGENTS : OPHTHALMIC STEROIDS DEXTENZA INST NON_PREFERRED
MAXIDEX SUSP PREFERRED
DEXAMETHASONE SODIUM PHOSPHATE SOLN PREFERRED
DUREZOL EMUL NON_PREFERRED
FML OINT PREFERRED
FLUOROMETHOLONE SUSP PREFERRED
FML FORTE SUSP PREFERRED
FML LIQUIFILM SUSP NON_PREFERRED
FLAREX SUSP PREFERRED
LOTEMAX GEL NON_PREFERRED
LOTEMAX SM GEL NON_PREFERRED
LOTEMAX OINT NON_PREFERRED
ALREX SUSP PREFERRED
INVELTYS SUSP NON_PREFERRED
LOTEMAX SUSP NON_PREFERRED
LOTEPREDNOL ETABONATE SUSP PREFERRED
OMNIPRED SUSP NON_PREFERRED
PRED FORTE SUSP NON_PREFERRED
PRED MILD SUSP PREFERRED
PREDNISOLONE ACETATE SUSP PREFERRED
PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED
PRED-G S.O.P. OINT NON_PREFERRED
PRED-G SUSP NON_PREFERRED
ZYLET SUSP NON_PREFERRED
Page 93 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
BLEPHAMIDE S.O.P. OINT NON_PREFERRED
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SOLN NON_PREFERRED
BLEPHAMIDE SUSP NON_PREFERRED
TOBRADEX OINT NON_PREFERRED
TOBRADEX SUSP NON_PREFERRED
TOBRADEX ST SUSP NON_PREFERRED
TOBRAMYCIN/DEXAMETHASONE SUSP PREFERRED
MAXITROL OINT NON_PREFERRED
NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT PREFERRED
MAXITROL SUSP NON_PREFERRED
NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP PREFERRED
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED
NEO-POLYCIN HC OINT PREFERRED
NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT PREFERRED
OTIC AGENTS CIPROFLOXACIN SOLN NON_PREFERRED
FLOXIN OTIC SOLN NON_PREFERRED
OFLOXACIN SOLN PREFERRED
DERMOTIC OIL NON_PREFERRED
FLAC OIL NON_PREFERRED
FLUOCINOLONE ACETONIDE OIL NON_PREFERRED
HYDROCORTISONE/ACETIC ACID SOLN NON_PREFERRED
ACETIC ACID SOLN PREFERRED
OTIC AGENTS : OTIC COMBINATIONS CIPRODEX SUSP PREFERRED
CIPROFLOXACIN/DEXAMETHASONE SUSP PREFERRED
CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF SOLN NON_PREFERRED
OTOVEL SOLN NON_PREFERRED
CIPRO HC SUSP NON_PREFERRED
NEOMYCIN/POLYMYXIN/HC SOLN PREFERRED
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SOLN PREFERRED
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED
CORTISPORIN-TC SUSP NON_PREFERRED
PROGESTINS HYDROXYPROGESTERONE CAPROATE OIL NON_PREFERRED
MAKENA OIL PREFERRED_WITH_PA
MAKENA SOAJ PREFERRED_WITH_PA
MEDROXYPROGESTERONE ACETATE TABS PREFERRED
PROVERA TABS NON_PREFERRED
MEGESTROL ACETATE SUSP NON_PREFERRED
AYGESTIN TABS NON_PREFERRED
NORETHINDRONE ACETATE TABS NON_PREFERRED
PROGESTERONE OIL PREFERRED
PROGESTERONE CAPS PREFERRED
PROMETRIUM CAPS NON_PREFERRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS :
ANTIDEMENTIA AGENTS ARICEPT TABS NON_PREFERRED
Page 94 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
DONEPEZIL HCL TABS PREFERRED
DONEPEZIL HYDROCHLORIDE TABS PREFERRED
DONEPEZIL HCL TBDP PREFERRED
DONEPEZIL HYDROCHLORIDE ODT TBDP PREFERRED
GALANTAMINE HYDROBROMIDEER CP24 NON_PREFERRED
RAZADYNE ER CP24 NON_PREFERRED
GALANTAMINE HYDROBROMIDE SOLN NON_PREFERRED
GALANTAMINE HYDROBROMIDE TABS NON_PREFERRED
EXELON PT24 NON_PREFERRED
RIVASTIGMINE TRANSDERMALSYSTEM PT24 NON_PREFERRED
RIVASTIGMINE TARTRATE CAPS NON_PREFERRED
MEMANTINE HYDROCHLORIDE ER CP24 NON_PREFERRED
NAMENDA XR CP24 NON_PREFERRED
NAMENDA XR TITRATION PACK CP24 NON_PREFERRED
MEMANTINE HYDROCHLORIDE SOLN NON_PREFERRED
MEMANTINE HCL TITRATION PAK TABS NON_PREFERRED
MEMANTINE HYDROCHLORIDE TABS PREFERRED
NAMENDA TABS NON_PREFERRED
NAMENDA TITRATION PAK TABS NON_PREFERRED
NAMZARIC C4PK NON_PREFERRED
NAMZARIC CP24 NON_PREFERRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MISC ERGOLOID MESYLATES TABS PREFERRED
PIMOZIDE TABS PREFERRED
FLUOXETINE HYDROCHLORIDE TABS NON_PREFERRED
SARAFEM TABS NON_PREFERRED
BRISDELLE CAPS NON_PREFERRED
PAROXETINE CAPS NON_PREFERRED
AUSTEDO TABS NON_PREFERRED
TETRABENAZINE TABS NON_PREFERRED
XENAZINE TABS NON_PREFERRED
INGREZZA CAPS NON_PREFERRED
INGREZZA CPPK NON_PREFERRED
XYREM SOLN NON_PREFERRED
XYWAV SOLN NON_PREFERRED
SAVELLA TITRATION PACK MISC NON_PREFERRED
SAVELLA TABS NON_PREFERRED
GRALISE TABS NON_PREFERRED
LYRICA CR TB24 NON_PREFERRED
PENTICAN THPK NON_PREFERRED
GABAPAL THPK NON_PREFERRED
LIDOTIN THPK NON_PREFERRED
LIPRITIN THPK NON_PREFERRED
LIPRITIN II THPK NON_PREFERRED
PRILOPENTIN THPK NON_PREFERRED
Page 95 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
HORIZANT TBCR NON_PREFERRED
NUEDEXTA CAPS NON_PREFERRED
TEGSEDI SOSY NON_PREFERRED
CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS PREFERRED
PERPHENAZINE/AMITRIPTYLINE TABS PREFERRED
OLANZAPINE/FLUOXETINE CAPS NON_PREFERRED
SYMBYAX CAPS NON_PREFERRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MULTIPLE
SCLEROSIS AGENTS COPAXONE INJ 20MG/ML SOSY PREFERRED
COPAXONE INJ 40MG/ML SOSY NON_PREFERRED
GLATIRAMER ACETATE SOSY NON_PREFERRED
GLATOPA SOSY NON_PREFERRED
MAVENCLAD TBPK NON_PREFERRED
AVONEX PEN AJKT NON_PREFERRED
AVONEX KIT NON_PREFERRED
AVONEX PSKT NON_PREFERRED
REBIF REBIDOSE SOAJ PREFERRED
REBIF REBIDOSE TITRATIONPACK SOAJ PREFERRED
REBIF SOSY PREFERRED
REBIF TITRATION PACK SOSY PREFERRED
BETASERON KIT PREFERRED
EXTAVIA KIT NON_PREFERRED
PLEGRIDY SOPN NON_PREFERRED
PLEGRIDY STARTER PACK SOPN NON_PREFERRED
PLEGRIDY SOSY NON_PREFERRED
PLEGRIDY STARTER PACK SOSY NON_PREFERRED
AUBAGIO TABS NON_PREFERRED
LEMTRADA SOLN NON_PREFERRED
TYSABRI CONC NON_PREFERRED
OCREVUS SOLN NON_PREFERRED
KESIMPTA SOAJ NON_PREFERRED
DIMETHYL FUMARATE CPDR NON_PREFERRED
TECFIDERA CPDR PREFERRED_WITH_PA
DIMETHYL FUMARATE STARTERPACK MISC NON_PREFERRED
TECFIDERA STARTER PACK MISC PREFERRED_WITH_PA
VUMERITY CPDR NON_PREFERRED
BAFIERTAM CPDR NON_PREFERRED
AMPYRA TB12 NON_PREFERRED
DALFAMPRIDINE ER TB12 NON_PREFERRED
GILENYA CAPS NON_PREFERRED
ZEPOSIA CAPS NON_PREFERRED
ZEPOSIA 7-DAY STARTER PACK CPPK NON_PREFERRED
ZEPOSIA STARTER KIT CPPK NON_PREFERRED
MAYZENT TABS NON_PREFERRED
Page 96 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
MAYZENT STARTER PACK TBPK NON_PREFERRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : SMOKING
DETERRENTS BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED
NICOTROL INHALER INHA PREFERRED
NICOTINE TRANSDERMAL SYSTEM KIT PREFERRED
GNP NICOTINE TRANSDERMALSYSTEM PT24 PREFERRED
GNP NICOTINE TRANSDERMALSYSTEM STEP 2 PT24 PREFERRED
HM NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED
HM NICOTINE TRANSDERMAL SYSTEM STEP 2 PT24 PREFERRED
HM NICOTINE TRANSDERMAL SYSTEM STEP 3 PT24 PREFERRED
NICOTINE TRANSDERMAL SYSTEM PT24 PREFERRED
NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED
NICOTINE TRANSDERMAL SYSTEM STEP 2 PT24 PREFERRED
NICOTINE TRANSDERMAL SYSTEM STEP 3 PT24 PREFERRED
SM NICOTINE TRANSDERMAL SYSTEM/STEP 1/CLEAR PT24 PREFERRED
SM NICOTINE TRANSDERMAL SYSTEM/STEP 2/CLEAR PT24 PREFERRED
SM NICOTINE TRANSDERMAL SYSTEM/STEP 3/CLEAR PT24 PREFERRED
NICOTROL NS SOLN PREFERRED
GNP NICOTINE GUM GUM PREFERRED
GNP NICOTINE POLACRILEX GUM PREFERRED
GOODSENSE NICOTINE GUM GUM PREFERRED
GOODSENSE NICOTINE POLACRILEX GUM GUM PREFERRED
HM NICOTINE POLACRILEX GUM PREFERRED
NICOTINE POLACRILEX GUM PREFERRED
SM NICOTINE GUM PREFERRED
SM NICOTINE POLACRILEX GUM PREFERRED
GNP NICOTINE MINI LOZENGE LOZG PREFERRED
GNP NICOTINE POLACRILEX LOZG PREFERRED
GNP NICOTINE POLACRILEX MINI LOZG PREFERRED
GOODSENSE NICOTINE LOZG PREFERRED
GOODSENSE NICOTINE POLACRILEX LOZG PREFERRED
HM NICOTINE POLACRILEX LOZG PREFERRED
NICOTINE LOZG PREFERRED
NICOTINE MINI LOZENGE LOZG PREFERRED
NICOTINE POLACRILEX LOZG PREFERRED
SM NICOTINE LOZG PREFERRED
SM NICOTINE POLACRILEX LOZG PREFERRED
CHANTIX TABS PREFERRED
CHANTIX CONTINUING MONTHPAK TABS PREFERRED
CHANTIX STARTING MONTH PAK TABS PREFERRED
RESPIRATORY AGENTS : CYSTIC FIBROSIS AGENTS KALYDECO PACK NON_PREFERRED
KALYDECO TABS NON_PREFERRED
PULMOZYME SOLN PREFERRED
ORKAMBI PACK NON_PREFERRED
Page 97 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
ORKAMBI TABS NON_PREFERRED
SYMDEKO TBPK NON_PREFERRED
TRIKAFTA TBPK NON_PREFERRED
RESPIRATORY AGENTS : MISC ESBRIET CAPS NON_PREFERRED
ESBRIET TABS NON_PREFERRED
OFEV CAPS NON_PREFERRED
SUBSTANCE USE DISORDER AGENTS ACAMPROSATE CALCIUM DR TBEC PREFERRED
ANTABUSE TABS PREFERRED
DISULFIRAM TABS PREFERRED
LUCEMYRA TABS PREFERRED
SUBLOCADE SOSY PREFERRED
PROBUPHINE IMPLANT KIT IMPL PREFERRED
BUPRENORPHINE HCL SUBL PREFERRED
BUPRENORPHINE HYDROCHLORIDE SUBL PREFERRED
BUNAVAIL FILM PREFERRED
BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE FILM PREFERRED
SUBOXONE FILM PREFERRED
BUPRENORPHINE HCL/NALOXONE HCL SUBL PREFERRED
BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE SUBL PREFERRED
ZUBSOLV SUBL PREFERRED
NARCAN LIQD PREFERRED
NALOXONE HCL SOCT PREFERRED
NALOXONE HCL SOLN PREFERRED
NALOXONE HYDROCHLORIDE SOLN PREFERRED
NALOXONE HCL SOSY PREFERRED
NALOXONE HYDROCHLORIDE SOSY PREFERRED
VIVITROL SUSR PREFERRED
NALTREXONE HCL TABS PREFERRED
NALTREXONE HYDROCHLORIDE TABS PREFERRED
THYROID AGENTS LEVOTHYROXINE SODIUM CAPS NON_PREFERRED
TIROSINT CAPS NON_PREFERRED
TIROSINT-SOL SOLN NON_PREFERRED
EUTHYROX TABS PREFERRED
LEVO-T TABS PREFERRED
LEVOTHYROXINE SODIUM TABS PREFERRED
LEVOXYL TABS PREFERRED
SYNTHROID TABS NON_PREFERRED
UNITHROID TABS PREFERRED
CYTOMEL TABS NON_PREFERRED
LIOTHYRONINE SODIUM TABS PREFERRED
ARMOUR THYROID TABS PREFERRED
LEVOTHYROXINE/LIOTHYRONINE TABS PREFERRED
NP THYROID 120 TABS PREFERRED
NP THYROID 15 TABS PREFERRED
Page 98 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
NP THYROID 30 TABS PREFERRED
NP THYROID 60 TABS PREFERRED
NP THYROID 90 TABS PREFERRED
METHIMAZOLE TABS PREFERRED
TAPAZOLE TABS NON_PREFERRED
PROPYLTHIOURACIL TABS PREFERRED
TUMOR NECROSIS FACTOR ALPHA INHIBITORS AND MISC
IMMUNOSUPPRESSIVES ENTYVIO SOLR NON_PREFERRED
STELARA SOLN NON_PREFERRED
CIMZIA KIT KIT NON_PREFERRED
CIMZIA PREFL KIT 200MG/ML KIT PREFERRED_WITH_PA
CIMZIA STARTER KIT KIT PREFERRED_WITH_PA
REMICADE SOLR NON_PREFERRED
RENFLEXIS SOLR NON_PREFERRED
AVSOLA SOLR NON_PREFERRED
INFLECTRA SOLR NON_PREFERRED
KINERET SOSY NON_PREFERRED
HUMIRA PEN PNKT PREFERRED_WITH_PA
HUMIRA PEN-CD/UC/HS STARTER PNKT PREFERRED_WITH_PA
HUMIRA PEN-PS/UV STARTER PNKT PREFERRED_WITH_PA
HUMIRA PSKT PREFERRED_WITH_PA
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT PREFERRED_WITH_PA
SIMPONI SOAJ NON_PREFERRED
SIMPONI ARIA SOLN NON_PREFERRED
SIMPONI SOSY NON_PREFERRED
ENBREL SURECLICK SOAJ PREFERRED_WITH_PA
ENBREL MINI SOCT PREFERRED_WITH_PA
ENBREL SOLN PREFERRED_WITH_PA
ENBREL SOLR PREFERRED_WITH_PA
ENBREL SOSY PREFERRED_WITH_PA
ORENCIA CLICKJECT SOAJ NON_PREFERRED
ORENCIA SOLR NON_PREFERRED
ORENCIA SOSY NON_PREFERRED
ARCALYST SOLR NON_PREFERRED
ILARIS SOLN NON_PREFERRED
KEVZARA SOAJ NON_PREFERRED
KEVZARA SOSY NON_PREFERRED
ACTEMRA ACTPEN SOAJ NON_PREFERRED
ACTEMRA SOLN NON_PREFERRED
ACTEMRA SOSY NON_PREFERRED
OLUMIANT TABS NON_PREFERRED
XELJANZ TABS PREFERRED_WITH_PA
XELJANZ XR TB24 PREFERRED_WITH_PA
RINVOQ TB24 NON_PREFERRED
Page 99 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
OTEZLA TABS NON_PREFERRED
OTEZLA TBPK NON_PREFERRED
ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : H-2
ANTAGONISTS CIMETIDINE TABS PREFERRED
CIMETIDINE HCL SOLN PREFERRED
CIMETIDINE HYDROCHLORIDE SOLN PREFERRED
RANITIDINE HYDROCHLORIDE CAPS NON_PREFERRED
RANITIDINE HCL SYRP NON_PREFERRED
RANITIDINE HYDROCHLORIDE SYRP NON_PREFERRED
RANITIDINE HCL TABS NON_PREFERRED
RANITIDINE HYDROCHLORIDE TABS NON_PREFERRED
FAMOTIDINE SUSR PREFERRED
FAMOTIDINE TABS PREFERRED
PEPCID TABS NON_PREFERRED
NIZATIDINE CAPS PREFERRED
NIZATIDINE SOLN PREFERRED
ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : MISC HYOSCYAMINE SULFATE ELIX PREFERRED
HYOSCYAMINE SULFATE SOLN PREFERRED
HYOSCYAMINE SULFATE SUBL PREFERRED
LEVSIN/SL SUBL NON_PREFERRED
OSCIMIN SUBL PREFERRED
HYOSCYAMINE SULFATE TABS PREFERRED
LEVSIN TABS NON_PREFERRED
OSCIMIN TABS PREFERRED
OSCIMIN SR TB12 PREFERRED
ANASPAZ TBDP NON_PREFERRED
ED-SPAZ TBDP PREFERRED
HYOSCYAMINE SULFATE TBDP PREFERRED
HYOSCYAMINE SULFATE ODT TBDP PREFERRED
NULEV TBDP PREFERRED
OSCIMIN TBDP PREFERRED
CUVPOSA SOLN NON_PREFERRED
GLYCATE TABS NON_PREFERRED
GLYCOPYRROLATE TABS PREFERRED
METHSCOPOLAMINE BROMIDE TABS NON_PREFERRED
PROPANTHELINE BROMIDE TABS PREFERRED
DICYCLOMINE HYDROCHLORIDE CAPS PREFERRED
DICYCLOMINE HCL SOLN PREFERRED
DICYCLOMINE HYDROCHLORIDE SOLN PREFERRED
DICYCLOMINE HYDROCHLORIDE TABS PREFERRED
BELLADONNA/OPIUM SUPP PREFERRED
CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS NON_PREFERRED
CHLORDIAZEPOXIDE HYDROCHLORIDE/CLIDINIUM BROMIDE CAPS NON_PREFERRED
Page 100 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
LIBRAX CAPS NON_PREFERRED
CYTOTEC TABS NON_PREFERRED
MISOPROSTOL TABS PREFERRED
CARAFATE SUSP PREFERRED
SUCRALFATE SUSP PREFERRED
CARAFATE TABS NON_PREFERRED
SUCRALFATE TABS PREFERRED
PYLERA CAPS NON_PREFERRED
HELIDAC THERAPY MISC NON_PREFERRED
LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN MISC NON_PREFERRED
OMECLAMOX-PAK MISC NON_PREFERRED
TALICIA CPDR NON_PREFERRED
OMEPRAZOLE/SODIUM BICARBONATE CAPS NON_PREFERRED
ZEGERID CAPS NON_PREFERRED
OMEPRAZOLE/SODIUM BICARBONATE PACK NON_PREFERRED
ZEGERID PACK NON_PREFERRED
ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : PROTON
PUMP INHIBITORS DEXILANT CPDR NON_PREFERRED
ESOMEPRAZOLE MAGNESIUM CPDR NON_PREFERRED
NEXIUM CPDR NON_PREFERRED
ESOMEPRAZOLE MAGNESIUM PACK NON_PREFERRED
NEXIUM PACK NON_PREFERRED
ESOMEPRAZOLE STRONTIUM CPDR NON_PREFERRED
LANSOPRAZOLE CPDR NON_PREFERRED
PREVACID CPDR NON_PREFERRED
LANSOPRAZOLE TBDD PREFERRED
LANSOPRAZOLE ODT TBDD PREFERRED
PREVACID SOLUTAB TBDD NON_PREFERRED
OMEPRAZOLE CPDR PREFERRED
OMEPRAZOLE DR CPDR PREFERRED
PRILOSEC PACK NON_PREFERRED
PANTOPRAZOLE SODIUM PACK NON_PREFERRED
PROTONIX PACK NON_PREFERRED
PANTOPRAZOLE SODIUM TBEC PREFERRED
PANTOPRAZOLE SODIUM DR TBEC PREFERRED
PROTONIX TBEC NON_PREFERRED
ACIPHEX SPRINKLE CPSP NON_PREFERRED
ACIPHEX TBEC NON_PREFERRED
RABEPRAZOLE SODIUM TBEC NON_PREFERRED
URINARY ANTISPASMODICS DARIFENACIN HYDROBROMIDEER TB24 NON_PREFERRED
ENABLEX TB24 NON_PREFERRED
TOVIAZ TB24 NON_PREFERRED
OXYTROL PTTW NON_PREFERRED
GELNIQUE GEL NON_PREFERRED
Page 101 of 102
DRUG CLASS DRUG NAMEDOSAGE
FORMPDL STATUS
OXYBUTYNIN CHLORIDE SYRP PREFERRED
OXYBUTYNIN CHLORIDE TABS PREFERRED
DITROPAN XL TB24 NON_PREFERRED
OXYBUTYNIN CHLORIDE ER TB24 PREFERRED
SOLIFENACIN SUCCINATE TABS PREFERRED
VESICARE TABS NON_PREFERRED
DETROL LA CP24 NON_PREFERRED
TOLTERODINE TARTRATE ER CP24 NON_PREFERRED
DETROL TABS NON_PREFERRED
TOLTERODINE TARTRATE TABS NON_PREFERRED
TROSPIUM CHLORIDE ER CP24 NON_PREFERRED
TROSPIUM CHLORIDE TABS NON_PREFERRED
MYRBETRIQ TB24 NON_PREFERRED
BETHANECHOL CHLORIDE TABS PREFERRED
URECHOLINE TABS NON_PREFERRED
FLAVOXATE HCL TABS NON_PREFERRED
VAGINAL PRODUCTS CLEOCIN CREA NON_PREFERRED
CLINDAMYCIN PHOSPHATE CREA PREFERRED
CLEOCIN SUPP PREFERRED
CLINDESSE CREA NON_PREFERRED
METROGEL-VAGINAL GEL NON_PREFERRED
METRONIDAZOLE VAGINAL GEL PREFERRED
NUVESSA GEL NON_PREFERRED
VANDAZOLE GEL PREFERRED
GYNAZOLE-1 CREA NON_PREFERRED
MICONAZOLE 3 SUPP PREFERRED
TERCONAZOLE CREA PREFERRED
TERCONAZOLE SUPP PREFERRED
ESTRACE CREA NON_PREFERRED
ESTRADIOL CREA PREFERRED
IMVEXXY MAINTENANCE PACK INST NON_PREFERRED
IMVEXXY STARTER PACK INST NON_PREFERRED
ESTRING RING NON_PREFERRED
ESTRADIOL TABS NON_PREFERRED
VAGIFEM TABS NON_PREFERRED
YUVAFEM TABS NON_PREFERRED
FEMRING RING NON_PREFERRED
PREMARIN CREA PREFERRED
CRINONE GEL NON_PREFERRED
ENDOMETRIN INST PREFERRED
INTRAROSA INST NON_PREFERRED
TRIMO-SAN GEL NON_PREFERRED
Page 102 of 102