Medicare Part D Formulary

Medicare Part D Formulary

For the 2016 Medicare Part D Formulary, please click here.

For the 2017 Medicare Part D Formulary, please click here.

2016 Plan Formularies

Select your location

Pennsylvania Residents:

If you live in one of the counties below, please click here:

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion,

Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson,

Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and

Westmoreland.


Adams, Berks, Bradford, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin,

Franklin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming,

Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Schuylkill,

Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York.

West Virginia Residents, please click here.

2016 Plan Formularies – Western PA

For Security Blue HMO Deluxe, Standard, and ValueRx, Community Blue Medicare

HMO Prestige and Signature, Freedom Blue PPO Classic, Select, and ValueRx, and Blue

Rx PDP Complete and Plus plans, please review this formulary.

For Prior Authorization criteria, please review this information.

2016 Plan Formularies – Central and Northeastern PA

For Freedom Blue PPO Deluxe, Standard, and ValueRx, Community Blue Medicare HMO Signature, and Blue Rx PDP Complete and Plus, please review this formulary.


2016 Plan Formularies – West Virginia

For Freedom Blue PPO Standard and ValueRx, and Blue Rx PDP Complete and Plus, please review

this formulary.


5T Medicare Part D: 5 Tier Closed Formulary

Drug Name Dosage Form Strength Tier Level

Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

8-Mop capsule 10 mg PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSabacavir tablet 300 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

abacavir-

lamivudine-

zidovudine

tablet 300-150-

300 mg

Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Abelcet suspension

5

mg/mLSpecialty-5 YES

ANTI - INFECTIVES

ANTIFUNGAL

AGENTS

Abilify tablet 10 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Abilify tablet 15 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

1 Formulary ID: 16256 Version: 17 Updated 09/2016



Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Abilify

Maintena

suspension,ex

tended rel

recon 300 mg

Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Abilify

Maintena

suspension,ex

tended rel

syring 300 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Abilify

Maintena

suspension,ex

tended rel

syring 400 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Abraxane suspension

for

reconstitution

100 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Abstral tablet

100

mcg

NonPrefBrand-4

124 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Abstral tablet

200

mcg

Specialty-5

124 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Abstral tablet

300

mcg

Specialty-5

124 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Abstral tablet

400

mcg

Specialty-5

119 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Abstral tablet

600

mcg

Specialty-5

79 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Abstral tablet

800

mcg

Specialty-5

60 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

acamprosate tablet,delayed

release

(DR/EC)

333 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Acanya gel with

pump

1.2-2.5

%

NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

acarbose tablet 25 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYacarbose tablet 50 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYacarbose tablet 100 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

acebutolol capsule 400 mg

PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

acetaminophe

n-codeine solution

300 mg-

30 mg

/12.5

mL

PrefGen-1

5167 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

acetaminophe

n-codeine tablet

300-15

mg

Generic-2

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

acetaminophe

n-codeine tablet

300-30

mg

Generic-2

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

acetaminophe

n-codeine tablet

300-60

mg

Generic-2

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Acetasol HC drops 1-2 % Generic-2 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

OTIC

PREPARATIONSacetazolamide tablet 125 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR

GLAUCOMAacetazolamide tablet 250 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR

GLAUCOMAacetazolamide capsule,

extended

release

500 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR

GLAUCOMA

acetazolamide

sodium

recon soln 500 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR

GLAUCOMAacetic acid solution 2 % Generic-2 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

OTIC

PREPARATIONS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

acetylcysteine solution 100

mg/mL

(10 %)

Generic-2 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

acetylcysteine solution 200

mg/mL

(20 %)


ALLERGY

PULMONARY

AGENTS

acitretin capsule 10 mg Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

acitretin capsule 25 mg Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

acitretin capsule 17.5 mg Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Actemra solution 200

mg/10

mL (20

mg/mL)

Specialty-5 40 28 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Actemra syringe

162

mg/0.9

mL

Specialty-5

3.6 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Actemra solution

80 mg/4

mL (20

mg/mL)

Specialty-5

40 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Actemra solution

400

mg/20

mL (20

mg/mL)

Specialty-5

40 28

YESMUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Acthar H.P. gel

80

unit/mLSpecialty-5 YES ENDOCRINE/DIABE

TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ActHIB (PF) recon soln

10

mcg/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Actimmune solution 100

mcg/0.5

mL

Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Actiq lozenge on a

handle

200

mcg

Specialty-5 124 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Actiq lozenge on a

handle

600

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Actiq lozenge on a

handle

800

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Actiq lozenge on a

handle

1,200

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Actiq lozenge on a

handle

1,600

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Actiq lozenge on a

handle

400

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Actoplus Met

XR

tablet, ER

multiphase 24

hr

15-

1,000

mg

NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Actoplus Met

XR

tablet, ER

multiphase 24

hr

30-

1,000

mg


TES

DIABETES

THERAPY

Acuvail (PF) dropperette 0.45 % NonPrefBrand-4 NO OPHTHALMOLOGY NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTSacyclovir capsule 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

acyclovir tablet 400 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

acyclovir ointment 5 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIVIRALS

acyclovir tablet 800 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

acyclovir suspension 200

mg/5

mL


acyclovir

sodium

solution 50

mg/mL

Generic-2 YES ANTI - INFECTIVES ANTIVIRALS

Aczone gel 5 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Adacel(Tdap

Adolesn/Adul

t)(PF) suspension

2 Lf-

(2.5-5-3-

5 mcg)-

5Lf/0.5

mL PrefBrand-3

NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Adagen solution 250

unit/mL

Specialty-5 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

adapalene gel 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

adapalene cream 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

adapalene gel 0.3 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Adcirca tablet 20 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSadefovir tablet 10 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Adempas tablet 0.5 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Adempas tablet 1 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS


ALLERGY

PULMONARY

AGENTS

Adempas tablet 2 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS


ALLERGY

PULMONARY

AGENTS

Adrenalin solution

1

mg/mL

(1 mL) Generic-2

NORESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Adrucil solution 500

mg/10

mL

Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Advair

Diskus

blister with

device

100-50

mcg/dos

e

NonPrefBrand-4 60 30 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Advair

Diskus

blister with

device

250-50

mcg/dos

e


ALLERGY

PULMONARY

AGENTS

Advair

Diskus

blister with

device

500-50

mcg/dos

e


ALLERGY

PULMONARY

AGENTS

Advair HFA HFA aerosol

inhaler

45-21

mcg/act

uation


ALLERGY

PULMONARY

AGENTS


inhaler

115-21

mcg/act

uation


ALLERGY

PULMONARY

AGENTS


inhaler

230-21

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

Afeditab CR tablet

extended

release

30 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Afeditab CR tablet

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Afinitor tablet 10 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Afinitor tablet 5 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Afinitor tablet 2.5 mg

Specialty-5 YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Afinitor

Disperz

tablet for

suspension 2 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Afinitor

Disperz

tablet for

suspension 3 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Afinitor

Disperz

tablet for

suspension 5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Aggrenox

capsule, ER

multiphase 12

hr

25-200

mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

A-Hydrocort recon soln 100 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES

Akynzeo capsule

300-0.5

mg

NonPrefBrand-4 YESGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Ala-Cort cream 1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Albenza tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

albuterol

sulfate

tablet 2 mg PrefGen-1 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSalbuterol

sulfate

tablet 4 mg PrefGen-1 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSalbuterol

sulfate

solution for

nebulization

5

mg/mL


ALLERGY

PULMONARY

AGENTSalbuterol

sulfate

solution for

nebulization

1.25

mg/3

mL


ALLERGY

PULMONARY

AGENTS

albuterol

sulfate

solution for

nebulization

0.63

mg/3

mL


ALLERGY

PULMONARY

AGENTS

albuterol

sulfate

tablet

extended

release 12 hr

4 mg Generic-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

albuterol

sulfate

tablet

extended

release 12 hr


ALLERGY

PULMONARY

AGENTS

albuterol

sulfate

solution for

nebulization

2.5 mg

/3 mL

(0.083

%)


ALLERGY

PULMONARY

AGENTS

albuterol

sulfate

syrup 2 mg/5

mL

PrefGen-1 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSalclometasone cream 0.05 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

alclometasone ointment 0.05 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Alcohol Pads pads,

medicated

Generic-2 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Aldurazyme solution 2.9

mg/5

mL

Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Alecensa capsule 150 mg

Specialty-5

248 31

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

alendronate tablet 35 mg PrefGen-1 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

alendronate tablet 40 mg PrefGen-1 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

alendronate tablet 10 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

alendronate solution 70

mg/75

mL

PrefGen-1 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

alfuzosin tablet

extended

release 24 hr

10 mg Generic-2 NO UROLOGICALS BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPYAlimta recon soln 500 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Alinia suspension

for

reconstitution

100

mg/5

mL

NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Alinia tablet 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESallopurinol tablet 100 mg PrefGen-1 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

allopurinol tablet 300 mg PrefGen-1 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

Allzital tablet

25-325

mg

NonPrefBrand-4

372 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

almotriptan

malate

tablet 6.25 mg Generic-2 16 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYalmotriptan

malate

tablet 12.5 mg Generic-2 8 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYAlocril drops 2 % NonPrefBrand-4 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CS

alogliptin tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

alogliptin tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

alogliptin tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

alogliptin-

metformin tablet

12.5-

1,000

mg

NonPrefBrand-4 NOENDOCRINE/DIABE

TES

DIABETES

THERAPYalogliptin-

metformin tablet

12.5-

500 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYalogliptin-

pioglitazone tablet

12.5-15

mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYalogliptin-

pioglitazone tablet

12.5-30


TES

DIABETES

THERAPYalogliptin-

pioglitazone tablet

12.5-45


TES

DIABETES

THERAPYalogliptin-

pioglitazone tablet

25-15


TES

DIABETES

THERAPYalogliptin-

pioglitazone tablet

25-30


TES

DIABETES

THERAPYalogliptin-

pioglitazone tablet

25-45


TES

DIABETES

THERAPY

Alomide drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CSAloprim recon soln 500 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

alosetron tablet 1 mg Specialty-5 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSalosetron tablet 0.5 mg Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSAloxi solution 0.25

mg/5

mL

NonPrefBrand-4 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Alphagan P drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY SYMPATHOMIMETI

CSalprazolam tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet 2 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet

extended

release 24 hr

0.5 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet

extended

release 24 hr

2 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

alprazolam tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

alprazolam tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Alprazolam

Intensol

concentrate 1

mg/mL

Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Altabax ointment 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

Altoprev tablet

extended

release 24 hr

60 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Altoprev

tablet

extended

release 24 hr 20 mg

NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Altoprev

tablet

extended

release 24 hr 40 mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

amantadine

HCl

solution 50 mg/5

mL


amantadine

HCl

capsule 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

amantadine

HCl

tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

AmBisome

suspension

for

reconstitution 50 mg

NonPrefBrand-4 YES

ANTI - INFECTIVES

ANTIFUNGAL

AGENTS

amcinonide cream 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

amcinonide ointment 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

amcinonide lotion 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Amerge tablet 1 mg NonPrefBrand-4 20 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYAmerge tablet 2.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Amethia

tablets,dose

pack,3 month

0.15 mg-

30 mcg

(84)/10

mcg (7)

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Amethyst tablet

90-20

mcg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

amifostine

crystalline

recon soln 500 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

amikacin solution 500

mg/2

mL

Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

amiloride tablet 5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPYamiloride-

hydrochloroth

iazide tablet 5-50 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amino acids

15 %

parenteral

solution 15 % Generic-2

YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn 7

% with

electrolytes

parenteral

solution 7 %

NonPrefBrand-4 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn 8.5

%-

electrolytes

parenteral

solution 8.5 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Aminosyn II

10 %

parenteral

solution

10 % NonPrefBrand-4 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn II

15 %

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Aminosyn II

7 %

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn II

8.5 %

parenteral

solution

8.5 % NonPrefBrand-4 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn II

8.5 %-

electrolytes

parenteral

solution 8.5 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Aminosyn M

3.5 %

parenteral

solution

3.5 % PrefBrand-3 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn-

HBC 7%

parenteral

solution

7 % PrefBrand-3 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn-PF

10 %

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSAminosyn-PF

7 % (sulfite-

free)

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Aminosyn-RF

5.2 %

parenteral

solution 5.2 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

amiodarone tablet 200 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

amiodarone solution 50

mg/mL

Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

amiodarone tablet 400 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Amitiza capsule 24 mcg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSAmitiza capsule 8 mcg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSamitriptyline tablet 100 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

amitriptyline tablet 150 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

amitriptyline-

chlordiazepox

ide

tablet 12.5-5

mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

amitriptyline-

chlordiazepox

ide

tablet 25-10

mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

amlodipine tablet 5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

atorvastatin

tablet 5-80 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 10-80

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 10-20

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 2.5-10

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 2.5-20

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

amlodipine-

atorvastatin


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 10-10

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 10-40

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

atorvastatin

tablet 2.5-40

mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSamlodipine-

benazepril

capsule 10-20

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

benazepril

capsule 10-40

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

benazepril

capsule 2.5-10

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

benazepril

capsule 5-10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

benazepril


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

amlodipine-

benazepril


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan

tablet 10-160

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan

tablet 10-320

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan

tablet 5-160

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan

tablet 5-320

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan-

hcthiazid

tablet 10-160-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan-

hcthiazid

tablet 10-320-

25 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan-

hcthiazid

tablet 5-160-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan-

hcthiazid

tablet 5-160-

25 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

amlodipine-

valsartan-

hcthiazid

tablet 10-160-

25 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

ammonium

chloride

solution 5

mEq/m

L

NonPrefBrand-4 NO UROLOGICALS MISCELLANEOUS

UROLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ammonium

lactate

lotion 12 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSammonium

lactate

cream 12 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSamoxapine tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

amoxapine tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

amoxicil-

clarithromy-

lansopraz

combo pack 500-500-

30 mg

Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

amoxicillin suspension

for

reconstitution

250

mg/5

mL

PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

amoxicillin tablet,chewab

le

125 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

amoxicillin capsule 250 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


for

reconstitution

400

mg/5

mL


amoxicillin capsule 500 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

amoxicillin tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

amoxicillin tablet 875 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS


for

reconstitution

125

mg/5

mL



for

reconstitution

200

mg/5

mL


amoxicillin tablet,chewab

le

250 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

amoxicillin-

pot

clavulanate

tablet 250-125

mg

Generic-2 NO ANTI - INFECTIVES PENICILLINS

amoxicillin-

pot

clavulanate

tablet 875-125

mg


amoxicillin-

pot

clavulanate

tablet 500-125

mg


amoxicillin-

pot

clavulanate

tablet,chewab

le

200-

28.5 mg


amoxicillin-

pot

clavulanate

tablet,chewab

le

400-57

mg





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

amoxicillin-

pot

clavulanate

suspension

for

reconstitution

250-

62.5

mg/5

mL


amoxicillin-

pot

clavulanate

suspension

for

reconstitution

200-

28.5

mg/5

mL


amoxicillin-

pot

clavulanate

suspension

for

reconstitution

400-57

mg/5

mL


amoxicillin-

pot

clavulanate

suspension

for

reconstitution

600-

42.9

mg/5

mL


amoxicillin-

pot

clavulanate

tablet

extended

release 12 hr

1,000-

62.5 mg


amphotericin

B

recon soln 50 mg Generic-2 YES ANTI - INFECTIVES ANTIFUNGAL

AGENTSampicillin suspension

for

reconstitution

250

mg/5

mL


ampicillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS

ampicillin suspension

for

reconstitution

125

mg/5

mL


ampicillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS

ampicillin

sodium

recon soln 125 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ampicillin

sodium

recon soln 1 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS

ampicillin

sodium


ampicillin-

sulbactam


ampicillin-

sulbactam


ampicillin-

sulbactam recon soln

1.5

gramGeneric-2 NO

ANTI - INFECTIVES PENICILLINS

Ampyra tablet

extended

release 12 hr

10 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Anadrol-50 tablet 50 mg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESanagrelide capsule 0.5 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

anagrelide capsule 1 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

anastrozole tablet 1 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Androderm patch 24 hour

2 mg/24

hour PrefBrand-3YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Androderm patch 24 hour

4 mg/24

hr PrefBrand-3YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

AndroGel

gel in metered-

dose pump

20.25

mg/1.25

gram

(1.62

%) PrefBrand-3

YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

AndroGel gel in packet

1.62 %

(20.25

mg/1.25

gram) PrefBrand-3

YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES


1 % (25

mg/2.5g

ram) PrefBrand-3

YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES


1.62 %

(40.5

mg/2.5

gram) PrefBrand-3

YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES


1 % (50

mg/5

gram) PrefBrand-3

YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Android capsule 10 mg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Angeliq tablet

0.5-1

mgNonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Antara capsule 30 mg


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS



, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Anzemet tablet 50 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Anzemet tablet 100 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSAnzemet solution 100

mg/5

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

ApexiCon E cream 0.05 %

Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Apidra solution 100

unit/mL


TES

DIABETES

THERAPYApidra

SoloStar

insulin pen 100

unit/mL


TES

DIABETES

THERAPY

Aplenzin

tablet

extended

release 24 hr 174 mg

NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aplenzin

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aplenzin

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

APOKYN cartridge 10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

apraclonidine drops 0.5 % Generic-2 NO OPHTHALMOLOGY SYMPATHOMIMETI

CS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Apri tablet 0.15-

0.03 mg

Generic-2 NO OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSApriso capsule,exten

ded release

24hr

0.375

gram

PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 15 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 20 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 30 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 40 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 50 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Aptensio XR

cap,ER

sprinkle,bipha

sic 40-60 60 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aptiom tablet 200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Aptivus capsule 250 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Aptivus solution 100

mg/mL

Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Aralast NP recon soln 500 mg

Specialty-5 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Aranelle (28) tablet 0.5/1/0.

5-35 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Aranesp (in

polysorbate)

solution 25

mcg/mL

PrefBrand-3 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

solution 40

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

solution 60

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

solution 100

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

solution 200

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

solution 300

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 100

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 40

mcg/0.4

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 300

mcg/0.6

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 150

mcg/0.3

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 200

mcg/0.4

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Aranesp (in

polysorbate)

syringe 500

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 25

mcg/0.4

2 mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate)

syringe 60

mcg/0.3

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Aranesp (in

polysorbate) syringe

10

mcg/0.4

mL PrefBrand-3

YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Arava tablet 10 mg Specialty-5 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSArava tablet 20 mg Specialty-5 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Arbinoxa liquid

4 mg/5

mL

Generic-2 NORESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Arbinoxa tablet 4 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Arcalyst recon soln 220 mg Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Arimidex tablet 1 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

aripiprazole tablet 15 mg PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

aripiprazole tablet 30 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

aripiprazole tablet 20 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

aripiprazole tablet,disinteg

rating

10 mg PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

aripiprazole tablet,disinteg

rating

15 mg PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Aristada

suspension,ex

tended rel

syring

441

mg/1.6

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aristada

suspension,ex

tended rel

syring

662

mg/2.4

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aristada

suspension,ex

tended rel

syring

882

mg/3.2

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Arixtra syringe 10

mg/0.8

mL

Specialty-5 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Arixtra syringe 5

mg/0.4

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Arixtra syringe 7.5

mg/0.6

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

armodafinil tablet 150 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Aromasin tablet 25 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Arranon solution 250

mg/50

mL

NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Asacol HD tablet,delayed

release

(DR/EC)

800 mg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Ascomp with

Codeine capsule

30-50-

325-40

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Ashlyna

tablets,dose

pack,3 month

0.15 mg-

30 mcg

(84)/10

mcg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Asmanex

HFA

HFA aerosol

inhaler

100

mcg/act

uation PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Asmanex

HFA

HFA aerosol

inhaler

200

mcg/act

uation PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Asmanex

Twisthaler

aerosol powdr

breath

activated

220

mcg

(120

doses)

PrefBrand-3 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Asmanex

Twisthaler

aerosol powdr

breath

activated

220

mcg (30

doses)


ALLERGY

PULMONARY

AGENTS

Asmanex

Twisthaler

aerosol powdr

breath

activated

220

mcg (60

doses)


ALLERGY

PULMONARY

AGENTS

Asmanex

Twisthaler

aerosol powdr

breath

activated

110

mcg (30

doses)


ALLERGY

PULMONARY

AGENTS

aspirin-

dipyridamole

capsule, ER

multiphase 12

hr

25-200

mg


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Assure ID

Insulin Safety

syringe 1 mL 29

gauge x

1/2"


TES

DIABETES

THERAPY

Astagraf XL

capsule,exten

ded release

24hr 0.5 mg PrefBrand-3

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Astagraf XL

capsule,exten

ded release

24hr 1 mg PrefBrand-3

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Astagraf XL

capsule,exten

ded release

24hr 5 mg PrefBrand-3

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

atenolol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

atenolol-

chlorthalidon

e

tablet 100-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

atenolol-

chlorthalidon

e

tablet 50-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Atgam solution 50

mg/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

atorvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSatorvastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSatovaquone suspension 750

mg/5

mL

Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

atovaquone-

proguanil

tablet 250-100

mg


ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

atovaquone-

proguanil

tablet 62.5-25

mg


ANTIINFECTIVESAtralin gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

ATRIPLA tablet 600-200-

300 mg


atropine syringe

0.05

mg/mL

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

atropine syringe

0.1

mg/mL

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

atropine drops 1 %Generic-2 NO

OPHTHALMOLOGY

CYCLOPLEGIC

MYDRIATICS

Atrovent

HFA

HFA aerosol

inhaler

17

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

Aubagio tablet 14 mg

Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Aubagio tablet 7 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Augmentin suspension

for

reconstitution

125-

31.25

mg/5

mL

NonPrefBrand-4 NO ANTI - INFECTIVES PENICILLINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Auryxia tablet

210 mg

iron


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Avandia tablet 2 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYAvandia tablet 4 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYAvastin solution 25

mg/mL

Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Avastin solution

25

mg/mL

(16 mL)

Specialty-5 NOANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

AVC Vaginal cream 15 % NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYN

Aveed solution

750

mg/3

mL

(250

mg/mL)

NonPrefBrand-4 YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Avelox ABC

Pack

tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES QUINOLONES

Avelox in

NaCl (iso-

osmotic)

piggyback 400

mg/250

mL

PrefBrand-3 NO ANTI - INFECTIVES QUINOLONES

Aviane tablet 0.1-20

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Avita cream 0.025 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Avita gel 0.025 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Avonex syringe kit 30

mcg/0.5

mL

Specialty-5 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Avonex

pen injector

kit

30

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Avonex (with

albumin)

kit 30 mcg Specialty-5 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Avycaz recon soln

2.5

gramSpecialty-5 NO

ANTI - INFECTIVES CEPHALOSPORINS

Axert tablet 6.25 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYAxert tablet 12.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Axiron

solution in

metered pump

w/app

30

mg/actu

ation

(1.5

mL)

NonPrefBrand-4 YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

azacitidine recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Azactam in

dextrose (iso-

osm)

piggyback 1

gram/50

mL

PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Azactam in

dextrose (iso-

osm)

piggyback 2

gram/50

mL

PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Azasan tablet 75 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Azasan tablet 100 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Azasite drops 1 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIBIOTICS

azathioprine tablet 50 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

azathioprine

sodium

recon soln 100 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

azelastine aerosol,spray 137

mcg

(0.1 %)

Generic-2 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

azelastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CSazelastine spray,non-

aerosol

0.15 %

(205.5

mcg)


THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

Azelex cream 20 %


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Azilect tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Azilect tablet 0.5 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

azithromycin suspension

for

reconstitution

200

mg/5

mL

Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESazithromycin tablet 600 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER


OTHER

MACROLIDESazithromycin suspension

for

reconstitution

100

mg/5

mL


OTHER


OTHER

MACROLIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

azithromycin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESazithromycin tablet 250 mg

(6 pack)


OTHER

MACROLIDESazithromycin packet 1 gram Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESazithromycin recon soln 500 mg

(2

mg/ml)


OTHER

MACROLIDESAzopt drops,suspens

ion

1 % PrefBrand-3 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGSAzor tablet 10-20

mg

PrefBrand-3 31 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Azor tablet 10-40

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Azor tablet 5-20 mg PrefBrand-3 31 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Azor tablet 5-40 mg PrefBrand-3 31 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

aztreonam recon soln 1 gram Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESBACiiM recon soln 50,000

unit


ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

bacitracin ointment 500

unit/gra

m

Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS

bacitracin recon soln 50,000

unit


ANTIINFECTIVESbacitracin-

polymyxin B

ointment 500-

10,000

unit/gra

m


baclofen tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYbaclofen tablet 20 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYBactroban

Nasal

ointment 2 % PrefBrand-3 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

balsalazide capsule 750 mg Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Balziva (28) tablet

0.4-35

mg-mcg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Banzel tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Banzel tablet 400 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Banzel suspension

40

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Baraclude tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Baraclude tablet 1 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Baraclude solution 0.05

mg/mL

PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

BCG vaccine,

live (PF)

suspension

for

reconstitution

50 mg NonPrefBrand-4 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Beconase AQ spray,non-

aerosol

42 mcg

(0.042

%)

NonPrefBrand-4 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Bekyree (28) tablet

0.15-

0.02

mgx21

/0.01

mg x 5 Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Belbuca film

150

mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Belbuca film

300

mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Belbuca film

450

mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Belbuca film

600

mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Belbuca film 75 mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Belbuca film

750

mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Belbuca film

900

mcg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Beleodaq recon soln 500 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

benazepril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

benazepril-

hydrochloroth

iazide

tablet 10-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

benazepril-

hydrochloroth

iazide

tablet 20-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

benazepril-

hydrochloroth

iazide

tablet 20-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

benazepril-

hydrochloroth

iazide

tablet 5-6.25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Benicar tablet 5 mg PrefBrand-3 93 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Benicar HCT tablet 40-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Benicar HCT tablet 40-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Benicar HCT tablet 20-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Benlysta recon soln 120 mg

NonPrefBrand-4 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


Specialty-5 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

benztropine solution 2 mg/2

mL

Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

benztropine tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

benztropine tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

benztropine tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Berinert kit 500 unit

(10 mL)

Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSBesivance drops,suspens

ion

0.6 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIBIOTICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

betamethason

e

dipropionate

ointment 0.05 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e

dipropionate

cream 0.05 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e

dipropionate

lotion 0.05 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e valerate


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e valerate


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e valerate


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e valerate foam 0.12 %

PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e, augmented

cream 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e, augmented

lotion 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e, augmented

ointment 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

betamethason

e, augmented

gel 0.05 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Betaseron kit 0.3 mg Specialty-5 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

betaxolol drops 0.5 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS

betaxolol tablet 10 mg Generic-2

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

betaxolol tablet 20 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bethanechol

chloride

tablet 10 mg Generic-2 NO UROLOGICALS CHOLINERGIC

STIMULANTSbethanechol

chloride



chloride



chloride


STIMULANTS

Bethkis

solution for

nebulization

300

mg/4

mL

NonPrefBrand-4 YES

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

Betimol drops 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS

Betimol drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS

Betoptic S drops,suspens

ion

0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS

bexarotene capsule 75 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Bexsero (PF) syringe

50-50-

50-25

mcg/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Beyaz tablet

3-0.02-

0.451

mg (24)

NonPrefBrand-4 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

bicalutamide tablet 50 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Bicillin C-R syringe 1,200,0

00 unit/

2

mL(600

k/600k)

PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS

Bicillin C-R syringe 1,200,0

00 unit/

2

mL(900

k/300k)


Bicillin L-A syringe 600,000

unit/mL


Bicillin L-A syringe 1,200,0

00

unit/2

mL


Bicillin L-A syringe 2,400,0

00

unit/4

mL





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

BiCNU recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

BiDil tablet 20-37.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Biltricide tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESbimatoprost drops 0.03 % Generic-2 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGSbisoprolol

fumarate

tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bisoprolol

fumarate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bisoprolol-

hydrochloroth

iazide

tablet 10-6.25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bisoprolol-

hydrochloroth

iazide

tablet 2.5-6.25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bisoprolol-

hydrochloroth

iazide

tablet 5-6.25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Bivigam solution 10 %

Specialty-5 YESIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

bleomycin recon soln 30 unit Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Bleph-10 drops 10 %NonPrefBrand-4 NO

OPHTHALMOLOGY SULFONAMIDES

Blephamide

drops,suspens

ion

10-0.2

% PrefBrand-3

NO

OPHTHALMOLOGY

STEROID-

SULFONAMIDE

COMBINATIONS

Blephamide

S.O.P. ointment

10-0.2

% PrefBrand-3

NO

OPHTHALMOLOGY

STEROID-

SULFONAMIDE

COMBINATIONS

Blisovi 24 Fe tablet

1 mg-20

mcg

(24)/75

mg (4) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Blisovi Fe

1.5/30 (28) tablet

1.5 mg-

30 mcg

(21)/75

mg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Blisovi Fe

1/20 (28) tablet

1 mg-20

mcg

(21)/75

mg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Boniva syringe 3 mg/3

mL

NonPrefBrand-4 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

Boostrix

Tdap syringe

2.5-8-5

Lf-mcg-

Lf/0.5m

L

NonPrefBrand-4 NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Boostrix

Tdap suspension

2.5-8-5

Lf-mcg-

Lf/0.5m

L


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Bosulif tablet 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Botox recon soln 100 unit NonPrefBrand-4 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Botox recon soln 200 unit NonPrefBrand-4 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Breo Ellipta

blister with

device

100-25

mcg/dos

e

NonPrefBrand-4

60 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Breo Ellipta

blister with

device

200-25

mcg/dos

e

NonPrefBrand-4

60 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Briellyn tablet

0.4-35

mg-mcg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Brilinta tablet 90 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Brilinta tablet 60 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

brimonidine drops 0.2 % Generic-2 NO OPHTHALMOLOGY SYMPATHOMIMETI

CSbrimonidine drops 0.15 % Generic-2 NO OPHTHALMOLOGY SYMPATHOMIMETI

CS

Brisdelle capsule 7.5 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Briviact solution

50 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Briviact tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Briviact solution

10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

bromfenac drops 0.09 % Generic-2 NO OPHTHALMOLOGY NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTSbromocriptine tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

bromocriptine capsule 5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Brovana solution for

nebulization

15

mcg/2

mL

NonPrefBrand-4 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

budesonide suspension

for

nebulization

1 mg/2

mL


ALLERGY

PULMONARY

AGENTS


for

nebulization

0.25

mg/2

mL


ALLERGY

PULMONARY

AGENTS


for

nebulization

0.5

mg/2

mL


ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

budesonide spray,non-

aerosol

32

mcg/act

uation

Generic-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

budesonide

capsule,delay

ed,extend.rele

ase 3 mg

NonPrefBrand-4 NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

bumetanide tablet 0.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bumetanide tablet 1 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bumetanide tablet 2 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

bumetanide solution 0.25

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Bunavail film

2.1-0.3

mg

NonPrefBrand-4

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Bunavail film

4.2-0.7

mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Bunavail film

6.3-1

mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Bupap tablet

50-300

mg

NonPrefBrand-4

403 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Buphenyl tablet 500 mg Specialty-5 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Buphenyl powder

0.94

gram/gr

am


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Buprenex solution 0.3

mg/mL

NonPrefBrand-4 267 30 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

buprenorphin

e HCl

syringe 0.3

mg/mL

PrefGen-1 267 30 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

buprenorphin

e HCl

tablet 2 mg Generic-2 15 60 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

buprenorphin

e HCl


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

buprenorphin

e-naloxone

tablet 2-0.5

mg

Generic-2 93 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

buprenorphin

e-naloxone

tablet 8-2 mg Generic-2 93 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Buproban

tablet

extended

release 150 mg

Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS

bupropion

HCl

tablet

extended

release 100 mg

PrefBrand-3

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

bupropion

HCl

tablet

extended

release 150 mg

PrefBrand-3

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

bupropion

HCl

tablet

extended

release 200 mg

PrefBrand-3

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

bupropion

HCl

tablet

extended


Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

bupropion

HCl

tablet

extended


Generic-2

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

bupropion

HCl tablet 100 mg

PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

bupropion

HCl tablet 75 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

buspirone tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

buspirone tablet 30 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

buspirone tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Busulfex solution 60

mg/10

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Butalbital

Compound

W/Codeine capsule

30-50-

325-40

mg

Generic-2

372 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

butalbital-

acetaminop-

caf-cod capsule

50-325-

40-30

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

butalbital-

acetaminop-

caf-cod capsule

50-300-

40-30

mg Generic-2 403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

butalbital-

acetaminophe

n

tablet 50-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

butalbital-

acetaminophe

n-caff

capsule 50-325-

40 mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

butalbital-

acetaminophe

n-caff

tablet 50-325-

40 mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

butalbital-

acetaminophe

n-caff

capsule 50-300-

40 mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

butalbital-

aspirin-

caffeine

capsule 50-325-

40 mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Butisol tablet 30 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

butorphanol

tartrate

solution 2

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

butorphanol

tartrate

solution 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

butorphanol

tartrate

spray,non-

aerosol

10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Butrans patch weekly 10

mcg/ho

ur

NonPrefBrand-4 4 28 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/ho

ur


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/ho

ur


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Butrans patch weekly

15

mcg/ho

ur

NonPrefBrand-4

4 28

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Butrans patch weekly

7.5

mcg/ho

ur

NonPrefBrand-4

4 28

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Bydureon

suspension,ex

tended rel

recon 2 mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Bydureon pen injector

2

mg/0.65

mL PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Bystolic tablet 10 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Bystolic tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

cabergoline tablet 0.5 mg Generic-2 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Cabometyx tablet 20 mg

Specialty-5

31 31

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


Specialty-5

31 31

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


Specialty-5

31 31

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cafergot tablet

1-100

mg


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

calcipotriene ointment 0.005 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

calcipotriene solution 0.005 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

calcipotriene cream 0.005 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

calcipotriene-

betamethason

e

ointment 0.005-

0.064 %


LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

calcitonin

(salmon)

spray,non-

aerosol

200

unit/act

uation


TES

MISCELLANEOUS

HORMONES

calcitriol capsule 0.25

mcg

Generic-2 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONEScalcitriol capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONEScalcitriol solution 1

mcg/mL


TES

MISCELLANEOUS

HORMONEScalcitriol solution 1

mcg/mL


TES

MISCELLANEOUS

HORMONEScalcitriol ointment 3

mcg/gra

m


LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

calcium

acetate

capsule 667 mg Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cambia powder in

packet

50 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Camila tablet 0.35 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSCanasa suppository 1,000

mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSCancidas recon soln 70 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSCancidas recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTScandesartan tablet 4 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

candesartan tablet 8 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

candesartan-

hydrochloroth

iazid

tablet 16-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

candesartan-

hydrochloroth

iazid

tablet 32-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

candesartan-

hydrochloroth

iazid

tablet 32-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Capastat recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Capex shampoo 0.01 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Capital with

Codeine suspension

120-12

mg/5

mL

PrefBrand-3

5167 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Caprelsa tablet 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

captopril tablet 100 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

captopril tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

captopril-

hydrochloroth

iazide

tablet 25-15

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

captopril-

hydrochloroth

iazide

tablet 25-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

captopril-

hydrochloroth

iazide

tablet 50-15

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

captopril-

hydrochloroth

iazide

tablet 50-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Carac cream 0.5 % Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSCarafate suspension 100

mg/mL


OGY

ULCER THERAPY

Carbaglu tablet,

dispersible

200 mg Specialty-5 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

carbamazepin

e

capsule, ER

multiphase 12

hr

300 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

capsule, ER

multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

tablet

extended

release 12 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

carbamazepin

e

tablet,chewab

le

100 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

suspension 100

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

capsule, ER

multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

tablet

extended

release 12 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbamazepin

e

tablet

extended

release 12 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Carbatrol capsule, ER

multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

carbidopa tablet 25 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet 10-100

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet 25-100

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet 25-250

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet

extended

release

25-100

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet

extended

release

50-200

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet,disinteg

rating

25-100

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

carbidopa-

levodopa

tablet,disinteg

rating

25-250

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa

tablet,disinteg

rating

10-100

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa-

entacapone

tablet 12.5-50-

200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa-

entacapone

tablet 25-100-

200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa-

entacapone

tablet 37.5-

150-200

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa-

entacapone

tablet 50-200-

200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa-

entacapone

tablet 31.25-

125-200

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

carbidopa-

levodopa-

entacapone

tablet 18.75-

75-200

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

carboplatin solution 10

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cardene IV in

sodium

chloride

piggyback 40

mg/200

mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Cardizem LA tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Carimune NF

Nanofiltered

recon soln 6 gram Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

carisoprodol-

ASA-codeine tablet

200-325-

16 mg


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY

Carnitor solution 100

mg/mL

NonPrefBrand-4 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Carnitor solution 200

mg/mL

NonPrefBrand-4 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Carnitor tablet 330 mg NonPrefBrand-4 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

carteolol drops 1 %Generic-2 NO

OPHTHALMOLOGY BETA-BLOCKERS

Cartia XT capsule,exten

ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

carvedilol tablet 6.25 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

carvedilol tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

carvedilol tablet 25 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

carvedilol tablet 3.125

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Casodex tablet 50 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cayston solution for

nebulization

75

mg/mL


ANTIINFECTIVEScefaclor capsule 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefaclor suspension

for

reconstitution

375

mg/5

mL

Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cefaclor tablet

extended

release 12 hr

500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefaclor suspension

for

reconstitution

125

mg/5

mL


cefaclor capsule 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefaclor suspension

for

reconstitution

250

mg/5

mL


cefadroxil suspension

for

reconstitution

500

mg/5

mL


cefadroxil tablet 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefadroxil suspension

for

reconstitution

250

mg/5

mL


cefadroxil capsule 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefazolin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefazolin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefazolin recon soln 1 gram Generic-2NO


cefazolin in

dextrose (iso-

os)

piggyback 1

gram/50

mL


cefdinir capsule 300 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cefdinir suspension

for

reconstitution

125

mg/5

mL


cefdinir suspension

for

reconstitution

250

mg/5

mL


cefepime recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefepime recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefepime in

dextrose 5 %

piggyback 1

gram/50

mL

NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS

cefepime in

dextrose 5 %

piggyback 2

gram/50

mL


cefixime suspension

for

reconstitution

100

mg/5

mL


cefixime suspension

for

reconstitution

200

mg/5

mL


cefotaxime recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefotaxime recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefotaxime recon soln 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefotetan recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


cefoxitin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS



cefoxitin in

dextrose, iso-

osm

piggyback 1

gram/50

mL


cefoxitin in

dextrose, iso-

osm

piggyback 2

gram/50

mL


cefpodoxime tablet 100 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefpodoxime suspension

for

reconstitution

100

mg/5

mL


cefpodoxime tablet 200 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefpodoxime suspension

for

reconstitution

50 mg/5

mL


cefprozil tablet 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefprozil tablet 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefprozil suspension

for

reconstitution

125

mg/5

mL





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cefprozil suspension

for

reconstitution

250

mg/5

mL


ceftazidime recon soln 6 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS



ceftazidime in

D5W

piggyback 1

gram/50

mL


ceftazidime in

D5W

piggyback 2

gram/50

mL


Ceftin suspension

for

reconstitution

125

mg/5

mL


Ceftin suspension

for

reconstitution

250

mg/5

mL


ceftriaxone recon soln 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

ceftriaxone recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS


ceftriaxone recon soln 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS


cefuroxime

axetil

tablet 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cefuroxime

axetil

tablet 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cefuroxime

sodium

recon soln 1.5

gram


cefuroxime

sodium

recon soln 7.5

gram


cefuroxime

sodium recon soln 750 mgGeneric-2 NO


celecoxib capsule 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

CellCept tablet 500 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

CellCept suspension

for

reconstitution

200

mg/mL

Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

CellCept capsule 250 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

CellCept

Intravenous

recon soln 500 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Celontin capsule 300 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

cephalexin tablet 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cephalexin suspension

for

reconstitution

125

mg/5

mL


cephalexin capsule 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS

cephalexin suspension

for

reconstitution

250

mg/5

mL



cephalexin tablet 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS


Cerdelga capsule 84 mgSpecialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cerebyx solution 500 mg

PE/10

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Cerezyme recon soln 400 unit Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Cervarix

Vaccine (PF) syringe

20-20

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Cesamet capsule 1 mg NonPrefBrand-4 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

cetirizine solution

1

mg/mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

cevimeline capsule 30 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Chantix tablet 0.5 mg NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS

Chantix tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS

Chantix

Continuing

Month Box

tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS

Chantix

Starting

Month Box

tablets,dose

pack

0.5 mg

(11)- 1

mg (42)

NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Chemet capsule 100 mg PrefBrand-3 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Chenodal tablet 250 mg Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSchlorampheni

col sod

succinate

recon soln 1 gram Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

chlordiazepox

ide HCl

capsule 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlordiazepox

ide HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlordiazepox

ide HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorhexidine

gluconate

mouthwash 0.12 % PrefGen-1 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

chloroquine

phosphate tablet 500 mgGeneric-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVESchloroquine

phosphate tablet 250 mgGeneric-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

chlorothiazid

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

chlorothiazid

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

chlorothiazid

e sodium

recon soln 500 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

chlorpromazi

ne tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorpromazi

ne tablet 100 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorpromazi

ne tablet 200 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorpromazi

ne tablet 25 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorpromazi

ne solution

25

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorpromazi

ne tablet 50 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

chlorthalidon

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

chlorthalidon

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Cholbam capsule 250 mg

Specialty-5 YESGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS



OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Cholestyrami

ne Light

powder in

packet

4 gram Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSchorionic

gonadotropin,

human

recon soln 10,000

unit


TES

MISCELLANEOUS

HORMONES

Cialis tablet 5 mg NonPrefBrand-4 31 31 YES UROLOGICALS MISCELLANEOUS

UROLOGICALSCialis tablet 2.5 mg NonPrefBrand-4 62 31 YES UROLOGICALS MISCELLANEOUS

UROLOGICALSciclopirox shampoo 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

ciclopirox cream 0.77 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

ciclopirox suspension 0.77 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

ciclopirox solution 8 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ciclopirox gel 0.77 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

cidofovir solution 75

mg/mL


cilostazol tablet 100 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

cilostazol tablet 50 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Ciloxan ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY ANTIBIOTICS

cimetidine tablet 200 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY


OGY

ULCER THERAPY


OGY

ULCER THERAPY


OGY

ULCER THERAPY

cimetidine

HCl

solution 300

mg/5

mL


OGY

ULCER THERAPY

Cimzia syringe kit 400

mg/2

mL

(200

mg/mL

x 2)

Specialty-5 2 28 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cimzia

Powder for

Reconst

kit 400 mg

(200 mg

x 2

vials)

Specialty-5 6 28 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Cinryze recon soln 500 unit

(5 mL)


ALLERGY

PULMONARY

AGENTSCipro HC drops,suspens

ion

0.2-1 % NonPrefBrand-4 NO EAR, NOSE /

THROAT

MEDICATIONS

OTIC STEROID /

ANTIBIOTIC

Ciprodex drops,suspens

ion

0.3-0.1

%

PrefBrand-3 NO EAR, NOSE /

THROAT

MEDICATIONS

OTIC STEROID /

ANTIBIOTIC

ciprofloxacin suspension,mi

crocapsule

recon

250

mg/5

mL

Generic-2 NO ANTI - INFECTIVES QUINOLONES

ciprofloxacin suspension,mi

crocapsule

recon

500

mg/5

mL


ciprofloxacin

(mixture)

tablet, ER

multiphase 24

hr

500 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES

ciprofloxacin

(mixture)

tablet, ER

multiphase 24

hr

1,000

mg


ciprofloxacin

HCl

tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES QUINOLONES

ciprofloxacin

HCl


ciprofloxacin

HCl


ciprofloxacin

HCl

drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY ANTIBIOTICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ciprofloxacin

HCl


ciprofloxacin

in 5 %

dextrose

piggyback 200

mg/100

mL


ciprofloxacin

lactate solution

400

mg/40

mL

PrefGen-1 NO

ANTI - INFECTIVES QUINOLONES

cisplatin solution 1

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

citalopram tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

citalopram solution 10 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

cladribine solution 10

mg/10

mL

Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Claforan recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS

Claravis capsule 10 mg Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Clarinex-D

12 HOUR

tablet, ER

multiphase 12

hr

2.5-120

mg

NonPrefBrand-4 NORESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

clarithromyci

n

tablet 250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESclarithromyci

n


OTHER


n

suspension

for

reconstitution

125

mg/5

mL


OTHER


n

suspension

for

reconstitution

250

mg/5

mL


OTHER


n

tablet

extended

release 24 hr

500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cleocin capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESCleocin suppository 100 mg NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNClimara Pro patch weekly 0.045-

0.015

mg/24

hr

NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

clindamycin

HCl

capsule 150 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESclindamycin

HCl



HCl



in 5 %

dextrose

piggyback 600

mg/50

mL


ANTIINFECTIVES

clindamycin

in 5 %

dextrose

piggyback 900

mg/50

mL


ANTIINFECTIVES

clindamycin

in 5 %

dextrose

piggyback 300

mg/50

mL


ANTIINFECTIVES

Clindamycin

Pediatric

recon soln 75 mg/5

mL



phosphate

lotion 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

clindamycin

phosphate

solution 600

mg/4

mL


ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

clindamycin

phosphate

gel 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

clindamycin

phosphate

solution 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

clindamycin

phosphate

cream 2 % Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNclindamycin

phosphate

foam 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

clindamycin

phosphate

swab 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

clindamycin-

benzoyl

peroxide

gel 1-5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Clindesse cream,extend

ed release

2 % NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNClinimix

5%/D15W

Sulfite Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix

5%/D25W

sulfite-free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix

2.75%/D5W

Sulfit Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix

4.25%/D10W

Sulf Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Clinimix

4.25%/D5W

Sulfit Free

parenteral

solution

4.25 % PrefBrand-3 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Clinimix

4.25%-D20W

sulf-free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Clinimix

4.25%-D25W

sulf-free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Clinimix 5%-

D20W(sulfite-

free)

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix E

2.75%/D10W

Sul Free

parenteral

solution

2.75 % NonPrefBrand-4 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Clinimix E

2.75%/D5W

Sulf Free

parenteral

solution

2.75 % NonPrefBrand-4 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Clinimix E

4.25%/D10W

Sul Free

parenteral

solution 4.25 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Clinimix E

4.25%/D25W

Sul Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix E

4.25%/D5W

Sulf Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix E

5%/D15W

Sulfit Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Clinimix E

5%/D20W

Sulfit Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinimix E

5%/D25W

Sulfit Free

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSClinisol SF

15 %

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSclobetasol foam 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol gel 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol ointment 0.05 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol solution 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol shampoo 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol lotion 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol spray,non-

aerosol

0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

clobetasol-

emollient

cream 0.05 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Clodan shampoo 0.05 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Cloderm cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Clolar solution 20

mg/20

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

clomipramine capsule 25 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clonazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

clonazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

clonazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

clonazepam tablet,disinteg

rating

0.125

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating

0.25 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

clonidine patch weekly

0.1

mg/24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


0.2

mg/24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


0.3

mg/24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

clonidine HCl tablet 0.1 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

clonidine HCl

tablet

extended

release 12 hr 0.1 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clopidogrel tablet 75 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

clopidogrel tablet 300 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

clorazepate

dipotassium

tablet 15 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clorazepate

dipotassium

tablet 3.75 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clorazepate

dipotassium


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Clorpres tablet 0.1-15

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


mg

PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

clotrimazole cream 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

clotrimazole solution 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

clotrimazole troche 10 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSclotrimazole-

betamethason

e

cream 1-0.05

%


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

clotrimazole-

betamethason

e

lotion 1-0.05

%


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

clozapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clozapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

clozapine tablet 200 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clozapine tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clozapine tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clozapine

tablet,disinteg

rating 200 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

clozapine

tablet,disinteg

rating 150 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Clozaril tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Clozaril tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Coartem tablet 20-120

mg


ANTIINFECTIVES

codeine

sulfate tablet 15 mg

Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

codeine


Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

codeine


Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

colchicine tablet 0.6 mg NonPrefBrand-4 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

colchicine capsule 0.6 mg


AL /

RHEUMATOLOGY GOUT THERAPY

colchicine-

probenecid

tablet 0.5-500

mg

Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

Colcrys tablet 0.6 mg PrefBrand-3 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

colestipol tablet 1 gram


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

colestipol granules 5 gram


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTScolistin

(colistimethat

e Na) recon soln 150 mg

Generic-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

Colocort enema 100

mg/60

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSColy-Mycin S drops,suspens

ion

3.3-3-10-

0.5

mg/mL

NonPrefBrand-4 NO EAR, NOSE /

THROAT

MEDICATIONS

OTIC STEROID /

ANTIBIOTIC

Combigan drops 0.2-0.5

%

PrefBrand-3 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGSCombivir tablet 150-300

mg


Cometriq capsule

140

mg/day(

80 mg

x1-20

mg x3)

Specialty-5 YES

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cometriq capsule

100

mg/day(

80 mg

x1-20

mg x1)

Specialty-5 YES

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cometriq capsule

60

mg/day

(20 mg

x 3/day)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Complera tablet

200-25-

300 mgSpecialty-5 NO

ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Compro suppository 25 mg Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSCondylox gel 0.5 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSConstulose solution 10

gram/15

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Copaxone syringe

20

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Copaxone syringe

40

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Copegus tablet 200 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Cordran Tape

Large Roll

tape 4

mcg/cm

2

PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Corlanor tablet 5 mg

NonPrefBrand-4 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS

Corlanor tablet 7.5 mg


, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS

Cormax solution 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

cortisone tablet 25 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cortisporin ointment 1 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

Cortisporin cream

3.5-

10,000-

0.5

mg/g-

unit/g-

% PrefBrand-3

NO

DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

Cosentyx syringe

150

mg/mL

Specialty-5

2 28

YES DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Cosentyx Pen pen injector

150

mg/mL

Specialty-5

2 28

YES DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Cotellic tablet 20 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Coumadin tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Coumadin tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Coumadin tablet 7.5 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Creon capsule,delay

ed

release(DR/E

C)

24,000-

76,000 -

120,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Creon capsule,delay

ed

release(DR/E

C)

6,000-

19,000 -

30,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Creon capsule,delay

ed

release(DR/E

C)

12,000-

38,000 -

60,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Creon

capsule,delay

ed

release(DR/E

C)

3,000-

9,500-

15,000

unit PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Creon

capsule,delay

ed

release(DR/E

C)

36,000-

114,000-

180,000

unit PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Cresemba capsule 186 mgSpecialty-5 NO

ANTI - INFECTIVES

ANTIFUNGAL

AGENTS

Cresemba recon soln 372 mgSpecialty-5 NO

ANTI - INFECTIVES

ANTIFUNGAL

AGENTS

Crestor tablet 40 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSCrestor tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Crinone gel 8 %NonPrefBrand-4 YES OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS


GYNECOLOGY

ESTROGENS /

PROGESTINS

Crixivan capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Crixivan capsule 400 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

cromolyn drops 4 % Generic-2 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cromolyn solution for

nebulization

20 mg/2

mL


ALLERGY

PULMONARY

AGENTScromolyn concentrate 100

mg/5

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSCryselle (28) tablet 0.3-30

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSCubicin recon soln 500 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESCuprimine capsule 250 mg Specialty-5 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSCutivate lotion 0.05 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Cuvposa solution

1 mg/5

mL (0.2

mg/mL)

NonPrefBrand-4 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

Cyclafem

1/35 (28) tablet

1-35 mg-

mcg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Cyclafem

7/7/7 (28) tablet

0.5/0.75

/1 mg-

35 mcg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

cyclobenzapri

ne

tablet 7.5 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cyclobenzapri

ne

tablet 5 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYcyclobenzapri

ne


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY

cyclophospha

mide capsule 25 mg

NonPrefBrand-4 YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyclophospha

mide capsule 50 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cycloset tablet 0.8 mg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYcyclosporine capsule 25 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyclosporine solution 250

mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyclosporine capsule 100 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

cyclosporine

modified

capsule 100 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyclosporine

modified

solution 100

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyclosporine

modified


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyclosporine

modified


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cyproheptadi

ne

syrup 2 mg/5

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTScyproheptadi

ne

tablet 4 mg Generic-2 NO RESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Cyramza solution

10

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cyramza solution

10

mg/mL

(50 mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cystadane powder 1

gram/1.

7 mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Cystagon capsule 150 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS

UROLOGICALSCystagon capsule 50 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS

UROLOGICALS

Cystaran drops 0.44 %

Specialty-5 NO

OPHTHALMOLOGY

MISCELLANEOUS

OPHTHALMOLOGI

CS

cytarabine solution 20

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

cytarabine

(PF)

solution 2

gram/20

mL

(100

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Cytovene recon soln 500 mg NonPrefBrand-4 YES ANTI - INFECTIVES ANTIVIRALS

D10 %-0.45

% sodium

chloride

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

D2.5 %-0.45

% sodium

chloride

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

D5 % and 0.9

% sodium

chloride

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

D5 %-0.45 %

sodium

chloride

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dacarbazine recon soln 200 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Dacogen recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Daklinza tablet 30 mgSpecialty-5

28 28YES



28 28YES



28 28YES


Daliresp tablet

500

mcg PrefBrand-3NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Dalvance solution 500 mgSpecialty-5 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

danazol capsule 100 mg Generic-2 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESdanazol capsule 200 mg Generic-2 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESdanazol capsule 50 mg Generic-2 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESdantrolene capsule 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYdantrolene capsule 25 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dantrolene capsule 50 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYdapsone tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESdapsone tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Daptacel

(DTaP

Pediatric)

(PF) suspension

15-10-5

Lf-mcg-

Lf/0.5m

L

NonPrefBrand-4 NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Daraprim tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESdarifenacin tablet

extended

release 24 hr

15 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

darifenacin tablet

extended

release 24 hr

7.5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

Darzalex solution

20

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

daunorubicin solution 5

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Daytrana patch 24 hour 10 mg/9

hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

DDAVP solution 0.1

mg/mL

(refriger

ate)


TES

MISCELLANEOUS

HORMONES

decitabine recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Delzicol

capsule,delay

ed

release(DR/E

C) 400 mg PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

demeclocycli

ne

tablet 150 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

demeclocycli

ne





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Demser capsule 250 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Denavir cream 1 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIVIRALS

Depacon solution

500

mg/5

mL

(100

mg/mL)

NonPrefBrand-4 NOAUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakene capsule 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakene solution

250

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakote

tablet,delayed

release

(DR/EC) 125 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakote

tablet,delayed

release

(DR/EC) 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakote

tablet,delayed

release

(DR/EC) 500 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Depakote ER

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakote ER

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depakote

Sprinkles

capsule,

sprinkle 125 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Depen

Titratabs

tablet 250 mg Specialty-5 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSDepo-

Estradiol

oil 5

mg/mL


GYNECOLOGY

ESTROGENS /

PROGESTINS

Depo-Medrol suspension

20

mg/mLNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES


40


TES

ADRENAL

HORMONES


80


TES

ADRENAL

HORMONES

Depo-Provera solution

400

mg/mLNonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Depo-

Testosterone

oil 100

mg/mL

NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESDepo-

Testosterone

oil 200

mg/mL


TES

MISCELLANEOUS

HORMONES

Descovy tablet

200-25

mgSpecialty-5 NO





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

desipramine tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

desloratadine tablet 5 mg Generic-2 NO RESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSdesloratadine tablet,disinteg

rating


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSdesloratadine tablet,disinteg

rating

2.5 mg Generic-2 NO RESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

desmopressin tablet 0.2 mg Generic-2 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESdesmopressin solution 4

mcg/mL


TES

MISCELLANEOUS

HORMONESdesmopressin spray,non-

aerosol

10

mcg/spr

ay (0.1

mL)


TES

MISCELLANEOUS

HORMONES

desmopressin tablet 0.1 mg Generic-2 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESdesmopressin solution 0.1

mg/mL

(refriger

ate)


TES

MISCELLANEOUS

HORMONES

Desonate gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desonide lotion 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desonide ointment 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desonide cream 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desoximetaso

ne


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desoximetaso

ne


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

desoximetaso

ne


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desoximetaso

ne


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desoximetaso

ne

gel 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

desvenlafaxin

e

tablet

extended

release 24 hr

100 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

desvenlafaxin

e

tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexamethaso

ne

tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONESdexamethaso

ne

tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONESdexamethaso

ne


TES

ADRENAL

HORMONESdexamethaso

ne


TES

ADRENAL

HORMONESdexamethaso

ne


TES

ADRENAL

HORMONESdexamethaso

ne


TES

ADRENAL

HORMONESdexamethaso

ne

elixir 0.5

mg/5

mL

PrefGen-1 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dexamethaso

ne


TES

ADRENAL

HORMONESDexamethaso

ne Intensol

drops 1

mg/mL


TES

ADRENAL

HORMONESdexamethaso

ne sodium

phosphate

drops 0.1 % Generic-2 NO OPHTHALMOLOGY STEROIDS

dexamethaso

ne sodium

phosphate

solution 10

mg/mL


TES

ADRENAL

HORMONES

dexamethaso

ne sodium

phosphate solution

4

mg/mL

Generic-2 NOENDOCRINE/DIABE

TES

ADRENAL

HORMONES

Dexedrine tablet 5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Dexedrine tablet 10 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate

capsule,ER

biphasic 50-

50


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate

capsule,ER

biphasic 50-

50


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate

capsule,ER

biphasic 50-

50


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dexmethylphe

nidate

capsule,ER

biphasic 50-

50


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate

capsule,ER

biphasic 50-

50


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dexmethylphe

nidate

capsule,ER

biphasic 50-

50 40 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

DexPak 13

Day

tablets,dose

pack

1.5 mg

(51

tabs)


TES

ADRENAL

HORMONES

dexrazoxane

HCl


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dextroamphet

amine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine

capsule,

extended

release


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine

capsule,

extended

release


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine

capsule,

extended

release


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

tablet 5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dextroamphet

amine-

amphetamine

tablet 15 mg PrefGen-1 62 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

tablet 12.5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

capsule,exten

ded release

24hr

10 mg Generic-2 31 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine

capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dextroamphet

amine-

amphetamine

capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextroamphet

amine-

amphetamine tablet 7.5 mg

PrefGen-1

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

dextrose 10

% and 0.2 %

NaCl

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

dextrose 10

% in water

(D10W)

parenteral

solution

10 % Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

dextrose 5 %

in water

(D5W)

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

dextrose 5 %-

lactated

ringers

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

dextrose 5%-

0.2 % sod

chloride

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

dextrose 5%-

0.3 %

sod.chloride

parenteral

solution


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Dextrose

With Sodium

Chloride

parenteral

solution

5-0.2 % Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Dextrose-KCl-

NaCl

solution 5-0.224-

0.225 %

Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Diastat kit 2.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Diastat

AcuDial

kit 5-7.5-10

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Diastat

AcuDial

kit 12.5-15-

17.5-20

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

diazepam tablet 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

diazepam solution 5 mg/5

mL (1

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

diazepam kit 2.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

diazepam kit 5-7.5-10

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

diazepam kit 12.5-15-

17.5-20

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Diazepam

Intensol

concentrate 5

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Dibenzyline capsule 10 mg Specialty-5 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

diclofenac

potassium


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac

sodium

drops 0.1 % PrefGen-1 NO OPHTHALMOLOGY NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTSdiclofenac

sodium

gel 1 % Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac

sodium

gel 3 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

diclofenac

sodium

tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac

sodium

tablet,delayed

release

(DR/EC)


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac

sodium

tablet,delayed

release

(DR/EC)


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac

sodium

tablet,delayed

release

(DR/EC)


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac

sodium

drops 1.5 % Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac-

misoprostol

tablet,IR,dela

yed

rel,biphasic

50-200

mg-mcg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

diclofenac-

misoprostol

tablet,IR,dela

yed

rel,biphasic

75-200

mg-mcg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

dicloxacillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS

dicloxacillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dicyclomine capsule 10 mg

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

dicyclomine solution

10

mg/mL

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

dicyclomine solution

10 mg/5

mL

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

dicyclomine tablet 20 mg

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

didanosine capsule,delay

ed

release(DR/E

C)

125 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS


ed

release(DR/E

C)



ed

release(DR/E

C)



ed

release(DR/E

C)





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Differin lotion 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Dificid tablet 200 mg

Specialty-5 NO

ANTI - INFECTIVES

ERYTHROMYCINS /

OTHER

MACROLIDES

diflorasone cream 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

diflorasone ointment 0.05 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

diflunisal tablet 500 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Digitek tablet 125

mcg

PrefGen-1 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

Digitek tablet 250

mcg

Generic-2 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

digoxin solution 250

mcg/mL


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

digoxin tablet 125

mcg

PrefGen-1 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

digoxin tablet 250

mcg


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

digoxin solution 50

mcg/mL


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

dihydroergota

mine

spray,non-

aerosol

0.5

mg/pum

p act. (4

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

dihydroergota

mine

solution 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYDilantin capsule 30 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Dilantin

Extended

capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Dilantin

Infatabs

tablet,chewab

le 50 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Dilantin-125 suspension

125

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Dilaudid liquid 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Dilaudid tablet 2 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

diltiazem HCl capsule,

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

diltiazem HCl capsule,exten

ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release 12

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release 12

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ded release 12

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

diltiazem HCl tablet 120 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

diltiazem HCl recon soln 100 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

diltiazem HCl solution 5

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

DILT-XR capsule,ext

release

degradable


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

DILT-XR capsule,ext

release

degradable


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

DILT-XR capsule,ext

release

degradable


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Dipentum capsule 250 mg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

diphenhydra

mine HCl solution

50

mg/mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

diphenoxylate-

atropine liquid

2.5-

0.025

mg/5

mL

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

diphenoxylate-

atropine tablet

2.5-

0.025

mg

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

disulfiram tablet 250 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

disulfiram tablet 500 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Diuril suspension 250

mg/5

mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

divalproex

tablet

extended

release 24 hr 250 mg PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

divalproex

tablet

extended


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

divalproex

capsule,

sprinkle 125 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

divalproex

tablet,delayed

release

(DR/EC) 125 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

divalproex

tablet,delayed

release

(DR/EC) 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

divalproex

tablet,delayed

release

(DR/EC) 500 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Divigel gel in packet 0.5 mg

(0.1 %)


GYNECOLOGY

ESTROGENS /

PROGESTINS

Docefrez recon soln 20 mg

NonPrefBrand-4 NOANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

docetaxel solution

80 mg/4

mL (20

mg/mL)

Generic-2 NOANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

docetaxel solution

80 mg/8

mL (10

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

dofetilide capsule 125

mcg


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


mcg


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


mcg


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

Dolophine tablet 10 mg NonPrefBrand-4 206 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Dolophine tablet 5 mg NonPrefBrand-4 248 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

donepezil

tablet,disinteg

rating 10 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

donepezil tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

donepezil

tablet,disinteg

rating 5 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY



DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Doribax recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESdorzolamide drops 2 % Generic-2 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGSdorzolamide-

timolol

drops 22.3-6.8

mg/mL

Generic-2 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGSdoxazosin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

doxazosin tablet 2 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

doxepin capsule 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

doxepin concentrate

10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

doxepin cream 5 %


LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

doxercalcifer

ol

solution 4 mcg/2

mL


TES

MISCELLANEOUS

HORMONESdoxercalcifer

ol

capsule 2.5 mcg Generic-2 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS


ol

capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS


ol

capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

doxorubicin solution

50

mg/25

mL

Generic-2 YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

doxorubicin,

peg-

liposomal suspension

2

mg/mL Generic-2

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Doxy-100 recon soln 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate


doxycycline

hyclate

capsule 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate


doxycycline

hyclate

tablet 20 mg PrefGen-1 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate

recon soln 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate


doxycycline

hyclate

tablet,delayed

release

(DR/EC)

75 mg PrefGen-1 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate

tablet,delayed

release

(DR/EC)

100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate

tablet,delayed

release

(DR/EC)

150 mg PrefGen-1 NO ANTI - INFECTIVES TETRACYCLINES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

doxycycline

hyclate

tablet,delayed

release

(DR/EC) 200 mg Generic-2

NO

ANTI - INFECTIVES TETRACYCLINES

doxycycline

hyclate

tablet,delayed

release

(DR/EC) 50 mg Generic-2

NO


doxycycline

monohydrate

suspension

for

reconstitution

25 mg/5

mL

Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

doxycycline

monohydrate


doxycycline

monohydrate


doxycycline

monohydrate


doxycycline

monohydrate


doxycycline

monohydrate capsule 50 mg Generic-2NO

ANTI - INFECTIVES TETRACYCLINESdoxycycline

monohydrate capsule 100 mg Generic-2NO


monohydrate tablet 100 mg Generic-2NO


monohydrate tablet 50 mg Generic-2NO


dronabinol capsule 10 mg Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSdronabinol capsule 2.5 mg Generic-2 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

dronabinol capsule 5 mg Generic-2 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSdrospirenone-

ethinyl

estradiol

tablet 3-0.02

mg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSdrospirenone-

ethinyl

estradiol

tablet 3-0.03

mg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSDroxia capsule 200 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Droxia capsule 300 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Droxia capsule 400 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Duexis tablet

800-

26.6 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Dulera

HFA aerosol

inhaler

100-5

mcg/act

uation

NonPrefBrand-4

13 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Dulera

HFA aerosol

inhaler

200-5

mcg/act

uation

NonPrefBrand-4

13 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

duloxetine capsule,delay

ed

release(DR/E

C)

20 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


ed

release(DR/E

C)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


ed

release(DR/E

C)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


ed

release(DR/E

C)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Duopa

intestinal

pump

suspension

4.63-20

mg/mL

NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Duragesic patch 72 hour 25

mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Duramorph

(PF)

solution 0.5

mg/mL

Generic-2 4000 30 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Duramorph

(PF)

solution 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Durezol drops 0.05 % PrefBrand-3 NO OPHTHALMOLOGY STEROIDS

dutasteride capsule 0.5 mg PrefBrand-3 NO UROLOGICALS BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPY

dutasteride-

tamsulosin

capsule, ER

multiphase 24

hr

0.5-0.4

mg

PrefBrand-3 NO

UROLOGICALS

BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPY

Dymista

spray,non-

aerosol

137-50

mcg/spr

ay


ALLERGY

PULMONARY

AGENTS

Dyrenium capsule 100 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Dyrenium capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Dysport recon soln 300 unit NonPrefBrand-4 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Dysport recon soln 500 unit

NonPrefBrand-4 YESIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

E.E.S. 400 tablet 400 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESE.E.S.

Granules

suspension

for

reconstitution

200

mg/5

mL

NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESeconazole cream 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Edarbyclor tablet

40-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Edarbyclor tablet

40-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Edecrin tablet 25 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Edurant tablet 25 mgNonPrefBrand-4 NO





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Effient tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Effient tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Egrifta recon soln 1 mg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Elaprase solution 6 mg/3

mL


TES

MISCELLANEOUS

HORMONES

Elelyso recon soln 200 unitSpecialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Elidel cream 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSEligard syringe 45 mg

(6

month)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Eligard syringe 30 mg

(4

month)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Eligard syringe 7.5 mg

(1

month)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Eligard syringe 22.5 mg

(3

month)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Eliphos tablet 667 mg Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

Eliquis tablet 2.5 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Eliquis tablet 5 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Elitek recon soln 1.5 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Elitek recon soln 7.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Elixophyllin elixir 80

mg/15

mL


ALLERGY

PULMONARY

AGENTS

Ellence solution 200

mg/100

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Elmiron capsule 100 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS

UROLOGICALSEmadine drops 0.05 % NonPrefBrand-4 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CSEmbeda capsule,oral

only,ext.rel

pell

100-4

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Embeda capsule,oral

only,ext.rel

pell

20-0.8

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Embeda capsule,oral

only,ext.rel

pell

30-1.2

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Embeda capsule,oral

only,ext.rel

pell

50-2 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Embeda capsule,oral

only,ext.rel

pell

60-2.4

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Embeda capsule,oral

only,ext.rel

pell

80-3.2

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Emcyt capsule 140 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Emend capsule 80 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSEmend capsule 125 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSEmend capsule 40 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Emend capsule,dose

pack

125 mg

(1)- 80

mg (2)

NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Emend recon soln 150 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Emoquette tablet

0.15-

0.03 mg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Empliciti recon soln 300 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Emsam patch 24 hour 6 mg/24

hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Emsam patch 24 hour 9 mg/24

hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Emsam patch 24 hour 12

mg/24

hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Emtriva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Emtriva solution 10

mg/mL


Emverm

tablet,chewab

le 100 mgNonPrefBrand-4 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

enalapril

maleate

tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

enalapril

maleate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

enalapril

maleate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

enalapril

maleate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

enalapril-

hydrochloroth

iazide

tablet 5-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

enalapril-

hydrochloroth

iazide

tablet 10-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Enbrel recon soln 25 mg

(1 mL)


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSEnbrel syringe 50

mg/mL

(0.98

mL)

Specialty-5 7.84 28 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Enbrel syringe 25

mg/0.5

mL

(0.51)


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Enbrel

SureClick pen injector

50

mg/mL

(0.98

mL)

Specialty-5

7.84 28

YESMUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Endocet tablet

10-325

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Endocet tablet

5-325

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Endocet tablet

7.5-325

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Engerix-B

(PF)

syringe 20

mcg/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Engerix-B

Pediatric (PF)

suspension 10

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Engerix-B

Pediatric (PF)

syringe 10

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

enoxaparin syringe 30

mg/0.3

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


mg/0.4

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


mg/0.6

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


mg/0.8

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


mg/0.8

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


mg/mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


mg/mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

enoxaparin solution 300

mg/3

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Enpresse tablet 50-30

(6)/75-

40

(5)/125-

30(10)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

entacapone tablet 200 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

entecavir tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

entecavir tablet 1 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Entresto tablet

24-26

mg PrefBrand-3 62 31

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS

Entresto tablet

49-51


YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS

Entresto tablet

97-103


YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS

Enulose solution 10

gram/15

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Envarsus XR

tablet

extended

release 24 hr 4 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Envarsus XR

tablet

extended



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Envarsus XR

tablet

extended

release 24 hr 1 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Epiduo gel with

pump

0.1-2.5

%


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Epiduo Forte

gel with

pump

0.3-2.5

%


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

epinastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CSepinephrine auto-injector 0.3

mg/0.3

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSepinephrine auto-injector 0.15

mg/0.15

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSEpiPen 2-Pak auto-injector 0.3

mg/0.3

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSEpiPen Jr 2-

Pak

auto-injector 0.15

mg/0.3

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSepirubicin solution 50

mg/25

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Epitol tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Epivir tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Epivir solution 10

mg/mL


Epivir tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Epivir HBV tablet 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Epivir HBV solution 25 mg/5

mL (5

mg/mL)


eplerenone tablet 25 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

eplerenone tablet 50 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Epogen solution 20,000

unit/2

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

eprosartan tablet 600 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Epzicom tablet 600-300

mg


Equetro capsule, ER

multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Equetro capsule, ER

multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Equetro capsule, ER

multiphase 12

hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Eraxis(Water

Diluent)

recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSErbitux solution 100

mg/50

mL

PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ergoloid tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Ergomar tablet 2 mg


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Erivedge capsule 150 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Errin tablet 0.35 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Erwinaze recon soln

10,000

unit


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ery Pads swab 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Erygel gel 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

EryPed 200 suspension

for

reconstitution

200

mg/5

mL


OTHER

MACROLIDESEryPed 400 suspension

for

reconstitution

400

mg/5

mL


OTHER

MACROLIDESEry-Tab tablet,delayed

release

(DR/EC)


OTHER


release

(DR/EC)


OTHER


release

(DR/EC)

500 mg PrefBrand-3 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDES

Erythrocin recon soln 500 mg

PrefBrand-3 NO

ANTI - INFECTIVES

ERYTHROMYCINS /

OTHER

MACROLIDES

Erythrocin (as

stearate)


OTHER

MACROLIDESerythromycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

erythromycin ointment 5

mg/gra

m (0.5

%)


erythromycin capsule,delay

ed

release(DR/E

C)


OTHER

MACROLIDES

erythromycin tablet 250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESerythromycin

ethylsuccinate


OTHER

MACROLIDESerythromycin

with ethanol

gel 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

erythromycin

with ethanol

solution 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

erythromycin-

benzoyl

peroxide

gel 3-5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Esbriet capsule 267 mgSpecialty-5

279 31YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

escitalopram

oxalate

tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

escitalopram

oxalate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

escitalopram

oxalate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

escitalopram

oxalate

solution 5 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

esomeprazole

magnesium

capsule,delay

ed

release(DR/E

C)

20 mg Generic-2 31 31 NO GASTROENTEROL

OGY

ULCER THERAPY

esomeprazole

sodium

recon soln 20 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

esomeprazole

sodium

recon soln 40 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

estazolam tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

estazolam tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Estrace cream 0.01 %

(0.1

mg/gra

m)


GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol tablet 0.5 mg PrefGen-1 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSestradiol tablet 1 mg PrefGen-1 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

estradiol tablet 2 mg PrefGen-1 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSestradiol patch weekly 0.05

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol patch weekly 0.1

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS


mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol patch

semiweekly

0.0375

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS


mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol patch

semiweekly

0.05

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol patch

semiweekly

0.1

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol patch

semiweekly

0.025

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS


mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS


mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

estradiol

patch

semiweekly

0.075

mg/24

hr

Generic-2 NOOBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

estradiol

valerate

oil 20

mg/mL


GYNECOLOGY

ESTROGENS /

PROGESTINSestradiol-

norethindrone

acet tablet

0.5-0.1

mg Generic-2

NOOBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSestradiol-

norethindrone

acet tablet

1-0.5

mg Generic-2

NOOBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Estring ring 2 mg NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSestropipate tablet 0.75 mg PrefGen-1 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSestropipate tablet 1.5 mg PrefGen-1 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSestropipate tablet 3 mg PrefGen-1 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSeszopiclone tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

eszopiclone tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

eszopiclone tablet 3 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ethacrynate

sodium

recon soln 50 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

ethambutol tablet 100 mgGeneric-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

ethambutol tablet 400 mgGeneric-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

ethosuximide capsule 250 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

ethosuximide solution 250

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

etidronate

disodium

tablet 200 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

etidronate

disodium

tablet 400 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

etodolac capsule 200 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

etodolac capsule 300 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

etodolac tablet 400 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

etodolac tablet 500 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

etodolac tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

etodolac tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

etodolac tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Etopophos recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

etoposide solution 20

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Eurax cream 10 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

SCABICIDES /

PEDICULICIDESEurax lotion 10 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

SCABICIDES /

PEDICULICIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Evamist spray,non-

aerosol

1.53

mg/spra

y

(1.7%)


GYNECOLOGY

ESTROGENS /

PROGESTINS

Evekeo tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Evekeo tablet 5 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Evotaz tablet

300-150

mg PrefBrand-3NO


Evzio auto-injector

0.4

mg/0.4

mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Exalgo ER tablet

extended

release 24 hr

12 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Exalgo ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Exalgo ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Exalgo ER

tablet

extended

release 24 hr 32 mg

NonPrefBrand-4

48 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Exelderm cream 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Exelderm solution 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Exelon patch 24 hour 9.5

mg/24

hr

PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Exelon patch 24 hour 4.6

mg/24

hr


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Exelon patch 24 hour

13.3

mg/24

hour PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

exemestane tablet 25 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Exjade tablet,

dispersible

125 mg Specialty-5 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Exjade tablet,

dispersible


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Exjade tablet,

dispersible


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Extavia kit 0.3 mg Specialty-5 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Fabrazyme recon soln 35 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESfamciclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

famciclovir tablet 125 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

famciclovir tablet 250 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

famotidine tablet 40 mg PrefGen-1 NO GASTROENTEROL

OGY

ULCER THERAPY

famotidine tablet 20 mg PrefGen-1 NO GASTROENTEROL

OGY

ULCER THERAPY

famotidine suspension 40 mg/5

mL (8

mg/mL)

PrefGen-1 NO GASTROENTEROL

OGY

ULCER THERAPY

famotidine

(PF)

solution 20 mg/2

mL


OGY

ULCER THERAPY

famotidine

(PF)-NaCl

(iso-os)

piggyback 20

mg/50

mL


OGY

ULCER THERAPY

Fanapt tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Fanapt tablets,dose

pack

1mg(2)-

2mg(2)-

4mg(2)-

6mg(2)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Fareston tablet 60 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Farxiga tablet 10 mg PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Farxiga tablet 5 mg PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Farydak capsule 10 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Faslodex syringe 250

mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

FazaClo tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating

12.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

FazaClo

tablet,disinteg

rating 200 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

FazaClo

tablet,disinteg

rating 150 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

felbamate tablet 400 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

felbamate tablet 600 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

felbamate suspension 600

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Felbatol tablet 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Felbatol tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Felbatol suspension 600

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

felodipine tablet

extended

release 24 hr

10 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

felodipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

felodipine tablet

extended

release 24 hr

2.5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Femara tablet 2.5 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Femring ring 0.05

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

Femring ring 0.1

mg/24

hr


GYNECOLOGY

ESTROGENS /

PROGESTINS

fenofibrate tablet 160 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate tablet 54 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fenofibrate

micronized

capsule 67 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate

micronized


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate

micronized


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate

micronized


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate

micronized


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate

nanocrystalliz

ed

tablet 145 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibrate

nanocrystalliz

ed

tablet 48 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibric

acid

tablet 105 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibric

acid


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenofibric

acid (choline)

capsule,delay

ed

release(DR/E

C)

135 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fenofibric

acid (choline)

capsule,delay

ed

release(DR/E

C)


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Fenoglide tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSFenoglide tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfenoprofen tablet 600 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

fenoprofen capsule 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

fentanyl patch 72 hour 75

mcg/hr

PrefBrand-3 12 30 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


mcg/hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

fentanyl patch 72 hour

37.5

mcg/ho

ur

NonPrefBrand-4

20 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


62.5

mcg/ho

ur

NonPrefBrand-4

15 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


87.5

mcg/ho

ur

NonPrefBrand-4

11 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

fentanyl

citrate

lozenge on a

handle

1,200

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

fentanyl

citrate

lozenge on a

handle

1,600

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

fentanyl

citrate

lozenge on a

handle

200

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fentanyl

citrate

lozenge on a

handle

400

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

fentanyl

citrate

lozenge on a

handle

600

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

fentanyl

citrate

lozenge on a

handle

800

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Fentora tablet,

effervescent

100

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Fentora tablet,

effervescent

200

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Fentora tablet,

effervescent

400

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Fentora tablet,

effervescent

600

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Fentora tablet,

effervescent

800

mcg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ferriprox tablet 500 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Ferriprox solution

100

mg/mL


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Fetzima

capsule,exten

ded release 24

hr 120 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Fetzima

capsule,exten

ded release 24

hr 20 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Fetzima

capsule,exten

ded release 24

hr 40 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Fetzima

capsule,exten

ded release 24

hr 80 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Fetzima

capsule,Ext

Rel 24hr dose

pack

20 mg

(2)- 40

mg (26)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Finacea gel 15 %


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Finacea foam 15 %


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

finasteride tablet 5 mg Generic-2 NO UROLOGICALS BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPY

Firazyr syringe

30 mg/3

mLSpecialty-5


ALLERGY

PULMONARY

AGENTS

Firmagon kit

w diluent

syringe

recon soln 80 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Firmagon kit

w diluent

syringe

recon soln 120 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

flavoxate tablet 100 mg

Generic-2 NO

UROLOGICALS

ANTICHOLINERGIC

S /

ANTISPASMODICS

Flebogamma

DIF solution 10 %


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

flecainide tablet 50 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Flector patch 12 hour 1.3 % NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

fluconazole tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSfluconazole tablet 150 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL



AGENTSfluconazole suspension

for

reconstitution

10

mg/mL

Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTS

fluconazole suspension

for

reconstitution

40

mg/mL


AGENTS

fluconazole in

dextrose(iso-

o) piggyback

400

mg/200

mL Generic-2

NO

ANTI - INFECTIVES

ANTIFUNGAL

AGENTSfluconazole in

NaCl (iso-

osm) piggyback

200

mg/100

mL Generic-2

NO

ANTI - INFECTIVES

ANTIFUNGAL

AGENTS

flucytosine capsule 250 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSflucytosine capsule 500 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSfludarabine recon soln 50 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fludrocortison

e

tablet 0.1 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES

flunisolide

spray,non-

aerosol

25 mcg

(0.025

%) Generic-2

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

fluocinolone ointment 0.025 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluocinolone cream 0.01 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluocinolone oil 0.01 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluocinolone solution 0.01 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS



LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluocinolone

acetonide oil drops 0.01 %


THROAT

MEDICATIONS

MISCELLANEOUS

OTIC

PREPARATIONS

fluocinonide ointment 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluocinonide gel 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluocinonide solution 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fluocinonide cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Fluocinonide-

E


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluoromethol

one

drops,suspens

ion

0.1 % Generic-2 NO OPHTHALMOLOGY STEROIDS

fluorouracil cream 5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSfluorouracil solution 2.5

gram/50

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

fluorouracil cream 0.5 % Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSfluorouracil solution 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSfluorouracil solution 5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSfluoxetine tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluoxetine capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluoxetine solution 20 mg/5

mL (4

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluoxetine tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluoxetine capsule,delay

ed

release(DR/E

C)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluoxetine tablet 60 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

decanoate

solution 25

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

HCl

elixir 2.5

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fluphenazine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

HCl

concentrate 5

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

HCl

tablet 2.5 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluphenazine

HCl

solution 2.5

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

flurandrenoli

de

cream 0.05 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

flurazepam capsule 15 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

flurazepam capsule 30 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

flurbiprofen tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

flurbiprofen tablet 50 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

flurbiprofen

sodium drops 0.03 %

Generic-2 NO

OPHTHALMOLOGY

NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTS

flutamide capsule 125 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

fluticasone ointment 0.005 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluticasone cream 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluticasone lotion 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

fluticasone spray,suspens

ion

50

mcg/act

uation


ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fluvastatin capsule 20 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfluvastatin capsule 40 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfluvastatin tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSfluvoxamine capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluvoxamine capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

fluvoxamine tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Focalin XR capsule,ER

biphasic 50-

50


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Focalin XR

capsule,ER

biphasic 50-

50 25 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Focalin XR

capsule,ER

biphasic 50-

50 35 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Folotyn solution 40 mg/2

mL (20

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

fomepizole solution 1

gram/m

L

PrefGen-1 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

fondaparinux syringe 10

mg/0.8

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

fondaparinux syringe 2.5

mg/0.5

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

fondaparinux syringe 5

mg/0.4

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

fondaparinux syringe 7.5

mg/0.6

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Foradil

Aerolizer

capsule,

w/inhalation

device 12 mcg PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Fortaz recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



Forteo pen injector

20

mcg/dos

e - 600

mcg/2.4

mL

Specialty-5

2.4 28

YES

MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

Fortesta

gel in metered-

dose pump

10

mg/0.5

gram

/actuatio

n

NonPrefBrand-4 YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

FORTICAL spray,non-

aerosol

200

unit/act

uation


TES

MISCELLANEOUS

HORMONES

fosinopril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

fosinopril-

hydrochloroth

iazide

tablet 10-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

fosinopril-

hydrochloroth

iazide

tablet 20-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

fosphenytoin solution 100 mg

PE/2

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Fosrenol tablet,chewab

le


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS


le

1,000

mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS


le

750 mg NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Fosrenol

powder in

packet

1,000

mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Fosrenol

powder in

packet 750 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Fragmin syringe

2,500

anti-Xa

unit/0.2

mL

PrefBrand-3 NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Fragmin syringe

5,000

anti-Xa

unit/0.2

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Fragmin syringe

7,500

anti-Xa

unit/0.3

mL

Specialty-5 NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Fragmin syringe

12,500

anti-Xa

unit/0.5

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Fragmin syringe

15,000

anti-Xa

unit/0.6

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Fragmin syringe

18,000

anti-Xa

unit/0.7

2 mL

Specialty-5 NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Fragmin syringe

10,000

anti-Xa

unit/mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Fragmin solution

25,000

anti-Xa

unit/mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Freamine

HBC 6.9 %

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSFrova tablet 2.5 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYfrovatriptan tablet 2.5 mg PrefBrand-3 12 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYfurosemide solution 10

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

furosemide solution 40 mg/5

mL (8

mg/mL)


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

furosemide tablet 80 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

furosemide solution 10

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

furosemide syringe 10

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Fusilev recon soln 50 mg


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Fuzeon recon soln 90 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Fyavolv tablet

0.5-2.5

mg-mcg Generic-2NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Fyavolv tablet

1-5 mg-

mcg Generic-2NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Fycompa tablet 2 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Fycompa tablet 4 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Fycompa tablet 6 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Fycompa tablet 8 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Fycompa tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Fycompa suspension

0.5

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

gabapentin solution 250

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

gabapentin capsule 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

gabapentin tablet 600 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

gabapentin tablet 800 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Gabitril tablet 12 mg PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Gabitril tablet 16 mg PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Gabitril tablet 2 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Gablofen solution

40,000

mcg/20

mL

(2,000

mcg/mL

)

NonPrefBrand-4 YES

AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY

Gablofen syringe

50

mcg/mL

(1 mL)


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY

Gablofen solution

10,000

mcg/20

mL

(500

mcg/mL

)

NonPrefBrand-4 YES

AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY

galantamine tablet 4 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

galantamine capsule,ext

rel. pellets 24

hr


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


rel. pellets 24

hr


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY


rel. pellets 24

hr


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

galantamine solution 4

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

GamaSTAN

S/D

solution 15-18 %

range

NonPrefBrand-4 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gammagard

Liquid

solution 10 % Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gammaked solution

1

gram/10

mL (10

%)


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gammaplex solution 5 %


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gamunex-C solution 1

gram/10

mL (10

%)


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ganciclovir

sodium

recon soln 500 mg Generic-2 YES ANTI - INFECTIVES ANTIVIRALS

Gardasil (PF) suspension 20-40-

40-20

mcg/0.5

mL

PrefBrand-3 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gardasil (PF) syringe 20-40-

40-20

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gardasil 9

(PF) suspension 0.5 mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Gardasil 9

(PF) syringe 0.5 mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

gatifloxacin drops 0.5 %Generic-2 NO

OPHTHALMOLOGY ANTIBIOTICS

Gattex One-

Vial kit 5 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Gauze Pad bandage 2 X 2 " PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Gavilyte-C recon soln

240-

22.72-

6.72 -

5.84

gram

Generic-2 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

GaviLyte-G recon soln

236-

22.74-

6.74 -

5.86

gram

Generic-2 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

GaviLyte-H

and Bisacodyl kit

5-210

mg-

gram Generic-2

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

GaviLyte-N recon soln

420

gram

Generic-2 NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Gelnique gel in packet 10 %

(100

mg/gra

m)

PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

gemcitabine recon soln 1 gram


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

gemfibrozil tablet 600 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSGenerlac solution 10

gram/15

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSGengraf capsule 100 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Gengraf solution 100

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Gengraf capsule 25 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Genotropin cartridge 5

mg/mL

(15

unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin cartridge

12

mg/mL

(36

unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 0.2

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 0.4

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 0.6

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 0.8

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 1.2

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 1.4

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 1.6

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Genotropin

MiniQuick

syringe 1.8

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 1

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Genotropin

MiniQuick

syringe 2

mg/0.25

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Gentak ointment 0.3 % (3

mg/gra

m)


gentamicin cream 0.1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

gentamicin ointment 0.1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

gentamicin ointment 0.3 % (3

mg/gra

m)


gentamicin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY ANTIBIOTICS

gentamicin solution 40

mg/mL

PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESgentamicin in

NaCl (iso-

osm)

piggyback 100

mg/100

mL


ANTIINFECTIVES

gentamicin in

NaCl (iso-

osm)

piggyback 80

mg/100

mL


ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

gentamicin in

NaCl (iso-

osm)

piggyback 90

mg/100

mL


ANTIINFECTIVES

gentamicin in

NaCl (iso-

osm)

piggyback 60

mg/50

mL


ANTIINFECTIVES

gentamicin in

NaCl (iso-

osm)

piggyback 70

mg/50

mL


ANTIINFECTIVES

gentamicin in

NaCl (iso-

osm)

piggyback 80

mg/50

mL


ANTIINFECTIVES

Genvoya tablet

150-150-

200-10

mg

Specialty-5 NO


Geodon recon soln 20

mg/mL

(final

conc.)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Gildagia tablet

0.4-35

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Gildess 24 Fe tablet

1 mg-20

mcg

(24)/75

mg (4) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Gilenya capsule 0.5 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Gilotrif tablet 20 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Glassia solution

1

gram/50

mL (2

%)

Specialty-5 YESDIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Glatopa syringe

20

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Gleevec tablet 100 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Gleevec tablet 400 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Gleostine capsule 10 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

glimepiride tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYglimepiride tablet 2 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYglimepiride tablet 4 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYglipizide tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYglipizide tablet

extended

release 24hr

2.5 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

glipizide tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYglipizide tablet

extended

release 24hr

5 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

glipizide tablet

extended

release 24hr


TES

DIABETES

THERAPY

glipizide-

metformin

tablet 2.5-250

mg


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

glipizide-

metformin

tablet 2.5-500

mg


TES

DIABETES

THERAPYglipizide-

metformin

tablet 5-500

mg


TES

DIABETES

THERAPYGlucaGen

HypoKit

recon soln 1 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYGlucagon

Emergency

Kit (human)

kit 1 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Glumetza tablet,ER

gast.retention

24 hr

500 mg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

glyburide tablet 1.25 mg Generic-2 YES ENDOCRINE/DIABE

TES

DIABETES

THERAPYglyburide tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABE

TES

DIABETES

THERAPYglyburide tablet 5 mg Generic-2 YES ENDOCRINE/DIABE

TES

DIABETES

THERAPYglyburide

micronized

tablet 3 mg Generic-2 YES ENDOCRINE/DIABE

TES

DIABETES

THERAPYglyburide

micronized

tablet 6 mg Generic-2 YES ENDOCRINE/DIABE

TES

DIABETES

THERAPYglyburide

micronized

tablet 1.5 mg Generic-2 YES ENDOCRINE/DIABE

TES

DIABETES

THERAPYglyburide-

metformin

tablet 1.25-

250 mg


TES

DIABETES

THERAPYglyburide-

metformin

tablet 2.5-500

mg


TES

DIABETES

THERAPYglyburide-

metformin

tablet 5-500

mg


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

glycopyrrolat

e

tablet 1 mg Generic-2 NO GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

glycopyrrolat

e


OGY

ANTIDIARRHEALS /

ANTISPASMODICS

glycopyrrolat

e

solution 0.2

mg/mL


OGY

ANTIDIARRHEALS /

ANTISPASMODICS

Glyset tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYGlyset tablet 50 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYGlyset tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Golytely

powder in

packet

227.1-

21.5-

6.36

gram

NonPrefBrand-4 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Gralise

tablet

extended


YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Gralise

tablet

extended


YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Gralise 30-

Day Starter

Pack

tablet

extended

release 24 hr

300 mg

(9)- 600

mg (69) PrefBrand-3

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

granisetron

(PF)

solution 100

mcg/mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSgranisetron

HCl

solution 1

mg/mL

(1 mL)


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSgranisetron

HCl

tablet 1 mg Generic-2 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Granix syringe

300

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Granix syringe

480

mcg/0.8

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Grastek tablet

2,800

BAU


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

griseofulvin

microsize

suspension 125

mg/5

mL


AGENTS

griseofulvin

microsize

tablet 500 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSgriseofulvin

ultramicrosize


AGENTSgriseofulvin

ultramicrosize


AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

guanfacine tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

guanfacine tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

guanfacine tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

guanfacine tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

guanidine tablet 125 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Gynazole-1 cream 2 % NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYN

Halaven solution

1 mg/2

mL (0.5

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Halcion tablet 0.25 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

halobetasol

propionate ointment 0.05 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

halobetasol

propionate cream 0.05 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Halog cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Halog ointment 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

haloperidol tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

haloperidol tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

haloperidol tablet 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

haloperidol

decanoate

solution 50

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

haloperidol

decanoate

solution 100

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

haloperidol

lactate

concentrate 2

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

haloperidol

lactate

solution 5

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Harvoni tablet

90-400

mgSpecialty-5

28 28YES


Havrix (PF) suspension 1,440

Elisa

unit/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Havrix (PF) syringe 720

Elisa

unit/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Hectorol capsule 2.5 mcg Specialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESHectorol solution 4 mcg/2

mL


TES

MISCELLANEOUS

HORMONESHectorol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Hectorol capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

heparin

(porcine) solution

1,000

unit/mL Generic-2

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

heparin

(porcine) solution

20,000

unit/mL Generic-2

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

heparin

(porcine) solution

5,000

unit/mL Generic-2

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

heparin

(porcine) solution

10,000

unit/mL Generic-2

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

heparin

(porcine) in 5

% dex

parenteral

solution

25,000

unit/250

mL(100

unit/mL Generic-2

NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

heparin

(porcine) in 5

% dex

parenteral

solution

20,000

unit/500

mL (40

unit/mL Generic-2

NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

heparin

(porcine) in 5

% dex

parenteral

solution

25,000

unit/500

mL (50

unit/mL Generic-2

NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Hepatamine

8%

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSHepsera tablet 10 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Herceptin recon soln 440 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Hetlioz capsule 20 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Hexalen capsule 50 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Hiberix (PF) recon soln

10

mcg/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Horizant

tablet

extended

release 600 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Horizant

tablet

extended

release 300 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Humalog solution 100

unit/mL

(prefille

d

syringe)

PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Humalog solution 100

unit/mL


TES

DIABETES

THERAPY

Humalog cartridge

100

unit/mL PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Humalog

KwikPen insulin pen

200

unit/mL

(3 mL) PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPYHumalog

KwikPen insulin pen

100


TES

DIABETES

THERAPY

Humalog Mix

50-50

suspension 100

unit/mL

(50-50)


TES

DIABETES

THERAPY

Humalog Mix

50-50

KwikPen

insulin pen 100

unit/mL

(50-50)


TES

DIABETES

THERAPY

Humalog Mix

75-25

suspension 100

unit/mL

(75-25)


TES

DIABETES

THERAPY

Humalog Mix

75-25

KwikPen

insulin pen 100

unit/mL

(75-25)


TES

DIABETES

THERAPY

Humatrope recon soln 5 (15

unit) mg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Humatrope cartridge 12 mg

(36

unit)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


(72

unit)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


(18

unit)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Humira syringe kit 40

mg/0.8

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Humira syringe kit 20

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Humira syringe kit

10

mg/0.2

mL

Specialty-5

0.4 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Humira

Pediatric

Crohn's Start syringe kit

40

mg/0.8

mL (6

pack)

Specialty-5

4.8 28

YESMUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSHumira

Pediatric

Crohn's Start syringe kit

40

mg/0.8

mL

Specialty-5

2.4 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Humira Pen

pen injector

kit

40

mg/0.8

mL

Specialty-5

1.6 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Humira Pen

Crohn's-UC-

HS Start

pen injector

kit

40

mg/0.8

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSHumulin

70/30

suspension 100

unit/mL

(70-30)


TES

DIABETES

THERAPY

Humulin

70/30

KwikPen

insulin pen 100

unit/mL

(70-30)


TES

DIABETES

THERAPY

Humulin N suspension 100

unit/mL


TES

DIABETES

THERAPYHumulin N

KwikPen

insulin pen 100

unit/mL

(3 mL)


TES

DIABETES

THERAPY

Humulin R solution 100

unit/mL


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

ClassHumulin R U-

500 (Conc)

Kwikpen insulin pen

500

unit/mL

(3 mL) PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Humulin R U-

500

(Concentrated

)

solution 500

unit/mL


TES

DIABETES

THERAPY

Hycet solution 7.5-325

mg/15

mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydralazine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

hydralazine solution 20

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

hydrochloroth

iazide


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

hydrochloroth

iazide

capsule 12.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

hydrochloroth

iazide


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

hydrochloroth

iazide

tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

hydrocodone-

acetaminophe

n

solution 7.5-325

mg/15

mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

acetaminophe

n

tablet 10-300

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

acetaminophe

n

tablet 5-300

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

acetaminophe

n

tablet 7.5-300

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

acetaminophe

n

tablet 10-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

acetaminophe

n

tablet 5-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

hydrocodone-

acetaminophe

n

tablet 7.5-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

acetaminophe

n

tablet 2.5-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

ibuprofen

tablet 5-200

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

ibuprofen

tablet 7.5-200

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocodone-

ibuprofen

tablet 10-200

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydrocortison

e


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e

cream 1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e

ointment 1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e


TES

ADRENAL

HORMONEShydrocortison

e


TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

hydrocortison

e


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e


TES

ADRENAL

HORMONEShydrocortison

e

enema 100

mg/60

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTShydrocortison

e


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e butyrate ointment 0.1 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e butyrate solution 0.1 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDShydrocortison

e butyr-

emollient cream 0.1 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e valerate ointment 0.2 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e valerate cream 0.2 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

hydrocortison

e-acetic acid

drops 1-2 % Generic-2 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

OTIC

PREPARATIONShydromorpho

ne

liquid 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

hydromorpho

ne

tablet 2 mg Generic-2 186 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne

syringe 2

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne

tablet

extended

release 24 hr

12 mg Generic-2 62 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne

tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne

tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydromorpho

ne

tablet

extended

release 24 hr 32 mg Generic-2 48 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

hydromorpho

ne (PF)

solution 10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

hydroxychlor

oquine tablet 200 mgGeneric-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVEShydroxyproge

sterone

caproate oil

250

mg/mL

Specialty-5 NOOBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

hydroxyurea capsule 500 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

hydroxyzine

HCl solution

25

mg/mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

hydroxyzine

HCl solution

50

mg/mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

HyperRAB

S/D (PF) solution

150

unit/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

HyperRAB

S/D (PF) solution

150

unit/mL

(10 ml)


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 20 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 30 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 40 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 60 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 80 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 100 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Hysingla ER

tablet,oral

only,ext.rel.2

4 hr 120 mg

NonPrefBrand-4

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

ibandronate tablet 150 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

ibandronate solution 3 mg/3

mL

Generic-2 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ibrance capsule 100 mg

Specialty-5

21 28

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


Specialty-5

21 28

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


Specialty-5

21 28

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ibuprofen suspension 100

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ibuprofen tablet 400 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ibuprofen-

oxycodone tablet

400-5

mg

Generic-2

30 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Iclusig tablet 15 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

idarubicin solution

1

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ifosfamide recon soln 1 gram Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Ilaris (PF) recon soln 180

mg/1.2

mL

(150

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Ilevro

drops,suspens

ion 0.3 % PrefBrand-3

NO

OPHTHALMOLOGY

NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTS

imatinib tablet 100 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

imatinib tablet 400 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Imbruvica capsule 140 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

imipenem-

cilastatin

recon soln 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESimipenem-

cilastatin

recon soln 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESimipramine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

imipramine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

imipramine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

imipramine

pamoate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

imipramine

pamoate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

imipramine

pamoate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

imipramine

pamoate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

imiquimod cream in

packet

5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSImitrex tablet 25 mg NonPrefBrand-4 36 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImitrex solution 6

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImitrex tablet 50 mg NonPrefBrand-4 18 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImitrex tablet 100 mg NonPrefBrand-4 9 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImitrex spray,non-

aerosol

20

mg/actu

ation


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImitrex spray,non-

aerosol

5

mg/actu

ation


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Imitrex

STATdose

Kit Refill

cartridge 4

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImitrex

STATdose

Kit Refill

cartridge 6

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYImovax

Rabies

Vaccine (PF)

recon soln 2.5 unit NonPrefBrand-4 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Imuran tablet 50 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Increlex solution 10

mg/mL


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

indapamide tablet 1.25 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

indapamide tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Indocin suspension 25 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

indomethacin capsule 25 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

indomethacin capsule 50 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

indomethacin capsule,

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Infanrix

(DTaP) (PF) suspension

25-58-

10 Lf-

mcg-

Lf/0.5m

L PrefBrand-3

NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Inlyta tablet 1 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Inlyta tablet 5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

InnoPran XL capsule,exten

ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

InnoPran XL capsule,exten

ded release

24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

insulin

syringe-

needle U-100

syringe 1/2 mL

28

gauge


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

insulin

syringe-

needle U-100

syringe 1 mL 29

gauge x

1/2"


TES

DIABETES

THERAPY

insulin

syringe-

syringe 0.3 mL

29


TES

DIABETES

THERAPYIntelence tablet 100 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Intelence tablet 200 mgSpecialty-5 NO


Intelence tablet 25 mgNonPrefBrand-4 NO


Intralipid emulsion 20 % Generic-2 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSIntralipid emulsion 30 % NonPrefBrand-4 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSIntron A solution 6

million

unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Intron A recon soln 50

million

unit (1

mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Intron A recon soln 10

million

unit (1

mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Intron A recon soln

18

million

unit (1

mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Introvale

tablets,dose

pack,3 month

0.15-30

mg-mcg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Intuniv ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Intuniv ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Intuniv ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Intuniv ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invanz recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESInvega tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega tablet

extended

release 24hr

6 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Invega tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega

Sustenna

syringe 78

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega

Sustenna

syringe 234

mg/1.5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega

Sustenna

syringe 156

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega

Sustenna

syringe 117

mg/0.75

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega

Sustenna

syringe 39

mg/0.25

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invega Trinza syringe

273

mg/0.87

5 mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


410

mg/1.31

5 mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


546

mg/1.75

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


819

mg/2.62

5 mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Invirase capsule 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Invirase tablet 500 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Invokamet tablet

150-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Invokamet tablet

150-500

mg PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Invokamet tablet

50-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Invokamet tablet

50-500


TES

DIABETES

THERAPY

Invokana tablet 100 mg PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Invokana tablet 300 mg PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Ionosol-B in

D5W

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ionosol-MB

in D5W

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSIopidine dropperette 1 % PrefBrand-3 NO OPHTHALMOLOGY SYMPATHOMIMETI

CSIPOL suspension 40-8-32

unit/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

ipratropium

bromide

spray,non-

aerosol

0.06 % PrefGen-1 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

ipratropium

bromide

spray,non-

aerosol

0.03 % PrefGen-1 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

ipratropium

bromide

solution 0.02 % PrefGen-1 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

ipratropium-

albuterol

solution for

nebulization

0.5 mg-

3

mg(2.5

mg

base)/3

mL Generic-2

YES

RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

irbesartan tablet 75 mg PrefGen-1 31 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

irbesartan-

hydrochloroth

iazide

tablet 150-

12.5 mg

Generic-2 31 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

irbesartan-

hydrochloroth

iazide

tablet 300-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Iressa tablet 250 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

irinotecan solution 100

mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Isentress tablet 400 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Isentress

tablet,chewab

le 100 mgSpecialty-5 NO


Isentress

tablet,chewab

le 25 mg PrefBrand-3NO


Isentress

powder in

packet 100 mgNonPrefBrand-4 NO


Isolyte-P in 5

% dextrose

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSIsolyte-S parenteral

solution

PrefBrand-3 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSisoniazid solution 50 mg/5

mL


ANTIINFECTIVESisoniazid solution 100

mg/mL


ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

isoniazid tablet 300 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESisoniazid tablet 100 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESIsordil tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

dinitrate


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

dinitrate


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

dinitrate

tablet

extended

release


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

dinitrate


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

dinitrate


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

mononitrate


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

mononitrate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

mononitrate


, HYPERTENSION /

LIPIDS

NITRATES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

isosorbide

mononitrate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

NITRATES

isosorbide

mononitrate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

NITRATES

isradipine capsule 2.5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

isradipine capsule 5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Istalol drops, once

daily

0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS

Istodax recon soln 10 mg/2

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

itraconazole capsule 100 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSivermectin tablet 3 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESIxempra recon soln 45 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Ixiaro (PF) syringe

6

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Jakafi tablet 10 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Jakafi tablet 5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Jakafi tablet 15 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Jakafi tablet 20 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Jakafi tablet 25 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Jantoven tablet 1 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Jantoven tablet 2.5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Jantoven tablet 7.5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Janumet tablet 50-

1,000

mg


TES

DIABETES

THERAPY

Janumet tablet 50-500

mg


TES

DIABETES

THERAPY

Janumet XR

tablet, ER

multiphase 24

hr

100-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Janumet XR

tablet, ER

multiphase 24

hr

50-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Janumet XR

tablet, ER

multiphase 24

hr

50-500

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Januvia tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYJanuvia tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Januvia tablet 50 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Jentadueto tablet

2.5-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Jentadueto tablet

2.5-500


TES

DIABETES

THERAPY

Jentadueto tablet

2.5-850


TES

DIABETES

THERAPY

Jentadueto

XR

tablet, IR -

ER, biphasic

24hr

2.5-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Jentadueto

XR

tablet, IR -

ER, biphasic

24hr

5-1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Jevtana solution

10

mg/mL

(first

dilution)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Jinteli tablet

1-5 mg-

mcgGeneric-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Jolivette tablet 0.35 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Juleber tablet

0.15-

0.03 mg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Junel 1.5/30

(21) tablet

1.5-30

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Junel 1/20

(21) tablet

1-20 mg-

mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Junel FE

1.5/30 (28) tablet

1.5 mg-

30 mcg

(21)/75

mg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Junel FE 1/20

(28) tablet

1 mg-20

mcg

(21)/75

mg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Junel Fe 24 tablet

1 mg-20

mcg

(24)/75

mg (4) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Juxtapid capsule 10 mg

Specialty-5 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS



, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS



, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS



, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS



, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Kadcyla recon soln 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Kadian capsule,exten

d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Kadian

capsule,exten

d.release

pellets 40 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Kaitlib Fe

tablet,chewab

le

0.8mg-

25mcg(

24) and

75 mg

(4) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Kaletra tablet 200-50

mg


Kaletra tablet 100-25

mg


Kaletra solution 400-100

mg/5

mL


Kalydeco tablet 150 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Kalydeco

granules in

packet 50 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Kalydeco

granules in

packet 75 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Kanuma solution

2

mg/mLSpecialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Kapvay

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Karbinal ER

suspension,ex

tended rel 12

hr

4 mg/5

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Kariva (28) tablet 0.15-

0.02

mgx21

/0.01

mg x 5


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Kelnor 1/35

(28)

tablet 1-35 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Kenalog aerosol

0.147

mg/gra

m PrefBrand-3

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Kepivance recon soln 6.25 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Keppra tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Keppra solution 100

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Keppra tablet 1,000

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Keppra XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Keppra XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Ketek tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESKetek tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESketoconazole shampoo 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

ketoconazole cream 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

ketoconazole tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ketoconazole foam 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

ketoprofen capsule 50 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ketoprofen capsule 75 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ketoprofen capsule,ext

rel. pellets 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ketorolac tablet 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ketorolac solution 15

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ketorolac solution 30

mg/mL

(1 mL)


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

ketorolac drops 0.4 % Generic-2 NO OPHTHALMOLOGY NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ketorolac drops 0.5 % Generic-2 NO OPHTHALMOLOGY NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTS

ketorolac cartridge

30

mg/mL Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Keveyis tablet 50 mg

NonPrefBrand-4

124 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Keytruda recon soln 50 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Keytruda solution

100

mg/4

mL (25

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Khedezla

tablet

extended

release 24hr 100 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Khedezla

tablet

extended

release 24hr 50 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Kimidess (28) tablet

0.15-

0.02

mgx21

/0.01

mg x 5 Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Kineret syringe 100

mg/0.67

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSKionex powder Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Klor-Con 10 tablet

extended

release

10 mEq Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

Klor-Con 8 tablet

extended

release


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

Klor-Con

M15

tablet,ER

particles/cryst

als


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

Klor-Con

M20

tablet,ER

particles/cryst

als


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

Klor-Con

Sprinkle

capsule,

extended

release 8 mEq Generic-2

NO VITAMINS,

HEMATINICS /

ELECTROLYTES ELECTROLYTES

Klor-Con

Sprinkle

capsule,

extended

release 10 mEq Generic-2

NO VITAMINS,

HEMATINICS /


Kombiglyze

XR

tablet, ER

multiphase 24

hr

2.5-

1,000

mg


TES

DIABETES

THERAPY

Kombiglyze

XR

tablet, ER

multiphase 24

hr

5-1,000

mg


TES

DIABETES

THERAPY

Kombiglyze

XR

tablet, ER

multiphase 24

hr

5-500

mg


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Korlym tablet 300 mgSpecialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

K-Tab tablet

extended

release

10 mEq NonPrefBrand-4 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

K-Tab

tablet

extended

release 20 mEq

NonPrefBrand-4 NO VITAMINS,

HEMATINICS /


K-Tab

tablet

extended

release 8 mEq

PrefGen-1 NO VITAMINS,

HEMATINICS /


Kuvan tablet,soluble 100 mgSpecialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Kynamro syringe

200

mg/mL


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

L

norgest/e.estr

adiol-e.estrad

tablets,dose

pack,3 month

0.15 mg-

30 mcg

(84)/10

mcg (7)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSlabetalol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

labetalol tablet 200 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

labetalol tablet 300 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

labetalol solution 5

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lacrisert insert 5 mg NonPrefBrand-4 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CSlactated

ringers

solution Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

IRRIGATING

SOLUTIONS

lactated

ringers

parenteral

solution


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

lactulose solution 10

gram/15

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSLamictal tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal tablet,

chewable

dispersible


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal tablet,

chewable

dispersible


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

ODT

tablet,disinteg

rating

100 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

ODT

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

ODT

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

ODT

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

Starter (Blue)

Kit

tablets,dose

pack

25 mg

(35)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

Starter

(Green) Kit

tablets,dose

pack

25 mg

(84) -

100 mg

(14)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal

Starter

(Orange) Kit

tablets,dose

pack

25 mg

(42) -

100 mg

(7)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lamictal XR tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal XR tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal XR tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal XR tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal XR

tablet

extended

release 24hr 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal XR

Starter (Blue)

tablet

extended

rel,dose pack

25 mg

(21) -50

mg (7)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamictal XR

Starter

(Green)

tablet

extended

rel,dose pack

50

mg(14)-

100mg

(14)-

200 mg

(7)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lamictal XR

Starter

(Orange)

tablet

extended

rel,dose pack

25mg

(14)-50

mg (14)-

100mg

(7)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lamisil tablet 250 mg NonPrefBrand-4 90 180 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSLamisil granules in

packet

125 mg NonPrefBrand-4 180 180 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSLamisil granules in

packet

187.5

mg

NonPrefBrand-4 120 180 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSlamivudine tablet 150 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

lamivudine solution 10

mg/mL


lamivudine tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

lamivudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

lamivudine-

zidovudine

tablet 150-300

mg


lamotrigine tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


rating


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine tablet,

chewable

dispersible


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine tablet,

chewable

dispersible


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

lamotrigine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine

tablet

extended

release 24hr 300 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

lamotrigine

tablet

extended

release 24hr 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lanoxin tablet 62.5

mcg


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

Lanoxin solution 250

mcg/mL


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

Lanoxin tablet 125

mcg


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

Lanoxin tablet 250

mcg


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lanoxin tablet

187.5

mcg


, HYPERTENSION /

LIPIDS

CARDIAC

GLYCOSIDES

lansoprazole capsule,delay

ed

release(DR/E

C)

30 mg PrefBrand-3 62 31 NO GASTROENTEROL

OGY

ULCER THERAPY

lansoprazole capsule,delay

ed

release(DR/E

C)

15 mg PrefBrand-3 31 31 NO GASTROENTEROL

OGY

ULCER THERAPY

Lantus solution 100

unit/mL


TES

DIABETES

THERAPYLantus

Solostar

insulin pen 100

unit/mL

(3 mL)


TES

DIABETES

THERAPY

Lastacaft drops 0.25 %

NonPrefBrand-4 NO

OPHTHALMOLOGY

MISCELLANEOUS

OPHTHALMOLOGI

CS

latanoprost drops 0.005 % PrefGen-1 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGS

Latuda tablet 40 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Latuda tablet 80 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Latuda tablet 20 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Latuda tablet 120 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Latuda tablet 60 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Layolis Fe

tablet,chewab

le

0.8mg-

25mcg(

24) and

75 mg

(4) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Lazanda

spray,non-

aerosol

100

mcg/spr

ay

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Lazanda

spray,non-

aerosol

400

mcg/spr

ay

Specialty-5

12 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Lazanda

spray,non-

aerosol

300

mcg/spr

ay

Specialty-5

16 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

leflunomide tablet 10 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

leflunomide tablet 20 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Lenvima capsule

14

mg/day(

10 mg x

1-4 mg

x 1)

Specialty-5 YES

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lenvima capsule

24

mg/day(

10 mg x

2-4 mg

x 1)

Specialty-5 YES

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lenvima capsule

10

mg/day

(10 mg

x 1/day)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lenvima capsule

20

mg/day

(10 mg

x 2)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lenvima capsule

8

mg/day

(4 mg x

2)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lenvima capsule

18

mg/day

(10 mg

x 1-4

mg x2)

Specialty-5 YES

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lenvima capsule

8

mg/day

(4 mg x

2) (60

pack)

Specialty-5 YES

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lescol XL tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSLessina tablet 0.1-20

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSLetairis tablet 10 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSLetairis tablet 5 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSletrozole tablet 2.5 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

leucovorin

calcium

tablet 10 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

leucovorin

calcium


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

leucovorin

calcium


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

leucovorin

calcium


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

leucovorin

calcium


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

leucovorin

calcium


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Leukeran tablet 2 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Leukine recon soln 250

mcg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

leuprolide kit 1

mg/0.2

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

levalbuterol

HCl

solution for

nebulization

1.25

mg/0.5

mL


ALLERGY

PULMONARY

AGENTS

levalbuterol

HCl

solution for

nebulization

0.63

mg/3

mL


ALLERGY

PULMONARY

AGENTS

levalbuterol

HCl

solution for

nebulization

0.31

mg/3

mL


ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Levemir solution 100

unit/mL


TES

DIABETES

THERAPYLevemir

FlexTouch

insulin pen 100

unit/mL

(3 mL)


TES

DIABETES

THERAPY

levetiracetam tablet 250 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam tablet 1,000

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam solution 100

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam solution 500

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

levetiracetam tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam

in NaCl (iso-

os) piggyback

1,000

mg/100

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam

in NaCl (iso-

os) piggyback

1,500

mg/100

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levetiracetam

in NaCl (iso-

os) piggyback

500

mg/100

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

levobunolol drops 0.5 %PrefGen-1 NO

OPHTHALMOLOGY BETA-BLOCKERS

levocarnitine tablet 330 mg Generic-2 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

levocarnitine solution 200

mg/mL

Generic-2 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

levocarnitine

(with sugar)

solution 100

mg/mL

Generic-2 YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

levocetirizine solution 2.5

mg/5

mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTSlevocetirizine tablet 5 mg Generic-2 NO RESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

levofloxacin tablet 250 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES



levofloxacin drops 0.5 % Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS

levofloxacin solution 250

mg/10

mL


levofloxacin solution 25

mg/mL


levofloxacin

in D5W

piggyback 500

mg/100

mL


levofloxacin

in D5W piggyback

750

mg/150

mL Generic-2

NO

ANTI - INFECTIVES QUINOLONES

levoleucovori

n calcium solution

10

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Levonest (28) tablet

50-30

(6)/75-

40

(5)/125-

30(10)

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

levonorgestre

l-ethinyl

estrad

tablet 0.1-20

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

levonorgestre

l-ethinyl

estrad

tablet 90-20

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSlevonorgestre

l-ethinyl

estrad

tablets,dose

pack,3 month

0.15-30

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSlevonorg-eth

estrad

triphasic

tablet 50-30

(6)/75-

40

(5)/125-

30(10)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Levora-28 tablet 0.15-

0.03 mg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSlevorphanol

tartrate

tablet 2 mg PrefGen-1 186 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

levothyroxine tablet 100

mcg


TES

THYROID

HORMONESlevothyroxine tablet 200

mcg


TES

THYROID


mcg


TES

THYROID

HORMONESlevothyroxine tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABE

TES

THYROID


TES

THYROID


TES

THYROID

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

levothyroxine tablet 125

mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


TES

THYROID


mcg


TES

THYROID

HORMONESLevoxyl tablet 25 mcg Generic-2 NO ENDOCRINE/DIABE

TES

THYROID


TES

THYROID


TES

THYROID


TES

THYROID

HORMONESLevoxyl tablet 112

mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Levoxyl tablet 100

mcg


TES

THYROID

HORMONESLexiva tablet 700 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Lexiva suspension 50

mg/mL


Lialda tablet,delayed

release

(DR/EC)

1.2

gram


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

lidocaine

adhesive

patch,medicat

ed 5 %

Generic-2 YES DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine ointment 5 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine (PF) solution

5

mg/mL

(0.5 %)


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine HCl solution

20

mg/mL

(2 %)


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine HCl solution 2 %


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine HCl solution

4 % (40

mg/mL)


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine HCl gel 2 %


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS



LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

lidocaine HCl

jelly in

applicator 2 %


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

lidocaine-

prilocaine

cream 2.5-2.5

%


LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

Lidoderm

adhesive

patch,medicat

ed 5 %

NonPrefBrand-4 YES DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANESTHETICS

Lincocin solution 300

mg/mL


ANTIINFECTIVESlincomycin solution 300

mg/mL


ANTIINFECTIVESlindane shampoo 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

SCABICIDES /

PEDICULICIDESlinezolid suspension

for

reconstitution

100

mg/5

mL


ANTIINFECTIVES

linezolid parenteral

solution

600

mg/300

mL


ANTIINFECTIVES

linezolid tablet 600 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Linzess capsule

145

mcg PrefBrand-3

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Linzess capsule

290

mcg PrefBrand-3

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lioresal solution 500

mcg/mL


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYLioresal solution 50

mcg/mL


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYLioresal solution 2,000

mcg/mL


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYliothyronine tablet 5 mcg Generic-2 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESliothyronine solution 10

mcg/mL


TES

THYROID

HORMONESliothyronine tablet 25 mcg Generic-2 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESliothyronine tablet 50 mcg Generic-2 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESLipofen capsule 150 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSLipofen capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSlisinopril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

lisinopril tablet 30 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

lisinopril tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

lisinopril-

hydrochloroth

iazide

tablet 10-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

lisinopril-

hydrochloroth

iazide

tablet 20-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

lisinopril-

hydrochloroth

iazide

tablet 20-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

lithium

carbonate

capsule 300 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lithium

carbonate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lithium

carbonate

tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

lithium

carbonate

tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lithium

carbonate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lithium

carbonate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lithium citrate solution 8 mEq/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Lithostat tablet 250 mg NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Livalo tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSLivalo tablet 2 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSLivalo tablet 4 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Lo Loestrin

Fe tablet

1 mg-10

mcg

(24)/10

mcg (2)

NonPrefBrand-4 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lonsurf tablet

15-6.14

mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lonsurf tablet

20-8.19

mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

loperamide capsule 2 mg

Generic-2 NO

GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

lorazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lorazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

lorazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Lorazepam

Intensol

concentrate 2

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Lorcet

(hydrocodone

) tablet

5-325

mg Generic-2 372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lorcet HD tablet

10-325

mg Generic-2 372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Lorcet Plus tablet

7.5-325

mg Generic-2 372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Lortab 10-

325 tablet

10-325

mg Generic-2 372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Lortab 5-325 tablet

5-325

mg Generic-2 372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Lortab 7.5-

325 tablet

7.5-325

mg Generic-2 372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Loryna (28) tablet

3-0.02

mg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

losartan tablet 100 mg

PrefGen-1

31 31

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


PrefGen-1

93 31

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


PrefGen-1

62 31

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Classlosartan-

hydrochloroth

iazide tablet

100-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPYlosartan-

hydrochloroth

iazide tablet

50-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPYlosartan-

hydrochloroth

iazide tablet

100-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Lotronex tablet 1 mg Specialty-5 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSLotronex tablet 0.5 mg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSlovastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSlovastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSlovastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSLovenox syringe 60

mg/0.6

mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Lovenox syringe 150

mg/mL


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

loxapine

succinate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

loxapine

succinate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

loxapine

succinate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

loxapine

succinate


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Lumigan drops 0.01 % PrefBrand-3 2.5 31

NO

OPHTHALMOLOGY

OTHER

GLAUCOMA

DRUGS

Lumizyme recon soln 50 mgSpecialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESLupaneta

Pack (1

month)

kit. syringe

and tablet

3.75 mg

-5 mg

(30)


GYNECOLOGY

MISCELLANEOUS

OB/GYNLupaneta

Pack (3

month)

kit. syringe

and tablet

11.25

mg -5

mg (90)


GYNECOLOGY

MISCELLANEOUS

OB/GYN

Lupron Depot syringe kit 3.75 mg PrefBrand-3

NOANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lupron Depot syringe kit 7.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lupron Depot

(3 Month) syringe kit 22.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lupron Depot

(3 Month) syringe kit

11.25

mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lupron Depot

(4 Month) syringe kit 30 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lupron Depot

(6 Month) syringe kit 45 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lupron Depot-

Ped kit

11.25

mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lupron Depot-

Ped kit 15 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lutera (28) tablet 0.1-20

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Lynparza capsule 50 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lyrica capsule 100 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lyrica solution 20

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Lysodren tablet 500 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Lyza tablet 0.35 mg Generic-2NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

magnesium

sulfate

solution 4

mEq/m

L (50

%)


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

magnesium

sulfate

syringe 4

mEq/m

L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

Makena oil

250

mg/mL

(1 mL)


GYNECOLOGY

ESTROGENS /

PROGESTINS

malathion lotion 0.5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

SCABICIDES /

PEDICULICIDES

maprotiline tablet 25 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Marinol capsule 2.5 mg Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSMarinol capsule 5 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSMarinol capsule 10 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Marlissa tablet

0.15-

0.03 mg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Marplan tablet 10 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Matulane capsule 50 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Matzim LA

tablet

extended



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Matzim LA

tablet

extended



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Matzim LA

tablet

extended



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Matzim LA

tablet

extended



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Matzim LA

tablet

extended



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Maxalt tablet 5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYMaxalt tablet 10 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYMaxalt-MLT tablet,disinteg

rating

5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYMaxalt-MLT tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

meclizine tablet 12.5 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

meclizine tablet 25 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

meclofenamat

e


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

meclofenamat

e


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Medrol tablet 2 mg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONESmedroxyprog

esterone tablet 10 mgGeneric-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSmedroxyprog

esterone suspension

150

mg/mLGeneric-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /


esterone tablet 2.5 mgGeneric-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /


esterone tablet 5 mgGeneric-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

mefenamic

acid


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

mefloquine tablet 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESMegace ES suspension 625

mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

megestrol suspension 625

mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

megestrol tablet 20 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

megestrol tablet 40 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

megestrol suspension 400

mg/10

mL (40

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Mekinist tablet 0.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Mekinist tablet 2 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

meloxicam tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

meloxicam tablet 7.5 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

meloxicam suspension 7.5

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

melphalan

HCl

recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

memantine tablet 10 mg

PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY



DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

memantine

tablets,dose

pack 5-10 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

memantine solution

2

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Menactra

(PF)

solution 4

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Menest tablet 0.3 mg NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSMenest tablet 0.625

mg


GYNECOLOGY

ESTROGENS /

PROGESTINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Menest tablet 1.25 mg NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSMenest tablet 2.5 mg NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Menhibrix

(PF) recon soln

5-2.5

mcg/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Menomune -

A/C/Y/W-

135 (PF)

recon soln 50 mcg PrefBrand-3 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Mentax cream 1 %


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Menveo A-C-

Y-W-135-Dip

(PF)

kit 10-5

mcg/0.5

mL

NonPrefBrand-4 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Mepron suspension 750

mg/5

mL


ANTIINFECTIVES

mercaptopuri

ne


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

meropenem recon soln 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESmesalamine

with

cleansing

enema kit 4

gram/60

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

mesna solution 100

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Mesnex tablet 400 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Mestinon syrup 60 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYMestinon

Timespan

tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY

Metadate ER

tablet

extended

release 20 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGSmetaproteren

ol tablet 10 mgGeneric-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSmetaproteren

ol syrup

10 mg/5

mLGeneric-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSmetaproteren

ol tablet 20 mgGeneric-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Metaxall tablet 800 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

metaxalone tablet 400 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYmetaxalone tablet 800 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYmetformin tablet

extended

release 24 hr


TES

DIABETES

THERAPY

metformin tablet

extended

release 24 hr


TES

DIABETES

THERAPY

metformin tablet

extended

release 24hr

1,000

mg


TES

DIABETES

THERAPY

metformin tablet 1,000

mg


TES

DIABETES

THERAPYmetformin tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYmetformin tablet 850 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYmethadone tablet 10 mg Generic-2 206 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

methadone solution 10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

methadone tablet 5 mg Generic-2 248 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

methadone solution 5 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

methadone solution 10 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

methampheta

mine tablet 5 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methazolamid

e

tablet 25 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR

GLAUCOMAmethazolamid

e

tablet 50 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR

GLAUCOMAmethenamine

hippurate tablet 1 gramGeneric-2 NO

ANTI - INFECTIVES

URINARY TRACT

AGENTS

methimazole tablet 10 mg Generic-2 NO ENDOCRINE/DIABE

TES

ANTITHYROID

AGENTSmethimazole tablet 5 mg Generic-2 NO ENDOCRINE/DIABE

TES

ANTITHYROID

AGENTSMethitest tablet 10 mg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESmethotrexate

sodium

tablet 2.5 mg PrefGen-1 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

methotrexate

sodium (PF)

recon soln 1 gram Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

methotrexate

sodium (PF)

solution 25

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

methoxsalen

rapid

capsule 10 mg Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSmethscopola

mine

tablet 2.5 mg Generic-2 NO GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

methscopola

mine


OGY

ANTIDIARRHEALS /

ANTISPASMODICS

methyclothiaz

ide


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

methyldopa-

hydrochloroth

iazide

tablet 250-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

methyldopa-

hydrochloroth

iazide

tablet 250-15

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

methylergono

vine tablet 0.2 mgGeneric-2 NO OBSTETRICS /

GYNECOLOGY OXYTOCICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Methylin

tablet,chewab

le 10 mg

NonPrefBrand-4

186 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Methylin

tablet,chewab

le 5 mg

NonPrefBrand-4

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Methylin

tablet,chewab

le 2.5 mg

NonPrefBrand-4

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate solution

10 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

capsule, ER

biphasic 30-

70 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet

extended

release 10 mg

Generic-2

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate tablet 10 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet,chewab

le 10 mg

Generic-2

186 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

methylphenid

ate

tablet

extended

release 24hr 18 mg

Generic-2

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

capsule,ER

biphasic 50-

50 20 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet

extended

release 24hr 27 mg

Generic-2

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

capsule, ER

biphasic 30-

70 30 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet

extended

release 24hr 36 mg

Generic-2

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

capsule,ER

biphasic 50-

50 40 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

capsule, ER

biphasic 30-

70 50 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet

extended

release 24hr 54 mg

Generic-2

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

methylphenid

ate

capsule, ER

biphasic 30-

70 60 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet

extended

release 20 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet,chewab

le 5 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate solution

5 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate

tablet,chewab

le 2.5 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate tablet 20 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylphenid

ate tablet 5 mg

Generic-2

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

methylprednis

olone

tablet 32 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONESmethylprednis

olone


TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

methylprednis

olone


TES

ADRENAL


olone


TES

ADRENAL


olone

tablets,dose

pack

4 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL


olone acetate suspension

40

mg/mL Generic-2NO ENDOCRINE/DIABE

TES

ADRENAL


olone acetate suspension

80

mg/mL Generic-2NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES

methylprednis

olone sodium

succ

recon soln 40 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES

methylprednis

olone sodium

succ

recon soln 125 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES

methyltestost

erone

capsule 10 mg Specialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESmetipranolol drops 0.3 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS

metocloprami

de HCl

solution 5 mg/5

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSmetocloprami

de HCl


OGY

MISCELLANEOUS

GASTROINTESTINA


de HCl


OGY

MISCELLANEOUS

GASTROINTESTINA


de HCl

solution 5

mg/mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

metocloprami

de HCl

tablet,disinteg

rating

10 mg Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA


de HCl

tablet,disinteg

rating


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSmetolazone tablet 10 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metolazone tablet 2.5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metolazone tablet 5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

succinate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

succinate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

succinate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

succinate

tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol ta-

hydrochloroth

iaz

tablet 100-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol ta-

hydrochloroth

iaz

tablet 50-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

metoprolol ta-

hydrochloroth

iaz

tablet 100-50

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

tartrate

solution 5 mg/5

mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

tartrate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

tartrate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

tartrate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metoprolol

tartrate syringe

5 mg/5

mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

metronidazol

e

gel 0.75 % Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNmetronidazol

e

capsule 375 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESmetronidazol

e

lotion 0.75 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

metronidazol

e


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

metronidazol

e

gel 0.75 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

metronidazol

e

tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

metronidazol

e

tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESmetronidazol

e

gel 1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

metronidazol

e in NaCl (iso-

os)

piggyback 500

mg/100

mL


ANTIINFECTIVES

mexiletine capsule 150 mg Generic-2

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

Miacalcin solution 200

unit/mL


TES

MISCELLANEOUS

HORMONES

Miconazole-3 suppository 200 mgGeneric-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYN

Microgestin

1.5/30 (21) tablet

1.5-30

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Microgestin

1/20 (21) tablet

1-20 mg-

mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Microgestin

Fe 1.5/30

(28) tablet

1.5 mg-

30 mcg

(21)/75

mg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Microgestin

FE 1/20 (28) tablet

1 mg-20

mcg

(21)/75

mg (7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

midodrine tablet 10 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

midodrine tablet 2.5 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

midodrine tablet 5 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Migergot suppository

2-100

mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

miglitol tablet 25 mg Generic-2 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYmiglitol tablet 50 mg Generic-2 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYmiglitol tablet 100 mg Generic-2 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYMigranal spray,non-

aerosol

0.5

mg/pum

p act. (4

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Millipred solution 10 mg/5

mL


TES

ADRENAL

HORMONESMillipred tablet 5 mg Generic-2 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

minocycline capsule 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES


minocycline tablet 50 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES




minocycline tablet

extended

release 24 hr


minocycline tablet

extended

release 24 hr


minocycline tablet

extended

release 24 hr


minoxidil tablet 10 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

minoxidil tablet 2.5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Mirapex ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Mirapex ER tablet

extended

release 24 hr

0.375

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Mirapex ER tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Mirapex ER

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Mirapex ER

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Mircera syringe

50

mcg/0.3

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Mircera syringe

75

mcg/0.3

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Mircera syringe

100

mcg/0.3

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Mircera syringe

200

mcg/0.3

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

mirtazapine tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

mirtazapine tablet 15 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

mirtazapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

misoprostol tablet 100

mcg


OGY

ULCER THERAPY

misoprostol tablet 200

mcg


OGY

ULCER THERAPY

Mitigare capsule 0.6 mg

NonPrefBrand-4

62 31

NO MUSCULOSKELET

AL /

RHEUMATOLOGY GOUT THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

mitomycin recon soln 20 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

mitoxantrone concentrate 2

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

M-M-R II

(PF)

recon soln 1,000-

12,500

TCID50

/0.5 mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

modafinil tablet 200 mg Generic-2 31 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

modafinil tablet 100 mg Generic-2 31 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Moderiba tablet 200 mg Generic-2NO


Moderiba

Dose Pack

tablets,dose

pack

400 mg

(7)- 400

mg (7) Generic-2

NO


Moderiba

Dose Pack

tablets,dose

pack

600 mg

(7)- 600

mg (7) Generic-2

NO





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

moexipril tablet 15 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

moexipril tablet 7.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPYmoexipril-

hydrochloroth

iazide tablet

15-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPYmoexipril-

hydrochloroth

iazide tablet

7.5-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPYmoexipril-

hydrochloroth

iazide tablet

15-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

molindone tablet 10 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

mometasone ointment 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

mometasone solution 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

mometasone cream 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

mometasone spray,non-

aerosol

50

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

Mononessa

(28)

tablet 0.25-35

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSmontelukast tablet 10 mg PrefBrand-3 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSmontelukast tablet,chewab

le


ALLERGY

PULMONARY

AGENTSmontelukast tablet,chewab

le


ALLERGY

PULMONARY

AGENTSmontelukast granules in

packet


ALLERGY

PULMONARY

AGENTSMonurol packet 3 gram NonPrefBrand-4 NO ANTI - INFECTIVES URINARY TRACT

AGENTSmorphine tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

morphine tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine capsule, ER

multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine capsule,exten

d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine tablet 15 mg Generic-2 186 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine solution 10 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine tablet 30 mg Generic-2 186 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine solution 20 mg/5

mL (4

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


d.release

pellets


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine syringe 10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine syringe 8

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine syringe

2

mg/mL

Generic-2

1000 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine syringe

4

mg/mL

Generic-2

500 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

morphine

concentrate

solution 100

mg/5

mL (20

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Movantik tablet 12.5 mg PrefBrand-3

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Movantik tablet 25 mg PrefBrand-3

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

MoviPrep powder in

packet

100-7.5-

2.691

gram


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSMoxatag tablet, ER

multiphase 24

hr

775 mg NonPrefBrand-4 NO ANTI - INFECTIVES PENICILLINS

Moxeza drops, viscous 0.5 %NonPrefBrand-4 NO

OPHTHALMOLOGY ANTIBIOTICS

moxifloxacin tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES QUINOLONES

moxifloxacin-

sod.ace,sul-

water

piggyback 400

mg/250

mL

NonPrefBrand-4 NO ANTI - INFECTIVES QUINOLONES

Mozobil solution 24

mg/1.2

mL (20

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

MS Contin tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

MS Contin tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

MS Contin tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

MS Contin tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

MS Contin tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Multaq tablet 400 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

mupirocin ointment 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

mupirocin

calcium

cream 2 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

Mustargen recon soln 10 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Myalept recon soln

5

mg/mL

(final

conc.)

Specialty-5 YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Mycamine recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSMycamine recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

mycophenolat

e mofetil

tablet 500 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

mycophenolat

e mofetil


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

mycophenolat

e mofetil

suspension

for

reconstitution

200

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

mycophenolat

e sodium

tablet,delayed

release

(DR/EC)

180 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

mycophenolat

e sodium

tablet,delayed

release

(DR/EC)

360 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Myfortic tablet,delayed

release

(DR/EC)

360 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Myfortic tablet,delayed

release

(DR/EC)

180 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Myorisan capsule 10 mg


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



LS/TOPICAL

THERAPY

THERAPY FOR

ACNE



LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Myorisan capsule 30 mg Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Myrbetriq

tablet

extended


NO

UROLOGICALS

ANTICHOLINERGIC

S /

ANTISPASMODICS

Myrbetriq

tablet

extended


NO

UROLOGICALS

ANTICHOLINERGIC

S /

ANTISPASMODICS

Mysoline tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Mysoline tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

nabumetone tablet 500 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

nabumetone tablet 750 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

nadolol tablet 20 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nadolol-

bendroflumet

hiazide

tablet 40-5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nadolol-

bendroflumet

hiazide


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nafcillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS

nafcillin recon soln 1 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS

nafcillin in

dextrose iso-

osm

piggyback 1

gram/50

mL


naftifine cream 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

naftifine cream 2 % PrefBrand-3

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Naftin gel 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Naftin cream 2 %


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Naftin gel 2 %


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Naglazyme solution 5 mg/5

mL


TES

MISCELLANEOUS

HORMONESnalbuphine solution 10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

nalbuphine solution 20

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naloxone syringe

1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naloxone solution

0.4

mg/mL Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naltrexone tablet 50 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Namenda tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Namenda tablet 5 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda solution

2

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda

Titration Pak

tablets,dose

pack 5-10 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda XR

capsule,sprink

le,ER 24hr 14 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda XR

capsule,sprink

le,ER 24hr 21 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda XR

capsule,sprink

le,ER 24hr 28 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda XR

capsule,sprink

le,ER 24hr 7 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namenda XR

cap,sprinkle,E

R 24hr dose

pack

7-14-21-

28 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Namzaric

capsule,sprink

le,ER 24hr

14-10

mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Namzaric

capsule,sprink

le,ER 24hr

28-10

mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Naprelan CR

tablet, ER

multiphase 24

hr 375 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Naprelan CR

tablet, ER

multiphase 24

hr 500 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Naprelan CR

tablet, ER

multiphase 24

hr 750 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen tablet 375 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

naproxen suspension 125

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen tablet,delayed

release

(DR/EC)


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen tablet,delayed

release

(DR/EC)


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen

sodium


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen

sodium


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen

sodium

tablet, ER

multiphase 24

hr 375 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naproxen

sodium

tablet, ER

multiphase 24

hr 500 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

naratriptan tablet 1 mg Generic-2 20 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

naratriptan tablet 2.5 mg Generic-2 8 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Narcan

spray,non-

aerosol

4

mg/actu

ation


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Nasonex spray,non-

aerosol

50

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

Natacyn drops,suspens

ion

5 % PrefBrand-3 NO OPHTHALMOLOGY ANTIBIOTICS

nateglinide tablet 120 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYnateglinide tablet 60 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Natesto

gel in metered-

dose pump

5.5

mg/0.12

2

gram/ac

tuation

NonPrefBrand-4 YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Natpara cartridge

25

mcg/dos

e

Specialty-5 YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Natpara cartridge

50

mcg/dos

e


TES

MISCELLANEOUS

HORMONES

Natpara cartridge

75

mcg/dos

e


TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Natpara cartridge

100

mcg/dos

e


TES

MISCELLANEOUS

HORMONES

Nebupent recon soln 300 mg NonPrefBrand-4 YES ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESNecon 0.5/35

(28)

tablet 0.5-35

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSNecon 1/35

(28)

tablet 1-35 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSNecon 10/11

(28)

tablet 0.5-35/1-

35 mg-

mcg/mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Necon 7/7/7

(28)

tablet 0.5/0.75

/1 mg-

35 mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

nefazodone tablet 100 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

neomycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

neomycin-

bacitracin-

poly-HC ointment

3.5-400-

10,000

mg-

unit/g-

1%

Generic-2 NO

OPHTHALMOLOGY

STEROID-

ANTIBIOTIC

COMBINATIONS

neomycin-

bacitracin-

polymyxin

ointment 3.5-400-

10,000

mg-unit-

unit/g


neomycin-

polymyxin B

GU

solution 40 mg-

200,000

unit/mL

PrefGen-1 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

IRRIGATING

SOLUTIONS

neomycin-

polymyxin B-

dexameth

ointment 3.5

mg/g-

10,000

unit/g-

0.1 %

Generic-2 NO OPHTHALMOLOGY STEROID-

ANTIBIOTIC

COMBINATIONS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

neomycin-

polymyxin B-

dexameth

drops,suspens

ion

3.5mg/

mL-

10,000

unit/mL-

0.1 %


ANTIBIOTIC

COMBINATIONS

neomycin-

polymyxin-

gramicidin

drops 1.75 mg-

10,000

unit-

0.025m

g/mL


neomycin-

polymyxin-

HC

solution 3.5-

10,000-

1

mg/mL-

unit/mL-

%


THROAT

MEDICATIONS

OTIC STEROID /

ANTIBIOTIC

neomycin-

polymyxin-

HC

drops,suspens

ion

3.5-

10,000-

10 mg-

unit-

mg/mL


ANTIBIOTIC

COMBINATIONS

neomycin-

polymyxin-

HC

drops,suspens

ion

3.5-

10,000-

1

mg/mL-

unit/mL-

%


THROAT

MEDICATIONS

OTIC STEROID /

ANTIBIOTIC

Neoral solution 100

mg/mL

PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Neoral capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Neoral capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Neo-Synalar cream

0.5 %

(0.35 %

base)-

0.025 %

NonPrefBrand-4 NO

DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

Nephramine

5.4 %

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Nesina tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Nesina tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Nesina tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Neuac gel

1.2 %(1

% base) -

5 % Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Neulasta syringe 6

mg/0.6

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Neupogen solution 480

mcg/1.6

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Neupogen syringe 300

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Neupogen syringe 480

mcg/0.8

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Neupogen solution

300

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Neupro patch 24 hour 2 mg/24

hour


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


hour


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


hour


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Neupro patch 24 hour

1 mg/24

hour


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


3 mg/24

hour


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


8 mg/24

hour


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Neurontin capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Neurontin tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Neurontin tablet 800 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Neurontin solution 250

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Nevanac drops,suspens

ion

0.1 % NonPrefBrand-4 NO OPHTHALMOLOGY NON-STEROIDAL

ANTI-

INFLAMMATORY

AGENTSnevirapine tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

nevirapine suspension 50 mg/5

mL





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

nevirapine

tablet

extended


Generic-2 NO


nevirapine

tablet

extended

release 24 hr 100 mg Generic-2

NO


Nexavar tablet 200 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

niacin

tablet

extended

release 24 hr

1,000

mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

niacin

tablet

extended

release 24 hr 500 mg PrefBrand-3 31 31

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

niacin

tablet

extended


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Niacor tablet 500 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSnicardipine solution 25

mg/10

mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nicardipine capsule 20 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nicardipine capsule 30 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Nicotrol cartridge 10 mg


MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS

Nicotrol NS spray,non-

aerosol

10

mg/mL

PrefBrand-3 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

SMOKING

DETERRENTS

Nifedical XL tablet

extended

release 24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Nifedical XL tablet

extended

release 24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nifedipine tablet

extended

release 24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nifedipine tablet

extended

release 24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nifedipine tablet

extended

release 24hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Nilandron tablet 150 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

nimodipine capsule 30 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Ninlaro capsule 2.3 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ninlaro capsule 3 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Nipent recon soln 10 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

nisoldipine tablet

extended

release 24 hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Nitro-Bid ointment 2 % Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

NITRATES

Nitro-Dur patch 24 hour 0.2

mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES

nitrofurantoin suspension 25 mg/5

mL

Generic-2 1800 365 YES ANTI - INFECTIVES URINARY TRACT

AGENTSnitrofurantoin

macrocrystal

capsule 25 mg Generic-2 360 365 YES ANTI - INFECTIVES URINARY TRACT


macrocrystal



macrocrystal capsule 100 mg Generic-2 90 365YES

ANTI - INFECTIVES

URINARY TRACT

AGENTS

nitrofurantoin

monohyd/m-

cryst


AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Classnitrofurantoin

monohyd/m-

cryst capsule

100 mg

(75/25) Generic-2 90 365

YES

ANTI - INFECTIVES

URINARY TRACT

AGENTS

nitroglycerin solution 50

mg/10

mL (5

mg/mL)


, HYPERTENSION /

LIPIDS

NITRATES

nitroglycerin patch 24 hour 0.6

mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES

nitroglycerin spray,non-

aerosol

400

mcg/spr

ay


, HYPERTENSION /

LIPIDS

NITRATES


mg/hr


, HYPERTENSION /

LIPIDS

NITRATES

Nitrostat tablet 0.3 mg NonPrefBrand-4 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

NITRATES


, HYPERTENSION /

LIPIDS

NITRATES


, HYPERTENSION /

LIPIDS

NITRATES

nizatidine capsule 300 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

nizatidine capsule 150 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

nizatidine solution 150

mg/10

mL


OGY

ULCER THERAPY

Norco tablet 10-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Norco tablet 5-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Norco tablet 7.5-325

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Norditropin

FlexPro

pen injector 15

mg/1.5

mL (10

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Norditropin

FlexPro

pen injector 5

mg/1.5

mL (3.3

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Norditropin

FlexPro

pen injector 10

mg/1.5

mL (6.7

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Norditropin

FlexPro

pen injector 30 mg/3

mL (10

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

noreth-ethinyl

estradiol-iron

tablet,chewab

le

0.8mg-

25mcg(

24) and

75 mg

(4) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

norethindrone

(contraceptiv

e)

tablet 0.35 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

norethindrone

acetate tablet 5 mgGeneric-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSnorethindrone

ac-eth

estradiol tablet

1-5 mg-

mcg

Generic-2 NOOBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSnorethindrone

ac-eth

estradiol tablet

0.5-2.5

mg-mcg Generic-2

NOOBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

norgestimate-

ethinyl

estradiol

tablet 0.18/0.2

15/0.25

mg-25

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSNoritate cream 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Normosol-M

in 5 %

dextrose

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSNormosol-R

in 5 %

dextrose

parenteral

solution 5 %


HEMATINICS /


Normosol-R

pH 7.4

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Northera capsule 100 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS



MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS



MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Nortrel 0.5/35

(28)

tablet 0.5-35

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSNortrel 1/35

(21)

tablet 1-35 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSNortrel 1/35

(28)

tablet 1-35 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSNortrel 7/7/7

(28)

tablet 0.5/0.75

/1 mg-

35 mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSnortriptyline capsule 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

nortriptyline capsule 50 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

nortriptyline solution 10 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Norvir capsule 100 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Norvir solution 80

mg/mL


Norvir tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Novarel recon soln 10,000

unit


TES

MISCELLANEOUS

HORMONESNovolin

70/30

suspension 100

unit/mL

(70-30)


TES

DIABETES

THERAPY

Novolin N suspension 100

unit/mL


TES

DIABETES

THERAPYNovolin R solution 100

unit/mL


TES

DIABETES

THERAPYNovolog solution 100

unit/mL


TES

DIABETES

THERAPYNovolog

Flexpen

insulin pen 100

unit/mL


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Novolog Mix

70-30 solution

100

unit/mL

(70-30)

PrefBrand-3 NOENDOCRINE/DIABE

TES

DIABETES

THERAPYNovolog Mix

70-30

FlexPen insulin pen

100

unit/mL

(70-30)

PrefBrand-3 NOENDOCRINE/DIABE

TES

DIABETES

THERAPYNovolog

PenFill cartridge

100


TES

DIABETES

THERAPY

Noxafil suspension 200

mg/5

mL (40

mg/mL)

Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTS

Nucala recon soln 100 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Nucynta tablet 100 mg NonPrefBrand-4 186 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Nucynta ER

tablet

extended


NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Nucynta ER

tablet

extended


NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Nucynta ER

tablet

extended


NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Nucynta ER

tablet

extended


NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Nucynta ER

tablet

extended

release 12 hr 50 mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Nuedexta capsule

20-10

mg PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Nulojix recon soln 250 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Nuplazid tablet 17 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Nutrestore

powder in

packet 5 gram


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Nutrilipid emulsion 20 % NonPrefBrand-4 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Nutrilipid emulsion 20 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Nutropin AQ cartridge 10 mg/2

mL (5

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Nutropin AQ cartridge 20 mg/2

mL (10

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Nutropin AQ

Nuspin pen injector

5 mg/2

mL (2.5

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Nutropin AQ

Nuspin pen injector

20 mg/2

mL (10

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Nutropin AQ

Nuspin pen injector

10 mg/2

mL (5

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

NuvaRing ring

0.12-

0.015

mg/24

hr PrefBrand-3

NO

OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYN

Nuvessa gel 1.3 %NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYN

Nuvigil tablet 150 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Nyamyc powder 100,000

unit/gra

m


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

nystatin suspension 100,000

unit/mL


AGENTS

nystatin tablet 500,000

unit


AGENTSnystatin cream 100,000

unit/gra

m


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

nystatin powder 100,000

unit/gra

m


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

nystatin ointment 100,000

unit/gra

m


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

nystatin-

triamcinolone ointment

100,000-

0.1

unit/gra

m-% PrefBrand-3

NODERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

nystatin-

triamcinolone cream

100,000-

0.1

unit/g-

% PrefBrand-3

NODERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Nystop powder 100,000

unit/gra

m


LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Octagam solution 5 % Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Octagam solution 10 %


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

octreotide

acetate

solution 50

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

octreotide

acetate

solution 100

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

octreotide

acetate

solution 500

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

octreotide

acetate

solution 1,000

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

octreotide

acetate

solution 200

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Odefsey tablet

200-25-

25 mgSpecialty-5 NO


Odomzo capsule 200 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Ofev capsule 100 mgSpecialty-5


ALLERGY

PULMONARY

AGENTS



ALLERGY

PULMONARY

AGENTS

ofloxacin tablet 400 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES

ofloxacin drops 0.3 % Generic-2 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

OTIC

PREPARATIONSofloxacin drops 0.3 % Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS

Ogestrel (28) tablet 0.5-50

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSolanzapine tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

olanzapine tablet 20 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine tablet 5 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine recon soln 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine-

fluoxetine

capsule 6-25 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine-

fluoxetine

capsule 12-25

mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine-

fluoxetine

capsule 12-50

mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine-

fluoxetine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olanzapine-

fluoxetine


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

olopatadine

spray,non-

aerosol 0.6 %


THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

olopatadine drops 0.1 % PrefBrand-3

NO

OPHTHALMOLOGY

MISCELLANEOUS

OPHTHALMOLOGI

CS

Olysio capsule 150 mgSpecialty-5

28 28YES


omega-3 acid

ethyl esters

capsule 1 gram PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSomeprazole capsule,delay

ed

release(DR/E

C)

40 mg PrefGen-1 NO GASTROENTEROL

OGY

ULCER THERAPY

omeprazole capsule,delay

ed

release(DR/E

C)


OGY

ULCER THERAPY

omeprazole capsule,delay

ed

release(DR/E

C)


OGY

ULCER THERAPY

omeprazole-

sodium

bicarbonate

capsule 20-1.1

mg-

gram


OGY

ULCER THERAPY

omeprazole-

sodium

bicarbonate

capsule 40-1.1

mg-

gram


OGY

ULCER THERAPY

Omnaris spray,non-

aerosol

50 mcg NonPrefBrand-4 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSOmnitrope recon soln 5.8 mg Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Omnitrope cartridge 10

mg/1.5

mL (6.7

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Omnitrope cartridge 5

mg/1.5

mL (3.3

mg/mL)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Oncaspar solution 750

unit/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ondansetron tablet,disinteg

rating

4 mg Generic-2 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSondansetron tablet,disinteg

rating

8 mg Generic-2 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSondansetron

HCl


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSondansetron

HCl


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSondansetron

HCl

solution 4 mg/5

mL

Generic-2 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSondansetron

HCl


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSondansetron

HCl (PF)

solution 4 mg/2

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ondansetron

HCl (PF) syringe

4 mg/2

mL Generic-2

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Onfi tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Onfi tablet 20 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Onfi suspension

2.5

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Onglyza tablet 5 mg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYOnglyza tablet 2.5 mg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Onzetra Xsail

aerosol powdr

breath

activated 11 mg

NonPrefBrand-4

16 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Opana tablet 5 mg

NonPrefBrand-4

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana tablet 10 mg

NonPrefBrand-4

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Opana ER

tablet,oral

only,ext.rel.1

2 hr 10 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana ER

tablet,oral

only,ext.rel.1

2 hr 15 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana ER

tablet,oral

only,ext.rel.1

2 hr 20 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana ER

tablet,oral

only,ext.rel.1

2 hr 30 mg

NonPrefBrand-4

69 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana ER

tablet,oral

only,ext.rel.1

2 hr 40 mg

NonPrefBrand-4

51 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana ER

tablet,oral

only,ext.rel.1

2 hr 5 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opana ER

tablet,oral

only,ext.rel.1

2 hr 7.5 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Opdivo solution

40 mg/4

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Opsumit tablet 10 mgSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Oralair tablet

300

indx

reactivit

y


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Orap tablet 2 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Orap tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Oravig

muco-

adhesive

buccal tablet 50 mg

NonPrefBrand-4 NO

ANTI - INFECTIVES

ANTIFUNGAL

AGENTS

Orbactiv recon soln 400 mgSpecialty-5 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

Orencia syringe

125

mg/mL

Specialty-5

4 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Orencia (with

maltose)

recon soln 250 mg Specialty-5 40 28 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Orenitram

tablet

extended

release

0.125

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Orenitram

tablet

extended

release 0.25 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Orenitram

tablet

extended

release 1 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Orenitram

tablet

extended

release 2.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Orfadin capsule 2 mg Specialty-5 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Orfadin suspension

4

mg/mL


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Orkambi tablet

200-125

mgSpecialty-5


ALLERGY

PULMONARY

AGENTS

Orsythia tablet

0.1-20

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Ortho Tri-

Cyclen Lo

(28)

tablet 0.18/0.2

15/0.25

mg-25

mcg

PrefBrand-3 NO OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Oseni tablet

12.5-15


TES

DIABETES

THERAPY

Oseni tablet

12.5-30


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Oseni tablet

12.5-45


TES

DIABETES

THERAPY

Oseni tablet

25-15


TES

DIABETES

THERAPY

Oseni tablet

25-30


TES

DIABETES

THERAPY

Oseni tablet

25-45


TES

DIABETES

THERAPY

OsmoPrep tablet 1.5

gram


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Otezla tablet 30 mg

Specialty-5 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Otezla Starter

tablets,dose

pack

10 mg

(4)-20

mg (4)-

30 mg

(47)

Specialty-5 YES

MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Otrexup (PF) auto-injector

10

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


15

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


20

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


25

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


7.5

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


17.5

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


22.5

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

oxacillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS

oxacillin recon soln 2 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS

oxacillin in

dextrose(iso-

osm)

piggyback 2

gram/50

mL


oxacillin in

dextrose(iso-

osm)

piggyback 1

gram/50

mL


oxaliplatin solution 100

mg/20

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

oxandrolone tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESoxandrolone tablet 10 mg Specialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESoxaprozin tablet 600 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

oxazepam capsule 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

oxcarbazepin

e

suspension 300

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

oxcarbazepin

e


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

oxcarbazepin

e


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

oxcarbazepin

e


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

oxiconazole cream 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Oxistat cream 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Oxistat lotion 1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIFUNGALS

Oxtellar XR

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Oxtellar XR

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Oxtellar XR

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

oxybutynin

chloride

syrup 5 mg/5

mL

Generic-2 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

oxybutynin

chloride

tablet

extended

release 24hr


S /

ANTISPASMODICS

oxybutynin

chloride

tablet

extended

release 24hr


S /

ANTISPASMODICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

oxybutynin

chloride

tablet

extended

release 24hr


S /

ANTISPASMODICS

oxybutynin

chloride

tablet 5 mg Generic-2 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

oxycodone

tablet,oral

only,ext.rel.1

2 hr 10 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone

tablet,oral

only,ext.rel.1

2 hr 15 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone

tablet,oral

only,ext.rel.1

2 hr 20 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone

tablet,oral

only,ext.rel.1

2 hr 30 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone

tablet,oral

only,ext.rel.1

2 hr 40 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone

tablet,oral

only,ext.rel.1

2 hr 60 mg

NonPrefBrand-4

69 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

oxycodone

tablet,oral

only,ext.rel.1

2 hr 80 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone solution

5 mg/5

mL

Generic-2

4133 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone tablet 15 mg

Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone concentrate

20

mg/mL

Generic-2

180 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone tablet 30 mg PrefBrand-3 138 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

oxycodone capsule 5 mg

Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone-

acetaminophe

n tablet

10-325


YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone-

acetaminophe

n tablet

5-325

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone-

acetaminophe

n tablet

7.5-325

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone-

acetaminophe

n solution

5-325

mg/5

mL

Generic-2

1860 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone-

acetaminophe

n tablet

2.5-325

mg

Generic-2

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxycodone-

aspirin

tablet 4.8355-

325 mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

OxyContin

tablet,oral

only,ext.rel.1

2 hr 10 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

OxyContin

tablet,oral

only,ext.rel.1

2 hr 15 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

OxyContin

tablet,oral

only,ext.rel.1

2 hr 20 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

OxyContin

tablet,oral

only,ext.rel.1

2 hr 30 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

OxyContin

tablet,oral

only,ext.rel.1

2 hr 40 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

OxyContin

tablet,oral

only,ext.rel.1

2 hr 60 mg

NonPrefBrand-4

69 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

OxyContin

tablet,oral

only,ext.rel.1

2 hr 80 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone

tablet

extended

release 12 hr 10 mg

Generic-2

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone

tablet

extended

release 12 hr 15 mg

Generic-2

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

oxymorphone

tablet

extended

release 12 hr 20 mg

Generic-2

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone

tablet

extended

release 12 hr 30 mg

Generic-2

69 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone

tablet

extended

release 12 hr 40 mg

Generic-2

51 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone

tablet

extended

release 12 hr 5 mg

Generic-2

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone

tablet

extended


Generic-2

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone tablet 5 mg

Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

oxymorphone tablet 10 mg

Generic-2

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Oxytrol patch

semiweekly

3.9

mg/24

hr

NonPrefBrand-4 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Pacerone tablet 200 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

paclitaxel concentrate 6

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

paliperidone tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paliperidone tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paliperidone tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paliperidone tablet

extended

release 24hr

1.5 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

pamidronate solution 30

mg/10

mL (3

mg/mL)


TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


mg/10

mL (6

mg/mL)


TES

MISCELLANEOUS

HORMONES


mg/10

mL (9

mg/mL)


TES

MISCELLANEOUS

HORMONES

Pancreaze

capsule,delay

ed

release(DR/E

C)

10,500-

25,000-

43,750

unit

PrefBrand-3 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Pancreaze

capsule,delay

ed

release(DR/E

C)

16,800-

40,000-

70,000

unit

PrefBrand-3 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Pancreaze

capsule,delay

ed

release(DR/E

C)

21,000-

37,000 -

61,000

unit

PrefBrand-3 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Pancreaze

capsule,delay

ed

release(DR/E

C)

4,200-

10,000-

17,500

unit

PrefBrand-3 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Pandel cream 0.1 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

Panretin gel 0.1 % Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSpantoprazole tablet,delayed

release

(DR/EC)


OGY

ULCER THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

pantoprazole recon soln 40 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

pantoprazole tablet,delayed

release

(DR/EC)


OGY

ULCER THERAPY

paricalcitol solution 5

mcg/mL


TES

MISCELLANEOUS

HORMONESparicalcitol solution 2

mcg/mL


TES

MISCELLANEOUS

HORMONESparicalcitol capsule 1 mcg Generic-2 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESparicalcitol capsule 2 mcg PrefGen-1 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESparicalcitol capsule 4 mcg PrefGen-1 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESparomomycin capsule 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESparoxetine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paroxetine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paroxetine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paroxetine

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

paroxetine

HCl

tablet

extended

release 24 hr

12.5 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paroxetine

HCl

tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

paroxetine

HCl

tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Paser granules DR

for susp in

packet

4 gram NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Pataday drops 0.2 % PrefBrand-3

NO

OPHTHALMOLOGY

MISCELLANEOUS

OPHTHALMOLOGI

CS

Paxil suspension 10 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Pazeo drops 0.7 % PrefBrand-3

NO

OPHTHALMOLOGY

MISCELLANEOUS

OPHTHALMOLOGI

CS

PCE tablet,

particles/cryst

als

333 mg NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDESPCE tablet,

particles/cryst

als

500 mg NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /

OTHER

MACROLIDES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Pedvax HIB

(PF)

solution 7.5

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

peg 3350-

electrolytes recon soln

236-

22.74-

6.74 -

5.86

gram

Generic-2 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Peganone tablet 250 mg PrefBrand-3 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Pegasys solution 180

mcg/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Pegasys syringe 180

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Pegasys

ProClick pen injector

135

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Pegasys

ProClick pen injector

180

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

peg-

electrolyte

soln

recon soln 420

gram


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSPegIntron kit 50

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

PegIntron kit 80

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

PegIntron kit 120

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

PegIntron kit 150

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

PegIntron

Redipen

pen injector

kit

120

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

PegIntron

Redipen

pen injector

kit

80

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

PegIntron

Redipen

pen injector

kit

150

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

PegIntron

Redipen

pen injector

kit

50

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

pen needle,

diabetic

needle 29

gauge x

1/2"


TES

DIABETES

THERAPY

penicillin G

pot in

dextrose

piggyback 2

million

unit/50


penicillin G

pot in

dextrose

piggyback 3

million

unit/50


penicillin G

potassium

recon soln 5

million





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

penicillin G

procaine

syringe 1.2

million

unit/2

mL


penicillin G

sodium

recon soln 5

million


penicillin V

potassium

recon soln 250

mg/5

mL


penicillin V

potassium

recon soln 125

mg/5

mL


penicillin V

potassium

tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

penicillin V

potassium

tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS

Pentam recon soln 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESPentasa capsule,

extended

release


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSPentasa capsule,

extended

release


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSpentazocine-

naloxone

tablet 50-0.5

mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

pentoxifylline tablet

extended

release


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Percocet tablet

10-325

mg

NonPrefBrand-4

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Percocet tablet

2.5-325

mg

NonPrefBrand-4

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Percocet tablet

5-325

mg

NonPrefBrand-4

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Percocet tablet

7.5-325

mg

NonPrefBrand-4

372 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Perforomist

solution for

nebulization

20

mcg/2

mL

NonPrefBrand-4 YESRESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

perindopril

erbumine


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

perindopril

erbumine


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

perindopril

erbumine


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Periogard mouthwash 0.12 % Generic-2 NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Perjeta solution

420

mg/14

mL (30

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

permethrin cream 5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

SCABICIDES /

PEDICULICIDESperphenazine tablet 16 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

perphenazine tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

perphenazine-

amitriptyline

tablet 2-10 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

perphenazine-

amitriptyline


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

perphenazine-

amitriptyline


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

perphenazine-

amitriptyline


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

perphenazine-

amitriptyline


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Phenadoz suppository 12.5 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

phenelzine tablet 15 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Phenergan suppository 12.5 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Phenergan suppository 25 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Phenergan suppository 50 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

phenobarbital tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

phenobarbital tablet 16.2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

phenobarbital elixir 20 mg/5

mL (4

mg/mL)


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

phenoxybenz

amine

capsule 10 mg Specialty-5 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Phenytek capsule 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Phenytek capsule 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

phenytoin suspension

125

mg/5

mL Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

phenytoin

tablet,chewab

le 50 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

phenytoin

sodium

solution 50

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

phenytoin

sodium

extended


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

phenytoin

sodium

extended


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

phenytoin

sodium

extended


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Phoslyra solution

667 mg

(169 mg

calcium

)/5 mL

NonPrefBrand-4 NO

VITAMINS,

HEMATINICS /


Phospholine

Iodide

drops 0.125 % PrefBrand-3 NO OPHTHALMOLOGY CHOLINESTERASE

INHIBITOR

MIOTICS

Picato gel 0.05 % PrefBrand-3

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS

Picato gel 0.015 % PrefBrand-3

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSpilocarpine

HCl drops 1 %Generic-2 NO

OPHTHALMOLOGY

DIRECT ACTING

MIOTICSpilocarpine


OPHTHALMOLOGY

DIRECT ACTING

MIOTICSpilocarpine


OPHTHALMOLOGY

DIRECT ACTING

MIOTICS

pilocarpine

HCl tablet 5 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

pilocarpine

HCl tablet 7.5 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

pimozide tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

pimozide tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Pimtrea (28) tablet

0.15-

0.02

mgx21

/0.01

mg x 5 Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

pindolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

pindolol tablet 5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

pioglitazone tablet 30 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYpioglitazone tablet 45 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYpioglitazone tablet 15 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYpioglitazone-

glimepiride

tablet 30-2 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES


glimepiride

tablet 30-4 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES


metformin

tablet 15-500

mg


TES

DIABETES


metformin

tablet 15-850

mg


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

piperacillin-

tazobactam

recon soln 3.375

gram


piperacillin-

tazobactam recon soln

4.5

gramGeneric-2 NO

ANTI - INFECTIVES PENICILLINS

Pirmella tablet

1-35 mg-

mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

piroxicam capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

piroxicam capsule 20 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Plasma-Lyte

148

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSPlasma-Lyte

A

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSPlasma-Lyte-

56 in 5 %

dextrose

parenteral

solution 5 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Plegridy syringe

125

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Plegridy syringe

63

mcg/0.5

mL- 94

mcg/0.5

mL

Specialty-5 NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Plegridy pen injector

125

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Plegridy pen injector

63

mcg/0.5

mL- 94

mcg/0.5

mL

Specialty-5 NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

podofilox solution 0.5 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSpolyethylene

glycol 3350

powder 17

gram/do

se


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSpolymyxin B

sulfate

recon soln 500,000

unit


ANTIINFECTIVESpolymyxin B

sulf-

trimethoprim

drops 10,000

unit- 1

mg/mL


Pomalyst capsule 1 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Portia tablet 0.15-

0.03 mg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSpotassium

chlorid-D5-

0.45%NaCl

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chlorid-D5-

0.45%NaCl

parenteral

solution

30

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chlorid-D5-

0.45%NaCl

parenteral

solution

40

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chlorid-D5-

0.45%NaCl

parenteral

solution

10

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

solution 2

mEq/m

L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

tablet,ER

particles/cryst

als

20 mEq PrefGen-1 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

capsule,

extended

release


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

piggyback 10

mEq/10

0 mL


HEMATINICS /

ELECTROLYTES

ELECTROLYTES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

potassium

chloride

piggyback 20

mEq/10

0 mL


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

liquid 20

mEq/15

mL


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

piggyback 40

mEq/10

0 mL


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

tablet

extended

release


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

liquid 40

mEq/15

mL


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

capsule,

extended

release


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride

tablet,ER

particles/cryst

als


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride in

0.9%NaCl

parenteral

solution

40

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride in

0.9%NaCl

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride in 5

% dex

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride in 5

% dex

parenteral

solution

40

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

potassium

chloride in

LR-D5

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride-0.45

% NaCl

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride-D5-

0.2%NaCl

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride-D5-

0.3%NaCl

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride-D5-

0.9%NaCl

parenteral

solution

20

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

chloride-D5-

0.9%NaCl

parenteral

solution

40

mEq/L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

potassium

citrate

tablet

extended

release

5 mEq

(540

mg)

Generic-2 NO UROLOGICALS MISCELLANEOUS

UROLOGICALS

potassium

citrate

tablet

extended

release

10 mEq

(1,080

mg)

PrefBrand-3 NO UROLOGICALS MISCELLANEOUS

UROLOGICALS

potassium

citrate

tablet

extended

release

15 mEq Generic-2 NO UROLOGICALS MISCELLANEOUS

UROLOGICALS

Potiga tablet 200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S



DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Potiga tablet 50 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Pradaxa capsule 150 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Praluent Pen pen injector

150

mg/mL

Specialty-5

2 28

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Praluent Pen pen injector

75

mg/mL

Specialty-5

2 28

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Praluent

Syringe syringe

150

mg/mL

Specialty-5

2 28

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Praluent

Syringe syringe

75

mg/mL

Specialty-5

2 28

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

pramipexole tablet 0.75 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole tablet 0.125

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole tablet 1 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole tablet

extended

release 24 hr

0.375

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

pramipexole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pramipexole

tablet

extended



DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

pravastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSpravastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSprazosin capsule 5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

prazosin capsule 1 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

prazosin capsule 2 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Pred-G drops,suspens

ion

0.3-1 % NonPrefBrand-4 NO OPHTHALMOLOGY STEROID-

ANTIBIOTIC

COMBINATIONSPred-G

S.O.P.

ointment 0.3-0.6

%

NonPrefBrand-4 NO OPHTHALMOLOGY STEROID-

ANTIBIOTIC

COMBINATIONSprednicarbate cream 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

prednicarbate ointment 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

prednisolone

acetate

drops,suspens

ion 1 % PrefBrand-3NO

OPHTHALMOLOGY STEROIDS

prednisolone

sodium

phosphate

solution 25 mg/5

mL (5

mg/mL)


TES

ADRENAL

HORMONES

prednisolone

sodium

phosphate

solution 15 mg/5

mL (3

mg/mL)


TES

ADRENAL

HORMONES

prednisolone

sodium

phosphate

solution 5 mg

base/5

mL (6.7

mg/5

mL)


TES

ADRENAL

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

prednisolone

sodium

phosphate

drops 1 % Generic-2 NO OPHTHALMOLOGY STEROIDS

prednisolone

sodium

phosphate

tablet,disinteg

rating


TES

ADRENAL

HORMONES

prednisolone

sodium

phosphate

tablet,disinteg

rating


TES

ADRENAL

HORMONES

prednisolone

sodium

phosphate

tablet,disinteg

rating


TES

ADRENAL

HORMONES

prednisone tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONESprednisone tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONESprednisone tablet 2.5 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

ADRENAL


TES

ADRENAL


TES

ADRENAL


TES

ADRENAL

HORMONESprednisone solution 5 mg/5

mL


TES

ADRENAL

HORMONESPrednisone

Intensol

concentrate 5

mg/mL


TES

ADRENAL

HORMONESPrefest tablet 1 mg

(15)/1

mg-

0.09 mg

(15)


GYNECOLOGY

ESTROGENS /

PROGESTINS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Pregnyl recon soln 10,000

unit


TES

MISCELLANEOUS

HORMONESPremarin cream 0.625

mg/gra

m

PrefBrand-3 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINS

Premasol 10

%

parenteral

solution

10 % Generic-2 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSPremasol 6 % parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSPrenatal

Vitamin Plus

Low Iron

tablet 27 mg

iron- 1

mg


HEMATINICS /

ELECTROLYTES

VITAMINS /

HEMATINICS

Prepopik

powder in

packet

10 mg-

3.5

gram-12

gram

NonPrefBrand-4 NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Prevalite powder 4 gram Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSPrevifem tablet 0.25-35

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Prezcobix tablet

800-150

mg-mg PrefBrand-3

NO


Prezista tablet 600 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Prezista tablet 75 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Prezista tablet 150 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Prezista suspension

100

mg/mL PrefBrand-3NO


Prezista tablet 800 mgSpecialty-5 NO


Priftin tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESprimaquine tablet 26.3 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESprimidone tablet 250 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

primidone tablet 50 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Primlev tablet

5-300

mg

NonPrefBrand-4

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Primlev tablet

10-300

mg

NonPrefBrand-4

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Primlev tablet

7.5-300

mg

NonPrefBrand-4

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Pristiq tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Pristiq tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Pristiq

tablet

extended

release 24 hr 25 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Privigen solution 10 % Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

ProAir HFA HFA aerosol

inhaler

90

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

ProAir

RespiClick

aerosol powdr

breath

activated

90

mcg/act

uation PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

probenecid tablet 500 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

procainamide solution 100

mg/mL


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

procainamide solution 500

mg/mL


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Procalamine

3%

parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSProCentra solution 5 mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

prochlorperaz

ine

suppository 25 mg Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSprochlorperaz

ine Edisylate

solution 10 mg/2

mL (5

mg/mL)


OGY

MISCELLANEOUS

GASTROINTESTINA


ine maleate


OGY

MISCELLANEOUS

GASTROINTESTINA


ine maleate


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSProcrit solution 10,000

unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Procrit solution 2,000

unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


unit/mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Procto-Med

HC cream 2.5 % Generic-2

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Procto-Pak cream 1 % Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Proctosol HC cream 2.5 % Generic-2

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Proctozone-

HC cream 2.5 % Generic-2

NOGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Procysbi

capsule,

delayed rel

sprinkle 25 mg

Specialty-5 YES

UROLOGICALS

MISCELLANEOUS

UROLOGICALS

Procysbi

capsule,

delayed rel

sprinkle 75 mg

Specialty-5 YES

UROLOGICALS

MISCELLANEOUS

UROLOGICALS

progesterone

micronized

capsule 100 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSprogesterone

micronized

capsule 200 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSProglycem suspension 50

mg/mL


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Prograf capsule 1 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Prograf capsule 5 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Prograf solution 5

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Prograf capsule 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Prolastin-C recon soln

1,000

mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Proleukin recon soln 22

million

unit


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Prolia syringe

60

mg/mL

NonPrefBrand-4

1 180

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

Promacta tablet 25 mg Specialty-5 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Promacta tablet 50 mg Specialty-5 YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Promacta tablet 12.5 mg


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

promethazine syrup

6.25

mg/5

mL

Generic-2 YESRESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

promethazine suppository 12.5 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

promethazine suppository 25 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

promethazine solution

25

mg/mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

promethazine suppository 50 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

promethazine solution

50

mg/mL


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Promethazine

VC syrup

6.25-5

mg/5

mL Generic-2

NORESPIRATORY AND

ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Promethegan suppository 25 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Promethegan suppository 50 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

propafenone capsule,exten

ded release 12

hr


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ded release 12

hr


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


ded release 12

hr


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

propafenone tablet 150 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

propantheline tablet 15 mg Generic-2 NO GASTROENTEROL

OGY

ANTIDIARRHEALS /

ANTISPASMODICS

propranolol solution 1

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propranolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propranolol capsule,exten

ded release 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ded release 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ded release 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propranolol solution 20 mg/5

mL (4

mg/mL)


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propranolol solution 40 mg/5

mL (8

mg/mL)


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propranolol-

hydrochloroth

iazid

tablet 40-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propranolol-

hydrochloroth

iazid

tablet 80-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

propylthioura

cil


TES

ANTITHYROID

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ProQuad (PF)

suspension

for

reconstitution

10exp3-

4.3-3-

3.99

TCID50

/0.5 PrefBrand-3

NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Prosol 20 % parenteral

solution


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSprotriptyline tablet 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

protriptyline tablet 5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Provigil tablet 200 mg Specialty-5 31 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Provigil tablet 100 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Prudoxin cream 5 %


LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS

Pulmicort suspension

for

nebulization

0.5

mg/2

mL


ALLERGY

PULMONARY

AGENTS


for

nebulization

1 mg/2

mL


ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


for

nebulization

0.25

mg/2

mL


ALLERGY

PULMONARY

AGENTS

Pulmozyme solution 1

mg/mL


ALLERGY

PULMONARY

AGENTS

Purixan suspension

20

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Pylera capsule

140-125-

125 mg


OGY ULCER THERAPY

pyrazinamide tablet 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESpyridostigmin

e bromide

tablet

extended

release


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYpyridostigmin

e bromide


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYQuasense tablets,dose

pack,3 month

0.15-30

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSquetiapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

quetiapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

quetiapine tablet 300 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Quillivant XR

suspension,ex

t rel

24hr,recon

5

mg/mL

(25

mg/5

mL)

NonPrefBrand-4 NOAUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

quinapril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

quinapril-

hydrochloroth

iazide

tablet 10-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

quinapril-

hydrochloroth

iazide

tablet 20-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

quinapril-

hydrochloroth

iazide

tablet 20-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

quinidine

gluconate

tablet

extended

release


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

quinidine

gluconate

solution 80

mg/mL


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

quinidine

sulfate


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

quinidine

sulfate


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

quinine

sulfate capsule 324 mgGeneric-2 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

Qvar aerosol 40

mcg/act

uation


ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Qvar aerosol

80

mcg/act

uation PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

RabAvert

(PF)

suspension

for

reconstitution

2.5 unit NonPrefBrand-4 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

rabeprazole tablet,delayed

release

(DR/EC)

20 mg Generic-2 62 31 NO GASTROENTEROL

OGY

ULCER THERAPY

Ragwitek tablet

12 Amb

a 1 unit


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

raloxifene tablet 60 mg PrefBrand-3

NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

ramipril capsule 2.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

ramipril capsule 5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

ramipril capsule 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

ramipril capsule 1.25 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Ranexa tablet

extended

release 12 hr

1,000

mg


, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ranexa tablet

extended

release 12 hr


, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTSranitidine

HCl

capsule 150 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

ranitidine

HCl

tablet 150 mg PrefGen-1 NO GASTROENTEROL

OGY

ULCER THERAPY

ranitidine

HCl

capsule 300 mg Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

ranitidine

HCl

tablet 300 mg PrefGen-1 NO GASTROENTEROL

OGY

ULCER THERAPY

ranitidine

HCl

solution 25

mg/mL


OGY

ULCER THERAPY

ranitidine

HCl

syrup 15

mg/mL


OGY

ULCER THERAPY

Rapaflo capsule 8 mg PrefBrand-3 NO UROLOGICALS BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPYRapaflo capsule 4 mg PrefBrand-3 NO UROLOGICALS BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPYRapamune solution 1

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rapamune tablet 1 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Rapamune tablet 2 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rapamune tablet 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rapivab solution

200

mg/20

mL (10

mg/mL)

NonPrefBrand-4 NO


Rasuvo (PF) auto-injector

10

mg/0.2

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


12.5

mg/0.25

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


15

mg/0.3

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


17.5

mg/0.35

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


20

mg/0.4

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


22.5

mg/0.45

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


25

mg/0.5

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


27.5

mg/0.55

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


30

mg/0.6

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS


7.5

mg/0.15

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Ravicti liquid

1.1

gram/m

L


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

REBETOL solution 40

mg/mL

NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Rebif (with

albumin)

syringe 44

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Rebif (with

albumin)

syringe 22

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Rebif

Rebidose pen injector

22

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Rebif


44

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Rebif


8.8mcg/

0.2mL-

22

mcg/0.5

mL (6)

Specialty-5 NO

IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Rebif

Titration Pack

syringe 8.8mcg/

0.2mL-

22

mcg/0.5

mL (6)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Reclipsen

(28)

tablet 0.15-

0.03 mg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSRecombivax

HB (PF)

suspension 10

mcg/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Recombivax

HB (PF)

syringe 10

mcg/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Recombivax

HB (PF)

syringe 5

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Recombivax

HB (PF)

suspension 40

mcg/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Rectiv ointment

0.4 %

(w/w)


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Regranex gel 0.01 % Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Relenza

Diskhaler

blister with

device

5

mg/actu

ation


Relistor solution

12

mg/0.6

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Relistor syringe

12

mg/0.6

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Relistor syringe

8

mg/0.4

mL


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Relpax tablet 20 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYRelpax tablet 40 mg NonPrefBrand-4 6 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYRemicade recon soln 100 mg Specialty-5 80 28 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSRemodulin solution 1

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Remodulin solution 2.5

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Remodulin solution 5

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Remodulin solution 10

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Renagel tablet 400 mg PrefBrand-3 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Renagel tablet 800 mg PrefBrand-3 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Renvela tablet 800 mg PrefBrand-3 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Renvela powder in

packet

2.4

gram


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Renvela powder in

packet

0.8

gram


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

repaglinide tablet 1 mg Generic-2 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYrepaglinide tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYrepaglinide tablet 2 mg Generic-2 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYrepaglinide-

metformin

tablet 1-500

mg


TES

DIABETES

THERAPYrepaglinide-

metformin

tablet 2-500

mg


TES

DIABETES

THERAPY

Repatha

SureClick pen injector

140

mg/mL

Specialty-5

2 28

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Repatha

Syringe syringe

140

mg/mL

Specialty-5

2 28

YES CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Reprexain tablet 5-200

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Reprexain tablet 10-200

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Rescriptor tablet,

dispersible

100 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Rescriptor tablet 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

reserpine tablet 0.1 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

reserpine tablet 0.25 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Restasis dropperette 0.05 % PrefBrand-3 NO OPHTHALMOLOGY MISCELLANEOUS

OPHTHALMOLOGI

CS

Retin-A

Micro Pump

gel with

pump 0.08 %


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Retrovir solution 10

mg/mL


Retrovir capsule 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Retrovir syrup 10

mg/mL





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Revatio tablet 20 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSRevatio solution 10

mg/12.5

mL


ALLERGY

PULMONARY

AGENTS

Revatio

suspension

for

reconstitution

10

mg/mL

Specialty-5 YESRESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Revlimid capsule 10 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Revlimid capsule 2.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Revlimid capsule 20 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Rexulti tablet 0.25 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Rexulti tablet 1 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Rexulti tablet 2 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Rexulti tablet 3 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Rexulti tablet 4 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Reyataz capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS



Reyataz

powder in

packet 50 mgNonPrefBrand-4 NO





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Rheumatrex

tablets,dose

pack

2.5 mg

(dose

pack 8)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rheumatrex

tablets,dose

pack

2.5 mg

(dose

pack

12)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rheumatrex

tablets,dose

pack

2.5 mg

(dose

pack

16)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rheumatrex

tablets,dose

pack

2.5 mg

(dose

pack

20)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Rheumatrex

tablets,dose

pack 2.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Ribasphere capsule 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Ribasphere tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Ribasphere tablet 400 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Ribasphere tablet 600 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Ribasphere

RibaPak

tablets,dose

pack

600-400

mg (28)-

mg (28)





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ribasphere

RibaPak

tablets,dose

pack

400-400

mg (28)-

mg (28)


Ribasphere

RibaPak

tablets,dose

pack

600-600

mg (28)-

mg (28)


ribavirin tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

ribavirin capsule 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Ridaura capsule 3 mg PrefBrand-3 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSrifabutin capsule 150 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESrifampin capsule 150 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESrifampin capsule 300 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESrifampin recon soln 600 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESRifater tablet 50-120-

300 mg


ANTIINFECTIVESRilutek tablet 50 mg Specialty-5 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

riluzole tablet 50 mg Specialty-5 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

rimantadine tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ringers parenteral

solution


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

ringers solution Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

IRRIGATING

SOLUTIONS

Riomet solution 500

mg/5

mL


TES

DIABETES

THERAPY

risedronate tablet 35 mg Generic-2 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

risedronate tablet 30 mg Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

risedronate tablet 35 mg

(4 pack)


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

risedronate tablet 35 mg

(12

pack)


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY

risedronate

tablet,delayed

release

(DR/EC) 35 mg


AL /

RHEUMATOLOGY

OSTEOPOROSIS

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Risperdal tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal tablet 3 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal solution 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal tablet 0.25 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal tablet 0.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal

Consta

syringe 12.5

mg/2

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Risperdal

Consta

syringe 37.5

mg/2

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal

Consta

syringe 50 mg/2

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal

Consta

syringe 25 mg/2

mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal M-

TAB

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal M-

TAB

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal M-

TAB

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal M-

TAB

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Risperdal M-

TAB

tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

risperidone solution 1

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

risperidone tablet 0.25 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

risperidone tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

risperidone tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

risperidone tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating

0.5 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


rating


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Ritalin LA

capsule,ER

biphasic 50-

50 10 mg

NonPrefBrand-4

186 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Rituxan concentrate 10

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

rivastigmine patch 24 hour 4.6

mg/24

hr


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

rivastigmine patch 24 hour 9.5

mg/24

hr


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

rivastigmine patch 24 hour

13.3

mg/24

hour Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

rivastigmine

tartrate


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

rivastigmine

tartrate


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

rivastigmine

tartrate

capsule 1.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

rivastigmine

tartrate

capsule 4.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

rizatriptan tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYrizatriptan tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

rizatriptan tablet 5 mg Generic-2 24 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYrizatriptan tablet 10 mg Generic-2 12 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYRocaltrol capsule 0.25

mcg


TES

MISCELLANEOUS

HORMONESRocaltrol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESRocaltrol solution 1

mcg/mL


TES

MISCELLANEOUS

HORMONESropinirole tablet 3 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

ropinirole tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

rosuvastatin tablet 40 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSrosuvastatin tablet 5 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSRotarix suspension

for

reconstitution

10exp6

CCID50

/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

RotaTeq

Vaccine

suspension 2 mL PrefBrand-3 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Roweepra tablet 500 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Roxicodone tablet 15 mg

NonPrefBrand-4

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS


NonPrefBrand-4

138 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


NonPrefBrand-4

186 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Rozerem tablet 8 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Ruconest recon soln

2,100

unitSpecialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Sabril tablet 500 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Sabril powder in

packet


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Safyral tablet

3-0.03-

0.451

mg

(21/7)

NonPrefBrand-4 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Saizen recon soln 5 mg Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Saizen recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Saizen

click.easy

cartridge 8.8

mg/1.5

mL

(Fnl)


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Samsca tablet 15 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSamsca tablet 30 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSancuso patch weekly 3.1

mg/24

hour

Specialty-5 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSSandimmune capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandimmune capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandimmune solution 250

mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandimmune solution 100

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandostatin solution 100

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandostatin solution 200

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Sandostatin solution 1,000

mcg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandostatin

LAR Depot

suspension,ex

tended rel

recon

20 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandostatin

LAR Depot

suspension,ex

tended rel

recon


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sandostatin

LAR Depot

suspension,ex

tended rel

recon


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Santyl ointment

250

unit/gra

m PrefBrand-3

NO DERMATOLOGICA

LS/TOPICAL

THERAPY TOPICAL ENZYMES

Saphris

(black cherry)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Saphris

(black cherry)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Saphris

(black cherry) tablet 2.5 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Savaysa tablet 15 mg


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY



, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY



, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Savella tablet 100 mg NonPrefBrand-4 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSSavella tablet 12.5 mg NonPrefBrand-4 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSSavella tablet 50 mg NonPrefBrand-4 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSSavella tablet 25 mg NonPrefBrand-4 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALSSavella tablets,dose

pack

12.5 mg

(5)-25

mg(8)-

50

mg(42)

NonPrefBrand-4 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Seconal

Sodium


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

selegiline

HCl


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

selegiline

HCl


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

selenium

sulfide


LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Selzentry tablet 150 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Selzentry tablet 300 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Semprex-D capsule 8-60 mg


ALLERGY

ANTIHISTAMINE /

ANTIALLERGENIC

AGENTS

Sensipar tablet 30 mg PrefBrand-3 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSensipar tablet 60 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSensipar tablet 90 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSerevent

Diskus

blister with

device

50

mcg/dos

e


ALLERGY

PULMONARY

AGENTS

Seroquel XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Seroquel XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Seroquel XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Seroquel XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Seroquel XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Serostim recon soln 4 mg Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

sertraline tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

sertraline concentrate 20

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Setlakin

tablets,dose

pack,3 month

0.15-30

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Signifor solution

0.3

mg/mL

(1 mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Signifor solution

0.6

mg/mL

(1 mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Signifor solution

0.9

mg/mL

(1 mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Signifor LAR

suspension

for



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Signifor LAR

suspension

for



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Signifor LAR

suspension

for



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

sildenafil tablet 20 mg PrefBrand-3 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSsildenafil solution 10

mg/12.5

mL


ALLERGY

PULMONARY

AGENTS

Silenor tablet 3 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Silenor tablet 6 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

silver

sulfadiazine

cream 1 % PrefGen-1 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

BURN THERAPY

Simbrinza

drops,suspens

ion 1-0.2 % PrefBrand-3

NO

OPHTHALMOLOGY

OTHER

GLAUCOMA

DRUGS

Simponi syringe 50

mg/0.5

mL


AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Simponi syringe

100

mg/mL

Specialty-5

1 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Simponi pen injector

50

mg/0.5

mL

Specialty-5

0.5 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Simponi pen injector

100

mg/mL

Specialty-5

1 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Simponi

ARIA solution

12.5

mg/mL

Specialty-5

16 28

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Simulect recon soln 20 mg NonPrefBrand-4 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

simvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSsimvastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSsirolimus tablet 1 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

sirolimus tablet 2 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

sirolimus tablet 0.5 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sirturo tablet 100 mgSpecialty-5 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

Sivextro tablet 200 mgSpecialty-5

6 31NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

Sivextro recon soln 200 mgSpecialty-5 NO

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

sodium

chloride

parenteral

solution

2.5

mEq/m

L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

sodium

chloride

solution 0.9 % Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

sodium

chloride 0.45

%

parenteral

solution

0.45 % Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

sodium

chloride 0.9

%

parenteral

solution

0.9 % Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

sodium

chloride 3 %

parenteral

solution

3 % Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

sodium

chloride 5 %

parenteral

solution

5 % Generic-2 NO VITAMINS,

HEMATINICS /

ELECTROLYTES

ELECTROLYTES

sodium

fluoride

tablet 1 mg

fluoride

(2.2 mg)


HEMATINICS /

ELECTROLYTES

VITAMINS /

HEMATINICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

sodium

lactate

solution 5

mEq/m

L


HEMATINICS /

ELECTROLYTES

ELECTROLYTES

sodium

phenylbutyrat

e powder

0.94

gram/gr

am


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

sodium

polystyrene

(sorb free)

suspension 15

gram/60

mL


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Soltamox solution 10 mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Solu-Cortef

(PF)

recon soln 100

mg/2

mL


TES

ADRENAL

HORMONES

Solu-Cortef

(PF)

recon soln 250

mg/2

mL


TES

ADRENAL

HORMONES

Solu-Medrol recon soln 2 gramNonPrefBrand-4 NO ENDOCRINE/DIABE

TES

ADRENAL

HORMONES

Solu-Medrol

(PF)

recon soln 500

mg/4

mL


TES

ADRENAL

HORMONES

Solu-Medrol

(PF)

recon soln 40

mg/mL


TES

ADRENAL

HORMONESSolu-Medrol

(PF)

recon soln 125

mg/2

mL


TES

ADRENAL

HORMONES

Somatuline

Depot

syringe 60

mg/0.2

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Somatuline

Depot

syringe 120

mg/0.5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Somatuline

Depot

syringe 90

mg/0.3

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Somavert recon soln 10 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSomavert recon soln 15 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESSomavert recon soln 20 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Somavert recon soln 30 mgSpecialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Somavert recon soln 25 mgSpecialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Soriatane capsule 10 mg Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Soriatane capsule 25 mg Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Soriatane capsule 17.5 mg Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Sorine tablet 120 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

sotalol tablet 160 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

Sotalol AF tablet 120 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

Sotylize solution

5

mg/mL


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

Sovaldi tablet 400 mgSpecialty-5

28 28YES


Spiriva

Respimat mist

2.5

mcg/act

uation PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Spiriva

Respimat mist

1.25

mcg/act

uation PrefBrand-3

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Spiriva with

HandiHaler

capsule,

w/inhalation

device

18 mcg PrefBrand-3 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

spironolacton

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

spironolacton

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

spironolacton

e


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

spironolacton-

hydrochloroth

iaz

tablet 25-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Sporanox solution 10

mg/mL

PrefBrand-3 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSSprintec (28) tablet 0.25-35

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Spritam

tablet for

suspension

1,000

mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Spritam

tablet for

suspension 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Spritam

tablet for

suspension 500 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Spritam

tablet for

suspension 750 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Sprycel tablet 20 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sprycel tablet 140 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sronyx tablet 0.1-20

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

SSD cream 1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

BURN THERAPY

stavudine capsule 15 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS




stavudine recon soln 1

mg/mL


Stelara syringe 45

mg/0.5

mL

Specialty-5 0.5 28 YES DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Stelara syringe 90

mg/mL

Specialty-5 1 28 YES DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Stimate spray,non-

aerosol

150

mcg/spr

ay (0.1

mL)


TES

MISCELLANEOUS

HORMONES

Stiolto

Respimat mist

2.5-2.5

mcg/act

uation PrefBrand-3 4 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Stivarga tablet 40 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Strattera capsule 10 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Strensiq solution

40


TES

MISCELLANEOUS

HORMONES

Strensiq solution

100


TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

streptomycin recon soln 1 gram PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESStriant mucoadhesive

System ER 12

hr

30 mg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Stribild tablet

150-150-

200-300

mg

Specialty-5 NO


Striverdi

Respimat mist

2.5

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

Suboxone film

2-0.5


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Suboxone film 8-2 mg PrefBrand-3 93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS


NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Subsys

spray,non-

aerosol

100

mcg/spr

ay

Specialty-5

124 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Subsys

spray,non-

aerosol

200

mcg/spr

ay

Specialty-5

124 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Subsys

spray,non-

aerosol

400

mcg/spr

ay

Specialty-5

86 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Subsys

spray,non-

aerosol

600

mcg/spr

ay

Specialty-5

57 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Subsys

spray,non-

aerosol

800

mcg/spr

ay

Specialty-5

43 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Sucraid solution 8,500

unit/mL

Specialty-5 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSsucralfate tablet 1 gram Generic-2 NO GASTROENTEROL

OGY

ULCER THERAPY

sulfacetamide

sodium ointment 10 %PrefGen-1 NO

OPHTHALMOLOGY SULFONAMIDESsulfacetamide

sodium drops 10 %Generic-2 NO

OPHTHALMOLOGY SULFONAMIDES

sulfacetamide

sodium (acne) suspension 10 %


LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

sulfacetamide-

prednisolone drops

10 %-

0.23 %

(0.25

%)

Generic-2 NO

OPHTHALMOLOGY

STEROID-

SULFONAMIDE

COMBINATIONS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

sulfadiazine tablet 500 mg Generic-2 NO ANTI - INFECTIVES SULFA'S / RELATED

AGENTSsulfamethoxa

zole-

trimethoprim

tablet 400-80

mg

PrefGen-1 NO ANTI - INFECTIVES SULFA'S / RELATED

AGENTS

sulfamethoxa

zole-

trimethoprim

tablet 800-160

mg


AGENTS

sulfamethoxa

zole-

trimethoprim

suspension 200-40

mg/5

mL


AGENTS

sulfamethoxa

zole-

trimethoprim

solution 400-80

mg/5

mL


AGENTS

Sulfamylon cream 85 mg/g PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIBACTERIALS

sulfasalazine tablet 500 mg Generic-2 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSsulfasalazine tablet,delayed

release

(DR/EC)


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSsulindac tablet 150 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

sulindac tablet 200 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

sumatriptan spray,non-

aerosol

5

mg/actu

ation


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYsumatriptan spray,non-

aerosol

20

mg/actu

ation


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYsumatriptan

succinate


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYsumatriptan

succinate


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYsumatriptan

succinate

solution 6

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYsumatriptan

succinate


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYsumatriptan

succinate

pen injector 6

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

sumatriptan

succinate pen injector

6

mg/0.5

mL

(auto-

Injector) Generic-2 4 31

NO

AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

sumatriptan

succinate cartridge

6

mg/0.5

mL Generic-2 4 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

sumatriptan

succinate cartridge

4

mg/0.5

mL Generic-2 6 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Sumavel

DosePro

needle-free

injector

6

mg/0.5

mL


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Sumavel

DosePro

needle-free

injector

4

mg/0.5

mL

NonPrefBrand-4

6 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Suprax suspension

for

reconstitution

100

mg/5

mL

PrefBrand-3 NO ANTI - INFECTIVES CEPHALOSPORINS

Suprax suspension

for

reconstitution

200

mg/5

mL

PrefBrand-3 NO ANTI - INFECTIVES CEPHALOSPORINS

Suprax capsule 400 mg PrefBrand-3NO


Suprax

suspension

for

reconstitution

500

mg/5

mL PrefBrand-3

NO





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Suprep

Bowel Prep

Kit recon soln

17.5-

3.13-1.6

gram PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Surmontil capsule 50 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Sustiva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Sustiva capsule 50 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Sustiva tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Sutent capsule 12.5 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sutent capsule 25 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Sutent capsule 50 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sutent capsule 37.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Sylatron kit

300

mcg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Sylatron kit

600

mcg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Sylatron kit

200

mcg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Sylvant recon soln 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Symbicort

HFA aerosol

inhaler

80-4.5

mcg/act

uation PrefBrand-3 10.2 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Symbicort

HFA aerosol

inhaler

160-4.5

mcg/act

uation PrefBrand-3 10.2 30

NORESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

SymlinPen

120

pen injector 2,700

mcg/2.7

mL


TES

DIABETES

THERAPY

SymlinPen 60 pen injector 1,500

mcg/1.5

mL


TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Synagis solution 50

mg/0.5

mL


Synalgos-DC capsule

16-

356.4-

30 mg

NonPrefBrand-4

300 30

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Synarel spray,non-

aerosol

2

mg/mL


TES

MISCELLANEOUS

HORMONESSynercid recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Synribo recon soln 3.5 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Synthroid tablet 25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESSynthroid tablet 75 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESSynthroid tablet 112

mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


TES

THYROID


mcg


TES

THYROID

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Synthroid tablet 200

mcg


TES

THYROID


mcg


TES

THYROID


TES

THYROID

HORMONESSyprine capsule 250 mg PrefBrand-3 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Tabloid tablet 40 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Taclonex suspension 0.005-

0.064 %

Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

tacrolimus capsule 1 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

tacrolimus capsule 5 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

tacrolimus ointment 0.03 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LStacrolimus capsule 0.5 mg Generic-2 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tacrolimus ointment 0.1 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS

Tafinlar capsule 50 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tagrisso tablet 40 mg

Specialty-5

31 31

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


Specialty-5

31 31

YESANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Taltz

Autoinjector auto-injector

80

mg/mL

Specialty-5

1 28

YES DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Taltz Syringe syringe

80

mg/mL

Specialty-5

1 28

YES DERMATOLOGICA

LS/TOPICAL

THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

Tamiflu capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS






Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tamiflu

suspension

for

reconstitution

6

mg/mL PrefBrand-3

NO


tamoxifen tablet 10 mg PrefGen-1 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

tamoxifen tablet 20 mg PrefGen-1 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

tamsulosin capsule,exten

ded release

24hr

0.4 mg PrefGen-1 NO UROLOGICALS BENIGN

PROSTATIC

HYPERPLASIA(BPH

) THERAPY

Tarceva tablet 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Targretin capsule 75 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Targretin gel 1 %


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tasigna capsule 200 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tasigna capsule 150 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tasmar tablet 100 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

TAZICEF recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS

TAZICEF recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS

TAZICEF recon soln 2 gramNonPrefBrand-4 NO


Tazorac gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Tazorac gel 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Tazorac cream 0.05 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tazorac cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Taztia XT capsule,

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Taztia XT capsule,

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Taztia XT capsule,

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Taztia XT capsule,

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Taztia XT capsule,

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tecentriq solution

1,200

mg/20

mL (60

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tecfidera

capsule,delay

ed

release(DR/E

C) 120 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Tecfidera

capsule,delay

ed

release(DR/E

C) 240 mg


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tecfidera

capsule,delay

ed

release(DR/E

C)

120 mg

(14)-

240 mg

(46)


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Technivie tablet

12.5-75-

50 mgSpecialty-5

56 28YES


Teflaro recon soln 400 mgNonPrefBrand-4 NO


Teflaro recon soln 600 mgNonPrefBrand-4 NO


Tegretol suspension 100

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tegretol tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tegretol XR tablet

extended

release 12 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tegretol XR tablet

extended

release 12 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tegretol XR tablet

extended

release 12 hr


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tekturna tablet 150 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tekturna

HCT tablet

150-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tekturna

HCT tablet

150-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tekturna

HCT tablet

300-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tekturna

HCT tablet

300-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan tablet 40 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan-

amlodipine

tablet 40-10

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan-

amlodipine

tablet 80-10

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan-

amlodipine


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

telmisartan-

amlodipine


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan-

hydrochloroth

iazid

tablet 40-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan-

hydrochloroth

iazid

tablet 80-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

telmisartan-

hydrochloroth

iazid

tablet 80-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

temazepam capsule 15 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

temazepam capsule 30 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

temazepam capsule 7.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

temazepam capsule 22.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Tencon tablet

50-325

mg Generic-2 372 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tenivac (PF) syringe

5-2 Lf

unit/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

terazosin capsule 10 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

terbinafine

HCl

tablet 250 mg PrefGen-1 90 180 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSterbutaline solution 1

mg/mL


ALLERGY

PULMONARY

AGENTSterbutaline tablet 2.5 mg Generic-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSterbutaline tablet 5 mg Generic-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSterconazole suppository 80 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNterconazole cream 0.4 % Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNterconazole cream 0.8 % Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYN

Testim gel

50 mg/5

gram (1

%)

NonPrefBrand-4 YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

testosterone

gel in metered-

dose pump

1.25

gram/

actuatio

n (1 %) PrefBrand-3

YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

testosterone

gel in metered-

dose pump

10

mg/0.5

gram

/actuatio

n PrefBrand-3

YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

testosterone gel in packet

1 % (25

mg/2.5g

ram) PrefBrand-3

YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

testosterone gel in packet

1 % (50

mg/5

gram) PrefBrand-3

YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

testosterone

cypionate

oil 100

mg/mL


TES

MISCELLANEOUS

HORMONEStestosterone

cypionate

oil 200

mg/mL


TES

MISCELLANEOUS

HORMONEStestosterone

enanthate

oil 200

mg/mL


TES

MISCELLANEOUS

HORMONESTestred capsule 10 mg Specialty-5 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

tetanus,diphth

eria tox

ped(PF) suspension

5-25 Lf

unit/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

tetanus-

diphtheria

toxoids-Td

suspension 2-2 Lf

unit/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tetrabenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

tetrabenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

tetracycline capsule 250 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

tetracycline capsule 500 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES

Thalomid capsule 50 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Theo-24 capsule,exten

ded release

24hr

100 mg NonPrefBrand-4 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ded release

24hr


ALLERGY

PULMONARY

AGENTS


ded release

24hr


ALLERGY

PULMONARY

AGENTS


ded release

24hr


ALLERGY

PULMONARY

AGENTS

theophylline tablet

extended

release 12 hr


ALLERGY

PULMONARY

AGENTS

theophylline tablet

extended

release


ALLERGY

PULMONARY

AGENTS

theophylline solution 80

mg/15

mL


ALLERGY

PULMONARY

AGENTS

theophylline tablet

extended

release 12 hr


ALLERGY

PULMONARY

AGENTS

theophylline tablet

extended

release 12 hr


ALLERGY

PULMONARY

AGENTS

theophylline tablet

extended

release 12 hr


ALLERGY

PULMONARY

AGENTS

theophylline tablet

extended

release


ALLERGY

PULMONARY

AGENTS

Thiola tablet 100 mg NonPrefBrand-4 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

thioridazine tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

thiotepa recon soln 15 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

thiothixene capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Thymoglobuli

n

recon soln 25 mg NonPrefBrand-4 NO IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Thyrolar-1 tablet 12.5-50

mcg


TES

THYROID

HORMONESThyrolar-1/2 tablet 6.25-25

mcg


TES

THYROID

HORMONESThyrolar-1/4 tablet 3.1-12.5

mcg


TES

THYROID

HORMONES

Thyrolar-2 tablet 25-100

mcg


TES

THYROID

HORMONESThyrolar-3 tablet 37.5-

150

mcg


TES

THYROID

HORMONES

tiagabine tablet 2 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

tiagabine tablet 4 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tikosyn capsule 125

mcg


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tikosyn capsule 250

mcg


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

Tikosyn capsule 500

mcg


, HYPERTENSION /

LIPIDS

ANTIARRHYTHMIC

AGENTS

timolol

maleate

drops 0.25 % PrefGen-1 NO OPHTHALMOLOGY BETA-BLOCKERS

timolol

maleate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

timolol

maleate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

timolol

maleate


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

timolol

maleate

gel forming

solution

0.25 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS

timolol

maleate

gel forming

solution

0.5 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS

timolol

maleate

drops 0.5 % PrefGen-1 NO OPHTHALMOLOGY BETA-BLOCKERS

Timoptic

Ocudose (PF)

dropperette 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS

Timoptic

Ocudose (PF)

dropperette 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS

tinidazole tablet 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVEStinidazole tablet 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tirosint capsule 112

mcg


TES

THYROID

HORMONESTirosint capsule 137

mcg


TES

THYROID

HORMONESTirosint capsule 75 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE

TES

THYROID


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


TES

THYROID


TES

THYROID


TES

THYROID

HORMONES

Tivicay tablet 50 mgSpecialty-5 NO


Tivicay tablet 10 mgNonPrefBrand-4 NO


Tivicay tablet 25 mgSpecialty-5 NO


tizanidine tablet 2 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tizanidine tablet 4 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYtizanidine capsule 6 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC


DRUGS,

NEUROLOGY /

PSYCH

MUSCLE

RELAXANTS /

ANTISPASMODIC

THERAPYTobi solution for

nebulization

300

mg/5

mL

NonPrefBrand-4 YES ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Tobi

Podhaler

capsule,

w/inhalation

device 28 mg

Specialty-5 YES

ANTI - INFECTIVES

MISCELLANEOUS

ANTIINFECTIVES

TobraDex ointment 0.3-0.1

%

PrefBrand-3 NO OPHTHALMOLOGY STEROID-

ANTIBIOTIC

COMBINATIONS

Tobradex ST

drops,suspens

ion

0.3-0.05

% PrefBrand-3

NO

OPHTHALMOLOGY

STEROID-

ANTIBIOTIC

COMBINATIONS

tobramycin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY ANTIBIOTICS

tobramycin in

0.225 %

NaCl

solution for

nebulization

300

mg/5

mL

Specialty-5 YES ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tobramycin

sulfate

solution 10

mg/mL


ANTIINFECTIVEStobramycin

sulfate

solution 40

mg/mL


ANTIINFECTIVEStobramycin-

dexamethaso

ne

drops,suspens

ion

0.3-0.1

%


ANTIBIOTIC

COMBINATIONSTobrex ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY ANTIBIOTICS

Tolak cream 4 %


LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS

tolazamide tablet 250 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYtolazamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYtolbutamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABE

TES

DIABETES

THERAPYtolcapone tablet 100 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

tolmetin capsule 400 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tolmetin tablet 600 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tolterodine tablet 1 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

tolterodine capsule,exten

ded release

24hr


S /

ANTISPASMODICS

tolterodine capsule,exten

ded release

24hr


S /

ANTISPASMODICS

tolterodine tablet 2 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

Topamax tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Topamax capsule,

sprinkle


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Topamax capsule,

sprinkle


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate tablet 50 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate capsule,

sprinkle


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate capsule,

sprinkle


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

topiramate

capsule,sprink

le,ER 24hr 50 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate

capsule,sprink

le,ER 24hr 25 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate

capsule,sprink

le,ER 24hr 100 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate

capsule,sprink

le,ER 24hr 200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

topiramate

capsule,sprink

le,ER 24hr 150 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Toposar solution 20

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

topotecan recon soln 4 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Torisel recon soln 30 mg/3

mL (10

mg/mL)

(first)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

torsemide tablet 10 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Toujeo

SoloStar insulin pen

300

unit/mL

(1.5

mL) PrefBrand-3

NO

ENDOCRINE/DIABE

TES

DIABETES

THERAPY

Toviaz tablet

extended

release 24 hr


S /

ANTISPASMODICS

Toviaz tablet

extended

release 24 hr


S /

ANTISPASMODICS

Tracleer tablet 62.5 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSTracleer tablet 125 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Tradjenta tablet 5 mg PrefBrand-3NO ENDOCRINE/DIABE

TES

DIABETES

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tramadol tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol tablet, ER

multiphase 24

hr


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol tablet 50 mg PrefGen-1 240 30 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol

capsule,ER

biphase 24 hr

25-75 100 mg

NonPrefBrand-4

30 30

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol

capsule,ER

biphase 24 hr

25-75 200 mg

NonPrefBrand-4

30 30

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol

capsule,ER

biphase 24 hr

17-83 300 mg

NonPrefBrand-4

30 30

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

tramadol-

acetaminophe

n

tablet 37.5-

325 mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

trandolapril tablet 2 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

trandolapril-

verapamil

tablet, IR -

ER, biphasic

24hr

1-240

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

trandolapril-

verapamil

tablet, IR -

ER, biphasic

24hr

2-180

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

trandolapril-

verapamil

tablet, IR -

ER, biphasic

24hr

2-240

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

trandolapril-

verapamil

tablet, IR -

ER, biphasic

24hr

4-240

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

tranexamic

acid

solution 1,000

mg/10

mL

(100

mg/mL)


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

tranexamic

acid

tablet 650 mg Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNTransderm-

Scop

patch 3 day 1.5 mg

(1 mg

over 3

days)


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

tranylcypromi

ne


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Travasol 10

%

parenteral

solution

10 % Generic-2 YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTSTravatan Z drops 0.004 % PrefBrand-3 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGStravoprost

(benzalkoniu

m)

drops 0.004 % Generic-2 NO OPHTHALMOLOGY OTHER

GLAUCOMA

DRUGStrazodone tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trazodone tablet 300 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trazodone tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trazodone tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Treanda recon soln 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Trecator tablet 250 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESTrelstar suspension

for

reconstitution

22.5 mg PrefBrand-3 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Trelstar syringe 3.75

mg/2

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Trelstar syringe 11.25

mg/2

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tresiba

FlexTouch U-

100 insulin pen

100

unit/mL

(3 mL)


TES

DIABETES

THERAPYTresiba

FlexTouch U-

200 insulin pen

200

unit/mL

(3 mL)


TES

DIABETES

THERAPY

tretinoin cream 0.025 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

tretinoin gel 0.05 % Generic-2 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

tretinoin

(chemotherap

y)

capsule 10 mg Generic-2 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

tretinoin

microspheres

gel with

pump


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

tretinoin

microspheres

gel with

pump


LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Trexall tablet 5 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Trexall tablet 7.5 mg PrefBrand-3 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Treximet tablet 85-500

mg


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

triamcinolone

acetonide cream 0.1 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone

acetonide ointment 0.025 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone



LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone



LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone



LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone



LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone

acetonide paste 0.1 %


THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

triamcinolone

acetonide aerosol

0.147

mg/gra

m


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamcinolone

acetonide lotion 0.025 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

triamcinolone

acetonide lotion 0.1 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triamterene-

hydrochloroth

iazid

capsule 50-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

triamterene-

hydrochloroth

iazid

capsule 37.5-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

triamterene-

hydrochloroth

iazid

tablet 37.5-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

triamterene-

hydrochloroth

iazid

tablet 75-50

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Trianex ointment 0.05 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

triazolam tablet 0.125

mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

triazolam tablet 0.25 mg Generic-2 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Tribenzor tablet

20-5-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tribenzor tablet

40-10-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tribenzor tablet

40-10-

25 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tribenzor tablet

40-5-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Tribenzor tablet

40-5-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Triderm cream 0.1 %


LS/TOPICAL

THERAPY

TOPICAL

CORTICOSTEROIDS

trifluoperazin

e


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trifluoperazin

e


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trifluoperazin

e


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trifluoperazin

e


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trifluridine drops 1 % Generic-2 NO OPHTHALMOLOGY ANTIVIRALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

trihexyphenid

yl


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

trihexyphenid

yl

elixir 0.4

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

trihexyphenid

yl


DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS

Tri-Legest Fe tablet

1-

20(5)/1-

30(7)

/1mg-

35mcg

(9) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Trileptal tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Trileptal suspension 300

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Tri-Lo-

Estarylla tablet

0.18/0.2

15/0.25

mg-25

mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Tri-Lo-

Sprintec

tablet 0.18/0.2

15/0.25

mg-25

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSTriLyte With

Flavor

Packets

recon soln 420

gram


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTStrimethoprim tablet 100 mg Generic-2 NO ANTI - INFECTIVES URINARY TRACT

AGENTStrimipramine capsule 100 mg PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trimipramine capsule 25 mg PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

trimipramine capsule 50 mg PrefBrand-3 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

TriNessa (28) tablet 0.18/0.2

15/0.25

mg-35

mcg

(28)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Trintellix tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Tri-Previfem

(28)

tablet 0.18/0.2

15/0.25

mg-35

mcg

(28)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Trisenox solution 10

mg/10

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Tri-Sprintec

(28)

tablet 0.18/0.2

15/0.25

mg-35

mcg

(28)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Triumeq tablet

600-50-

300 mgSpecialty-5 NO





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Trivora (28) tablet 50-30

(6)/75-

40

(5)/125-

30(10)


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Trizivir tablet 300-150-

300 mg


Trokendi XR

capsule,exten

ded release

24hr 50 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Trokendi XR

capsule,exten

ded release

24hr 25 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Trokendi XR

capsule,exten

ded release

24hr 100 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Trokendi XR

capsule,exten

ded release

24hr 200 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

TrophAmine

10 %

parenteral

solution 10 %


HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS

Trophamine

6%

parenteral

solution 6 % PrefBrand-3

YES VITAMINS,

HEMATINICS /

ELECTROLYTES

MISCELLANEOUS

NUTRITION

PRODUCTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

trospium tablet 20 mg Generic-2 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

trospium capsule,exten

ded release

24hr

60 mg Generic-2 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

Trumenba syringe

120

mcg/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Truvada tablet 200-300

mg


Truvada tablet

100-150

mgSpecialty-5 NO


Truvada tablet

133-200

mgSpecialty-5 NO


Truvada tablet

167-250

mgSpecialty-5 NO


Twinrix (PF) suspension 720

Elisa

unit -20

mcg/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Tybost tablet 150 mg PrefBrand-3NO


Tygacil recon soln 50 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESTykerb tablet 250 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Tylenol-

Codeine #3 tablet

300-30

mg

NonPrefBrand-4

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Tylenol-

Codeine #4 tablet

300-60

mg

NonPrefBrand-4

403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Typhim VI solution 25

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Typhim VI syringe

25

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Tysabri solution 300

mg/15

mL


DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Tyvaso solution for

nebulization

1.74

mg/2.9

mL (0.6

mg/mL)


ALLERGY

PULMONARY

AGENTS

Tyzeka tablet 600 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Tyzine drops 0.05 % PrefBrand-3

NO EAR, NOSE /

THROAT

MEDICATIONS

MISCELLANEOUS

AGENTS

Uloric tablet 40 mg PrefBrand-3 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Uloric tablet 80 mg PrefBrand-3 NO MUSCULOSKELET

AL /

RHEUMATOLOGY

GOUT THERAPY

Unithroid tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESUnithroid tablet 88 mcg PrefGen-1 NO ENDOCRINE/DIABE

TES

THYROID

HORMONESUnithroid tablet 100

mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


mcg


TES

THYROID


TES

THYROID


mcg


TES

THYROID


TES

THYROID

HORMONES

Uptravi tablet

1,000

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi tablet

1,200

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Uptravi tablet

1,400

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi tablet

1,600

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi tablet

200

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi tablet

400

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi tablet

600

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi tablet

800

mcg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Uptravi

tablets,dose

pack

200

mcg

(140)-

800

mcg

(60)

Specialty-5 YES

CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

ursodiol tablet 500 mg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSursodiol capsule 300 mg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSursodiol tablet 250 mg PrefBrand-3 NO GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Uvadex solution 20

mcg/mL


LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSVagifem tablet 10 mcg NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGY

ESTROGENS /

PROGESTINSvalacyclovir tablet 1 gram Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

valacyclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

Valchlor gel 0.016 %

NonPrefBrand-4 YES DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS

Valcyte tablet 450 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Valcyte recon soln 50

mg/mL


valganciclovir tablet 450 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

valproate

sodium solution

500

mg/5

mL

(100

mg/mL)

Generic-2 NOAUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

valproic acid capsule 250 mg


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

valproic acid

(as sodium

salt) solution

250

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

valsartan tablet 80 mg Generic-2 62 31 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

valsartan-

hydrochloroth

iazide

tablet 80-12.5

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

valsartan-

hydrochloroth

iazide

tablet 160-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

valsartan-

hydrochloroth

iazide

tablet 160-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

valsartan-

hydrochloroth

iazide

tablet 320-

12.5 mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

valsartan-

hydrochloroth

iazide

tablet 320-25

mg


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Vancocin capsule 125 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN

Vancocin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN

vancomycin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES VANCOMYCIN




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

vancomycin capsule 125 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN

vancomycin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN

vancomycin recon soln 1,000

mg

Generic-2 NO ANTI - INFECTIVES VANCOMYCIN

vancomycin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES VANCOMYCIN

Vandazole gel 0.75 % Generic-2 NO OBSTETRICS /

GYNECOLOGY

MISCELLANEOUS

OB/GYNVaqta (PF) syringe 50

unit/mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Vaqta (PF) syringe 25

unit/0.5

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Varivax (PF)

suspension

for

reconstitution

1,350

unit/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Varizig solution

125

unit/1.2

mL


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Varubi tablet 90 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Vascepa capsule 1 gram


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Vecamyl tablet 2.5 mg


, HYPERTENSION /

LIPIDS

MISCELLANEOUS

CARDIOVASCULAR

AGENTS

Vectibix solution 100

mg/5

mL (20

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Velcade recon soln 3.5 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Velivet

Triphasic

Regimen (28)

tablet 0.1/.125

/.15-25

mg-mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Velphoro

tablet,chewab

le 500 mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Veltassa

powder in

packet

8.4

gram

NonPrefBrand-4

30 30

YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Veltassa

powder in

packet

16.8

gram

NonPrefBrand-4

30 30

YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Veltassa

powder in

packet

25.2

gram

NonPrefBrand-4

30 30

YES DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Venclexta tablet 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Venclexta

Starting Pack

tablets,dose

pack

10 mg-

50 mg-

100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

venlafaxine tablet 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

venlafaxine capsule,exten

ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


ded release

24hr

37.5 mg Generic-2 31 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

venlafaxine tablet 37.5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ded release

24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

venlafaxine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

venlafaxine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

venlafaxine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

venlafaxine tablet

extended

release 24hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Ventavis solution for

nebulization

10

mcg/mL


ALLERGY

PULMONARY

AGENTSVentavis solution for

nebulization

20

mcg/mL


ALLERGY

PULMONARY

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Ventolin

HFA

HFA aerosol

inhaler

90

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

Veramyst spray,suspens

ion

27.5

mcg/act

uation


ALLERGY

PULMONARY

AGENTS

verapamil capsule, 24 hr

ER pellet CT


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ER pellet CT


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


ER pellet CT


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

verapamil capsule,ext

rel. pellets 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


rel. pellets 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


rel. pellets 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


rel. pellets 24

hr


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

verapamil tablet

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

verapamil tablet

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

verapamil tablet

extended

release


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

verapamil tablet 120 mg Generic-2 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

verapamil solution 2.5

mg/mL


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

verapamil tablet

extended

release

120 mg

(24

hours)


, HYPERTENSION /

LIPIDS

ANTIHYPERTENSIV

E THERAPY

Veregen ointment 15 % NonPrefBrand-4 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LSVeripred 20 solution 20 mg/5

mL (4

mg/mL)


TES

ADRENAL

HORMONES

Versacloz suspension

50

mg/mL PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Vesicare tablet 10 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Vesicare tablet 5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC

S /

ANTISPASMODICS

Vestura (28) tablet

3-0.02

mg

Generic-2 NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Vfend tablet 50 mg Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSVfend tablet 200 mg Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSVfend suspension

for

reconstitution

200

mg/5

mL (40

mg/mL)

Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTS

Viberzi tablet 75 mg

Specialty-5

62 31

YESGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS


Specialty-5

62 31

YESGASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Vicodin tablet

5-300

mg Generic-2 403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Vicodin ES tablet

7.5-300

mg Generic-2 403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Vicodin HP tablet

10-300

mg Generic-2 403 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Victoza 3-Pak pen injector 0.6

mg/0.1

mL (18

mg/3

mL)


TES

DIABETES

THERAPY

Vidaza recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Videx 2 gram

Pediatric

recon soln 10

mg/mL

(Final)


Videx EC capsule,delay

ed

release(DR/E

C)

125 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS


ed

release(DR/E

C)



ed

release(DR/E

C)



ed

release(DR/E

C)





Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Viekira Pak

tablets,dose

pack

12.5 mg-

75 mg -

50

mg/250

mg

Specialty-5

112 28

YES


Vienva tablet

0.1-20

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Vigamox drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIBIOTICS

Viibryd tablet 10 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Viibryd

tablets,dose

pack

10 mg

(7)- 20

mg (23)


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Vimovo

tablet,IR,dela

yed

rel,biphasic

375-20

mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Vimovo

tablet,IR,dela

yed

rel,biphasic

500-20

mg


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Vimpat solution 200

mg/20

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Vimpat tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Vimpat solution

10

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

vinblastine solution 1

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Vincasar PFS solution 1

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

vincristine solution 1

mg/mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

vinorelbine solution 50 mg/5

mL


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Viracept tablet 250 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Viracept tablet 625 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS

Viramune suspension 50 mg/5

mL


Viramune XR

tablet

extended


NonPrefBrand-4 NO


Viramune XR

tablet

extended


NonPrefBrand-4 NO


Virazole recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Viread tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS

Viread tablet 250 mg PrefBrand-3NO







Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class



Viread powder

40

mg/scoo

p (40

mg/gra

m) PrefBrand-3

NO


Vitekta tablet 85 mgSpecialty-5 NO


Vitekta tablet 150 mgSpecialty-5 NO


Vivitrol suspension,ex

tended rel

recon


DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Vogelxo

gel in metered-

dose pump

1.25

gram/

actuatio

n (1 %)

NonPrefBrand-4 YES

ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Vogelxo gel

50 mg/5

gram (1

%)

NonPrefBrand-4 YESENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Voltaren gel 1 % NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

voriconazole tablet 200 mg Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSvoriconazole tablet 50 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTSvoriconazole solution 200 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

voriconazole suspension

for

reconstitution

200

mg/5

mL (40

mg/mL)


AGENTS

Votrient tablet 200 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

VPRIV recon soln 400 unit Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Vraylar capsule 1.5 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Vraylar capsule 3 mg

Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


Specialty-5

31 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Vraylar

capsule,dose

pack

1.5 mg

(1)- 3

mg (6)

NonPrefBrand-4

14 365

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Vyfemla (28) tablet

0.4-35

mg-mcg Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Vyvanse capsule 20 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Vyvanse capsule 10 mg

NonPrefBrand-4

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

warfarin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

warfarin tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

warfarin tablet 7.5 mg PrefGen-1 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

water for

irrigation,

sterile

solution Generic-2 NO DIAGNOSTICS /

MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

WelChol powder in

packet

3.75

gram


, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

WelChol tablet 625 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTS

Wellbutrin

SR

tablet

extended

release 100 mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Wellbutrin

SR

tablet

extended

release 150 mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Wellbutrin

SR

tablet

extended

release 200 mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Wellbutrin

XL

tablet

extended


NonPrefBrand-4

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Wellbutrin

XL

tablet

extended


NonPrefBrand-4

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xalkori capsule 200 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Xanax tablet 0.25 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax tablet 0.5 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax tablet 1 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax tablet 2 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax XR tablet

extended

release 24 hr


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Xanax XR tablet

extended

release 24 hr

0.5 mg NonPrefBrand-4 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Xarelto tablet 10 mg PrefBrand-3

NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY


NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Xarelto

tablets,dose

pack

15 mg

(42)- 20

mg (9) PrefBrand-3

NOCARDIOVASCULAR

, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY

Xeljanz tablet 5 mg

Specialty-5 YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Xeljanz XR

tablet

extended

release 24 hr 11 mg

Specialty-5

31 31

YES MUSCULOSKELET

AL /

RHEUMATOLOGY

OTHER

RHEUMATOLOGIC

ALS

Xenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Xenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MISCELLANEOUS

NEUROLOGICAL

THERAPY

Xeomin recon soln 50 unit


VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Xgeva solution

120

mg/1.7

mL (70

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Xifaxan tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESXifaxan tablet 550 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVES

Xigduo XR

tablet, IR -

ER, biphasic

24hr

10-

1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Xigduo XR

tablet, IR -

ER, biphasic

24hr

5-500

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Xigduo XR

tablet, IR -

ER, biphasic

24hr

5-1,000

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Xigduo XR

tablet, IR -

ER, biphasic

24hr

10-500

mg PrefBrand-3

NOENDOCRINE/DIABE

TES

DIABETES

THERAPY

Xodol 10/300 tablet 10-300

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Xodol 5/300 tablet 5-300

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Xodol

7.5/300

tablet 7.5-300

mg


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Xolair recon soln 150 mg Specialty-5 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSXopenex solution for

nebulization

0.63

mg/3

mL


ALLERGY

PULMONARY

AGENTS

Xopenex solution for

nebulization

0.31

mg/3

mL


ALLERGY

PULMONARY

AGENTS

Xopenex solution for

nebulization

1.25

mg/3

mL


ALLERGY

PULMONARY

AGENTS

Xtampza ER

capsule,sprink

le,ER 12hr

tmprr 9 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Xtampza ER

capsule,sprink

le,ER 12hr

tmprr 13.5 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Xtampza ER

capsule,sprink

le,ER 12hr

tmprr 18 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Xtampza ER

capsule,sprink

le,ER 12hr

tmprr 27 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Xtampza ER

capsule,sprink

le,ER 12hr

tmprr 36 mg

NonPrefBrand-4

62 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Xtandi capsule 40 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Xyrem solution 500

mg/mL


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Yervoy solution

50

mg/10

mL (5

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

YF-Vax (PF)

suspension

for

reconstitution

10

exp4.74

unit/0.5

mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

zafirlukast tablet 20 mg Generic-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSzafirlukast tablet 10 mg Generic-2 NO RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSzaleplon capsule 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

zaleplon capsule 5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zaltrap solution

100

mg/4

mL (25

mg/mL)


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zamicet solution 10-325

mg/15

mL


DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Zanosar recon soln 1 gram NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Zarontin capsule 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Zarontin solution 250

mg/5

mL


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Zarxio syringe

300

mcg/0.5

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Zarxio syringe

480

mcg/0.8

mL


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Zavesca capsule 100 mg Specialty-5 NO ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Zebutal capsule

50-325-

40 mg Generic-2 372 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Zelapar tablet,disinteg

rating

1.25 mg Specialty-5 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTIPARKINSONIS

M AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zelboraf tablet 240 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Zemaira recon soln

1,000

mg


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Zembrace

Symtouch pen injector

3

mg/0.5

mL

NonPrefBrand-4

8 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Zemplar solution 5

mcg/mL


TES

MISCELLANEOUS

HORMONESZemplar solution 2

mcg/mL


TES

MISCELLANEOUS

HORMONESZemplar capsule 1 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONESZemplar capsule 2 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Zenatane capsule 30 mg Generic-2

NO DERMATOLOGICA

LS/TOPICAL

THERAPY

THERAPY FOR

ACNE

Zenchent Fe

tablet,chewab

le

0.4mg-

35mcg(

21) and

75 mg

(7) Generic-2

NO

OBSTETRICS /

GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS

Zenpep capsule,delay

ed

release(DR/E

C)

10,000-

34,000 -

55,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class


ed

release(DR/E

C)

15,000-

51,000 -

82,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS


ed

release(DR/E

C)

20,000-

68,000 -

109,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS


ed

release(DR/E

C)

5,000-

17,000 -

27,000

unit


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zenpep

capsule,delay

ed

release(DR/E

C)

3,000-

10,000-

16,000

unit PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zenpep

capsule,delay

ed

release(DR/E

C)

25,000-

85,000-

136,000

unit PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zenpep

capsule,delay

ed

release(DR/E

C)

40,000-

136,000-

218,000

unit PrefBrand-3

NO

GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zenzedi tablet 10 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zenzedi tablet 5 mg Generic-2

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zenzedi tablet 2.5 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zenzedi tablet 15 mg


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS



DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zepatier tablet

50-100

mgSpecialty-5

28 28YES


Zerbaxa recon soln

1.5

gramSpecialty-5 NO


Zerit capsule 15 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS







Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zerit recon soln 1

mg/mL


Zetia tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR

, HYPERTENSION /

LIPIDS

LIPID/CHOLESTER

OL LOWERING

AGENTSZiagen tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS

Ziagen solution 20

mg/mL


zidovudine capsule 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

zidovudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS

zidovudine syrup 10

mg/mL


Zinecard (as

HCl)

recon soln 250 mg NonPrefBrand-4 NO ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ADJUNCTIVE

AGENTS

Zioptan (PF) dropperette

0.0015

%

NonPrefBrand-4 NO

OPHTHALMOLOGY

OTHER

GLAUCOMA

DRUGS

ziprasidone

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

ziprasidone

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

ziprasidone

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

ziprasidone

HCl


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zirgan gel 0.15 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIVIRALS

Zmax suspension,ex

tended rel

recon

2

gram/60

mL


OTHER

MACROLIDESZofran (as

hydrochloride

)

tablet 4 mg Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSZofran (as

hydrochloride

)

tablet 8 mg Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSZofran (as

hydrochloride

)

solution 4 mg/5

mL

Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSZofran ODT tablet,disinteg

rating

4 mg NonPrefBrand-4 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTSZofran ODT tablet,disinteg

rating

8 mg Specialty-5 YES GASTROENTEROL

OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zohydro ER

capsule, oral

only, ER 12hr 10 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zohydro ER

capsule, oral

only, ER 12hr 15 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Zohydro ER

capsule, oral

only, ER 12hr 20 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Zohydro ER

capsule, oral

only, ER 12hr 30 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Zohydro ER

capsule, oral

only, ER 12hr 40 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

Zohydro ER

capsule, oral

only, ER 12hr 50 mg

NonPrefBrand-4

100 31

YES AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NARCOTIC

ANALGESICS

zoledronic

acid

solution 4 mg/5

mL


TES

MISCELLANEOUS

HORMONESzoledronic

acid-mannitol-

water

solution 5

mg/100

mL


MISCELLANEOUS

AGENTS

MISCELLANEOUS

AGENTS

Zolinza capsule 100 mg Specialty-5 YES ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

zolmitriptan tablet 2.5 mg Generic-2 16 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

zolmitriptan tablet 5 mg Generic-2 8 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYzolmitriptan tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYzolmitriptan tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYzolpidem tablet 10 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

zolpidem tablet 5 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

zolpidem tablet,ext

release

multiphase


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

zolpidem tablet,ext

release

multiphase


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

zolpidem tablet 1.75 mg PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

zolpidem tablet 3.5 mg PrefBrand-3

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zomacton recon soln 10 mg


VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS



VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Zometa solution 4 mg/5

mL


TES

MISCELLANEOUS

HORMONES

Zometa solution

4

mg/100

mL

Specialty-5 NOENDOCRINE/DIABE

TES

MISCELLANEOUS

HORMONES

Zomig tablet 2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYZomig tablet 5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYZomig spray,non-

aerosol


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY

Zomig

spray,non-

aerosol 2.5 mg

NonPrefBrand-4

16 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zomig ZMT tablet,disinteg

rating

2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYZomig ZMT tablet,disinteg

rating


DRUGS,

NEUROLOGY /

PSYCH

MIGRAINE /

CLUSTER

HEADACHE

THERAPYZonegran capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Zonegran capsule 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

zonisamide capsule 100 mg Generic-2 NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S


DRUGS,

NEUROLOGY /

PSYCH

ANTICONVULSANT

S

Zontivity tablet 2.08 mg


, HYPERTENSION /

LIPIDS

COAGULATION

THERAPY




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zorbtive recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

BIOTECHNOLOGY

DRUGS

Zortress tablet 0.25 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Zostavax (PF)

suspension

for

reconstitution

19,400

unit/0.6

5 mL PrefBrand-3

NOIMMUNOLOGY,

VACCINES /

BIOTECHNOLOGY

VACCINES /

MISCELLANEOUS

IMMUNOLOGICALS

Zosyn in

dextrose (iso-

osm)

piggyback 2.25

gram/50

mL


Zosyn in

dextrose (iso-

osm)

piggyback 3.375

gram/50

mL


Zovia 1/35E

(28)

tablet 1-35 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTSZovia 1/50E

(28)

tablet 1-50 mg-

mcg


GYNECOLOGY

ORAL

CONTRACEPTIVES

/ RELATED

AGENTS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zovirax cream 5 % PrefBrand-3 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

TOPICAL

ANTIVIRALS

Zubsolv tablet

1.4-0.36

mg

NonPrefBrand-4

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Zubsolv tablet

5.7-1.4

mg

NonPrefBrand-4

31 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Zubsolv tablet

11.4-2.9

mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Zubsolv tablet

8.6-2.1

mg

NonPrefBrand-4

62 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Zubsolv tablet

2.9-0.71

mg

NonPrefBrand-4

93 31

NO AUTONOMIC / CNS

DRUGS,

NEUROLOGY /

PSYCH

NON-NARCOTIC

ANALGESICS

Zuplenz film 8 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zuplenz film 4 mg


OGY

MISCELLANEOUS

GASTROINTESTINA

L AGENTS

Zyclara

cream in

packet 3.75 %

Specialty-5 NO DERMATOLOGICA

LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zyclara

cream in

metered-dose

pump 2.5 %


LS/TOPICAL

THERAPY

MISCELLANEOUS

DERMATOLOGICA

LS

Zydelig tablet 100 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS



IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Zyflo tablet 600 mg NonPrefBrand-4 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTSZyflo CR tablet, ER

multiphase 12

hr

600 mg Specialty-5 YES RESPIRATORY AND

ALLERGY

PULMONARY

AGENTS

Zykadia capsule 150 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS

Zylet drops,suspens

ion

0.3-0.5

%

NonPrefBrand-4 NO OPHTHALMOLOGY STEROID-

ANTIBIOTIC

COMBINATIONSZyprexa

Relprevv

suspension

for

reconstitution


DRUGS,

NEUROLOGY /

PSYCH

PSYCHOTHERAPEU

TIC DRUGS

Zytiga tablet 250 mg


IMMUNOSUPPRESS

ANT DRUGS

ANTINEOPLASTIC /

IMMUNOSUPPRESS

ANT DRUGS




Quantity Limit

Amount

Quantity

Limit Days

Prior

Authorization

HPMS Therapeutic

Category

HPMS Therapeutic

Class

Zyvox parenteral

solution

600

mg/300

mL


ANTIINFECTIVES

Zyvox tablet 600 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS

ANTIINFECTIVESZyvox suspension

for

reconstitution

100

mg/5

mL


ANTIINFECTIVES


Medicare Part D: PA Criteria

PA Group Covered Use

Exclusion

Criteria Required Medical Information

Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteria

actemra All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Kineret,

Remicade,

Humira,

Orencia, Enbrel,

Simponi, Cimzia

Documentation of moderate to

severe rheumatoid arthritis -OR-

documentation of moderate to

severe juvenile idiopathic

rheumatoid arthritis (Actemra IV

only)

12 months For Actemra SubQ,

patients must have an

adequate trial or

intolerance to the

preferred SubQ

products, Enbrel and

Humira, for

rheumatoid arthritis.

For Actemra IV,


adequate trial or

intolerance to one of

the preferred IV

products, Remicade or

Simponi Aria, for


1 Formulary ID: 16256 Version: 17 Update: 09/2016



Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Covered for the following

indications: 1. Infantile spasms

(West syndrome) 2. Acute

exacerbations of multiple sclerosis

(MS) for patients receiving

concurrent immunomodulator

therapy (e.g., interferon beta,

glatiramer acetate, dimethyl

fumerate, fingolimod,

teriflunomide) 3. Rheumatic

disorders 4. Collagen diseases 5.

Dermatologic diseases 6. Allergic

states 7. Ophthalmic diseases 8.

Respiratory diseases 9.

Transfusion reaction due to serum

protein reaction 10. Proteinuria in

nephrotic syndrome and

trial/failure or contraindication to

two therapies from any of the

following different classes:

corticosteroids (e.g., cortisone or

dexamethasone), calcineurin

inhibitors (e.g, cyclosporine or

tacrolimus, per DRUGDEX). 11.

Diagnosis for adrenal insufficiency

with trial/failure or

acthar h.p. All medically

accepted

indications

not otherwise

excluded from

Part D

neurologist for

infantile

spasm

1 month




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriawith trial/failure or

contraindication to cosyntropin.

12. Gout and intolerance or

contraindication to at least two

first-line gout therapies (e.g,

allopurinol, probenecid,

colchicine). 13. Pediatric acquired

epileptic aphasia. For covered

indications 2 through 9,

limited/unsatisfactory response or

intolerance (i.e. severe

anaphylaxis) to two corticosteroids

(i.e. IV methylprednisolone, IV

dexamethasone, or high dose oral

steroids) must be documented.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


actimmune All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis 12 months Applies to new starts

only

Diagnosis of pulmonary

hypertension, substantiated by

results from Doppler

echocardiography and/or direct

measurement of pulmonary arterial

pressure, defined as a mean

pulmonary arterial pressure of

greater than or equal to 25 mmHg,

with a pulmonary capillary wedge

pressure of less than 15 mmHg -

OR- diagnosis of chronic

thromboembolic pulmonary

hypertension (CTEPH) (WHO

group 4) after surgical treatment or

inoperable CTEPH.

adempas All FDA

approved

indications

not otherwise

excluded from

Part D

cardiologist,

pulmonologist

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


ADHD

Drugs

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of ADHD -AND-

trial/failure, intolerance or

contraindication to a stimulant

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


afinitor All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of advanced renal

cell carcinoma -OR-

documentation of patients with

progressive neuroendocrine

tumors of pancreatic origin

(PNET) that is unresectable,

locally advanced or metastatic -OR-

documentation of renal

angiomyolipoma and tuberous

sclerosis complex (TSC) -OR-

documentation of use in

postmenopausal advanced

hormone receptor-positive, HER2-

negative breast cancer in

combination with exemestane after

failure of treatment with letrozole

or anastrozole -OR-

documentation of SEGA

associated with tuberous sclerosis

for those not a candidate for

surgical resection.

oncologist 12 months Applies to new starts

only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


alecensa All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of metastatic non-

small cell lung cancer (NSCLC)

that is anaplastic lymphoma kinase

(ALK) positive AND previous

trial and failure or intolerance to

crizotinib (Xalkori)

12 months Applies to new starts

only

ALPHA1-

PROTEIN

ASE

INHIBITO

RS

All FDA

approved

indications

not otherwise

excluded from

Part D

Diagnosis of panacinar

emphysema AND documentation

of a decline in forced expiratory

volume in 1 second (fev1) despite

optimal medical therapy

(bronchodilators, corticosteroids,

oxygen if indicated) AND

documentation of phenotype

(pi*zz, pi*znull or pi*nullnull)

associated with causing serum

alpha 1-antitrypsin of less than 80

mg/dl AND documentation of an

alpha 1-antitrypsin serum level

below the value of 35% of normal

(less than 80 mg/dl).

Deny if less

than 18 years

of age

12 months Covered under Part B

when furnished

incident to a physician

service and is not self-

administered.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


ampyra All FDA

approved

indications

not otherwise

excluded from

Part D

history of

seizure disorder,

Cr Cl less than

50ml/min

Documentation of diagnosis and

functional status score (EDSS

score)

12 months doses greater than 20

mg/day will not be

approved

anabolic

steroids

All medically

accepted

indications

not otherwise

excluded from

Part D

Documentation of diagnosis 12 months

atypical

antipsychot

ics

All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis. If

medication is being used for major

depressive disorder,

documentation of adjunctive

therapy and an adequate trial of 1

alternative antidepressant is

required (e.g. SSRI, SNRI, NDRIs,

TCA, MAOI).


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


aubagio All FDA

approved

indications

not otherwise

excluded from

Part D

Concomitant use

of Aubagio and

other disease

modifying

agents such as

fingolimod,

interferons,

Copaxone ,

Tysabri

Documentation of relapsing-

remitting or relapsing secondary

progressive multiple sclerosis

neurologist 12 months Doses greater than 14

mg per day will not be

approved

belbuca All FDA

approved

indications

not otherwise

excluded from

Part D


severe chronic pain -AND- trial

and failure of at least two previous

federal legend medications for

pain, including NSAIDs, tramadol,

or opioid analgesics

12 months Belbuca should not be

used concomitantly

with substance abuse

therapies.

BELEODA

Q

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of relapsed or

refractory peripheral T-cell

lymphoma (PTCL)


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


berinert All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of use for

treatment of acute abdominal,

facial, or laryngeal attacks of

hereditary angioedema (HAE)

Deny is less

than 12 years

of age

12 months

bosulif All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of chronic

myelogenous leukemia (CML) of

any phase and lack of response or

intolerance to prior therapy (e.g.

imatinib, dasatinib, nilotinib)


only

botulinum

toxin

All medically

accepted

indications

not otherwise

excluded from

Part D

Use for cosmetic

purposes





Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


butrans All FDA

approved

indications

not otherwise

excluded from

Part D


severe chronic pain -AND- trial

and failure of at least two previous

federal legend medications for

pain, including NSAIDs, tramadol,

or opioid analgesics

12 months Butrans should not be

used concomitantly

with substance abuse

therapies.

cabometyx All FDA

approved

indications

not otherwise

excluded from

Part D


cell carcinoma (RCC) and failure

of one prior anti-angiogenic

therapy


only

caprelsa All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of symptomatic or

progressive medullary thyroid

cancer in patients with

unresectable locally advanced or

metastatic disease


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


carbaglu All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of use as an

adjunct therapy for acute

hyperammonemia or maintenance

therapy for chronic

hyperammonemia due to hepatic

enzyme N-acetylglutamate

synthase (NAGS) deficiency

12 months

CERDELG

A

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of type 1 Gaucher

disease

Deny if less

than 18 years

of age

12 months

CF drugs All FDA

approved

indications

not otherwise

excluded from

Part D

Diagnosis of cystic fibrosis. For

Bethkis: failure on, intolerance to,

or contraindication to generic

tobramycin inhalation solution

12 months Inhalation solutions

covered under Part B

when administered in

the home setting using

a covered nebulizer

(i.e. DME).




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


chenodal All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of small (less than

15mm in diameter), floatable

radiolucent gallstones AND an

inadequate response to ursodiol

therapy

12 months for

initial

approval with

an additional

12 months

upon renewal

Safety of use beyond

24 months is not

established

cholbam All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of bile acid

synthesis disorders due to single

enzyme defects (SEDs) -OR-

documentation of use as

adjunctive therapy for peroxisomal

disorders (PDs), including

Zellweger spectrum disorders, in

patients who exhibit

manifestations of liver disease,

steatorrhea, or complications from

decreased fat soluble vitamin

absorption.

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


cialis All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of benign prostatic

hyperplasia (BPH) and alternatives

tried/failed (one or more alpha-1

adrenergic blocker)

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage




moderate to severe Crohn's disease

-OR- psoriatic arthritis -OR-

ankylosing spondylitis

concomitant use

of Enbrel,

Remicade,

Humira,

Orencia,

Simponi,

Actemra,

Kineret

All FDA

approved

indications

not otherwise

excluded from

Part D

cimzia Patients must have an

adequate trial or

intolerance to one

corticosteorid (e.g.,

prednisone or

hydrocortisone) and

the preferred biologic

product, Humira, for a

diagnosis of Crohn's

disease. Patients must

have an adequate trial

or intolerance to both

preferred products,

Enbrel and Humira,

for rheumatoid

arthritis, psoriatic

arthritis and

ankylosing

spondylitis. For initial

and indication therapy

dosing, doses above

plan quantity limit

will be approved

aligned with

recommended initial

12 monthsGastroenterolo

gist/

Rheumatologi

st




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriarecommended initial

and induction therapy

dosing regimens per

indication.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


cinryze All FDA

approved

indications

not otherwise

excluded from

Part D

Coverage for the following two

indications: 1. Use as prophylaxis

for hereditary angioedema (HAE)

type I & II -AND- documentation

that clinical laboratory

performance C4 below lower limit

of laboratory reference range -

AND- C1 inhibitor level below

lower limit of laboratory reference

range -OR- normal C1 inhibitor

level and a low C1INH functional

level below laboratory reference

range -AND- documentation of at

least 1 symptom of angioedema

attack -AND- medications that

cause angioedema have been

evaluated and discontinued. 2.

Use as prophylaxis for hereditary

angioedema (HAE) type III -AND-

documentation that clinical

laboratory performance C4, C1

inhibitor, and C1INH functional

level are within normal limits of

laboratory reference ranges -AND-

documentation of family history of

HAE -OR- FXII mutation -AND-

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


cometriq All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of progressive,

metastatic medullary thyroid

cancer


only

HAE -OR- FXII mutation -AND-

documentation of at least 1

symptom of angioedema attack -

AND- medications that cause

angioedema have been evaluated

and discontinued.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


corlanor All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of stable,

symptomatic heart failure and

normal sinus rhythm AND left

ventricular ejection fraction less

than or equal to 35 percent AND

resting heart rate greater than or

equal to 70 beats per minute AND

trial/failure of maximum tolerated

dose of one beta-blocker used for

treatment of heart failure (e.g.,

bisoprolol, carvedilol, metoprolol

succinate) OR contraindication to

beta-blocker use

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Cosentyx All FDA

approved

indications

not otherwise

excluded from

Part D


severe psoriasis and failure of one

systemic therapy (e.g.

methotrexate, cyclosporine) or

phototherapy -OR- active psoriatic

arthritis -OR- active ankylosing

spondylitis

12 months Patients must have an

adequate trial or

intolerance to the

preferred product,

Humira, for psoriasis

and the preferred


Humira, for psoriatic

arthritis and

ankylosing

spondylitis. For

induction therapy

dosing, doses above

plan quantity limit

will be approved

aligned with

recommended

induction therapy

dosing regimens per

indication.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


cotellic All FDA

approved

indications

not otherwise

excluded from

Part D

Disease

progression on

prior BRAF

inhibitor therapy

Documentation of unresectable or

metastatic melanoma in patients

with a BRAF V600E or V600K

mutation AND used in

combination with vemurafenib

oncologist,

hematologist


only

crinone All medically

accepted

indications

not otherwise

excluded from

Part D

Use to promote

fertility





Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


daklinza All FDA

approved

indications

not otherwise

excluded from

Part D

Covered for the following: 1.

Chronic hepatitis C (CHC) gt 1a,

1b, 2 or 3 infection in adults -

AND- documentation that

Daklinza will be used with Sovaldi

-AND- documentation that

Daklinza and Sovaldi will not be

used with other agents to treat

hepatitis C, except ribavirin. 2.

CHC gt 1, 2, 3, or 4 in an allograft -

AND- using with Sovaldi -AND-

using with ribavirin unless

intolerant or ineligible

Deny if less

than 18 years

of age

G1,3:12w

txnncr,txexncr

,24w

txncr,txexcr,R

/INFinel.G2:1

2w txn,24w

txex

INFinel.G1-

4al:12w,24w

Rinel

darzalex All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation for use in the

treatment of multiple myeloma in

patients who have received at least

3 prior lines of therapy including a

proteasome inhibitor (PI) and an

immunomodulatory agent OR for

use in multiple myeloma patients

who are double-refractory to a PI

and an immunomodulatory agent

oncologist,

hematologist


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


egfr

tyrosine

kinase

inhibitors

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of diagnosis,

alternatives tried and failed and

concomitant therapy, if applicable

to diagnosis

oncologist,

hematologist

12 months Coverage of

pancreatic cancer

diagnosis applies only

to erlotinib (Tarceva).

The use of Tarceva

and Gilotrif for non-

small cell lung cancer

(NSCLC) will be

approved as a first-

line therapy. Applies

to new starts only.

egrifta All FDA

approved

indications

not otherwise

excluded from

Part D

Documented diagnosis of HIV and

lipodystrophy, member must

actively be receiving antiretroviral

therapy including protease

inhibitors, nucleoside reverse

transcriptase inhibitors, or non-

nucleoside reverse transcriptase

inhibitors


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


enbrel All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Remicade,

Cimzia, Humira,

Orencia,

Simponi,

Actemra,

Kineret, Stelara



psoriatic arthritis -OR- ankylosing

spondylitis -OR- moderate to


rheumatoid arthritis and an

inadequate response or intolerance

to at least one DMARD (e.g.,

methotrexate, leflunamide) -OR-

moderate to severe psoriasis after

failure of either systemic therapy

(e.g., methotrexate or

cyclosporine) or phototherapy.

Deny if less

than 2 years

old

rheumatologist

, dermatologist

12 months For psoriasis trial of 1

alternative therapy,

either systemic

therapy (e.g.

methotrexate or

cyclosporine) or

phototherapy, is

required.

entresto All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of an ACE

inhibitor or

ARB

Documentation of chronic heart

failure (NYHA Class II to IV)

AND systolic dysfunction (LVEF

less than or equal to 40 percent)

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


erivedge All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of advanced basal

cell carcinoma (BCC), which

includes metastatic and locally

advanced basal cell carcinoma, for

whom surgery is inappropriate

oncologist,

dermatologist


only, doses greater

than 150mg/day will

not be approved

farydak All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of use in

combination with bortezomib and

dexamethasone for patients with

multiple myeloma who have

received at least 2 prior regimens,

including bortezomib and an

immunomodulatory agent (i.e.

Thalomid, Revlimid, Pomolyst)


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Acute hereditary angioedema

(HAE) type I & II: Documentation













evaluated and discontinued. Acute

hereditary angioedema (HAE) type

III: Documentation that clinical


inhibitor level and C1INH

functional level are within normal

limits of the laboratory's reference

range -AND- documentation of

HAE family history -OR- FXL

mutation -AND- documentation of

at least 1 symptom of angioedema


All FDA

approved

indications

not otherwise

excluded from

Part D

firazyr Deny if less

than 18 years

of age

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


flector All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of diagnosis 1 month



evaluated and discontinued




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


forteo All FDA

approved

indications

not otherwise

excluded from

Part D

Diagnosis of

underlying

hypercalcemic

disorder such as

hypercalcemia,

hyperparathyroi

dism or

hypoparathyroid

ism, or high risk

for

osteosarcoma

(Paget's disease,

prior radiation

therapy, bone

metastases, open

epiphyses, etc.).

Treatment

duration greater

than 24 months.

Documentation to support use for

treatment of osteoporosis and the

prevention of fractures in

postmenopausal women and men

having a T score of less than -2.5

and a trial and failure or

contraindication to at least one

bisphosphonate -OR- use to

prevent fractures in men and

postmenopausal women with a

low bone mass (T score between -

1.0 and -2.5) and history of

previous osteoporotic fracture or

those who are found to have a 10-

year risk of major osteoporotic

fracture greater than or equal to 20

percent or a risk of hip fracture

greater than or equal to 3 percent

and had a trial and failure or


bisphosphonate

24 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


gattex All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of short bowel

syndrome (SBS) AND dependence

on parenteral nutrition or

intravenous nutritional support for

at least 12 months AND requiring

parenteral nutrition at least 3 times

per week

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


All FDA

approved

indications

not otherwise

excluded from

Part D

gilenya neurologist 12 months Doses greater than

0.5mg/day will not be

approved

Members must have a documented

diagnosis of relapsing-remitting,

relapsing secondary progressive or

progressive relapsing multiple

sclerosis -AND- new starts to

therapy have the following

baseline information documented

within 6 months of initiating

therapy: ophthalmologic

evaluation, liver transaminase and

bilirubin, complete blood count,

and electrocardiogram if using an

antiarrhythmic agent or have

second degree or greater AV block

-AND- new starts to therapy do

not have any of the following

comorbid conditions or

concomitant therapies:

bradycardia, congestive heart

failure, sick sinus syndrome,

prolonged QT interval, ischemic

cardiac disease, irregular

heartbeat, current neutropenia,

current chronic or acute infections,

use of antineoplastics,

immunosuppressive or immune

Concomitant

use of Gilenya

and other

disease

modifying

agents such as

interferons,

Copaxone ,

Tysabri




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


gleevec All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis and

alternatives tried or concomitant

therapy, if applicable for diagnosis


only

gralise All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of diagnosis 12 months Applies to new starts

only

immunosuppressive or immune

modulating therapies




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


GRASTEK All FDA

approved

indications

not otherwise

excluded from

Part D

Asthma (severe,

unstable or

unconrolled),

concomitant

sublingual or

subcutaneous

immunotherapy,

therapy

initiation during

active allergy

season

Documentation of allergic rhinitis

and use for Timothy grass pollen

or cross reactive grass pollens

(Sweet Vernal, Orchard, Perennial

Rye, Timothy, Kentucky Blue

Grass pollen, Redtop, or meadow

fescue) -AND- allergic rhinitis

with or without conjunctivitis has

been confirmed by a pollen

specific positive skin test or in

vitro testing for pollen-specific IgE

antibodies -AND- trial and failure

or intolerance to an intranasal

steroid and an oral non-sedating

antihistamine, intranasal

antihistamine or intranasal

anticholinergic agent

Deny if less

than 5 years

of age or

greater than

65 years of

age

allergy

specialist,

otolaryngologi

st

12 months Member must also be

prescribed an

epinephrine auto

injector

growth

hormone

All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis,

growth chart, bone age, growth

velocity, and response to

stimulation test, when applicable

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


HARVONI All FDA

approved

indications

not otherwise

excluded from

Part D

CHC gt 1a, 1b, 4, 5, or 6 infection

in adults (18 years and older) -

AND- Harvoni will not be used

with another agent to treat hep C

unless tx-exp and using with RBV -

AND- HCV RNA level

documented prior to tx (within

past 6 months of request) -AND-

if cirrhotic, member has comp

cirrhosis -OR- recurrent CHC gt 1

or 4 infection post-liver

transplantation in adults -AND-

using with RBV unless RBV

intolerant or ineligible -OR- CHC

gt 1 or 4 in adults -AND-

decompensated cirrhosis -AND-

using with RBV -AND-

documentation of previous HCV

regimens used

Deny if less

than 18 years

of age

G1:12w txn

nocir, t/f

PR.24w txex

cir,

t/fPI,SOF.G4,

5,6:12w.Dcp

G1,4:12,24w

t/fSOF.Posttx

G1,4:12,24w

Doses greater than

one tablet per day will

not be approved.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


HETLIOZ All FDA

approved

indications

not otherwise

excluded from

Part D

Documented diagnosis of Non-24

Sleep-Wake disorder -AND-

patient is totally blind

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


high-risk

meds

All FDA

approved

indications

not otherwise

excluded from

Part D

Automatic

approval if

less than 65

years of age


only for protected

class drugs. Digoxin

doses less than or

equal to 0.125 mg per

day and doxepin

doses less than or

equal to 6 mg per day

will receive automatic

approval.

For all medications subject to this

PA group, the following

information (1 through 3) is

required: 1. Documentation of

diagnosis 2. Explanation of risk-

benefit profile favoring use of the

high-risk medication 3.

Documentation of ongoing

monitoring plan to identify and

address treatment-related adverse

events. In addition to requirements

1 through 3 above, for digoxin

doses exceeding 0.125 mg daily,

provider confirmation that a lower

dose of digoxin has or would be

ineffective in managing the

member's condition is required.

For the target high-risk

medications glyburide, TCAs and

nitrofurantoin, in addition to

criteria 1 through 3 above, trial

and failure or documentation of

intolerance or contraindication to

at least 2 non-high risk alternative

drugs for the same indication, if

available, is required. Non-high




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriaavailable, is required. Non-high

risk alternative medications for

those target high-risk medications

include the following: 1.

Glyburide (non-high risk

alternatives include glipizide and

glimepiride) 2. TCAs (non-high

risk alternatives include SSRIs and

SNRIs) 3. Nitrofurantoin (non-

high risk alternatives include

Bactrim, Cipro, or cephalexin). If

using one of the above 3 high-risk

medications for a medically-

accepted indication not shared by

the safer alternatives listed, then

no trial of alternatives is required

for that target high-risk

medication.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


homozygou

s fh

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of homozygous

familial hypercholesterolemia

(HoFH) confirmed by genetic

testing showing functional

mutation(s) in both LDL receptor

alleles or alleles known to affect

LDL receptor functionality -OR-

untreated LDL-C concentrations

greater than 500 mg/dL, treated

LDL-C concentrations greater than

or equal to 300 mg/dL, or a non-

HDL-C concentration greater than

or equal to 330mg/dL -AND- the

presence of Xanthomas in the first

decade of life -OR- documentation

of elevated LDL-C greater than

190 mg/dL prior to lipid-lowering

therapy consistent with HoFH in

both parents

6 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


horizant All FDA

approved

indications

not otherwise

excluded from

Part D


severe active primary restless leg

syndrome and trial and failure of

two accepted medications for the

treatment of this condition one of

which must include pramipexole

or ropinirole -OR- documentation

of post herpetic neuralgia


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


concomitant use

of Remicade,

Cimzia, Enbrel,

Orencia,

Simponi,

Actemra,

Kineret, Stelara

All FDA

approved

indications

not otherwise

excluded from

Part D

humira For psoriasis trial of 1


either systemic

therapy (e.g.

methotrexate or

cyclosporine) or

phototherapy, is

required. For Crohn's

disease, trial of 2

immunosuppressants

(e.g. corticosteroids,

azathioprine) or

monotherapy with

infliximab is required.

For Ulcerative Colitis,

trial of 2

immunosuppressants


azathioprine or 6-

mercaptopurine) is

required. For plaque

psoriasis induction

therapy, doses above

plan quantity limit

will be approved

aligned with

12 monthsrheumatologist

,

dermatologist,

or

gastroenterolo

gist

Deny if less

than 2 years

old


severe hidradenitis suppurativa -

OR- moderate to severe

rheumatoid arthritis -OR- psoriatic

arthritis -OR- ankylosing

spondylitis -OR- moderate to


rheumatoid arthritis and an


to at least one DMARD (e.g.,

methotrexate, leflunamide) -OR-


failure of either systemic therapy

(e.g., methotrexate or

cyclosporine) or phototherapy. -

OR- moderate to severe Crohn's

disease after failure of two

immunosuppressants (e.g.,

corticosteroids, azathioprine) or

monotherapy with infliximab -OR-

moderate to severe ulcerative

colitis after failure of two

immunosuppressants (e.g.

corticosteroids, azathioprine or 6-

mercaptopurine).




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Ibrance All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of ER-positive,

HER2-negative metastatic breast

cancer in postmenopausal women

AND used as initial endocrine-

based therapy for metastatic

disease in combination with

letrozole (Femara)


only

aligned with

recommended

induction therapy

dosing regimen. For

rheumatoid arthritis

therapy without

concomitant

methotrexate, doses

above plan quantity

limit will be approved

aligned with

recommended weekly

dosing regimen.

Induction therapy or

treatment regimens

for other indications

are aligned with plan

quantity limit on

Humira starter kit.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


iclusig All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of T3151 chronic

phase, accelerated phase or blast

phase CML -OR- documentation

of T3151 Ph+ ALL -OR-

documentation of chronic phase,

accelerated phase or blast phase

CML in patients for whom no

other tyrosine kinase inhibitor

therapy is indicated -OR-

documentation of Ph+ ALL in

patients for whom no other

tyrosine kinase inhibitor therapy is

indicated.


only

ig All medically

accepted

indications

not otherwise

excluded from

Part D

Documentation of diagnosis 12 months Covered under Part B

when administered in

the home to a member

with a diagnosis of

primary

immunodeficiency

disease




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


imbruvica All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of mantle cell

lymphoma and treatment with at

least one prior therapy -OR-

documentation of chronic

lymphocytic leukemia and

treatment with at least one prior

therapy -OR- documentation of

Waldenstrom macroglobulinemia


only

increlex All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis,

growth chart, stimulation test

results, growth velocity, IGF-1

level

Deny if

greater than

18 years old

12 months

inlyta All FDA

approved

indications

not otherwise

excluded from

Part D


cell carcinoma (RCC) and failure

one prior systemic therapy


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


interferon

alfa

All medically

accepted

indications

not otherwise

excluded from

Part D

documentation of diagnosis only 12 months

interleukin-

1b blockers

All FDA

approved

indications

not otherwise

excluded from

Part D

Concomitant use

with agents that

inhibit IL-1 or

TNF including

Remicade,

Humira, Enbrel,

Orencia, or

Kineret

documentation of diagnosis Deny if less

than 12 years

of age

(Arcalyst) or

less than 2

years of age

(Ilaris)

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


IPF

AGENTS

All FDA

approved

indications

not otherwise

excluded from

Part D

Concomitant use

of pirfenidone

and nintedanib

Documentation of idiopathic

pulmonary fibrosis -AND-

baseline forced vital capacity

(FVC) of at least 50% and a

percent predicted diffusing

capacity of the lungs of carbon

monoxide (DLCO) of at least

30%.

pulmonologist 12 months

iressa All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of metastatic non-

small cell lung cancer (NSCLC) in

patients whose tumors express

EGFR exon 19 deletion mutations

or exon 21 (L858R) mutations as

detected by an FDA-approved test

oncologist,

hematologist


only

jakafi All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of intermediate or

high-risk myelofibrosis, including

primary myelofibrosis, post-

polycythemia vera myelofibrosis

and post-essential

thrombocythemia myelofibrosis

oncologist,

hematologist


only. Platelet count to

be provided.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


kalydeco All FDA

approved

indications

not otherwise

excluded from

Part D

Homozygous for

the F508del

mutation in the

CFTR gene

Documentation of cystic fibrosis

(CF) in patients who have one of

the following mutations in the

cystic fibrosis transmembrane

conductance regulator (CFTR)

gene, G551D, G1244E, G1349D,

G178R, G551S, S1251N, S1255P,

S549N, S549R or R117H.

Deny if less

than 6 years

of age for oral

tablets and

less than 2

years of age

for oral

granules

pulmonologist 12 months Doses greater than

300mg/day will not be

approved

kanuma All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of diagnosis of

Lysosomal Acid Lipase (LAL)

deficiency

12 months

keveyis All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of one of the

following: 1. Primary

hyperkalemic periodic paralysis 2.

Primary hypokalemic periodic

paralysis 3. Related variants of

primary periodic paralysis

Deny if less

than 18 years

of age

12 months Doses exceeding 200

mg per day will not be

approved.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


KEYTRUD

A

All FDA

approved

indications

not otherwise

excluded from

Part D


metastatic melanoma and disease

progression following ipilimumab

(Yervoy) and, if BRAF V600

mutation positive, a BRAF

inhibitor -OR- metastatic non-

small cell lung cancer (NSCLC)

with PD-L1-positive expressing

tumor, as determined by an FDA-

approved test, after failure of prior

platinum-based chemotherapy


only

kineret All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Actemra,

Remicade,

Humira,

Orencia, Enbrel,

Simponi, Cimzia


severe rheumatoid arthritis and

trial and failure of one DMARD -

OR- neonatal-onset multisystem

inflammatory disease (NOMID) or

chronic infantile neurological,

cutaneous and articular (CINCA)

syndrome

rheumatologist 12 months Patients must have an

adequate trial or

intolerance to the

preferred products,

Enbrel and Humira,

for rheumatoid

arthritis.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


korlym All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of hyperglycemia

secondary to hypercortisolism in

patients with endogenous

Cushing's syndrome who have

Type 2 Diabetes Mellitus or

glucose intolerance AND patient is

not a candidate for surgery or

radiotherapy or where surgery or

radiotherapy has failed

Deny if less

than 18 years

of age

12 months

lenvima All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of locally recurrent

or metastatic, progressive,

radioactive iodine refractory

differentiated thyroid cancer


only

leukotriene

modifiers

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of asthma -OR-

documentation of exercise-induced

bronchoconstriction

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


lidoderm All medically

accepted

indications

not otherwise

excluded from

Part D

documentation of postherpetic

neuralgia (PHN) and trial and

failure of 1 other agent used to

treat PHN (e.g. gabapentin) -OR-

documentation of diabetic

neuropathy

12 months

lonsurf All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of metastatic

colorectal cancer in patients who

have previously been treated with

fluoropyrimidine-, oxaliplatin-,

and irinotecan-based

chemotherapy, an anti-VEGF

therapy, and if RAS wild-type, an

anti-EGFR therapy


only

lynparza All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of use as

monotherapy in patients with

deleterious or suspected

deleterious germline BRCA

mutated advanced ovarian cancer

after trial of three or more prior

lines of chemotherapy (e.g.

carboplatin, cisplatin, paclitaxel,

gemcitabine)


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


lyrica All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of DPN -OR- PHN

-OR- seizures and trial/failure or

intolerance to two AEDS -OR-

neuropathic pain associated with

spinal cord injury -OR-

documentation to support a

diagnosis of fibromyalgia and

trial/failure or intolerance to

duloxetine


only

mekinist All FDA

approved

indications

not otherwise

excluded from

Part D

Disease

progression on

prior BRAF

inhibitor therapy


metastatic melanoma with

BRAFV600E or BRAFV600K

mutations


only

mozobil All FDA

approved

indications

not otherwise

excluded from

Part D

used in combination with

granulocyte-colony stimulating

factor (G-CSF) to mobilize

hematopoietic stem cells to the

peripheral blood for collection and

subsequent autologous

transplantation in patients with

multiple myeloma (MM) and non-

Hodgkins lymphoma (NHL).

oncologist,

hematologist


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


myalept All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of congenital or

acquired generalized lipodystrophy

with absence or loss of

subcutaneous body fat -AND-

Leptin levels less than 8 ng/mL for

males or less than 12 ng/mL for

females -AND- the patient has

been optimized on current diabetic

medication and/or

hypertriglyceridemia medication as

needed -AND- the member has a

diagnosis of diabetes or fasting

insulin levels greater than

30uU/mL or fasting

hypertriglyceridemia greater than

200mg/dL.

12 months For initial

reauthorization, the

member should have a

decreased A1C level

by at least 0.8 or

decreased

triglycerides by 25

percent or decreased

fasting plasma

glucose by 25 percent.

namenda All medically

accepted

indications

not otherwise

excluded from

Part D

Documentation of diagnosis Automatic

approval if 18

years of age

or older

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


namzaric All medically

accepted

indications

not otherwise

excluded from

Part D

Documentation of diagnosis Automatic

approval if 18

years of age

or older

12 months

natpara All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of use as an

adjunct to calcium and vitamin D

to control hypocalcemia in patients

with hypoparathyroidism

12 months

nexavar All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of hepatocellular

carcinoma -OR- advanced renal

cell carcinoma after treatment of 1

other systemic therapy -OR-

locally recurrent or metastatic,

progressive, differentiated thyroid

carcinoma refractory to radioactive

iodine treatment

oncologist,

hematologist


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


ninlaro All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of multiple

myeloma AND previous treatment

with at least 1 prior therapy AND

used in combination with

lenalidomide and dexamethasone

oncologist,

hematologist


only

NORTHER

A

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of neurogenic

orthostatic hypotension caused by

primary autonomic failure (e.g.,

Parkinson's disease, multiple

system atrophy, or pure autonomic

failure), dopamine beta-

hydroxylase deficiency or non-

diabetic autonomic neuropathy

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Documentation of diagnosis of

severe asthma evidenced by

pretreatment forced expiratory

volume in 1 second (FEV1) less

than 80% predicted and FEV1

reversibility of at least 12% after

albuterol administration -AND-

Either 1 or 2. 1)History of 2 or

more exacerbations in the previous

year despite at least 12 months of

high-dose inhaled corticosteroid

(ICS) given in combination with at

least 3 months of controller

medication (e.g. long-acting beta2-

agonist [LABA], leukotriene

receptor antagonist [LTRA], or

theophylline), unless intolerant of

or contraindication to all of these

agents. 2)Symptoms are

inadequately controlled with use

of 6 months of ICS with daily oral

glucocorticoids given in

combination with a minimum of 3

months of controller medication

(e.g. LABA, LTRA, or


nucala Deny if less

than 12 years

old

12 monthsAll FDA

approved

indications

not otherwise

excluded from

Part D




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


nuplazid All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of hallucinations

and delusions associated with

Parkinson's disease psychosis

Deny if less

than 18 years

of age


only


or contraindication to all of these

agents. -AND- 3 or 4. 3)Greater

than or equal to 150 cells/uL

screening within 6 weeks of

dosing. 4)Greater than or equal to

300 cells/uL within 12 months of

screening.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


odomzo All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of locally

advanced basal cell carcinoma

(laBCC) that has recurred

following surgery or radiation

therapy or for use in patients who

are not candidates for surgery or

radiation therapy


only

olysio All FDA

approved

indications

not otherwise

excluded from

Part D

Previous failure

of a Protease

Inhibitor used in

hepatitis C

(boceprevir,

telaprevir or

simeprevir) -OR-

decompensated

cirrhosis


hepatitis C genotype 1 infection in

adult patients with compensated

liver disease, including cirrhosis,

who are previously untreated or

who have failed previous

interferon and ribavirin therapy -

AND- used in combination with

peginterferon alfa and ribavirin -

AND- the genotype 1A patient has

been screened and is negative for

the NS3 Q80K polymorphism -OR-


hepatitis C genotype 1infection -

AND- patient will be using

concomitantly with sofosbuvir -

AND- documentation stating

absence or presence of cirrhosis

Deny if less

than 18 years

old

12 wks or 24

wks

depending on

treatment

regimen and

presence or

absence of

cirrhosis

Doses greater than or

less than 150mg/day

will not be approved




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


opdivo All FDA

approved

indications

not otherwise

excluded from

Part D


metastatic melanoma in patients

previously treated with ipilimumab

(Yervoy) and, if BRAF V600

mutation positive, a BRAF

inhibitor -OR- documentation of

metastatic squamous non-small

cell lung cancer (NSCLC) with

progression on or after platinum-

based chemotherapy -OR-

advanced renal cell carcinoma in

patients who have received prior

antiangiogenic therapy.


only

oralair All FDA

approved

indications

not otherwise

excluded from

Part D

Asthma (severe,

unstable or

unconrolled),

concomitant

sublingual or

subcutaneous

immunotherapy,

therapy

initiation during

active allergy

season


and use for Sweet Vernal,

Orchard, Perennial Rye, or

Kentucky Blue Grass pollens -

AND- allergic rhinitis with or

without conjunctivitis has been

confirmed by a pollen specific

positive skin test or in vitro testing

for pollen-specific IgE antibodies -

AND- trial and failure or

intolerance to an intranasal steroid

and an oral non-sedating

antihistamine, intranasal

antihistamine or intranasal

anticholinergic agent

Deny if less

than 10 years

of age or

greater than

65 years of

age

allergy

specialist,

otolaryngologi

st


prescribed an

epinephrine auto

injector




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


orencia All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Enbrel,

Remicade,

Humira,

Orencia,

Simponi,

Kineret, Cimzia





rheumatoid arthritis (Orencia IV

only)

rheumatologist 12 months For Orencia SubQ,


adequate trial or

intolerance to the

preferred SubQ


Humira, for


For Orencia IV,


adequate trial or

intolerance to one of

the preferred IV

products, Remicade or

Simponi Aria, for


orkambi All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of cystic fibrosis

and homozygous F508del

mutation

Deny if less

than 12 years

of age

6 months

initial

authorization,

12 months

reauthorizatio

n

For reauthorization,

documentation

showing a FEV1

improvement from

baseline must be

provided.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


OTEZLA All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Enbrel,

Remicade,

Humira, Cimzia,

Simponi, Stelara

Documentation of active psoriatic

arthritis -OR- documentation of

moderate to severe psoriasis

Deny if less

than 18 years

of age

rheumatologist

, dermatologist

12 months Maintenance doses

greater than 60 mg per

day will not be

approved. Patients

must have an adequate

trial or intolerance to

the preferred



arthritis and psoriasis.

pomalyst All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of multiple

myeloma, previous trial of at least

2 therapies including lenalidomide

and bortezomib, and disease

progression on or within 60 days

of last therapy


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Documentation of the following:

1. Heterozygous Familial

Hypercholesterolemia (HeFH) as

supported by the presence of

causal mutation of familial

hypercholesterolemia by genetic

testing, physical signs of FD (e.g.

xanthomas, xanthelasma), clinical

diagnosis based on WHO

criteria/Dutch Lipid Clinical

Network criteria with score greater

than 8 points, or Simon Broome

register diagnostic criteria AND

LDL-C greater than or equal to

190 mg/dL prior to lipid lowering

therapy (greater than or equal to

160 mg/dL if age less than 20) or

LDL-C greater than or equal to

160 mg/dL after treatment with

antihyperlipidemic agents but prior

to Praluent therapy AND Previous

treatment with at least two trials of

different high-intensity statins (e.g.

atorvastatin, rosuvastatin) has been

ineffective in achieving LDL-C

goal AND Praluent must be used

Prescribed by

or in

consultation

with a

cardiologist,

lipid

specialist, or

endocrinologis

t

6 months

initial

authorization,

12 months

reauthorizatio

n


documentation

showing an LDL-C

reduction on Praluent

therapy from baseline

must be provided.

praluent All FDA

approved

indications

not otherwise

excluded from

Part D

Deny if less

than 18 years

of age




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriagoal AND Praluent must be used

concomitantly with a statin which

is dosed at maximally tolerated

dose OR documentation of statin

intolerance is provided as defined

by statin related rhabdomyolysis or

skeletal-related muscle symptoms

while receiving at least 2 separate

trials of different high intensity

statin which resolved upon

discontinuation of statin. 2.

Hypercholesterolemia ASCVD

(e.g. acute coronary syndrome,

history of myocardial infarction)

AND Previous treatment with at

least two trials of different high-

intensity statins (e.g. atorvastatin,

rosuvastatin) has been ineffective

in achieving LDL-C goal (LDL-C

is still greater than or equal to 100

mg/dL) AND Praluent must be

used concomitantly with a statin

which is dosed at maximally

tolerated dose OR documentation

of statin intolerance is provided as

defined by statin related

rhabdomyolysis or skeletal-related




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriarhabdomyolysis or skeletal-related

muscle symptoms while receiving

at least 2 separate trials of

different high intensity statin

which resolved upon

discontinuation of statin.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


For concomitant use of an opiate

agonist and substance abuse

therapy, documentation that the

member has a documented acute

pain condition (e.g. acute

traumatic injury) in which

treatment with other agents would

cause insufficient pain control or if

the member requires treatment for

pain related to a terminal illness.

For concomitant use of an opiate

agonist, benzodiazepine and a

centrally acting skeletal muscle

relaxant, documentation that the

member has tried/failed at least 2

other skeletal muscle relaxant (e.g,

methocarbamol, metaxalone),

understanding these skeletal

muscle relaxants are high-risk

medications in geriatric patients

AND documentation of an

ongoing monitoring plan to

identify and address concomitant

drug-drug interaction adverse

events

Opiate agonists will

receive automatic

approval if no recent

claims for a substance

abuse therapy (e.g,

buprenorphine-

naloxone) OR a

benzodiazepine (e.g.,

triazolam, alprazolam)

AND a centrally

acting skeletal muscle

relaxant (e.g.,

carisoprodol).

Benzodiazepines (e.g,

triazolam, alprazolam)

will receive automatic

approval if no recent

claims for an opiate

agonist (e.g.,

oxycodone,

hydrocodone,

oxymorphone) AND a

centrally acting

skeletal muscle

relaxant (e.g.,

carisoprodol).

1 mo.

opiate/substan

ce abuse

therapy use,

12 mo.

opiate/benzod

iazepine/skele

tal muscle

relaxant use

All FDA

approved

indications

not otherwise

excluded from

Part D

prescriptio

n drug

combo




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


pristiq All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of major

depressive disorder and trial and

failure of two other

antidepressants.


only

PROCYSB

I

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of nephropathic

cystinosis AND previous trial and

failure or intolerance to immediate-

release cysteamine bitartrate

(Cystagon)

Deny if less

than 2 years

of age

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Documentation of use to increase

bone mass in men at high risk for

fracture receiving androgen

deprivation therapy or women at

high risk for fracture receiving

adjuvant aromatase inhibitor

therapy -OR- use for treatment of

osteoporosis and the prevention of

fractures in postmenopausal

women and men having a T score

of less than -2.5 and a trial and

failure or contraindication to at

least one bisphosphonate -OR- use

to prevent fractures in men and

postmenopausal women with a

low bone mass (T score between -

1.0 and -2.5) and history of

previous osteoporotic fracture or

those who are found to have a 10-

year risk of major osteoporotic

fracture greater than or equal to 20

percent or a risk of hip fracture

greater than or equal to 3 percent

and had a trial and failure or


bisphosphonate

Covered under Part B

for female patients

eligible for home

health services when

provider certifies that

patient sustained bone

fracture related to post-

menopausal

osteoporosis and is

unable to learn the

skills needed to self-

administer the drug or

is otherwise

physically or mentally

incapable of

administering the drug

or family/caregivers

are unable or

unwilling to

administer the drug

12 monthsDiagnosis of

underlying

hypercalcemic

disorder such as

hypercalcemia,

hyperparathyroi

dism or

hypoparathyroid

ism, or high risk

for

osteosarcoma

(Paget's disease,

prior radiation

therapy, bone

metastases, open

epiphyses, etc.)

All FDA

approved

indications

not otherwise

excluded from

Part D

prolia




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


provigil All medically

accepted

indications

not otherwise

excluded from

Part D

Diagnosis of shift work sleep

disorder (SWSD) -OR- diagnosis

of narcolepsy documented by

MSLT less than 10 min or other

appropriate testing -OR- Diagnosis

of obstructive sleep

apnea/hypopnea syndrome

(OSAHS) documented by

objective polysomnography and

continuous positive airway

pressure (CPAP) history and

status. Diagnosis established in

accordance with ICSD or DSM IV

criteria acceptable for all

indications.

12 months

pulmonary

arterial

hypertensio

n

All FDA

approved

indications

not otherwise

excluded from

Part D

Diagnosis of pulmonary

hypertension, substantiated by

results from Doppler

echocardiography and/or direct

measurement of pulmonary arterial

pressure, defined as a mean

pulmonary arterial pressure of

greater than or equal to 25 mmHg,

with a pulmonary capillary wedge

pressure of less than 15 mmHg.

cardiologist,

pulmonologist

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


RAGWITE

K

All FDA

approved

indications

not otherwise

excluded from

Part D

Asthma (severe,

unstable or

unconrolled),

concomitant

sublingual or

subcutaneous

immunotherapy,

therapy

initiation during

active allergy

season


and use for ragweed pollen -AND-

allergic rhinitis with or without

conjunctivitis has been confirmed

by a pollen specific positive skin

test or in vitro testing for pollen-

specific IgE antibodies -AND-


an intranasal steroid and an oral

non-sedating antihistamine,

intranasal antihistamine or

intranasal anticholinergic agent

Deny if less

than 18 years

of age or

greater than

65 years of

age

allergy

specialist,

otolaryngologi

st


prescribed an

epinephrine auto

injector

ravicti All FDA

approved

indications

not otherwise

excluded from

Part D

Urea cycle

disorders due to

N-

acetylglutamates

ynthetase

deficiency

Documentation of use with dietary

protein restriction for chronic

management of a urea cycle

disorders (UCDs) when the

condition cannot be managed by

dietary protein restriction alone

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


remicade All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Humira,

Cimzia, Enbrel,

Orencia,

Simponi,

Actemra,

Kineret, Stelara


severe rheumatoid arthritis and use

in combination with methotrexate -

OR- psoriatic arthritis -OR-

ankylosing spondylitis -OR-


failure of systemic therapy or

phototherapy -OR- moderate to

severe Crohn's disease after failure

of two immunosuppressants -OR-


colitis after failure of two

immunosuppressants

For Crohn's

disease and

ulcerative

colitis, deny if

less than 6

years old

rheumatologist

,

dermatologist,

or

gastroenterolo

gist

12 months For psoriasis trial of 1


either systemic

therapy (e.g.

methotrexate or

cyclosporine) or

phototherapy, is

required. For Crohn's

disease and ulcerative

colitis, trial of 2

immunosuppressants


azathioprine, 6-

mercaptopurine) is

required.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


repatha All FDA

approved

indications

not otherwise

excluded from

Part D

1.Homozygous Familial

Hypercholesterolemia(HoFH)

supported by genetic confirmation

of two mutant alleles at LDLR,

APOB, OCSK9, or LDLRAP1

gene or untreated LDL-C greater

than 500mg/dL(or treated LDL-C

greater than 300mg/dL) with

cutaneous or tendon xanthoma

before age 10 yrs or heterozygous

familial hypercholesterolemia

(HeFH) in both parents AND

Repatha will be used with a

maximally tolerated statin unless

all statins are contraindicated or

not tolerated AND Repatha will

not be used with lomitapide,

mipomersen, or another PCSK9

inhibitor. 2.HeFH supported by

presence of causal mutation of FH

by genetic testing, physical signs

of FD(e.g. xanthomas,

xanthelasma), diagnosis based on

WHO criteria/Dutch Lipid Clinical

Network criteria with score greater

than 8 points, or Simon Broome

Deny if less

than 18 years

of age for

HeFH and

ASCVD or

less than 13

years of age

for HoFH

Prescribed by

or in

consultation

with a

cardiologist,

lipid

specialist, or

endocrinologis

t

6 months

initial

authorization,

12 months

reauthorizatio

n


documentation

showing an LDL-C

reduction on Repatha

therapy from baseline

must be provided.

For HoFH diagnosis,

3 syringes per month

will be approved

aligned with

recommended dosing

regimen for this

indication.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriathan 8 points, or Simon Broome

register criteria AND LDL-C

greater than or equal to 190mg/dL

prior to lipid lowering therapy

(greater than or equal to 160mg/dL

if age less than 20) or LDL-C

greater than or equal to 160mg/dL

after treatment with

antihyperlipidemic agents but prior

to Repatha therapy AND Prior

therapy with at least 2 trials of

different high-intensity statins(e.g.

atorvastatin, rosuvastatin) has not

achieved LDL-C goal AND must

be used with maximally tolerated

statin dose OR documentation of

statin intolerance as defined by

statin related rhabdomyolysis or

skeletal muscle symptoms while

receiving at least 2 separate trials

of different high intensity statin

which resolved upon

discontinuation of statin. 3.

Hypercholesterolemia ASCVD

AND Prior therapy with at least 2

trials of different high-intensity

statins (e.g. atorvastatin,




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage

Duration Other Criteriastatins (e.g. atorvastatin,

rosuvastatin) has not achieved

LDL-C goal(LDL-C is still greater

than or equal to 100mg/dL) AND

must be used with maximally

tolerated statin dose OR

documentation of statin

intolerance as defined by statin

related rhabdomyolysis or skeletal

muscle symptoms while receiving

at least 2 separate trials of

different high intensity statin

which resolved upon

discontinuation of statin.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


revlimid All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation

of severe

neutropenia,

severe

thrombocytopeni

a, or treatment-

related MDS

Diagnosis of multiple myeloma -

OR- diagnosis of myelodyplastic

syndrome (MDS) with 5-q

deletion along with documentation

of transfusion-dependent anemia

or an anemia with documented

hemoglobin of less than 10g/dL -

OR- diagnosis of mantle cell

lymphoma (MCL) in which

disease has relapsed or progressed

after two prior therapies (e.g.

anthracycline, mitoxantrone,

cyclophosphamide, rituximab,

bortezomib) one of which included

bortezomib


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Acute hereditary angioedema

(HAE) type I & II: Documentation













evaluated and discontinued. Acute

hereditary angioedema (HAE) type

III: Documentation that clinical


inhibitor level and C1INH

functional level are within normal

limits of the laboratory's reference

range -AND- documentation HAE

family history -OR- FXL mutation -

AND- documentation of at least 1

symptom of angioedema attack -

AND- medications that cause

angioedema have been evaluated

and discontinued

12 monthsruconest All FDA

approved

indications

not otherwise

excluded from

Part D

Deny if less

than 13 years

of age




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


savella All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation to support a

diagnosis of fibromyalgia and

trial/failure or intolerance to

duloxetine

12 months

signifor All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of Cushing's

disease AND patient is not a

candidate for pituitary surgery or

surgery has not been curative

Deny if less

than 18 years

of age

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


simponi Alternatives for

Ulcerative Colitis

include

immunosuppressants

such as

corticosteroids,

azathioprine or 6-

mercaptopurine.

Patients must have an

adequate trial or

intolerance to the

preferred product,

Humira, for ulcerative

colitis and the

preferred products,

Enbrel and Humira,

for rheumatoid

arthritis, psoriatic

arthritis and

ankylosing

spondylitis. For

ulcerative colitis

indication therapy,

doses above plan

quantity limit will be

approved aligned with

recommended

induction therapy

dosing regimen.

12 monthsDocumentation of moderate to


in combination with methotrexate -

OR- psoriatic arthritis -OR-

ankylosing spondylitis -OR-


colitis and an inadequate response

to two immunosupressants or in

those patients requiring continuous

steroid therapy

concomitant use

of Actemra,

Kineret,

Remicade,

Humira,

Orencia, Enbrel,

Cimzia

All FDA

approved

indications

not otherwise

excluded from

Part D




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


simponi

aria

All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Actemra,

Kineret,

Remicade,

Humira,

Orencia, Enbrel,

Cimzia



in combination with methotrexate

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


CHC gt 1 infection in adults -AND-

using with SMV -AND- the

patient may or may not also be

taking RBV concomitantly if

cirrhotic and tx-exp -OR- CHC gt

2 infection in adults -AND- SOF is

being used with RBV -AND- SOF

is being used with PEG if pt tx-

exp with SOF -OR- CHC gt 3 -

AND- using with PEG/RBV -OR-

CHC genotype 4 in adults -AND-

using with RBV -AND- using with

PEG if tx-exp with P/R and PEG

eligible -OR- Gt 5 or 6 infection in

adults -AND- using with P/R -

AND- if tx-exp, only failed P/R

OR- CHC gt 1, 2, 3, or 4 in

allograft AND- tx-naïve or exp

AND- comp cirrh AND- using

with daclatasvir AND- using with

RBV unless intolerant or ineligible

OR- CHC gt 2 or 3 -AND-

decomp cirrhosis -AND- using

with RBV -OR- Recurrent CHC gt

2 or 3 post-liver transplant -AND-

using with RBV -AND- with or

without decompensated or

compensated cirrhosis

All FDA

approved

indications

not otherwise

excluded from

Part D

sovaldi Deny if less

than 18 years

of age

12w:G1nocr.

G2nocr

txn,t/fSOF.G3

,5,6,G4wPR.1

6w:G2cr,t/fP

R.24w:G1cr,

G2txe,G4

wR,G2,3allo.

48w:G2,3dcp

Doses greater than or

less than 400 mg/day

will not be approved.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


sprycel All FDA

approved

indications

not otherwise

excluded from

Part D


failure of Gleevec therapy (failure

of Gleevec is not necessary for the

indication of newly diagnosed

adults with chronic phase PH+

CML).


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


All FDA

approved

indications

not otherwise

excluded from

Part D

stelara Patients must have an

adequate trial or

intolerance to the

preferred product,

Humira, for psoriasis

and the preferred



arthritis. Must follow

recommended dosing

guidelines based upon

weight. Psoriasis: For

patients weighing less

than 100 kilograms

(220 pounds), 45 mg

dosing will be

approved. For patients

weighing more than

100 kilograms (220

pounds), 90 mg

dosing will be

approved. Psoriatic

Arthritis: 45 mg

dosing will be

approved. For patients

with co-existent

12 monthsdermatologistDocumentation of moderate to

severe plaque psoriasis and failure

of one systemic therapy (e.g.


phototherapy OR psoriatic arthritis

AND documentation of member

weight and prescribed dose

concomitant use

of Enbrel,

Remicade,

Humira,

Simponi




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


stivarga All FDA

approved

indications

not otherwise

excluded from

Part D


colorectal cancer and trial of a

fluoropyrimidine-, oxaliplatin-,

and irinotecan-containing

chemotherapy (i.e.

FOLFIRINOX), AND an anti-

VEGF therapy (i.e. aflibercept)

AND if KRAS wild type, an anti-

EGFR therapy (i.e. cetuximab,

panitumumab) -OR-

documentation of locally

advanced, unresectable or

metastatic gastrointestinal stromal

tumor (GIST) after treatment with

both imatinib and sunitinib


only

with co-existent

moderate to severe

plaque psoriasis

weighing greater than

100 kilograms (220

pounds), 90 mg

dosing will be

approved.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


strensiq All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of

perinatal/infantile-onset or

juvenile-onset hypophosphatasia

(HPP)

12 months

sutent All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis and

failure of Gleevec therapy, if

applicable

oncologist,

hematologist


only

sylvant All FDA

approved

indications

not otherwise

excluded from

Part D

Documented diagnosis of

multicentric Castleman's disease -

AND- negative HIV and HHV-8

test -AND- baseline absolute

neutrophil count greater than or

equal to 1.0x10*9/L -AND-

baseline platelet count greater than

or equal to 75x10*9/L -AND-

baseline hemoglobin less than

17g/dL.


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


tagrisso All FDA

approved

indications

not otherwise

excluded from

Part D


EGFR T790M mutation-positive

NSCLC AND progression on or

after EGFR TKI therapy

oncologist,

hematologist


only

taltz All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Enbrel,

Remicade,

Humira,

Simponi, Stelara


severe psoriasis and failure of one

systemic therapy (e.g.


phototherapy

Deny if less

than 18 years

of age

dermatologist 12 months Patients must have an

adequate trial or

intolerance to the

preferred product,

Humira, for psoriasis.

For psoriasis

induction therapy,

doses above plan

quantity limit will be

approved aligned with

recommended

induction therapy

dosing regimen.

tasigna All FDA

approved

indications

not otherwise

excluded from

Part D


failure of Gleevec therapy (failure

of Gleevec is not necessary for the

indication of newly diagnosed

adults with chronic phase PH+

CML).

oncologist,

hematologist


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


tecfidera All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

with other

disease

modifying

agents such as

interferons,

Copaxone ,

Tysabri,

Aubagio,

Gilenya

Documentation of relapsing form

of multiple sclerosis (relapsing-

remitting, relapsing secondary

progressive, or progressive

relapsing multiple sclerosis)

neurologist 12 months Doses greater than

240 mg twice-daily

will not be approved

technivie All FDA

approved

indications

not otherwise

excluded from

Part D

Severe hepatic

impairment

(Child-Pugh C)


hepatitis C genotype 4 without

cirrhosis AND using with ribavirin

unless the member is treatement-

naive and has a contraindication or

intolerance to ribavirin

Deny if less

than 18 years

of age

12 weeks




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


Documentation of primary or

secondary hypogonadism in males

with testicular failure due to

cryptorchidism, bilateral torsions,

orchitis, vanishing testis

syndrome, orchidectomy,

Klinefelter's syndrome,

chemotherapy, radiation or toxic

damage -OR- documentation of

primary or secondary

hypogonadism in males with

multiple symptoms of

hypogonadism including at least

one of the following specific

symptoms: height loss due to

vertebral fractures, low trauma

fractures, low bone density,

incomplete or delayed sexual

development, breast discomfort,

loss of axillar and/or pubic body

hair, hot flushes -OR-

documentation of HIV infection

in men with weight loss -OR-

documentation of chronic steroid

treatment in men. In all previously

noted indications, members must

All medically

accepted

indications

not otherwise

excluded from

Part D

testosterone

(androgens

)

Deny if less

than

recommended

age per FDA

product

labeling

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


thalomid All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of multiple

myeloma -OR- documentation for

use in the treatment or prophylaxis

of cutaneous manifestations of

moderate to severe erythema

nodosum leprosum


only

noted indications, members must

also have documented low

testosterone level below the

normal range for the laboratory -

OR- a total testosterone level near

the lower limit of the normal range

with a low free testosterone level

which is less than normal based

upon the laboratory reference

range. Additional approvable

indications include vulvar

dystrophies in women (topical

ointment only) -AND- palliative

treatment in female patients with

metastatic breast cancer

(testosterone enanthate only).




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


thrombopoi

esis

stimulating

agents

All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis of

chronic immune idiopathic

thrombocytopenia purpura and

trial and failure of corticosteroid

or immunoglobulin therapy or

splenectomy -OR- documentation

of thrombocytopenia in patients

with chronic hepatitis C to allow

the initiation and maintenance of

interferon-based therapy

(eltrombopag only)

12 months Platelet count to be

provided

transmucos

al fentanyl

citrate

All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of therapeutic use

and long acting opioid therapy

12 months




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


tykerb All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of Tykerb in

combination with Xeloda

(capecitabine) for patients with

advanced, metastatic breast cancer

that is HER2 positive who have

received prior therapy, including a

taxane, an anthracycline and

trastuzumab (Herceptin) -OR-

documentation of Tykerb in

combination with Femara

(letrozole) for the treatment of

postmenopausal women with

hormone receptor positive

metastatic breast cancer that over

expresses the HER2 receptor for

whom hormonal therapy is

indicated


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


VALCHLO

R

All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of cutaneous

manifestations in patients with

cutaneous T-cell lymphoma who

have limited localized or

generalized skin involvement who

received at least one prior skin

directed therapy -OR-

documentation of cutaneous


cutaneous T-cell lymphoma who

have limited localized or

generalized skin involvement and

mechlorethamine gel will be used

in combination with other skin

directed therapies. Skin directed

therapies may include but are not

limited to topical corticosteroids,

topical chemotherapy, local

radiation and topical retinoids.


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


veltassa All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of hyperkalemia as

defined by serum potassium level

between 5.1 and 6.4 mmol/L on at

least two (2) screenings -AND-

modification of medications to

reduce serum potassium levels,

when applicable -AND- trial and

failure, intolerance, or

contraindication to sodium

polystyrene sulfonate

Deny if less

than 18 years

of age

6 months For reauthorization,

documentation of

reduction in serum

potassium levels

following Veltassa

administration is

required.

venclexta All FDA

approved

indications

not otherwise

excluded from

Part D


lymphocytic leukemia (CLL) with

17p deletion -AND- previous

treatment with at least one prior

therapy


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


viberzi All FDA

approved

indications

not otherwise

excluded from

Part D

Severe (Child-

Pugh C) hepatic

impairment

Documentation of diarrhea

predominant, irritable bowel

syndrome (IBS-D) -AND- no

alcohol abuse in the previous six

months.

12 months

VIEKIRA

PAK

All FDA

approved

indications

not otherwise

excluded from

Part D

Severe (Child-

Pugh C) hepatic

impairment

CHC genotype 1a or 1b infection

in adults -AND- using RBV for

gt1a -AND- past HCV therapies

documented -OR- Documentation

of recurrent CHC gt 1 infection

post-liver transplantation -AND-

concomitant use of RBV -AND-

has no fibrosis to mild fibrosis

(Metavir F0, F1, F2)

Deny if less

than 18 years

of age

12wk: gt 1a

noncirr -OR-

gt 1b. 24wk:

gt1a cirr -OR-

gt 1 in

allograft

Doses greater than

four tablets per day

will not be approved.

viibryd All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis major

depressive disorder and trial and

failure of any two antidepressants


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


votrient All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis (renal

cell carcinoma) -OR-

documentation of advanced soft-

tissue sarcoma excluding

adipocytic soft tissue sarcoma or

gastrointestinal stromal tumors

after failure of at least one prior

chemotherapy regimen

oncologist,

hematologist


only

vraylar All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of schizophrenia

OR acute treatment of manic or

mixed episodes associated with

bipolar I disorder

Deny if less

than 18 years

of age


only

xalkori All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of locally

advanced or metastatic non-small

cell lung cancer (NSCLC) that is

anaplastic lymphoma kinase

(ALK) positive

oncologist,

hematologist


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


xeljanz All FDA

approved

indications

not otherwise

excluded from

Part D

concomitant use

of Enbrel,

Remicade,

Humira, Kineret,

Simponi,

Orencia, Stelara,

Actemra,

azathioprine,

cyclosporine


severe rheumatoid arthritis and an


to methotrexate

12 months Doses greater than 10

mg per day for

Xeljanz and 11 mg

per day for Xeljanz

XR will not be

approved. Patients

must have an adequate

trial or intolerance to

the preferred


Humira, for


xenazine All FDA

approved

indications

not otherwise

excluded from

Part D

documentation of diagnosis 12 months Patients with

comorbid depression

should be on an

antidepressant

medication.

xtandi All FDA

approved

indications

not otherwise

excluded from

Part D


castration-resistant prostate cancer

and prior therapy with docetaxel


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


xyrem All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of excessive

daytime sleepiness in patients with

a diagnosis of narcolepsy as

documented by MSLT less than 10

min or other appropriate testing -

OR- documentation of cataplexy

associated with narcolepsy as

documented by MSLT or other

appropriate testing.

12 months

zelboraf All FDA

approved

indications

not otherwise

excluded from

Part D

Wild-type

BRAF

melanoma


metastatic melanoma with

BRAFV600E mutation

oncologist,

hematologist


only

zepatier All FDA

approved

indications

not otherwise

excluded from

Part D

Severe (Child-

Pugh C) hepatic

impairment

Criteria will be applied consistent

with current AASLD/IDSA

guidance

Deny if less

than 18 years

of age

12wk:gt1a

without NS5A-

OR-gt1b-OR-

gt4 tx naive.

16wk:gt1a

with NS5A-

OR-gt4 tx

exp.




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


zolinza All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of cutaneous


cutaneous T-cell lymphoma

(CTCL) who have progressive,

persistent, or recurrent disease on

or following 2 systemic therapies.

Systemic therapies include

bexarotene, interferon alpha,

extracorpeal photochemotherapy,

PUVA, single agent or

combination chemotherapies (e.g.

cyclophosphamide, vinblastine,

romidepsin)

oncologist,

hematologist


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


ZYDELIG All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of relapsed

chronic lymphocytic leukemia

(CLL) and use in combination

with rituximab in patients for

whom rituximab alone would be

considered appropriate therapy

due to other co-morbidities -OR-

documentation of relapsed

follicular B-cell non-Hodgkin

lymphoma (FL) in patients who

have received at least two prior

systemic therapies (e.g. alkylating

agents, single or multi-drug

chemotherapy, target

immunotherapy) -OR-

documentation of relapsed small

lymphocytic lymphoma (SLL) in

patients who have received at least

two prior systemic therapies (e.g.

alkylating agents, single or multi-

drug chemotherapy, target

immunotherapy)


only




Exclusion


Age

Restriction

Prescriber

Restriction

Coverage


zykadia All FDA

approved

indications

not otherwise

excluded from

Part D

Documentation of non-small cell

lung cancer (NSCLC) that is

anaplastic lymphoma kinase

(ALK) positive AND previous


crizotinib (Xalkori)


only

zytiga All FDA

approved

indications

not otherwise

excluded from

Part D


castration resistant prostate cancer

and concurrent use with

prednisone


only


2017 Plan Formularies

Select your location

Pennsylvania Residents:


Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion,

Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson,

Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and

Westmoreland.


Adams, Berks, Bradford, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin,

Franklin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming,

Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Schuylkill,

Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York.

West Virginia Residents, please click here.

2017 Plan Formularies – Western PA

For Security Blue HMO Deluxe, Standard, and ValueRx, Community Blue Medicare

HMO Prestige and Signature, Freedom Blue PPO Classic, Select, and ValueRx, and Blue

Rx PDP Complete and Plus plans, please review this formulary.


2017 Plan Formularies – Central and Northeastern PA

For Freedom Blue PPO Deluxe, Standard, and ValueRx, Community Blue Medicare HMO Signature, and Blue Rx PDP Complete and Plus, please review this formulary.


2017 Plan Formularies – West Virginia

For Freedom Blue PPO Standard and Blue Rx PDP Complete and Plus, please review this

formulary.



1 Formulary ID: 17499 Version: 7 Updated: 01/2017

Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount

Quantity Limit Days

Authorization

HPMS Therapeutic Category

HPMS Therapeutic Class

8-Mop capsule 10 mg PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY

MISCELLANEOUS DERMATOLOGICALS

abacavir tablet 300 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

abacavir-lamivudine-zidovudine

tablet 300-150-300 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Abelcet suspension 5 mg/mL Specialty-5 YES ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Abilify tablet 10 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

PSYCHOTHERAPEUTIC DRUGS

Abilify tablet 15 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization





Abilify Maintena

suspension,extended rel syring 300 mg

Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Abilify Maintena

suspension,extended rel syring 400 mg



Abilify Maintena

suspension,extended rel recon 300 mg



Abraxane suspension for reconstitution

100 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

Abstral tablet 100 mcg

NonPrefBrand-4

124 31

YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


Specialty-5

124 31


NARCOTIC ANALGESICS


Specialty-5

124 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization




Specialty-5

119 31


NARCOTIC ANALGESICS


Specialty-5

79 31


NARCOTIC ANALGESICS


Specialty-5

60 31


NARCOTIC ANALGESICS

acamprosate tablet,delayed release (DR/EC)

333 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

MISCELLANEOUS AGENTS

Acanya gel with pump 1.2-2.5 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

acarbose tablet 50 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY


DIABETES THERAPY


DIABETES THERAPY


PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIHYPERTENSIVE THERAPY







Quantity Limit Days

Authorization



acetaminophen-codeine

solution 300 mg-30 mg /12.5 mL

PrefGen-1 5167 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


tablet 300-15 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

Acetasol HC drops 1-2 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS OTIC PREPARATIONS

acetazolamide

tablet 125 mg Generic-2 NO OPHTHALMOLOGY

ORAL DRUGS FOR GLAUCOMA

acetazolamide



acetazolamide

capsule, extended release

500 mg Generic-2 NO OPHTHALMOLOGY


acetazolamide sodium

recon soln 500 mg Generic-2 NO OPHTHALMOLOGY





Quantity Limit Days

Authorization



acetic acid solution 2 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS


acetylcysteine

solution 100 mg/mL (10 %)

Generic-2 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

acetylcysteine

solution 200 mg/mL (20 %)


PULMONARY AGENTS

acitretin capsule 10 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin capsule 25 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


acitretin capsule 17.5 mg NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Actemra syringe 162 mg/0.9 mL

Specialty-5

3.6 28

YES MUSCULOSKELETAL / RHEUMATOLOGY

OTHER RHEUMATOLOGICALS

Actemra solution80 mg/4 mL (20 mg/mL)

Specialty-5

40 28




Specialty-5

40 28






Quantity Limit Days

Authorization




Specialty-5

40 28



Acthar H.P. gel 80 unit/mLSpecialty-5 YES ENDOCRINE/DIA

BETESADRENAL HORMONES

ActHIB (PF) recon soln 10 mcg/0.5 mL

PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

Actimmune solution 100 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Actiq lozenge on a handle

400 mcg Specialty-5 119 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization




1,200 mcg Specialty-5 40 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

Actoplus Met XR

tablet, ER multiphase 24 hr

15-1,000 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Actoplus Met XR


30-1,000 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Acuvail (PF) dropperette 0.45 % NonPrefBrand-4 NO OPHTHALMOLOGY

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

acyclovir capsule 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

acyclovir tablet 400 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

acyclovir ointment 5 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIVIRALS

acyclovir tablet 800 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

acyclovir suspension 200 mg/5 mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

acyclovir sodium solution 50 mg/mL

Generic-2 YES ANTI - INFECTIVES ANTIVIRALS




Quantity Limit Days

Authorization



Aczone gel 5 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Adacel(Tdap Adolesn/Adult)(PF) suspension

2 Lf-(2.5-5-3-5 mcg)-5Lf/0.5 mL



Adagen solution 250 unit/mL Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


adapalene gel 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

adapalene cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

adapalene gel 0.3 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Adcirca tablet 20 mg Specialty-5 62 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

adefovir tablet 10 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Adempas tablet 0.5 mgSpecialty-5

93 31YES RESPIRATORY

AND ALLERGYPULMONARY AGENTS

Adempas tablet 1 mgSpecialty-5






Adempas tablet 2 mgSpecialty-5






Quantity Limit Days

Authorization






Adrenalin solution 1 mg/mL (1 mL)

Generic-2 NO

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

Adrucil solution 500 mg/10 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Advair Diskus

blister with device

100-50 mcg/dose NonPrefBrand-4 60 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Advair Diskus

blister with device


PULMONARY AGENTS

Advair Diskus

blister with device


PULMONARY AGENTS

Advair HFA HFA aerosol inhaler

45-21 mcg/actuation

NonPrefBrand-4 12 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS


115-21 mcg/actuation


PULMONARY AGENTS




PULMONARY AGENTS

Afeditab CR tablet extended release

30 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Afeditab CR tablet extended release






Quantity Limit Days

Authorization



Afinitor tablet 10 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Afinitor tablet 5 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS



Specialty-5

31 31

YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS



Specialty-5

31 31



Afinitor Disperz

tablet for suspension 2 mg

Specialty-5

62 31



Afinitor Disperz


Specialty-5

93 31



Afinitor Disperz


Specialty-5

62 31



Aggrenox

capsule, ER multiphase 12 hr 25-200 mg

PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY




Quantity Limit Days

Authorization



A-Hydrocort recon soln 100 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

Akynzeo capsule 300-0.5 mg

NonPrefBrand-4 YES

GASTROENTEROLOGY

MISCELLANEOUS GASTROINTESTINAL AGENTS

Ala-Cort cream 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL CORTICOSTEROIDS

Albenza tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES

MISCELLANEOUS ANTIINFECTIVES

albuterol sulfate

tablet 2 mg PrefGen-1 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

albuterol sulfate

tablet 4 mg PrefGen-1 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

albuterol sulfate

solution for nebulization

5 mg/mL Generic-2 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

albuterol sulfate


1.25 mg/3 mL Generic-2 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

albuterol sulfate



PULMONARY AGENTS

albuterol sulfate

tablet extended release 12 hr

4 mg Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

albuterol sulfate



PULMONARY AGENTS

albuterol sulfate


2.5 mg /3 mL (0.083 %)


PULMONARY AGENTS

albuterol sulfate

syrup 2 mg/5 mL PrefGen-1 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS




Quantity Limit Days

Authorization



alclometasone

cream 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


alclometasone

ointment 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


Alcohol Pads

pads, medicated Generic-2 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Aldurazyme solution 2.9 mg/5 mL Specialty-5 NO ENDOCRINE/DIABETES

MISCELLANEOUS HORMONES

Alecensa capsule 150 mg

Specialty-5

248 31



alendronate tablet 35 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY

OSTEOPOROSIS THERAPY

alendronate tablet 40 mg PrefGen-1 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


alendronate tablet 10 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY









Quantity Limit Days

Authorization



alendronate solution 70 mg/75 mL PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY


alfuzosin tablet extended release 24 hr

10 mg Generic-2 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Alimta recon soln 500 mg

PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Alinia suspension for reconstitution

100 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES


Alinia tablet 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES


allopurinol tablet 100 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol tablet 300 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

Allzital tablet 25-325 mg

NonPrefBrand-4

372 31

NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



almotriptan malate

tablet 6.25 mg Generic-2 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

MIGRAINE / CLUSTER HEADACHE THERAPY

almotriptan malate

tablet 12.5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Alocril drops 2 % NonPrefBrand-4 NO OPHTHALMOLOGY

MISCELLANEOUS OPHTHALMOLOGICS

alogliptin tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIA

BETESDIABETES THERAPY

alogliptin tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIA


alogliptin tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIA


alogliptin-metformin tablet 12.5-1,000 mg

NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

alogliptin-metformin tablet 12.5-500 mg


DIABETES THERAPY

alogliptin-pioglitazone tablet 12.5-15 mg


DIABETES THERAPY



DIABETES THERAPY



DIABETES THERAPY

alogliptin-pioglitazone tablet 25-15 mg


DIABETES THERAPY



DIABETES THERAPY




Quantity Limit Days

Authorization





DIABETES THERAPY

Alomide drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY


Aloprim recon soln 500 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

alosetron tablet 1 mg Specialty-5 NO GASTROENTEROLOGY


alosetron tablet 0.5 mg Generic-2 NO GASTROENTEROLOGY


Aloxi solution 0.25 mg/5 mL

NonPrefBrand-4 NO

GASTROENTEROLOGY


Alphagan P drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY

SYMPATHOMIMETICS

alprazolam tablet 1 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


alprazolam tablet 2 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



alprazolam tablet 0.25 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


alprazolam tablet 0.5 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


alprazolam tablet extended release 24 hr

0.5 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH



2 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








alprazolam tablet,disintegrating









Quantity Limit Days

Authorization









Alprazolam Intensol

concentrate 1 mg/mL Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Altabax ointment 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIBACTERIALS

Altoprevtablet extended release 24 hr 20 mg

NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

LIPID/CHOLESTEROL LOWERING AGENTS

Altoprevtablet extended release 24 hr 40 mg



amantadine HCl

solution 50 mg/5 mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

amantadine HCl

capsule 100 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

amantadine HCl

tablet 100 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

AmBisome suspension for reconstitution

50 mg NonPrefBrand-4 YES ANTI - INFECTIVES

ANTIFUNGAL AGENTS




Quantity Limit Days

Authorization



amcinonide cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


amcinonide ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


amcinonide lotion 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


Amerge tablet 1 mg NonPrefBrand-4 20 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Amerge tablet 2.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Amethiatablets,dose pack,3 month

0.15 mg-30 mcg (84)/10 mcg (7)

Generic-2 NO

OBSTETRICS / GYNECOLOGY

ORAL CONTRACEPTIVES / RELATED AGENTS

Amethyst tablet 90-20 mcg

Generic-2 NO



amifostine crystalline

recon soln 500 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

amikacin solution 500 mg/2 mL

Generic-2 NO

ANTI - INFECTIVES





Quantity Limit Days

Authorization



amiloride tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


amiloride-hydrochlorothiazide

tablet 5-50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


amino acids 15 %

parenteral solution 15 %

Generic-2 YES VITAMINS, HEMATINICS / ELECTROLYTES

MISCELLANEOUS NUTRITION PRODUCTS

Aminosyn 7 % with electrolytes


NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES


Aminosyn 8.5 %-electrolytes

parenteral solution 8.5 %



Aminosyn II 10 %

parenteral solution

10 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES


Aminosyn II 15 %

parenteral solution



Aminosyn II 7 %

parenteral solution



Aminosyn II 8.5 %

parenteral solution

8.5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES


Aminosyn II 8.5 %-electrolytes







Quantity Limit Days

Authorization



Aminosyn-HBC 7%

parenteral solution

7 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES


Aminosyn-PF 10 %

parenteral solution



Aminosyn-PF 7 % (sulfite-free)

parenteral solution



Aminosyn-RF 5.2 %




amiodarone tablet 200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone tablet 400 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


amiodarone solution 50 mg/mL

Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Amitiza capsule 24 mcg PrefBrand-3 62 31 NO GASTROENTEROLOGY


Amitiza capsule 8 mcg PrefBrand-3 62 31 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



amitriptyline tablet 100 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH












amitriptyline-chlordiazepoxide

tablet 12.5-5 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


amitriptyline-chlordiazepoxide

tablet 25-10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



amlodipine tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


amlodipine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


amlodipine tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


amlodipine-atorvastatin

tablet 5-80 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS









tablet 2.5-10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








Quantity Limit Days

Authorization





















amlodipine-benazepril

capsule 10-20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








Quantity Limit Days

Authorization




capsule 2.5-10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS











amlodipine-valsartan















Quantity Limit Days

Authorization



amlodipine-valsartan-hcthiazid

tablet 10-160-12.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS



tablet 10-320-25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS



tablet 5-160-12.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








ammonium chloride

solution 5 mEq/mL NonPrefBrand-4 NO UROLOGICALS MISCELLANEOUS UROLOGICALS

ammonium lactate

lotion 12 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


ammonium lactate

cream 12 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



amoxapine tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








amoxicil-clarithromy-lansopraz

combo pack 500-500-30 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

amoxicillin suspension for reconstitution

250 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS

amoxicillin tablet,chewable 125 mg PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS

amoxicillin capsule 250 mg PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS



PENICILLINS

amoxicillin capsule 500 mg PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS

amoxicillin tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS

amoxicillin tablet 875 mg PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS




Quantity Limit Days

Authorization





PENICILLINS



PENICILLINS

amoxicillin tablet,chewable 250 mg PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS

amoxicillin-pot clavulanate

tablet 250-125 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS



PENICILLINS



PENICILLINS


tablet,chewable 200-28.5 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS


tablet,chewable 400-57 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS


suspension for reconstitution

250-62.5 mg/5 mL Generic-2 NO ANTI - INFECTIVES

PENICILLINS




PENICILLINS



400-57 mg/5 mL Generic-2 NO ANTI - INFECTIVES

PENICILLINS




PENICILLINS




Quantity Limit Days

Authorization





1,000-62.5 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS

amphotericin B

recon soln 50 mg Generic-2 YES ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ampicillin suspension for reconstitution

250 mg/5 mL Generic-2 NO ANTI - INFECTIVES

PENICILLINS

ampicillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS

ampicillin suspension for reconstitution


PENICILLINS

ampicillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS

ampicillin sodium

recon soln 125 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS

ampicillin sodium

recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

PENICILLINS

ampicillin sodium recon soln 1 gram


ampicillin-sulbactam


PENICILLINS

ampicillin-sulbactam recon soln 1.5 gram


ampicillin-sulbactam recon soln 3 gram


Ampyra tablet extended release 12 hr

10 mg Specialty-5 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

MISCELLANEOUS NEUROLOGICAL THERAPY

Anadrol-50 tablet 50 mg NonPrefBrand-4 YES ENDOCRINE/DIABETES





Quantity Limit Days

Authorization



anagrelide capsule 0.5 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


anagrelide capsule 1 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


anastrozole tablet 1 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Androderm patch 24 hour 2 mg/24 hourPrefBrand-3 YES ENDOCRINE/DIA

BETESMISCELLANEOUS HORMONES

Androderm patch 24 hour 4 mg/24 hrPrefBrand-3 YES ENDOCRINE/DIA


AndroGelgel in metered-dose pump

20.25 mg/1.25 gram (1.62 %)

PrefBrand-3 YES ENDOCRINE/DIABETES


AndroGel gel in packet1.62 % (20.25 mg/1.25 gram)



AndroGel gel in packet1 % (25 mg/2.5gram)



AndroGel gel in packet1.62 % (40.5 mg/2.5 gram)



AndroGel gel in packet1 % (50 mg/5 gram)



Angeliq tablet 0.5-1 mgNonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGYESTROGENS / PROGESTINS







Quantity Limit Days

Authorization






Anzemet tablet 50 mg NonPrefBrand-4 YES GASTROENTEROLOGY


Anzemet tablet 100 mg NonPrefBrand-4 YES GASTROENTEROLOGY


Anzemet solution 100 mg/5 mL NonPrefBrand-4 NO GASTROENTEROLOGY


ApexiCon E cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


Apidra solution 100 unit/mL NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Apidra SoloStar

insulin pen 100 unit/mL NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Aplenzin tablet extended release 24 hr

174 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








Quantity Limit Days

Authorization






APOKYN cartridge 10 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTIPARKINSONISM AGENTS

apraclonidine

drops 0.5 % Generic-2 NO OPHTHALMOLOGY

SYMPATHOMIMETICS

Apri tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Apriso capsule,extended release 24hr

0.375 gram PrefBrand-3 NO GASTROENTEROLOGY


Aptensio XR

cap,ER sprinkle,biphasic 40-60 10 mg

NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Aptensio XR




Aptensio XR







Quantity Limit Days

Authorization



Aptensio XR




Aptensio XR




Aptensio XR




Aptensio XR






ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS




Quantity Limit Days

Authorization



Aptivus capsule 250 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Aptivus solution 100 mg/mL Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Aralast NP recon soln 500 mg

Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


Aranelle (28)

tablet 0.5/1/0.5-35 mg-mcg

Generic-2 NO OBSTETRICS / GYNECOLOGY


Aranesp (in polysorbate)

solution 25 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS


solution 300 mcg/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization




syringe 100 mcg/0.5 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS


syringe 300 mcg/0.6 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS


syringe 500 mcg/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



Aranesp (in polysorbate) syringe 10 mcg/0.4 mL

PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Aranesp (in polysorbate) solution 200 mcg/mL

Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Arava tablet 10 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY


Arava tablet 20 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY


Arbinoxa liquid 4 mg/5 mL

Generic-2 NO



Arbinoxa tablet 4 mg

Generic-2 NO



Arcalyst recon soln 220 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Arimidex tablet 1 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



aripiprazole tablet 15 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




aripiprazole tablet 30 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


aripiprazole tablet 20 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






aripiprazole tablet,disintegrating

10 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


aripiprazole tablet,disintegrating

15 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Aristadasuspension,extended rel syring 441 mg/1.6 mL









Arixtra syringe 10 mg/0.8 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Arixtra syringe 5 mg/0.4 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Arixtra syringe 7.5 mg/0.6 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

armodafinil tablet 150 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH







Quantity Limit Days

Authorization







Aromasin tablet 25 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Arranon solution 250 mg/50 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Asacol HD tablet,delayed release (DR/EC)

800 mg PrefBrand-3 NO GASTROENTEROLOGY


Ascomp with Codeine

capsule 30-50-325-40 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Ashlynatablets,dose pack,3 month

0.15 mg-30 mcg (84)/10 mcg (7)

Generic-2 NO



Asmanex HFA

HFA aerosol inhaler 100 mcg/actuation

PrefBrand-313 30

NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Asmanex HFA

HFA aerosol inhaler 200 mcg/actuation

PrefBrand-313 30


PULMONARY AGENTS




Quantity Limit Days

Authorization



Asmanex Twisthaler

aerosol powdr breath activated

220 mcg (120 doses)

PrefBrand-3 1 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Asmanex Twisthaler


220 mcg (30 doses)


PULMONARY AGENTS

Asmanex Twisthaler


220 mcg (60 doses)


PULMONARY AGENTS

Asmanex Twisthaler


110 mcg (30 doses)


PULMONARY AGENTS

aspirin-dipyridamole

capsule, ER multiphase 12 hr

25-200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Assure ID Insulin Safety

syringe 1 mL 29 gauge x 1/2"


DIABETES THERAPY

Astagraf XLcapsule,extended release 24hr 0.5 mg

PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Astagraf XLcapsule,extended release 24hr 1 mg



Astagraf XLcapsule,extended release 24hr 5 mg






Quantity Limit Days

Authorization



atenolol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






atenolol-chlorthalidone



atenolol-chlorthalidone



Atgam solution 50 mg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


atorvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS







Quantity Limit Days

Authorization







atovaquone suspension 750 mg/5 mL Specialty-5 NO ANTI - INFECTIVES


atovaquone-proguanil



atovaquone-proguanil

tablet 62.5-25 mg Generic-2 NO ANTI - INFECTIVES


Atralin gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

ATRIPLA tablet 600-200-300 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

atropine syringe 0.05 mg/mL

Generic-2 NO

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

atropine syringe 0.1 mg/mL

Generic-2 NO

GASTROENTEROLOGY





Quantity Limit Days

Authorization



atropine drops 1 %Generic-2 NO OPHTHALMOLO

GYCYCLOPLEGIC MYDRIATICS

Atrovent HFA

HFA aerosol inhaler

17 mcg/actuation PrefBrand-3 25.8 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Aubagio tablet 14 mg

Specialty-5

31 31



Aubagio tablet 7 mg

Specialty-5

31 31



Augmentin suspension for reconstitution

125-31.25 mg/5 mL

NonPrefBrand-4 NO ANTI - INFECTIVES

PENICILLINS

Auryxia tablet 210 mg iron

NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Avandia tablet 2 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Avandia tablet 4 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Avastin solution 25 mg/mL

Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Avastin solution25 mg/mL (16 mL)



AVC Vaginal

cream 15 % NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY

MISCELLANEOUS OB/GYN

Aveed solution750 mg/3 mL (250 mg/mL)

NonPrefBrand-4 YES ENDOCRINE/DIABETES





Quantity Limit Days

Authorization



Avelox ABC Pack

tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES

QUINOLONES

Avelox in NaCl (iso-osmotic)

piggyback 400 mg/250 mL PrefBrand-3 NO ANTI - INFECTIVES

QUINOLONES

Aviane tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


Avita cream 0.025 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Avita gel 0.025 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Avonex syringe kit 30 mcg/0.5 mL Specialty-5 4 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Avonex pen injector kit 30 mcg/0.5 mL

Specialty-5

4 28

NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Avonex (with albumin)

kit 30 mcg Specialty-5 1 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Avycaz recon soln 2.5 gramSpecialty-5 NO ANTI -

INFECTIVESCEPHALOSPORINS

Axert tablet 6.25 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Axert tablet 12.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Axiron

solution in metered pump w/app

30 mg/actuation (1.5 mL)

NonPrefBrand-4 YESENDOCRINE/DIABETES


azacitidine recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Azactam in dextrose (iso-osm) piggyback 2 gram/50 mL

PrefBrand-3 NO

ANTI - INFECTIVES


Azasan tablet 75 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Azasan tablet 100 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Azasite drops 1 % NonPrefBrand-4 NO OPHTHALMOLOGY

ANTIBIOTICS

azathioprine tablet 50 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


azathioprine sodium

recon soln 100 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



azelastine aerosol,spray 137 mcg (0.1 %) Generic-2 NO EAR, NOSE / THROAT MEDICATIONS


azelastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY


azelastine spray,non-aerosol

0.15 % (205.5 mcg)

Generic-2 NO EAR, NOSE / THROAT MEDICATIONS


Azelex cream 20 %

NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Azilect tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Azilect tablet 0.5 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


azithromycin suspension for reconstitution


ERYTHROMYCINS / OTHER MACROLIDES

azithromycin tablet 600 mg Generic-2 NO ANTI - INFECTIVES




azithromycin suspension for reconstitution






Quantity Limit Days

Authorization





azithromycin tablet 250 mg (6 pack) Generic-2 NO ANTI - INFECTIVES


azithromycin packet 1 gram Generic-2 NO ANTI - INFECTIVES


azithromycin recon soln 500 mg

Generic-2 NOANTI - INFECTIVES


Azopt drops,suspension

1 % PrefBrand-3 NO OPHTHALMOLOGY

OTHER GLAUCOMA DRUGS

Azor tablet 10-20 mg PrefBrand-3 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS











Quantity Limit Days

Authorization



aztreonam recon soln 1 gram

Generic-2 NO

ANTI - INFECTIVES


BACiiM recon soln 50,000 unit Generic-2 NO ANTI - INFECTIVES


bacitracin ointment 500 unit/gram Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

bacitracin recon soln 50,000 unit Generic-2 NO ANTI - INFECTIVES


bacitracin-polymyxin B

ointment 500-10,000 unit/gram

Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

baclofen tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen tablet 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Bactroban Nasal

ointment 2 % PrefBrand-3 NO EAR, NOSE / THROAT MEDICATIONS


balsalazide capsule 750 mg Generic-2 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



Balziva (28) tablet 0.4-35 mg-mcg

Generic-2 NO



Banzel tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Banzel tablet 400 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Banzel suspension 40 mg/mL


ANTICONVULSANTS

Baraclude tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Baraclude tablet 1 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Baraclude solution 0.05 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

BCG vaccine, live (PF)

suspension for reconstitution 50 mg

NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Beconase AQ

spray,non-aerosol

42 mcg (0.042 %) NonPrefBrand-4 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Bekyree (28) tablet0.15-0.02 mgx21 /0.01 mg x 5

Generic-2 NO






Quantity Limit Days

Authorization



Belbuca film 150 mcg

NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

Belbuca film 75 mcg

NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

Beleodaq recon soln 500 mg

Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



benazepril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








benazepril-hydrochlorothiazide

tablet 10-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS














Quantity Limit Days

Authorization



Benicar tablet 5 mg NonPrefBrand-4 93 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






Benicar HCT

tablet 40-25 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Benicar HCT

tablet 40-12.5 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Benicar HCT

tablet 20-12.5 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS



NonPrefBrand-4 NO MUSCULOSKELETAL / RHEUMATOLOGY



Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



benztropine solution 2 mg/2 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


benztropine tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


benztropine tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


benztropine tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Berinert kit 500 unit (10 mL) Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Besivance drops,suspension

0.6 % NonPrefBrand-4 NO OPHTHALMOLOGY

ANTIBIOTICS

betamethasone dipropionate







lotion 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


betamethasone valerate






Quantity Limit Days

Authorization









betamethasone valerate foam 0.12 %

PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


betamethasone, augmented

cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY



lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY



ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY



gel 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


Betaseron kit 0.3 mg Specialty-5 15 31 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

betaxolol drops 0.5 % Generic-2 NO OPHTHALMOLOGY

BETA-BLOCKERS







Quantity Limit Days

Authorization






bethanechol chloride

tablet 10 mg Generic-2 NO UROLOGICALS CHOLINERGIC STIMULANTS







Bethkissolution for nebulization 300 mg/4 mL

NonPrefBrand-4 YES

ANTI - INFECTIVES


Betimol drops 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY

BETA-BLOCKERS

Betimol drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY

BETA-BLOCKERS

Betoptic S drops,suspension


BETA-BLOCKERS

bexarotene capsule 75 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Bexsero (PF) syringe50-50-50-25 mcg/0.5 mL






Quantity Limit Days

Authorization



Beyaz tablet3-0.02-0.451 mg (24)

NonPrefBrand-4 NO



bicalutamide tablet 50 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Bicillin C-R syringe 1,200,000 unit/ 2 mL(600k/600k)

PrefBrand-3 NO ANTI - INFECTIVES

PENICILLINS

Bicillin C-R syringe 1,200,000 unit/ 2 mL(900k/300k)


PENICILLINS

Bicillin L-A syringe 600,000 unit/mL PrefBrand-3 NO ANTI - INFECTIVES

PENICILLINS

Bicillin L-A syringe 1,200,000 unit/2 mL


PENICILLINS

Bicillin L-A syringe 2,400,000 unit/4 mL


PENICILLINS

BiCNU recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


BiDil tablet 20-37.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Biltricide tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES


bimatoprost drops 0.03 % Generic-2 NO OPHTHALMOLOGY





Quantity Limit Days

Authorization



bisoprolol fumarate

tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


bisoprolol fumarate



bisoprolol-hydrochlorothiazide




tablet 2.5-6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Bivigam solution 10 %

Specialty-5 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY


bleomycin recon soln 30 unit

Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Bleph-10 drops 10 %NonPrefBrand-4 NO OPHTHALMOLO

GY SULFONAMIDES




Quantity Limit Days

Authorization



Blephamidedrops,suspension 10-0.2 %

PrefBrand-3 NO

OPHTHALMOLOGY

STEROID-SULFONAMIDE COMBINATIONS

Blephamide S.O.P. ointment 10-0.2 %

PrefBrand-3 NO

OPHTHALMOLOGY


Blisovi 24 Fe tablet

1 mg-20 mcg (24)/75 mg (4)

Generic-2 NO



Blisovi Fe 1.5/30 (28) tablet

1.5 mg-30 mcg (21)/75 mg (7)

Generic-2 NO



Blisovi Fe 1/20 (28) tablet

1 mg-20 mcg (21)/75 mg (7)

Generic-2 NO



Boniva syringe 3 mg/3 mL NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY


Boostrix Tdap syringe

2.5-8-5 Lf-mcg-Lf/0.5mL






Quantity Limit Days

Authorization



Boostrix Tdap suspension

2.5-8-5 Lf-mcg-Lf/0.5mL









Botox recon soln 100 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Botox recon soln 200 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Breo Elliptablister with device 100-25 mcg/dose

PrefBrand-360 30


PULMONARY AGENTS

Breo Elliptablister with device 200-25 mcg/dose

PrefBrand-360 30


PULMONARY AGENTS

Briellyn tablet 0.4-35 mg-mcg

Generic-2 NO






Quantity Limit Days

Authorization



Brilinta tablet 90 mg


COAGULATION THERAPY

Brilinta tablet 60 mg


COAGULATION THERAPY

brimonidine drops 0.2 % Generic-2 NO OPHTHALMOLOGY

SYMPATHOMIMETICS

brimonidine drops 0.15 % Generic-2 NO OPHTHALMOLOGY

SYMPATHOMIMETICS

Brisdelle capsule 7.5 mg



Briviact solution 50 mg/5 mL


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS




Quantity Limit Days

Authorization





ANTICONVULSANTS



ANTICONVULSANTS

Briviact solution 10 mg/mL


ANTICONVULSANTS

bromfenac drops 0.09 % Generic-2 NO OPHTHALMOLOGY


bromocriptine

tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


bromocriptine

capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Brovana solution for nebulization

15 mcg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

budesonide suspension for nebulization

1 mg/2 mL Generic-2 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS



PULMONARY AGENTS



PULMONARY AGENTS




Quantity Limit Days

Authorization



budesonide spray,non-aerosol

32 mcg/actuation Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

budesonidecapsule,delayed,extend.release 3 mg

NonPrefBrand-4 NO

GASTROENTEROLOGY


bumetanide tablet 0.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


bumetanide tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


bumetanide tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


bumetanide solution 0.25 mg/mL



Bunavail film 2.1-0.3 mg

NonPrefBrand-4

31 31


NON-NARCOTIC ANALGESICS

Bunavail film 4.2-0.7 mg

NonPrefBrand-4

62 31






Quantity Limit Days

Authorization



Bunavail film 6.3-1 mg

NonPrefBrand-4

62 31



Bupap tablet 50-300 mg

NonPrefBrand-4

403 31


NARCOTIC ANALGESICS

Buphenyl tablet 500 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Buphenyl powder 0.94 gram/gram Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Buprenex solution 0.3 mg/mL NonPrefBrand-4 267 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

buprenorphine HCl

solution 0.3 mg/mL PrefGen-1 267 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

buprenorphine HCl

tablet 2 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

buprenorphine HCl


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



buprenorphine HCl syringe 0.3 mg/mL

PrefGen-1

267 30


NARCOTIC ANALGESICS

buprenorphine-naloxone

tablet 2-0.5 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


buprenorphine-naloxone

tablet 8-2 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Buproban tablet extended release

150 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

SMOKING DETERRENTS

bupropion HCl

tablet extended release

100 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


bupropion HCl




bupropion HCl




bupropion HCl


150 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



bupropion HCl




bupropion HCl

tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


bupropion HCl



buspirone tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




buspirone tablet 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




buspirone tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Busulfex solution 60 mg/10 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Butalbital Compound W/Codeine

capsule 30-50-325-40 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

butalbital-acetaminop-caf-cod

capsule 50-325-40-30 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

butalbital-acetaminop-caf-cod capsule 50-300-40-30 mg

Generic-2

403 31


NARCOTIC ANALGESICS

butalbital-acetaminophen

tablet 50-325 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

butalbital-acetaminophen-caff

capsule 50-325-40 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


tablet 50-325-40 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


capsule 50-300-40 mg Generic-2 403 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



butalbital-aspirin-caffeine

capsule 50-325-40 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Butisol tablet 30 mg



butorphanol tartrate

solution 1 mg/mL Generic-2 720 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


butorphanol tartrate

spray,non-aerosol

10 mg/mL Generic-2 5 28 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


butorphanol tartrate solution 2 mg/mL

Generic-2

360 30



Butrans patch weekly 10 mcg/hour NonPrefBrand-4 4 28 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


NARCOTIC ANALGESICS


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Butrans patch weekly 15 mcg/hour

NonPrefBrand-4

4 28


NARCOTIC ANALGESICS

Butrans patch weekly 7.5 mcg/hour

NonPrefBrand-4

4 28


NARCOTIC ANALGESICS

Bydureonsuspension,extended rel recon 2 mg

PrefBrand-34 28

NO ENDOCRINE/DIABETES

DIABETES THERAPY

Bydureon pen injector 2 mg/0.65 mLPrefBrand-3

4 28NO ENDOCRINE/DIA


Bystolic tablet 10 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Bystolic tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






cabergoline tablet 0.5 mg Generic-2 NO ENDOCRINE/DIABETES





Quantity Limit Days

Authorization




Specialty-5

31 31




Specialty-5

31 31




Specialty-5

31 31



Cafergot tablet 1-100 mg



calcipotriene ointment 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


calcipotriene solution 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


calcipotriene cream 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


calcipotriene-betamethasone

ointment 0.005-0.064 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



calcitonin (salmon)

spray,non-aerosol

200 unit/actuation Generic-2 NO ENDOCRINE/DIABETES


calcitriol capsule 0.25 mcg Generic-2 YES ENDOCRINE/DIABETES


calcitriol capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABETES


calcitriol solution 1 mcg/mL Generic-2 YES ENDOCRINE/DIABETES


calcitriol solution 1 mcg/mL Generic-2 YES ENDOCRINE/DIABETES


calcitriol ointment 3 mcg/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


calcium acetate

capsule 667 mg Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

Cambia powder in packet



Camila tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

Canasa suppository 1,000 mg PrefBrand-3 NO GASTROENTEROLOGY


Cancidas recon soln 70 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Cancidas recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS




Quantity Limit Days

Authorization



candesartan tablet 4 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








candesartan-hydrochlorothiazid









Capastat recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



Capex shampoo 0.01 %



Capital with Codeine

suspension 120-12 mg/5 mL PrefBrand-3 5167 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS







captopril tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


captopril tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS









Quantity Limit Days

Authorization



captopril-hydrochlorothiazide












Carac cream 0.5 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


Carafate suspension 100 mg/mL PrefBrand-3 NO GASTROENTEROLOGY

ULCER THERAPY

Carbaglu tablet, dispersible

200 mg Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


carbamazepine


100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

carbamazepine



ANTICONVULSANTS




Quantity Limit Days

Authorization



carbamazepine



ANTICONVULSANTS

carbamazepine

tablet,chewable 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

carbamazepine

suspension 100 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

carbamazepine


ANTICONVULSANTS

carbamazepine



ANTICONVULSANTS

carbamazepine



ANTICONVULSANTS

carbamazepine



ANTICONVULSANTS

Carbatrol capsule, ER multiphase 12 hr


ANTICONVULSANTS




Quantity Limit Days

Authorization





ANTICONVULSANTS



ANTICONVULSANTS

carbidopa tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


carbidopa-levodopa

tablet 10-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


carbidopa-levodopa



carbidopa-levodopa



carbidopa-levodopa


25-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


carbidopa-levodopa







Quantity Limit Days

Authorization



carbidopa-levodopa

tablet,disintegrating



carbidopa-levodopa




carbidopa-levodopa




carbidopa-levodopa-entacapone

tablet 12.5-50-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH



tablet 25-100-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






tablet 50-200-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








Quantity Limit Days

Authorization






carboplatin solution 10 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Cardene IV in sodium chloride

piggyback 40 mg/200 mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Cardizem LA


120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Carimune NF Nanofiltered

recon soln 6 gram Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


carisoprodol-ASA-codeine

tablet 200-325-16 mg Generic-2 2582 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Carnitor solution 100 mg/mL NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


Carnitor solution 200 mg/mL NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS





Quantity Limit Days

Authorization



Carnitor tablet 330 mg NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


carteolol drops 1 % Generic-2 NO OPHTHALMOLOGY

BETA-BLOCKERS

Cartia XT capsule,extended release 24hr












carvedilol tablet 6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS




carvedilol tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization





Casodex tablet 50 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Cayston solution for nebulization

75 mg/mL Specialty-5 NO ANTI - INFECTIVES


cefaclor capsule 500 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefaclor suspension for reconstitution


CEPHALOSPORINS

cefaclor tablet extended release 12 hr

500 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS



CEPHALOSPORINS

cefaclor capsule 250 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS



CEPHALOSPORINS

cefadroxil suspension for reconstitution


CEPHALOSPORINS

cefadroxil tablet 1 gram Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefadroxil suspension for reconstitution


CEPHALOSPORINS

cefadroxil capsule 500 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS




Quantity Limit Days

Authorization



cefazolin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefazolin recon soln 1 gramGeneric-2 NO ANTI -


cefazolin recon soln 500 mgGeneric-2 NO ANTI -


cefdinir capsule 300 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefdinir suspension for reconstitution


CEPHALOSPORINS

cefdinir suspension for reconstitution


CEPHALOSPORINS

cefepime recon soln 2 gramGeneric-2 NO ANTI -


cefepime recon soln 1 gramGeneric-2 NO ANTI -


cefixime suspension for reconstitution


CEPHALOSPORINS

cefixime suspension for reconstitution


CEPHALOSPORINS

cefotaxime recon soln 500 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefotaxime recon soln 1 gramGeneric-2 NO ANTI -


cefotaxime recon soln 2 gramGeneric-2 NO ANTI -


cefotetan recon soln 1 gramGeneric-2 NO ANTI -


cefotetan recon soln 2 gramGeneric-2 NO ANTI -


cefoxitin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS




Quantity Limit Days

Authorization



cefoxitin recon soln 1 gramGeneric-2 NO ANTI -


cefoxitin recon soln 2 gramGeneric-2 NO ANTI -


cefpodoxime tablet 100 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefpodoxime suspension for reconstitution


CEPHALOSPORINS

cefpodoxime tablet 200 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefpodoxime suspension for reconstitution


CEPHALOSPORINS

cefprozil tablet 250 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefprozil tablet 500 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefprozil suspension for reconstitution


CEPHALOSPORINS

cefprozil suspension for reconstitution


CEPHALOSPORINS

ceftazidime recon soln 6 gram Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

ceftazidime recon soln 1 gramGeneric-2 NO ANTI -


ceftazidime recon soln 2 gramGeneric-2 NO ANTI -


Ceftin suspension for reconstitution


CEPHALOSPORINS

Ceftin suspension for reconstitution


CEPHALOSPORINS

ceftriaxone recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS




Quantity Limit Days

Authorization



ceftriaxone recon soln 250 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

ceftriaxone recon soln 500 mgGeneric-2 NO ANTI -


ceftriaxone recon soln 1 gramGeneric-2 NO ANTI -


ceftriaxone recon soln 2 gramGeneric-2 NO ANTI -


cefuroxime axetil


CEPHALOSPORINS

cefuroxime axetil


CEPHALOSPORINS

cefuroxime sodium

recon soln 7.5 gram Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefuroxime sodium recon soln 1.5 gram

Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cefuroxime sodium recon soln 750 mg


CEPHALOSPORINS

celecoxib capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH









Quantity Limit Days

Authorization





CellCept tablet 500 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


CellCept suspension for reconstitution

200 mg/mL NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


CellCept capsule 250 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


CellCept Intravenous

recon soln 500 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Celontin capsule 300 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

cephalexin tablet 500 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cephalexin suspension for reconstitution


CEPHALOSPORINS

cephalexin capsule 250 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS

cephalexin suspension for reconstitution


CEPHALOSPORINS




Quantity Limit Days

Authorization




CEPHALOSPORINS

cephalexin tablet 250 mg Generic-2 NO ANTI - INFECTIVES

CEPHALOSPORINS


CEPHALOSPORINS

Cerdelga capsule 84 mgSpecialty-5 YES ENDOCRINE/DIA


Cerebyx solution 500 mg PE/10 mL


ANTICONVULSANTS

Cerezyme recon soln 400 unitSpecialty-5 NO ENDOCRINE/DIA


Cervarix Vaccine (PF) syringe 20-20 mcg/0.5 mL



Cesamet capsule 1 mg NonPrefBrand-4 YES GASTROENTEROLOGY


cetirizine solution 1 mg/mL

Generic-2 NO



cevimeline capsule 30 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Chantix tablet 0.5 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

SMOKING DETERRENTS




Quantity Limit Days

Authorization



Chantix tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

SMOKING DETERRENTS

Chantix Continuing Month Box

tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

SMOKING DETERRENTS

Chantix Starting Month Box

tablets,dose pack

0.5 mg (11)- 1 mg (42)


SMOKING DETERRENTS

Chemet capsule 100 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Chenodal tablet 250 mg Specialty-5 YES GASTROENTEROLOGY


chloramphenicol sod succinate



chlordiazepoxide HCl












Quantity Limit Days

Authorization



chlorhexidine gluconate

mouthwash 0.12 % PrefGen-1 NO EAR, NOSE / THROAT MEDICATIONS


chloroquine phosphate tablet 500 mg

Generic-2 NO

ANTI - INFECTIVES


chloroquine phosphate tablet 250 mg

Generic-2 NO

ANTI - INFECTIVES


chlorothiazide



chlorothiazide



chlorothiazide sodium

recon soln 500 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


chlorpromazine

tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


chlorpromazine






Quantity Limit Days

Authorization



chlorpromazine



chlorpromazine



chlorpromazine



chlorpromazine solution 25 mg/mL

Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


chlorthalidone



chlorthalidone




Specialty-5 YES

GASTROENTEROLOGY



Specialty-5 YES

GASTROENTEROLOGY





Quantity Limit Days

Authorization



Cholestyramine Light

powder in packet

4 gram Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


chorionic gonadotropin, human

recon soln 10,000 unit Generic-2 YES ENDOCRINE/DIABETES


Cialis tablet 5 mg NonPrefBrand-4 31 31 YES UROLOGICALS MISCELLANEOUS UROLOGICALS

Cialis tablet 2.5 mg NonPrefBrand-4 62 31 YES UROLOGICALS MISCELLANEOUS UROLOGICALS

ciclopirox shampoo 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ciclopirox cream 0.77 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ciclopirox suspension 0.77 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ciclopirox solution 8 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ciclopirox gel 0.77 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

cidofovir solution 75 mg/mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



cilostazol tablet 100 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

cilostazol tablet 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Ciloxan ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY

ANTIBIOTICS

cimetidine tablet 200 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY


ULCER THERAPY


ULCER THERAPY


ULCER THERAPY

cimetidine HCl

solution 300 mg/5 mL Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

Cimzia syringe kit 400 mg/2 mL (200 mg/mL x 2)

Specialty-5 2 28 YES GASTROENTEROLOGY


Cimzia Powder for Reconst

kit 400 mg (200 mg x 2 vials)

Specialty-5 6 28 YES GASTROENTEROLOGY


Cinryze recon soln 500 unit (5 mL) Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Cipro HC drops,suspension

0.2-1 % NonPrefBrand-4 NO EAR, NOSE / THROAT MEDICATIONS

OTIC STEROID / ANTIBIOTIC




Quantity Limit Days

Authorization



Ciprodex drops,suspension

0.3-0.1 % PrefBrand-3 NO EAR, NOSE / THROAT MEDICATIONS


ciprofloxacin

suspension,microcapsule recon


QUINOLONES

ciprofloxacin

suspension,microcapsule recon


QUINOLONES

ciprofloxacin (mixture)



QUINOLONES

ciprofloxacin (mixture)


1,000 mg Generic-2 NO ANTI - INFECTIVES

QUINOLONES

ciprofloxacin HCl

tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES

QUINOLONES

ciprofloxacin HCl


QUINOLONES

ciprofloxacin HCl


QUINOLONES

ciprofloxacin HCl

drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY

ANTIBIOTICS

ciprofloxacin HCl


QUINOLONES

ciprofloxacin in 5 % dextrose piggyback 200 mg/100 mL

Generic-2 NOANTI - INFECTIVES QUINOLONES

ciprofloxacin lactate solution 400 mg/40 mL

PrefGen-1 NO ANTI - INFECTIVES QUINOLONES

cisplatin solution 1 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



citalopram tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




citalopram solution 10 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




cladribine solution 10 mg/10 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Claforan recon soln 1 gramNonPrefBrand-4 NO ANTI -


Claravis capsule 10 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE


THERAPY FOR ACNE


THERAPY FOR ACNE




Quantity Limit Days

Authorization




THERAPY FOR ACNE

Clarinex-D 12 HOUR

tablet, ER multiphase 12 hr 2.5-120 mg

NonPrefBrand-4 NO



clarithromycin



clarithromycin



clarithromycin




clarithromycin




clarithromycin




Cleocin capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES


Cleocin suppository 100 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


Climara Pro patch weekly 0.045-0.015 mg/24 hr

NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


Clindacin Pac kit 1 %


THERAPY FOR ACNE




Quantity Limit Days

Authorization



clindamycin HCl



clindamycin HCl



clindamycin HCl



clindamycin in 5 % dextrose

piggyback 600 mg/50 mL Generic-2 NO ANTI - INFECTIVES








Clindamycin Pediatric

recon soln 75 mg/5 mL Generic-2 NO ANTI - INFECTIVES


clindamycin phosphate

lotion 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE




Quantity Limit Days

Authorization




gel 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE


solution 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE


cream 2 % Generic-2 NO OBSTETRICS / GYNECOLOGY



foam 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE


swab 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

clindamycin phosphate solution 150 mg/mL

Generic-2 NO

ANTI - INFECTIVES


clindamycin phosphate solution 600 mg/4 mL

Generic-2 NO

ANTI - INFECTIVES


clindamycin phosphate solution

150 (mg/mL) (6 ml)

Generic-2 NO

ANTI - INFECTIVES


clindamycin-benzoyl peroxide

gel 1-5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Clindesse cream,extended release

2 % NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY





Quantity Limit Days

Authorization



Clinimix 5%/D15W Sulfite Free

parenteral solution



Clinimix 5%/D25W sulfite-free

parenteral solution



Clinimix 2.75%/D5W Sulfit Free

parenteral solution

2.75 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES


Clinimix 4.25%/D10W Sulf Free

parenteral solution



Clinimix 4.25%/D5W Sulfit Free

parenteral solution

4.25 % PrefBrand-3 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


Clinimix 4.25%-D20W sulf-free

parenteral solution



Clinimix 4.25%-D25W sulf-free

parenteral solution



Clinimix 5%-D20W(sulfite-free)

parenteral solution



Clinimix E 2.75%/D10W Sul Free

parenteral solution

2.75 % NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS





Quantity Limit Days

Authorization



Clinimix E 2.75%/D5W Sulf Free

parenteral solution

2.75 % NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS







parenteral solution



Clinimix E 4.25%/D5W Sulf Free

parenteral solution



Clinimix E 5%/D15W Sulfit Free

parenteral solution




parenteral solution




parenteral solution



Clinisol SF 15 %

parenteral solution



clobetasol foam 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


clobetasol gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


clobetasol ointment 0.05 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



clobetasol solution 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


clobetasol shampoo 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


clobetasol lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


clobetasol spray,non-aerosol

0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


clobetasol-emollient

cream 0.05 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY


Clodan shampoo 0.05 %

Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


Cloderm cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Clolar solution 20 mg/20 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


clomipramine

capsule 25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


clomipramine






Quantity Limit Days

Authorization



clomipramine



clonazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

clonazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

clonazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

clonazepam tablet,disintegrating

0.125 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS




Quantity Limit Days

Authorization





ANTICONVULSANTS

clonidine patch weekly 0.1 mg/24 hr









clonidine HCl

tablet 0.1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


clonidine HCl



clonidine HCl



clonidine HCl

tablet extended release 12 hr 0.1 mg

Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



clopidogrel tablet 75 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

clopidogrel tablet 300 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

clorazepate dipotassium









Clorpres tablet 0.1-15 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Clorpres tablet 0.2-15 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Clorpres tablet 0.3-15 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



clotrimazole cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

clotrimazole solution 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

clotrimazole troche 10 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

clotrimazole-betamethasone

cream 1-0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

clotrimazole-betamethasone

lotion 1-0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

clozapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


clozapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


clozapine tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


clozapine tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



clozapine tablet,disintegrating









clozapinetablet,disintegrating 200 mg



clozapinetablet,disintegrating 150 mg



Clozaril tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Clozaril tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Coartem tablet 20-120 mg NonPrefBrand-4 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



codeine sulfate tablet 15 mg

Generic-2

186 31


NARCOTIC ANALGESICS


Generic-2

186 31


NARCOTIC ANALGESICS


Generic-2

186 31


NARCOTIC ANALGESICS

colchicine tablet 0.6 mg NonPrefBrand-4 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

colchicine capsule 0.6 mg

NonPrefBrand-4 NO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY

colchicine-probenecid

tablet 0.5-500 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

Colcrys tablet 0.6 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

colestipol tablet 1 gram






Quantity Limit Days

Authorization



colestipol granules 5 gram



colistin (colistimethate Na) recon soln 150 mg

Generic-2 NO

ANTI - INFECTIVES


Colocort enema 100 mg/60 mL Generic-2 NO GASTROENTEROLOGY


Coly-Mycin S

drops,suspension

3.3-3-10-0.5 mg/mL

NonPrefBrand-4 NO EAR, NOSE / THROAT MEDICATIONS


Combigan drops 0.2-0.5 % PrefBrand-3 NO OPHTHALMOLOGY


Combivent Respimat mist


NonPrefBrand-44 30


PULMONARY AGENTS

Combivir tablet 150-300 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Cometriq capsule140 mg/day(80 mg x1-20 mg x3)



Cometriq capsule100 mg/day(80 mg x1-20 mg x1)






Quantity Limit Days

Authorization



Cometriq capsule60 mg/day (20 mg x 3/day)



Complera tablet 200-25-300 mgSpecialty-5 NO ANTI -

INFECTIVES ANTIVIRALSCompro suppository 25 mg Generic-2 NO GASTROENTERO

LOGYMISCELLANEOUS GASTROINTESTINAL AGENTS

Condylox gel 0.5 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY


Constulose solution 10 gram/15 mL Generic-2 NO GASTROENTEROLOGY


Copaxone syringe 20 mg/mL

Specialty-5

31 31



Copaxone syringe 40 mg/mL

Specialty-5

12 28



Copegus tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Cordran Tape Large Roll

tape 4 mcg/cm2 PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



Corlanor tablet 5 mg

NonPrefBrand-4

93 31

YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

MISCELLANEOUS CARDIOVASCULAR AGENTS

Corlanor tablet 7.5 mg

NonPrefBrand-4

62 31



Cormax solution 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


cortisone tablet 25 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

Cortisporin ointment 1 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY


Cortisporin cream3.5-10,000-0.5 mg/g-unit/g-%

PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY


Cosentyx syringe 150 mg/mL

Specialty-5

2 28

YESDERMATOLOGICALS/TOPICAL THERAPY


Cosentyx Pen pen injector 150 mg/mL

Specialty-5

2 28



Cotellic tablet 20 mg






Quantity Limit Days

Authorization



Coumadin tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY

Coumadin tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY




Quantity Limit Days

Authorization



Coumadin tablet 7.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Creon capsule,delayed release(DR/EC)

24,000-76,000 -120,000 unit

PrefBrand-3 NO GASTROENTEROLOGY



6,000-19,000 -30,000 unit




12,000-38,000 -60,000 unit



Creoncapsule,delayed release(DR/EC)

3,000-9,500- 15,000 unit

PrefBrand-3 NO

GASTROENTEROLOGY


Creoncapsule,delayed release(DR/EC)

36,000-114,000- 180,000 unit

PrefBrand-3 NO

GASTROENTEROLOGY


Cresemba capsule 186 mgSpecialty-5 NO ANTI -

INFECTIVESANTIFUNGAL AGENTS

Cresemba recon soln 372 mgSpecialty-5 NO ANTI -

INFECTIVESANTIFUNGAL AGENTS








Quantity Limit Days

Authorization



Crixivan capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Crixivan capsule 400 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

cromolyn drops 4 % Generic-2 NO OPHTHALMOLOGY


cromolyn solution for nebulization

20 mg/2 mL Generic-2 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

cromolyn concentrate 100 mg/5 mL Generic-2 NO GASTROENTEROLOGY


Cryselle (28) tablet 0.3-30 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


Cubicin recon soln 500 mg Specialty-5 NO ANTI - INFECTIVES


Cuprimine capsule 250 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY


Cutivate lotion 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Cuvposa solution1 mg/5 mL (0.2 mg/mL)

NonPrefBrand-4 NO

GASTROENTEROLOGY





Quantity Limit Days

Authorization



Cyclafem 1/35 (28) tablet 1-35 mg-mcg

Generic-2 NO



Cyclafem 7/7/7 (28) tablet

0.5/0.75/1 mg- 35 mcg

Generic-2 NO



cyclobenzaprine

tablet 7.5 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


cyclobenzaprine

tablet 5 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


cyclobenzaprine



cyclophosphamide capsule 25 mg

NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


cyclophosphamide capsule 50 mg



Cycloset tablet 0.8 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization



cyclosporine capsule 25 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


cyclosporine solution 250 mg/5 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


cyclosporine capsule 100 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


cyclosporine modified

capsule 100 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS



solution 100 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS








cyproheptadine

syrup 2 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY





Quantity Limit Days

Authorization



cyproheptadine

tablet 4 mg Generic-2 NO RESPIRATORY AND ALLERGY


Cyramza solution 10 mg/mL



Cyramza solution10 mg/mL (50 mL)



Cystadane powder 1 gram/1.7 mL PrefBrand-3 NO GASTROENTEROLOGY


Cystagon capsule 150 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS

Cystagon capsule 50 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS

Cystaran drops 0.44 %

Specialty-5 NO

OPHTHALMOLOGY


cytarabine solution 20 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



cytarabine (PF)

solution 2 gram/20 mL (100 mg/mL)



Cytovene recon soln 500 mg NonPrefBrand-4 YES ANTI - INFECTIVES

ANTIVIRALS

D10 %-0.45 % sodium chloride

parenteral solution

Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


D2.5 %-0.45 % sodium chloride

parenteral solution



D5 % and 0.9 % sodium chloride

parenteral solution



D5 %-0.45 % sodium chloride

parenteral solution



dacarbazine recon soln 200 mg

Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Dacogen recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS



28 28YES ANTI -

INFECTIVES ANTIVIRALS


28 28YES ANTI -





Quantity Limit Days

Authorization




28 28YES ANTI -


Daliresp tablet 500 mcgPrefBrand-3

31 31NO RESPIRATORY


Dalvance solution 500 mg

Specialty-5 NO

ANTI - INFECTIVES


danazol capsule 100 mg Generic-2 NO ENDOCRINE/DIABETES






dantrolene capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






dapsone tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



dapsone tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES


Daptacel (DTaP Pediatric) (PF) suspension

15-10-5 Lf-mcg-Lf/0.5mL



Daraprim tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES


darifenacin tablet extended release 24 hr

15 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

darifenacin tablet extended release 24 hr

7.5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Darzalex solution 20 mg/mL



daunorubicin solution 5 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Daytrana patch 24 hour 10 mg/9 hr NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization









DDAVP solution 0.1 mg/mL (refrigerate)



decitabine recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Delzicolcapsule,delayed release(DR/EC) 400 mg

PrefBrand-3 NO

GASTROENTEROLOGY


demeclocycline


TETRACYCLINES

demeclocycline


TETRACYCLINES

Demser capsule 250 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Denavir cream 1 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIVIRALS




Quantity Limit Days

Authorization



Depacon solution500 mg/5 mL (100 mg/mL)


ANTICONVULSANTS

Depakene capsule 250 mg


ANTICONVULSANTS

Depakene solution 250 mg/5 mL


ANTICONVULSANTS

Depakote

tablet,delayed release (DR/EC) 125 mg


ANTICONVULSANTS

Depakote



ANTICONVULSANTS

Depakote



ANTICONVULSANTS

Depakote ER

tablet extended release 24 hr 250 mg


ANTICONVULSANTS

Depakote ER



ANTICONVULSANTS




Quantity Limit Days

Authorization



Depakote Sprinkles

capsule, sprinkle 125 mg


ANTICONVULSANTS

Depen Titratabs

tablet 250 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY


Depo-Estradiol

oil 5 mg/mL NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


Depo-Medrol suspension 20 mg/mL


ADRENAL HORMONES



ADRENAL HORMONES



ADRENAL HORMONES

Depo-Provera solution 400 mg/mL



Depo-Testosterone

oil 100 mg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Depo-Testosterone

oil 200 mg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Descovy tablet 200-25 mgSpecialty-5

31 31NO ANTI -








Quantity Limit Days

Authorization


















desloratadine tablet 5 mg Generic-2 NO RESPIRATORY AND ALLERGY


desloratadine tablet,disintegrating



desloratadine tablet,disintegrating

2.5 mg Generic-2 NO RESPIRATORY AND ALLERGY





Quantity Limit Days

Authorization



desmopressin

tablet 0.2 mg Generic-2 NO ENDOCRINE/DIABETES


desmopressin

solution 4 mcg/mL Generic-2 NO ENDOCRINE/DIABETES


desmopressin

spray,non-aerosol

10 mcg/spray (0.1 mL)

Generic-2 NO ENDOCRINE/DIABETES


desmopressin



desmopressin

solution 0.1 mg/mL (refrigerate)



Desonate gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


desonide lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


desonide ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


desonide cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


desoximetasone



desoximetasone



desoximetasone






Quantity Limit Days

Authorization



desoximetasone



desoximetasone

gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


desvenlafaxine




desvenlafaxine




dexamethasone

tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

dexamethasone

tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

dexamethasone


ADRENAL HORMONES

dexamethasone


ADRENAL HORMONES

dexamethasone


ADRENAL HORMONES

dexamethasone


ADRENAL HORMONES

dexamethasone

elixir 0.5 mg/5 mL PrefGen-1 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

dexamethasone


ADRENAL HORMONES

Dexamethasone Intensol

drops 1 mg/mL Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES




Quantity Limit Days

Authorization



dexamethasone sodium phosphate


STEROIDS

dexamethasone sodium phosphate

solution 10 mg/mL Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

dexamethasone sodium phosphate solution 4 mg/mL

Generic-2 NOENDOCRINE/DIABETES

ADRENAL HORMONES

Dexedrine tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Dexedrine tablet 10 mg



dexmethylphenidate

capsule,ER biphasic 50-50



dexmethylphenidate




dexmethylphenidate




dexmethylphenidate







Quantity Limit Days

Authorization



dexmethylphenidate




dexmethylphenidate



dexmethylphenidate



dexmethylphenidate



dexmethylphenidate

capsule,ER biphasic 50-50 40 mg



DexPak 13 Day

tablets,dose pack

1.5 mg (51 tabs) NonPrefBrand-4 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

dexrazoxane HCl recon soln 250 mg


ADJUNCTIVE AGENTS

dextroamphetamine






Quantity Limit Days

Authorization



dextroamphetamine



dextroamphetamine




dextroamphetamine




dextroamphetamine




dextroamphetamine-amphetamine




tablet 5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






tablet 15 mg PrefGen-1 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization







tablet 12.5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH



capsule,extended release 24hr


























Quantity Limit Days

Authorization



dextroamphetamine-amphetamine tablet 7.5 mg

PrefGen-1

62 31



dextrose 10 % and 0.2 % NaCl

parenteral solution



dextrose 10 % in water (D10W)

parenteral solution

10 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


dextrose 5 % in water (D5W)

parenteral solution



dextrose 5 %-lactated ringers

parenteral solution



dextrose 5%-0.2 % sod chloride

parenteral solution



dextrose 5%-0.3 % sod.chloride

parenteral solution



Dextrose With Sodium Chloride

parenteral solution

5-0.2 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Dextrose-KCl-NaCl

solution 5-0.224-0.225 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

Diastat kit 2.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization



Diastat AcuDial

kit 5-7.5-10 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Diastat AcuDial

kit 12.5-15-17.5-20 mg


ANTICONVULSANTS

diazepam tablet 10 mg Generic-2 124 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






diazepam solution 5 mg/5 mL (1 mg/mL)

Generic-2 1500 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


diazepam kit 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

diazepam kit 5-7.5-10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization



diazepam kit 12.5-15-17.5-20 mg


ANTICONVULSANTS

Diazepam Intensol

concentrate 5 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Dibenzyline capsule 10 mg Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


diclofenac potassium



diclofenac sodium



diclofenac sodium

gel 1 % PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


diclofenac sodium

gel 3 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


diclofenac sodium


100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



diclofenac sodium

tablet,delayed release (DR/EC)



diclofenac sodium




diclofenac sodium




diclofenac sodium

drops 1.5 % Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


diclofenac-misoprostol

tablet,IR,delayed rel,biphasic

50-200 mg-mcg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


diclofenac-misoprostol

tablet,IR,delayed rel,biphasic 75-200 mg-mcg



dicloxacillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS

dicloxacillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES

PENICILLINS

dicyclomine capsule 10 mg Generic-2 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



dicyclomine solution 10 mg/mL Generic-2 NO GASTROENTEROLOGY


dicyclomine solution 10 mg/5 mL Generic-2 NO GASTROENTEROLOGY


dicyclomine tablet 20 mg Generic-2 NO GASTROENTEROLOGY


didanosine capsule,delayed release(DR/EC)


ANTIVIRALS



ANTIVIRALS



ANTIVIRALS



ANTIVIRALS

Differin lotion 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE




Quantity Limit Days

Authorization



Dificid tablet 200 mg

Specialty-5

20 10

NOANTI - INFECTIVES


diflorasone cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


diflorasone ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


diflunisal tablet 500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Digitek tablet 125 mcg PrefGen-1 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

Digitek tablet 250 mcg Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

digoxin solution 250 mcg/mL Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

digoxin tablet 125 mcg PrefGen-1 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

digoxin tablet 250 mcg Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES




Quantity Limit Days

Authorization



digoxin solution 50 mcg/mL Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

dihydroergotamine

spray,non-aerosol

0.5 mg/pump act. (4 mg/mL)

Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


dihydroergotamine

solution 1 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Dilantin capsule 30 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Dilantin Extended

capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Dilantin Infatabs tablet,chewable 50 mg


ANTICONVULSANTS

Dilantin-125 suspension 125 mg/5 mL


ANTICONVULSANTS

Dilaudid liquid 1 mg/mL NonPrefBrand-4 1550 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Dilaudid tablet 2 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


NARCOTIC ANALGESICS


NARCOTIC ANALGESICS

diltiazem HCl




diltiazem HCl




diltiazem HCl




diltiazem HCl




diltiazem HCl







Quantity Limit Days

Authorization



diltiazem HCl

capsule,extended release 12 hr



diltiazem HCl




diltiazem HCl




diltiazem HCl



diltiazem HCl



diltiazem HCl



diltiazem HCl




diltiazem HCl

recon soln 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



diltiazem HCl



diltiazem HCl

solution 5 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


DILT-XR capsule,ext release degradable









Dipentum capsule 250 mg PrefBrand-3 NO GASTROENTEROLOGY


diphenhydramine HCl solution 50 mg/mL

Generic-2 NO



diphenoxylate-atropine liquid

2.5-0.025 mg/5 mL

Generic-2 NO

GASTROENTEROLOGY





Quantity Limit Days

Authorization



diphenoxylate-atropine tablet 2.5-0.025 mg

Generic-2 NO

GASTROENTEROLOGY


disulfiram tablet 250 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


disulfiram tablet 500 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Diuril suspension 250 mg/5 mL PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


divalproextablet extended release 24 hr 250 mg

PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

divalproextablet extended release 24 hr 500 mg


ANTICONVULSANTS

divalproexcapsule, sprinkle 125 mg


ANTICONVULSANTS

divalproex



ANTICONVULSANTS




Quantity Limit Days

Authorization



divalproex



ANTICONVULSANTS

divalproex



ANTICONVULSANTS

Divigel gel in packet 0.5 mg (0.1 %) NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


Docefrez recon soln 20 mg

NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


docetaxel solution80 mg/4 mL (20 mg/mL)



docetaxel solution80 mg/8 mL (10 mg/mL)



dofetilide capsule 125 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS







Quantity Limit Days

Authorization





Dolophine tablet 10 mg NonPrefBrand-4 206 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Dolophine tablet 5 mg NonPrefBrand-4 248 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

donepeziltablet,disintegrating 10 mg






donepeziltablet,disintegrating 5 mg












Quantity Limit Days

Authorization



Doribax recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES


dorzolamide drops 2 % Generic-2 NO OPHTHALMOLOGY


dorzolamide-timolol

drops 22.3-6.8 mg/mL Generic-2 NO OPHTHALMOLOGY


doxazosin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS














Quantity Limit Days

Authorization



doxepin concentrate 10 mg/mL















doxepin cream 5 %

Generic-2 NODERMATOLOGICALS/TOPICAL THERAPY





doxercalciferol

solution 4 mcg/2 mL Generic-2 YES ENDOCRINE/DIABETES


doxercalciferol

capsule 2.5 mcg Generic-2 YES ENDOCRINE/DIABETES





Quantity Limit Days

Authorization



doxercalciferol

capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABETES


doxercalciferol

capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABETES


doxorubicin solution 50 mg/25 mL



doxorubicin, peg-liposomal suspension 2 mg/mL



Doxy-100 recon soln 100 mg Generic-2 NO ANTI - INFECTIVES

TETRACYCLINES

doxycycline hyclate


TETRACYCLINES

doxycycline hyclate

recon soln 100 mg Generic-2 NO ANTI - INFECTIVES

TETRACYCLINES

doxycycline hyclate


75 mg PrefGen-1 NO ANTI - INFECTIVES

TETRACYCLINES

doxycycline hyclate



TETRACYCLINES

doxycycline hyclate


150 mg PrefGen-1 NO ANTI - INFECTIVES

TETRACYCLINES

doxycycline hyclate


Generic-2 NOANTI - INFECTIVES TETRACYCLINES

doxycycline hyclate capsule 50 mg





Quantity Limit Days

Authorization



doxycycline hyclate capsule 100 mg


doxycycline hyclate tablet 100 mg


doxycycline hyclate



doxycycline monohydrate


TETRACYCLINES



TETRACYCLINES

doxycycline monohydrate capsule 50 mg


doxycycline monohydrate tablet 75 mg


doxycycline monohydrate capsule 100 mg



suspension for reconstitution 25 mg/5 mL









Quantity Limit Days

Authorization





dronabinol capsule 10 mg Specialty-5 YES GASTROENTEROLOGY


dronabinol capsule 2.5 mg Generic-2 YES GASTROENTEROLOGY


dronabinol capsule 5 mg Generic-2 YES GASTROENTEROLOGY


drospirenone-ethinyl estradiol

tablet 3-0.02 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


drospirenone-ethinyl estradiol

tablet 3-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Droxia capsule 200 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS







Quantity Limit Days

Authorization





Duexis tablet 800-26.6 mg

NonPrefBrand-4

93 31



duloxetine capsule,delayed release(DR/EC)












Duopaintestinal pump suspension 4.63-20 mg/mL

NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Duragesic patch 72 hour 25 mcg/hr NonPrefBrand-4 20 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization




NARCOTIC ANALGESICS


NARCOTIC ANALGESICS


NARCOTIC ANALGESICS


NARCOTIC ANALGESICS

Duramorph (PF)

solution 0.5 mg/mL Generic-2 4000 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Duramorph (PF)

solution 1 mg/mL Generic-2 2000 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Durezol drops 0.05 % PrefBrand-3 NO OPHTHALMOLOGY

STEROIDS

dutasteride capsule 0.5 mg PrefBrand-3 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY




Quantity Limit Days

Authorization



dutasteride-tamsulosin

capsule, ER multiphase 24 hr 0.5-0.4 mg

PrefBrand-3 NO

UROLOGICALS

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Dymistaspray,non-aerosol 137-50 mcg/spray

NonPrefBrand-4 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Dyrenium capsule 100 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Dyrenium capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Dysport recon soln 300 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Dysport recon soln 500 unit

NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY


E.E.S. 400 tablet 400 mg Generic-2 NO ANTI - INFECTIVES


E.E.S. Granules




econazole cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS




Quantity Limit Days

Authorization



Edarbyclor tablet 40-12.5 mg



Edarbyclor tablet 40-25 mg



Edecrin tablet 25 mg



Edurant tablet 25 mgNonPrefBrand-4 NO ANTI -

INFECTIVES ANTIVIRALSEffient tablet 10 mg PrefBrand-3 NO CARDIOVASCUL

AR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Effient tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Egrifta recon soln 1 mg


BIOTECHNOLOGY DRUGS

Elaprase solution 6 mg/3 mL Specialty-5 NO ENDOCRINE/DIABETES


Elelyso recon soln 200 unitSpecialty-5 NO ENDOCRINE/DIA





Quantity Limit Days

Authorization



Elidel cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Eligard syringe 45 mg (6 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Eligard syringe 30 mg (4 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Eligard syringe 7.5 mg (1 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Eligard syringe 22.5 mg (3 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Eliphos tablet 667 mg Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

Eliquis tablet 2.5 mg

PrefBrand-3

62 31

NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Eliquis tablet 5 mg

PrefBrand-3

74 31


COAGULATION THERAPY




Quantity Limit Days

Authorization



Elitek recon soln 1.5 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

Elitek recon soln 7.5 mg


ADJUNCTIVE AGENTS

Elixophyllin elixir 80 mg/15 mL PrefBrand-3 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Ellence solution 200 mg/100 mL



Elmiron capsule 100 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS

Emadine drops 0.05 % NonPrefBrand-4 NO OPHTHALMOLOGY


Embeda capsule,oral only,ext.rel pell

100-4 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS


20-0.8 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization





NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

Emcyt capsule 140 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Emend capsule 80 mg NonPrefBrand-4 YES GASTROENTEROLOGY






Emend capsule,dose pack

125 mg (1)- 80 mg (2)

NonPrefBrand-4 YES GASTROENTEROLOGY





Quantity Limit Days

Authorization



Emend recon soln 150 mg

NonPrefBrand-4 NO

GASTROENTEROLOGY


Emoquette tablet 0.15-0.03 mg

Generic-2 NO









Emsam patch 24 hour 6 mg/24 hr Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






Emtriva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Emtriva solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Emverm tablet,chewable 100 mg

NonPrefBrand-4 NO

ANTI - INFECTIVES


enalapril maleate



enalapril maleate



enalapril maleate



enalapril maleate



enalapril-hydrochlorothiazide



enalapril-hydrochlorothiazide



Enbrel recon soln 25 mg (1 mL) Specialty-5 8 28 YES MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



Enbrel syringe 50 mg/mL (0.98 mL)

Specialty-5 7.84 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Enbrel syringe 25 mg/0.5mL (0.51)

Specialty-5 4 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Enbrel SureClick pen injector

50 mg/mL (0.98 mL)

Specialty-5

7.84 28



Endocet tablet 10-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Endocet tablet 5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Endocet tablet 7.5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Engerix-B (PF)

syringe 20 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



Engerix-B Pediatric (PF)



Engerix-B Pediatric (PF) suspension 10 mcg/0.5 mL

PrefBrand-3 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY


enoxaparin syringe 30 mg/0.3 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY

enoxaparin syringe 120 mg/0.8 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY




Quantity Limit Days

Authorization



enoxaparin syringe 100 mg/mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

enoxaparin syringe 150 mg/mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

enoxaparin solution 300 mg/3 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Enpresse tablet 50-30 (6)/75-40 (5)/125-30(10)



entacapone tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


entecavir tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

entecavir tablet 1 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Entresto tablet 24-26 mg

PrefBrand-3

62 31




PrefBrand-3

62 31






Quantity Limit Days

Authorization




PrefBrand-3

62 31



Enulose solution 10 gram/15 mL Generic-2 NO GASTROENTEROLOGY


Envarsus XRtablet extended release 24 hr 4 mg



Envarsus XRtablet extended release 24 hr 0.75 mg



Envarsus XRtablet extended release 24 hr 1 mg



Epiduo gel with pump 0.1-2.5 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Epiduo Forte gel with pump 0.3-2.5 %


THERAPY FOR ACNE

epinastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY





Quantity Limit Days

Authorization



epinephrine auto-injector 0.3 mg/0.3 mL NonPrefBrand-4 NO RESPIRATORY AND ALLERGY


epinephrine auto-injector 0.15 mg/0.15 mL NonPrefBrand-4 NO RESPIRATORY AND ALLERGY


EpiPen 2-Pak

auto-injector 0.3 mg/0.3 mL PrefBrand-3 NO RESPIRATORY AND ALLERGY


EpiPen Jr 2-Pak

auto-injector 0.15 mg/0.3 mL PrefBrand-3 NO RESPIRATORY AND ALLERGY


Epitol tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Epivir tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Epivir solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Epivir tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Epivir HBV tablet 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Epivir HBV solution 25 mg/5 mL (5 mg/mL)


ANTIVIRALS




Quantity Limit Days

Authorization



eplerenone tablet 25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


eplerenone tablet 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Epogen solution 3,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS

Epogen solution 20,000 unit/2 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS

eprosartan tablet 600 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



Epzicom tablet 600-300 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Equetro capsule, ER multiphase 12 hr


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Eraxis(Water Diluent)

recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Erbitux solution 100 mg/50 mL



ergoloid tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Ergomar tablet 2 mg



Erivedge capsule 150 mg






Quantity Limit Days

Authorization



Errin tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Erwinaze recon soln 10,000 unit



Ery Pads swab 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Erygel gel 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

EryPed 200 suspension for reconstitution



EryPed 400 suspension for reconstitution



Ery-Tab tablet,delayed release (DR/EC)







500 mg PrefBrand-3 NO ANTI - INFECTIVES


Erythrocin recon soln 500 mg

PrefBrand-3 NOANTI - INFECTIVES


Erythrocin (as stearate)






Quantity Limit Days

Authorization



erythromycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES


erythromycin ointment 5 mg/gram (0.5 %) Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

erythromycin capsule,delayed release(DR/EC)



erythromycin tablet 250 mg Generic-2 NO ANTI - INFECTIVES


erythromycin ethylsuccinate



erythromycin with ethanol

gel 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

erythromycin with ethanol

solution 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

erythromycin-benzoyl peroxide

gel 3-5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Esbriet capsule 267 mgSpecialty-5



escitalopram oxalate

tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization










solution 5 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


esomeprazole magnesium

capsule,delayed release(DR/EC)

20 mg Generic-2 31 31 NO GASTROENTEROLOGY

ULCER THERAPY

esomeprazole magnesium



ULCER THERAPY

esomeprazole sodium

recon soln 20 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

esomeprazole sodium

recon soln 40 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

estazolam tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


estazolam tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Estrace cream 0.01 % (0.1 mg/gram)



estradiol tablet 0.5 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY


estradiol tablet 1 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY


estradiol tablet 2 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY


estradiol patch weekly 0.05 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY






estradiol patch semiweekly

0.0375 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY

















estradiolpatch semiweekly 0.075 mg/24 hr



estradiol valerate

oil 20 mg/mL Generic-2 NO OBSTETRICS / GYNECOLOGY





Quantity Limit Days

Authorization



estradiol-norethindrone acet tablet 0.5-0.1 mg

Generic-2 NOOBSTETRICS / GYNECOLOGY


estradiol-norethindrone acet tablet 1-0.5 mg



Estring ring 2 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


estropipate tablet 0.75 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY


estropipate tablet 1.5 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY


estropipate tablet 3 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY


eszopiclone tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






ethacrynate sodium

recon soln 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



ethambutol tablet 100 mg Generic-2 NO ANTI - INFECTIVES


ethambutol tablet 400 mg Generic-2 NO ANTI - INFECTIVES


ethosuximide


ANTICONVULSANTS

ethosuximide

solution 250 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

etidronate disodium

tablet 200 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


etidronate disodium

tablet 400 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


etodolac capsule 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


etodolac capsule 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



etodolac tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


etodolac tablet 500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


etodolac tablet extended release 24 hr









Etopophos recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


etoposide solution 20 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Eurax cream 10 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL SCABICIDES / PEDICULICIDES




Quantity Limit Days

Authorization



Eurax lotion 10 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Evamist spray,non-aerosol

1.53 mg/spray (1.7%)



Evotaz tablet 300-150 mgPrefBrand-3 NO ANTI -


Evzio auto-injector 0.4 mg/0.4 mL



Exalgo ER tablet extended release 24 hr

12 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

Exalgo ERtablet extended release 24 hr 32 mg

NonPrefBrand-4

48 31


NARCOTIC ANALGESICS

Exelderm cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

Exelderm solution 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS




Quantity Limit Days

Authorization



Exelon patch 24 hour 9.5 mg/24 hr PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Exelon patch 24 hour 4.6 mg/24 hr PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Exelon patch 24 hour 13.3 mg/24 hour



exemestane tablet 25 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Exjade tablet, dispersible

125 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS








Extavia kit 0.3 mg Specialty-5 15 31 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Fabrazyme recon soln 35 mg Specialty-5 NO ENDOCRINE/DIABETES


famciclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization




ANTIVIRALS


ANTIVIRALS

famotidine tablet 40 mg PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

famotidine tablet 20 mg PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

famotidine suspension 40 mg/5 mL (8 mg/mL)

PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

famotidine (PF)

solution 20 mg/2 mL PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

famotidine (PF)-NaCl (iso-os)

piggyback 20 mg/50 mL Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

Fanapt tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization









Fanapt tablets,dose pack

1mg(2)-2mg(2)- 4mg(2)-6mg(2)



Fareston tablet 60 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Farxiga tablet 10 mgPrefBrand-3 NO ENDOCRINE/DIA


Farxiga tablet 5 mgPrefBrand-3 NO ENDOCRINE/DIA











Quantity Limit Days

Authorization






Faslodex syringe 250 mg/5 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


FazaClo tablet,disintegrating







12.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


FazaClotablet,disintegrating 200 mg



FazaClotablet,disintegrating 150 mg



felbamate tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization



felbamate tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

felbamate suspension 600 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Felbatol tablet 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Felbatol tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Felbatol suspension 600 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

felodipine tablet extended release 24 hr

10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



Femara tablet 2.5 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Femring ring 0.05 mg/24 hr NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


Femring ring 0.1 mg/24 hr NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


fenofibrate tablet 160 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibrate tablet 54 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibrate tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibrate tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibrate micronized

capsule 67 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








Quantity Limit Days

Authorization












fenofibrate nanocrystallized

tablet 145 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibrate nanocrystallized

tablet 48 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibric acid

tablet 105 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenofibric acid



fenofibric acid (choline)


135 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



fenofibric acid (choline)




Fenoglide tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Fenoglide tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fenoprofen tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fenoprofen capsule 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fentanyl patch 72 hour 75 mcg/hr PrefBrand-3 12 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

fentanyl patch 72 hour 25 mcg/hr Generic-2 20 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

fentanyl patch 72 hour 50 mcg/hr Generic-2 17 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization




NARCOTIC ANALGESICS


NARCOTIC ANALGESICS

fentanyl patch 72 hour 37.5 mcg/hour

NonPrefBrand-4

20 30


NARCOTIC ANALGESICS


NonPrefBrand-4

15 30


NARCOTIC ANALGESICS


NonPrefBrand-4

11 30


NARCOTIC ANALGESICS

fentanyl citrate

lozenge on a handle


NARCOTIC ANALGESICS

fentanyl citrate

lozenge on a handle


NARCOTIC ANALGESICS

fentanyl citrate

lozenge on a handle

200 mcg Generic-2 124 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



fentanyl citrate

lozenge on a handle


NARCOTIC ANALGESICS

fentanyl citrate

lozenge on a handle


NARCOTIC ANALGESICS

fentanyl citrate

lozenge on a handle


NARCOTIC ANALGESICS

Fentora tablet, effervescent


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Ferriprox tablet 500 mg

Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Ferriprox solution 100 mg/mL



Fetzimacapsule,extended release 24 hr 120 mg












Fetzimacapsule,Ext Rel 24hr dose pack

20 mg (2)- 40 mg (26)



Finacea gel 15 %


THERAPY FOR ACNE

Finacea foam 15 %


THERAPY FOR ACNE




Quantity Limit Days

Authorization



finasteride tablet 5 mg Generic-2 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Firazyr syringe 30 mg/3 mLSpecialty-5



Firmagon kit w diluent syringe

recon soln 80 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Firmagon kit w diluent syringe

recon soln 120 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


flavoxate tablet 100 mg

Generic-2 NO

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

Flebogamma DIF solution 10 %



flecainide tablet 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS







Quantity Limit Days

Authorization





Flector patch 12 hour 1.3 % NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fluconazole tablet 100 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS


ANTIFUNGAL AGENTS


ANTIFUNGAL AGENTS


ANTIFUNGAL AGENTS

fluconazole suspension for reconstitution

10 mg/mL Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

fluconazole suspension for reconstitution

40 mg/mL Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

fluconazole in NaCl (iso-osm) piggyback 400 mg/200 mL


ANTIFUNGAL AGENTS

fluconazole in NaCl (iso-osm) piggyback 200 mg/100 mL


ANTIFUNGAL AGENTS

flucytosine capsule 250 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

flucytosine capsule 500 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS




Quantity Limit Days

Authorization



fludarabine recon soln 50 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


fludrocortisone


ADRENAL HORMONES

flunisolidespray,non-aerosol 25 mcg (0.025 %)

Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

fluocinolone ointment 0.025 %






fluocinolone oil 0.01 %



fluocinolone solution 0.01 %






fluocinolone acetonide oil drops 0.01 %



fluocinonide ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


fluocinonide gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



fluocinonide solution 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


fluocinonide cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Fluocinonide-E



fluorometholone

drops,suspension

0.1 % Generic-2 NO OPHTHALMOLOGY

STEROIDS

fluorouracil cream 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


fluorouracil solution 2.5 gram/50 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


fluorouracil cream 0.5 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


fluorouracil solution 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


fluorouracil solution 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



fluoxetine tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fluoxetine capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




fluoxetine solution 20 mg/5 mL (4 mg/mL)

PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




fluoxetine tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fluoxetine capsule,delayed release(DR/EC)



fluoxetine tablet 60 mg






Quantity Limit Days

Authorization



fluphenazine decanoate



fluphenazine HCl

elixir 2.5 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fluphenazine HCl



fluphenazine HCl



fluphenazine HCl

concentrate 5 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fluphenazine HCl



fluphenazine HCl

tablet 2.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


fluphenazine HCl

solution 2.5 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



flurandrenolide

cream 0.05 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY


flurazepam capsule 15 mg



flurazepam capsule 30 mg



flurbiprofen tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


flurbiprofen tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


flurbiprofen sodium drops 0.03 %

Generic-2 NO

OPHTHALMOLOGY


flutamide capsule 125 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


fluticasone ointment 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



fluticasone cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


fluticasone lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


fluticasone spray,suspension

50 mcg/actuation Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

fluvastatin capsule 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fluvastatin capsule 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


fluvastatin tablet extended release 24 hr



fluvoxamine capsule,extended release 24hr



fluvoxamine capsule,extended release 24hr



fluvoxamine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization







Focalin XR capsule,ER biphasic 50-50



Focalin XRcapsule,ER biphasic 50-50 25 mg



Focalin XRcapsule,ER biphasic 50-50 35 mg



Folotyn solution 40 mg/2 mL (20 mg/mL)



fomepizole solution 1 gram/mL PrefGen-1 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


fondaparinux

syringe 10 mg/0.8 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY




Quantity Limit Days

Authorization



fondaparinux

syringe 2.5 mg/0.5 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

fondaparinux

syringe 5 mg/0.4 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

fondaparinux

syringe 7.5 mg/0.6 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Foradil Aerolizer

capsule, w/inhalation device 12 mcg

PrefBrand-3

60 30

NORESPIRATORY AND ALLERGY

PULMONARY AGENTS

Fortaz recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES

CEPHALOSPORINS

Fortaz recon soln 1 gramNonPrefBrand-4 NO ANTI -


Fortaz recon soln 2 gramNonPrefBrand-4 NO ANTI -


Forteo pen injector20 mcg/dose - 600 mcg/2.4 mL

Specialty-5

2.4 28



Fortestagel in metered-dose pump

10 mg/0.5 gram /actuation



FORTICAL spray,non-aerosol

200 unit/actuation Generic-2 NO ENDOCRINE/DIABETES


fosinopril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization







fosinopril-hydrochlorothiazide



fosinopril-hydrochlorothiazide



fosphenytoin solution 100 mg PE/2 mL


ANTICONVULSANTS

Fosrenol tablet,chewable 500 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Fosrenol tablet,chewable 1,000 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Fosrenol tablet,chewable 750 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Fosrenolpowder in packet 1,000 mg






Quantity Limit Days

Authorization



Fosrenolpowder in packet 750 mg



Fragmin syringe 2,500 anti-Xa unit/0.2 mL


COAGULATION THERAPY



COAGULATION THERAPY


Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY



COAGULATION THERAPY



COAGULATION THERAPY



COAGULATION THERAPY

Fragmin syringe 10,000 anti-Xa unit/mL


COAGULATION THERAPY




Quantity Limit Days

Authorization



Fragmin solution 25,000 anti-Xa unit/mL


COAGULATION THERAPY

Freamine HBC 6.9 %

parenteral solution



Frova tablet 2.5 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


frovatriptan tablet 2.5 mg PrefBrand-3 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


furosemide solution 10 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


furosemide solution 40 mg/5 mL (8 mg/mL)



furosemide tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS







Quantity Limit Days

Authorization





furosemide syringe 10 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


furosemide solution 10 mg/mL



Fusilev recon soln 50 mg


ADJUNCTIVE AGENTS

Fuzeon recon soln 90 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Fyavolv tablet 0.5-2.5 mg-mcgGeneric-2 NO OBSTETRICS /


Fyavolv tablet 1-5 mg-mcgGeneric-2 NO OBSTETRICS /


Fycompa tablet 2 mg


ANTICONVULSANTS

Fycompa tablet 4 mg


ANTICONVULSANTS




Quantity Limit Days

Authorization



Fycompa tablet 6 mg


ANTICONVULSANTS

Fycompa tablet 8 mg


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Fycompa suspension 0.5 mg/mL


ANTICONVULSANTS

gabapentin solution 250 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

gabapentin capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS

gabapentin tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

gabapentin tablet 800 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Gablofen syringe50 mcg/mL (1 mL)






Quantity Limit Days

Authorization



Gablofen solution10,000 mcg/20mL (500 mcg/mL)



Gablofen solution40,000 mcg/20mL (2,000 mcg/mL)



galantamine tablet 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






galantamine capsule,ext rel. pellets 24 hr












Quantity Limit Days

Authorization



galantamine solution 4 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


GamaSTAN S/D

solution 15-18 % range NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Gammagard Liquid

solution 10 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Gammaked solution1 gram/10 mL (10 %)



Gammaplex solution 5 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Gamunex-C solution 1 gram/10 mL (10 %)



ganciclovir sodium

recon soln 500 mg Generic-2 YES ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Gardasil (PF)

suspension 20-40-40-20 mcg/0.5 mL

PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Gardasil (PF)

syringe 20-40-40-20 mcg/0.5 mL



Gardasil 9 (PF) suspension 0.5 mL



Gardasil 9 (PF) syringe 0.5 mL



gatifloxacin drops 0.5 % Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

Gattex One-Vial kit 5 mg

Specialty-5 YES

GASTROENTEROLOGY


Gauze Pad bandage 2 X 2 " PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Gavilyte-C recon soln 240-22.72-6.72 -5.84 gram

Generic-2 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



GaviLyte-G recon soln 236-22.74-6.74 -5.86 gram



GaviLyte-H and Bisacodyl kit 5-210 mg-gram

Generic-2 NO

GASTROENTEROLOGY


GaviLyte-N recon soln 420 gram Generic-2 NO GASTROENTEROLOGY


Gelnique gel in packet 10 % (100 mg/gram)

PrefBrand-3 30 30 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

gemcitabine recon soln 1 gram



gemfibrozil tablet 600 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Generlac solution 10 gram/15 mL Generic-2 NO GASTROENTEROLOGY


Gengraf capsule 100 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Gengraf solution 100 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Gengraf capsule 25 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Genotropin cartridge 5 mg/mL (15 unit/mL)


BIOTECHNOLOGY DRUGS

Genotropin cartridge12 mg/mL (36 unit/mL)


BIOTECHNOLOGY DRUGS

Genotropin MiniQuick

syringe 0.2 mg/0.25 mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS


syringe 0.4 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization





BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS


syringe 1 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS


syringe 2 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Gentak ointment 0.3 % (3 mg/gram) Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

gentamicin cream 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


gentamicin ointment 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



gentamicin ointment 0.3 % (3 mg/gram) Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

gentamicin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY

ANTIBIOTICS

gentamicin solution 40 mg/mL PrefGen-1 NO ANTI - INFECTIVES


gentamicin in NaCl (iso-osm)












Genvoya tablet150-150-200-10 mg


Geodon recon soln 20 mg/mL (final conc.)






Quantity Limit Days

Authorization



Gildagia tablet 0.4-35 mg-mcg

Generic-2 NO



Gildess 24 Fe tablet

1 mg-20 mcg (24)/75 mg (4)

Generic-2 NO



Gilenya capsule 0.5 mg

Specialty-5

31 31












Glassia solution1 gram/50 mL (2 %)



Glatopa syringe 20 mg/mL

Specialty-5

31 31






Quantity Limit Days

Authorization



Gleevec tablet 100 mg Specialty-5 93 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Gleevec tablet 400 mg Specialty-5 62 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS














glimepiride tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY


DIABETES THERAPY


DIABETES THERAPY

glipizide tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization



glipizide tablet extended release 24hr

2.5 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

glipizide tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY


5 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY



DIABETES THERAPY

glipizide-metformin

tablet 2.5-250 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

glipizide-metformin

tablet 2.5-500 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

glipizide-metformin

tablet 5-500 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

GlucaGen HypoKit

recon soln 1 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Glucagon Emergency Kit (human)

kit 1 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Glumetza tablet,ER gast.retention 24 hr

500 mg NonPrefBrand-4 124 31 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide tablet 1.25 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide tablet 5 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide micronized

tablet 3 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY


tablet 6 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization




tablet 1.5 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide-metformin

tablet 1.25-250 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide-metformin

tablet 2.5-500 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glyburide-metformin

tablet 5-500 mg Generic-2 YES ENDOCRINE/DIABETES

DIABETES THERAPY

glycopyrrolate

tablet 1 mg Generic-2 NO GASTROENTEROLOGY


glycopyrrolate



glycopyrrolate

solution 0.2 mg/mL Generic-2 NO GASTROENTEROLOGY


Glyset tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY


DIABETES THERAPY


DIABETES THERAPY

Golytely powder in packet

227.1-21.5-6.36 gram

NonPrefBrand-4 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



Gralisetablet extended release 24 hr 300 mg

PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Gralisetablet extended release 24 hr 600 mg


ANTICONVULSANTS

Gralise 30-Day Starter Pack


300 mg (9)- 600 mg (69)


ANTICONVULSANTS

granisetron (PF)

solution 100 mcg/mL Generic-2 NO GASTROENTEROLOGY


granisetron HCl

solution 1 mg/mL Generic-2 NO GASTROENTEROLOGY


granisetron HCl

tablet 1 mg Generic-2 YES GASTROENTEROLOGY


granisetron HCl solution 1 mg/mL (1 mL)

Generic-2 NO

GASTROENTEROLOGY


Granix syringe 300 mcg/0.5 mL

Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



Granix syringe 480 mcg/0.8 mL


BIOTECHNOLOGY DRUGS

Grastek tablet 2,800 BAU



griseofulvin microsize

suspension 125 mg/5 mL Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

griseofulvin microsize


ANTIFUNGAL AGENTS

griseofulvin ultramicrosize


ANTIFUNGAL AGENTS

griseofulvin ultramicrosize


ANTIFUNGAL AGENTS

guanfacine tablet extended release 24 hr

1 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization






guanidine tablet 125 mg



Gynazole-1 cream 2 % NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


Halaven solution1 mg/2 mL (0.5 mg/mL)



Halcion tablet 0.25 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


halobetasol propionate



halobetasol propionate



Halog cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Halog ointment 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



haloperidol tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


haloperidol tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








haloperidol tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


haloperidol decanoate



haloperidol decanoate solution 50 mg/mL






Quantity Limit Days

Authorization



haloperidol lactate

concentrate 2 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


haloperidol lactate



Harvoni tablet 90-400 mgSpecialty-5

28 28YES ANTI -

INFECTIVES ANTIVIRALSHavrix (PF) syringe 720 Elisa unit/0.5

mLPrefBrand-3 NO IMMUNOLOGY,

VACCINES / BIOTECHNOLOGY


Havrix (PF) suspension1,440 Elisa unit/mL



Hectorol capsule 2.5 mcg Specialty-5 YES ENDOCRINE/DIABETES


Hectorol solution 4 mcg/2 mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Hectorol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES


Hectorol capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABETES


heparin (porcine) solution 20,000 unit/mL


COAGULATION THERAPY




Quantity Limit Days

Authorization





COAGULATION THERAPY



COAGULATION THERAPY



COAGULATION THERAPY

heparin (porcine) in 5 % dex

parenteral solution

20,000 unit/500 mL (40 unit/mL)


COAGULATION THERAPY


parenteral solution

25,000 unit/250 mL(100 unit/mL)


COAGULATION THERAPY


parenteral solution

25,000 unit/500 mL (50 unit/mL)


COAGULATION THERAPY

Hepatamine 8%

parenteral solution



Hepsera tablet 10 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Herceptin recon soln 440 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Hetlioz capsule 20 mg

Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Hexalen capsule 50 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Hiberix (PF) recon soln 10 mcg/0.5 mL



Horizanttablet extended release 600 mg



Horizanttablet extended release 300 mg



Humalog solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Humalog cartridge 100 unit/mLPrefBrand-3 NO ENDOCRINE/DIA


Humalog KwikPen insulin pen

200 unit/mL (3 mL)

PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Humalog KwikPen insulin pen 100 unit/mL


DIABETES THERAPY

Humalog Mix 50-50

suspension 100 unit/mL (50-50)


DIABETES THERAPY




Quantity Limit Days

Authorization



Humalog Mix 50-50 KwikPen

insulin pen 100 unit/mL (50-50)


DIABETES THERAPY

Humalog Mix 75-25



DIABETES THERAPY

Humalog Mix 75-25 KwikPen



DIABETES THERAPY

Humatrope recon soln 5 (15 unit) mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Humatrope cartridge 12 mg (36 unit) Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Humatrope cartridge 24 mg (72 unit) Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Humatrope cartridge 6 mg (18 unit) NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Humira syringe kit 40 mg/0.8 mL Specialty-5 2 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Humira syringe kit 20 mg/0.4 mL Specialty-5 2 28 YES MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



Humira syringe kit 10 mg/0.2 mL

Specialty-5

2 28



Humira Pediatric Crohn's Start syringe kit

40 mg/0.8 mL (6 pack)

Specialty-5

6 28



Humira Pediatric Crohn's Start syringe kit 40 mg/0.8 mL

Specialty-5

3 28



Humira Pen pen injector kit 40 mg/0.8 mL

Specialty-5

2 28



Humira Pen Crohn's-UC-HS Start

pen injector kit 40 mg/0.8 mL Specialty-5 6 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Humulin 70/30



DIABETES THERAPY

Humulin 70/30 KwikPen



DIABETES THERAPY

Humulin N suspension 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Humulin N KwikPen

insulin pen 100 unit/mL (3 mL)


DIABETES THERAPY

Humulin R solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization



Humulin R U-500 (Conc) Kwikpen insulin pen

500 unit/mL (3 mL)

PrefBrand-3 NO

ENDOCRINE/DIABETES

DIABETES THERAPY

Humulin R U-500 (Concentrated)

solution 500 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Hycet solution 7.5-325 mg/15 mL NonPrefBrand-4 5723 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

hydralazine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








hydralazine solution 20 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



hydrochlorothiazide



hydrochlorothiazide

capsule 12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


hydrochlorothiazide



hydrochlorothiazide



hydrocodone-acetaminophen

solution 7.5-325 mg/15 mL Generic-2 5723 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS


tablet 7.5-300 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization





NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

hydrocodone-ibuprofen


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

hydrocortisone






Quantity Limit Days

Authorization



hydrocortisone

cream 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


hydrocortisone


ADRENAL HORMONES

hydrocortisone


ADRENAL HORMONES

hydrocortisone



hydrocortisone


ADRENAL HORMONES

hydrocortisone

ointment 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY


hydrocortisone

enema 100 mg/60 mL PrefGen-1 NO GASTROENTEROLOGY


hydrocortisone



hydrocortisone butyrate ointment 0.1 %



hydrocortisone butyrate solution 0.1 %



hydrocortisone butyr-emollient cream 0.1 %






Quantity Limit Days

Authorization



hydrocortisone valerate ointment 0.2 %



hydrocortisone valerate cream 0.2 %



hydrocortisone-acetic acid

drops 1-2 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS


hydromorphone

liquid 1 mg/mL Generic-2 1550 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

hydromorphone

tablet 2 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

hydromorphone


NARCOTIC ANALGESICS

hydromorphone


NARCOTIC ANALGESICS

hydromorphone

syringe 2 mg/mL Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

hydromorphone



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



hydromorphone



NARCOTIC ANALGESICS

hydromorphone



NARCOTIC ANALGESICS

hydromorphone


Generic-2

48 31


NARCOTIC ANALGESICS

hydromorphone (PF) solution 10 mg/mL

Generic-2

124 31


NARCOTIC ANALGESICS

hydromorphone (PF) solution 10 (mg/mL) (5 ml)

Generic-2

124 31


NARCOTIC ANALGESICS

hydroxychloroquine



hydroxyprogesterone caproate oil 250 mg/mL

Specialty-5 NOOBSTETRICS / GYNECOLOGY


hydroxyurea capsule 500 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



hydroxyzine HCl



hydroxyzine HCl

solution 10 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY


hydroxyzine HCl



hydroxyzine HCl

solution 25 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY


hydroxyzine HCl



hydroxyzine HCl



HyperRAB S/D (PF) solution 150 unit/mL






Quantity Limit Days

Authorization



HyperRAB S/D (PF) solution

150 unit/mL (10 ml)



Hysingla ER

tablet,oral only,ext.rel.24 hr 20 mg

NonPrefBrand-4

31 31


NARCOTIC ANALGESICS

Hysingla ER


NonPrefBrand-4

31 31


NARCOTIC ANALGESICS

Hysingla ER


NonPrefBrand-4

31 31


NARCOTIC ANALGESICS

Hysingla ER


NonPrefBrand-4

31 31


NARCOTIC ANALGESICS

Hysingla ER


NonPrefBrand-4

31 31


NARCOTIC ANALGESICS

Hysingla ER


NonPrefBrand-4

31 31


NARCOTIC ANALGESICS

Hysingla ER


NonPrefBrand-4

31 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



ibandronate tablet 150 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY


ibandronate solution 3 mg/3 mL Generic-2 YES MUSCULOSKELETAL / RHEUMATOLOGY



Specialty-5

21 28




Specialty-5

21 28




Specialty-5

21 28



ibuprofen suspension 100 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ibuprofen tablet 400 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH







Quantity Limit Days

Authorization





ibuprofen-oxycodone tablet 400-5 mg

Generic-2

30 30


NARCOTIC ANALGESICS







idarubicin solution 1 mg/mL



ifosfamide recon soln 1 gram Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Ilaris (PF) recon soln 180 mg/1.2 mL (150 mg/mL)


BIOTECHNOLOGY DRUGS

Ilevrodrops,suspension 0.3 %

PrefBrand-3 NO

OPHTHALMOLOGY





Quantity Limit Days

Authorization



imatinib tablet 100 mg Specialty-5 93 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


imatinib tablet 400 mg Specialty-5 62 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Imbruvica capsule 140 mg

Specialty-5

124 31



imipenem-cilastatin recon soln 250 mg

Generic-2 NO

ANTI - INFECTIVES


imipenem-cilastatin recon soln 500 mg

Generic-2 NO

ANTI - INFECTIVES


imipramine HCl



imipramine HCl



imipramine HCl






Quantity Limit Days

Authorization



imipramine pamoate



imipramine pamoate



imipramine pamoate



imipramine pamoate



imiquimod cream in packet 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


Imitrex tablet 25 mg NonPrefBrand-4 36 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Imitrex solution 6 mg/0.5 mL NonPrefBrand-4 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH







Quantity Limit Days

Authorization





Imitrex spray,non-aerosol

20 mg/actuation NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Imitrex spray,non-aerosol

5 mg/actuation NonPrefBrand-4 32 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Imitrex STATdose Kit Refill

cartridge 4 mg/0.5 mL NonPrefBrand-4 6 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Imitrex STATdose Kit Refill

cartridge 6 mg/0.5 mL NonPrefBrand-4 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Imovax Rabies Vaccine (PF)

recon soln 2.5 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Imuran tablet 50 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Increlex solution 10 mg/mL Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS





Quantity Limit Days

Authorization



indapamide tablet 1.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


indapamide tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Indocin suspension 25 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


indomethacin

capsule 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


indomethacin



indomethacin




Infanrix (DTaP) (PF) suspension

25-58-10 Lf-mcg-Lf/0.5mL



Inlyta tablet 1 mg






Quantity Limit Days

Authorization



Inlyta tablet 5 mg



InnoPran XL capsule,extended release 24hr



InnoPran XL capsule,extended release 24hr



insulin syringe-needle U-100

syringe 1/2 mL 28 gauge PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY


syringe 1 mL 29 gauge x 1/2"


DIABETES THERAPY


syringe 0.3 mL 29 PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Intelence tablet 100 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Intelence tablet 200 mgSpecialty-5 NO ANTI -


Intelence tablet 25 mgNonPrefBrand-4 NO ANTI -

INFECTIVES ANTIVIRALSIntralipid emulsion 20 % Generic-2 YES VITAMINS,

HEMATINICS / ELECTROLYTES





Quantity Limit Days

Authorization



Intralipid emulsion 30 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES


Intron A solution 6 million unit/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Intron A recon soln 50 million unit (1 mL)


BIOTECHNOLOGY DRUGS

Intron A recon soln18 million unit (1 mL)


BIOTECHNOLOGY DRUGS

Intron A recon soln10 million unit (1 mL)


BIOTECHNOLOGY DRUGS

Introvaletablets,dose pack,3 month 0.15-30 mg-mcg

Generic-2 NO



Intuniv ER tablet extended release 24 hr

1 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








Quantity Limit Days

Authorization









Invanz recon soln 1 gram

NonPrefBrand-4 NO

ANTI - INFECTIVES


Invega tablet extended release 24hr




6 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








Invega Sustenna

syringe 78 mg/0.5 mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Invega Sustenna



Invega Sustenna

syringe 156 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Invega Sustenna



Invega Sustenna

syringe 39 mg/0.25 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Invega Trinza syringe 273 mg/0.875 mL















Quantity Limit Days

Authorization



Invirase capsule 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Invirase tablet 500 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Invokamet tablet 150-1,000 mgPrefBrand-3 NO ENDOCRINE/DIA


Invokamet tablet 150-500 mgPrefBrand-3 NO ENDOCRINE/DIA


Invokamet tablet 50-1,000 mgPrefBrand-3 NO ENDOCRINE/DIA


Invokamet tablet 50-500 mgPrefBrand-3 NO ENDOCRINE/DIA


Invokana tablet 100 mgPrefBrand-3 NO ENDOCRINE/DIA


Invokana tablet 300 mgPrefBrand-3 NO ENDOCRINE/DIA


Ionosol-B in D5W

parenteral solution



Ionosol-MB in D5W

parenteral solution



Iopidine dropperette 1 % PrefBrand-3 NO OPHTHALMOLOGY

SYMPATHOMIMETICS

IPOL suspension 40-8-32 unit/0.5 mL



ipratropium bromide

spray,non-aerosol

0.06 % PrefGen-1 NO EAR, NOSE / THROAT MEDICATIONS





Quantity Limit Days

Authorization



ipratropium bromide

spray,non-aerosol

0.03 % PrefGen-1 NO EAR, NOSE / THROAT MEDICATIONS


ipratropium bromide

solution 0.02 % PrefGen-1 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

ipratropium-albuterol


0.5 mg-3 mg(2.5 mg base)/3 mL


PULMONARY AGENTS

irbesartan tablet 75 mg PrefGen-1 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






irbesartan-hydrochlorothiazide

tablet 150-12.5 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


irbesartan-hydrochlorothiazide



Iressa tablet 250 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



irinotecan solution 100 mg/5 mL



Isentress tablet 400 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Isentress tablet,chewable 100 mgSpecialty-5 NO ANTI -


Isentress tablet,chewable 25 mgPrefBrand-3 NO ANTI -


Isentresspowder in packet 100 mg


Isolyte-P in 5 % dextrose

parenteral solution



Isolyte-S parenteral solution

PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES


isoniazid solution 50 mg/5 mL Generic-2 NO ANTI - INFECTIVES


isoniazid tablet 300 mg PrefGen-1 NO ANTI - INFECTIVES


isoniazid solution 100 mg/mL PrefGen-1 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



isoniazid tablet 100 mg PrefGen-1 NO ANTI - INFECTIVES


Isordil tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

NITRATES

isosorbide dinitrate


NITRATES



NITRATES




NITRATES



NITRATES



NITRATES

isosorbide mononitrate


NITRATES




Quantity Limit Days

Authorization






NITRATES



NITRATES




NITRATES




NITRATES

isradipine capsule 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


isradipine capsule 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Istalol drops, once daily


BETA-BLOCKERS

Istodax recon soln 10 mg/2 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


itraconazole capsule 100 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS




Quantity Limit Days

Authorization



ivermectin tablet 3 mg Generic-2 NO ANTI - INFECTIVES


Ixiaro (PF) syringe 6 mcg/0.5 mL



Jakafi tablet 10 mg

Specialty-5

62 31



Jakafi tablet 5 mg

Specialty-5

62 31



Jakafi tablet 15 mg

Specialty-5

62 31



Jakafi tablet 20 mg

Specialty-5

62 31



Jakafi tablet 25 mg

Specialty-5

62 31



Jantoven tablet 1 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY




Quantity Limit Days

Authorization




COAGULATION THERAPY


COAGULATION THERAPY

Jantoven tablet 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY

Jantoven tablet 7.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY




Quantity Limit Days

Authorization



Janumet tablet 50-1,000 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Janumet tablet 50-500 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Janumet XR

tablet, ER multiphase 24 hr 100-1,000 mg

PrefBrand-3 NOENDOCRINE/DIABETES

DIABETES THERAPY

Janumet XR



DIABETES THERAPY

Janumet XR

tablet, ER multiphase 24 hr 50-500 mg


DIABETES THERAPY

Januvia tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY


DIABETES THERAPY


DIABETES THERAPY

Jentadueto tablet 2.5-1,000 mgPrefBrand-3 NO ENDOCRINE/DIA


Jentadueto tablet 2.5-500 mgPrefBrand-3 NO ENDOCRINE/DIA


Jentadueto tablet 2.5-850 mgPrefBrand-3 NO ENDOCRINE/DIA


Jentadueto XR

tablet, IR - ER, biphasic 24hr 2.5-1,000 mg


DIABETES THERAPY

Jentadueto XR

tablet, IR - ER, biphasic 24hr 5-1,000 mg


DIABETES THERAPY

Jevtana solution10 mg/mL (first dilution)






Quantity Limit Days

Authorization



Jinteli tablet 1-5 mg-mcgGeneric-2 NO OBSTETRICS /


Jolivette tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Juleber tablet 0.15-0.03 mg

Generic-2 NO



Junel 1.5/30 (21) tablet 1.5-30 mg-mcg

Generic-2 NO



Junel 1/20 (21) tablet 1-20 mg-mcg

Generic-2 NO



Junel FE 1.5/30 (28) tablet

1.5 mg-30 mcg (21)/75 mg (7)

Generic-2 NO



Junel FE 1/20 (28) tablet

1 mg-20 mcg (21)/75 mg (7)

Generic-2 NO



Junel Fe 24 tablet1 mg-20 mcg (24)/75 mg (4)

Generic-2 NO




Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization


















Kadcyla recon soln 100 mg



Kadian capsule,extend.release pellets


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization





NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

Kadiancapsule,extend.release pellets 40 mg

NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

Kaitlib Fe tablet,chewable0.8mg-25mcg(24) and 75 mg (4)

Generic-2 NO






Quantity Limit Days

Authorization



Kaletra tablet 200-50 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Kaletra tablet 100-25 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Kaletra solution 400-100 mg/5 mL Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Kalydeco tablet 150 mgSpecialty-5



Kalydecogranules in packet 50 mg

Specialty-556 28

YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Kalydecogranules in packet 75 mg

Specialty-556 28


PULMONARY AGENTS

Kanuma solution 2 mg/mLSpecialty-5 YES ENDOCRINE/DIA


Kapvaytablet extended release 12 hr 0.1 mg



Karbinal ERsuspension,extended rel 12 hr 4 mg/5 mL

NonPrefBrand-4 NO



Kariva (28) tablet 0.15-0.02 mgx21 /0.01 mg x 5



Kelnor 1/35 (28)

tablet 1-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


Kenalog aerosol 0.147 mg/gram






Quantity Limit Days

Authorization



Kepivance recon soln 6.25 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

Keppra tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS

Keppra solution 100 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Keppra tablet 1,000 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Keppra XR tablet extended release 24 hr


ANTICONVULSANTS

Keppra XR tablet extended release 24 hr


ANTICONVULSANTS




Quantity Limit Days

Authorization



Ketek tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES


Ketek tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES


ketoconazole shampoo 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ketoconazole tablet 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ketoconazole cream 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ketoconazole foam 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

ketoprofen capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ketoprofen capsule 75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ketoprofen capsule,ext rel. pellets 24 hr






Quantity Limit Days

Authorization



ketorolac tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ketorolac solution 15 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ketorolac drops 0.4 % Generic-2 NO OPHTHALMOLOGY


ketorolac drops 0.5 % Generic-2 NO OPHTHALMOLOGY


ketorolac solution 30 mg/mL (1 mL)



ketorolac cartridge 30 mg/mL



Keveyis tablet 50 mg

NonPrefBrand-4

124 31






Quantity Limit Days

Authorization



Keytruda recon soln 50 mg



Keytruda solution100 mg/4 mL (25 mg/mL)



Khedezlatablet extended release 24hr 100 mg



Khedezlatablet extended release 24hr 50 mg



Kimidess (28) tablet

0.15-0.02 mgx21 /0.01 mg x 5

Generic-2 NO



Kineret syringe 100 mg/0.67 mL Specialty-5 18.76 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Kionex powder Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Klor-Con 10 tablet extended release

10 mEq Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

Klor-Con 8 tablet extended release


ELECTROLYTES




Quantity Limit Days

Authorization



Klor-Con M15

tablet,ER particles/crystals


ELECTROLYTES

Klor-Con M20



ELECTROLYTES

Klor-Con Sprinkle

capsule, extended release 8 mEq

Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

Klor-Con Sprinkle

capsule, extended release 10 mEq


Kombiglyze XR

tablet, ER multiphase 24 hr 2.5-1,000 mg

NonPrefBrand-4 NOENDOCRINE/DIABETES

DIABETES THERAPY

Kombiglyze XR



DIABETES THERAPY

Kombiglyze XR

tablet, ER multiphase 24 hr 5-500 mg


DIABETES THERAPY

Korlym tablet 300 mgSpecialty-5 YES ENDOCRINE/DIA


K-Tab tablet extended release

10 mEq NonPrefBrand-4 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

K-Tabtablet extended release 20 mEq

NonPrefBrand-4 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

K-Tabtablet extended release 8 mEq

PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES




Quantity Limit Days

Authorization



Kuvan tablet,soluble 100 mgSpecialty-5 NO ENDOCRINE/DIA


Kynamro syringe 200 mg/mL



L norgest/e.estradiol-e.estrad

tablets,dose pack,3 month

0.15 mg-30 mcg (84)/10 mcg (7)



labetalol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






labetalol solution 5 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Lacrisert insert 5 mg NonPrefBrand-4 NO OPHTHALMOLOGY


lactated ringers

solution Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS




Quantity Limit Days

Authorization



lactated ringers

parenteral solution

Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

lactulose solution 10 gram/15 mL PrefGen-1 NO GASTROENTEROLOGY


Lamictal tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS

Lamictal tablet, chewable dispersible


ANTICONVULSANTS

Lamictal tablet, chewable dispersible


ANTICONVULSANTS




Quantity Limit Days

Authorization



Lamictal ODT


100 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Lamictal ODT



ANTICONVULSANTS

Lamictal ODT



ANTICONVULSANTS

Lamictal ODT



ANTICONVULSANTS

Lamictal Starter (Blue) Kit

tablets,dose pack

25 mg (35) NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Lamictal Starter (Green) Kit

tablets,dose pack

25 mg (84) -100 mg (14)


ANTICONVULSANTS

Lamictal Starter (Orange) Kit

tablets,dose pack

25 mg (42) -100 mg (7)


ANTICONVULSANTS

Lamictal XR tablet extended release 24hr


ANTICONVULSANTS




Quantity Limit Days

Authorization





ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Lamictal XRtablet extended release 24hr 250 mg


ANTICONVULSANTS

Lamictal XR Starter (Blue)

tablet extended rel,dose pack

25 mg (21) -50 mg (7)


ANTICONVULSANTS

Lamictal XR Starter (Green)


50 mg(14)-100mg (14)-200 mg (7)


ANTICONVULSANTS

Lamictal XR Starter (Orange)


25mg (14)-50 mg (14)-100mg (7)


ANTICONVULSANTS

Lamisil tablet 250 mg NonPrefBrand-4 90 180 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Lamisil granules in packet

125 mg NonPrefBrand-4 182 180 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS




Quantity Limit Days

Authorization



Lamisil granules in packet

187.5 mg NonPrefBrand-4 126 180 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

lamivudine tablet 150 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

lamivudine solution 10 mg/mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS


ANTIVIRALS


ANTIVIRALS

lamivudine-zidovudine


ANTIVIRALS

lamotrigine tablet,disintegrating


ANTICONVULSANTS

lamotrigine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS



ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

lamotrigine tablet, chewable dispersible


ANTICONVULSANTS

lamotrigine tablet, chewable dispersible


ANTICONVULSANTS

lamotrigine tablet extended release 24hr


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS




Quantity Limit Days

Authorization





ANTICONVULSANTS

lamotriginetablet extended release 24hr 300 mg


ANTICONVULSANTS

lamotriginetablet extended release 24hr 250 mg


ANTICONVULSANTS

Lanoxin tablet 62.5 mcg NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

Lanoxin solution 250 mcg/mL NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

Lanoxin tablet 125 mcg NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

Lanoxin tablet 250 mcg NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES

Lanoxin tablet 187.5 mcg

NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

CARDIAC GLYCOSIDES




Quantity Limit Days

Authorization



lansoprazole capsule,delayed release(DR/EC)

30 mg PrefBrand-3 62 31 NO GASTROENTEROLOGY

ULCER THERAPY

lansoprazole capsule,delayed release(DR/EC)

15 mg PrefBrand-3 31 31 NO GASTROENTEROLOGY

ULCER THERAPY

Lantus solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Lantus Solostar



DIABETES THERAPY

Lastacaft drops 0.25 %

NonPrefBrand-4 NO

OPHTHALMOLOGY


latanoprost drops 0.005 % PrefGen-1 NO OPHTHALMOLOGY


Latuda tablet 40 mg



Latuda tablet 80 mg



Latuda tablet 20 mg






Quantity Limit Days

Authorization



Latuda tablet 120 mg



Latuda tablet 60 mg



Layolis Fe tablet,chewable0.8mg-25mcg(24) and 75 mg (4)

Generic-2 NO



Lazandaspray,non-aerosol 100 mcg/spray

Specialty-5

31 31


NARCOTIC ANALGESICS


Specialty-5

12 31


NARCOTIC ANALGESICS


Specialty-5

16 31


NARCOTIC ANALGESICS

leflunomide tablet 10 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY


leflunomide tablet 20 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



Lenvima capsule14 mg/day(10 mg x 1-4 mg x 1)



Lenvima capsule24 mg/day(10 mg x 2-4 mg x 1)



Lenvima capsule10 mg/day (10 mg x 1/day)



Lenvima capsule20 mg/day (10 mg x 2)



Lenvima capsule18 mg/day (10 mg x 1-4 mg x2)



Lenvima capsule8 mg/day (4 mg x 2)



Lescol XL tablet extended release 24 hr



Lessina tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY





Quantity Limit Days

Authorization



Letairis tablet 10 mg Specialty-5 31 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Letairis tablet 5 mg Specialty-5 31 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

letrozole tablet 2.5 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


leucovorin calcium

tablet 10 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium


ADJUNCTIVE AGENTS

leucovorin calcium


ADJUNCTIVE AGENTS

leucovorin calcium


ADJUNCTIVE AGENTS

leucovorin calcium


ADJUNCTIVE AGENTS

leucovorin calcium


ADJUNCTIVE AGENTS




Quantity Limit Days

Authorization



Leukeran tablet 2 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Leukine recon soln 250 mcg Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

leuprolide kit 1 mg/0.2 mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


levalbuterol HCl


1.25 mg/0.5 mL Generic-2 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

levalbuterol HCl



PULMONARY AGENTS

levalbuterol HCl



PULMONARY AGENTS

Levemir solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Levemir FlexTouch



DIABETES THERAPY

levetiracetam


ANTICONVULSANTS

levetiracetam


ANTICONVULSANTS




Quantity Limit Days

Authorization



levetiracetam


ANTICONVULSANTS

levetiracetam

tablet 1,000 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

levetiracetam


ANTICONVULSANTS

levetiracetam

solution 500 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

levetiracetam



ANTICONVULSANTS

levetiracetam



ANTICONVULSANTS

levetiracetam in NaCl (iso-os) piggyback 1,000 mg/100 mL


ANTICONVULSANTS

levetiracetam in NaCl (iso-os) piggyback 1,500 mg/100 mL


ANTICONVULSANTS




Quantity Limit Days

Authorization



levetiracetam in NaCl (iso-os) piggyback 500 mg/100 mL


ANTICONVULSANTS

levobunolol drops 0.5 %PrefGen-1 NO OPHTHALMOLO

GY BETA-BLOCKERSlevocarnitine tablet 330 mg Generic-2 YES DIAGNOSTICS /



levocarnitine (with sugar)

solution 100 mg/mL Generic-2 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


levocetirizine

solution 2.5 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY


levocetirizine



levofloxacin tablet 250 mg Generic-2 NO ANTI - INFECTIVES

QUINOLONES


QUINOLONES


QUINOLONES

levofloxacin drops 0.5 % Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS

levofloxacin solution 250 mg/10 mL Generic-2 NO ANTI - INFECTIVES

QUINOLONES

levofloxacin solution 25 mg/mLGeneric-2 NO ANTI -

INFECTIVES QUINOLONES




Quantity Limit Days

Authorization



levofloxacin in D5W piggyback 500 mg/100 mL


levofloxacin in D5W piggyback 750 mg/150 mL


levoleucovorin calcium solution 10 mg/mL


ADJUNCTIVE AGENTS

Levonest (28) tablet

50-30 (6)/75-40 (5)/125-30(10)

Generic-2 NO



levonorgestrel-ethinyl estrad

tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY



tablet 90-20 mcg Generic-2 NO OBSTETRICS / GYNECOLOGY



tablets,dose pack,3 month

0.15-30 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


levonorg-eth estrad triphasic

tablet 50-30 (6)/75-40 (5)/125-30(10)



Levora-28 tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY





Quantity Limit Days

Authorization



levorphanol tartrate

tablet 2 mg PrefGen-1 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

levothyroxine

tablet 100 mcg PrefGen-1 NO ENDOCRINE/DIABETES

THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

levothyroxine


THYROID HORMONES

Levoxyl tablet 25 mcg Generic-2 NO ENDOCRINE/DIABETES

THYROID HORMONES


THYROID HORMONES




Quantity Limit Days

Authorization




THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES

Lexiva tablet 700 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Lexiva suspension 50 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Lialda tablet,delayed release (DR/EC)

1.2 gram PrefBrand-3 NO GASTROENTEROLOGY


lidocaineadhesive patch,medicated 5 %

Generic-2

124 31

YES DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANESTHETICS

lidocaine ointment 5 %


TOPICAL ANESTHETICS




Quantity Limit Days

Authorization



lidocaine (PF) solution 5 mg/mL (0.5 %)


TOPICAL ANESTHETICS

lidocaine HCl solution 20 mg/mL (2 %)


TOPICAL ANESTHETICS

lidocaine HCl solution 2 %


TOPICAL ANESTHETICS

lidocaine HCl solution 4 % (40 mg/mL)


TOPICAL ANESTHETICS



TOPICAL ANESTHETICS



TOPICAL ANESTHETICS

lidocaine HCl

jelly in applicator 2 %


TOPICAL ANESTHETICS

lidocaine-prilocaine

cream 2.5-2.5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANESTHETICS

Lidodermadhesive patch,medicated 5 %

NonPrefBrand-4

124 31

YES DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANESTHETICS

Lincocin solution 300 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



lincomycin solution 300 mg/mL Generic-2 NO ANTI - INFECTIVES


lindane shampoo 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


linezolid suspension for reconstitution

100 mg/5 mL Specialty-5 NO ANTI - INFECTIVES


linezolid tablet 600 mg Specialty-5 NO ANTI - INFECTIVES


linezolidparenteral solution 600 mg/300 mL

NonPrefBrand-4 NO

ANTI - INFECTIVES


Linzess capsule 145 mcg

PrefBrand-3

31 31

NO

GASTROENTEROLOGY


Linzess capsule 290 mcg

PrefBrand-3

31 31

NO

GASTROENTEROLOGY


Lioresal solution 500 mcg/mL NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Lioresal solution 50 mcg/mL NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Lioresal solution 2,000 mcg/mL



liothyronine tablet 5 mcg Generic-2 NO ENDOCRINE/DIABETES

THYROID HORMONES

liothyronine solution 10 mcg/mL Generic-2 NO ENDOCRINE/DIABETES

THYROID HORMONES


THYROID HORMONES


THYROID HORMONES

Lipofen capsule 150 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Lipofen capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


lisinopril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS







Quantity Limit Days

Authorization



lisinopril tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








lisinopril-hydrochlorothiazide









lithium carbonate






Quantity Limit Days

Authorization



lithium carbonate



lithium carbonate




lithium carbonate




lithium carbonate



lithium carbonate



lithium citrate

solution 8 mEq/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Lithostat tablet 250 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Livalo tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization







Lo Loestrin Fe tablet

1 mg-10 mcg (24)/10 mcg (2)

NonPrefBrand-4 NO



Lonsurf tablet 15-6.14 mg



Lonsurf tablet 20-8.19 mg



loperamide capsule 2 mg Generic-2 NO GASTROENTEROLOGY


lorazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


lorazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



lorazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Lorazepam Intensol

concentrate 2 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Lorcet (hydrocodone) tablet 5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Lorcet Plus tablet 7.5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Lortab 10-325 tablet 10-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Lortab 5-325 tablet 5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Lortab 7.5-325 tablet 7.5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Loryna (28) tablet 3-0.02 mg

Generic-2 NO






Quantity Limit Days

Authorization



losartan tablet 100 mg PrefGen-1 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






losartan-hydrochlorothiazide









Lotronex tablet 1 mg Specialty-5 NO GASTROENTEROLOGY


Lotronex tablet 0.5 mg PrefBrand-3 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



lovastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






Lovenox syringe 60 mg/0.6 mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

Lovenox syringe 150 mg/mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

loxapine succinate



loxapine succinate



loxapine succinate






Quantity Limit Days

Authorization



loxapine succinate



Lumigan drops 0.01 %

PrefBrand-3

5 31

NOOPHTHALMOLOGY


Lumizyme recon soln 50 mg Specialty-5 NO ENDOCRINE/DIABETES


Lupaneta Pack (1 month)

kit. syringe and tablet

3.75 mg -5 mg (30)



Lupaneta Pack (3 month)

kit. syringe and tablet

11.25 mg -5 mg (90)









Lupron Depot (3 Month) syringe kit 22.5 mg



Lupron Depot (3 Month) syringe kit 11.25 mg






Quantity Limit Days

Authorization



Lupron Depot (4 Month) syringe kit 30 mg



Lupron Depot (6 Month) syringe kit 45 mg



Lupron Depot-Ped kit 11.25 mg



Lupron Depot-Ped kit 15 mg



Lutera (28) tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


Lynparza capsule 50 mg



Lyrica capsule 100 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS

Lyrica solution 20 mg/mL NonPrefBrand-4 930 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Lysodren tablet 500 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Lyza tablet 0.35 mgGeneric-2 NO OBSTETRICS /


magnesium sulfate

syringe 4 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

magnesium sulfate solution 4 mEq/mL (50 %)


Makena oil250 mg/mL (1 mL)

Specialty-5 NO OBSTETRICS / GYNECOLOGY


malathion lotion 0.5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


maprotiline tablet 25 mg









Marinol capsule 2.5 mg Specialty-5 YES GASTROENTEROLOGY


Marinol capsule 5 mg NonPrefBrand-4 YES GASTROENTEROLOGY





Quantity Limit Days

Authorization



Marinol capsule 10 mg NonPrefBrand-4 YES GASTROENTEROLOGY


Marlissa tablet 0.15-0.03 mg

Generic-2 NO



Marplan tablet 10 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Matulane capsule 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Matzim LAtablet extended release 24 hr 420 mg















Quantity Limit Days

Authorization






Maxalt tablet 5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Maxalt tablet 10 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Maxalt-MLT tablet,disintegrating

5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Maxalt-MLT tablet,disintegrating



meclizine tablet 12.5 mg

Generic-2 NO

GASTROENTEROLOGY


meclizine tablet 25 mg

Generic-2 NO

GASTROENTEROLOGY


meclofenamate






Quantity Limit Days

Authorization



meclofenamate



Medrol tablet 2 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

medroxyprogesterone tablet 10 mg



medroxyprogesterone suspension 150 mg/mL



medroxyprogesterone tablet 2.5 mg



medroxyprogesterone tablet 5 mg



mefenamic acid



mefloquine tablet 250 mg Generic-2 NO ANTI - INFECTIVES


Megace ES suspension 625 mg/5 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


megestrol suspension 625 mg/5 mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



megestrol tablet 20 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


megestrol tablet 40 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


megestrol suspension 400 mg/10 mL (40 mg/mL)



Mekinist tablet 0.5 mg



Mekinist tablet 2 mg



meloxicam tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


meloxicam tablet 7.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


meloxicam suspension 7.5 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



melphalan HCl

recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS








memantinetablets,dose pack 5-10 mg



memantine solution 2 mg/mL



Menactra (PF)

solution 4 mcg/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Menest tablet 0.3 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY











Quantity Limit Days

Authorization



Menhibrix (PF) recon soln 5-2.5 mcg/0.5 mL



Menomune - A/C/Y/W-135 (PF) recon soln 50 mcg



Mentax cream 1 %


TOPICAL ANTIFUNGALS

Menveo A-C-Y-W-135-Dip (PF)

kit 10-5 mcg/0.5 mL NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Mepron suspension 750 mg/5 mL Specialty-5 NO ANTI - INFECTIVES


mercaptopurine



meropenem recon soln 500 mg

Generic-2 NO

ANTI - INFECTIVES





Quantity Limit Days

Authorization



mesalamine with cleansing wipe

enema kit 4 gram/60 mL Generic-2 NO GASTROENTEROLOGY


mesna solution 100 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

Mesnex tablet 400 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

Mestinon syrup 60 mg/5 mL PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Mestinon Timespan




Metadate ERtablet extended release 20 mg

Generic-2

93 31



metaproterenol


PULMONARY AGENTS

metaproterenol

syrup 10 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

metaproterenol


PULMONARY AGENTS




Quantity Limit Days

Authorization



Metaxall tablet 800 mg



metaxalone tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


metaxalone tablet 800 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


metformin tablet extended release 24 hr


DIABETES THERAPY

metformin tablet extended release 24 hr


DIABETES THERAPY

metformin tablet extended release 24hr

1,000 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

metformin tablet 1,000 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

metformin tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

metformin tablet 850 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

methadone tablet 10 mg Generic-2 206 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

methadone solution 10 mg/mL Generic-2 160 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



methadone tablet 5 mg Generic-2 248 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

methadone solution 5 mg/5 mL Generic-2 2066 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

methadone solution 10 mg/5 mL Generic-2 1033 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

methamphetamine

tablet 5 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


methazolamide



methazolamide



methenamine hippurate

tablet 1 gram Generic-2 NO ANTI - INFECTIVES

URINARY TRACT AGENTS

methimazole tablet 10 mg Generic-2 NO ENDOCRINE/DIABETES

ANTITHYROID AGENTS

methimazole tablet 5 mg Generic-2 NO ENDOCRINE/DIABETES

ANTITHYROID AGENTS

Methitest tablet 10 mg NonPrefBrand-4 YES ENDOCRINE/DIABETES





Quantity Limit Days

Authorization



methotrexate sodium

tablet 2.5 mg PrefGen-1 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


methotrexate sodium (PF)

recon soln 1 gram Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


methotrexate sodium (PF) solution 25 mg/mL



methoxsalen rapid

capsule 10 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


methscopolamine

tablet 2.5 mg Generic-2 NO GASTROENTEROLOGY


methscopolamine



methyclothiazide



methyldopa-hydrochlorothiazide






Quantity Limit Days

Authorization



methyldopa-hydrochlorothiazide



methylergonovine tablet 0.2 mg

Generic-2 NO OBSTETRICS / GYNECOLOGY OXYTOCICS

methylphenidate solution 10 mg/5 mL



methylphenidate

capsule, ER biphasic 30-70 10 mg



methylphenidate

tablet extended release 10 mg

Generic-2

31 31



methylphenidate tablet 10 mg

Generic-2

93 31



methylphenidate tablet,chewable 10 mg

Generic-2

186 31



methylphenidate

tablet extended release 24hr 18 mg

Generic-2

31 31






Quantity Limit Days

Authorization



methylphenidate




methylphenidate


Generic-2

31 31



methylphenidate




methylphenidate


Generic-2

31 31



methylphenidate




methylphenidate




methylphenidate


Generic-2

31 31



methylphenidate







Quantity Limit Days

Authorization



methylphenidate

tablet extended release 20 mg

Generic-2

93 31



methylphenidate tablet,chewable 5 mg

Generic-2

93 31



methylphenidate solution 5 mg/5 mL



methylphenidate tablet,chewable 2.5 mg

Generic-2

93 31




Generic-2

93 31




Generic-2

93 31



methylprednisolone

tablet 32 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

methylprednisolone


ADRENAL HORMONES

methylprednisolone


ADRENAL HORMONES

methylprednisolone


ADRENAL HORMONES




Quantity Limit Days

Authorization



methylprednisolone

tablets,dose pack

4 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

methylprednisolone acetate suspension 40 mg/mL


ADRENAL HORMONES

methylprednisolone acetate suspension 80 mg/mL


ADRENAL HORMONES

methylprednisolone sodium succ

recon soln 40 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

methylprednisolone sodium succ

recon soln 125 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

methyltestosterone

capsule 10 mg Specialty-5 YES ENDOCRINE/DIABETES


metipranolol drops 0.3 % Generic-2 NO OPHTHALMOLOGY

BETA-BLOCKERS

metoclopramide HCl



metoclopramide HCl



metoclopramide HCl






Quantity Limit Days

Authorization



metoclopramide HCl

solution 5 mg/mL Generic-2 NO GASTROENTEROLOGY


metoclopramide HCl


10 mg Generic-2 NO GASTROENTEROLOGY


metoclopramide HCl




metolazone tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


metolazone tablet 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


metolazone tablet 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


metoprolol succinate











Quantity Limit Days

Authorization











metoprolol ta-hydrochlorothiaz









metoprolol tartrate

solution 5 mg/5 mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


metoprolol tartrate



metoprolol tartrate






Quantity Limit Days

Authorization



metoprolol tartrate



metoprolol tartrate syringe 5 mg/5 mL



metronidazole

gel 0.75 % Generic-2 NO OBSTETRICS / GYNECOLOGY


metronidazole

capsule 375 mg PrefGen-1 NO ANTI - INFECTIVES


metronidazole


THERAPY FOR ACNE

metronidazole

gel 0.75 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

metronidazole



metronidazole

lotion 0.75 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

metronidazole






Quantity Limit Days

Authorization



metronidazole

gel 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

metronidazole in NaCl (iso-os)



mexiletine capsule 150 mg









Miacalcin solution 200 unit/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Miconazole-3

suppository 200 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Microgestin 1.5/30 (21) tablet 1.5-30 mg-mcg

Generic-2 NO



Microgestin 1/20 (21) tablet 1-20 mg-mcg

Generic-2 NO






Quantity Limit Days

Authorization



Microgestin Fe 1.5/30 (28) tablet

1.5 mg-30 mcg (21)/75 mg (7)

Generic-2 NO



Microgestin FE 1/20 (28) tablet

1 mg-20 mcg (21)/75 mg (7)

Generic-2 NO



midodrine tablet 10 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


midodrine tablet 2.5 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


midodrine tablet 5 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Migergot suppository 2-100 mg



miglitol tablet 25 mg Generic-2 NO ENDOCRINE/DIABETES

DIABETES THERAPY


DIABETES THERAPY


DIABETES THERAPY

Migranal spray,non-aerosol

0.5 mg/pump act. (4 mg/mL)

NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Millipred solution 10 mg/5 mL NonPrefBrand-4 NO ENDOCRINE/DIABETES

ADRENAL HORMONES




Quantity Limit Days

Authorization



Millipred tablet 5 mg Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

minocycline capsule 100 mg Generic-2 NO ANTI - INFECTIVES

TETRACYCLINES


TETRACYCLINES

minocycline tablet 50 mg Generic-2 NO ANTI - INFECTIVES

TETRACYCLINES


TETRACYCLINES


TETRACYCLINES


TETRACYCLINES

minocycline tablet extended release 24 hr


TETRACYCLINES



TETRACYCLINES



TETRACYCLINES

minoxidil tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


minoxidil tablet 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Mirapex ER tablet extended release 24 hr






Quantity Limit Days

Authorization









Mirapex ERtablet extended release 24 hr 2.25 mg



Mirapex ERtablet extended release 24 hr 3.75 mg



Mircera syringe 50 mcg/0.3 mL

NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



mirtazapine tablet,disintegrating









mirtazapine tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






mirtazapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


misoprostol tablet 100 mcg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

misoprostol tablet 200 mcg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY




Quantity Limit Days

Authorization



Mitigare capsule 0.6 mg

NonPrefBrand-4

62 31

NO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY

mitomycin recon soln 5 mg









mitoxantrone

concentrate 2 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


M-M-R II (PF)

recon soln 1,000-12,500 TCID50/0.5 mL

NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


modafinil tablet 200 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


modafinil tablet 100 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Moderiba tablet 200 mgGeneric-2 NO ANTI -

INFECTIVES ANTIVIRALSModeriba Dose Pack

tablets,dose pack

400 mg (7)- 400 mg (7)


Moderiba Dose Pack

tablets,dose pack

600 mg (7)- 600 mg (7)


moexipril tablet 15 mg



moexipril tablet 7.5 mg



moexipril-hydrochlorothiazide tablet 15-12.5 mg



moexipril-hydrochlorothiazide tablet 7.5-12.5 mg



moexipril-hydrochlorothiazide tablet 15-25 mg



molindone tablet 10 mg






Quantity Limit Days

Authorization









mometasone ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


mometasone solution 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


mometasone cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


mometasone spray,non-aerosol

50 mcg/actuation PrefBrand-3 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Mononessa (28)



montelukast tablet 10 mg PrefBrand-3 31 31 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

montelukast tablet,chewable 5 mg Generic-2 31 31 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

montelukast tablet,chewable 4 mg Generic-2 31 31 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

montelukast granules in packet

4 mg Generic-2 31 31 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Monurol packet 3 gram NonPrefBrand-4 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



morphine tablet extended release


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

morphine capsule, ER multiphase 24 hr


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

morphine capsule,extend.release pellets


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization





NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

morphine tablet 15 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

morphine solution 10 mg/5 mL Generic-2 2800 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



morphine tablet 30 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

morphine solution 20 mg/5 mL (4 mg/mL)

Generic-2 1400 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

morphine syringe 10 mg/mL NonPrefBrand-4 200 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

morphine syringe 8 mg/mL NonPrefBrand-4 250 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



morphine syringe 2 mg/mL

Generic-2

1000 30


NARCOTIC ANALGESICS

morphine syringe 4 mg/mL

Generic-2

500 30


NARCOTIC ANALGESICS

morphine concentrate

solution 100 mg/5 mL (20 mg/mL)

Generic-2 310 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Movantik tablet 12.5 mg

PrefBrand-3

31 31

NO

GASTROENTEROLOGY


Movantik tablet 25 mg

PrefBrand-3

31 31

NO

GASTROENTEROLOGY


MoviPrep powder in packet

100-7.5-2.691 gram



Moxeza drops, viscous 0.5 %NonPrefBrand-4 NO OPHTHALMOLO

GY ANTIBIOTICSmoxifloxacin

tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES

QUINOLONES

moxifloxacin-sod.ace,sul-water

piggyback 400 mg/250 mL NonPrefBrand-4 NO ANTI - INFECTIVES

QUINOLONES




Quantity Limit Days

Authorization



Mozobil solution 24 mg/1.2 mL (20 mg/mL)


BIOTECHNOLOGY DRUGS

MS Contin tablet extended release


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS

Multaq tablet 400 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


mupirocin ointment 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



mupirocin calcium

cream 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


Mustargen recon soln 10 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Myalept recon soln5 mg/mL (final conc.)

Specialty-5 YES ENDOCRINE/DIABETES


Mycamine recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Mycamine recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

mycophenolate mofetil




tablet 500 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS




200 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


mycophenolate sodium


180 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


mycophenolate sodium


360 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Myfortic tablet,delayed release (DR/EC)

360 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Myfortic tablet,delayed release (DR/EC)

180 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS




THERAPY FOR ACNE



THERAPY FOR ACNE



THERAPY FOR ACNE



THERAPY FOR ACNE

Myrbetriqtablet extended release 24 hr 25 mg

PrefBrand-3

31 31

NO

UROLOGICALS


Myrbetriqtablet extended release 24 hr 50 mg

PrefBrand-3

31 31

NO

UROLOGICALS


Mysoline tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization



Mysoline tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

nabumetone tablet 500 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


nabumetone tablet 750 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


nadolol tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






nadolol-bendroflumethiazide



nadolol-bendroflumethiazide






Quantity Limit Days

Authorization



nafcillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

PENICILLINS

nafcillin recon soln 1 gramGeneric-2 NO ANTI -

INFECTIVES PENICILLINSnaftifine cream 1 % NonPrefBrand-4 NO DERMATOLOGIC

ALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

naftifine cream 2 %


TOPICAL ANTIFUNGALS

Naftin gel 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

Naftin cream 2 %


TOPICAL ANTIFUNGALS

Naftin gel 2 %


TOPICAL ANTIFUNGALS

Naglazyme solution 5 mg/5 mL Specialty-5 NO ENDOCRINE/DIABETES


nalbuphine solution 10 mg/mL Generic-2 200 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


nalbuphine solution 20 mg/mL Generic-2 100 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


naloxone syringe 1 mg/mL






Quantity Limit Days

Authorization



naloxone solution 0.4 mg/mL



naltrexone tablet 50 mg



Namenda tablet 10 mg



Namenda tablet 5 mg



Namenda solution 2 mg/mL



Namenda Titration Pak

tablets,dose pack 5-10 mg



Namenda XR

capsule,sprinkle,ER 24hr 14 mg



Namenda XR







Quantity Limit Days

Authorization



Namenda XR




Namenda XR




Namenda XR

cap,sprinkle,ER 24hr dose pack 7-14-21-28 mg



Namzariccapsule,sprinkle,ER 24hr 14-10 mg



Namzariccapsule,sprinkle,ER 24hr 28-10 mg



Naprelan CR

tablet, ER multiphase 24 hr 375 mg



Naprelan CR




Naprelan CR







Quantity Limit Days

Authorization



naproxen tablet 375 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






naproxen suspension 125 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


naproxen tablet,delayed release (DR/EC)



naproxen tablet,delayed release (DR/EC)



naproxen sodium



naproxen sodium






Quantity Limit Days

Authorization



naproxen sodium




naproxen sodium




naratriptan tablet 1 mg Generic-2 20 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


naratriptan tablet 2.5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Narcanspray,non-aerosol 4 mg/actuation



Nasonex spray,non-aerosol

50 mcg/actuation NonPrefBrand-4 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Natacyn drops,suspension

5 % PrefBrand-3 NO OPHTHALMOLOGY

ANTIBIOTICS

nateglinide tablet 120 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

nateglinide tablet 60 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Natestogel in metered-dose pump

5.5 mg/0.122 gram/actuation



Natpara cartridge 25 mcg/doseSpecialty-5 YES ENDOCRINE/DIA





Quantity Limit Days

Authorization









Nebupent recon soln 300 mg NonPrefBrand-4 YES ANTI - INFECTIVES


Necon 0.5/35 (28)



Necon 1/35 (28)



Necon 10/11 (28)

tablet 0.5-35/1-35 mg-mcg/mg-mcg



Necon 7/7/7 (28)

tablet 0.5/0.75/1 mg- 35 mcg









Quantity Limit Days

Authorization















neomycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES


neomycin-bacitracin-poly-HC ointment

3.5-400-10,000 mg-unit/g-1%

Generic-2 NO

OPHTHALMOLOGY

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-polymyxin

ointment 3.5-400-10,000 mg-unit-unit/g


ANTIBIOTICS

neomycin-polymyxin B GU

solution 40 mg-200,000 unit/mL

PrefGen-1 NO DIAGNOSTICS / MISCELLANEOUS AGENTS





Quantity Limit Days

Authorization



neomycin-polymyxin B-dexameth

ointment 3.5 mg/g-10,000 unit/g-0.1 %



neomycin-polymyxin B-dexameth

drops,suspension

3.5mg/mL-10,000 unit/mL-0.1 %



neomycin-polymyxin-gramicidin

drops 1.75 mg-10,000 unit-0.025mg/mL


ANTIBIOTICS

neomycin-polymyxin-HC

solution 3.5-10,000-1 mg/mL-unit/mL-%




drops,suspension

3.5-10,000-10 mg-unit-mg/mL




drops,suspension

3.5-10,000-1 mg/mL-unit/mL-%



Neoral solution 100 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Neoral capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Neoral capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Neo-Synalar cream0.5 % (0.35 % base)-0.025 %



Nephramine 5.4 %

parenteral solution



Nesina tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIA


Nesina tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIA


Nesina tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIA


Neuac gel1.2 %(1 % base) -5 %


THERAPY FOR ACNE

Neulasta syringe 6 mg/0.6mL Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Neupogen syringe 300 mcg/0.5 mL Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Neupogen syringe 480 mcg/0.8 mL Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Neupogen solution 300 mcg/mL


BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



Neupogen solution 480 mcg/1.6 mL


BIOTECHNOLOGY DRUGS

Neupro patch 24 hour 2 mg/24 hour NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






Neupro patch 24 hour 1 mg/24 hour









Neurontin capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS


ANTICONVULSANTS

Neurontin tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Neurontin tablet 800 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Neurontin solution 250 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Nevanac drops,suspension



nevirapine tablet 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

nevirapine suspension 50 mg/5 mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

nevirapinetablet extended release 24 hr 400 mg


nevirapinetablet extended release 24 hr 100 mg





Quantity Limit Days

Authorization



Nexavar tablet 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


niacintablet extended release 24 hr 1,000 mg



niacintablet extended release 24 hr 500 mg

PrefBrand-3

31 31



niacintablet extended release 24 hr 750 mg



Niacor tablet 500 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


nicardipine solution 25 mg/10 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


nicardipine capsule 20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


nicardipine capsule 30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



Nicotrol cartridge 10 mg


SMOKING DETERRENTS

Nicotrol NS spray,non-aerosol

10 mg/mL PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS

SMOKING DETERRENTS

Nifedical XL tablet extended release 24hr



Nifedical XL tablet extended release 24hr



nifedipine tablet extended release 24hr









Nilandron tablet 150 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



nimodipine capsule 30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Ninlaro capsule 2.3 mg









Nipent recon soln 10 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


nisoldipine tablet extended release 24 hr












Quantity Limit Days

Authorization















Nitro-Bid ointment 2 % Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

NITRATES

Nitro-Dur patch 24 hour 0.2 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

NITRATES


NITRATES


NITRATES




Quantity Limit Days

Authorization




NITRATES


NITRATES


NITRATES

nitrofurantoin

suspension 25 mg/5 mL Generic-2 1800 365 YES ANTI - INFECTIVES


nitrofurantoin macrocrystal

capsule 25 mg Generic-2 360 365 YES ANTI - INFECTIVES


nitrofurantoin macrocrystal

capsule 50 mg Generic-2 180 365 YES ANTI - INFECTIVES


nitrofurantoin macrocrystal capsule 100 mg

Generic-2

90 365

YESANTI - INFECTIVES


nitrofurantoin monohyd/m-cryst capsule 100 mg

Generic-2

90 365

YES

ANTI - INFECTIVES


nitroglycerin solution 50 mg/10 mL (5 mg/mL)


NITRATES




Quantity Limit Days

Authorization



nitroglycerin patch 24 hour 0.6 mg/hr Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

NITRATES


NITRATES


NITRATES

nitroglycerin spray,non-aerosol

400 mcg/spray Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

NITRATES


NITRATES

Nitrostat tablet 0.3 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

NITRATES


NITRATES


NITRATES




Quantity Limit Days

Authorization



nizatidine capsule 300 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

nizatidine capsule 150 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

nizatidine solution 150 mg/10 mL Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

Norco tablet 10-325 mg NonPrefBrand-4 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Norco tablet 5-325 mg NonPrefBrand-4 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Norco tablet 7.5-325 mg NonPrefBrand-4 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Norditropin FlexPro

pen injector 15 mg/1.5 mL (10 mg/mL)


BIOTECHNOLOGY DRUGS

Norditropin FlexPro

pen injector 5 mg/1.5 mL (3.3 mg/mL)


BIOTECHNOLOGY DRUGS

Norditropin FlexPro

pen injector 10 mg/1.5 mL (6.7 mg/mL)


BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



Norditropin FlexPro

pen injector 30 mg/3 mL (10 mg/mL)


BIOTECHNOLOGY DRUGS

noreth-ethinyl estradiol-iron tablet,chewable

0.8mg-25mcg(24) and 75 mg (4)

Generic-2 NO



norethindrone (contraceptive)

tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


norethindrone acetate tablet 5 mg



norethindrone ac-eth estradiol tablet 1-5 mg-mcg



norethindrone ac-eth estradiol tablet 0.5-2.5 mg-mcg



norgestimate-ethinyl estradiol

tablet 0.18/0.215/0.25 mg-25 mcg



Noritate cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Normosol-M in 5 % dextrose

parenteral solution



Normosol-R in 5 % dextrose


NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES




Quantity Limit Days

Authorization



Normosol-R pH 7.4

parenteral solution












Nortrel 0.5/35 (28)



Nortrel 1/35 (21)



Nortrel 1/35 (28)



Nortrel 7/7/7 (28)

tablet 0.5/0.75/1 mg- 35 mcg



nortriptyline capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization







nortriptyline solution 10 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




Norvir capsule 100 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Norvir solution 80 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Norvir tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Novarel recon soln 10,000 unit Generic-2 YES ENDOCRINE/DIABETES


Novolin 70/30



DIABETES THERAPY

Novolin N suspension 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Novolin R solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Novolog solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization



Novolog Flexpen insulin pen 100 unit/mL


DIABETES THERAPY

Novolog Mix 70-30

solution 100 unit/mL (70-30)


DIABETES THERAPY

Novolog Mix 70-30 FlexPen



DIABETES THERAPY

Novolog PenFill cartridge 100 unit/mL


DIABETES THERAPY

Noxafil suspension 200 mg/5 mL (40 mg/mL)

Specialty-5 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Nucala recon soln 100 mgSpecialty-5 YES RESPIRATORY


Nucynta tablet 100 mg NonPrefBrand-4 155 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






Nucynta ERtablet extended release 12 hr 100 mg

NonPrefBrand-4

62 31




NonPrefBrand-4

62 31






Quantity Limit Days

Authorization




NonPrefBrand-4

62 31




NonPrefBrand-4

62 31




NonPrefBrand-4

62 31



Nuedexta capsule 20-10 mg



Nulojix recon soln 250 mg



Nuplazid tablet 17 mg

Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Nutrestorepowder in packet 5 gram



Nutrilipid emulsion 20 %






Quantity Limit Days

Authorization



Nutropin AQ cartridge20 mg/2 mL (10 mg/mL)


BIOTECHNOLOGY DRUGS

Nutropin AQ cartridge10 mg/2 mL (5 mg/mL)


BIOTECHNOLOGY DRUGS

Nutropin AQ Nuspin

pen injector 5 mg/2 mL (2.5 mg/mL)


BIOTECHNOLOGY DRUGS

Nutropin AQ Nuspin pen injector

20 mg/2 mL (10 mg/mL)


BIOTECHNOLOGY DRUGS

Nutropin AQ Nuspin pen injector

10 mg/2 mL (5 mg/mL)


BIOTECHNOLOGY DRUGS

NuvaRing ring0.12-0.015 mg/24 hr

PrefBrand-3 NO OBSTETRICS / GYNECOLOGY


Nuvessa gel 1.3 %NonPrefBrand-4 NO OBSTETRICS /

GYNECOLOGYMISCELLANEOUS OB/GYN

Nyamyc powder 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

nystatin suspension 100,000 unit/mL Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

nystatin tablet 500,000 unit Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS




Quantity Limit Days

Authorization



nystatin cream 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

nystatin powder 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

nystatin ointment 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

nystatin-triamcinolone ointment

100,000-0.1 unit/gram-%


TOPICAL ANTIFUNGALS

nystatin-triamcinolone cream

100,000-0.1 unit/g-%


TOPICAL ANTIFUNGALS

Nystop powder 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

Octagam solution 5 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Octagam solution 10 %



octreotide acetate

solution 50 mcg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



octreotide acetate

solution 100 mcg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


octreotide acetate

solution 500 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


octreotide acetate

solution 1,000 mcg/mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


octreotide acetate

solution 200 mcg/mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Odefsey tablet 200-25-25 mgSpecialty-5

31 31NO ANTI -


Odomzo capsule 200 mg









ofloxacin tablet 400 mg Generic-2 NO ANTI - INFECTIVES

QUINOLONES

ofloxacin drops 0.3 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS


ofloxacin drops 0.3 % Generic-2 NO OPHTHALMOLOGY

ANTIBIOTICS




Quantity Limit Days

Authorization



Ogestrel (28) tablet 0.5-50 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


olanzapine tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


olanzapine tablet 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


olanzapine tablet,disintegrating





olanzapine tablet 5 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


olanzapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH







Quantity Limit Days

Authorization












olanzapine recon soln 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


olanzapine-fluoxetine

capsule 6-25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH














Quantity Limit Days

Authorization






olopatadinespray,non-aerosol 0.6 %



olopatadine drops 0.1 %

PrefBrand-3 NO

OPHTHALMOLOGY


Olysio capsule 150 mgSpecialty-5

28 28YES ANTI -

INFECTIVES ANTIVIRALSomega-3 acid ethyl esters

capsule 1 gram PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


omeprazole capsule,delayed release(DR/EC)

20 mg PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY



ULCER THERAPY



ULCER THERAPY

omeprazole-sodium bicarbonate

capsule 20-1.1 mg-gram Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY




Quantity Limit Days

Authorization



omeprazole-sodium bicarbonate

capsule 40-1.1 mg-gram Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

Omnaris spray,non-aerosol

50 mcg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Omnitrope recon soln 5.8 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Omnitrope cartridge 10 mg/1.5 mL (6.7 mg/mL)


BIOTECHNOLOGY DRUGS

Omnitrope cartridge 5 mg/1.5 mL (3.3 mg/mL)


BIOTECHNOLOGY DRUGS

ondansetron tablet,disintegrating

4 mg Generic-2 YES GASTROENTEROLOGY


ondansetron tablet,disintegrating

8 mg Generic-2 YES GASTROENTEROLOGY


ondansetron HCl



ondansetron HCl






Quantity Limit Days

Authorization



ondansetron HCl

solution 4 mg/5 mL Generic-2 YES GASTROENTEROLOGY


ondansetron HCl



ondansetron HCl (PF)



ondansetron HCl (PF) syringe 4 mg/2 mL

Generic-2 NO

GASTROENTEROLOGY


Onfi tablet 10 mg


ANTICONVULSANTS

Onfi tablet 20 mg


ANTICONVULSANTS

Onfi suspension 2.5 mg/mL


ANTICONVULSANTS

Onglyza tablet 5 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Onglyza tablet 2.5 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization



Onzetra Xsail

aerosol powdr breath activated 11 mg

NonPrefBrand-4

16 31



Opana tablet 5 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Opana tablet 10 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Opana ER tablet,oral only,ext.rel.12 hr


NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization





NARCOTIC ANALGESICS


7.5 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Opdivo solution 40 mg/4 mL



Opsumit tablet 10 mgSpecialty-5



Oralair tablet 300 indx reactivity



Orap tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Oravigmuco-adhesive buccal tablet 50 mg


ANTIFUNGAL AGENTS

Orbactiv recon soln 400 mg

Specialty-5 NO

ANTI - INFECTIVES


Orencia syringe 125 mg/mL

Specialty-5

4 28






Quantity Limit Days

Authorization



Orencia (with maltose)

recon soln 250 mg Specialty-5 8 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Orenitramtablet extended release 0.125 mg

NonPrefBrand-4

93 31




Specialty-5

186 31



Orenitramtablet extended release 1 mg

Specialty-5

186 31




Specialty-5

521 31



Orfadin capsule 2 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS






Orfadin suspension 4 mg/mL






Quantity Limit Days

Authorization



Orkambi tablet 200-125 mgSpecialty-5



Orsythia tablet 0.1-20 mg-mcg

Generic-2 NO



Ortho Tri-Cyclen Lo (28)

tablet 0.18/0.215/0.25 mg-25 mcg

PrefBrand-3 NO OBSTETRICS / GYNECOLOGY


Oseni tablet 12.5-15 mgNonPrefBrand-4 NO ENDOCRINE/DIA






Oseni tablet 25-15 mgNonPrefBrand-4 NO ENDOCRINE/DIA






OsmoPrep tablet 1.5 gram NonPrefBrand-4 NO GASTROENTEROLOGY


Otezla tablet 30 mg

Specialty-5

62 31






Quantity Limit Days

Authorization



Otezla Starter

tablets,dose pack

10 mg (4)-20 mg (4)-30 mg (47)

Specialty-5

55 28



Otrexup (PF) auto-injector 10 mg/0.4 mL

NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY











Otrexup (PF) auto-injector 7.5 mg/0.4 mL












Quantity Limit Days

Authorization



oxacillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

PENICILLINS

oxacillin recon soln 2 gram Generic-2 NO ANTI - INFECTIVES

PENICILLINS

oxacillin in dextrose(iso-osm)

piggyback 2 gram/50 mL Generic-2 NO ANTI - INFECTIVES

PENICILLINS

oxacillin in dextrose(iso-osm)

piggyback 1 gram/50 mL Generic-2 NO ANTI - INFECTIVES

PENICILLINS

oxaliplatin solution 100 mg/20 mL



oxandrolone tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABETES


oxandrolone tablet 10 mg Specialty-5 YES ENDOCRINE/DIABETES


oxaprozin tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


oxazepam capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH







Quantity Limit Days

Authorization





oxcarbazepine

suspension 300 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

oxcarbazepine


ANTICONVULSANTS

oxcarbazepine


ANTICONVULSANTS

oxcarbazepine


ANTICONVULSANTS

oxiconazole cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

Oxistat cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

Oxistat lotion 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIFUNGALS

Oxtellar XRtablet extended release 24 hr 150 mg


ANTICONVULSANTS




Quantity Limit Days

Authorization





ANTICONVULSANTS



ANTICONVULSANTS

oxybutynin chloride

syrup 5 mg/5 mL Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

oxybutynin chloride

tablet extended release 24hr


oxybutynin chloride



oxybutynin chloride



oxybutynin chloride

tablet 5 mg Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

oxycodone


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



oxycodone


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

oxycodone


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

oxycodone


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

oxycodone


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

oxycodone


NonPrefBrand-4

69 31


NARCOTIC ANALGESICS

oxycodone


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

oxycodone solution 5 mg/5 mL

Generic-2

4133 31


NARCOTIC ANALGESICS


Generic-2

186 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



oxycodone concentrate 20 mg/mL

Generic-2

180 31


NARCOTIC ANALGESICS


PrefBrand-3

138 31


NARCOTIC ANALGESICS


Generic-2

186 31


NARCOTIC ANALGESICS


Generic-2

186 31


NARCOTIC ANALGESICS


Generic-2

186 31


NARCOTIC ANALGESICS

oxycodone capsule 5 mg

Generic-2

186 31


NARCOTIC ANALGESICS

oxycodone-acetaminophen tablet 10-325 mg

PrefBrand-3

372 31


NARCOTIC ANALGESICS

oxycodone-acetaminophen tablet 5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



oxycodone-acetaminophen tablet 7.5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

oxycodone-acetaminophen solution 5-325 mg/5 mL

Generic-2

1860 31


NARCOTIC ANALGESICS

oxycodone-acetaminophen tablet 2.5-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

oxycodone-aspirin


NARCOTIC ANALGESICS

OxyContin


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

OxyContin


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

OxyContin


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

OxyContin


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



OxyContin


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

OxyContin


NonPrefBrand-4

69 31


NARCOTIC ANALGESICS

OxyContin


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

oxymorphone



NARCOTIC ANALGESICS

oxymorphone



NARCOTIC ANALGESICS

oxymorphone



NARCOTIC ANALGESICS

oxymorphone



NARCOTIC ANALGESICS

oxymorphone



NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



oxymorphone



NARCOTIC ANALGESICS

oxymorphone



NARCOTIC ANALGESICS

oxymorphone


NARCOTIC ANALGESICS

oxymorphone


NARCOTIC ANALGESICS

Oxytrol patch semiweekly

3.9 mg/24 hr NonPrefBrand-4 8 28 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Pacerone tablet 200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS









Quantity Limit Days

Authorization



paclitaxel concentrate 6 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


paliperidone tablet extended release 24hr










1.5 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


pamidronate solution30 mg/10 mL (3 mg/mL)

Generic-2 YES ENDOCRINE/DIABETES








Pancreaze capsule,delayed release(DR/EC)

10,500-25,000- 43,750 unit






Quantity Limit Days

Authorization




16,800-40,000- 70,000 unit




21,000-37,000 -61,000 unit




4,200-10,000- 17,500 unit



Pandel cream 0.1 %



Panretin gel 0.1 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


pantoprazole tablet,delayed release (DR/EC)


ULCER THERAPY

pantoprazole recon soln 40 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

pantoprazole tablet,delayed release (DR/EC)


ULCER THERAPY

paricalcitol solution 5 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


paricalcitol capsule 1 mcg Generic-2 YES ENDOCRINE/DIABETES


paricalcitol capsule 2 mcg PrefGen-1 YES ENDOCRINE/DIABETES





Quantity Limit Days

Authorization



paricalcitol capsule 4 mcg PrefGen-1 YES ENDOCRINE/DIABETES


paricalcitol solution 2 mcg/mLNonPrefBrand-4 YES ENDOCRINE/DIA


paromomycin



paroxetine HCl tablet 10 mg












paroxetine HCl




paroxetine HCl







Quantity Limit Days

Authorization



paroxetine HCl




Paser granules DR for susp in packet

4 gram NonPrefBrand-4 NO ANTI - INFECTIVES


Pataday drops 0.2 %

PrefBrand-3 NO

OPHTHALMOLOGY


Paxil suspension 10 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Pazeo drops 0.7 %

PrefBrand-3 NO

OPHTHALMOLOGY


PCE tablet, particles/crystals

333 mg NonPrefBrand-4 NO ANTI - INFECTIVES


PCE tablet, particles/crystals



Pedvax HIB (PF)

solution 7.5 mcg/0.5 mL NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



peg 3350-electrolytes

recon soln 236-22.74-6.74 -5.86 gram



Peganone tablet 250 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Pegasys solution 180 mcg/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Pegasys syringe 180 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Pegasys ProClick pen injector 135 mcg/0.5 mL


BIOTECHNOLOGY DRUGS

Pegasys ProClick pen injector 180 mcg/0.5 mL


BIOTECHNOLOGY DRUGS

peg-electrolyte soln

recon soln 420 gram Generic-2 NO GASTROENTEROLOGY


PegIntron kit 50 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization




BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS

PegIntron Redipen

pen injector kit 120 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

PegIntron Redipen


BIOTECHNOLOGY DRUGS

PegIntron Redipen


BIOTECHNOLOGY DRUGS

PegIntron Redipen


BIOTECHNOLOGY DRUGS

pen needle, diabetic

needle 29 gauge x 1/2" NonPrefBrand-4 NO ENDOCRINE/DIABETES

DIABETES THERAPY

penicillin G pot in dextrose

piggyback 3 million unit/50 mL


PENICILLINS




Quantity Limit Days

Authorization



penicillin G pot in dextrose

piggyback 2 million unit/50 mL


PENICILLINS

penicillin G potassium

recon soln 5 million unit Generic-2 NO ANTI - INFECTIVES

PENICILLINS

penicillin G procaine

syringe 1.2 million unit/2 mL


PENICILLINS

penicillin G sodium

recon soln 5 million unit Generic-2 NO ANTI - INFECTIVES

PENICILLINS

penicillin V potassium

recon soln 250 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS


recon soln 125 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES

PENICILLINS



PENICILLINS



PENICILLINS

Pentam recon soln 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES


Pentasa capsule, extended release



Pentasa capsule, extended release



pentazocine-naloxone

tablet 50-0.5 mg Generic-2 335 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



pentoxifylline



COAGULATION THERAPY

Percocet tablet 10-325 mg

NonPrefBrand-4

372 31


NARCOTIC ANALGESICS

Percocet tablet 2.5-325 mg

NonPrefBrand-4

372 31


NARCOTIC ANALGESICS

Percocet tablet 5-325 mg

NonPrefBrand-4

372 31


NARCOTIC ANALGESICS

Percocet tablet 7.5-325 mg

NonPrefBrand-4

372 31


NARCOTIC ANALGESICS

Perforomistsolution for nebulization 20 mcg/2 mL

NonPrefBrand-4 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

perindopril erbumine









Quantity Limit Days

Authorization






Periogard mouthwash 0.12 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS


Perjeta solution420 mg/14 mL (30 mg/mL)



permethrin cream 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


perphenazine tablet 16 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization



perphenazine-amitriptyline















Phenadoz suppository 12.5 mg Generic-2 NO RESPIRATORY AND ALLERGY


phenelzine tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Phenergan suppository 12.5 mg Generic-2 NO RESPIRATORY AND ALLERGY





Quantity Limit Days

Authorization



Phenergan suppository 25 mg Generic-2 NO RESPIRATORY AND ALLERGY


Phenergan suppository 50 mg Generic-2 NO RESPIRATORY AND ALLERGY


phenobarbital


ANTICONVULSANTS

phenobarbital


ANTICONVULSANTS

phenobarbital


ANTICONVULSANTS

phenobarbital


ANTICONVULSANTS

phenobarbital


ANTICONVULSANTS

phenobarbital


ANTICONVULSANTS




Quantity Limit Days

Authorization



phenobarbital


ANTICONVULSANTS

phenobarbital


ANTICONVULSANTS

phenobarbital

elixir 20 mg/5 mL (4 mg/mL)


ANTICONVULSANTS

phenoxybenzamine

capsule 10 mg Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Phenytek capsule 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Phenytek capsule 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

phenytoin suspension 125 mg/5 mL


ANTICONVULSANTS

phenytoin tablet,chewable 50 mg


ANTICONVULSANTS




Quantity Limit Days

Authorization



phenytoin sodium solution 50 mg/mL


ANTICONVULSANTS

phenytoin sodium extended


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Phoslyra solution667 mg (169 mg calcium)/5 mL

NonPrefBrand-4 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

Phospholine Iodide

drops 0.125 % PrefBrand-3 NO OPHTHALMOLOGY

CHOLINESTERASE INHIBITOR MIOTICS

Picato gel 0.05 %

PrefBrand-3 NODERMATOLOGICALS/TOPICAL THERAPY


Picato gel 0.015 %

PrefBrand-3 NODERMATOLOGICALS/TOPICAL THERAPY


pilocarpine HCl drops 1 %


DIRECT ACTING MIOTICS




Quantity Limit Days

Authorization









pilocarpine HCl tablet 5 mg



pilocarpine HCl tablet 7.5 mg



pimozide tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


pimozide tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Pimtrea (28) tablet0.15-0.02 mgx21 /0.01 mg x 5

Generic-2 NO



pindolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


pindolol tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


pioglitazone tablet 30 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization




DIABETES THERAPY


DIABETES THERAPY

pioglitazone-glimepiride


DIABETES THERAPY

pioglitazone-glimepiride


DIABETES THERAPY

pioglitazone-metformin


DIABETES THERAPY

pioglitazone-metformin


DIABETES THERAPY

piperacillin-tazobactam

recon soln 40.5 gram Generic-2 NO ANTI - INFECTIVES

PENICILLINS

piperacillin-tazobactam recon soln 3.375 gram


piperacillin-tazobactam recon soln 4.5 gram


Pirmella tablet 1-35 mg-mcg

Generic-2 NO



piroxicam capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


piroxicam capsule 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Plasma-Lyte 148

parenteral solution






Quantity Limit Days

Authorization



Plasma-Lyte A

parenteral solution



Plasma-Lyte-56 in 5 % dextrose




Plegridy syringe 125 mcg/0.5 mL

Specialty-5

1 28


BIOTECHNOLOGY DRUGS

Plegridy pen injector 125 mcg/0.5 mL

Specialty-5

1 28


BIOTECHNOLOGY DRUGS

Plegridy pen injector63 mcg/0.5 mL- 94 mcg/0.5 mL

Specialty-5

1 28


BIOTECHNOLOGY DRUGS

podofilox solution 0.5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


polyethylene glycol 3350

powder 17 gram/dose Generic-2 NO GASTROENTEROLOGY


polymyxin B sulfate

recon soln 500,000 unit Generic-2 NO ANTI - INFECTIVES


polymyxin B sulf-trimethoprim

drops 10,000 unit- 1 mg/mL


ANTIBIOTICS




Quantity Limit Days

Authorization




Specialty-5

21 28




Specialty-5

21 28




Specialty-5

21 28




Specialty-5

21 28



Portia tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


potassium chlorid-D5-0.45%NaCl

parenteral solution

20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES


parenteral solution


ELECTROLYTES


parenteral solution


ELECTROLYTES


parenteral solution


ELECTROLYTES




Quantity Limit Days

Authorization



potassium chloride


20 mEq PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

potassium chloride

solution 2 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

potassium chloride



ELECTROLYTES

potassium chloride

piggyback 10 mEq/100 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

potassium chloride


ELECTROLYTES

potassium chloride

liquid 20 mEq/15 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

potassium chloride


ELECTROLYTES

potassium chloride



ELECTROLYTES

potassium chloride

liquid 40 mEq/15 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

potassium chloride



ELECTROLYTES

potassium chloride



ELECTROLYTES




Quantity Limit Days

Authorization



potassium chloride in 0.9%NaCl

parenteral solution


ELECTROLYTES

potassium chloride in 0.9%NaCl

parenteral solution


ELECTROLYTES

potassium chloride in 5 % dex

parenteral solution


ELECTROLYTES

potassium chloride in 5 % dex

parenteral solution


ELECTROLYTES

potassium chloride in LR-D5

parenteral solution


ELECTROLYTES

potassium chloride-0.45 % NaCl

parenteral solution


ELECTROLYTES

potassium chloride-D5-0.2%NaCl

parenteral solution


ELECTROLYTES


parenteral solution


ELECTROLYTES


parenteral solution


ELECTROLYTES


parenteral solution


ELECTROLYTES




Quantity Limit Days

Authorization



potassium citrate


5 mEq (540 mg) Generic-2 NO UROLOGICALS MISCELLANEOUS UROLOGICALS

potassium citrate


10 mEq (1,080 mg)

PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS

potassium citrate


15 mEq Generic-2 NO UROLOGICALS MISCELLANEOUS UROLOGICALS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Potiga tablet 50 mg


ANTICONVULSANTS

Pradaxa capsule 150 mg

PrefBrand-3

62 31


COAGULATION THERAPY


PrefBrand-3

62 31


COAGULATION THERAPY




Quantity Limit Days

Authorization




PrefBrand-3

62 31


COAGULATION THERAPY

Praluent Pen pen injector 150 mg/mL

Specialty-5

2 28



Praluent Pen pen injector 75 mg/mL

Specialty-5

2 28



Praluent Syringe syringe 150 mg/mL

Specialty-5

2 28



Praluent Syringe syringe 75 mg/mL

Specialty-5

2 28



pramipexole tablet 0.75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH









Quantity Limit Days

Authorization







pramipexole tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


pramipexole tablet extended release 24 hr


















Quantity Limit Days

Authorization



pramipexoletablet extended release 24 hr 2.25 mg



pravastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








prazosin capsule 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS









Quantity Limit Days

Authorization



Pred-G drops,suspension

0.3-1 % NonPrefBrand-4 NO OPHTHALMOLOGY


Pred-G S.O.P.

ointment 0.3-0.6 % NonPrefBrand-4 NO OPHTHALMOLOGY


prednicarbate



prednicarbate



prednisolone acetate

drops,suspension 1 %

PrefBrand-3 NO OPHTHALMOLOGY STEROIDS

prednisolone sodium phosphate



ADRENAL HORMONES




ADRENAL HORMONES


solution 5 mg base/5 mL (6.7 mg/5 mL)


ADRENAL HORMONES


drops 1 % Generic-2 NO OPHTHALMOLOGY

STEROIDS




ADRENAL HORMONES




Quantity Limit Days

Authorization






ADRENAL HORMONES




ADRENAL HORMONES

prednisone tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABETES

ADRENAL HORMONES


ADRENAL HORMONES

prednisone tablet 2.5 mg PrefGen-1 NO ENDOCRINE/DIABETES

ADRENAL HORMONES


ADRENAL HORMONES


ADRENAL HORMONES


ADRENAL HORMONES

prednisone solution 5 mg/5 mL PrefGen-1 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

Prednisone Intensol

concentrate 5 mg/mL Generic-2 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

Prefest tablet 1 mg (15)/1 mg- 0.09 mg (15)



Pregnyl recon soln 10,000 unit NonPrefBrand-4 YES ENDOCRINE/DIABETES


Premarin cream 0.625 mg/gram PrefBrand-3 NO OBSTETRICS / GYNECOLOGY


Premasol 10 %

parenteral solution

10 % Generic-2 YES VITAMINS, HEMATINICS / ELECTROLYTES





Quantity Limit Days

Authorization



Premasol 6 %

parenteral solution



Prenatal Vitamin Plus Low Iron

tablet 27 mg iron- 1 mg Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

VITAMINS / HEMATINICS

Prepopikpowder in packet

10 mg-3.5 gram-12 gram

NonPrefBrand-4 NO

GASTROENTEROLOGY


Prevalite powder 4 gram Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Previfem tablet 0.25-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


Prezcobix tablet 800-150 mg-mgPrefBrand-3 NO ANTI -

INFECTIVES ANTIVIRALSPrezista tablet 600 mg Specialty-5 NO ANTI -

INFECTIVESANTIVIRALS

Prezista tablet 75 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Prezista tablet 150 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Prezista suspension 100 mg/mLPrefBrand-3 NO ANTI -


Prezista tablet 800 mgSpecialty-5 NO ANTI -





Quantity Limit Days

Authorization



Priftin tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES


primaquine tablet 26.3 mg PrefBrand-3 NO ANTI - INFECTIVES


primidone tablet 250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

primidone tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Primlev tablet 5-300 mg

NonPrefBrand-4

403 31


NARCOTIC ANALGESICS

Primlev tablet 10-300 mg

NonPrefBrand-4

403 31


NARCOTIC ANALGESICS

Primlev tablet 7.5-300 mg

NonPrefBrand-4

403 31


NARCOTIC ANALGESICS

Pristiq tablet extended release 24 hr






Quantity Limit Days

Authorization



Pristiq tablet extended release 24 hr



Pristiqtablet extended release 24 hr 25 mg



Privigen solution 10 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


ProAir HFA HFA aerosol inhaler

90 mcg/actuation PrefBrand-3 17 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

ProAir RespiClick

aerosol powdr breath activated 90 mcg/actuation

PrefBrand-3

2 30

NORESPIRATORY AND ALLERGY

PULMONARY AGENTS

probenecid tablet 500 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

procainamide

solution 100 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


procainamide



Procalamine 3%

parenteral solution






Quantity Limit Days

Authorization



ProCentra solution 5 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


prochlorperazine

suppository 25 mg Generic-2 NO GASTROENTEROLOGY


prochlorperazine Edisylate




prochlorperazine maleate



prochlorperazine maleate



Procrit solution 3,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization




BIOTECHNOLOGY DRUGS

Procrit solution 40,000 unit/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Procrit solution 10,000 unit/mL


BIOTECHNOLOGY DRUGS

Procto-Pak cream 1 % Generic-2 NO GASTROENTEROLOGY


Proctosol HC cream 2.5 %

Generic-2 NO

GASTROENTEROLOGY


Proctozone-HC cream 2.5 %

Generic-2 NO

GASTROENTEROLOGY


Procysbicapsule, delayed rel sprinkle 25 mg

Specialty-5 YES

UROLOGICALSMISCELLANEOUS UROLOGICALS

Procysbicapsule, delayed rel sprinkle 75 mg

Specialty-5 YES

UROLOGICALSMISCELLANEOUS UROLOGICALS

progesterone micronized

capsule 100 mg Generic-2 NO OBSTETRICS / GYNECOLOGY





Quantity Limit Days

Authorization



progesterone micronized

capsule 200 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Proglycem suspension 50 mg/mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Prograf capsule 1 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Prograf capsule 5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Prograf solution 5 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Prograf capsule 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Prolastin-C recon soln 1,000 mg



Proleukin recon soln 22 million unit Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Prolia syringe 60 mg/mL NonPrefBrand-4 1 180 YES MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



Promacta tablet 25 mg Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY

Promacta tablet 12.5 mg


COAGULATION THERAPY

promethazine

syrup 6.25 mg/5 mL Generic-2 YES RESPIRATORY AND ALLERGY


promethazine

suppository 12.5 mg Generic-2 NO RESPIRATORY AND ALLERGY


promethazine

suppository 25 mg Generic-2 NO RESPIRATORY AND ALLERGY


promethazine






Quantity Limit Days

Authorization



promethazine

suppository 50 mg Generic-2 NO RESPIRATORY AND ALLERGY


promethazine



Promethazine VC syrup 6.25-5 mg/5 mL

Generic-2 NO



Promethegan suppository 25 mg Generic-2 NO RESPIRATORY AND ALLERGY


Promethegan suppository 50 mg Generic-2 NO RESPIRATORY AND ALLERGY


propafenone capsule,extended release 12 hr












Quantity Limit Days

Authorization



propafenone tablet 150 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






propantheline



propranolol solution 1 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


propranolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS




propranolol capsule,extended release 24 hr






Quantity Limit Days

Authorization


















propranolol solution 20 mg/5 mL (4 mg/mL)



propranolol solution 40 mg/5 mL (8 mg/mL)






Quantity Limit Days

Authorization



propranolol-hydrochlorothiazid



propranolol-hydrochlorothiazid



propylthiouracil


ANTITHYROID AGENTS

ProQuad (PF)


10exp3-4.3-3- 3.99 TCID50/0.5



Prosol 20 % parenteral solution



protriptyline tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


protriptyline tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Provigil tablet 200 mg Specialty-5 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Provigil tablet 100 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Prudoxin cream 5 %

Generic-2 NODERMATOLOGICALS/TOPICAL THERAPY


Pulmicort suspension for nebulization

0.5 mg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS


1 mg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS



PULMONARY AGENTS

Pulmozyme solution 1 mg/mL Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Purixan suspension 20 mg/mL



Pylera capsule 140-125-125 mgNonPrefBrand-4 NO GASTROENTERO

LOGY ULCER THERAPYpyrazinamide



pyridostigmine bromide







Quantity Limit Days

Authorization



pyridostigmine bromide



Quadracel (PF) suspension

15 Lf-48 mcg- 5 Lf unit/0.5mL



Quasense tablets,dose pack,3 month

0.15-30 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


quetiapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


quetiapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization





Quillivant XR

suspension,ext rel 24hr,recon

5 mg/mL (25 mg/5 mL)



quinapril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








quinapril-hydrochlorothiazide









Quantity Limit Days

Authorization






quinidine gluconate




quinidine gluconate



quinidine sulfate



quinidine sulfate



quinine sulfate capsule 324 mg

Generic-2 NO

ANTI - INFECTIVES


Qvar aerosol 40 mcg/actuation PrefBrand-3 8.7 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Qvar aerosol 80 mcg/actuationPrefBrand-3

17.4 30NO RESPIRATORY


RabAvert (PF)


2.5 unit NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



rabeprazole tablet,delayed release (DR/EC)


ULCER THERAPY

Ragwitek tablet 12 Amb a 1 unit



raloxifene tablet 60 mg

PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY


ramipril capsule 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


ramipril capsule 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


ramipril capsule 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


ramipril capsule 1.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Ranexa tablet extended release 12 hr

1,000 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



Ranexa tablet extended release 12 hr



ranitidine HCl

capsule 150 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

ranitidine HCl

tablet 150 mg PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

ranitidine HCl

capsule 300 mg Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

ranitidine HCl

tablet 300 mg PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

ranitidine HCl

solution 25 mg/mL PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

ranitidine HCl

syrup 15 mg/mL PrefGen-1 NO GASTROENTEROLOGY

ULCER THERAPY

Rapaflo capsule 8 mg PrefBrand-3 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Rapaflo capsule 4 mg PrefBrand-3 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

Rapamune solution 1 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Rapamune tablet 1 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Rapamune tablet 2 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Rapamune tablet 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Rasuvo (PF) auto-injector 10 mg/0.2 mL



Rasuvo (PF) auto-injector 12.5 mg/0.25 mL


















Quantity Limit Days

Authorization















Ravicti liquid 1.1 gram/mL



REBETOL solution 40 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Rebif (with albumin)

syringe 44 mcg/0.5 mL Specialty-5 6 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Rebif (with albumin)

syringe 22 mcg/0.5 mL Specialty-5 6 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Rebif Rebidose pen injector 22 mcg/0.5 mL

Specialty-5

6 28


BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



Rebif Rebidose pen injector 44 mcg/0.5 mL

Specialty-5

6 28


BIOTECHNOLOGY DRUGS

Rebif Rebidose pen injector

8.8mcg/0.2mL-22 mcg/0.5mL (6)

Specialty-5

4.2 365


BIOTECHNOLOGY DRUGS

Rebif Titration Pack

syringe 8.8mcg/0.2mL-22 mcg/0.5mL (6)

Specialty-5 8.4 365 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Reclipsen (28)

tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Recombivax HB (PF)

syringe 10 mcg/mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Recombivax HB (PF)

syringe 5 mcg/0.5 mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Recombivax HB (PF)

suspension 40 mcg/mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



Recombivax HB (PF) suspension 10 mcg/mL



Rectiv ointment 0.4 % (w/w)

NonPrefBrand-4 NO

GASTROENTEROLOGY


Regranex gel 0.01 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


Relenza Diskhaler

blister with device

5 mg/actuation PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Relistor solution 12 mg/0.6 mL NonPrefBrand-4 18.6 31 NO GASTROENTEROLOGY


Relistor syringe 12 mg/0.6 mL

NonPrefBrand-4

18.6 31

NO

GASTROENTEROLOGY


Relistor syringe 8 mg/0.4 mL

NonPrefBrand-4

12.4 31

NO

GASTROENTEROLOGY


Relpax tablet 20 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Relpax tablet 40 mg NonPrefBrand-4 6 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Remicade recon soln 100 mg Specialty-5 8 28 YES GASTROENTEROLOGY


Remodulin solution 1 mg/mL Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS


Remodulin solution 2.5 mg/mL Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS






Renagel tablet 400 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Renagel tablet 800 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Renvela tablet 800 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS





Quantity Limit Days

Authorization



Renvela powder in packet

2.4 gram PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Renvela powder in packet

0.8 gram PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


repaglinide tablet 1 mg Generic-2 NO ENDOCRINE/DIABETES

DIABETES THERAPY

repaglinide tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

repaglinide tablet 2 mg Generic-2 NO ENDOCRINE/DIABETES

DIABETES THERAPY

repaglinide-metformin

tablet 1-500 mg Generic-2 NO ENDOCRINE/DIABETES

DIABETES THERAPY

repaglinide-metformin

tablet 2-500 mg Generic-2 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Repatha SureClick pen injector 140 mg/mL

Specialty-5

2 28



Repatha Syringe syringe 140 mg/mL

Specialty-5

2 28



Reprexain tablet 5-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Reprexain tablet 10-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Rescriptor tablet, dispersible

100 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Rescriptor tablet 200 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

reserpine tablet 0.1 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


reserpine tablet 0.25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Restasis dropperette 0.05 % PrefBrand-3 NO OPHTHALMOLOGY


Retin-A Micro Pump gel with pump 0.08 %


THERAPY FOR ACNE

Retrovir solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Retrovir capsule 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Retrovir syrup 10 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Revatio tablet 20 mg Specialty-5 93 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Revatio solution 10 mg/12.5 mL Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Revatiosuspension for reconstitution 10 mg/mL

Specialty-5224 31


PULMONARY AGENTS




Quantity Limit Days

Authorization



Revlimid capsule 10 mg Specialty-5 21 28 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS








Revlimid capsule 2.5 mg

Specialty-5

21 28



Revlimid capsule 20 mg

Specialty-5

21 28




Specialty-5

31 31




Specialty-5

31 31






Quantity Limit Days

Authorization



Rexulti tablet 1 mg

Specialty-5

31 31



Rexulti tablet 2 mg

Specialty-5

31 31



Rexulti tablet 3 mg

Specialty-5

31 31



Rexulti tablet 4 mg

Specialty-5

31 31



Reyataz capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS


ANTIVIRALS


ANTIVIRALS

Reyatazpowder in packet 50 mg


Rheumatrextablets,dose pack

2.5 mg (dose pack 8)










Quantity Limit Days

Authorization











Rheumatrextablets,dose pack 2.5 mg



Ribasphere capsule 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Ribasphere tablet 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Ribasphere tablet 400 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Ribasphere tablet 600 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Ribasphere RibaPak

tablets,dose pack

600-400 mg (28)-mg (28)


ANTIVIRALS

Ribasphere RibaPak

tablets,dose pack

400-400 mg (28)-mg (28)


ANTIVIRALS

Ribasphere RibaPak

tablets,dose pack

600-600 mg (28)-mg (28)


ANTIVIRALS

ribavirin tablet 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

ribavirin capsule 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Ridaura capsule 3 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY


rifabutin capsule 150 mg Generic-2 NO ANTI - INFECTIVES


rifampin capsule 150 mg Generic-2 NO ANTI - INFECTIVES


rifampin capsule 300 mg Generic-2 NO ANTI - INFECTIVES


rifampin recon soln 600 mg Generic-2 NO ANTI - INFECTIVES


Rifater tablet 50-120-300 mg NonPrefBrand-4 NO ANTI - INFECTIVES


Rilutek tablet 50 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


riluzole tablet 50 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


rimantadine tablet 100 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



ringers parenteral solution


ELECTROLYTES

ringers solution Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Riomet solution 500 mg/5 mL NonPrefBrand-4 791 31 YES ENDOCRINE/DIABETES

DIABETES THERAPY

risedronate tablet 35 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY




risedronate tablet 30 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS




risedronate tablet 35 mg (4 pack) Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY


risedronate tablet 35 mg (12 pack) Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



risedronate


Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY


Risperdal tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




Risperdal tablet 3 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH




Risperdal tablet 0.25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Risperdal tablet 0.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Risperdal solution 1 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Risperdal Consta

syringe 12.5 mg/2 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Risperdal Consta

syringe 37.5 mg/2 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Risperdal Consta

syringe 50 mg/2 mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Risperdal Consta

syringe 25 mg/2 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Risperdal M-TAB




Risperdal M-TAB




Risperdal M-TAB




Risperdal M-TAB







Quantity Limit Days

Authorization



Risperdal M-TAB




risperidone solution 1 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


risperidone tablet 0.25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


risperidone tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


risperidone tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization



risperidone tablet,disintegrating







0.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Ritalin LAcapsule,ER biphasic 50-50 10 mg

NonPrefBrand-4

186 31



Rituxan concentrate 10 mg/mL






Quantity Limit Days

Authorization



rivastigmine patch 24 hour 4.6 mg/24 hr Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


rivastigmine patch 24 hour 9.5 mg/24 hr Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


rivastigmine patch 24 hour 13.3 mg/24 hour



rivastigmine tartrate







capsule 1.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH



capsule 4.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


rizatriptan tablet,disintegrating






Quantity Limit Days

Authorization



rizatriptan tablet,disintegrating



rizatriptan tablet 5 mg Generic-2 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


rizatriptan tablet 10 mg Generic-2 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Rocaltrol solution 1 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Rocaltrol capsule 0.25 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES


Rocaltrol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES


ropinirole tablet 3 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ropinirole tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


ropinirole tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization











ropinirole tablet extended release 24 hr















Quantity Limit Days

Authorization






rosuvastatin tablet 40 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








Rotarix suspension for reconstitution

10exp6 CCID50/mL



RotaTeq Vaccine

suspension 2 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



Roweepra tablet 500 mg


ANTICONVULSANTS


NonPrefBrand-4

186 31


NARCOTIC ANALGESICS


NonPrefBrand-4

138 31


NARCOTIC ANALGESICS


NonPrefBrand-4

186 31


NARCOTIC ANALGESICS

Rozerem tablet 8 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Ruconest recon soln 2,100 unitSpecialty-5 YES RESPIRATORY


Sabril tablet 500 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Sabril powder in packet


ANTICONVULSANTS




Quantity Limit Days

Authorization



Safyral tablet3-0.03-0.451 mg (21/7)

NonPrefBrand-4 NO



Saizen recon soln 5 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Saizen recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Saizen click.easy

cartridge 8.8 mg/1.5 mL (Fnl)


BIOTECHNOLOGY DRUGS

Samsca tablet 15 mg Specialty-5 NO ENDOCRINE/DIABETES


Samsca tablet 30 mg Specialty-5 NO ENDOCRINE/DIABETES


Sancuso patch weekly 3.1 mg/24 hour NonPrefBrand-4 NO GASTROENTEROLOGY


Sandimmune capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sandimmune capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Sandimmune solution 250 mg/5 mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sandimmune solution 100 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sandostatin solution 100 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sandostatin solution 200 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sandostatin solution 1,000 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sandostatin LAR Depot

suspension,extended rel recon

20 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS













Quantity Limit Days

Authorization



Santyl ointment 250 unit/gram


TOPICAL ENZYMES

Saphris (black cherry)



Saphris (black cherry)



Saphris (black cherry) tablet 2.5 mg




NonPrefBrand-4

31 31


COAGULATION THERAPY


NonPrefBrand-4

31 31


COAGULATION THERAPY


NonPrefBrand-4

31 31


COAGULATION THERAPY

Savella tablet 100 mg NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY





Quantity Limit Days

Authorization



Savella tablet 12.5 mg NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY






Savella tablets,dose pack

12.5 mg (5)-25 mg(8)-50 mg(42)



selegiline HCl



selegiline HCl



selenium sulfide



Selzentry tablet 150 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Selzentry tablet 300 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Semprex-D capsule 8-60 mg

NonPrefBrand-4 NO



Sensipar tablet 30 mg PrefBrand-3 NO ENDOCRINE/DIABETES


Sensipar tablet 60 mg Specialty-5 NO ENDOCRINE/DIABETES


Sensipar tablet 90 mg Specialty-5 NO ENDOCRINE/DIABETES


Serevent Diskus

blister with device

50 mcg/dose NonPrefBrand-4 60 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Seroquel XR tablet extended release 24 hr


















Quantity Limit Days

Authorization



Serostim recon soln 4 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS


BIOTECHNOLOGY DRUGS

sertraline tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






sertraline concentrate 20 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Setlakintablets,dose pack,3 month 0.15-30 mg-mcg

Generic-2 NO






Quantity Limit Days

Authorization



Signifor solution 0.3 mg/mL (1 mL)









Signifor LAR




Signifor LAR




Signifor LAR




sildenafil tablet 20 mg PrefBrand-3 93 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

sildenafil solution 10 mg/12.5 mL Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Silenor tablet 3 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Silenor tablet 6 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


silver sulfadiazine

cream 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY

BURN THERAPY

Simbrinzadrops,suspension 1-0.2 %

PrefBrand-3 NOOPHTHALMOLOGY


Simponi syringe 50 mg/0.5 mL Specialty-5 0.5 28 YES MUSCULOSKELETAL / RHEUMATOLOGY


Simponi syringe 100 mg/mL

Specialty-5

1 28



Simponi pen injector 50 mg/0.5 mL

Specialty-5

0.5 28



Simponi pen injector 100 mg/mL

Specialty-5

1 28



Simponi ARIA solution 12.5 mg/mL

Specialty-5

16 28






Quantity Limit Days

Authorization



Simulect recon soln 20 mg



simvastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS










sirolimus tablet 1 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


sirolimus tablet 2 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



sirolimus tablet 0.5 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sirturo tablet 100 mg

Specialty-5 NO

ANTI - INFECTIVES


Sivextro tablet 200 mg

Specialty-5

6 31

NO

ANTI - INFECTIVES


Sivextro recon soln 200 mg

Specialty-5 NO

ANTI - INFECTIVES


sodium chloride

parenteral solution

2.5 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

sodium chloride

solution 0.9 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


sodium chloride 0.45 %

parenteral solution

0.45 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

sodium chloride 0.9 %

parenteral solution

0.9 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


sodium chloride 3 %

parenteral solution

3 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES




Quantity Limit Days

Authorization



sodium chloride 5 %

parenteral solution

5 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

sodium fluoride

tablet 1 mg fluoride (2.2 mg)


VITAMINS / HEMATINICS

sodium lactate

solution 5 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

sodium phenylbutyrate

powder 0.94 gram/gram Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


sodium polystyrene (sorb free)

suspension 15 gram/60 mL Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Soltamox solution 10 mg/5 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Solu-Cortef (PF)

recon soln 100 mg/2 mL NonPrefBrand-4 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

Solu-Cortef (PF) recon soln 250 mg/2 mL


ADRENAL HORMONES

Solu-Medrol recon soln 2 gramNonPrefBrand-4 NO ENDOCRINE/DIA

BETESADRENAL HORMONES

Solu-Medrol (PF)


ADRENAL HORMONES

Solu-Medrol (PF)

recon soln 40 mg/mL NonPrefBrand-4 NO ENDOCRINE/DIABETES

ADRENAL HORMONES

Solu-Medrol (PF)


ADRENAL HORMONES




Quantity Limit Days

Authorization



Somatuline Depot

syringe 60 mg/0.2 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Somatuline Depot



Somatuline Depot



Somavert recon soln 10 mg Specialty-5 NO ENDOCRINE/DIABETES






Somavert recon soln 30 mgSpecialty-5 NO ENDOCRINE/DIA


Somavert recon soln 25 mgSpecialty-5 NO ENDOCRINE/DIA


Soriatane capsule 10 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


Soriatane capsule 25 mg NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



Soriatane capsule 17.5 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


Sorine tablet 120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








sotalol tablet 160 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS









Quantity Limit Days

Authorization



Sotalol AF tablet 120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Sotylize solution 5 mg/mL



Sovaldi tablet 400 mgSpecialty-5

28 28YES ANTI -

INFECTIVES ANTIVIRALSSpiriva Respimat mist 2.5 mcg/actuation

PrefBrand-34 30


PULMONARY AGENTS

Spiriva Respimat mist

1.25 mcg/actuation

PrefBrand-34 30


PULMONARY AGENTS

Spiriva with HandiHaler

capsule, w/inhalation device

18 mcg PrefBrand-3 30 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

spironolactone



spironolactone



spironolactone



spironolacton-hydrochlorothiaz






Quantity Limit Days

Authorization



Sporanox solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Sprintec (28) tablet 0.25-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


Spritamtablet for suspension 1,000 mg


ANTICONVULSANTS

Spritamtablet for suspension 250 mg


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

Sprycel tablet 20 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS







Quantity Limit Days

Authorization








Specialty-5

31 31




Specialty-5

31 31



Sronyx tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY


SSD cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

BURN THERAPY

stavudine capsule 15 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS


ANTIVIRALS


ANTIVIRALS


ANTIVIRALS

stavudine recon soln 1 mg/mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Stelara syringe 45 mg/0.5 mL Specialty-5 0.5 28 YES DERMATOLOGICALS/TOPICAL THERAPY


Stelara syringe 90 mg/mL Specialty-5 1 28 YES DERMATOLOGICALS/TOPICAL THERAPY


Stimate spray,non-aerosol

150 mcg/spray (0.1 mL)



Stiolto Respimat mist

2.5-2.5 mcg/actuation

PrefBrand-34 30


PULMONARY AGENTS

Stivarga tablet 40 mg



Strattera capsule 10 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH











Quantity Limit Days

Authorization









Strensiq solution 40 mg/mLSpecialty-5 YES ENDOCRINE/DIA


Strensiq solution 100 mg/mLSpecialty-5 YES ENDOCRINE/DIA


streptomycin recon soln 1 gram PrefBrand-3 NO ANTI - INFECTIVES


Striant mucoadhesive System ER 12 hr

30 mg NonPrefBrand-4 YES ENDOCRINE/DIABETES


Stribild tablet150-150-200-300 mg


Striverdi Respimat mist 2.5 mcg/actuation

NonPrefBrand-44 30


PULMONARY AGENTS

Suboxone film 2-0.5 mg

PrefBrand-3

93 31






Quantity Limit Days

Authorization



Suboxone film 8-2 mg

PrefBrand-3

93 31




PrefBrand-3

93 31




PrefBrand-3

62 31



Subsysspray,non-aerosol 100 mcg/spray

Specialty-5

124 31


NARCOTIC ANALGESICS


Specialty-5

124 31


NARCOTIC ANALGESICS


Specialty-5

86 31


NARCOTIC ANALGESICS


Specialty-5

57 31


NARCOTIC ANALGESICS


Specialty-5

43 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Sucraid solution 8,500 unit/mL Specialty-5 NO GASTROENTEROLOGY


sucralfate tablet 1 gram Generic-2 NO GASTROENTEROLOGY

ULCER THERAPY

sulfacetamide sodium ointment 10 %

PrefGen-1 NO OPHTHALMOLOGY SULFONAMIDES

sulfacetamide sodium drops 10 %

Generic-2 NO OPHTHALMOLOGY SULFONAMIDES

sulfacetamide sodium (acne) suspension 10 %



sulfacetamide-prednisolone drops

10 %-0.23 % (0.25 %)

Generic-2 NO

OPHTHALMOLOGY


sulfadiazine tablet 500 mg Generic-2 NO ANTI - INFECTIVES

SULFA'S / RELATED AGENTS

sulfamethoxazole-trimethoprim

tablet 400-80 mg PrefGen-1 NO ANTI - INFECTIVES



tablet 800-160 mg PrefGen-1 NO ANTI - INFECTIVES



suspension 200-40 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES



solution 400-80 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



Sulfamylon cream 85 mg/g PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY


sulfasalazine tablet 500 mg Generic-2 NO GASTROENTEROLOGY


sulfasalazine tablet,delayed release (DR/EC)



sulindac tablet 150 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


sulindac tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


sumatriptan spray,non-aerosol

5 mg/actuation Generic-2 32 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


sumatriptan spray,non-aerosol

20 mg/actuation Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


sumatriptan succinate






Quantity Limit Days

Authorization







solution 6 mg/0.5 mL Generic-2 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






syringe 6 mg/0.5 mL Generic-2 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


sumatriptan succinate pen injector 6 mg/0.5 mL

Generic-2

4 31



sumatriptan succinate cartridge 6 mg/0.5 mL

Generic-2

4 31



sumatriptan succinate cartridge 4 mg/0.5 mL

Generic-2

6 31



Sumavel DosePro

needle-free injector

6 mg/0.5 mL NonPrefBrand-4 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Sumavel DosePro

needle-free injector 4 mg/0.5 mL

NonPrefBrand-4

6 31



Suprax suspension for reconstitution

100 mg/5 mL PrefBrand-3 NO ANTI - INFECTIVES

CEPHALOSPORINS

Suprax suspension for reconstitution

200 mg/5 mL PrefBrand-3 NO ANTI - INFECTIVES

CEPHALOSPORINS

Suprax capsule 400 mgPrefBrand-3 NO ANTI -


Supraxsuspension for reconstitution 500 mg/5 mL


CEPHALOSPORINS

Suprep Bowel Prep Kit recon soln

17.5-3.13-1.6 gram

PrefBrand-3 NO

GASTROENTEROLOGY


Surmontil capsule 50 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






Sustiva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Sustiva capsule 50 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Sustiva tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Sutent capsule 12.5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sutent capsule 25 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sutent capsule 50 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Sutent capsule 37.5 mg



Sylatron kit 300 mcg


BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS




Quantity Limit Days

Authorization



Sylvant recon soln 100 mg



SymbicortHFA aerosol inhaler

80-4.5 mcg/actuation

PrefBrand-310.2 30


PULMONARY AGENTS

SymbicortHFA aerosol inhaler

160-4.5 mcg/actuation

PrefBrand-310.2 30


PULMONARY AGENTS

SymlinPen 120

pen injector 2,700 mcg/2.7 mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

SymlinPen 60

pen injector 1,500 mcg/1.5 mL PrefBrand-3 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Synagis solution 50 mg/0.5 mLSpecialty-5 NO ANTI -


Synalgos-DC capsule 16-356.4-30 mg

NonPrefBrand-4

300 30


NARCOTIC ANALGESICS

Synarel spray,non-aerosol

2 mg/mL Specialty-5 NO ENDOCRINE/DIABETES


Synercid recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES


Synribo recon soln 3.5 mg



Synthroid tablet 25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES


THYROID HORMONES




Quantity Limit Days

Authorization




THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES

Syprine capsule 250 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


Tabloid tablet 40 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Taclonex suspension 0.005-0.064 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY





Quantity Limit Days

Authorization



tacrolimus capsule 1 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


tacrolimus capsule 5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


tacrolimus ointment 0.03 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY


tacrolimus capsule 0.5 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


tacrolimus ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY









Specialty-5

31 31






Quantity Limit Days

Authorization




Specialty-5

31 31



Taltz Autoinjector (3 Pack) auto-injector 80 mg/mL

Specialty-5

1 28



Taltz Syringe syringe 80 mg/mL

Specialty-5

1 28



Tamiflu capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS


ANTIVIRALS


ANTIVIRALS

Tamiflususpension for reconstitution 6 mg/mL


tamoxifen tablet 10 mg PrefGen-1 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


tamoxifen tablet 20 mg PrefGen-1 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


tamsulosin capsule,extended release 24hr

0.4 mg PrefGen-1 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY




Quantity Limit Days

Authorization




Specialty-5

31 31




Specialty-5

31 31




Specialty-5

31 31



Targretin capsule 75 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Targretin gel 1 % Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Tasigna capsule 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Tasigna capsule 150 mg



Tasmar tablet 100 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



TAZICEF recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES

CEPHALOSPORINS

TAZICEF recon soln 1 gramNonPrefBrand-4 NO ANTI -


TAZICEF recon soln 2 gramNonPrefBrand-4 NO ANTI -


Tazorac gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Tazorac gel 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Tazorac cream 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Tazorac cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Taztia XT capsule, extended release












Quantity Limit Days

Authorization









Tecentriq solution1,200 mg/20 mL (60 mg/mL)



Tecfideracapsule,delayed release(DR/EC) 120 mg

Specialty-5

62 31



Tecfideracapsule,delayed release(DR/EC) 240 mg

Specialty-5

62 31



Tecfideracapsule,delayed release(DR/EC)

120 mg (14)- 240 mg (46)

Specialty-5

120 365



Technivie tablet 12.5-75-50 mgSpecialty-5

56 28YES ANTI -


Teflaro recon soln 400 mgNonPrefBrand-4 NO ANTI -


Teflaro recon soln 600 mgNonPrefBrand-4 NO ANTI -





Quantity Limit Days

Authorization



Tegretol suspension 100 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Tegretol tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Tegretol XR tablet extended release 12 hr


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS







Tekturna HCT tablet 150-12.5 mg






Quantity Limit Days

Authorization



Tekturna HCT tablet 150-25 mg



Tekturna HCT tablet 300-12.5 mg



Tekturna HCT tablet 300-25 mg



telmisartan tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






telmisartan-amlodipine









Quantity Limit Days

Authorization









telmisartan-hydrochlorothiazid









temazepam capsule 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


temazepam capsule 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


temazepam capsule 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



temazepam capsule 22.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Tencon tablet 50-325 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Tenivac (PF) syringe 5-2 Lf unit/0.5 mL



terazosin capsule 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








terbinafine HCl

tablet 250 mg PrefGen-1 90 180 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

terbutaline solution 1 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS




Quantity Limit Days

Authorization



terbutaline tablet 2.5 mg Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

terbutaline tablet 5 mg Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

terconazole suppository 80 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


terconazole cream 0.4 % Generic-2 NO OBSTETRICS / GYNECOLOGY


terconazole cream 0.8 % Generic-2 NO OBSTETRICS / GYNECOLOGY


Testim gel50 mg/5 gram (1 %)



testosteronegel in metered-dose pump

1.25 gram/ actuation (1 %)



testosteronegel in metered-dose pump

10 mg/0.5 gram /actuation



testosterone gel in packet1 % (25 mg/2.5gram)



testosterone gel in packet1 % (50 mg/5 gram)



testosterone cypionate

oil 100 mg/mL Generic-2 YES ENDOCRINE/DIABETES


testosterone cypionate



testosterone enanthate



tetanus,diphtheria tox ped(PF) suspension

5-25 Lf unit/0.5 mL






Quantity Limit Days

Authorization



tetanus-diphtheria toxoids-Td

suspension 2-2 Lf unit/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


tetrabenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


tetrabenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


tetracycline capsule 250 mg Generic-2 NO ANTI - INFECTIVES

TETRACYCLINES

tetracycline capsule 500 mg Generic-2 NO ANTI - INFECTIVES

TETRACYCLINES

Thalomid capsule 50 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS











Quantity Limit Days

Authorization



Theo-24 capsule,extended release 24hr

100 mg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS



PULMONARY AGENTS



PULMONARY AGENTS



PULMONARY AGENTS

theophylline tablet extended release 12 hr


PULMONARY AGENTS

theophylline tablet extended release


PULMONARY AGENTS

theophylline solution 80 mg/15 mL Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS



PULMONARY AGENTS



PULMONARY AGENTS



PULMONARY AGENTS

theophylline tablet extended release


PULMONARY AGENTS

Thiola tablet 100 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


thioridazine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH







Quantity Limit Days

Authorization







thiotepa recon soln 15 mg



thiothixene capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH








Thymoglobulin

recon soln 25 mg NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



Thyrolar-1 tablet 12.5-50 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES

Thyrolar-1/2 tablet 6.25-25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES

Thyrolar-1/4 tablet 3.1-12.5 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES

Thyrolar-2 tablet 25-100 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES

Thyrolar-3 tablet 37.5-150 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES

tiagabine tablet 2 mg


ANTICONVULSANTS

tiagabine tablet 4 mg


ANTICONVULSANTS

Tikosyn capsule 125 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






timolol maleate


BETA-BLOCKERS




Quantity Limit Days

Authorization



timolol maleate



timolol maleate



timolol maleate



timolol maleate

gel forming solution


BETA-BLOCKERS

timolol maleate

gel forming solution


BETA-BLOCKERS

timolol maleate


BETA-BLOCKERS

Timoptic Ocudose (PF)

dropperette 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY

BETA-BLOCKERS

Timoptic Ocudose (PF)

dropperette 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY

BETA-BLOCKERS

tinidazole tablet 500 mg Generic-2 NO ANTI - INFECTIVES


tinidazole tablet 250 mg Generic-2 NO ANTI - INFECTIVES





Quantity Limit Days

Authorization



Tirosint capsule 112 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES

THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES

Tivicay tablet 50 mgSpecialty-5 NO ANTI -


Tivicay tablet 10 mgNonPrefBrand-4 NO ANTI -


Tivicay tablet 25 mgSpecialty-5 NO ANTI -

INFECTIVES ANTIVIRALStizanidine tablet 2 mg Generic-2 NO AUTONOMIC /

CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



tizanidine tablet 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


tizanidine capsule 6 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






Tobi solution for nebulization

300 mg/5 mL NonPrefBrand-4 YES ANTI - INFECTIVES


Tobi Podhaler

capsule, w/inhalation device 28 mg

PrefBrand-3 YES

ANTI - INFECTIVES


TobraDex ointment 0.3-0.1 % PrefBrand-3 NO OPHTHALMOLOGY


Tobradex STdrops,suspension 0.3-0.05 %

PrefBrand-3 NO

OPHTHALMOLOGY





Quantity Limit Days

Authorization



tobramycin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY

ANTIBIOTICS

tobramycin in 0.225 % NaCl


300 mg/5 mL Specialty-5 YES ANTI - INFECTIVES


tobramycin sulfate

solution 10 mg/mL PrefGen-1 NO ANTI - INFECTIVES


tobramycin sulfate

solution 40 mg/mL PrefGen-1 NO ANTI - INFECTIVES


tobramycin-dexamethasone

drops,suspension

0.3-0.1 % Generic-2 NO OPHTHALMOLOGY


Tobrex ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY

ANTIBIOTICS

Tolak cream 4 %

NonPrefBrand-4 NODERMATOLOGICALS/TOPICAL THERAPY


tolazamide tablet 250 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

tolazamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY

tolbutamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABETES

DIABETES THERAPY




Quantity Limit Days

Authorization



tolcapone tablet 100 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


tolmetin capsule 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


tolmetin tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


tolterodine tablet 1 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

tolterodine capsule,extended release 24hr


tolterodine capsule,extended release 24hr


tolterodine tablet 2 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Topamax tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS

Topamax capsule, sprinkle


ANTICONVULSANTS

Topamax capsule, sprinkle


ANTICONVULSANTS

topiramate tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS

topiramate capsule, sprinkle


ANTICONVULSANTS

topiramate capsule, sprinkle


ANTICONVULSANTS

topiramatecapsule,sprinkle,ER 24hr 50 mg


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS




Quantity Limit Days

Authorization



Toposar solution 20 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


topotecan recon soln 4 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Torisel recon soln 30 mg/3 mL (10 mg/mL) (first)



torsemide tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








Toujeo SoloStar insulin pen

300 unit/mL (1.5 mL)


DIABETES THERAPY




Quantity Limit Days

Authorization



Toviaz tablet extended release 24 hr

4 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Toviaz tablet extended release 24 hr

8 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Tracleer tablet 62.5 mg Specialty-5 62 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Tracleer tablet 125 mg Specialty-5 62 31 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Tradjenta tablet 5 mgPrefBrand-3 NO ENDOCRINE/DIA


tramadol tablet extended release 24 hr



tramadol tablet extended release 24 hr



tramadol tablet, ER multiphase 24 hr



tramadol tablet 50 mg PrefGen-1 240 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



tramadol

capsule,ER biphase 24 hr 25-75 100 mg

NonPrefBrand-4

30 30



tramadol


NonPrefBrand-4

30 30



tramadol


NonPrefBrand-4

30 30



tramadol-acetaminophen

tablet 37.5-325 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


trandolapril tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






trandolapril-verapamil

tablet, IR - ER, biphasic 24hr






Quantity Limit Days

Authorization















tranexamic acid

solution 1,000 mg/10 mL (100 mg/mL)


COAGULATION THERAPY

tranexamic acid

tablet 650 mg Generic-2 NO OBSTETRICS / GYNECOLOGY


Transderm-Scop

patch 3 day 1.5 mg (1 mg over 3 days)



tranylcypromine



Travasol 10 %

parenteral solution

10 % Generic-2 YES VITAMINS, HEMATINICS / ELECTROLYTES


Travatan Z drops 0.004 % PrefBrand-3 NO OPHTHALMOLOGY





Quantity Limit Days

Authorization



travoprost (benzalkonium)



trazodone tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


trazodone tablet 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






Treanda recon soln 100 mg



Trecator tablet 250 mg NonPrefBrand-4 NO ANTI - INFECTIVES


Trelstar suspension for reconstitution

22.5 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



Trelstar syringe 3.75 mg/2 mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Trelstar syringe 11.25 mg/2 mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Tresiba FlexTouch U-100 insulin pen

100 unit/mL (3 mL)


DIABETES THERAPY

Tresiba FlexTouch U-200 insulin pen

200 unit/mL (3 mL)


DIABETES THERAPY

tretinoin cream 0.025 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE


THERAPY FOR ACNE


THERAPY FOR ACNE

tretinoin gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE


THERAPY FOR ACNE


THERAPY FOR ACNE




Quantity Limit Days

Authorization



tretinoin (chemotherapy)

capsule 10 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


tretinoin microspheres

gel with pump 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

tretinoin microspheres

gel with pump 0.04 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY

THERAPY FOR ACNE

Trexall tablet 5 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS




Trexall tablet 7.5 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS




Treximet tablet 85-500 mg NonPrefBrand-4 10 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


triamcinolone acetonide cream 0.1 %






Quantity Limit Days

Authorization



triamcinolone acetonide ointment 0.025 %















triamcinolone acetonide paste 0.1 %



triamcinolone acetonide aerosol 0.147 mg/gram



triamcinolone acetonide lotion 0.025 %



triamcinolone acetonide lotion 0.1 %



triamterene-hydrochlorothiazid






Quantity Limit Days

Authorization




capsule 37.5-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS



tablet 37.5-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Trianex ointment 0.05 %



triazolam tablet 0.125 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


triazolam tablet 0.25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Tribenzor tablet 20-5-12.5 mg









Quantity Limit Days

Authorization



Tribenzor tablet 40-10-25 mg






Tribenzor tablet 40-5-25 mg



Triderm cream 0.1 %



trifluoperazine



trifluoperazine



trifluoperazine



trifluoperazine



trifluridine drops 1 % Generic-2 NO OPHTHALMOLOGY

ANTIVIRALS




Quantity Limit Days

Authorization



trihexyphenidyl



trihexyphenidyl

elixir 0.4 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


trihexyphenidyl



Tri-Legest Fe tablet

1-20(5)/1-30(7) /1mg-35mcg (9)

Generic-2 NO



Trileptal tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS

Trileptal suspension 300 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS




Quantity Limit Days

Authorization



Tri-Lo-Estarylla tablet

0.18/0.215/0.25 mg-25 mcg

Generic-2 NO



Tri-Lo-Sprintec

tablet 0.18/0.215/0.25 mg-25 mcg



TriLyte With Flavor Packets

recon soln 420 gram Generic-2 NO GASTROENTEROLOGY


trimethoprim tablet 100 mg Generic-2 NO ANTI - INFECTIVES


trimipramine capsule 100 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH






TriNessa (28)

tablet 0.18/0.215/0.25 mg-35 mcg (28)






Quantity Limit Days

Authorization












Tri-Previfem (28)

tablet 0.18/0.215/0.25 mg-35 mcg (28)



Trisenox solution 10 mg/10 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Tri-Sprintec (28)

tablet 0.18/0.215/0.25 mg-35 mcg (28)



Triumeq tablet 600-50-300 mgSpecialty-5 NO ANTI -

INFECTIVES ANTIVIRALSTrivora (28) tablet 50-30 (6)/75-40

(5)/125-30(10)Generic-2 NO OBSTETRICS /

GYNECOLOGYORAL CONTRACEPTIVES / RELATED AGENTS

Trizivir tablet 300-150-300 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS




Quantity Limit Days

Authorization



Trokendi XRcapsule,extended release 24hr 50 mg


ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS



ANTICONVULSANTS

TrophAmine 10 %




Trophamine 6%


PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES


trospium tablet 20 mg Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

trospium capsule,extended release 24hr

60 mg Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS




Quantity Limit Days

Authorization



Trumenba syringe 120 mcg/0.5 mL



Truvada tablet 200-300 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Truvada tablet 100-150 mgSpecialty-5 NO ANTI -





INFECTIVES ANTIVIRALSTwinrix (PF) suspension 720 Elisa unit -20

mcg/mLPrefBrand-3 NO IMMUNOLOGY,

VACCINES / BIOTECHNOLOGY


Tybost tablet 150 mgPrefBrand-3 NO ANTI -

INFECTIVES ANTIVIRALSTygacil recon soln 50 mg Specialty-5 NO ANTI -

INFECTIVESMISCELLANEOUS ANTIINFECTIVES

Tykerb tablet 250 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Tylenol-Codeine #3

tablet 300-30 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Tylenol-Codeine #4


NARCOTIC ANALGESICS

Typhim VI solution 25 mcg/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Typhim VI syringe 25 mcg/0.5 mL



Tysabri solution 300 mg/15 mL Specialty-5 15 28 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Tyvaso solution for nebulization

1.74 mg/2.9 mL (0.6 mg/mL)

Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Tyzeka tablet 600 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Uloric tablet 40 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

Uloric tablet 80 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

Unithroid tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABETES

THYROID HORMONES




Quantity Limit Days

Authorization




THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES


THYROID HORMONES

Uptravi tablet 1,000 mcg

Specialty-5

62 31




Specialty-5

62 31




Specialty-5

62 31






Quantity Limit Days

Authorization




Specialty-5

62 31



Uptravi tablet 200 mcg

Specialty-5

144 28




Specialty-5

62 31




Specialty-5

62 31




Specialty-5

62 31



Uptravitablets,dose pack

200 mcg (140)- 800 mcg (60)

Specialty-5

200 28



ursodiol tablet 500 mg PrefBrand-3 NO GASTROENTEROLOGY


ursodiol capsule 300 mg PrefBrand-3 NO GASTROENTEROLOGY





Quantity Limit Days

Authorization



ursodiol tablet 250 mg PrefBrand-3 NO GASTROENTEROLOGY


Uvadex solution 20 mcg/mL NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Vagifem tablet 10 mcg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY


valacyclovir tablet 1 gram Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

valacyclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Valchlor gel 0.016 %

NonPrefBrand-4 YESDERMATOLOGICALS/TOPICAL THERAPY


Valcyte tablet 450 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Valcyte recon soln 50 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

valganciclovir

tablet 450 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

valproate sodium solution

500 mg/5 mL (100 mg/mL)


ANTICONVULSANTS

valproic acid capsule 250 mg


ANTICONVULSANTS




Quantity Limit Days

Authorization



valproic acid (as sodium salt) solution 250 mg/5 mL


ANTICONVULSANTS

valsartan tablet 80 mg Generic-2 62 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS








valsartan-hydrochlorothiazide







tablet 160-25 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization







tablet 320-25 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Vancocin capsule 125 mg Specialty-5 NO ANTI - INFECTIVES

VANCOMYCIN

Vancocin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES

VANCOMYCIN

vancomycin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES

VANCOMYCIN

vancomycin capsule 125 mg NonPrefBrand-4 NO ANTI - INFECTIVES

VANCOMYCIN

vancomycin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES

VANCOMYCIN

vancomycin recon soln 1,000 mg Generic-2 NO ANTI - INFECTIVES

VANCOMYCIN

vancomycin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES

VANCOMYCIN

Vandazole gel 0.75 % Generic-2 NO OBSTETRICS / GYNECOLOGY


Vaqta (PF) syringe 50 unit/mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY





Quantity Limit Days

Authorization



Vaqta (PF) syringe 25 unit/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY


Varivax (PF)suspension for reconstitution 1,350 unit/0.5 mL



Varizig solution 125 unit/1.2 mL



Varubi tablet 90 mg

NonPrefBrand-4 YES

GASTROENTEROLOGY


Vascepa capsule 1 gram



Vecamyl tablet 2.5 mg



Vectibix solution100 mg/5 mL (20 mg/mL)






Quantity Limit Days

Authorization



Velcade recon soln 3.5 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Velivet Triphasic Regimen (28)

tablet 0.1/.125/.15-25 mg-mcg



Velphoro tablet,chewable 500 mg



Veltassapowder in packet 8.4 gram

NonPrefBrand-4

30 30

YES DIAGNOSTICS / MISCELLANEOUS AGENTS



NonPrefBrand-4

30 30




NonPrefBrand-4

30 30















Quantity Limit Days

Authorization



Venclexta Starting Pack

tablets,dose pack

10 mg-50 mg- 100 mg



venlafaxine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


venlafaxine capsule,extended release 24hr






37.5 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


venlafaxine tablet 37.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH










Quantity Limit Days

Authorization





venlafaxine tablet extended release 24hr












Ventavis solution for nebulization

10 mcg/mL Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Ventavis solution for nebulization

20 mcg/mL Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Ventolin HFA

HFA aerosol inhaler

90 mcg/actuation PrefBrand-3 36 30 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Veramyst spray,suspension

27.5 mcg/actuation

NonPrefBrand-4 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

verapamil capsule, 24 hr ER pellet CT






Quantity Limit Days

Authorization









verapamil capsule,ext rel. pellets 24 hr












verapamil tablet extended release









Quantity Limit Days

Authorization






verapamil tablet 120 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS






verapamil solution 2.5 mg/mL



Veregen ointment 15 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY


Veripred 20 solution 20 mg/5 mL (4 mg/mL)


ADRENAL HORMONES

Versacloz suspension 50 mg/mL






Quantity Limit Days

Authorization



Vesicare tablet 10 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Vesicare tablet 5 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

Vestura (28) tablet 3-0.02 mg

Generic-2 NO



Vfend tablet 50 mg Specialty-5 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Vfend tablet 200 mg Specialty-5 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

Vfend suspension for reconstitution

200 mg/5 mL (40 mg/mL)


ANTIFUNGAL AGENTS


Specialty-5

62 31

YES

GASTROENTEROLOGY



Specialty-5

62 31

YES

GASTROENTEROLOGY


Vicodin tablet 5-300 mg

Generic-2

403 31


NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Vicodin ES tablet 7.5-300 mg

Generic-2

403 31


NARCOTIC ANALGESICS

Vicodin HP tablet 10-300 mg

Generic-2

403 31


NARCOTIC ANALGESICS

Victoza 3-Pak

pen injector 0.6 mg/0.1 mL (18 mg/3 mL)

PrefBrand-3 9 30 NO ENDOCRINE/DIABETES

DIABETES THERAPY

Vidaza recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Videx 2 gram Pediatric

recon soln 10 mg/mL (Final) PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Videx EC capsule,delayed release(DR/EC)


ANTIVIRALS



ANTIVIRALS



ANTIVIRALS



ANTIVIRALS




Quantity Limit Days

Authorization



Viekira Paktablets,dose pack

12.5 mg-75 mg -50 mg/250 mg

Specialty-5112 28

YES ANTI - INFECTIVES ANTIVIRALS

Vienva tablet 0.1-20 mg-mcg

Generic-2 NO



Vigamox drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY

ANTIBIOTICS










Viibrydtablets,dose pack

10 mg (7)- 20 mg (23)



Vimovo tablet,IR,delayed rel,biphasic



Vimovo tablet,IR,delayed rel,biphasic






Quantity Limit Days

Authorization



Vimpat solution 200 mg/20 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Vimpat tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS


ANTICONVULSANTS

Vimpat solution 10 mg/mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

vinblastine solution 1 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Vincasar PFS

solution 1 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS





Quantity Limit Days

Authorization



vincristine solution 1 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


vinorelbine solution 50 mg/5 mL



Viracept tablet 250 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Viracept tablet 625 mg Specialty-5 NO ANTI - INFECTIVES

ANTIVIRALS

Viramune suspension 50 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Viramune XR



Viramune XR



Virazole recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Viread tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

Viread tablet 250 mgPrefBrand-3 NO ANTI -






Viread powder40 mg/scoop (40 mg/gram)


Vitekta tablet 85 mgSpecialty-5 NO ANTI -





Quantity Limit Days

Authorization



Vitekta tablet 150 mgSpecialty-5 NO ANTI -

INFECTIVES ANTIVIRALSVivitrol suspension,exte

nded rel recon380 mg NonPrefBrand-4 NO AUTONOMIC /

CNS DRUGS, NEUROLOGY / PSYCH


Vogelxogel in metered-dose pump

1.25 gram/ actuation (1 %)



Vogelxo gel50 mg/5 gram (1 %)



Voltaren gel 1 % NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


voriconazole tablet 200 mg Specialty-5 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

voriconazole tablet 50 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

voriconazole solution 200 mg Generic-2 NO ANTI - INFECTIVES

ANTIFUNGAL AGENTS

voriconazole suspension for reconstitution

200 mg/5 mL (40 mg/mL)


ANTIFUNGAL AGENTS

Votrient tablet 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


VPRIV recon soln 400 unit Specialty-5 NO ENDOCRINE/DIABETES



Specialty-5

31 31






Quantity Limit Days

Authorization




Specialty-5

31 31




Specialty-5

31 31




Specialty-5

31 31



Vraylarcapsule,dose pack

1.5 mg (1)- 3 mg (6)

NonPrefBrand-4

14 365



Vyfemla (28) tablet 0.4-35 mg-mcg

Generic-2 NO



Vyvanse capsule 20 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH









Quantity Limit Days

Authorization









Vyvanse capsule 10 mg

NonPrefBrand-4

31 31



warfarin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY

warfarin tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY




Quantity Limit Days

Authorization




COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY


COAGULATION THERAPY

warfarin tablet 7.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS

COAGULATION THERAPY

water for irrigation, sterile

solution Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS


WelChol powder in packet

3.75 gram PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


WelChol tablet 625 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS





Quantity Limit Days

Authorization



Wellbutrin SR




Wellbutrin SR




Wellbutrin SR




Wellbutrin XL




Wellbutrin XL





Specialty-5

62 31




Specialty-5

62 31



Xanax tablet 0.25 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Xanax tablet 0.5 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Xanax tablet 1 mg NonPrefBrand-4 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Xanax tablet 2 mg NonPrefBrand-4 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Xanax XR tablet extended release 24 hr










0.5 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Xarelto tablet 10 mg

PrefBrand-3

31 31


COAGULATION THERAPY




Quantity Limit Days

Authorization




PrefBrand-3

52 31


COAGULATION THERAPY


PrefBrand-3

31 31


COAGULATION THERAPY

Xareltotablets,dose pack

15 mg (42)- 20 mg (9)

PrefBrand-3

51 30


COAGULATION THERAPY

Xeljanz tablet 5 mg

Specialty-5

62 31



Xeljanz XRtablet extended release 24 hr 11 mg

Specialty-5

31 31



Xenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Xenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Xeomin recon soln 50 unit






Quantity Limit Days

Authorization



Xgeva solution120 mg/1.7 mL (70 mg/mL)


ADJUNCTIVE AGENTS

Xifaxan tablet 200 mg NonPrefBrand-4 9 3 NO ANTI - INFECTIVES


Xifaxan tablet 550 mg Specialty-5 62 31 YES ANTI - INFECTIVES


Xigduo XRtablet, IR - ER, biphasic 24hr 10-1,000 mg


DIABETES THERAPY

Xigduo XRtablet, IR - ER, biphasic 24hr 5-500 mg


DIABETES THERAPY

Xigduo XRtablet, IR - ER, biphasic 24hr 5-1,000 mg


DIABETES THERAPY

Xigduo XRtablet, IR - ER, biphasic 24hr 10-500 mg


DIABETES THERAPY

Xodol 10/300


NARCOTIC ANALGESICS

Xodol 5/300 tablet 5-300 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS

Xodol 7.5/300

tablet 7.5-300 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Xolair recon soln 150 mgSpecialty-5 NO RESPIRATORY


Xopenex solution for nebulization


PULMONARY AGENTS



PULMONARY AGENTS



PULMONARY AGENTS

Xtampza ERcapsule,sprinkle,ER 12hr tmprr 9 mg

NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

Xtampza ERcapsule,sprinkle,ER 12hr tmprr 13.5 mg

NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS


NonPrefBrand-4

62 31


NARCOTIC ANALGESICS

Xtandi capsule 40 mg

Specialty-5

124 31






Quantity Limit Days

Authorization



Xyrem solution 500 mg/mL Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Yervoy solution50 mg/10 mL (5 mg/mL)



YF-Vax (PF)suspension for reconstitution

10 exp4.74 unit/0.5 mL



zafirlukast tablet 20 mg Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

zafirlukast tablet 10 mg Generic-2 NO RESPIRATORY AND ALLERGY

PULMONARY AGENTS

zaleplon capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


zaleplon capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Zaltrap solution100 mg/4 mL (25 mg/mL)



Zamicet solution 10-325 mg/15 mL Generic-2 5723 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

NARCOTIC ANALGESICS




Quantity Limit Days

Authorization



Zanosar recon soln 1 gram NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Zarontin capsule 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Zarontin solution 250 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Zarxio syringe 300 mcg/0.5 mL


BIOTECHNOLOGY DRUGS

Zarxio syringe 480 mcg/0.8 mL


BIOTECHNOLOGY DRUGS

Zavesca capsule 100 mg Specialty-5 NO ENDOCRINE/DIABETES


Zebutal capsule 50-325-40 mg

Generic-2

372 31


NARCOTIC ANALGESICS

Zelapar tablet,disintegrating

1.25 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Zelboraf tablet 240 mg



Zemaira recon soln 1,000 mg Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS


Zembrace Symtouch pen injector 3 mg/0.5 mL

NonPrefBrand-4

8 31



Zemplar solution 5 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Zemplar solution 2 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES


Zemplar capsule 1 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES


Zemplar capsule 2 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES


Zenatane capsule 30 mg


THERAPY FOR ACNE

Zenchent Fe tablet,chewable0.4mg-35mcg(21) and 75 mg (7)

Generic-2 NO



Zenpep capsule,delayed release(DR/EC)

10,000-34,000 -55,000 unit






Quantity Limit Days

Authorization




15,000-51,000 -82,000 unit




20,000-68,000 -109,000 unit




5,000-17,000 -27,000 unit



Zenpepcapsule,delayed release(DR/EC)

3,000-10,000- 16,000 unit

PrefBrand-3 NO

GASTROENTEROLOGY



25,000-85,000- 136,000 unit

PrefBrand-3 NO

GASTROENTEROLOGY



40,000-136,000- 218,000 unit

PrefBrand-3 NO

GASTROENTEROLOGY





Zenzedi tablet 5 mg






Quantity Limit Days

Authorization


















Zepatier tablet 50-100 mgSpecialty-5

28 28YES ANTI -


Zerbaxa recon soln 1.5 gramNonPrefBrand-4 NO ANTI -


Zerit capsule 15 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS


ANTIVIRALS


ANTIVIRALS


ANTIVIRALS




Quantity Limit Days

Authorization



Zerit recon soln 1 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Zetia tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS


Ziagen tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES

ANTIVIRALS

Ziagen solution 20 mg/mL PrefBrand-3 NO ANTI - INFECTIVES

ANTIVIRALS

zidovudine capsule 100 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

zidovudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

zidovudine syrup 10 mg/mL Generic-2 NO ANTI - INFECTIVES

ANTIVIRALS

Zinecard (as HCl) recon soln 250 mg


ADJUNCTIVE AGENTS

Zioptan (PF) dropperette 0.0015 %

NonPrefBrand-4 NOOPHTHALMOLOGY


ziprasidone HCl



ziprasidone HCl






Quantity Limit Days

Authorization



ziprasidone HCl



ziprasidone HCl



Zirgan gel 0.15 % NonPrefBrand-4 NO OPHTHALMOLOGY

ANTIVIRALS

Zmax suspension,extended rel recon

2 gram/60 mL NonPrefBrand-4 NO ANTI - INFECTIVES


Zofran (as hydrochloride)

tablet 4 mg Specialty-5 YES GASTROENTEROLOGY



tablet 8 mg Specialty-5 YES GASTROENTEROLOGY



solution 4 mg/5 mL Specialty-5 YES GASTROENTEROLOGY


Zofran ODT tablet,disintegrating

4 mg NonPrefBrand-4 YES GASTROENTEROLOGY


Zofran ODT tablet,disintegrating

8 mg Specialty-5 YES GASTROENTEROLOGY





Quantity Limit Days

Authorization



Zohydro ERcapsule, oral only, ER 12hr 10 mg

NonPrefBrand-4

100 31


NARCOTIC ANALGESICS


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS


NonPrefBrand-4

100 31


NARCOTIC ANALGESICS

zoledronic acid

solution 4 mg/5 mL Generic-2 NO ENDOCRINE/DIABETES


zoledronic acid-mannitol-water

solution 5 mg/100 mL Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS





Quantity Limit Days

Authorization



Zolinza capsule 100 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


zolmitriptan tablet 2.5 mg Generic-2 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


zolmitriptan tablet 5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


zolmitriptan tablet,disintegrating



zolmitriptan tablet,disintegrating



zolpidem tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


zolpidem tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


zolpidem tablet,ext release multiphase






Quantity Limit Days

Authorization



zolpidem tablet,ext release multiphase



zolpidem tablet 1.75 mg



zolpidem tablet 3.5 mg





BIOTECHNOLOGY DRUGS



BIOTECHNOLOGY DRUGS

Zometa solution 4 mg/5 mL Specialty-5 NO ENDOCRINE/DIABETES


Zometa solution 4 mg/100 mLSpecialty-5 NO ENDOCRINE/DIA


Zomig tablet 2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Zomig tablet 5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH





Quantity Limit Days

Authorization



Zomig spray,non-aerosol



Zomigspray,non-aerosol 2.5 mg

NonPrefBrand-4

16 31



Zomig ZMT tablet,disintegrating

2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH


Zomig ZMT tablet,disintegrating



Zonegran capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

Zonegran capsule 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

zonisamide capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS


ANTICONVULSANTS




Quantity Limit Days

Authorization




ANTICONVULSANTS

Zontivity tablet 2.08 mg


COAGULATION THERAPY

Zorbtive recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

Zortress tablet 0.25 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Zortress tablet 0.5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Zortress tablet 0.75 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS


Zostavax (PF)


19,400 unit/0.65 mL



Zosyn in dextrose (iso-osm) piggyback 2.25 gram/50 mL

PrefBrand-3 NOANTI - INFECTIVES PENICILLINS




Quantity Limit Days

Authorization



Zosyn in dextrose (iso-osm) piggyback 3.375 gram/50 mL

PrefBrand-3 NOANTI - INFECTIVES PENICILLINS

Zovia 1/35E (28)



Zovia 1/50E (28)



Zovirax cream 5 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY

TOPICAL ANTIVIRALS

Zubsolv tablet 1.4-0.36 mg

NonPrefBrand-4

93 31




NonPrefBrand-4

31 31




NonPrefBrand-4

62 31




NonPrefBrand-4

62 31






Quantity Limit Days

Authorization




NonPrefBrand-4

93 31



Zuplenz film 8 mg

NonPrefBrand-4 YES

GASTROENTEROLOGY


Zuplenz film 4 mg

NonPrefBrand-4 YES

GASTROENTEROLOGY


Zyclara cream in packet 3.75 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY


Zyclara

cream in metered-dose pump 2.5 %

NonPrefBrand-4 NODERMATOLOGICALS/TOPICAL THERAPY








Zyflo tablet 600 mg NonPrefBrand-4 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS

Zyflo CR tablet, ER multiphase 12 hr

600 mg Specialty-5 YES RESPIRATORY AND ALLERGY

PULMONARY AGENTS




Quantity Limit Days

Authorization



Zykadia capsule 150 mg



Zylet drops,suspension

0.3-0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY


Zyprexa Relprevv




Zytiga tablet 250 mg

Specialty-5

124 31



Zyvox tablet 600 mg Specialty-5 NO ANTI - INFECTIVES


Zyvox suspension for reconstitution

100 mg/5 mL Specialty-5 NO ANTI - INFECTIVES


Zyvoxparenteral solution 600 mg/300 mL

Specialty-5 NO

ANTI - INFECTIVES



1 Formulary ID: 17499 Version 7 Updated 01/2017

PA Group Covered Use Exclusion CriteriaRequired Medical Information

Age Restrictions

Prescriber Restrictions

Coverage Duration Other Criteria

actemra All FDA approved indications not otherwise excluded from Part D

concomitant use of Kineret, Remicade, Humira, Orencia, Enbrel, Simponi, Cimzia

Documentation of moderate to severe rheumatoid arthritis -OR- documentation of moderate to severe juvenile idiopathic rheumatoid arthritis (Actemra IV only)

12 months For Actemra SubQ, patients must have an adequate trial or intolerance to the preferred SubQ products, Enbrel and Humira, for rheumatoid arthritis. For Actemra IV, patients must have an adequate trial or intolerance to one of the preferred IV products, Remicade or Simponi Aria, for rheumatoid arthritis.




Age Restrictions


Coverage Duration Other Criteria1 monthneurologist

for infantile spasm

All medically accepted indications not otherwise excluded from Part D

acthar h.p. Covered for the following indications: 1. Infantile spasms (West syndrome) 2. Acute exacerbations of multiple sclerosis (MS) for patients receiving concurrent immunomodulator therapy (e.g., interferon beta, glatiramer acetate, dimethyl fumerate, fingolimod, teriflunomide) 3. Rheumatic disorders 4. Collagen diseases 5. Dermatologic diseases 6. Allergic states 7. Ophthalmic diseases 8. Respiratory diseases 9. Transfusion reaction due to serum protein

i 10




Age Restrictions



reaction 10. Proteinuria in nephrotic syndrome and trial/failure or contraindication to two therapies from any of the following different classes: corticosteroids (e.g., cortisone or dexamethasone), calcineurin inhibitors (e.g, cyclosporine or tacrolimus, per DRUGDEX). 11. Diagnosis for adrenal insufficiency with trial/failure or contraindication to cosyntropin. 12. Gout and intolerance or contraindication to at least two first-line gout therapies (e g




Age Restrictions



gout therapies (e.g, allopurinol, probenecid, colchicine). 13. Pediatric acquired epileptic aphasia. For covered indications 2 through 9, limited/unsatisfactory response or intolerance (i.e. severe anaphylaxis) to two corticosteroids (i.e. IV methylprednisolone, IV dexamethasone, or high dose oral steroids) must be documented.




Age Restrictions






Age Restrictions



actimmune All FDA approved indications not otherwise excluded from Part D

documentation of diagnosis

12 months Applies to new starts only




Age Restrictions



Diagnosis of pulmonary hypertension, substantiated by results from Doppler echocardiography and/or direct measurement of pulmonary arterial pressure, defined as a mean pulmonary arterial pressure of greater than or equal to 25 mmHg, with a pulmonary capillary wedge pressure of less than 15 mmHg -OR- diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) (WHO group 4) after surgical treatment or inoperable CTEPH.

12 monthscardiologist, pulmonologist

All FDA approved indications not otherwise excluded from Part D

adempas




Age Restrictions



ADHD Drugs All FDA approved indications not otherwise excluded from Part D

Documentation of ADHD -AND- trial/failure, intolerance or contraindication to a stimulant

12 months




Age Restrictions



oncologist 12 months Applies to new starts only. For renal cell carcinoma with clear cell histology additional trial/failure of cabozantinib or nivolumab per NCCN guidelines.

Documentation of advanced renal cell carcinoma and trial/failure with sunitinib or sorafenib for clear cell histology -OR- documentation of patients with progressive neuroendocrine tumors of pancreatic origin (PNET) that is unresectable, locally advanced or metastatic -OR- documentation of renal angiomyolipoma and tuberous sclerosis complex (TSC) -OR- documentation of use in postmenopausal advanced hormone

i i


afinitor




Age Restrictions



receptor-positive, HER2-negative breast cancer in combination with exemestane after failure of treatment with letrozole or anastrozole -OR- documentation of SEGA associated with tuberous sclerosis for those not a candidate for surgical resection.




Age Restrictions






Age Restrictions



alecensa All FDA approved indications not otherwise excluded from Part D

Documentation of metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK) positive AND previous trial and failure or intolerance to crizotinib (Xalkori)





Age Restrictions




ALPHA1-PROTEINASE INHIBITORS

Deny if less than 18 years of age

12 monthsDiagnosis of panacinar emphysema AND documentation of a decline in forced expiratory volume in 1 second (fev1) despite optimal medical therapy (bronchodilators, corticosteroids, oxygen if indicated) AND documentation of phenotype (pi*zz, pi*znull or pi*nullnull) associated with causing serum alpha 1-antitrypsin of less than 80 mg/dl AND documentation of an alpha 1-antitrypsin serum level below the value of 35% of normal (less than 80

/dl)

Covered under Part B when furnished incident to a physician service and is not self-administered.




Age Restrictions



mg/dl).




Age Restrictions



ampyra All FDA approved indications not otherwise excluded from Part D

history of seizure disorder, Cr Cl less than 50ml/min

Documentation of diagnosis -AND- baseline timed 25-foot walk test -AND- documentation that the patient is ambulatory and has walking impairment as evidenced by one of the following. 1. Functional status score (EDSS score). 2. Timed 25-foot Walk Test (T25W).

3 months initial authorization, 12 months reauthorization

Doses greater than 20 mg/day will not be approved. For reauthorization, documentation supporting 20% improvement in walking impairment from baseline is required.




Age Restrictions



anabolic steroids

Documentation of diagnosis -AND- either 1 or 2 when applicable to diagnosis. 1. For the diagnosis of anemia of chronic renal failure the trial/failure, intolerance or contraindication to an erythropoiesis stimulating agent is required. 2. For the diagnosis of osteoporosis the trial/failure, intolerance or contraindication to at least 2 federal legend drugs indicated for use in osteoporisis.

12 monthsAll medically accepted indications not otherwise excluded from Part D




Age Restrictions






Age Restrictions



atypical antipsychotics


documentation of diagnosis. If medication is being used for major depressive disorder, documentation of adjunctive therapy and an adequate trial of 1 alternative antidepressant is required (e.g. SSRI, SNRI, NDRIs, TCA, MAOI).


aubagio All FDA approved indications not otherwise excluded from Part D

Concomitant use of Aubagio and other disease modifying agents such as fingolimod, interferons, Copaxone , Tysabri

Documentation of relapsing-remitting or relapsing secondary progressive multiple sclerosis

neurologist 12 months Doses greater than 14 mg per day will not be approved




Age Restrictions



belbuca All FDA approved indications not otherwise excluded from Part D

documentation of moderate to severe chronic pain -AND- trial and failure of at least two previous federal legend medications for pain, including NSAIDs, tramadol, or opioid analgesics

12 months Belbuca should not be used concomitantly with substance abuse therapies.

BELEODAQ All FDA approved indications not otherwise excluded from Part D

Documentation of relapsed or refractory peripheral T-cell lymphoma (PTCL)





Age Restrictions



berinert All FDA approved indications not otherwise excluded from Part D

Documentation of use for treatment of acute abdominal, facial, or laryngeal attacks of hereditary angioedema (HAE)

Deny is less than 12 years of age

12 months

bosulif All FDA approved indications not otherwise excluded from Part D

Documentation of chronic myelogenous leukemia (CML) of any phase and lack of response or intolerance to prior therapy (e.g. imatinib, dasatinib, nilotinib)


botulinum toxin


Use for cosmetic purposes Documentation of diagnosis

12 months




Age Restrictions



Documentation of diagnosis -AND- Either 1, 2, or 3. 1) For oral immediate release (IR) tablets, trial/failure of generic metformin (IR). 2) For oral extended release (ER) tablets, trial/failure of generic metformin IR and metformin ER (i.e. generic Glucophage XR). 3) For Riomet oral solution, trial/failure of generic metformin IR OR documentation supporting the inability to swallow or difficulty swallowing tablets containing metformin.


brand metformin

12 months




Age Restrictions



brand NSAIDs


Documentation of diagnosis AND trial/failure of at least 2 generic formulary NSAIDs (e.g. diclofenac, ibuprofen, etc.) or contraindication to all oral NSAIDs.

12 months




Age Restrictions



butrans All FDA approved indications not otherwise excluded from Part D

documentation of moderate to severe chronic pain -AND- trial and failure of at least two previous federal legend medications for pain, including NSAIDs, tramadol, or opioid analgesics

12 months Butrans should not be used concomitantly with substance abuse therapies.

cabometyx All FDA approved indications not otherwise excluded from Part D

Documentation of advanced renal cell carcinoma (RCC) and failure of one prior anti-angiogenic therapy





Age Restrictions



caprelsa All FDA approved indications not otherwise excluded from Part D

documentation of symptomatic or progressive medullary thyroid cancer in patients with unresectable locally advanced or metastatic disease


carbaglu All FDA approved indications not otherwise excluded from Part D

Documentation of use as an adjunct therapy for acute hyperammonemia or maintenance therapy for chronic hyperammonemia due to hepatic enzyme N-acetylglutamate synthase (NAGS) deficiency

12 months




Age Restrictions



CERDELGA All FDA approved indications not otherwise excluded from Part D

Documentation of type 1 Gaucher disease


12 months

CF drugs All FDA approved indications not otherwise excluded from Part D

Diagnosis of cystic fibrosis. For Bethkis: failure on, intolerance to, or contraindication to generic tobramycin inhalation solution

12 months Inhalation solutions covered under Part B when administered in the home setting using a covered nebulizer (i.e. DME).




Age Restrictions



chenodal All FDA approved indications not otherwise excluded from Part D

Documentation of small (less than 15mm in diameter), floatable radiolucent gallstones AND an inadequate response to ursodiol therapy

12 months for initial approval with an additional 12 months upon renewal

Safety of use beyond 24 months is not established




Age Restrictions



cholbam Documentation of bile acid synthesis disorders due to single enzyme defects (SEDs) -OR- documentation of use as adjunctive therapy for peroxisomal disorders (PDs), including Zellweger spectrum disorders, in patients who exhibit manifestations of liver disease, steatorrhea, or complications from decreased fat soluble vitamin absorption.

12 monthsAll FDA approved indications not otherwise excluded from Part D




Age Restrictions



cialis All FDA approved indications not otherwise excluded from Part D

Documentation of benign prostatic hyperplasia (BPH) and trial/failure of at least two alternative medications in the following classes (alpha-1 adrenergic blockers and/or 5-alpha reductase inhibitors)

12 months




Age Restrictions



cimzia All FDA approved indications not otherwise excluded from Part D

concomitant use of Enbrel, Remicade, Humira, Orencia, Simponi, Actemra, Kineret

Documentation of moderate to severe rheumatoid arthritis -OR- moderate to severe Crohn's disease -OR- psoriatic arthritis -OR- ankylosing spondylitis

Gastroenterologist/ Rheumatologist

12 months Patients must have an adequate trial or intolerance to one corticosteorid (e.g., prednisone or hydrocortisone) or Remicade-AND- the preferred biologic product, Humira, for a diagnosis of Crohn's disease. Patients must have an adequate trial or intolerance to both preferred products, Enbrel and Humira, for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. For initial and indication therapy dosing, doses above plan quantity limit will be approved aligned with recommended initial and induction therapy dosing regimens per indication.




Age Restrictions



cinryze All FDA approved indications not otherwise excluded from Part D

12 monthsCoverage for the following two indications: 1. Use as prophylaxis for hereditary angioedema (HAE) type I & II -AND- documentation that clinical laboratory performance C4 below lower limit of laboratory reference range -AND- C1 inhibitor level below lower limit of laboratory reference range -OR- normal C1 inhibitor level and a low C1INH functional level below laboratory reference range -AND- documentation of at least 1 symptom of angioedema attack -AND di i




Age Restrictions



AND- medications that cause angioedema have been evaluated and discontinued. 2. Use as prophylaxis for hereditary angioedema (HAE) type III -AND- documentation that clinical laboratory performance C4, C1 inhibitor, and C1INH functional level are within normal limits of laboratory reference ranges -AND-documentation of family history of HAE -OR- FXII mutation -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that ca se




Age Restrictions



that cause angioedema have been evaluated and discontinued.




Age Restrictions



cometriq All FDA approved indications not otherwise excluded from Part D

Documentation of progressive, metastatic medullary thyroid cancer





Age Restrictions




corlanor Documentation of stable, symptomatic heart failure and normal sinus rhythm AND left ventricular ejection fraction less than or equal to 35 percent AND resting heart rate greater than or equal to 70 beats per minute AND trial/failure of maximum tolerated dose of one beta-blocker used for treatment of heart failure (e.g., bisoprolol, carvedilol, metoprolol succinate) OR contraindication to beta-blocker use

12 months




Age Restrictions



Cosentyx All FDA approved indications not otherwise excluded from Part D

Documentation of moderate to severe psoriasis and failure of one systemic therapy (e.g. methotrexate, cyclosporine) or phototherapy -OR- active psoriatic arthritis -OR- active ankylosing spondylitis.

12 months Patients must have an adequate trial or intolerance to the preferred product, Humira, for psoriasis and the preferred products, Enbrel and Humira, for psoriatic arthritis and ankylosing spondylitis. For induction therapy dosing, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimens per indication.

cotellic All FDA approved indications not otherwise excluded from Part D

Disease progression on prior BRAF inhibitor therapy

Documentation of unresectable or metastatic melanoma in patients with a BRAF V600E or V600K mutation AND used in combination with vemurafenib

oncologist, hematologist





Age Restrictions



crinone All medically accepted indications not otherwise excluded from Part D

Use to promote fertility Documentation of diagnosis

12 months

daklinza All FDA approved indications not otherwise excluded from Part D

Criteria will be applied consistent with current AASLD/IDSA guidance


G1,3:12w txnncr,txexncr,24w txncr,txexcr,R/INFinel.G2:12w txn,24w txex INFinel.G1-4al:12w,24w Rinel

Combination therapy with Sovaldi + Daklinza for 24 weeks in GT3 patients will only be approved if the patient has a contraindication to Sovaldi+ Peginterferon+ Ribavirin therapy.




Age Restrictions



darzalex All FDA approved indications not otherwise excluded from Part D

Documentation for use in the treatment of multiple myeloma in patients who have received at least 3 prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent OR for use in multiple myeloma patients who are double-refractory to a PI and an immunomodulatory agent






Age Restrictions



duexis All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis -AND- Both of the following. 1) Trial/failure of ibuprofen used in combination with famotidine. 2) Trial/failure of one additional generic formulary NSAID (other than ibuprofen) used in combination with one additional generic formulary H2-receptor blocker (other than famotidine).


12 months




Age Restrictions



egfr tyrosine kinase inhibitors


Documentation of diagnosis -AND- both of the following. 1) Epidermal growth factor receptor (EGFR) mutations, if applicable to diagnosis. 2) Alternatives tried/failed and concomitant therapy, if applicable to diagnosis


12 months Coverage of pancreatic cancer diagnosis applies only to erlotinib (Tarceva). The use of Tarceva and Gilotrif for non-small cell lung cancer (NSCLC) will be approved as a first-line therapy. Applies to new starts only.




Age Restrictions



egrifta All FDA approved indications not otherwise excluded from Part D

Documented diagnosis of HIV and lipodystrophy, member must actively be receiving antiretroviral therapy including protease inhibitors, nucleoside reverse transcriptase inhibitors, or non-nucleoside reverse transcriptase inhibitors





Age Restrictions



Documentation of moderate to severe rheumatoid arthritis -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe juvenile idiopathic rheumatoid arthritis and an inadequate response or intolerance to at least one DMARD (e.g., methotrexate, leflunamide) -OR- moderate to severe psoriasis after failure of either systemic therapy (e.g., methotrexate or cyclosporine) or phototherapy.

For psoriasis trial of 1 alternative therapy, either systemic therapy (e.g. methotrexate or cyclosporine) or phototherapy, is required.

12 monthsrheumatologist, dermatologist

Deny if less than 2 years old

concomitant use of Remicade, Cimzia, Humira, Orencia, Simponi, Actemra, Kineret, Stelara


enbrel




Age Restrictions



entresto All FDA approved indications not otherwise excluded from Part D

concomitant use of an ACE inhibitor or ARB

Documentation of chronic heart failure (NYHA Class II to IV) AND systolic dysfunction (LVEF less than or equal to 40 percent)

12 months

erivedge All FDA approved indications not otherwise excluded from Part D

Documentation of advanced basal cell carcinoma (BCC), which includes metastatic and locally advanced basal cell carcinoma, for whom surgery is inappropriate

oncologist, dermatologist

12 months Applies to new starts only, doses greater than 150mg/day will not be approved




Age Restrictions



farydak All FDA approved indications not otherwise excluded from Part D

Documentation of use in combination with bortezomib and dexamethasone for patients with multiple myeloma who have received at least 2 prior regimens, including bortezomib and an immunomodulatory agent (i.e. Thalomid, Revlimid, Pomolyst)





Age Restrictions



firazyr All FDA approved indications not otherwise excluded from Part D

Acute hereditary angioedema (HAE) type I & II: Documentation that clinical laboratory performance C4 below lower limit of laboratory reference range -AND- C1 inhibitor level below lower limit of laboratory reference range -OR- normal C1 inhibitor level and a low C1INH functional level below laboratory reference range -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that cause angioedema have been evaluated and


12 months




Age Restrictions



flector All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis AND trial/failure, intolerance, or contraindication to 3 oral generic NSAIDs one of which must be diclofenac

1 month




Age Restrictions



Documentation to support use for treatment of osteoporosis and the prevention of fractures in postmenopausal women and men having a T score of less than -2.5 and a trial and failure or contraindication to at least one bisphosphonate -OR- use to prevent fractures in men and postmenopausal women with a low bone mass (T score between -1.0 and -2.5) and history of previous osteoporotic fracture or those who are found to have a 10-year risk of major

i f

Diagnosis of underlying hypercalcemic disorder such as hypercalcemia, hyperparathyroidism or hypoparathyroidism, or high risk for osteosarcoma (Paget's disease, prior radiation therapy, bone metastases, open epiphyses, etc.). Treatment duration greater than 24 months.


forteo 24 months




Age Restrictions



osteoporotic fracture greater than or equal to 20 percent or a risk of hip fracture greater than or equal to 3 percent and had a trial and failure or contraindication to at least one bisphosphonate




Age Restrictions



gattex All FDA approved indications not otherwise excluded from Part D

Documentation of short bowel syndrome (SBS) AND dependence on parenteral nutrition or intravenous nutritional support for at least 12 months AND requiring parenteral nutrition at least 3 times per week

12 months




Age Restrictions



Members must have a documented diagnosis of relapsing-remitting, relapsing secondary progressive or progressive relapsing multiple sclerosis -AND- new starts to therapy have the following baseline information documented within 6 months of initiating therapy: ophthalmologic evaluation, liver transaminase and bilirubin, complete blood count, and electrocardiogram if using an antiarrhythmic agent or have second degree or greater AV block -AND-

h

Doses greater than 0.5mg/day will not be approved

12 monthsneurologistConcomitant use of Gilenya and other disease modifying agents such as interferons, Copaxone , Tysabri


gilenya




Age Restrictions



new starts to therapy do not have any of the following comorbid conditions or concomitant therapies: bradycardia, congestive heart failure, sick sinus syndrome, prolonged QT interval, ischemic cardiac disease, irregular heartbeat, current neutropenia, current chronic or acute infections, use of antineoplastics, immunosuppressive or immune modulating therapies




Age Restrictions






Age Restrictions



gleevec All FDA approved indications not otherwise excluded from Part D

documentation of diagnosis and alternatives tried or concomitant therapy, if applicable for diagnosis


gralise All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis





Age Restrictions




GRASTEK Documentation of allergic rhinitis and use for Timothy grass pollen or cross reactive grass pollens (Sweet Vernal, Orchard, Perennial Rye, Timothy, Kentucky Blue Grass pollen, Redtop, or meadow fescue) -AND- allergic rhinitis with or without conjunctivitis has been confirmed by a pollen specific positive skin test or in vitro testing for pollen-specific IgE antibodies -AND- trial and failure or intolerance to an intranasal steroid and an oral non-sedating

ihi i

Deny if less than 5 years of age or greater than 65 years of age

allergy specialist, otolaryngologist

12 months Member must also be prescribed an epinephrine auto injector

Asthma (severe, unstable or unconrolled), concomitant sublingual or subcutaneous immunotherapy, therapy initiation during active allergy season




Age Restrictions



growth hormone


documentation of diagnosis, growth chart, bone age, growth velocity, and response to stimulation test, when applicable

12 months

antihistamine, intranasal antihistamine or intranasal anticholinergic agent




Age Restrictions



HARVONI All FDA approved indications not otherwise excluded from Part D



G1:12w txn nocir, t/f PR.24w txex cir, t/fPI,SOF.G4,5,6:12w.DcpG1,4:12,24w t/fSOF.PosttxG1,4:12,24w

Doses greater than one tablet per day will not be approved.

HETLIOZ All FDA approved indications not otherwise excluded from Part D

Documented diagnosis of Non-24 Sleep-Wake disorder -AND- patient is totally blind

12 months




Age Restrictions



Applies to new starts only for protected class drugs. Digoxin doses less than or equal to 0.125 mg per day and doxepin doses less than or equal to 6 mg per day will receive automatic approval.

12 monthsAutomatic approval if less than 65 years of age


For all medications subject to this PA group, the following information (1 through 3) is required: 1. Documentation of diagnosis 2. Explanation of risk-benefit profile favoring use of the high-risk medication 3. Documentation of ongoing monitoring plan to identify and address treatment-related adverse events. In addition to requirements 1 through 3 above, for digoxin doses exceeding 0.125 mg daily, provider confirmation that a lower dose of digoxin has or

ld b i ff i

high-risk meds




Age Restrictions



would be ineffective in managing the member's condition is required. For the target high-risk medications glyburide, TCAs and nitrofurantoin, in addition to criteria 1 through 3 above, trial and failure or documentation of intolerance or contraindication to at least 2 non-high risk alternative drugs for the same indication, if available, is required. Non-high risk alternative medications for those target high-risk medications include the follo ing: 1




Age Restrictions



following: 1. Glyburide (non-high risk alternatives include glipizide and glimepiride) 2. TCAs (non-high risk alternatives include SSRIs and SNRIs) 3. Nitrofurantoin (non-high risk alternatives include Bactrim, Cipro, or cephalexin). If using one of the above 3 high-risk medications for a medically-accepted indication not shared by the safer alternatives listed, then no trial of alternatives is required for that target high-risk medication.




Age Restrictions






Age Restrictions




homozygous fh

Documentation of homozygous familial hypercholesterolemia (HoFH) confirmed by genetic testing showing functional mutation(s) in both LDL receptor alleles or alleles known to affect LDL receptor functionality -OR- untreated LDL-C concentrations greater than 500 mg/dL, treated LDL-C concentrations greater than or equal to 300 mg/dL, or a non-HDL-C concentration greater than or equal to 330mg/dL -AND- the presence of Xanthomas in the first decade of life -OR d i

Patients must have an adequate trial/failure or contraindication to the preferred product Repatha.

6 months




Age Restrictions



OR- documentation of elevated LDL-C greater than 190 mg/dL prior to lipid-lowering therapy consistent with HoFH in both parents -AND- will not be used concomitantly with a PCSK9 inhibitor [e.g. alirocumab (Praluent), evolocumab (Repatha)].




Age Restrictions



horizant All FDA approved indications not otherwise excluded from Part D

Documentation of moderate to severe active primary restless leg syndrome and trial and failure of two accepted medications for the treatment of this condition one of which must include pramipexole or ropinirole -OR- documentation of post herpetic neuralgia





Age Restrictions




humira Documentation of moderate to severe hidradenitis suppurativa -OR- moderate to severe rheumatoid arthritis -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe juvenile idiopathic rheumatoid arthritis and an inadequate response or intolerance to at least one DMARD (e.g., methotrexate, leflunamide) -OR- moderate to severe psoriasis after failure of either systemic therapy (e.g., methotrexate or cyclosporine) or phototherapy. -OR-

d

For psoriasis trial of 1 alternative therapy, either systemic therapy (e.g. methotrexate or cyclosporine) or phototherapy, is required. For Crohn's disease in adults (18 years or older), trial of 2 immunosuppressants (e.g. corticosteroids, azathioprine) or monotherapy with infliximab is required. For Crohn's disease in pediatrics, trial of 1 immunosuppressant (e.g. corticosteroids, azathioprine) or monotherapy with infliximab is required. For Ulcerative Colitis, trial of 2 immunosuppressants (e.g. corticosteroids, azathioprine or 6-mercaptopurine) is required. For plaque psoriasis induction therapy, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimen. For rheumatoid arthritis therapy without

i h d

12 monthsrheumatologist, dermatologist, or gastroenterologist


concomitant use of Remicade, Cimzia, Enbrel, Orencia, Simponi, Actemra, Kineret, Stelara




Age Restrictions



moderate to severe Crohn's disease after failure of two immunosuppressants (e.g., corticosteroids, azathioprine) or monotherapy with infliximab -OR- moderate to severe ulcerative colitis after failure of two immunosuppressants (e.g. corticosteroids, azathioprine or 6-mercaptopurine).

concomitant methotrexate, doses above plan quantity limit will be approved aligned with recommended weekly dosing regimen. Induction therapy or treatment regimens for other indications are aligned with plan quantity limit on Humira starter kit.




Age Restrictions






Age Restrictions



Applies to new starts only12 monthsDocumentation of ER-positive, HER2-negative metastatic breast cancer in postmenopausal women AND used as initial endocrine-based therapy for metastatic disease in combination with letrozole (Femara)-OR- documentation of use with fulvestrant (Faslodex) in women with HR-positive, HER2-negative metastatic breast cancer with disease progression following endocrine therapy.


Ibrance




Age Restrictions




iclusig Applies to new starts only12 monthsDocumentation of T3151 chronic phase, accelerated phase or blast phase CML -OR- documentation of T3151 Ph+ ALL -OR- documentation of chronic phase, accelerated phase or blast phase CML in patients for whom no other tyrosine kinase inhibitor therapy is indicated -OR- documentation of Ph+ ALL in patients for whom no other tyrosine kinase inhibitor therapy is indicated.




Age Restrictions


Coverage Duration Other Criteria12 months Covered under Part B when

administered in the home to a member with a diagnosis of primary immunodeficiency disease

Documentation of diagnosis. For select diagnoses the following apply- 1) For Myasthenia Gravis Syndrome, documentation that the patient is refractory to other standard therapies (e.g., cholinesterase inhibitors, corticosteroids, azathioprine) given in therapeutic doses over at least 3 months OR is intolerant of/has a contraindication to those standard therapies. 2) For Multiple Sclerosis, patient is refractory to other standard therapies (e.g., interferons) given in h i d

ig All medically accepted indications not otherwise excluded from Part D




Age Restrictions



therapeutic doses over at least 3 months, OR is intolerant of/has a contraindication to those standard therapies. 3) For Inflammatory Myopathies, the patient is refractory to corticosteroids given in therapeutic doses over at least 4 months, OR is intolerant of/has a contraindication to corticosteroids.




Age Restrictions



imbruvica All FDA approved indications not otherwise excluded from Part D

Documentation of mantle cell lymphoma and treatment with at least one prior therapy -OR- documentation of chronic lymphocytic leukemia and treatment with at least one prior therapy -OR- documentation of Waldenstrom macroglobulinemia





Age Restrictions



increlex All FDA approved indications not otherwise excluded from Part D

documentation of diagnosis, growth chart, stimulation test results, growth velocity, IGF-1 level

Deny if greater than 18 years old

12 months

inlyta All FDA approved indications not otherwise excluded from Part D

Documentation of advanced renal cell carcinoma (RCC) and failure one prior systemic therapy

oncologist 12 months Applies to new starts only

interferon alfa


documentation of diagnosis only

12 months




Age Restrictions



interleukin-1b blockers


Concomitant use with agents that inhibit IL-1 or TNF including Remicade, Humira, Enbrel, Orencia, or Kineret


Deny if less than 12 years of age (Arcalyst) or less than 2 years of age (Ilaris)

12 months

IPF AGENTS All FDA approved indications not otherwise excluded from Part D

Concomitant use of pirfenidone and nintedanib

Documentation of idiopathic pulmonary fibrosis -AND- baseline forced vital capacity (FVC) of at least 50% and a percent predicted diffusing capacity of the lungs of carbon monoxide (DLCO) of at least 30%.

pulmonologist

12 months




Age Restrictions



iressa All FDA approved indications not otherwise excluded from Part D

Documentation of metastatic non-small cell lung cancer (NSCLC) in patients whose tumors express EGFR exon 19 deletion mutations or exon 21 (L858R) mutations as detected by an FDA-approved test






Age Restrictions



jakafi All FDA approved indications not otherwise excluded from Part D

Documentation of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis


12 months Applies to new starts only. Platelet count to be provided.




Age Restrictions



kalydeco All FDA approved indications not otherwise excluded from Part D

Homozygous for the F508del mutation in the CFTR gene

Documentation of cystic fibrosis (CF) in patients who have one of the following mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, S549R or R117H.

Deny if less than 6 years of age for oral tablets and less than 2 years of age for oral granules

pulmonologist

12 months Doses greater than 300mg/day will not be approved

kanuma All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis of Lysosomal Acid Lipase (LAL) deficiency

12 months




Age Restrictions



keveyis All FDA approved indications not otherwise excluded from Part D

Documentation of one of the following: 1. Primary hyperkalemic periodic paralysis 2. Primary hypokalemic periodic paralysis 3. Related variants of primary periodic paralysis


12 months Doses exceeding 200 mg per day will not be approved.




Age Restrictions




KEYTRUDA Documentation of unresectable or metastatic melanoma and disease progression following ipilimumab (Yervoy) and, if BRAF V600 mutation positive, a BRAF inhibitor -OR- metastatic non-small cell lung cancer (NSCLC) with PD-L1-positive expressing tumor, as determined by an FDA-approved test, after failure of prior platinum-based chemotherapy

Applies to new starts only12 months




Age Restrictions



kineret All FDA approved indications not otherwise excluded from Part D

concomitant use of Actemra, Remicade, Humira, Orencia, Enbrel, Simponi, Cimzia

Documentation of moderate to severe rheumatoid arthritis and trial and failure of one DMARD -OR- neonatal-onset multisystem inflammatory disease (NOMID) or chronic infantile neurological, cutaneous and articular (CINCA) syndrome

rheumatologist

12 months Patients must have an adequate trial or intolerance to the preferred products, Enbrel and Humira, for rheumatoid arthritis.




Age Restrictions



korlym All FDA approved indications not otherwise excluded from Part D

Documentation of hyperglycemia secondary to hypercortisolism in patients with endogenous Cushing's syndrome who have Type 2 Diabetes Mellitus or glucose intolerance AND patient is not a candidate for surgery or radiotherapy or where surgery or radiotherapy has failed


12 months




Age Restrictions



lenvima All FDA approved indications not otherwise excluded from Part D

Documentation of locally recurrent or metastatic, progressive, radioactive iodine refractory differentiated thyroid cancer


leukotriene modifiers


Documentation of asthma -OR- documentation of exercise-induced bronchoconstriction -AND- trial/failure of generic montelukast

12 months




Age Restrictions



lidoderm All medically accepted indications not otherwise excluded from Part D

documentation of postherpetic neuralgia (PHN) and trial and failure of 1 other agent used to treat PHN (e.g. gabapentin) -OR- documentation of diabetic neuropathy

12 months

lonsurf All FDA approved indications not otherwise excluded from Part D

Documentation of metastatic colorectal cancer in patients who have previously been treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF therapy, and if RAS wild-type, an anti-EGFR therapy

oncologist 12 months Applies to new starts only




Age Restrictions



lynparza All FDA approved indications not otherwise excluded from Part D

Documentation of use as monotherapy in patients with deleterious or suspected deleterious germline BRCA mutated advanced ovarian cancer after trial of three or more prior lines of chemotherapy (e.g. carboplatin, cisplatin, paclitaxel, gemcitabine)





Age Restrictions



lyrica All FDA approved indications not otherwise excluded from Part D

Documentation of DPN and trial/failure or intolerance to duloxetine-OR- PHN and trial/failure or intolerance to gabapentin -OR- seizures and trial/failure or intolerance to two AEDS -OR- neuropathic pain associated with spinal cord injury -OR- documentation to support a diagnosis of fibromyalgia and trial/failure or intolerance to duloxetine





Age Restrictions



mekinist All FDA approved indications not otherwise excluded from Part D

Disease progression on prior BRAF inhibitor therapy

Documentation of unresectable or metastatic melanoma with BRAFV600E or BRAFV600K mutations


methamphetamine


Documentation of diagnosis

12 months




Age Restrictions



mozobil All FDA approved indications not otherwise excluded from Part D

used in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with multiple myeloma (MM) and non-Hodgkins lymphoma (NHL).






Age Restrictions


Coverage Duration Other Criteria12 months For initial reauthorization, the

member should have a decreased A1C level by at least 0.8 or decreased triglycerides by 25 percent or decreased fasting plasma glucose by 25 percent.

myalept Documentation of congenital or acquired generalized lipodystrophy with absence or loss of subcutaneous body fat -AND- Leptin levels less than 8 ng/mL for males or less than 12 ng/mL for females -AND- the patient has been optimized on current diabetic medication and/or hypertriglyceridemia medication as needed -AND- the member has a diagnosis of diabetes or fasting insulin levels greater than 30uU/mL or fasting hypertriglyceridemia greater than 200 /dL





Age Restrictions



namenda All medically accepted indications not otherwise excluded from Part D

Documentation of diagnosis and trial/failure of generic memantine

12 months

namzaric All medically accepted indications not otherwise excluded from Part D

Documentation of diagnosis and trial/failure of generic memantine and generic donepezil

12 months

200mg/dL.




Age Restrictions



natpara All FDA approved indications not otherwise excluded from Part D

Documentation of use as an adjunct to calcium and vitamin D to control hypocalcemia in patients with hypoparathyroidism

12 months

nexavar All FDA approved indications not otherwise excluded from Part D

Documentation of hepatocellular carcinoma -OR- advanced renal cell carcinoma after treatment of 1 other systemic therapy -OR- locally recurrent or metastatic, progressive, differentiated thyroid carcinoma refractory to radioactive iodine treatment






Age Restrictions



ninlaro All FDA approved indications not otherwise excluded from Part D

Documentation of multiple myeloma AND previous treatment with at least 1 prior therapy AND used in combination with lenalidomide and dexamethasone






Age Restrictions



NORTHERA All FDA approved indications not otherwise excluded from Part D

Documentation of neurogenic orthostatic hypotension caused by primary autonomic failure (e.g., Parkinson's disease, multiple system atrophy, or pure autonomic failure), dopamine beta-hydroxylase deficiency or non-diabetic autonomic neuropathy

12 months




Age Restrictions


Coverage Duration Other Criteria12 monthsDeny if less

than 12 years old


nucala Documentation of diagnosis of severe asthma evidenced by pretreatment forced expiratory volume in 1 second (FEV1) less than 80% predicted and FEV1 reversibility of at least 12% after albuterol administration -AND- Either 1 or 2. 1)History of 2 or more exacerbations in the previous year despite at least 12 months of high-dose inhaled corticosteroid (ICS) given in combination with at least 3 months of controller medication (e.g. long-acting beta2-

i [LABA]




Age Restrictions



agonist [LABA], leukotriene receptor antagonist [LTRA], or theophylline), unless intolerant of or contraindication to all of these agents. 2)Symptoms are inadequately controlled with use of 6 months of ICS with daily oral glucocorticoids given in combination with a minimum of 3 months of controller medication (e.g. LABA, LTRA, or theophylline), unless intolerant of or contraindication to all of these agents. -AND- 3 or 4. 3)Greater than or equal to 150 cells/ L screening




Age Restrictions



cells/uL screening within 6 weeks of dosing. 4)Greater than or equal to 300 cells/uL within 12 months of screening.




Age Restrictions



nuplazid All FDA approved indications not otherwise excluded from Part D

Documentation of hallucinations and delusions associated with Parkinson's disease psychosis



OAB drugs All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis -AND- trial/failure of at least 2 generic alternatives (e.g. oxybutynin, trospium, tolterodine)

12 months




Age Restrictions



odomzo All FDA approved indications not otherwise excluded from Part D

Documentation of locally advanced basal cell carcinoma (laBCC) that has recurred following surgery or radiation therapy or for use in patients who are not candidates for surgery or radiation therapy





Age Restrictions



olysio All FDA approved indications not otherwise excluded from Part D

Previous failure of a Protease Inhibitor used in hepatitis C (boceprevir, telaprevir or simeprevir) -OR- decompensated cirrhosis



12 wks or 24 wks depending on treatment regimen and presence or absence of cirrhosis

Doses greater than or less than 150mg/day will not be approved




Age Restrictions



Documentation of unresectable or metastatic melanoma in patients previously treated with ipilimumab (Yervoy) and, if BRAF V600 mutation positive, a BRAF inhibitor -OR- documentation of metastatic squamous non-small cell lung cancer (NSCLC) with progression on or after platinum-based chemotherapy -OR- advanced renal cell carcinoma in patients who have received prior antiangiogenic therapy.


opdivo 12 months Applies to new starts only




Age Restrictions






Age Restrictions




oralair Documentation of allergic rhinitis and use for Sweet Vernal, Orchard, Perennial Rye, or Kentucky Blue Grass pollens -AND- allergic rhinitis with or without conjunctivitis has been confirmed by a pollen specific positive skin test or in vitro testing for pollen-specific IgE antibodies -AND- trial and failure or intolerance to an intranasal steroid and an oral non-sedating antihistamine, intranasal antihistamine or intranasal anticholinergic

Member must also be prescribed an epinephrine auto injector

12 monthsallergy specialist, otolaryngologist






Age Restrictions



orencia All FDA approved indications not otherwise excluded from Part D

concomitant use of Enbrel, Remicade, Humira, Orencia, Simponi, Kineret, Cimzia

Documentation of moderate to severe rheumatoid arthritis -OR- documentation of moderate to severe juvenile idiopathic rheumatoid arthritis (Orencia IV only)

rheumatologist

12 months For Orencia SubQ, patients must have an adequate trial or intolerance to the preferred SubQ products, Enbrel and Humira, for rheumatoid arthritis. For Orencia IV, patients must have an adequate trial or intolerance to one of the preferred IV products, Remicade or Simponi Aria, for rheumatoid arthritis.

agent




Age Restrictions



orkambi All FDA approved indications not otherwise excluded from Part D

Documentation of cystic fibrosis and homozygous F508del mutation



For reauthorization, documentation showing a FEV1 improvement from baseline must be provided.

OTEZLA All FDA approved indications not otherwise excluded from Part D

concomitant use of Enbrel, Remicade, Humira, Cimzia, Simponi, Stelara

Documentation of active psoriatic arthritis -OR- documentation of moderate to severe psoriasis


rheumatologist, dermatologist

12 months Maintenance doses greater than 60 mg per day will not be approved. Patients must have an adequate trial or intolerance to the preferred products, Enbrel and Humira, for psoriatic arthritis and psoriasis.

otrexup All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis AND trial/failure, intolerance, or contraindication to oral generic methotrexate tablets

12 months




Age Restrictions



pomalyst All FDA approved indications not otherwise excluded from Part D

Documentation of multiple myeloma, previous trial of at least 2 therapies including lenalidomide and bortezomib, and disease progression on or within 60 days of last therapy





Age Restrictions



Documentation of the following: 1. Heterozygous Familial Hypercholesterolemia (HeFH) as supported by the presence of causal mutation of familial hypercholesterolemia by genetic testing, physical signs of FD (e.g. xanthomas, xanthelasma), clinical diagnosis based on WHO criteria/Dutch Lipid Clinical Network criteria with score greater than 8 points, or Simon Broome register diagnostic criteria AND LDL-C greater than or equal to 190 mg/dL prior to lipid l i h

For reauthorization, documentation showing an LDL-C reduction on Praluent therapy from baseline must be provided.


Prescribed by or in consultation with a cardiologist, lipid specialist, or endocrinologist



praluent




Age Restrictions



lowering therapy (greater than or equal to 160 mg/dL if age less than 20) or LDL-C greater than or equal to 160 mg/dL after treatment with antihyperlipidemic agents but prior to Praluent therapy AND Previous treatment with at least two trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin) has been ineffective in achieving LDL-C goal AND Praluent must be used concomitantly with a statin which is dosed at maximally tolerated dose OR doc mentation of




Age Restrictions



documentation of statin intolerance is provided as defined by statin related rhabdomyolysis or skeletal-related muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin. 2. Hypercholesterolemia ASCVD (e.g. acute coronary syndrome, history of myocardial infarction) AND Previous treatment with at least two trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin) has been ineffective in




Age Restrictions



been ineffective in achieving LDL-C goal (LDL-C is still greater than or equal to 100 mg/dL) AND Praluent must be used concomitantly with a statin which is dosed at maximally tolerated dose OR documentation of statin intolerance is provided as defined by statin related rhabdomyolysis or skeletal-related muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin.




Age Restrictions






Age Restrictions






Age Restrictions


Coverage Duration Other Criteria1 mo. opiate/substance abuse therapy use, 12 mo. opiate/benzodiazepine/skeletal muscle relaxant use

Opiate agonists will receive automatic approval if no recent claims for a substance abuse therapy (e.g, buprenorphine-naloxone) OR a benzodiazepine (e.g., triazolam, alprazolam) AND a centrally acting skeletal muscle relaxant (e.g., carisoprodol). Benzodiazepines (e.g, triazolam, alprazolam) will receive automatic approval if no recent claims for an opiate agonist (e.g., oxycodone, hydrocodone, oxymorphone) AND a centrally acting skeletal muscle relaxant (e.g., carisoprodol).

For concomitant use of an opiate agonist and substance abuse therapy, documentation that the member has a documented acute pain condition (e.g. acute traumatic injury) in which treatment with other agents would cause insufficient pain control or if the member requires treatment for pain related to a terminal illness. For concomitant use of an opiate agonist, benzodiazepine and a centrally acting skeletal muscle relaxant, documentation that the member has

i d/f il d l 2


prescription drug combo




Age Restrictions



tried/failed at least 2 other skeletal muscle relaxant (e.g, methocarbamol, metaxalone), understanding these skeletal muscle relaxants are high-risk medications in geriatric patients AND documentation of an ongoing monitoring plan to identify and address concomitant drug-drug interaction adverse events




Age Restrictions



pristiq All FDA approved indications not otherwise excluded from Part D

Documentation of major depressive disorder and trial and failure of two other antidepressants.


PROCYSBI All FDA approved indications not otherwise excluded from Part D

Documentation of nephropathic cystinosis AND previous trial and failure or intolerance to immediate-release cysteamine bitartrate (Cystagon)


12 months




Age Restrictions



Documentation of use to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy or women at high risk for fracture receiving adjuvant aromatase inhibitor therapy -OR- use for treatment of osteoporosis and the prevention of fractures in postmenopausal women and men having a T score of less than -2.5 and a trial and failure or contraindication to at least one bisphosphonate -OR- use to prevent fractures in men and postmenopausal

i h l

Diagnosis of underlying hypercalcemic disorder such as hypercalcemia, hyperparathyroidism or hypoparathyroidism, or high risk for osteosarcoma (Paget's disease, prior radiation therapy, bone metastases, open epiphyses, etc.)


prolia 12 months Covered under Part B for female patients eligible for home health services when provider certifies that patient sustained bone fracture related to post-menopausal osteoporosis and is unable to learn the skills needed to self-administer the drug or is otherwise physically or mentally incapable of administering the drug or family/caregivers are unable or unwilling to administer the drug




Age Restrictions



women with a low bone mass (T score between -1.0 and -2.5) and history of previous osteoporotic fracture or those who are found to have a 10-year risk of major osteoporotic fracture greater than or equal to 20 percent or a risk of hip fracture greater than or equal to 3 percent and had a trial and failure or contraindication to at least one bisphosphonate




Age Restrictions






Age Restrictions


Coverage Duration Other Criteria12 monthsprovigil All medically

accepted indications not otherwise excluded from Part D

Documentation of 1 of the following. 1) Diagnosis of shift work sleep disorder (SWSD) as defined by a minimum of 5 night shifts per month with at least 3 of those nights occuring consecutively and the shift is 6 to 12 hours in duration occuring between 10pm and 8am. 2) Diagnosis of narcolepsy documented by MSLT less than 8 minutes and 2 sleep-onset rapid eye movement periods (SOREMP) or other appropriate testing. 3) Diagnosis of obstructive sleep

/h




Age Restrictions



apnea/hypopnea syndrome (OSAHS) documented by objective polysomnography and continuous positive airway pressure (CPAP) history and status are provided. Diagnosis established in accordance with ICSD or DSM IV criteria acceptable for all indications.




Age Restrictions






Age Restrictions


Coverage Duration Other Criteria12 monthsDiagnosis of

pulmonary hypertension, substantiated by results from right heart catheterization and/or direct measurement of pulmonary arterial pressure, defined as a mean pulmonary arterial pressure of greater than or equal to 25 mmHg at rest, with a pulmonary capillary wedge pressure of less than 15 mmHg, and a PVR greater than 3 Wood units -AND- WHO Group -AND- WHO Functional Class ll or lll symptoms

pulmonary arterial hypertension


cardiologist, pulmonologist




Age Restrictions



Documentation of allergic rhinitis and use for ragweed pollen -AND- allergic rhinitis with or without conjunctivitis has been confirmed by a pollen specific positive skin test or in vitro testing for pollen-specific IgE antibodies -AND- trial and failure or intolerance to an intranasal steroid and an oral non-sedating antihistamine, intranasal antihistamine or intranasal anticholinergic agent

RAGWITEK All FDA approved indications not otherwise excluded from Part D



allergy specialist, otolaryngologist

12 months Member must also be prescribed an epinephrine auto injector




Age Restrictions



rasuvo All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis AND trial/failure, intolerance, or contraindication to oral generic methotrexate tablets

12 months

ravicti All FDA approved indications not otherwise excluded from Part D

Urea cycle disorders due to N-acetylglutamatesynthetase deficiency

Documentation of use with dietary protein restriction for chronic management of a urea cycle disorders (UCDs) when the condition cannot be managed by dietary protein restriction alone

12 months




Age Restrictions


Coverage Duration Other Criteria12 months For psoriasis trial of 1 alternative

therapy, either systemic therapy (e.g. methotrexate or cyclosporine) or phototherapy, is required. For Crohn's disease and ulcerative colitis, trial of 2 immunosuppressants (e.g. corticosteroids, azathioprine, 6-mercaptopurine) is required.

Documentation of moderate to severe rheumatoid arthritis and use in combination with methotrexate -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe psoriasis after failure of systemic therapy or phototherapy -OR- moderate to severe Crohn's disease after failure of two immunosuppressants -OR- moderate to severe ulcerative colitis after failure of two immunosuppressants

concomitant use of Humira, Cimzia, Enbrel, Orencia, Simponi, Actemra, Kineret, Stelara


remicade For Crohn's disease and ulcerative colitis, deny if less than 6 years old

rheumatologist, dermatologist, or gastroenterologist




Age Restrictions



1.Homozygous Familial Hypercholesterolemia(HoFH) supported by genetic confirmation of two mutant alleles at LDLR, APOB, OCSK9, or LDLRAP1 gene or untreated LDL-C greater than 500mg/dL(or treated LDL-C greater than 300mg/dL) with cutaneous or tendon xanthoma before age 10 yrs or heterozygous familial hypercholesterolemia (HeFH) in both parents AND Repatha will be used with a maximally tolerated

i l ll

repatha All FDA approved indications not otherwise excluded from Part D

Deny if less than 18 years of age for HeFH and ASCVD or less than 13 years of age for HoFH

Prescribed by or in consultation with a cardiologist, lipid specialist, or endocrinologist


For reauthorization, documentation showing an LDL-C reduction on Repatha therapy from baseline must be provided. For HoFH diagnosis, 3 syringes per month will be approved aligned with recommended dosing regimen for this indication.




Age Restrictions



statin unless all statins are contraindicated or not tolerated AND Repatha will not be used with lomitapide, mipomersen, or another PCSK9 inhibitor. 2.HeFH supported by presence of causal mutation of FH by genetic testing, physical signs of FD(e.g. xanthomas, xanthelasma), diagnosis based on WHO criteria/Dutch Lipid Clinical Network criteria with score greater than 8 points, or Simon Broome register criteria AND LDL-C greater than or eq al to




Age Restrictions



than or equal to 190mg/dL prior to lipid lowering therapy (greater than or equal to 160mg/dL if age less than 20) or LDL-C greater than or equal to 160mg/dL after treatment with antihyperlipidemic agents but prior to Repatha therapy AND Prior therapy with at least 2 trials of different high-intensity statins(e.g. atorvastatin, rosuvastatin) has not achieved LDL-C goal AND must be used with maximally tolerated statin dose OR documentation of statin intolerance as defined by statin




Age Restrictions



defined by statin related rhabdomyolysis or skeletal muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin. 3. Hypercholesterolemia ASCVD AND Prior therapy with at least 2 trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin) has not achieved LDL-C goal(LDL-C is still greater than or equal to 100mg/dL) AND must be used with maximally tolerated statin dose OR




Age Restrictions



statin dose OR documentation of statin intolerance as defined by statin related rhabdomyolysis or skeletal muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin.




Age Restrictions






Age Restrictions


Coverage Duration Other Criteria12 months Applies to new starts onlyDiagnosis of

multiple myeloma -OR- diagnosis of myelodyplastic syndrome (MDS) with 5-q deletion along with documentation of transfusion-dependent anemia or an anemia with documented hemoglobin of less than 10g/dL -OR- diagnosis of mantle cell lymphoma (MCL) in which disease has relapsed or progressed after two prior therapies (e.g. anthracycline, mitoxantrone, cyclophosphamide, rituximab, bortezomib) one of which included b ib

Documentation of severe neutropenia, severe thrombocytopenia, or treatment-related MDS


revlimid




Age Restrictions



bortezomib




Age Restrictions



Acute hereditary angioedema (HAE) type I & II: Documentation that clinical laboratory performance C4 below lower limit of laboratory reference range -AND- C1 inhibitor level below lower limit of laboratory reference range -OR- normal C1 inhibitor level and a low C1INH functional level below laboratory reference range -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that cause angioedema have been evaluated and di i d A


ruconest Deny if less than 13 years of age

12 months




Age Restrictions



discontinued. Acute hereditary angioedema (HAE) type III: Documentation that clinical laboratory performance C4, C1 inhibitor level and C1INH functional level are within normal limits of the laboratory's reference range -AND- documentation HAE family history -OR- FXL mutation -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that cause angioedema have been evaluated and discontinued




Age Restrictions



savella All FDA approved indications not otherwise excluded from Part D

Documentation to support a diagnosis of fibromyalgia and trial/failure or intolerance to duloxetine

12 months




Age Restrictions



signifor All FDA approved indications not otherwise excluded from Part D

Documentation of Cushing's disease AND patient is not a candidate for pituitary surgery or surgery has not been curative


12 months




Age Restrictions



simponi All FDA approved indications not otherwise excluded from Part D

concomitant use of Actemra, Kineret, Remicade, Humira, Orencia, Enbrel, Cimzia

Documentation of moderate to severe rheumatoid arthritis and use in combination with methotrexate -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe ulcerative colitis and an inadequate response to two immunosupressants or in those patients requiring continuous steroid therapy

12 months Alternatives for Ulcerative Colitis include immunosuppressants such as corticosteroids, azathioprine or 6-mercaptopurine. Patients must have an adequate trial or intolerance to the preferred product, Humira, for ulcerative colitis and the preferred products, Enbrel and Humira, for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. For ulcerative colitis indication therapy, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimen.




Age Restrictions



simponi aria All FDA approved indications not otherwise excluded from Part D

concomitant use of Actemra, Kineret, Remicade, Humira, Orencia, Enbrel, Cimzia

Documentation of moderate to severe rheumatoid arthritis and use in combination with methotrexate

12 months

sovaldi All FDA approved indications not otherwise excluded from Part D



12w:G1nocr.G2nocr txn,t/fSOF.G3,5,6,G4wPR.16w:G2cr,t/fPR.24w:G1cr,G2txe,G4 wR,G2,3allo.48w:G2,3dcp

Doses greater than or less than 400 mg/day will not be approved.




Age Restrictions



sprycel All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis and failure of Gleevec therapy (failure of Gleevec is not necessary for the indication of newly diagnosed adults with chronic phase PH+ CML).





Age Restrictions



Patients must have an adequate trial or intolerance to the preferred product, Humira, for psoriasis and the preferred products, Enbrel and Humira, for psoriatic arthritis. Must follow recommended dosing guidelines based upon weight. Psoriasis: For patients weighing less than 100 kilograms (220 pounds), 45 mg dosing will be approved. For patients weighing more than 100 kilograms (220 pounds), 90 mg dosing will be approved. Psoriatic Arthritis: 45 mg dosing will be approved. For patients with co-existent moderate to severe plaque psoriasis weighing greater than 100 kilograms (220 pounds), 90 mg dosing will be approved.

12 monthsdermatologist

Documentation of moderate to severe plaque psoriasis and failure of one systemic therapy (e.g. methotrexate, cyclosporine) or phototherapy OR psoriatic arthritis AND documentation of member weight and prescribed dose

concomitant use of Enbrel, Remicade, Humira, Simponi


stelara




Age Restrictions


Coverage Duration Other Criteria12 months Applies to new starts onlyDocumentation of

metastatic colorectal cancer and trial of a fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy (i.e. FOLFIRINOX), AND an anti-VEGF therapy (i.e. aflibercept) AND if KRAS wild type, an anti-EGFR therapy (i.e. cetuximab, panitumumab) -OR- documentation of locally advanced, unresectable or metastatic gastrointestinal stromal tumor (GIST) after treatment with both imatinib and sunitinib


stivarga




Age Restrictions



strensiq All FDA approved indications not otherwise excluded from Part D

Documentation of perinatal/infantile-onset or juvenile-onset hypophosphatasia (HPP)

12 months

sutent All FDA approved indications not otherwise excluded from Part D

documentation of diagnosis and failure of Gleevec therapy, if applicable






Age Restrictions



sylvant All FDA approved indications not otherwise excluded from Part D

Documented diagnosis of multicentric Castleman's disease -AND- negative HIV and HHV-8 test -AND- baseline absolute neutrophil count greater than or equal to 1.0x10*9/L -AND- baseline platelet count greater than or equal to 75x10*9/L -AND- baseline hemoglobin less than 17g/dL.





Age Restrictions



tagrisso All FDA approved indications not otherwise excluded from Part D

Documentation of metastatic EGFR T790M mutation-positive NSCLC AND progression on or after EGFR TKI therapy



taltz All FDA approved indications not otherwise excluded from Part D

concomitant use of Enbrel, Remicade, Humira, Simponi, Stelara

Documentation of moderate to severe psoriasis and failure of one systemic therapy (e.g. methotrexate, cyclosporine) or phototherapy


dermatologist

12 months Patients must have an adequate trial or intolerance to the preferred product, Humira, for psoriasis. For psoriasis induction therapy, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimen.




Age Restrictions



tasigna All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis and failure of Gleevec therapy (failure of Gleevec is not necessary for the indication of newly diagnosed adults with chronic phase PH+ CML).



tecfidera All FDA approved indications not otherwise excluded from Part D

concomitant use with other disease modifying agents such as interferons, Copaxone , Tysabri, Aubagio, Gilenya

Documentation of relapsing form of multiple sclerosis (relapsing-remitting, relapsing secondary progressive, or progressive relapsing multiple sclerosis)

neurologist 12 months Doses greater than 240 mg twice-daily will not be approved




Age Restrictions



technivie All FDA approved indications not otherwise excluded from Part D

Severe hepatic impairment (Child-Pugh C)

Documentation of chronic hepatitis C genotype 4 without cirrhosis AND using with ribavirin unless the member is treatement-naive and has a contraindication or intolerance to ribavirin


12 weeks




Age Restrictions




testosterone (androgens)

Documentation of primary or secondary hypogonadism in males with testicular failure due to cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, orchidectomy, Klinefelter's syndrome, chemotherapy, radiation or toxic damage -OR- documentation of primary or secondary hypogonadism in males with multiple symptoms of hypogonadism including at least one of the following specific symptoms: h i h l d

Deny if less than recommended age per FDA product labeling

12 months




Age Restrictions



height loss due to vertebral fractures, low trauma fractures, low bone density, incomplete or delayed sexual development, breast discomfort, loss of axillar and/or pubic body hair, hot flushes -OR- documentation of HIV infection in men with weight loss -OR- documentation of chronic steroid treatment in men. In all previously noted indications, members must also have documented low testosterone level below the normal range for the laboratory -OR- a total testosterone




Age Restrictions



total testosterone level near the lower limit of the normal range with a low free testosterone level which is less than normal based upon the laboratory reference range. Additional approvable indications include vulvar dystrophies in women (topical ointment only) -AND- palliative treatment in female patients with metastatic breast cancer (testosterone enanthate only), primary or secondary hypogonadism in males with testicular failure due to double orchidectomy




Age Restrictions



orchidectomy




Age Restrictions



thalomid All FDA approved indications not otherwise excluded from Part D

documentation of multiple myeloma -OR- documentation for use in the treatment or prophylaxis of cutaneous manifestations of moderate to severe erythema nodosum leprosum





Age Restrictions



documentation of diagnosis of chronic immune idiopathic thrombocytopenia purpura and trial and failure of corticosteroid or immunoglobulin therapy or splenectomy -OR- documentation of thrombocytopenia in patients with chronic hepatitis C to allow the initiation and maintenance of interferon-based therapy (eltrombopag only)

Platelet count to be provided12 monthsAll FDA approved indications not otherwise excluded from Part D

thrombopoiesis stimulating agents




Age Restrictions



transmucosal fentanyl citrate


documentation of therapeutic use and long acting opioid therapy

12 months




Age Restrictions


Coverage Duration Other Criteria12 months Applies to new starts onlyDocumentation of

Tykerb in combination with Xeloda (capecitabine) for patients with advanced, metastatic breast cancer that is HER2 positive who have received prior therapy, including a taxane, an anthracycline and trastuzumab (Herceptin) -OR- documentation of Tykerb in combination with Femara (letrozole) for the treatment of postmenopausal women with hormone receptor positive metastatic breast cancer that over expresses the HER2 f


tykerb oncologist




Age Restrictions



HER2 receptor for whom hormonal therapy is indicated




Age Restrictions



Documentation of cutaneous manifestations in patients with cutaneous T-cell lymphoma who have limited localized or generalized skin involvement who received at least one prior skin directed therapy -OR- documentation of cutaneous manifestations in patients with cutaneous T-cell lymphoma who have limited localized or generalized skin involvement and mechlorethamine gel will be used in combination with

h ki di d


VALCHLOR 12 months Applies to new starts only




Age Restrictions



other skin directed therapies. Skin directed therapies may include but are not limited to topical corticosteroids, topical chemotherapy, local radiation and topical retinoids.




Age Restrictions



veltassa All FDA approved indications not otherwise excluded from Part D

Documentation of hyperkalemia as defined by serum potassium level between 5.1 and 6.4 mmol/L on at least two (2) screenings -AND- modification of medications to reduce serum potassium levels, when applicable -AND- trial and failure, intolerance, or contraindication to sodium polystyrene sulfonate


6 months For reauthorization, documentation of reduction in serum potassium levels following Veltassa administration is required.




Age Restrictions



venclexta All FDA approved indications not otherwise excluded from Part D

Documentation of chronic lymphocytic leukemia (CLL) with 17p deletion -AND- previous treatment with at least one prior therapy


viberzi All FDA approved indications not otherwise excluded from Part D

Severe (Child-Pugh C) hepatic impairment

Documentation of diarrhea predominant, irritable bowel syndrome (IBS-D) -AND- no alcohol abuse in the previous six months.

12 months




Age Restrictions



VIEKIRA PAK





12wk: gt 1a noncirr -OR- gt 1b. 24wk: gt1a cirr -OR- gt 1 in allograft

Doses greater than four tablets per day will not be approved.

viibryd All FDA approved indications not otherwise excluded from Part D

documentation of diagnosis major depressive disorder and trial and failure of any two antidepressants





Age Restrictions



vimovo All FDA approved indications not otherwise excluded from Part D

Documentation of diagnosis -AND- Both of the following. 1) Trial/failure of naproxen used in combination with omeprazole. 2) Trial/failure of one additional generic formulary NSAID (other than naproxen) used in combination with another generic formulary PPI (other than omeprazole).


12 months




Age Restrictions



votrient All FDA approved indications not otherwise excluded from Part D

documentation of diagnosis (renal cell carcinoma) -OR- documentation of advanced soft- tissue sarcoma excluding adipocytic soft tissue sarcoma or gastrointestinal stromal tumors after failure of at least one prior chemotherapy regimen






Age Restrictions



vraylar All FDA approved indications not otherwise excluded from Part D

Documentation of schizophrenia OR acute treatment of manic or mixed episodes associated with bipolar I disorder



xalkori All FDA approved indications not otherwise excluded from Part D

Documentation of locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK) positive






Age Restrictions



xeljanz All FDA approved indications not otherwise excluded from Part D

concomitant use of Enbrel, Remicade, Humira, Kineret, Simponi, Orencia, Stelara, Actemra, azathioprine, cyclosporine

Documentation of moderate to severe rheumatoid arthritis and an inadequate response or intolerance to methotrexate

12 months Doses greater than 10 mg per day for Xeljanz and 11 mg per day for Xeljanz XR will not be approved. Patients must have an adequate trial or intolerance to the preferred products, Enbrel and Humira, for rheumatoid arthritis.

xenazine All FDA approved indications not otherwise excluded from Part D


12 months Patients with comorbid depression should be on an antidepressant medication.




Age Restrictions



Documentation of 1 or 2. 1) Diagnosis of hepatic encephalopathy AND trial/failure, intolerance, or contraindication to lactulose. 2) Diagnosis of Irritable Bowel Syndrome with Diarrhea (IBS-D) AND trial/failure, intolerance to two of the following medications for IBS-D or documentation of contraindication to all: loperamide, cholestyramine, Colestipol, dicyclomine, tricyclic antidepressants, selective serotonin reuptake inhibitors.


xifaxan Deny if less than 18 years of age

Hepatic encephalopathy: 1 year. IBS-D: 14 days.

No more than three courses of rifaximin for the treatment of IBS-D will be approved per lifetime.




Age Restrictions



xtandi All FDA approved indications not otherwise excluded from Part D

Documentation of metastatic castration-resistant prostate cancer and prior therapy with docetaxel





Age Restrictions



xyrem All FDA approved indications not otherwise excluded from Part D

Documentation of excessive daytime sleepiness in patients with a diagnosis of narcolepsy as documented by MSLT less than 10 min or other appropriate testing -OR- documentation of cataplexy associated with narcolepsy as documented by MSLT or other appropriate testing.

12 months

zelboraf All FDA approved indications not otherwise excluded from Part D

Wild-type BRAF melanoma Documentation of unresectable or metastatic melanoma with BRAFV600E mutation






Age Restrictions



zepatier All FDA approved indications not otherwise excluded from Part D




12wk:gt1a without NS5A-OR-gt1b-OR-gt4 tx naive. 16wk:gt1a with NS5A-OR-gt4 tx exp.




Age Restrictions




zolinza Documentation of cutaneous manifestations in patients with cutaneous T-cell lymphoma (CTCL) who have progressive, persistent, or recurrent disease on or following 2 systemic therapies. Systemic therapies include bexarotene, interferon alpha, extracorpeal photochemotherapy, PUVA, single agent or combination chemotherapies (e.g. cyclophosphamide, vinblastine, romidepsin)

Applies to new starts only12 monthsoncologist, hematologist




Age Restrictions






Age Restrictions




ZYDELIG Documentation of relapsed chronic lymphocytic leukemia (CLL) and use in combination with rituximab in patients for whom rituximab alone would be considered appropriate therapy due to other co-morbidities -OR- documentation of relapsed follicular B-cell non-Hodgkin lymphoma (FL) in patients who have received at least two prior systemic therapies (e.g. alkylating agents, single or multi-drug chemotherapy, target immunotherapy) -OR- documentation f l d ll

Applies to new starts only12 months




Age Restrictions



of relapsed small lymphocytic lymphoma (SLL) in patients who have received at least two prior systemic therapies (e.g. alkylating agents, single or multi-drug chemotherapy, target immunotherapy)




Age Restrictions



zykadia All FDA approved indications not otherwise excluded from Part D

Documentation of non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK) positive AND previous trial and failure or intolerance to crizotinib (Xalkori)


zytiga All FDA approved indications not otherwise excluded from Part D

Documentation of metastatic castration resistant prostate cancer and concurrent use with prednisone


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Medicare Part D Formulary

Documents