list of covered drugs - priority health/media/documents/individual/2015... · list of covered drugs...

List of covered drugsThis is a list of covered drugs for MyPrioritySM and small business plans effective Jan. 1, 2015, or later.

Please read: This document contains information about the drugs we cover in this plan.

Important: Please read your Priority Health coverage documents and riders for details about

prescriptions covered by your plan.

This list changes frequently. For the most current information, please refer to the “Approved Drug

List” at priorityhealth.com.

Tips for getting the most out of your Priority Health prescription coverage:

• Show your Priority Health member ID card every time you fill a prescription. Even if the drug is

not covered, you’ll be able to take advantage of Priority Health discounts.

• The amount you pay depends on your plan and on what option is prescribed. Ask your

pharmacist if a less expensive option will work for you. Options include:

- Generic: The same active ingredients as brand-name drugs, but more affordable.

- Preferred brand: These drugs cost more than generics, but less than non-preferred

brands. Ask your doctor to select a preferred brand when no generic is available.

- Non-preferred brand: More expensive brand name drugs — usually these drugs have a

less costly option available.

- Preferred specialty: Drugs that treat chronic illnesses and rare or complex conditions.

You’ll usually pay less if your drug is on the “preferred” list.

- Non-preferred specialty: In general, non-preferred specialty drugs cost you more. Ask

your doctor if a preferred specialty drug will work for you.

Last updated: August 2014

*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 1 of 85

Drug Name Dosage Form

Drug Tier Requirements/

Limits

Antihistamine Drugs

First Generation Antihistamines

carbinoxamine maleate SOLN Generic

carbinoxamine maleate TABS Generic

chlorpheniramine maleate TBCR Generic

CLEMASTINE FUMARATE SYRP Generic

clemastine fumarate TABS Generic

cyproheptadine hcl SYRP Generic

cyproheptadine hcl TABS Generic

diphenhydramine hcl CAPS Generic

PHENERGAN SOLN Medical Benefit-Non-Preferred

Specialty

promethazine hcl plain SYRP Generic

promethazine hcl SUPP Generic

promethazine hcl TABS Generic

PROMETHAZINE VC PLAIN SYRP Generic

PROMETHEGAN SUPP Generic

pyril d SUSP Non-Preferred Brand

pyrilamine-phenylephrine SUSP Generic

Second Generation Antihistamines

alavert allergy/sinus TB12 Excluded

alavert TABS Excluded

alavert TBDP Excluded

ALLEGRA ALLERGY CHILDRENS SUSP Excluded

ALLEGRA ALLERGY CHILDRENS TABS Excluded

ALLEGRA ALLERGY TABS Excluded

ALLEGRA-D 12 HOUR ALLERGY & CONGESTION

TB12 Excluded

ALLEGRA-D 24 HOUR ALLERGY & CONGESTION

TB24 Excluded

allergy relief/nasal decongestant TB24 Excluded

cetirizine hcl childrens allergy SYRP Excluded

cetirizine hcl/pseudoephedrine hcl er TB12 Excluded

cetirizine hcl CHEW Excluded

cetirizine hcl TABS Excluded

childrens loratadine SYRP Excluded

CLARINEX SYRP Excluded

CLARINEX TABS Excluded

CLARINEX-D 12 HOUR TB12 Excluded

CLARITIN REDITABS TBDP Excluded

CLARITIN CHEW Excluded

CLARITIN SYRP Excluded

CLARITIN TABS Excluded

CLARITIN-D 12 HOUR TB12 Excluded

CLARITIN-D 24 HOUR TB24 Excluded




Limits

desloratadine TABS Excluded

fexofenadine hcl TABS Excluded

levocetirizine dihydrochloride SOLN Excluded

levocetirizine dihydrochloride TABS Excluded

loratadine hives relief SOLN Excluded

loratadine TABS Excluded

loratadine-d 24hr TB24 Excluded

SEMPREX-D CAPS Non-Preferred Brand

XYZAL TABS Excluded

ZYRTEC ALLERGY TABS Excluded

ZYRTEC CHILDRENS ALLERGY CHEW Excluded

ZYRTEC CHILDRENS ALLERGY SYRP Excluded

ZYRTEC-D ALLERGY/CONGESTION TB12 Excluded

Anti-infective Agents

Anthelmintics

ALBENZA TABS Preferred Brand QL

STROMECTOL TABS Preferred Brand

Antibacterials

ADOXA CAPS Non-Preferred Brand

ADOXA TABS Non-Preferred Brand

amoxicillin/clavulanate potassium CHEW Generic

amoxicillin/clavulanate potassium SUSR Generic

amoxicillin/clavulanate potassium TABS Generic

amoxicillin CAPS Generic

AMOXICILLIN CHEW Generic

amoxicillin SUSR Generic

amoxicillin TABS Generic

ampicillin CAPS Generic

AMPICILLIN SUSR Preferred Brand

AUGMENTIN XR TB12 Non-Preferred Brand

AUGMENTIN SUSR Preferred Brand

AUGMENTIN TABS Non-Preferred Brand

AVELOX TABS Preferred Brand

AVELOX SOLN Medical Benefit

azithromycin SUSR Generic

azithromycin TABS Generic

AZULFIDINE EN-TABS TBEC Non-Preferred Brand

AZULFIDINE TABS Non-Preferred Brand

BACITRACIN SOLR Medical Benefit

BACTRIM DS TABS Non-Preferred Brand

BACTRIM TABS Non-Preferred Brand

BETHKIS NEBU Non-Preferred Specialty

PA

BIAXIN XL TB24 Non-Preferred Brand

BIAXIN SUSR Non-Preferred Brand

BIAXIN TABS Non-Preferred Brand




Limits

CAYSTON SOLR Preferred Specialty QL

CEDAX CAPS Non-Preferred Brand

CEDAX SUSR Non-Preferred Brand

CEFACLOR ER TB12 Preferred Brand

cefaclor CAPS Generic

cefadroxil CAPS Generic

cefadroxil SUSR Generic

cefadroxil TABS Generic

cefdinir CAPS Generic

cefdinir SUSR Generic

CEFDITOREN PIVOXIL TABS Generic

cefpodoxime proxetil SUSR Generic

cefpodoxime proxetil TABS Generic

cefprozil SUSR Generic

cefprozil TABS Generic

CEFTIN SUSR Non-Preferred Brand

CEFTIN TABS Non-Preferred Brand

cefuroxime axetil SUSR Generic

cefuroxime axetil TABS Generic

cephalexin CAPS Generic

cephalexin SUSR Generic

CEPHALEXIN TABS Preferred Brand

CIPRO SUSR Preferred Brand

CIPRO TABS Non-Preferred Brand

ciprofloxacin er TB24 Generic

ciprofloxacin hcl TABS Generic

clarithromycin er TB24 Generic

clarithromycin SUSR Generic

clarithromycin TABS Generic

CLEOCIN IN D5W SOLN Medical Benefit

CLEOCIN PEDIATRIC GRANULES SOLR Preferred Brand

CLEOCIN CAPS Preferred Brand

CLEOCIN CAPS Non-Preferred Brand

clindamycin hcl CAPS Generic

CUBICIN SOLR Medical Benefit

demeclocycline hcl TABS Generic

dicloxacillin sodium CAPS Generic

DIFICID TABS Non-Preferred Specialty

QL ST

DORYX TBEC Non-Preferred Brand ST

doxycycline hyclate dr TBEC Generic

doxycycline hyclate CAPS Generic

doxycycline hyclate TABS Generic

doxycycline hyclate SOLR Medical Benefit

doxycycline monohydrate CAPS Generic

doxycycline monohydrate TABS Generic




Limits

doxycycline CAPS Generic

doxycycline SUSR Generic

E.E.S. 400 TABS Generic

E.E.S. GRANULES SUSR Preferred Brand

ERYPED 200 SUSR Preferred Brand

ERYPED 400 SUSR Preferred Brand

ERY-TAB TBEC Preferred Brand

ERYTHROCIN STEARATE TABS Preferred Brand

ERYTHROMYCIN BASE TABS Preferred Brand

ERYTHROMYCIN ETHYLSUCCINATE TABS Generic

erythromycin/sulfisoxazole SUSR Generic

erythromycin CPEP Preferred Brand

FACTIVE TABS Non-Preferred Brand

INVANZ SOLR Medical Benefit

KEFLEX CAPS Non-Preferred Brand

KETEK TABS Non-Preferred Brand

LEVAQUIN SOLN Non-Preferred Brand

LEVAQUIN TABS Non-Preferred Brand

LEVAQUIN SOLN Medical Benefit

levofloxacin SOLN Generic

levofloxacin TABS Generic

MERREM SOLR Medical Benefit

MINOCIN CAPS Non-Preferred Brand

minocycline hcl CAPS Generic

minocycline hcl TABS Generic

MONODOX CAPS Non-Preferred Brand

MOXATAG TB24 Non-Preferred Brand

NOROXIN TABS Preferred Brand

ofloxacin TABS Generic

PCE TBEC Preferred Brand

penicillin v potassium SOLR Generic

penicillin v potassium TABS Generic

ROCEPHIN SOLR Medical Benefit

SPECTRACEF TABS Non-Preferred Brand

SULFADIAZINE TABS Generic

sulfamethoxazole/trimethoprim ds TABS Generic

sulfamethoxazole/trimethoprim SUSP Generic

sulfamethoxazole/trimethoprim TABS Generic

sulfasalazine TABS Generic

sulfazine ec TBEC Generic

SUPRAX CAPS Preferred Brand

SUPRAX CHEW Preferred Brand

SUPRAX SUSR Preferred Brand

SUPRAX TABS Preferred Brand

TEFLARO SOLR Medical Benefit-Non-Preferred




Limits

Specialty

TETRACYCLINE HCL CAPS Generic

TOBI PODHALER CAPS Non-Preferred Specialty

QL PA

TOBI NEBU Non-Preferred Specialty

QL PA

tobramycin NEBU Preferred Specialty QL PA

VANCOCIN HCL CAPS Non-Preferred Specialty

QL

vancomycin hcl CAPS Preferred Specialty QL

vancomycin hcl SOLR Medical Benefit

VIBATIV SOLR Medical Benefit-Non-Preferred

Specialty

PA

VIBRAMYCIN SYRP Preferred Brand

VIBRAMYCIN CAPS Non-Preferred Brand

VIBRAMYCIN SUSR Non-Preferred Brand

XIFAXAN TABS Preferred Brand QL

ZITHROMAX TRI-PAK TABS Non-Preferred Brand

ZITHROMAX Z-PAK TABS Non-Preferred Brand

ZITHROMAX PACK Preferred Brand

ZITHROMAX SUSR Non-Preferred Brand

ZITHROMAX TABS Non-Preferred Brand

ZMAX SUSR Non-Preferred Brand

ZOSYN SOLN Medical Benefit

ZOSYN SOLR Medical Benefit

ZYVOX SUSR Preferred Specialty QL PA

ZYVOX TABS Preferred Specialty QL PA

ZYVOX SOLN Medical Benefit-Preferred

Specialty

Antifungals

CANCIDAS SOLR Medical Benefit-Preferred

Specialty

DIFLUCAN SUSR Non-Preferred Brand

DIFLUCAN TABS Non-Preferred Brand

fluconazole SUSR Generic

fluconazole TABS Generic

GRIFULVIN V TABS Preferred Brand

griseofulvin microsize SUSP Generic

GRIS-PEG TABS Preferred Brand

itraconazole CAPS Generic QL

ketoconazole TABS Generic

LAMISIL TABS Non-Preferred Brand

MYCAMINE SOLR Medical Benefit-Preferred




Limits

Specialty

NOXAFIL SUSP Preferred Specialty QL ST

nystatin SUSP Generic

nystatin TABS Generic

SPORANOX PULSEPAK CAPS Non-Preferred Brand QL

SPORANOX SOLN Preferred Brand

SPORANOX CAPS Non-Preferred Brand QL

terbinafine hcl TABS Generic

VFEND IV SOLR Medical Benefit-Non-Preferred

Specialty

VFEND SUSR Non-Preferred Specialty

QL

VFEND TABS Non-Preferred Specialty

QL

voriconazole SUSR Preferred Specialty

voriconazole TABS Preferred Specialty QL

voriconazole SOLR Medical Benefit-Preferred

Specialty

Antimycobacterials

CYCLOSERINE CAPS Generic

DAPSONE TABS Preferred Brand

ethambutol hcl TABS Generic

isoniazid TABS Generic

ISONIAZID SYRP Preferred Brand

MYCOBUTIN CAPS Preferred Brand

PRIFTIN TABS Preferred Brand

pyrazinamide TABS Generic

RIFADIN CAPS Non-Preferred Brand

RIFADIN SOLR Medical Benefit-Non-Preferred

Specialty

rifampin CAPS Generic

rifampin SOLR Medical Benefit-Preferred

Specialty

SEROMYCIN CAPS Non-Preferred Brand

SIRTURO TABS Preferred Specialty

Antiprotozoals

ALINIA SUSR Preferred Brand

ALINIA TABS Preferred Brand

ARALEN TABS Non-Preferred Brand

atovaquone/proguanil hcl TABS Generic

chloroquine phosphate TABS Generic

DARAPRIM TABS Preferred Brand

FLAGYL ER TB24 Non-Preferred Brand ST




Limits

FLAGYL CAPS Non-Preferred Brand

FLAGYL TABS Non-Preferred Brand

hydroxychloroquine sulfate TABS Generic

MALARONE TABS Non-Preferred Brand

mefloquine hcl TABS Generic

MEPRON SUSP Preferred Brand

metronidazole TABS Generic

NEBUPENT SOLR Preferred Brand

paromomycin sulfate CAPS Generic

PENTAM 300 SOLR Medical Benefit

PLAQUENIL TABS Non-Preferred Brand

PRIMAQUINE PHOSPHATE TABS Preferred Brand

QUALAQUIN CAPS Non-Preferred Brand PA

quinine sulfate CAPS Generic

TINDAMAX TABS Non-Preferred Brand

tinidazole TABS Generic

Antivirals

abacavir sulfate/lamivudine/zidovudine TABS Preferred Specialty QL

abacavir TABS Generic

acyclovir sodium SOLR Medical Benefit

acyclovir CAPS Generic

acyclovir SUSP Generic

acyclovir TABS Generic

adefovir dipivoxil TABS Preferred Specialty QL

APTIVUS CAPS Preferred Specialty QL ST

APTIVUS SOLN Preferred Specialty QL ST

ATRIPLA TABS Preferred Specialty QL

BARACLUDE SOLN Non-Preferred Brand

BARACLUDE TABS Non-Preferred Brand

COMBIVIR TABS Non-Preferred Specialty

QL

COMPLERA TABS Preferred Specialty QL

COPEGUS TABS Non-Preferred Specialty

QL

CRIXIVAN CAPS Preferred Brand

CYTOVENE SOLR Medical Benefit

didanosine CPDR Generic

EDURANT TABS Preferred Brand

EMTRIVA CAPS Preferred Brand

EMTRIVA SOLN Preferred Brand

EPIVIR HBV SOLN Preferred Brand

EPIVIR HBV TABS Non-Preferred Brand

EPIVIR SOLN Preferred Brand

EPIVIR TABS Non-Preferred Brand

EPZICOM TABS Preferred Specialty QL

famciclovir TABS Generic QL




Limits

FAMVIR TABS Non-Preferred Brand QL

FOSCARNET SODIUM SOLN Medical Benefit-Preferred

Specialty

HEPSERA TABS Non-Preferred Specialty

QL

INCIVEK TABS Non-Preferred Specialty

QL PA

INFERGEN INJ Preferred Specialty QL PA

INTELENCE TABS Preferred Specialty QL

INVIRASE CAPS Preferred Specialty QL

INVIRASE TABS Preferred Specialty QL

ISENTRESS TABS Preferred Specialty QL

KALETRA SOLN Preferred Specialty QL

KALETRA TABS Preferred Specialty QL

lamivudine/zidovudine TABS Preferred Specialty QL

lamivudine TABS Generic

LEXIVA SUSP Preferred Specialty QL

LEXIVA TABS Preferred Specialty QL

nevirapine TABS Generic

NORVIR CAPS Preferred Brand

NORVIR SOLN Preferred Brand

OLYSIO CAPS Preferred Specialty QL PA

PEGASYS PROCLICK SOLN Non-Preferred Specialty

QL PA

PEGASYS KIT Non-Preferred Specialty

QL PA

PEGASYS SOLN Non-Preferred Specialty

QL PA

PEG-INTRON REDIPEN PAK 4 KIT Preferred Specialty QL

PEG-INTRON REDIPEN KIT Preferred Specialty QL

PEG-INTRON KIT Preferred Specialty QL

PREZISTA SUSP Preferred Specialty QL

PREZISTA TABS Preferred Specialty QL

REBETOL CAPS Non-Preferred Specialty

QL

REBETOL SOLN Non-Preferred Specialty

QL

RELENZA DISKHALER AEPB Non-Preferred Brand

RESCRIPTOR TABS Preferred Brand

RETROVIR CAPS Non-Preferred Brand

RETROVIR SYRP Non-Preferred Brand

REYATAZ CAPS Preferred Specialty QL

RIBAPAK TABS Non-Preferred Specialty

QL ST

ribasphere CAPS Non-Preferred Specialty

QL ST




Limits

ribasphere TABS Non-Preferred Specialty

QL ST

ribavirin CAPS Preferred Specialty QL

ribavirin TABS Preferred Specialty QL

rimantadine hcl TABS Generic

SELZENTRY TABS Preferred Specialty QL PA

SOVALDI TABS Preferred Specialty QL PA

stavudine CAPS Generic

STRIBILD TABS Preferred Specialty QL

SUSTIVA CAPS Preferred Brand

SUSTIVA TABS Preferred Brand

SYNAGIS SOLN Medical Benefit-Preferred

Specialty

PA

TAMIFLU CAPS Preferred Brand QL

TAMIFLU SUSR Preferred Brand QL

TIVICAY TABS Preferred Specialty QL

TRIZIVIR TABS Non-Preferred Specialty

QL

TRUVADA TABS Preferred Specialty QL

TYZEKA TABS Preferred Specialty QL ST

valacyclovir hcl TABS Generic

VALCYTE TABS Preferred Specialty QL

VALTREX TABS Preferred Brand

VALTREX TABS Non-Preferred Brand

VICTRELIS CAPS Non-Preferred Specialty

QL PA

VIDEX EC CPDR Non-Preferred Brand

VIDEX PEDIATRIC SOLR Preferred Brand

VIRACEPT TABS Preferred Specialty QL

VIRAMUNE XR TB24 Preferred Brand QL

VIRAMUNE SUSP Preferred Brand

VIRAMUNE TABS Non-Preferred Brand

VIRAZOLE SOLR Medical Benefit-Preferred

Specialty

VIREAD TABS Preferred Specialty QL

VISTIDE SOLN Medical Benefit-Preferred

Specialty

ZERIT CAPS Non-Preferred Brand

ZERIT SOLR Non-Preferred Brand

ZIAGEN SOLN Preferred Brand

ZIAGEN TABS Non-Preferred Brand

zidovudine CAPS Generic

zidovudine SYRP Generic

zidovudine TABS Generic




Limits

ZOVIRAX CAPS Non-Preferred Brand

ZOVIRAX SUSP Non-Preferred Brand

ZOVIRAX TABS Non-Preferred Brand

Urinary Anti-infectives

FURADANTIN SUSP Preferred Brand

hyophen TABS Generic

MACROBID CAPS Non-Preferred Brand

MACRODANTIN CAPS Preferred Brand

MACRODANTIN CAPS Non-Preferred Brand

methenamine hippurate TABS Generic

MONUROL PACK Preferred Brand QL

nitrofurantoin macrocrystals CAPS Generic

nitrofurantoin monohydrate CAPS Generic

PROSED/DS TABS Non-Preferred Brand

trimethoprim TABS Generic

URIBEL CAPS Non-Preferred Brand

Antineoplastic Agents

ABRAXANE SUSR Medical Benefit-Preferred

Specialty

ADCETRIS SOLR Medical Benefit-Preferred

Specialty

PA

adriamycin SOLN Medical Benefit

adriamycin SOLR Medical Benefit

adrucil SOLN Medical Benefit

AFINITOR DISPERZ TBSO Preferred Specialty QL PA

AFINITOR TABS Preferred Specialty QL PA

ALFERON N SOLN Medical Benefit-Preferred

Specialty

ALIMTA SOLR Medical Benefit-Preferred

Specialty

ALKERAN TABS Preferred Brand

ALKERAN SOLR Medical Benefit-Preferred

Specialty

anastrozole TABS Generic

ARIMIDEX TABS Non-Preferred Brand

AROMASIN TABS Non-Preferred Brand

ARZERRA CONC Medical Benefit-Non-Preferred

Specialty

PA

AVASTIN SOLN Medical Benefit-Preferred




Limits

Specialty

bicalutamide TABS Generic

BICNU SOLR Medical Benefit

bleomycin sulfate SOLR Medical Benefit

BOSULIF TABS Non-Preferred Specialty

QL PA

BUSULFEX SOLN Medical Benefit

CAMPTOSAR SOLN Medical Benefit-Preferred

Specialty

CAPRELSA TABS Preferred Specialty QL PA

carboplatin SOLN Medical Benefit

CASODEX TABS Non-Preferred Brand

CERUBIDINE SOLR Medical Benefit

cisplatin SOLN Medical Benefit-Preferred

Specialty

cladribine SOLN Medical Benefit

COMETRIQ KIT Preferred Specialty QL PA

COSMEGEN SOLR Medical Benefit-Preferred

Specialty

CYCLOPHOSPHAMIDE TABS Generic

CYCLOPHOSPHAMIDE SOLR Medical Benefit

cytarabine SOLR Generic

dacarbazine SOLR Medical Benefit

DACOGEN SOLR Medical Benefit-Preferred

Specialty

daunorubicin hcl SOLR Medical Benefit

DAUNOXOME INJ Medical Benefit

DEPOCYT SUSP Medical Benefit

DOCEFREZ SOLR Medical Benefit-Preferred

Specialty

DOCETAXEL CONC Medical Benefit-Preferred

Specialty

DOXIL INJ Medical Benefit-Preferred

Specialty

doxorubicin hcl SOLN Medical Benefit

ELIGARD KIT Medical Benefit-Preferred

Specialty

ELLENCE SOLN Medical Benefit-Preferred




Limits

Specialty

ELOXATIN SOLN Medical Benefit-Preferred

Specialty

ELSPAR SOLR Medical Benefit

EMCYT CAPS Preferred Brand

ERBITUX SOLN Medical Benefit-Preferred

Specialty

PA

ERIVEDGE CAPS Preferred Specialty QL PA

ERWINAZE SOLR Medical Benefit-Non-Preferred

Specialty

PA

ETOPOSIDE CAPS Generic

exemestane TABS Generic

FARESTON TABS Non-Preferred Brand QL ST

FASLODEX SOLN Medical Benefit-Preferred

Specialty

FEMARA TABS Non-Preferred Brand

FIRMAGON SOLR Medical Benefit-Non-Preferred

Specialty

floxuridine SOLR Medical Benefit

FLUDARA SOLR Medical Benefit

fludarabine phosphate SOLR Medical Benefit

flutamide CAPS Medical Benefit

FOLOTYN SOLN Medical Benefit-Preferred

Specialty

GAZYVA SOLN Medical Benefit-Preferred

Specialty

GEMZAR SOLR Medical Benefit-Preferred

Specialty

GILOTRIF TABS Preferred Specialty QL PA

GLEEVEC TABS Preferred Specialty QL PA

HALAVEN SOLN Medical Benefit-Non-Preferred

Specialty

HERCEPTIN SOLR Medical Benefit-Preferred

Specialty

HYCAMTIN CAPS Preferred Specialty QL

HYCAMTIN SOLR Medical Benefit-Preferred

Specialty




Limits

HYDREA CAPS Non-Preferred Brand

hydroxyurea CAPS Generic

ICLUSIG TABS Non-Preferred Specialty

QL PA

IDAMYCIN PFS SOLN Medical Benefit-Preferred

Specialty

idarubicin hcl SOLN Medical Benefit

IFEX SOLR Medical Benefit

ifosfamide SOLR Medical Benefit

IMBRUVICA CAPS Non-Preferred Specialty

QL PA

INLYTA TABS Preferred Specialty QL PA

INTRON-A W/DILUENT SOLR Preferred Specialty QL

INTRON-A SOLN Preferred Specialty QL

IXEMPRA KIT SOLR Medical Benefit-Non-Preferred

Specialty

JAKAFI TABS Preferred Specialty QL PA

JEVTANA SOLN Medical Benefit-Non-Preferred

Specialty

PA

KADCYLA SOLR Medical Benefit-Preferred

Specialty

PA

KYPROLIS SOLR Medical Benefit-Preferred

Specialty

letrozole TABS Generic

LEUKERAN TABS Preferred Brand

leuprolide acetate KIT Generic

LOMUSTINE CAPS Generic

LUPANETA PACK KIT Medical Benefit-Non-Preferred

Specialty

LUPRON DEPOT KIT Medical Benefit-Preferred

Specialty

LUPRON DEPOT-PED KIT Medical Benefit-Preferred

Specialty

LYSODREN TABS Preferred Specialty PA

MARQIBO SUSP Medical Benefit-Non-Preferred

Specialty

PA

MATULANE CAPS Preferred Specialty QL PA

MEGACE ORAL SUSP Non-Preferred Brand

megestrol acetate SUSP Generic




Limits

megestrol acetate TABS Generic

MEKINIST TABS Non-Preferred Specialty

QL PA

mercaptopurine TABS Generic

methotrexate sodium SOLN Generic

methotrexate sodium SOLR Generic

methotrexate TABS Generic

mitomycin SOLR Medical Benefit

mitoxantrone hcl CONC Medical Benefit

MUSTARGEN SOLR Medical Benefit

NAVELBINE SOLN Medical Benefit

NEXAVAR TABS Preferred Specialty QL PA

NIPENT SOLR Medical Benefit-Preferred

Specialty

ONCASPAR SOLN Medical Benefit-Preferred

Specialty

ONTAK SOLN Medical Benefit

paclitaxel CONC Medical Benefit

PERJETA SOLN Medical Benefit-Preferred

Specialty

PA

PHOTOFRIN SOLR Medical Benefit-Preferred

Specialty

POMALYST CAPS Non-Preferred Specialty

PA

PROLEUKIN SOLR Medical Benefit-Preferred

Specialty

REVLIMID CAPS Preferred Specialty QL

RHEUMATREX TABS Preferred Brand

RITUXAN CONC Medical Benefit-Preferred

Specialty

PA

SPRYCEL TABS Preferred Specialty QL PA

STIVARGA TABS Non-Preferred Specialty

QL PA

SUPPRELIN LA KIT Medical Benefit-Preferred

Specialty

SUTENT CAPS Preferred Specialty QL PA

SYLATRON KIT Preferred Specialty QL PA

SYNRIBO SOLR Medical Benefit-Non-Preferred

Specialty

ST




Limits

TABLOID TABS Preferred Brand

TAFINLAR CAPS Non-Preferred Specialty

QL PA

tamoxifen citrate TABS Generic

TARCEVA TABS Preferred Specialty QL PA

TARGRETIN CAPS Preferred Specialty QL PA

TASIGNA CAPS Preferred Specialty QL PA

TAXOTERE CONC Medical Benefit-Preferred

Specialty

TEMODAR CAPS Preferred Specialty QL

TENIPOSIDE SOLN Medical Benefit

THIOTEPA SOLR Medical Benefit

toposar SOLN Medical Benefit

TREANDA SOLR Medical Benefit-Preferred

Specialty

TRELSTAR DEPOT SUSR Medical Benefit-Preferred

Specialty

TRELSTAR LA SUSR Medical Benefit-Preferred

Specialty

TRELSTAR MIXJECT SUSR Medical Benefit-Preferred

Specialty

tretinoin CAPS Preferred Specialty QL PA

TRISENOX SOLN Medical Benefit-Preferred

Specialty

TYKERB TABS Preferred Specialty QL PA

VANTAS KIT Medical Benefit-Preferred

Specialty

VECTIBIX SOLN Medical Benefit-Preferred

Specialty

PA

VELCADE SOLR Medical Benefit-Preferred

Specialty

VINBLASTINE SULFATE SOLN Medical Benefit

vincasar pfs SOLN Medical Benefit

vincristine sulfate SOLN Medical Benefit

vinorelbine tartrate SOLN Medical Benefit

VOTRIENT TABS Preferred Specialty QL PA

XALKORI CAPS Preferred Specialty QL PA

XELODA TABS Preferred Specialty QL




Limits

XTANDI CAPS Non-Preferred Specialty

QL PA

YERVOY SOLN Medical Benefit-Preferred

Specialty

PA

ZALTRAP SOLN Medical Benefit-Non-Preferred

Specialty

ZANOSAR SOLR Medical Benefit

ZELBORAF TABS Preferred Specialty QL PA

ZEVALIN IN-111 KIT Medical Benefit-Preferred

Specialty

PA

ZEVALIN Y-90 KIT Medical Benefit-Preferred

Specialty

PA

ZOLADEX IMPL Medical Benefit-Preferred

Specialty

ZOLINZA CAPS Preferred Specialty QL PA

ZYTIGA TABS Preferred Specialty QL PA

Autonomic Drugs

Anticholinergic Agents

ANASPAZ TBDP Non-Preferred Brand

ATROPINE SULFATE SOLN Generic

ATROVENT HFA AERS Preferred Brand

ATROVENT SOLN Non-Preferred Brand

BELLADONNA & OPIUM SUPP Preferred Brand

BELLADONNA ALKALOIDS & OPIUM SUPP Preferred Brand

BENTYL CAPS Non-Preferred Brand

BENTYL TABS Non-Preferred Brand

CANTIL TABS Preferred Brand

chlordiazepoxide hcl/clidinium bromide CAPS Generic

CUVPOSA SOLN Non-Preferred Specialty

QL

dicyclomine hcl CAPS Generic

DICYCLOMINE HCL SOLN Generic

dicyclomine hcl TABS Generic

DONNATAL EXTENTABS TBCR Preferred Brand

DONNATAL ELIX Non-Preferred Brand

DONNATAL TABS Non-Preferred Brand

GLYCATE TABS Non-Preferred Brand

glycopyrrolate SOLN Generic

glycopyrrolate TABS Generic

hyomax-sl SUBL Generic

hyoscyamine sulfate er TB12 Generic

hyoscyamine sulfate ELIX Generic




Limits

hyoscyamine sulfate SOLN Generic

hyoscyamine sulfate SUBL Generic

hyoscyamine sulfate TABS Generic

hyoscyamine sulfate TBDP Generic

ipratropium bromide SOLN Generic

LEVSIN/SL SUBL Non-Preferred Brand

LEVSIN TABS Non-Preferred Brand

methscopolamine bromide TABS Generic

nulev TBDP Generic

oscimin sr TB12 Generic

PAMINE FORTE TABS Non-Preferred Brand

PROPANTHELINE BROMIDE TABS Generic

ROBINUL FORTE TABS Non-Preferred Brand

ROBINUL SOLN Non-Preferred Brand

ROBINUL TABS Non-Preferred Brand

SPIRIVA HANDIHALER CAPS Preferred Brand

SYMAX DUOTAB TBCR Non-Preferred Brand

TUDORZA PRESSAIR AEPB Preferred Brand

Autonomic Drugs, Miscellaneous

CHANTIX STARTING MONTH PAK TABS Preferred Brand

CHANTIX TABS Preferred Brand

COMMIT LOZG Preferred Brand

nicotine polacrilex GUM Generic

nicotine polacrilex LOZG Generic

nicotine PT24 Generic

NICOTROL INHALER INHA Preferred Brand QL

NICOTROL NS SOLN Preferred Brand

Parasympathomimetic (Cholinergic) Agents

ARICEPT ODT TBDP Non-Preferred Brand

ARICEPT TABS Non-Preferred Brand

bethanechol chloride TABS Generic

donepezil hcl TABS Generic

donepezil hcl TBDP Generic

EVOXAC CAPS Preferred Brand

EXELON PT24 Preferred Brand QL

EXELON SOLN Preferred Brand

EXELON CAPS Non-Preferred Brand

galantamine hydrobromide CP24 Generic

galantamine hydrobromide SOLN Generic

galantamine hydrobromide TABS Generic

MESTINON SYRP Preferred Brand

MESTINON TABS Non-Preferred Brand

pilocarpine hcl TABS Generic

pilocarpine hydrochloride TABS Generic

pyridostigmine bromide TABS Generic

RAZADYNE ER CP24 Non-Preferred Brand




Limits

RAZADYNE SOLN Non-Preferred Brand

RAZADYNE TABS Non-Preferred Brand

rivastigmine tartrate CAPS Generic

SALAGEN TABS Non-Preferred Brand

Skeletal Muscle Relaxants

AMRIX CP24 Non-Preferred Brand

baclofen TABS Generic

carisoprodol/aspirin/codeine TABS Generic

carisoprodol/aspirin TABS Generic

carisoprodol TABS Generic

chlorzoxazone TABS Generic

cyclobenzaprine hcl TABS Generic

DANTRIUM CAPS Non-Preferred Brand

dantrolene sodium CAPS Generic

LIORESAL INTRATHECAL SOLN Medical Benefit-Preferred

Specialty

LORZONE TABS Non-Preferred Brand QL ST

metaxalone TABS Generic

methocarbamol TABS Generic

orphenadrine citrate er TB12 Generic

PARAFON FORTE DSC TABS Non-Preferred Brand

ROBAXIN TABS Non-Preferred Brand

ROBAXIN-750 TABS Non-Preferred Brand

SKELAXIN TABS Non-Preferred Brand

SOMA TABS Non-Preferred Brand

tizanidine hcl CAPS Generic

tizanidine hcl TABS Generic

ZANAFLEX CAPS Non-Preferred Brand

ZANAFLEX TABS Non-Preferred Brand

Sympatholytic (Adrenergic Blocking) Agents

alfuzosin hcl er TB24 Generic

DIBENZYLINE CAPS Preferred Specialty QL

DIHYDROERGOTAMINE MESYLATE SOLN Generic

dihydroergotamine mesylate SOLN Medical Benefit

ERGOLOID MESYLATES TABS Generic

FLOMAX CAPS Non-Preferred Brand

MIGRANAL SOLN Non-Preferred Brand

RAPAFLO CAPS Non-Preferred Brand ST

tamsulosin hcl CAPS Generic

UROXATRAL TB24 Preferred Brand

Sympathomimetic (Adrenergic) Agents

ACCUNEB NEBU Non-Preferred Brand

ADRENACLICK SOAJ Non-Preferred Brand QL

ADVAIR DISKUS AEPB Non-Preferred Brand

ADVAIR HFA AERO Non-Preferred Brand




Limits

albuterol sulfate er TB12 Generic

albuterol sulfate NEBU Generic

albuterol sulfate SYRP Generic

albuterol sulfate TABS Generic

ARCAPTA NEOHALER CAPS Non-Preferred Brand

AUVI-Q SOAJ Non-Preferred Brand QL ST

BROVANA NEBU Preferred Brand

COMBIVENT RESPIMAT AERS Preferred Brand QL

COMBIVENT AERO Preferred Brand

DUONEB SOLN Non-Preferred Brand QL

EPINEPHRINE SOAJ Generic QL

EPIPEN 2-PAK SOAJ Preferred Brand QL

EPIPEN-JR 2-PAK SOAJ Preferred Brand QL

FORADIL AEROLIZER CAPS Preferred Brand

ipratropium bromide/albuterol sulfate SOLN Generic QL

levalbuterol hcl NEBU Generic

levalbuterol NEBU Generic

MAXAIR AUTOHALER AERB Non-Preferred Brand

METAPROTERENOL SULFATE SYRP Generic

METAPROTERENOL SULFATE TABS Generic

midodrine hcl TABS Generic

PERFOROMIST NEBU Preferred Brand

PROAIR HFA AERS Generic

PROVENTIL HFA AERS Non-Preferred Brand

SEREVENT DISKUS AEPB Preferred Brand

terbutaline sulfate TABS Generic

terbutaline sulfate SOLN Medical Benefit

VENTOLIN HFA AERS Preferred Brand

VOSPIRE ER TB12 Non-Preferred Brand

XOPENEX CONCENTRATE NEBU Non-Preferred Brand

XOPENEX HFA AERO Preferred Brand

XOPENEX NEBU Non-Preferred Brand

Blood Formation,Coagulation & Thrombosis

Antianemia Drugs

dexferrum SOLN Medical Benefit

FERAHEME SOLN Medical Benefit

FERREX 150 FORTE PLUS CAPS Excluded

ferrex 150 forte CAPS Excluded

FERREX 150 PLUS CAPS Excluded

ferrex 150 CAPS Excluded

FERREX 28 TABS Excluded

FERRLECIT SOLN Medical Benefit

ferrous sulfate SOLN Generic

infed SOLN Medical Benefit

INJECTAFER SOLN Medical Benefit-Non-Preferred




Limits

Specialty

MYKIDZ IRON 10 SUSP Preferred Brand

VENOFER SOLN Medical Benefit

VITAFOL SYRP Preferred Brand

wee care SUSP Generic

Antihemorrhagic Agents

ADVATE SOLR Preferred Specialty QL

ALPHANATE/VON WILLEBRAND FACTOR COMPLEX/HUMAN

SOLR Preferred Specialty QL

aminocaproic acid SYRP Generic

aminocaproic acid TABS Generic

BEBULIN VH SOLR Preferred Specialty QL

BEBULIN SOLR Preferred Specialty QL

BENEFIX SOLR Preferred Specialty QL

CORIFACT KIT Medical Benefit-Preferred

Specialty

FEIBA NF SOLR Preferred Specialty QL

HELIXATE FS KIT Preferred Specialty QL

HEMOFIL M SOLR Preferred Specialty QL

HUMATE-P SOLR Preferred Specialty QL

KOATE-DVI SOLR Preferred Specialty QL

KOGENATE FS BIO-SET KIT Preferred Specialty QL

KOGENATE FS KIT Preferred Specialty QL

LYSTEDA TABS Non-Preferred Brand

MONOCLATE-P KIT Preferred Specialty QL

MONONINE SOLR Preferred Specialty QL

NOVOSEVEN RT SOLR Preferred Specialty QL

RECOMBINATE SOLR Preferred Specialty QL

RIXUBIS SOLR Non-Preferred Specialty

tranexamic acid TABS Generic

WILATE SOLR Preferred Specialty QL

XYNTHA KIT Preferred Specialty QL

Antithrombotic Agents

AGGRENOX CP12 Preferred Brand

AGRYLIN CAPS Non-Preferred Brand

anagrelide hydrochloride CAPS Generic

ARIXTRA SOLN Non-Preferred Specialty

QL

BRILINTA TABS Preferred Brand

cilostazol TABS Generic

clopidogrel TABS Generic

COUMADIN TABS Preferred Brand

EFFIENT TABS Preferred Brand QL

ELIQUIS TABS Preferred Brand QL

enoxaparin sodium SOLN Generic




Limits

fondaparinux sodium SOLN Preferred Specialty QL

FRAGMIN SOLN Non-Preferred Specialty

QL

heparin sodium SOLN Generic

jantoven TABS Generic

LOVENOX SOLN Non-Preferred Specialty

QL

PLAVIX TABS Non-Preferred Brand

PLETAL TABS Non-Preferred Brand

PRADAXA CAPS Preferred Brand QL

THROMBATE III W/10 ML STERILE WATER SOLR Medical Benefit-Preferred

Specialty

ticlopidine hcl TABS Generic

warfarin sodium TABS Generic

XARELTO TABS Preferred Brand QL

Hematopoietic Agents

ARANESP ALBUMIN FREE SOLN Preferred Specialty QL

EPOGEN SOLN Non-Preferred Specialty

QL

GRANIX SOSY Generic

LEUKINE SOLR Medical Benefit-Preferred

Specialty

MOZOBIL SOLN Medical Benefit-Non-Preferred

Specialty

NEULASTA SOLN Preferred Specialty QL

NEUMEGA SOLR Preferred Specialty QL

NEUPOGEN SOLN Non-Preferred Specialty

QL

NPLATE SOLR Medical Benefit-Preferred

Specialty

PA

OMONTYS SOLN Non-Preferred Specialty

QL

PROCRIT SOLN Non-Preferred Specialty

QL

PROMACTA TABS Preferred Specialty QL PA

Hemorrheologic Agents

pentoxifylline er TBCR Generic

TRENTAL TBCR Non-Preferred Brand

Cardiovascular Drugs

alpha-Adrenergic Blocking Agents

CARDURA XL TB24 Non-Preferred Brand ST

CARDURA TABS Non-Preferred Brand

doxazosin mesylate TABS Generic




Limits

MINIPRESS CAPS Non-Preferred Brand

prazosin hcl CAPS Generic

terazosin hcl CAPS Generic

Antilipemic Agents

ADVICOR TB24 Preferred Brand

ALTOPREV TB24 Non-Preferred Brand ST

ANTARA CAPS Non-Preferred Brand

atorvastatin calcium TABS Generic

cholestyramine light PACK Generic

cholestyramine light POWD Generic

cholestyramine PACK Generic

cholestyramine POWD Generic

COLESTID GRAN Non-Preferred Brand

COLESTID PACK Non-Preferred Brand

COLESTID TABS Non-Preferred Brand

colestipol hcl for oral suspension PACK Generic

colestipol hcl GRAN Generic

colestipol hcl TABS Generic

CRESTOR TABS Preferred Brand

fenofibrate micronized CAPS Generic

fenofibrate CAPS Generic

fenofibrate TABS Generic

fenofibric acid dr CPDR Generic

FENOFIBRIC ACID TABS Generic

FENOGLIDE TABS Non-Preferred Brand ST

FIBRICOR TABS Non-Preferred Brand

fluvastatin CAPS Generic

gemfibrozil TABS Generic

JUXTAPID CAPS Non-Preferred Specialty

PA

KYNAMRO SOLN Non-Preferred Brand PA

LESCOL XL TB24 Non-Preferred Brand ST

LESCOL CAPS Non-Preferred Brand

LIPITOR TABS Non-Preferred Brand

LIPOFEN CAPS Non-Preferred Brand ST

LIPTRUZET TABS Non-Preferred Brand QL ST

LIVALO TABS Non-Preferred Brand ST

LOFIBRA CAPS Non-Preferred Brand

LOFIBRA TABS Non-Preferred Brand

LOPID TABS Non-Preferred Brand

lovastatin TABS Generic

LOVAZA CAPS Preferred Brand PA

MEVACOR TABS Non-Preferred Brand

niacin er TBCR Generic

NIASPAN TBCR Non-Preferred Brand

PRAVACHOL TABS Non-Preferred Brand




Limits

pravastatin sodium TABS Generic

prevalite PACK Generic

prevalite POWD Generic

QUESTRAN LIGHT POWD Non-Preferred Brand

QUESTRAN POWD Non-Preferred Brand

SIMCOR TB24 Preferred Brand QL

simvastatin TABS Generic

TRICOR TABS Non-Preferred Brand

TRIGLIDE TABS Non-Preferred Brand

TRILIPIX CPDR Non-Preferred Brand

VASCEPA CAPS Non-Preferred Brand PA

VYTORIN TABS Non-Preferred Brand ST

WELCHOL TABS Preferred Brand

ZETIA TABS Preferred Brand

ZOCOR TABS Non-Preferred Brand QL

beta-Adrenergic Blocking Agents

acebutolol hcl CAPS Generic

atenolol/chlorthalidone TABS Generic

atenolol TABS Generic

BETAPACE TABS Non-Preferred Brand

betaxolol hcl TABS Generic

bisoprolol fumarate/hydrochlorothiazide TABS Generic

bisoprolol fumarate TABS Generic

BYSTOLIC TABS Non-Preferred Brand ST

carvedilol TABS Generic

COREG CR CP24 Preferred Brand ST

COREG TABS Non-Preferred Brand

CORGARD TABS Non-Preferred Brand

CORZIDE TABS Non-Preferred Brand

INDERAL LA CP24 Non-Preferred Brand

INNOPRAN XL CP24 Non-Preferred Brand ST

KERLONE TABS Non-Preferred Brand

labetalol hcl TABS Generic

LEVATOL TABS Preferred Brand

LOPRESSOR HCT TABS Non-Preferred Brand

LOPRESSOR TABS Non-Preferred Brand

LOPRESSOR SOLN Medical Benefit-Non-Preferred

Specialty

metoprolol succinate er TB24 Generic

metoprolol tartrate TABS Generic

metoprolol/hydrochlorothiazide TABS Generic

nadolol/bendroflumethiazide TABS Generic

nadolol TABS Generic

pindolol TABS Generic

propranolol hcl er CP24 Generic




Limits

PROPRANOLOL HCL SOLN Generic

propranolol hcl TABS Generic

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS Generic

SECTRAL CAPS Non-Preferred Brand

sorine TABS Generic

sotalol hcl TABS Generic

TENORETIC 100 TABS Non-Preferred Brand

TENORETIC 50 TABS Non-Preferred Brand

TENORMIN TABS Non-Preferred Brand

TIMOLOL MALEATE TABS Generic

TOPROL XL TB24 Non-Preferred Brand

TRANDATE TABS Non-Preferred Brand

ZEBETA TABS Non-Preferred Brand

ZIAC TABS Non-Preferred Brand

Calcium-Channel Blocking Agents

ADALAT CC TB24 Non-Preferred Brand

afeditab cr TB24 Generic

amlodipine besylate/atorvastatin calcium TABS Generic

amlodipine besylate/benazepril hcl CAPS Generic

amlodipine besylate/benazepril hcl CAPS Preferred Brand

amlodipine besylate/benazepril hydrochloride CAPS Generic

amlodipine besylate TABS Generic

AZOR TABS Non-Preferred Brand ST

CADUET TABS Non-Preferred Brand

CALAN SR TBCR Non-Preferred Brand

CALAN TABS Non-Preferred Brand

CARDENE SR CP12 Non-Preferred Brand ST

CARDIZEM CD CP24 Non-Preferred Brand

CARDIZEM LA TB24 Preferred Brand

CARDIZEM LA TB24 Non-Preferred Brand

CARDIZEM TABS Non-Preferred Brand

cartia xt CP24 Generic

DILACOR XR CP24 Non-Preferred Brand

dilt-cd CP24 Generic

diltiazem cd CP24 Generic

diltiazem hcl er CP12 Generic

diltiazem hcl er CP24 Generic

diltiazem hcl TABS Generic

dilt-xr CP24 Generic

diltzac CP24 Generic

EXFORGE HCT TABS Preferred Brand ST

EXFORGE TABS Preferred Brand ST

felodipine er TB24 Generic

ISOPTIN SR TBCR Non-Preferred Brand

ISRADIPINE CAPS Generic

LOTREL CAPS Non-Preferred Brand




Limits

matzim la TB24 Generic

nicardipine hcl CAPS Generic

nifediac cc TB24 Generic

nifedipine er TB24 Generic

nifedipine CAPS Generic

nimodipine CAPS Preferred Specialty QL

NISOLDIPINE ER TB24 Generic

nisoldipine TB24 Generic

NORVASC TABS Non-Preferred Brand

NYMALIZE SOLN Non-Preferred Specialty

QL ST

PROCARDIA XL TB24 Non-Preferred Brand

SULAR TB24 Non-Preferred Brand

TARKA TBCR Preferred Brand

TARKA TBCR Non-Preferred Brand

telmisartan/amlodipine TABS Generic

TIAZAC CP24 Non-Preferred Brand

TRIBENZOR TABS Non-Preferred Brand ST

TWYNSTA TABS Non-Preferred Brand

verapamil hcl er CP24 Generic

verapamil hcl er TBCR Generic

verapamil hcl TABS Generic

VERELAN PM CP24 Non-Preferred Brand

VERELAN CP24 Non-Preferred Brand

Cardiac Drugs

amiodarone hcl TABS Generic

CORDARONE TABS Non-Preferred Brand

digox TABS Generic

DIGOXIN SOLN Preferred Brand

disopyramide phosphate CAPS Generic

flecainide acetate TABS Generic

LANOXIN PEDIATRIC SOLN Medical Benefit-Non-Preferred

Specialty

LANOXIN TABS Non-Preferred Brand

mexiletine hcl CAPS Generic

MULTAQ TABS Preferred Brand

NORPACE CR CP12 Preferred Brand

NORPACE CAPS Non-Preferred Brand

pacerone TABS Generic

pacerone TABS Preferred Brand

propafenone hcl er CP12 Generic

propafenone hcl TABS Generic

quinidine gluconate cr TBCR Generic

QUINIDINE SULFATE ER TBCR Generic

QUINIDINE SULFATE TABS Generic




Limits

RANEXA TB12 Preferred Brand

RYTHMOL SR CP12 Non-Preferred Brand QL

RYTHMOL TABS Non-Preferred Brand

TAMBOCOR TABS Non-Preferred Brand

TIKOSYN CAPS Preferred Brand

Hypotensive Agents

CATAPRES TABS Non-Preferred Brand

CATAPRES-TTS-1 PTWK Non-Preferred Brand



clonidine hcl er TB12 Generic

clonidine hcl PTWK Generic

clonidine hcl TABS Generic

CLORPRES TABS Generic

guanfacine hcl TABS Generic

hydralazine hcl TABS Generic

KAPVAY TB12 Non-Preferred Brand

METHYLDOPA/HYDROCHLOROTHIAZIDE TABS Generic

methyldopa TABS Generic

minoxidil TABS Generic

RESERPINE TABS Generic

TENEX TABS Non-Preferred Brand

VECAMYL TABS Preferred Specialty

Renin-Angiotensin-Aldosterone Sys Inhib

ACCUPRIL TABS Non-Preferred Brand

ACCURETIC TABS Non-Preferred Brand

ALDACTAZIDE TABS Preferred Brand

ALDACTAZIDE TABS Non-Preferred Brand

ALDACTONE TABS Non-Preferred Brand

ALTACE CAPS Non-Preferred Brand

AMTURNIDE TABS Preferred Brand QL

ATACAND HCT TABS Non-Preferred Brand

ATACAND TABS Non-Preferred Brand

AVALIDE TABS Non-Preferred Brand

AVAPRO TABS Non-Preferred Brand

benazepril hcl/hydrochlorothiazide TABS Generic

benazepril hcl TABS Generic

BENICAR HCT TABS Non-Preferred Brand ST

BENICAR TABS Non-Preferred Brand ST

candesartan cilexetil/hydrochlorothiazide TABS Generic

candesartan cilexetil TABS Generic

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS Generic

captopril TABS Generic

COZAAR TABS Non-Preferred Brand

DIOVAN HCT TABS Non-Preferred Brand

DIOVAN TABS Preferred Brand QL ST




Limits

EDARBI TABS Non-Preferred Brand ST

EDARBYCLOR TABS Non-Preferred Brand ST

enalapril maleate/hydrochlorothiazide TABS Generic

enalapril maleate TABS Generic

EPANED SOLR Non-Preferred Brand

eplerenone TABS Generic

fosinopril sodium/hydrochlorothiazide TABS Generic

fosinopril sodium TABS Generic

HYZAAR TABS Non-Preferred Brand

INSPRA TABS Non-Preferred Brand

irbesartan/hydrochlorothiazide TABS Generic

irbesartan TABS Generic

lisinopril/hydrochlorothiazide TABS Generic

lisinopril TABS Generic

losartan potassium/hydrochlorothiazide TABS Generic

losartan potassium TABS Generic

LOTENSIN HCT TABS Non-Preferred Brand

LOTENSIN TABS Non-Preferred Brand

MAVIK TABS Non-Preferred Brand

MICARDIS HCT TABS Non-Preferred Brand

MICARDIS TABS Non-Preferred Brand

moexipril hcl TABS Generic

moexipril/hydrochlorothiazide TABS Generic

perindopril erbumine TABS Generic

PRINIVIL TABS Non-Preferred Brand

quinapril hcl TABS Generic

quinapril/hydrochlorothiazide TABS Generic

ramipril CAPS Generic

spironolactone/hydrochlorothiazide TABS Generic

spironolactone TABS Generic

TEKAMLO TABS Preferred Brand ST

TEKTURNA HCT TABS Preferred Brand ST

TEKTURNA TABS Preferred Brand ST

telmisartan/hydrochloroth TABS Generic

telmisartan/hydrochlorothiazide TABS Generic

telmisartan TABS Generic

TEVETEN HCT TABS Non-Preferred Brand ST

TEVETEN TABS Non-Preferred Brand ST

trandolapril TABS Generic

UNIRETIC TABS Non-Preferred Brand

UNIVASC TABS Non-Preferred Brand

valsartan/hydrochlorothiazide TABS Generic

VASERETIC TABS Non-Preferred Brand

VASOTEC TABS Non-Preferred Brand

ZESTORETIC TABS Non-Preferred Brand

ZESTRIL TABS Non-Preferred Brand




Limits

Vasodilating Agents

ADCIRCA TABS Preferred Specialty QL PA

ADEMPAS TABS Preferred Specialty QL PA

BIDIL TABS Preferred Brand

CAVERJECT IMPULSE KIT Excluded

CAVERJECT SOLR Excluded

CIALIS TABS Excluded

CIALIS TABS Excluded ST

dipyridamole TABS Generic

EDEX KIT Preferred Brand QL

epoprostenol sodium SOLR Medical Benefit-Preferred

Specialty

FLOLAN SOLR Medical Benefit-Non-Preferred

Specialty

isoditrate er TBCR Generic

ISORDIL TITRADOSE TABS Preferred Brand

ISORDIL TITRADOSE TABS Non-Preferred Brand

isosorbide dinitrate er TBCR Generic

ISOSORBIDE DINITRATE SUBL Generic

isosorbide dinitrate TABS Generic

isosorbide mononitrate er TB24 Generic

isosorbide mononitrate TABS Generic

LETAIRIS TABS Non-Preferred Specialty

QL

LEVITRA TABS Excluded

minitran PT24 Generic

MUSE PLLT Preferred Brand QL

NITRO-BID OINT Preferred Brand

NITRO-DUR PT24 Preferred Brand

NITRO-DUR PT24 Non-Preferred Brand

nitroglycerin er CPCR Generic

nitroglycerin transdermal PT24 Generic

NITROLINGUAL PUMPSPRAY SOLN Preferred Brand

NITROSTAT SUBL Generic

nitro-time CPCR Generic

OPSUMIT TABS Non-Preferred Specialty

QL PA

PERSANTINE TABS Non-Preferred Brand

REMODULIN SOLN Medical Benefit-Preferred

Specialty

PA

REVATIO TABS Non-Preferred Specialty

QL PA

sildenafil citrate TABS Generic PA

STAXYN TBDP Excluded




Limits

STENDRA TABS Excluded

TRACLEER TABS Preferred Specialty QL

TYVASO SOLN Preferred Specialty QL PA

VENTAVIS SOLN Preferred Brand PA

VIAGRA TABS Excluded

Cellular Therapy

PROVENGE SUSP Medical Benefit-Non-Preferred

Specialty

PA

Central Nervous System Agents

Analgesics and Antipyretics

ABSTRAL SUBL Non-Preferred Brand PA

acetaminophen/codeine #3 TABS Generic

acetaminophen/codeine SOLN Generic

acetaminophen/codeine TABS Generic

ACTIQ LPOP Non-Preferred Specialty

QL PA

ANAPROX DS TABS Non-Preferred Brand

ANAPROX TABS Non-Preferred Brand

ARTHROTEC 50 TBEC Non-Preferred Brand

ARTHROTEC 75 TBEC Non-Preferred Brand

ASCRIPTIN TABS Generic

aspirin ec low dose TBEC Generic

aspirin ec TBEC Generic

aspirin CHEW Generic

ASPIRIN-CAFFEINE-DIHYDROCODEINE CAPS Generic

AVINZA CP24 Preferred Brand QL ST

buffered aspirin TABS Generic

BUFFERIN LOW DOSE TABS Non-Preferred Brand

BUFFERIN TABS Non-Preferred Brand

BUPRENEX SOLN Medical Benefit

buprenorphine hcl/naloxone hcl SUBL Generic QL

buprenorphine hcl SUBL Generic QL

butalbital/acetaminophen/caffeine/codeine CAPS Generic QL

butalbital/acetaminophen/caffeine TABS Generic

butalbital/acetaminophen TABS Generic

butalbital/apap/caffeine CAPS Generic QL

butalbital/asa/caffeine CAPS Generic

BUTALBITAL/ASPIRIN/CAFFEINE TABS Generic

butorphanol tartrate SOLN Generic

BUTRANS PTWK Non-Preferred Brand QL

CAMBIA PACK Non-Preferred Brand ST

CAPITAL/CODEINE SUSP Preferred Brand

CATAFLAM TABS Non-Preferred Brand

CELEBREX CAPS Preferred Brand PA




Limits

choline magnesium trisalicylate LIQD Generic

choline magnesium trisalicylate TABS Generic

CLINORIL TABS Non-Preferred Brand

CODEINE PHOSPHATE SOLN Medical Benefit

CODEINE SULFATE TABS Generic

CONZIP CP24 Non-Preferred Brand QL ST

DAYPRO TABS Non-Preferred Brand

diclofenac potassium TABS Generic

diclofenac sodium dr TBEC Generic

diclofenac sodium er TB24 Generic

diclofenac sodium/misoprostol TBEC Generic

diflunisal TABS Generic

DILAUDID TABS Non-Preferred Brand QL

DILAUDID SOLN Medical Benefit-Non-Preferred

Specialty

DOANS REGULAR STRENGTH TABS Generic

DOLOPHINE HCL TABS Non-Preferred Brand

DOLOPHINE TABS Non-Preferred Brand

DUEXIS TABS Non-Preferred Brand QL ST

DURAGESIC PT72 Non-Preferred Brand QL

EC-NAPROSYN TBEC Non-Preferred Brand

ESGIC TABS Non-Preferred Brand

etodolac er TB24 Generic

etodolac CAPS Generic

etodolac TABS Generic

EXALGO T24A Non-Preferred Brand QL ST

FELDENE CAPS Non-Preferred Brand

fentanyl citrate oral transmucosal LPOP Preferred Specialty QL PA

fentanyl PT72 Generic QL

FENTORA TABS Preferred Specialty QL PA

FIORICET/CODEINE CAPS Non-Preferred Brand QL

FIORICET CAPS Non-Preferred Brand QL

FIORINAL/CODEINE #3 CAPS Non-Preferred Brand

FIORINAL CAPS Non-Preferred Brand

flurbiprofen TABS Generic

GRALISE STARTER MISC Non-Preferred Brand ST

GRALISE TABS Non-Preferred Brand QL ST

HALFPRIN TBEC Preferred Brand

HYCET SOLN Non-Preferred Brand

hydrocodone bitartrate/acetaminophen SOLN Generic

HYDROCODONE BITARTRATE/ACETAMINOPHEN

TABS Generic

hydrocodone bitartrate/acetaminophen TABS Excluded

hydrocodone/acetaminophen SOLN Generic

hydrocodone/acetaminophen TABS Generic




Limits

hydrocodone/ibuprofen TABS Generic

HYDROMORPHONE HCL SUPP Generic

hydromorphone hcl TABS Generic QL

hydromorphone hcl SOLN Medical Benefit

ibuprofen TABS Generic

ILARIS SOLR Medical Benefit-Non-Preferred

Specialty

PA

INDOCIN SUSP Preferred Brand

indomethacin er CPCR Generic

indomethacin CAPS Generic

KADIAN CP24 Non-Preferred Brand QL

KETOPROFEN ER CP24 Generic

ketoprofen CAPS Generic

ketorolac tromethamine TABS Generic QL

LAZANDA SOLN Non-Preferred Specialty

QL PA

LEVORPHANOL TARTRATE TABS Generic

LORCET 10/650 TABS Non-Preferred Brand

LORCET PLUS TABS Non-Preferred Brand

LORTAB TABS Non-Preferred Brand

mefenamic acid CAPS Generic

meloxicam TABS Generic

MEPERIDINE HCL SOLN Generic

meperidine hcl TABS Generic

meperidine hcl SOLN Medical Benefit

methadone hcl intensol CONC Generic

methadone hcl CONC Generic

methadone hcl TABS Generic

METHADONE HCL SOLN Preferred Brand

METHADOSE CONC Generic

MOBIC TABS Non-Preferred Brand

morphine sulfate er CP24 Generic QL

morphine sulfate er TBCR Generic

morphine sulfate SOLN Generic

MORPHINE SULFATE SUPP Generic

MORPHINE SULFATE TABS Generic

morphine sulfate SOLN Preferred Brand

MS CONTIN TBCR Non-Preferred Brand

nabumetone TABS Generic

NAPRELAN TB24 Non-Preferred Brand

NAPROSYN SUSP Non-Preferred Brand

NAPROSYN TABS Non-Preferred Brand

naproxen dr TBEC Generic

naproxen sodium TABS Generic

naproxen SUSP Generic




Limits

naproxen TABS Generic

NORCO TABS Non-Preferred Brand

NUCYNTA ER TB12 Non-Preferred Brand QL

NUCYNTA TABS Non-Preferred Brand

OFIRMEV SOLN Medical Benefit

ONSOLIS FILM Non-Preferred Brand PA

OPANA ER (CRUSH RESISTANT) T12A Non-Preferred Brand QL ST

OPANA TABS Non-Preferred Brand ST

orphenadrine/asa/caffeine TABS Generic

oxaprozin TABS Generic

OXECTA TABA Non-Preferred Brand PA

oxycodone hcl CAPS Generic

oxycodone hcl TABS Generic

oxycodone/acetaminophen TABS Generic

oxycodone/aspirin TABS Generic

OXYCONTIN T12A Preferred Brand QL

oxymorphone hydrochloride er TB12 Generic QL

oxymorphone hydrochloride TABS Generic

pentazocine/acetaminophen TABS Generic

pentazocine/naloxone hcl TABS Generic

PERCOCET TABS Non-Preferred Brand

PHRENILIN FORTE CAPS Preferred Brand

piroxicam CAPS Generic

PONSTEL CAPS Non-Preferred Brand

PRIALT SOLN Medical Benefit

roxicet TABS Generic

salsalate TABS Generic

SPRIX SOLN Non-Preferred Brand QL ST

SUBOXONE FILM Preferred Brand QL

SUBOXONE SUBL Non-Preferred Brand QL

sulindac TABS Generic

SYNALGOS-DC CAPS Non-Preferred Brand

tolmetin sodium CAPS Generic

TOLMETIN SODIUM TABS Generic

tramadol hcl er TB24 Generic QL

tramadol hcl TABS Generic

tramadol hydrochloride/acetaminophen TABS Generic

TREZIX CAPS Generic QL

TYLENOL/CODEINE #3 TABS Non-Preferred Brand

TYLENOL/CODEINE #4 TABS Non-Preferred Brand

ULTRACET TABS Non-Preferred Brand

ULTRAM ER TB24 Non-Preferred Brand QL

ULTRAM TABS Non-Preferred Brand

vicodin es TABS Excluded

vicodin hp TABS Excluded

vicodin TABS Excluded




Limits

VICOPROFEN TABS Non-Preferred Brand

VIMOVO TBEC Excluded

VOLTAREN-XR TB24 Non-Preferred Brand

zebutal CAPS Generic

ZIPSOR CAPS Non-Preferred Brand ST

ZORVOLEX CAPS Non-Preferred Brand QL ST

ZUBSOLV SUBL Non-Preferred Brand QL

Anorexigenic Agents and Respiratory and CNS Stimulants

ADDERALL XR CP24 Preferred Brand QL

ADDERALL TABS Non-Preferred Brand

amphetamine/dextroamphetamine CP24 Generic QL

amphetamine/dextroamphetamine TABS Generic

BELVIQ TABS Excluded

CONCERTA TBCR Non-Preferred Brand QL

DAYTRANA PTCH Non-Preferred Brand QL

DEXEDRINE CP24 Non-Preferred Brand

dexmethylphenidate hcl TABS Generic

dextroamphetamine sulfate er CP24 Generic

dextroamphetamine sulfate TABS Generic

FOCALIN XR CP24 Non-Preferred Brand QL

FOCALIN TABS Non-Preferred Brand

METADATE CD CPCR Non-Preferred Brand QL

metadate er TBCR Generic

methamphetamine hcl TABS Generic QL

METHYLIN CHEW Non-Preferred Brand

METHYLIN SOLN Non-Preferred Brand

methylphenidate hcl cd CPCR Generic QL

methylphenidate hcl er CP24 Generic QL

methylphenidate hcl er TBCR Generic QL

methylphenidate hcl sr TBCR Generic

methylphenidate hcl TABS Generic

methylphenidate hydrochloride SOLN Generic

modafinil TABS Generic QL PA

NUVIGIL TABS Non-Preferred Brand PA

phentermine hcl CAPS Excluded

phentermine hcl TABS Excluded

PROVIGIL TABS Non-Preferred Brand QL PA

QSYMIA CP24 Excluded

QUILLIVANT XR SUSR Non-Preferred Brand QL ST

RITALIN LA CP24 Non-Preferred Brand QL

RITALIN SR TBCR Non-Preferred Brand

RITALIN TABS Non-Preferred Brand

SUPRENZA TBDP Excluded

VYVANSE CAPS Preferred Brand QL

zenzedi TABS Generic QL




Limits

ZENZEDI TABS Non-Preferred Brand QL ST

Anticonvulsants

BANZEL TABS Preferred Brand PA

carbamazepine er TB12 Generic

carbamazepine CHEW Generic

carbamazepine SUSP Generic

carbamazepine TABS Generic

CARBATROL CP12 Preferred Brand

CELONTIN CAPS Preferred Brand

clonazepam odt TBDP Generic

clonazepam TABS Generic

DEPACON SOLN Medical Benefit

DEPAKENE CAPS Non-Preferred Brand

DEPAKENE SYRP Non-Preferred Brand

DEPAKOTE ER TB24 Non-Preferred Brand

DEPAKOTE SPRINKLES CPSP Non-Preferred Brand

DEPAKOTE TBEC Non-Preferred Brand

DILANTIN INFATABS CHEW Preferred Brand

DILANTIN CAPS Preferred Brand

DILANTIN CAPS Non-Preferred Brand

DILANTIN SUSP Non-Preferred Brand

divalproex sodium dr TBEC Generic

divalproex sodium er TB24 Generic

divalproex sodium CPSP Generic

epitol TABS Generic

EQUETRO CP12 Non-Preferred Brand

ethosuximide CAPS Generic

ethosuximide SOLN Generic

felbamate SUSP Generic

felbamate TABS Generic

FELBATOL SUSP Non-Preferred Brand

FELBATOL TABS Non-Preferred Brand

FYCOMPA TABS Non-Preferred Brand QL ST

gabapentin CAPS Generic

gabapentin SOLN Generic

gabapentin TABS Generic

GABITRIL TABS Preferred Brand

GABITRIL TABS Non-Preferred Brand

HORIZANT TB24 Non-Preferred Brand QL ST

KEPPRA XR TB24 Non-Preferred Brand

KEPPRA SOLN Non-Preferred Brand

KEPPRA TABS Non-Preferred Brand

KLONOPIN TABS Non-Preferred Brand

LAMICTAL CHEWABLE DISPERSIBLE CHEW Non-Preferred Brand

LAMICTAL ODT KIT Non-Preferred Brand ST

LAMICTAL ODT TBDP Non-Preferred Brand ST




Limits

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE

KIT Non-Preferred Brand

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

KIT Non-Preferred Brand

LAMICTAL STARTER/TAKING VALPROATE KIT Non-Preferred Brand

LAMICTAL XR KIT Non-Preferred Brand

LAMICTAL XR TB24 Non-Preferred Brand

LAMICTAL TABS Non-Preferred Brand

lamotrigine er TB24 Generic

lamotrigine CHEW Generic

lamotrigine TABS Generic

levetiracetam er TB24 Generic

levetiracetam SOLN Generic

levetiracetam TABS Generic

LYRICA CAPS Preferred Brand ST

MYSOLINE TABS Non-Preferred Brand

NEURONTIN CAPS Non-Preferred Brand

NEURONTIN SOLN Non-Preferred Brand

NEURONTIN TABS Non-Preferred Brand

ONFI SUSP Preferred Brand

ONFI TABS Preferred Brand QL ST

oxcarbazepine TABS Generic

OXTELLAR XR TB24 Non-Preferred Brand

PHENYTEK CAPS Preferred Brand

phenytoin sodium extended CAPS Generic

phenytoin SUSP Generic

POTIGA TABS Non-Preferred Brand QL ST

primidone TABS Generic

SABRIL TABS Non-Preferred Specialty

QL

STAVZOR CPDR Non-Preferred Brand ST

TEGRETOL SUSP Non-Preferred Brand

TEGRETOL TABS Non-Preferred Brand

TEGRETOL-XR TB12 Preferred Brand

TEGRETOL-XR TB12 Non-Preferred Brand

tiagabine hydrochloride TABS Generic

TOPAMAX SPRINKLE CPSP Non-Preferred Brand

TOPAMAX TABS Non-Preferred Brand

topiramate CPSP Generic

topiramate TABS Generic

TRILEPTAL SUSP Non-Preferred Brand

TRILEPTAL TABS Non-Preferred Brand

TROKENDI XR CP24 Non-Preferred Brand QL ST

valproic acid CAPS Generic

valproic acid SYRP Generic

VIMPAT SOLN Preferred Brand ST




Limits

VIMPAT TABS Preferred Brand ST

ZARONTIN CAPS Non-Preferred Brand

ZARONTIN SOLN Non-Preferred Brand

ZONEGRAN CAPS Non-Preferred Brand

zonisamide CAPS Generic

Antimanic Agents

lithium carbonate er TBCR Generic

lithium carbonate CAPS Generic

LITHIUM CITRATE SOLN Generic

LITHOBID TBCR Non-Preferred Brand

Antimigraine Agents

ALSUMA SOAJ Non-Preferred Brand

AMERGE TABS Non-Preferred Brand

AXERT TABS Non-Preferred Brand QL ST

CAFERGOT TABS Non-Preferred Brand

FROVA TABS Non-Preferred Brand QL ST

IMITREX STATDOSE REFILL SOCT Preferred Brand

IMITREX STATDOSE SYSTEM SOAJ Preferred Brand

IMITREX SOLN Preferred Brand

IMITREX SOLN Non-Preferred Brand

IMITREX TABS Non-Preferred Brand

isometheptene/dichloralphenazone/acetaminophen CAPS Generic

MAXALT TABS Non-Preferred Brand

MAXALT-MLT TBDP Non-Preferred Brand

MIGERGOT SUPP Generic

naratriptan hcl TABS Generic

RELPAX TABS Non-Preferred Brand QL ST

rizatriptan benzoate odt TBDP Generic

rizatriptan benzoate TABS Generic

sumatriptan succinate SOAJ Generic

sumatriptan succinate TABS Generic

SUMATRIPTAN SOLN Generic

SUMAVEL DOSEPRO SOTJ Non-Preferred Brand QL ST

TREXIMET TABS Non-Preferred Brand QL ST

zolmitriptan odt TBDP Generic

zolmitriptan TABS Generic

ZOMIG NASAL SPRAY SOLN Preferred Brand QL ST

ZOMIG ZMT TBDP Non-Preferred Brand

ZOMIG TABS Non-Preferred Brand

Antiparkinsonian Agents

amantadine hcl CAPS Generic

amantadine hcl SYRP Generic

AMANTADINE HCL TABS Generic

AZILECT TABS Non-Preferred Brand ST

benztropine mesylate TABS Generic

bromocriptine mesylate CAPS Generic




Limits

bromocriptine mesylate TABS Generic

cabergoline TABS Generic

carbidopa/levodopa er TBCR Generic

carbidopa/levodopa odt TBDP Generic

CARBIDOPA/LEVODOPA/ENTACAPONE TABS Generic

carbidopa/levodopa TABS Generic

COGENTIN SOLN Medical Benefit-Non-Preferred

Specialty

COMTAN TABS Non-Preferred Brand

ELDEPRYL CAPS Non-Preferred Brand

EMSAM PT24 Non-Preferred Brand ST

entacapone TABS Generic

MIRAPEX ER TB24 Non-Preferred Brand ST

MIRAPEX TABS Preferred Brand

MIRAPEX TABS Non-Preferred Brand

NEUPRO PT24 Non-Preferred Brand QL ST

PARCOPA TBDP Non-Preferred Brand

PARLODEL CAPS Non-Preferred Brand

PARLODEL TABS Non-Preferred Brand

pramipexole dihydrochloride TABS Generic

REQUIP XL TB24 Non-Preferred Brand

REQUIP TABS Non-Preferred Brand

ropinirole er TB24 Generic

ropinirole hcl TABS Generic

selegiline hcl TABS Preferred Brand

SINEMET CR TBCR Non-Preferred Brand

STALEVO 100 TABS Non-Preferred Brand






TASMAR TABS Preferred Brand

trihexyphenidyl hcl ELIX Generic

trihexyphenidyl hcl TABS Generic

Anxiolytics, Sedatives, and Hypnotics

alprazolam er TB24 Generic QL

ALPRAZOLAM INTENSOL CONC Generic QL

alprazolam odt TBDP Generic

alprazolam TABS Generic

AMBIEN CR TBCR Non-Preferred Brand QL

AMBIEN TABS Non-Preferred Brand QL

ATIVAN TABS Non-Preferred Brand

ATIVAN SOLN Medical Benefit-Non-Preferred




Limits

Specialty

buspirone hcl TABS Generic

chlordiazepoxide hcl CAPS Generic

clorazepate dipotassium TABS Generic

DIASTAT ACUDIAL GEL Preferred Brand

DIASTAT PEDIATRIC GEL Preferred Brand

DIAZEPAM INTENSOL CONC Preferred Brand

DIAZEPAM GEL Generic

diazepam TABS Generic

EDLUAR SUBL Non-Preferred Brand QL ST

estazolam TABS Generic

flurazepam hcl CAPS Generic QL

HALCION TABS Non-Preferred Brand

hydroxyzine hcl SYRP Generic

hydroxyzine hcl TABS Generic

hydroxyzine pamoate CAPS Generic

INTERMEZZO SUBL Non-Preferred Brand ST

LORAZEPAM INTENSOL CONC Generic

lorazepam TABS Generic

lorazepam SOLN Medical Benefit

LUNESTA TABS Preferred Brand QL ST

meprobamate TABS Generic

midazolam hcl SYRP Generic

NIRAVAM TBDP Non-Preferred Brand

oxazepam CAPS Generic

phenobarbital ELIX Generic

phenobarbital TABS Generic

PHENOBARBITAL TABS Preferred Brand

RESTORIL CAPS Non-Preferred Brand QL

ROZEREM TABS Non-Preferred Brand QL ST

SECONAL CAPS Non-Preferred Brand QL

SONATA CAPS Non-Preferred Brand QL

temazepam CAPS Generic QL

TRANXENE T TABS Non-Preferred Brand

triazolam TABS Generic QL

VALIUM TABS Non-Preferred Brand

VISTARIL CAPS Non-Preferred Brand

XANAX XR TB24 Non-Preferred Brand QL

XANAX TABS Non-Preferred Brand

zaleplon CAPS Generic QL

zolpidem tartrate er TBCR Generic QL

zolpidem tartrate TABS Generic QL

ZOLPIMIST SOLN Non-Preferred Brand QL ST

Central Nervous System Agents, Misc

acamprosate calcium dr TBEC Generic

CAMPRAL TBEC Non-Preferred Brand




Limits

INTUNIV TB24 Non-Preferred Brand QL ST

NAMENDA TITRATION PAK TABS Preferred Brand

NAMENDA XR TITRATION PACK CP24 Non-Preferred Brand

NAMENDA XR CP24 Non-Preferred Brand

NAMENDA SOLN Preferred Brand QL

NAMENDA TABS Preferred Brand QL

NUEDEXTA CAPS Non-Preferred Brand PA

RILUTEK TABS Non-Preferred Specialty

QL

riluzole TABS Generic

STRATTERA CAPS Preferred Brand QL

XENAZINE TABS Preferred Specialty QL

XYREM SOLN Preferred Specialty QL PA

Fibromyalgia Agents

SAVELLA TITRATION PACK MISC Preferred Brand QL ST

SAVELLA TABS Preferred Brand QL ST

General Anesthetics

ketamine hcl SOLN Excluded

Opiate Antagonists

naltrexone hcl TABS Generic

REVIA TABS Non-Preferred Brand

VIVITROL SUSR Medical Benefit-Preferred

Specialty

Psychotherapeutic Agents

ABILIFY DISCMELT TBDP Non-Preferred Brand QL ST

ABILIFY MAINTENA SUSR Medical Benefit-Non-Preferred

Specialty

ABILIFY SOLN Non-Preferred Brand ST

ABILIFY TABS Non-Preferred Brand QL ST

amitriptyline hcl TABS Generic

AMOXAPINE TABS Generic

APLENZIN TB24 Non-Preferred Brand ST

BRINTELLIX TABS Non-Preferred Brand ST

BRISDELLE CAPS Non-Preferred Brand QL ST

budeprion sr TB12 Generic QL

buproban TB12 Generic

bupropion hcl sr TB12 Generic QL

bupropion hcl xl TB24 Generic QL

bupropion hcl TABS Generic

CELEXA TABS Non-Preferred Brand

CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS Generic

chlorpromazine hcl TABS Generic

citalopram hydrobromide SOLN Generic

citalopram hydrobromide TABS Generic QL

clomipramine hcl CAPS Generic




Limits

CLOZAPINE ODT TBDP Generic

clozapine TABS Generic

CLOZARIL TABS Non-Preferred Brand

compro SUPP Generic

CYMBALTA CPEP Non-Preferred Brand QL

desipramine hcl TABS Generic

DESVENLAFAXINE ER TB24 Generic

doxepin hcl CAPS Generic

doxepin hcl CONC Generic

duloxetine hcl CPEP Generic QL

EFFEXOR XR CP24 Non-Preferred Brand

escitalopram oxalate TABS Generic

FANAPT TITRATION PACK TABS Non-Preferred Brand QL ST

FANAPT TABS Non-Preferred Brand QL ST

FAZACLO TBDP Preferred Brand ST

FETZIMA TITRATION PACK C4PK Non-Preferred Brand QL ST

FETZIMA CP24 Non-Preferred Brand QL ST

fluoxetine dr CPDR Generic

fluoxetine hcl CAPS Generic

fluoxetine hcl SOLN Generic

fluoxetine hcl TABS Generic

FLUPHENAZINE DECANOATE SOLN Generic

fluphenazine hcl TABS Generic

fluvoxamine maleate er CP24 Generic QL

fluvoxamine maleate TABS Generic

FORFIVO XL TB24 Non-Preferred Brand ST

GEODON CAPS Non-Preferred Brand ST

GEODON SOLR Medical Benefit

HALDOL DECANOATE 100 SOLN Medical Benefit-Non-Preferred

Specialty

HALDOL DECANOATE 50 SOLN Medical Benefit-Non-Preferred

Specialty

HALDOL SOLN Medical Benefit-Non-Preferred

Specialty

haloperidol decanoate SOLN Medical Benefit

haloperidol lactate SOLN Generic

haloperidol TABS Generic

imipramine hcl TABS Generic

imipramine pamoate CAPS Generic

INVEGA SUSTENNA SUSP Medical Benefit

INVEGA SUSTENNA SUSP Medical Benefit-Preferred

Specialty

INVEGA TB24 Non-Preferred Brand ST




Limits

KHEDEZLA TB24 Non-Preferred Brand QL ST

LATUDA TABS Non-Preferred Brand QL ST

LEXAPRO SOLN Non-Preferred Brand

LEXAPRO TABS Non-Preferred Brand

loxapine succinate CAPS Generic

loxapine CAPS Generic

LOXITANE CAPS Non-Preferred Brand

LUVOX CR CP24 Non-Preferred Brand QL

MAPROTILINE HCL TABS Generic

MARPLAN TABS Preferred Brand QL

mirtazapine odt TBDP Generic

mirtazapine TABS Generic

mirtazapine TBDP Generic

NARDIL TABS Non-Preferred Brand

nefazodone hcl TABS Generic

NORPRAMIN TABS Non-Preferred Brand

nortriptyline hcl CAPS Generic

olanzapine odt TBDP Generic

olanzapine TABS Generic

olanzapine SOLR Medical Benefit

ORAP TABS Preferred Brand QL

PAMELOR CAPS Non-Preferred Brand

PARNATE TABS Non-Preferred Brand

paroxetine hcl er TB24 Generic QL

paroxetine hcl TABS Generic

PAXIL CR TB24 Non-Preferred Brand QL

PAXIL SUSP Non-Preferred Brand

PAXIL TABS Non-Preferred Brand

PERPHENAZINE/AMITRIPTYLINE TABS Generic

perphenazine TABS Generic

PEXEVA TABS Non-Preferred Brand QL ST

phenelzine sulfate TABS Generic

PRISTIQ TB24 Non-Preferred Brand QL ST

prochlorperazine edisylate SOLN Generic

prochlorperazine maleate TABS Generic

prochlorperazine SUPP Generic

protriptyline hcl TABS Generic

PROZAC WEEKLY CPDR Non-Preferred Brand

PROZAC CAPS Non-Preferred Brand

quetiapine fumarate TABS Generic

REMERON SOLTAB TBDP Non-Preferred Brand

REMERON TABS Non-Preferred Brand

RISPERDAL CONSTA SUSR Medical Benefit-Preferred

Specialty

RISPERDAL M-TAB TBDP Non-Preferred Brand




Limits

RISPERDAL SOLN Non-Preferred Brand

RISPERDAL TABS Non-Preferred Brand

risperidone m-tab TBDP Generic

risperidone SOLN Generic

risperidone TABS Generic

SAPHRIS SUBL Non-Preferred Brand QL ST

SARAFEM TABS Non-Preferred Brand

SEROQUEL XR TB24 Preferred Brand QL ST

SEROQUEL TABS Non-Preferred Brand

sertraline hcl CONC Generic

sertraline hcl TABS Generic QL

SILENOR TABS Non-Preferred Brand QL ST

SURMONTIL CAPS Non-Preferred Brand

SYMBYAX CAPS Non-Preferred Brand ST

thioridazine hcl TABS Generic

thiothixene CAPS Generic

TOFRANIL TABS Non-Preferred Brand

TOFRANIL-PM CAPS Non-Preferred Brand

tranylcypromine sulfate TABS Generic

trazodone hcl TABS Generic

trifluoperazine hcl TABS Generic

trimipramine maleate CAPS Generic

venlafaxine hcl er CP24 Generic

venlafaxine hcl er TB24 Generic

VENLAFAXINE HCL ER TB24 Preferred Brand

venlafaxine hcl TABS Generic

VERSACLOZ SUSP Non-Preferred Specialty

QL ST

VIIBRYD KIT Non-Preferred Brand ST

VIIBRYD TABS Non-Preferred Brand QL ST

VIVACTIL TABS Non-Preferred Brand

WELLBUTRIN SR TB12 Non-Preferred Brand QL

WELLBUTRIN XL TB24 Non-Preferred Brand QL

WELLBUTRIN TABS Non-Preferred Brand

ziprasidone hcl CAPS Generic

ZOLOFT CONC Non-Preferred Brand

ZOLOFT TABS Non-Preferred Brand QL

ZYBAN TB12 Non-Preferred Brand

ZYPREXA RELPREVV SUSR Medical Benefit-Preferred

Specialty

ZYPREXA ZYDIS TBDP Non-Preferred Brand

ZYPREXA TABS Non-Preferred Brand

ZYPREXA SOLR Medical Benefit

Contraceptives




Limits

ORTHO DIAPHRAGM ALL-FLEX/65MM DPRH Preferred Brand




ORTHO DIAPHRAGM COIL SPRING KIT 100 KIT Preferred Brand



ORTHO DIAPHRAGM FLAT SPRING KIT 55 KIT Preferred Brand









Devices

AEROCHAMBER PLUS FLOW-VU/LARGE MASK MISC Preferred Brand QL

AEROCHAMBER PLUS FLOW-VU/MASK MISC Preferred Brand QL

AEROCHAMBER PLUS FLOW-VU/SMALL MASK MISC Preferred Brand QL

AEROCHAMBER PLUS FLOW-VU MISC Preferred Brand QL

BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"

MISC Preferred Brand

BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2"


BD INSULIN SYRINGE ULTRAFINE/1ML/30G X 1/2"


BREATHERITE COLLAPSIBLE ADULT SPACER W/MASK

MISC Preferred Brand QL

BREATHERITE COLLAPSIBLE CHILD SPACER W/MASK


BREATHERITE COLLAPSIBLE INFANT SPACER W/MASK


BREATHERITE COLLAPSIBLE SMALL CHILD SPACER W/MASK


BREATHERITE COLLAPSIBLE SPACER W/ NEONATE MASK


BREATHERITE RIGID SPACER W/MASK MISC Preferred Brand QL

BREATHERITE W/LARGE MASK MISC Preferred Brand QL

BREATHERITE W/MEDIUM MASK MISC Preferred Brand QL

BREATHERITE W/SMALL MASK MISC Preferred Brand QL

BREATHERITE MISC Preferred Brand QL

EASIVENT/MASK-LARGE MISC Preferred Brand QL

EASIVENT/MASK-MEDIUM MISC Preferred Brand QL

EASIVENT/MASK-SMALL MISC Preferred Brand QL

EASIVENT MISC Preferred Brand QL

LANCETS MISC Generic




Limits

OPTICHAMBER ADVANTAGE/LARGE MASK MISC Preferred Brand QL

OPTICHAMBER ADVANTAGE/MEDIUM FACE MASK


OPTICHAMBER ADVANTAGE/SMALL FACE MASK


OPTICHAMBER ADVANTAGE MISC Preferred Brand QL

OPTICHAMBER DIAMOND MISC Preferred Brand

OPTICHAMBER FACE MASK/LARGE MISC Preferred Brand QL

OPTICHAMBER FACE MASK/MEDIUM MISC Preferred Brand QL

OPTICHAMBER FACE MASK/SMALL MISC Preferred Brand QL

ULTICARE INSULIN SYRINGE ULTRAFINE U-100/1ML/31G X 5/16"


VALVED HOLDING CHAMBER DEVI Generic

V-GO 20 KIT Preferred Brand



Diagnostic Agents

Diabetes Mellitus

ACCU-CHEK ACTIVE STRIPS STRP Generic

ACCU-CHEK AVIVA STRP Generic

ACCU-CHEK COMFORT CURVE TEST STRIPS STRP Generic

ACCU-CHEK COMPACT PLUS STRP Generic

ACCU-CHEK COMPACT TEST DRUM STRP Generic

ACCU-CHEK SMARTVIEW STRIPS STRP Generic

AGAMATRIX AMP NO CODE TEST STRIPS STRP Non-Preferred Brand

ASCENSIA AUTODISC TEST STRIPS DISK Non-Preferred Brand

BAYER BREEZE 2 TEST DISC DISK Non-Preferred Brand

BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS

STRP Non-Preferred Brand

BAYER CONTOUR NEXT BLOOD GLUCOSE TEST


ECLIPSE TEST STRIPS STRP Non-Preferred Brand

FASTTAKE TEST STRIPS STRP Preferred Brand

FREESTYLE LITE TEST STRIPS STRP Non-Preferred Brand

FREESTYLE TEST STRIPS STRP Non-Preferred Brand

GLUCOCARD 01 SENSOR STRP Non-Preferred Brand

GLUCOCARD 01 TEST STRIPS STRP Non-Preferred Brand

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS


GLUCOCARD VITAL TEST STRIPS STRP Non-Preferred Brand

GLUCOCARD X-SENSOR STRP Non-Preferred Brand

ONETOUCH BASIC/PROFILE TEST STRIPS STRP Generic

ONETOUCH ULTRA BLUE STRP Generic

ONETOUCH VERIO TEST STRIPS STRP Generic

PRECISION PCX PLUS TEST STRIPS STRP Non-Preferred Brand

PRECISION POINT OF CARE TEST STRIPS STRP Non-Preferred Brand

PRECISION QID TEST STRIPS STRP Non-Preferred Brand




Limits

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS


SURESTEP TEST STRIPS STRP Non-Preferred Brand

TRUETRACK TEST STRP Non-Preferred Brand

UNISTRIP1 GENERIC STRP Non-Preferred Brand

Pituitary Function

ACTHREL SOLR Medical Benefit

Thyroid Function

THYROGEN SOLR Medical Benefit-Preferred

Specialty

Electrolytic, Caloric, and Water Balance

Alkalinizing Agents

cytra k crystals PACK Generic

cytra-2 SOLN Generic

CYTRA-3 SYRP Generic

CYTRA-K SOLN Generic

POTASSIUM CITRATE ER TBCR Generic

POTASSIUM CITRATE TBCR Generic

SODIUM CITRATE GRAN Generic

TRICITRATES SOLN Generic

UROCIT-K 10 TBCR Non-Preferred Brand



Ammonia Detoxicants

BUPHENYL TABS Preferred Specialty QL PA

BUPHENYL POWD Non-Preferred Specialty

PA

CARBAGLU TABS Preferred Specialty QL PA

enulose SOLN Generic

generlac SOLN Generic

KRISTALOSE PACK Preferred Brand

lactulose SOLN Generic

RAVICTI LIQD Preferred Specialty PA

sodium phenylbutyrate POWD Preferred Specialty PA

Diuretics

amiloride hcl TABS Generic

amiloride/hydrochlorothiazide TABS Generic

bumetanide TABS Generic

chlorothiazide TABS Generic

CHLORTHALIDONE TABS Generic

CHLORTHALIDONE TABS Preferred Brand

DEMADEX TABS Non-Preferred Brand

DIURIL SUSP Non-Preferred Brand

DYAZIDE CAPS Non-Preferred Brand

DYRENIUM CAPS Preferred Brand




Limits

EDECRIN TABS Preferred Brand

furosemide SOLN Generic

furosemide TABS Generic

hydrochlorothiazide CAPS Generic

hydrochlorothiazide TABS Generic

indapamide TABS Generic

LASIX TABS Non-Preferred Brand

MAXZIDE-25 TABS Non-Preferred Brand

METHYCLOTHIAZIDE TABS Generic

metolazone TABS Generic

MICROZIDE CAPS Non-Preferred Brand

SAMSCA TABS Preferred Specialty QL PA

torsemide TABS Generic

triamterene/hydrochlorothiazide CAPS Generic

triamterene/hydrochlorothiazide TABS Generic

ZAROXOLYN TABS Non-Preferred Brand

Ion-removing Agents

FOSRENOL CHEW Non-Preferred Specialty

QL

kionex SUSP Generic

RENAGEL TABS Preferred Brand QL

RENVELA TABS Preferred Specialty QL

sodium polystyrene sulfonate POWD Generic

sodium polystyrene sulfonate SUSP Generic

SPS SUSP Non-Preferred Brand

Irrigating Solutions

sodium chloride 0.9% SOLN Generic

Replacement Preparations

calcium acetate CAPS Generic

effervescent pot chloride TBEF Generic

GALZIN CAPS Preferred Brand

k-effervescent TBEF Generic

klor-con 10 TBCR Generic

KLOR-CON 25 PACK Non-Preferred Brand

klor-con 8 TBCR Non-Preferred Brand

klor-con m10 TBCR Generic

KLOR-CON M15 TBCR Generic

klor-con m20 TBCR Generic

K-TAB TBCR Non-Preferred Brand

PHOSLO CAPS Non-Preferred Brand

PHOSLYRA SOLN Non-Preferred Specialty

ST

potassium bicarbonate TBEF Generic

potassium chloride er CPCR Generic

potassium chloride er TBCR Generic

potassium chloride sr TBCR Generic




Limits

potassium chloride LIQD Generic

Uricosuric Agents

probenecid TABS Generic

Enzymes

ALDURAZYME SOLN Medical Benefit-Preferred

Specialty

CEREZYME SOLR Medical Benefit-Preferred

Specialty

ELELYSO SOLR Medical Benefit-Preferred

Specialty

ELITEK SOLR Medical Benefit-Preferred

Specialty

FABRAZYME SOLR Medical Benefit-Preferred

Specialty

PA

LUMIZYME SOLR Medical Benefit-Preferred

Specialty

NAGLAZYME SOLN Medical Benefit-Preferred

Specialty

SUCRAID SOLN Preferred Specialty QL

VPRIV SOLR Medical Benefit-Preferred

Specialty

XIAFLEX SOLR Medical Benefit-Preferred

Specialty

PA

Eye, Ear, Nose & Throat Preparations

Antiallergic Agents

alaway SOLN Generic

ALOCRIL SOLN Non-Preferred Brand ST

ALOMIDE SOLN Preferred Brand

ASTELIN SOLN Non-Preferred Brand

ASTEPRO SOLN Non-Preferred Brand

azelastine hcl SOLN Generic

BEPREVE SOLN Non-Preferred Brand ST

cromolyn sodium SOLN Generic

DYMISTA SUSP Non-Preferred Brand ST

ELESTAT SOLN Non-Preferred Brand

EMADINE SOLN Preferred Brand ST

epinastine hcl SOLN Generic




Limits

ketotifen fumarate SOLN Generic

LASTACAFT SOLN Non-Preferred Brand QL ST

OPTIVAR SOLN Non-Preferred Brand

PATADAY SOLN Preferred Brand ST

PATANASE SOLN Non-Preferred Brand ST

PATANOL SOLN Preferred Brand ST

ZADITOR SOLN Generic

Antiglaucoma Agents

acetazolamide er CP12 Generic

acetazolamide TABS Generic

ALPHAGAN P SOLN Non-Preferred Brand

AZOPT SUSP Preferred Brand

BETAGAN SOLN Non-Preferred Brand

betaxolol hcl SOLN Preferred Brand

BETIMOL SOLN Non-Preferred Brand

BETOPTIC-S SUSP Preferred Brand

brimonidine tartrate SOLN Generic

carteolol hcl SOLN Generic

COMBIGAN SOLN Preferred Brand

COSOPT SOLN Non-Preferred Brand

DIAMOX CP12 Non-Preferred Brand

dorzolamide hcl/timolol maleate SOLN Generic

dorzolamide hcl SOLN Generic

ISOPTO CARBACHOL SOLN Preferred Brand

ISOPTO CARPINE SOLN Non-Preferred Brand

ISTALOL SOLN Non-Preferred Brand ST

latanoprost SOLN Generic

levobunolol hcl SOLN Generic

LUMIGAN SOLN Preferred Brand

metipranolol SOLN Generic

OPTIPRANOLOL SOLN Non-Preferred Brand

PHOSPHOLINE IODIDE SOLR Preferred Brand

pilocarpine hcl SOLN Generic

PILOPINE HS GEL Preferred Brand

SIMBRINZA SUSP Preferred Brand

timolol maleate ophthalmic gel forming SOLG Generic

timolol maleate SOLN Generic

TIMOPTIC SOLN Non-Preferred Brand

TIMOPTIC-XE SOLG Non-Preferred Brand

TRAVATAN Z SOLN Non-Preferred Brand

TRAVOPROST SOLN Generic

TRUSOPT SOLN Non-Preferred Brand

XALATAN SOLN Non-Preferred Brand

ZIOPTAN SOLN Non-Preferred Brand

Anti-infectives

AZASITE SOLN Non-Preferred Brand ST




Limits

bacitracin/polymyxin b OINT Generic

BESIVANCE SUSP Non-Preferred Brand

BLEPH-10 SOLN Non-Preferred Brand

CETRAXAL SOLN Non-Preferred Brand

chlorhexidine gluconate SOLN Generic

CILOXAN OINT Preferred Brand

CILOXAN SOLN Non-Preferred Brand

ciprofloxacin hcl SOLN Generic

erythromycin OINT Generic

gatifloxacin SOLN Generic

gentak OINT Generic

gentamicin sulfate SOLN Generic

levofloxacin SOLN Generic

MOXEZA SOLN Preferred Brand

neomycin/bacitracin/polymyxin OINT Generic

neomycin/polymyxin/gramicidin SOLN Generic

NEOSPORIN SOLN Non-Preferred Brand

OCUFLOX SOLN Non-Preferred Brand

ofloxacin SOLN Generic

PERIDEX SOLN Non-Preferred Brand

polymyxin b sulfate/trimethoprim sulfate SOLN Generic

POLYTRIM SOLN Non-Preferred Brand

sodium sulfacetamide SOLN Generic

SULFACETAMIDE SODIUM OINT Generic

tobramycin sulfate SOLN Generic

TOBREX OINT Preferred Brand

TOBREX SOLN Non-Preferred Brand

trifluridine SOLN Generic

VIGAMOX SOLN Preferred Brand

VIROPTIC SOLN Non-Preferred Brand

ZIRGAN GEL Non-Preferred Brand

ZYMAXID SOLN Non-Preferred Brand ST

Anti-inflammatory Agents

ACULAR LS SOLN Non-Preferred Brand

ACULAR SOLN Non-Preferred Brand

ACUVAIL SOLN Non-Preferred Brand

ALREX SUSP Non-Preferred Brand ST

BECONASE AQ SUSP Non-Preferred Brand ST

BLEPHAMIDE S.O.P. OINT Preferred Brand

BLEPHAMIDE SUSP Preferred Brand

BROMFENAC SOLN Generic

CIPRO HC SUSP Preferred Brand

CIPRODEX SUSP Preferred Brand

COLY-MYCIN S SUSP Non-Preferred Brand

CORTANE-B-OTIC SOLN Non-Preferred Brand

CORTISPORIN SOLN Non-Preferred Brand




Limits

CORTISPORIN-TC SUSP Non-Preferred Brand

diclofenac sodium SOLN Generic

DUREZOL EMUL Non-Preferred Brand ST

FLAREX SUSP Preferred Brand

FLONASE SUSP Non-Preferred Brand

FLUNISOLIDE SOLN Generic

fluorometholone SUSP Generic

flurbiprofen sodium SOLN Generic

fluticasone propionate SUSP Generic

FML FORTE SUSP Preferred Brand

FML LIQUIFILM SUSP Non-Preferred Brand

FML OINT Preferred Brand

ILEVRO SUSP Non-Preferred Brand QL ST

ketorolac tromethamine SOLN Generic

LOTEMAX SUSP Preferred Brand

LOTEMAX GEL Non-Preferred Brand

LOTEMAX OINT Non-Preferred Brand

MAXITROL OINT Non-Preferred Brand

MAXITROL SUSP Non-Preferred Brand

NASACORT AQ AERS Non-Preferred Brand

NASONEX SUSP Non-Preferred Brand ST

neomycin/polymyxin/bacitracin/hydrocortisone OINT Generic

neomycin/polymyxin/dexamethasone OINT Generic

neomycin/polymyxin/dexamethasone SUSP Generic

neomycin/polymyxin/hydrocortisone SOLN Generic

NEVANAC SUSP Non-Preferred Brand ST

OMNARIS SUSP Preferred Brand ST

oto-end 10 SOLN Generic

OZURDEX IMPL Medical Benefit-Preferred

Specialty

PRED FORTE SUSP Non-Preferred Brand

PRED MILD SUSP Preferred Brand

PRED-G SUSP Preferred Brand

prednisolone acetate SUSP Generic

PREDNISOLONE SODIUM PHOSPHATE SOLN Preferred Brand

PROLENSA SOLN Non-Preferred Brand ST

QNASL AERS Non-Preferred Brand ST

RESTASIS EMUL Preferred Brand QL

RETISERT IMPL Medical Benefit-Preferred

Specialty

PA

RHINOCORT AQUA SUSP Non-Preferred Brand ST

sulfacetamide sodium/prednisolone sodium phosphate

SOLN Generic

TOBRADEX OINT Preferred Brand

TOBRADEX SUSP Non-Preferred Brand




Limits

tobramycin/dexamethasone SUSP Generic

triamcinolone acetonide INHA Generic

VERAMYST SUSP Non-Preferred Brand ST

VEXOL SUSP Preferred Brand

ZETONNA AERS Non-Preferred Brand ST

ZYLET SUSP Non-Preferred Brand ST

EENT Drugs, Miscellaneous

ACETIC ACID/ALUMINUM ACETATE SOLN Generic

acetic acid SOLN Generic

APHTHASOL PSTE Preferred Brand QL

apraclonidine SOLN Generic

CYSTARAN SOLN Preferred Specialty QL

EYLEA SOLN Medical Benefit-Non-Preferred

Specialty

PA

HEALON SOLN Medical Benefit

IOPIDINE SOLN Non-Preferred Brand

JETREA SOLN Medical Benefit-Preferred

Specialty

LACRISERT INST Non-Preferred Brand

LUCENTIS SOLN Medical Benefit-Non-Preferred

Specialty

PA

MACUGEN SOLN Medical Benefit-Preferred

Specialty

PA

PROVISC SOLN Medical Benefit

VISUDYNE SOLR Medical Benefit-Preferred

Specialty

Local Anesthetics

antipyrine/benzocaine SOLN Generic

lidocaine viscous SOLN Generic

TREAGAN OTIC SOLN Preferred Brand

Mydriatics

atropine sulfate SOLN Generic

CYCLOGYL SOLN Preferred Brand

CYCLOGYL SOLN Non-Preferred Brand

cyclopentolate hcl SOLN Generic

homatropaire SOLN Generic

ISOPTO ATROPINE SOLN Non-Preferred Brand

ISOPTO HOMATROPINE SOLN Preferred Brand

ISOPTO HOMATROPINE SOLN Non-Preferred Brand

Vasoconstrictors

NAPHAZOLINE HCL SOLN Generic

phenylephrine hcl SOLN Generic




Limits

Gastrointestinal Drugs

Antidiarrhea Agents

DIPHENOXYLATE/ATROPINE LIQD Generic

diphenoxylate/atropine TABS Generic

FULYZAQ TBEC Non-Preferred Brand ST

LOMOTIL TABS Non-Preferred Brand

loperamide hcl CAPS Generic

OPIUM TINCTURE (PAREGORIC) TINC Generic

opium tincture TINC Generic

Antiemetics

ALOXI SOLN Medical Benefit

ANTIVERT TABS Non-Preferred Brand

ANZEMET TABS Non-Preferred Brand QL

ANZEMET SOLN Medical Benefit

CESAMET CAPS Non-Preferred Brand

DICLEGIS TBEC Excluded

dronabinol CAPS Generic QL

dronabinol CAPS Preferred Specialty QL

EMEND CAPS Preferred Brand QL

granisetron hcl TABS Generic QL

granisetron hcl SOLN Medical Benefit

MARINOL CAPS Non-Preferred Specialty

QL

meclizine hcl TABS Generic

ondansetron hcl SOLN Generic

ondansetron hcl TABS Generic

ondansetron hcl SOLN Medical Benefit

ondansetron odt TBDP Generic

SANCUSO PTCH Non-Preferred Brand QL ST

TIGAN CAPS Non-Preferred Brand

TRANSDERM-SCOP PT72 Preferred Brand

trimethobenzamide hcl CAPS Generic

trimethobenzamide hcl SOLN Generic

ZOFRAN ODT TBDP Non-Preferred Brand

ZOFRAN SOLN Non-Preferred Brand

ZOFRAN TABS Non-Preferred Brand

ZOFRAN SOLN Medical Benefit-Non-Preferred

Specialty

ZUPLENZ FILM Non-Preferred Brand QL ST


APRISO CP24 Non-Preferred Brand QL

ASACOL HD TBEC Preferred Brand QL

balsalazide disodium CAPS Generic

CANASA SUPP Preferred Brand

COLAZAL CAPS Non-Preferred Brand




Limits

DELZICOL CPDR Preferred Brand

DIPENTUM CAPS Non-Preferred Brand

GIAZO TABS Non-Preferred Specialty

QL

LIALDA TBEC Non-Preferred Brand QL

LOTRONEX TABS Preferred Brand

mesalamine ENEM Generic

PENTASA CPCR Non-Preferred Brand QL

ROWASA KIT Non-Preferred Brand

SFROWASA ENEM Non-Preferred Brand QL

Antiulcer Agents and Acid Suppressants

ACIPHEX SPRINKLE CPSP Excluded

ACIPHEX TBEC Excluded

AXID CAPS Non-Preferred Brand

AXID SOLN Non-Preferred Brand

CARAFATE SUSP Non-Preferred Brand

CARAFATE TABS Non-Preferred Brand

cimetidine hcl SOLN Generic

cimetidine TABS Generic

CYTOTEC TABS Non-Preferred Brand

DEXILANT CPDR Excluded

ESOMEPRAZOLE STRONTIUM CPDR Excluded

famotidine TABS Generic

famotidine SOLN Medical Benefit

FIRST-LANSOPRAZOLE SUSP Generic

FIRST-OMEPRAZOLE SUSP Generic

HELIDAC MISC Non-Preferred Brand

lansoprazole/amoxicillin/clarithromycin MISC Generic

lansoprazole CPDR Generic

misoprostol TABS Generic

NEXIUM CPDR Excluded

nizatidine CAPS Generic

nizatidine SOLN Generic

omeprazole/sodium bicarbonate CAPS Generic

omeprazole CPDR Generic

OMEPRAZOLE TBEC Generic

pantoprazole sodium TBEC Generic

PEPCID SUSR Preferred Brand

PEPCID TABS Non-Preferred Brand

PREVACID 24HR CPDR Generic

PREVACID SOLUTAB TBDP Excluded

PREVACID CPDR Excluded

PREVPAC MISC Non-Preferred Brand

PRILOSEC OTC TBEC Generic

PRILOSEC CPDR Excluded

PROTONIX PACK Excluded




Limits

PROTONIX TBEC Excluded

PYLERA CAPS Non-Preferred Brand

rabeprazole sodium TBEC Generic

ranitidine 75 TABS Generic

ranitidine hcl CAPS Generic

ranitidine hcl SYRP Generic

ranitidine hcl TABS Generic

SUCRALFATE SUSP Generic

sucralfate TABS Generic

ZANTAC SYRP Non-Preferred Brand

ZANTAC TABS Non-Preferred Brand

ZANTAC SOLN Medical Benefit-Non-Preferred

Specialty

ZEGERID OTC CAPS Generic

ZEGERID CAPS Excluded

ZEGERID PACK Excluded

Cathartics and Laxatives

COLYTE-FLAVOR PACKS SOLR Non-Preferred Brand

enemeez mini ENEM Non-Preferred Brand QL

enemeez plus ENEM Non-Preferred Brand QL

gavilyte-c SOLR Generic

gavilyte-g SOLR Generic

gavilyte-n/flavor pack SOLR Generic

GOLYTELY SOLR Preferred Brand

GOLYTELY SOLR Non-Preferred Brand

HALFLYTELY BOWEL PREP/FLAVOR PACKS KIT Preferred Brand

MIRALAX POWD Non-Preferred Brand

MOVIPREP SOLR Non-Preferred Brand

NULYTELY/FLAVOR PACKS SOLR Non-Preferred Brand

OSMOPREP TABS Non-Preferred Brand

peg 3350/electrolytes SOLR Generic

peg 3350 POWD Generic

peg-3350/electrolytes SOLR Generic

polyethylene glycol 3350 POWD Generic

PREPOPIK PACK Non-Preferred Brand

smooth lax POWD Generic

SUCLEAR KIT Non-Preferred Brand

SUPREP BOWEL PREP SOLN Non-Preferred Brand

trilyte SOLR Generic

Cholelitholytic Agents

ACTIGALL CAPS Non-Preferred Brand

URSO 250 TABS Non-Preferred Brand

URSO FORTE TABS Non-Preferred Brand

ursodiol CAPS Generic

ursodiol TABS Generic




Limits

Digestants

CREON CPEP Preferred Brand

PANCREAZE CPEP Preferred Specialty

PERTZYE CPEP Non-Preferred Specialty

QL

ULTRESA CPEP Preferred Specialty

VIOKACE TABS Non-Preferred Specialty

QL

ZENPEP CPEP Preferred Brand

GI Drugs, Miscellaneous

AMITIZA CAPS Non-Preferred Brand QL

GATTEX KIT Non-Preferred Specialty

PA

LINZESS CAPS Non-Preferred Brand

RELISTOR KIT Non-Preferred Brand PA

RELISTOR SOLN Non-Preferred Brand PA

XENICAL CAPS Excluded

Prokinetic Agents

metoclopramide hcl SOLN Generic

metoclopramide hcl TABS Generic

METOZOLV ODT TBDP Non-Preferred Brand ST

REGLAN TABS Non-Preferred Brand

Gold Compounds

RIDAURA CAPS Preferred Brand

Heavy Metal Antagonists

CHEMET CAPS Preferred Brand

CUPRIMINE CAPS Preferred Brand

deferoxamine mesylate SOLR Medical Benefit

DESFERAL SOLR Medical Benefit

EXJADE TBSO Preferred Specialty QL

FERRIPROX TABS Preferred Specialty QL

Hormones and Synthetic Substitutes

Adrenals

ALVESCO AERS Preferred Brand QL

ASMANEX 120 METERED DOSES AEPB Non-Preferred Brand




BREO ELLIPTA AEPB Non-Preferred Brand ST

budesonide SUSP Generic

CORTEF TABS Non-Preferred Brand

CORTISONE ACETATE TABS Generic

DEPO-MEDROL SUSP Medical Benefit

DEXAMETHASONE INTENSOL CONC Preferred Brand

dexamethasone ELIX Generic




Limits

dexamethasone TABS Generic

DEXAMETHASONE SOLN Preferred Brand

DEXAMETHASONE TABS Preferred Brand

DULERA AERO Generic

ENTOCORT EC CP24 Preferred Brand

FLOVENT DISKUS AEPB Non-Preferred Brand

FLOVENT HFA AERO Non-Preferred Brand

fludrocortisone acetate TABS Generic

hydrocortisone TABS Generic

MEDROL TABS Preferred Brand

MEDROL TABS Non-Preferred Brand

methylprednisolone dose pack TABS Generic

methylprednisolone TABS Generic

ORAPRED ODT TBDP Preferred Brand QL

ORAPRED SOLN Non-Preferred Brand

prednisolone sodium phosphate SOLN Generic

prednisolone SOLN Generic

PREDNISONE INTENSOL CONC Preferred Brand

prednisone TABS Generic

PREDNISONE SOLN Preferred Brand

PREDNISONE TABS Preferred Brand

PRELONE SYRP Non-Preferred Brand

PULMICORT FLEXHALER AEPB Generic

PULMICORT SUSP Preferred Brand QL

PULMICORT SUSP Non-Preferred Brand

QVAR AERS Generic

RAYOS TBEC Non-Preferred Brand ST

SYMBICORT AERO Generic

UCERIS TB24 Non-Preferred Specialty

QL ST

Androgens

ANDRODERM PT24 Preferred Brand PA

ANDROGEL PUMP GEL Preferred Brand PA

ANDROGEL GEL Preferred Brand PA

ANDROID CAPS Non-Preferred Brand

AXIRON SOLN Preferred Brand PA

danazol CAPS Generic

DEPO-TESTOSTERONE OIL Non-Preferred Brand

FIRST-TESTOSTERONE MC COMPOUNDING KIT

CREA Non-Preferred Brand PA

FIRST-TESTOSTERONE OINT Non-Preferred Brand PA

FORTESTA GEL Non-Preferred Brand QL PA

METHITEST TABS Preferred Brand

STRIANT MISC Non-Preferred Brand PA

TESTIM GEL Non-Preferred Brand PA

TESTOPEL PLLT Medical Benefit PA




Limits

testosterone cypionate OIL Generic

testosterone enanthate OIL Generic

TESTRED CAPS Non-Preferred Brand PA

Antidiabetic Agents

acarbose TABS Generic

ACTOPLUS MET XR TB24 Preferred Brand

ACTOPLUS MET TABS Non-Preferred Brand

ACTOS TABS Non-Preferred Brand

AMARYL TABS Non-Preferred Brand

APIDRA SOLOSTAR SOPN Non-Preferred Brand ST

APIDRA SOLN Non-Preferred Brand ST

AVANDAMET TABS Preferred Brand

AVANDARYL TABS Preferred Brand

AVANDIA TABS Preferred Brand

BYDUREON SUSR Preferred Brand

BYETTA SOPN Preferred Brand

CHLORPROPAMIDE TABS Generic

CYCLOSET TABS Non-Preferred Brand

DIABETA TABS Non-Preferred Brand

DUETACT TABS Non-Preferred Brand

FARXIGA TABS Non-Preferred Brand QL

FORTAMET TB24 Non-Preferred Brand ST

glimepiride TABS Generic

glipizide er TB24 Generic

glipizide xl TB24 Generic

glipizide/metformin hcl TABS Generic

glipizide TABS Generic

GLUCOPHAGE XR TB24 Non-Preferred Brand

GLUCOPHAGE TABS Non-Preferred Brand

GLUCOTROL XL TB24 Non-Preferred Brand

GLUCOTROL TABS Non-Preferred Brand

GLUCOVANCE TABS Non-Preferred Brand

GLUMETZA TB24 Non-Preferred Brand ST

glyburide micronized TABS Generic

glyburide/metformin hcl TABS Generic

glyburide TABS Generic

GLYNASE TABS Non-Preferred Brand

GLYSET TABS Non-Preferred Brand

HUMALOG KWIKPEN SOPN Generic

HUMALOG MIX 50/50 KWIKPEN SUPN Generic

HUMALOG MIX 50/50 SUSP Generic

HUMALOG MIX 75/25 KWIKPEN SUPN Generic

HUMALOG MIX 75/25 SUSP Generic

HUMALOG SOLN Generic

HUMULIN 70/30 PEN SUPN Generic

HUMULIN 70/30 SUSP Generic




Limits

HUMULIN N U-100 PEN SUPN Generic

HUMULIN N SUSP Generic

HUMULIN R U-500 (CONCENTRATED) SOLN Generic

HUMULIN R SOLN Generic

INVOKANA TABS Preferred Brand QL

JANUMET XR TB24 Preferred Brand

JANUMET TABS Preferred Brand

JANUVIA TABS Preferred Brand QL

JENTADUETO TABS Non-Preferred Brand

JUVISYNC TABS Preferred Brand QL

KAZANO TABS Non-Preferred Brand QL

KOMBIGLYZE XR TB24 Preferred Brand QL

KORLYM TABS Non-Preferred Specialty

QL PA

LANTUS SOLOSTAR SOPN Generic

LANTUS SOLN Generic

LEVEMIR FLEXPEN SOPN Non-Preferred Brand ST

LEVEMIR SOLN Non-Preferred Brand ST

METAGLIP TABS Non-Preferred Brand

metformin hcl er TB24 Generic

metformin hcl TABS Generic

nateglinide TABS Generic

NESINA TABS Non-Preferred Brand

NOVOLIN 70/30 SUSP Non-Preferred Brand ST

NOVOLIN N SUSP Non-Preferred Brand ST

NOVOLIN R SOLN Non-Preferred Brand ST

NOVOLOG FLEXPEN SOPN Non-Preferred Brand ST

NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN Non-Preferred Brand ST

NOVOLOG MIX 70/30 SUSP Non-Preferred Brand ST

NOVOLOG PENFILL SOCT Non-Preferred Brand ST

NOVOLOG SOLN Non-Preferred Brand ST

ONGLYZA TABS Preferred Brand QL

OSENI TABS Non-Preferred Brand QL

pioglitazone hcl/metformin hcl TABS Generic

pioglitazone hcl TABS Generic

pioglitazone hcl-glimepiride TABS Generic

PRANDIMET TABS Non-Preferred Brand

PRANDIN TABS Non-Preferred Brand

PRECOSE TABS Non-Preferred Brand

repaglinide TABS Generic

STARLIX TABS Non-Preferred Brand

SYMLINPEN 120 SOPN Preferred Brand

SYMLINPEN 60 SOPN Preferred Brand

tolazamide TABS Preferred Brand

TOLBUTAMIDE TABS Preferred Brand

TRADJENTA TABS Non-Preferred Brand QL




Limits

VICTOZA SOPN Preferred Brand

Antihypoglycemic Agents

GLUCAGEN HYPOKIT SOLR Preferred Brand

GLUCAGON EMERGENCY KIT KIT Preferred Brand

Contraceptives

altavera TABS Non-Preferred Brand

amethia lo TABS Generic

amethia TABS Generic

apri TABS Generic

aviane TABS Generic

azurette TABS Generic

balziva TABS Generic

BEYAZ TABS Non-Preferred Brand

camila TABS Generic

camrese lo TABS Generic

camrese TABS Generic

cryselle-28 TABS Generic

cyclafem 1/35 TABS Generic

cyclafem 7/7/7 TABS Generic

DESOGEN TABS Non-Preferred Brand

ELLA TABS Non-Preferred Brand

emoquette TABS Generic

enpresse-28 TABS Generic

errin TABS Generic

ESTROSTEP FE TABS Non-Preferred Brand

FEMCON FE CHEW Non-Preferred Brand

GENERESS FE CHEW Non-Preferred Brand

gianvi TABS Generic

gildess fe 1.5/30 TABS Generic

gildess fe 1/20 TABS Generic

introvale TABS Generic

jolessa TABS Generic

jolivette TABS Generic

junel 1.5/30 TABS Generic

junel 1/20 TABS Generic

junel fe 1.5/30 TABS Generic

junel fe 1/20 TABS Generic

kariva TABS Generic

levonorgestrel and ethinyl estradiol TABS Generic

levonorgestrel TABS Generic

levora 0.15/30-28 TABS Generic

LO LOESTRIN FE TABS Non-Preferred Brand

LO MINASTRIN FE THPK Non-Preferred Brand

LOESTRIN 24 FE TABS Non-Preferred Brand

LOESTRIN FE 1.5/30 TABS Non-Preferred Brand

LOESTRIN FE 1/20 TABS Non-Preferred Brand




Limits

LOMEDIA 24 FE TABS Generic

LOSEASONIQUE TABS Non-Preferred Brand

low-ogestrel TABS Generic

lutera TABS Generic

microgestin 1.5/30 TABS Generic

microgestin 1/20 TABS Generic

microgestin fe 1.5/30 TABS Generic

microgestin fe TABS Generic

MINASTRIN 24 FE CHEW Non-Preferred Brand

MIRCETTE TABS Non-Preferred Brand

mononessa TABS Generic

NATAZIA TABS Non-Preferred Brand

necon 0.5/35-28 TABS Generic

necon 1/35 TABS Generic

NECON 1/50-28 TABS Generic

NECON 10/11-28 TABS Generic

necon 7/7/7 TABS Generic

NEXPLANON IMPL Medical Benefit

next choice one dose TABS Generic

nora-be TABS Generic

NORINYL 1+50 TABS Non-Preferred Brand

NOR-QD TABS Non-Preferred Brand

nortrel 1/35 TABS Generic

nortrel 7/7/7 TABS Generic

NUVARING RING Non-Preferred Brand

ocella TABS Generic

OGESTREL TABS Generic

ORTHO EVRA PTWK Non-Preferred Brand

ORTHO MICRONOR TABS Non-Preferred Brand

ORTHO TRI-CYCLEN LO TABS Preferred Brand

ORTHO TRI-CYCLEN TABS Non-Preferred Brand

ORTHO-CEPT TABS Non-Preferred Brand

ORTHO-CYCLEN TABS Non-Preferred Brand

ORTHO-NOVUM 1/35 TABS Non-Preferred Brand

ORTHO-NOVUM 7/7/7 TABS Non-Preferred Brand

OVCON-35 TABS Non-Preferred Brand

PLAN B ONE-STEP TABS Non-Preferred Brand

PLAN B TABS Non-Preferred Brand

portia-28 TABS Generic

previfem TABS Generic

QUARTETTE TABS Non-Preferred Brand

quasense TABS Generic

reclipsen TABS Generic

SAFYRAL TABS Non-Preferred Brand

SEASONIQUE TABS Non-Preferred Brand

SKYLA IUD Medical Benefit




Limits

solia TABS Generic

sprintec 28 TABS Generic

sronyx TABS Generic

tri-estarylla TABS Generic

tri-legest fe TABS Generic

trinessa TABS Generic

TRI-NORINYL 28 TABS Non-Preferred Brand

tri-previfem TABS Generic

tri-sprintec TABS Generic

trivora-28 TABS Generic

velivet TABS Generic

YASMIN 28 TABS Non-Preferred Brand

YAZ TABS Non-Preferred Brand

zenchent TABS Generic

zovia 1/35e TABS Generic

ZOVIA 1/50E TABS Generic

Estrogens and Antiestrogens

ACTIVELLA TABS Non-Preferred Brand

ALORA PTTW Preferred Brand

ANGELIQ TABS Non-Preferred Brand ST

CENESTIN TABS Preferred Brand

CLIMARA PRO PTWK Preferred Brand

CLIMARA PTWK Non-Preferred Brand

CLOMID TABS Non-Preferred Brand

clomiphene citrate TABS Generic

COMBIPATCH PTTW Preferred Brand

DELESTROGEN OIL Non-Preferred Brand

DEPO-ESTRADIOL OIL Preferred Brand

DIVIGEL GEL Preferred Brand QL

DUAVEE TABS Non-Preferred Brand QL

ELESTRIN GEL Non-Preferred Brand

ENJUVIA TABS Non-Preferred Brand QL

esterified estrogens/methyltestosterone ds TABS Generic

esterified estrogens/methyltestosterone hs TABS Generic

ESTRACE CREA Preferred Brand

ESTRACE TABS Non-Preferred Brand

estradiol valerate OIL Generic

estradiol/norethindrone acetate TABS Generic

estradiol PTWK Generic

estradiol TABS Generic

ESTRASORB EMUL Preferred Brand

ESTRING RING Preferred Brand

ESTROGEL GEL Preferred Brand QL

estropipate TABS Generic

EVAMIST SOLN Preferred Brand

EVISTA TABS Non-Preferred Brand




Limits

FEMHRT LOW DOSE TABS Preferred Brand

FEMRING RING Preferred Brand

JINTELI TABS Generic

MENEST TABS Preferred Brand

MENOSTAR PTWK Non-Preferred Brand QL

MINIVELLE PTTW Non-Preferred Brand

ortho-est TABS Non-Preferred Brand

OSPHENA TABS Preferred Brand PA

PREFEST TABS Non-Preferred Brand

PREMARIN CREA Preferred Brand

PREMARIN TABS Preferred Brand QL

PREMPHASE TABS Preferred Brand

PREMPRO TABS Preferred Brand

raloxifene hydrochloride TABS Generic

serophene TABS Generic

VAGIFEM TABS Preferred Brand

VIVELLE-DOT PTTW Generic

Gonadotropins

BRAVELLE SOLR Preferred Brand

FOLLISTIM AQ SOLN Non-Preferred Brand ST

GONAL-F RFF PEN SOLN Preferred Brand

GONAL-F RFF SOLR Preferred Brand

GONAL-F SOLR Preferred Brand

MENOPUR SOLR Preferred Brand

novarel SOLR Preferred Brand

OVIDREL INJ Preferred Brand

pregnyl w/diluent benzyl alcohol/nacl SOLR Generic

REPRONEX SOLR Preferred Brand

SYNAREL SOLN Preferred Brand

Parathyroid

calcitonin-salmon SOLN Generic

FORTEO SOLN Preferred Specialty QL PA

FORTICAL SOLN Generic

MIACALCIN SOLN Non-Preferred Brand

Pituitary

ACTHAR HP GEL Preferred Specialty QL PA

DDAVP SOLN Non-Preferred Brand

DDAVP TABS Non-Preferred Brand

DDAVP SOLN Medical Benefit

desmopressin acetate SOLN Generic

desmopressin acetate TABS Generic

STIMATE SOLN Preferred Brand

Progestins

AYGESTIN TABS Non-Preferred Brand

CRINONE GEL Preferred Brand QL

DEPO-PROVERA CONTRACEPTIVE SUSP Non-Preferred Brand




Limits

DEPO-PROVERA SUSP Medical Benefit

DEPO-SUBQ PROVERA 104 SUSP Non-Preferred Brand

ENDOMETRIN INST Preferred Brand

MAKENA OIL Excluded

medroxyprogesterone acetate SUSP Generic

medroxyprogesterone acetate TABS Generic

MEGACE ES SUSP Non-Preferred Brand ST

norethindrone acetate TABS Generic

progesterone CAPS Generic

progesterone OIL Generic

PROMETRIUM CAPS Non-Preferred Brand

PROVERA TABS Non-Preferred Brand

Somatostatin Agonists and Antagonists

octreotide acetate SOLN Preferred Specialty QL

SANDOSTATIN LAR DEPOT KIT Medical Benefit

SANDOSTATIN SOLN Non-Preferred Specialty

QL

SIGNIFOR SOLN Non-Preferred Specialty

PA

SOMATULINE DEPOT SOLN Preferred Specialty QL

Somatotropin Agonists and Antagonists

GENOTROPIN MINIQUICK SOLR Non-Preferred Specialty

QL PA

GENOTROPIN SOLR Non-Preferred Specialty

QL PA

HUMATROPE COMBO PACK SOLR Non-Preferred Specialty

QL PA

HUMATROPE SOLR Non-Preferred Specialty

QL PA

INCRELEX SOLN Preferred Specialty QL PA

NORDITROPIN FLEXPRO SOLN Preferred Specialty QL PA

NORDITROPIN NORDIFLEX PEN SOLN Preferred Specialty QL PA

NUTROPIN AQ NUSPIN 10 SOLN Non-Preferred Specialty

QL PA

NUTROPIN AQ NUSPIN 5 SOLN Non-Preferred Specialty

QL PA

NUTROPIN AQ PEN SOLN Non-Preferred Specialty

QL PA

NUTROPIN SOLR Non-Preferred Specialty

QL PA

OMNITROPE SOLN Non-Preferred Specialty

QL PA

OMNITROPE SOLR Non-Preferred Specialty

QL PA

SAIZEN CLICK.EASY SOLR Non-Preferred Specialty

QL PA

SAIZEN SOLR Non-Preferred QL PA




Limits

Specialty

SEROSTIM SOLR Non-Preferred Specialty

QL PA

SOMAVERT SOLR Preferred Specialty QL PA

TEV-TROPIN SOLR Non-Preferred Specialty

QL PA

ZORBTIVE SOLR Non-Preferred Specialty

QL PA

Thyroid and Antithyroid Agents

ARMOUR THYROID TABS Preferred Brand

CYTOMEL TABS Non-Preferred Brand

levothroid TABS Generic

LEVOTHYROXINE SODIUM SOLR Generic

levothyroxine sodium TABS Generic

LEVOTHYROXINE SODIUM SOLR Non-Preferred Specialty

QL

levoxyl TABS Generic

liothyronine sodium TABS Generic

methimazole TABS Generic

NATURE-THROID TABS Preferred Brand

propylthiouracil TABS Generic

SYNTHROID TABS Non-Preferred Brand

TAPAZOLE TABS Non-Preferred Brand

THYROLAR-1/2 TABS Preferred Brand

THYROLAR-1/4 TABS Preferred Brand

THYROLAR-1 TABS Preferred Brand



TIROSINT CAPS Non-Preferred Brand

unithroid TABS Generic

WESTHROID TABS Generic

Local Anesthetics

EXPAREL SUSP Medical Benefit

Miscellaneous Therapeutic Agents

5-alpha-Reductase Inhibitors

AVODART CAPS Non-Preferred Brand ST

finasteride TABS Generic

JALYN CAPS Non-Preferred Brand ST

PROSCAR TABS Non-Preferred Brand

Alcohol Deterrents

ANTABUSE TABS Non-Preferred Brand

disulfiram TABS Generic

Antidotes

acetylcysteine SOLN Generic

FUSILEV SOLR Medical Benefit




Limits

leucovorin calcium TABS Generic

LEUCOVORIN CALCIUM TABS Preferred Brand

VORAXAZE SOLR Medical Benefit-Preferred

Specialty

Antigout Agents

allopurinol TABS Generic

COLCRYS TABS Preferred Brand QL

KRYSTEXXA SOLN Medical Benefit-Preferred

Specialty

PA

ULORIC TABS Preferred Brand ST

ZYLOPRIM TABS Non-Preferred Brand

Bone Resorption Inhibitors

ACTONEL TABS Preferred Brand ST

ALENDRONATE SODIUM SOLN Generic

alendronate sodium TABS Generic

ATELVIA TBEC Non-Preferred Brand ST

BINOSTO TBEF Non-Preferred Brand ST

BONIVA TABS Non-Preferred Brand

BONIVA SOLN Medical Benefit-Non-Preferred

Specialty

PA

ETIDRONATE DISODIUM TABS Generic

FOSAMAX PLUS D TABS Non-Preferred Brand QL ST

FOSAMAX TABS Non-Preferred Brand

ibandronate sodium TABS Generic

pamidronate disodium SOLR Medical Benefit

PROLIA SOLN Medical Benefit-Preferred

Specialty

PA

RECLAST SOLN Medical Benefit-Non-Preferred

Specialty

SKELID TABS Preferred Specialty QL

XGEVA SOLN Medical Benefit-Preferred

Specialty

PA

zoledronic acid CONC Medical Benefit-Non-Preferred

Specialty

PA

zoledronic acid SOLN Medical Benefit-Non-Preferred

Specialty

ZOMETA CONC Medical Benefit-Preferred

Specialty




Limits

Cariostatic Agents

cavarest GEL Generic

cavirinse SOLN Generic

controlrx CREA Generic

denta 5000 plus CREA Generic

dentagel GEL Generic

FLUORABON SOLN Preferred Brand

fluor-a-day SOLN Preferred Brand

fluoridex daily defense GEL Generic

LURIDE CHEW Non-Preferred Brand

LURIDE SOLN Non-Preferred Brand

neutragard advanced GEL Generic

phos-flur GEL Generic

PREVIDENT 5000 BOOSTER PSTE Non-Preferred Brand

PREVIDENT 5000 PLUS CREA Non-Preferred Brand

PREVIDENT FLUORIDE GEL Non-Preferred Brand

PREVIDENT SOLN Non-Preferred Brand

sf 5000 plus CREA Generic

sf GEL Generic

sodium fluoride CHEW Generic

sodium fluoride SOLN Generic

Complement Inhibitors

BERINERT KIT Medical Benefit-Non-Preferred

Specialty

CINRYZE SOLR Medical Benefit-Preferred

Specialty

QL

FIRAZYR SOLN Non-Preferred Specialty

QL PA

KALBITOR SOLN Medical Benefit-Preferred

Specialty

SOLIRIS SOLN Medical Benefit-Preferred

Specialty

PA

Disease-modifying Antirheumatic Drugs

ACTEMRA SOSY Non-Preferred Specialty

ACTEMRA SOLN Medical Benefit-Preferred

Specialty

PA

ARAVA TABS Non-Preferred Specialty

QL

CIMZIA KIT Non-Preferred Specialty

QL PA

ENBREL SURECLICK SOLN Preferred Specialty QL PA




Limits

ENBREL KIT Preferred Specialty QL PA

ENBREL SOLN Preferred Specialty QL PA

HUMIRA PEN KIT Preferred Specialty QL PA

HUMIRA PEN-CROHNS DISEASESTARTER KIT Preferred Specialty QL PA

HUMIRA PEN-PSORIASIS STARTER KIT Preferred Specialty QL PA

HUMIRA KIT Preferred Specialty QL PA

KINERET SOLN Preferred Specialty QL PA

leflunomide TABS Preferred Specialty QL

ORENCIA SOLN Non-Preferred Specialty

QL PA

ORENCIA SOLR Medical Benefit-Non-Preferred

Specialty

PA

OTREXUP SOAJ Non-Preferred Brand ST

REMICADE SOLR Medical Benefit-Non-Preferred

Specialty

PA

SIMPONI ARIA SOLN Medical Benefit-Non-Preferred

Specialty

QL PA

SIMPONI SOLN Non-Preferred Specialty

QL PA

XELJANZ TABS Non-Preferred Specialty

PA

Gonadotropin-releasing Hormone Antagonists

CETROTIDE KIT Preferred Brand

GANIRELIX ACETATE SOLN Preferred Brand

Immunomodulatory Agents

ACTIMMUNE SOLN Preferred Specialty QL

AUBAGIO TABS Non-Preferred Specialty

QL PA

AVONEX PEN KIT Preferred Specialty QL

AVONEX KIT Preferred Specialty QL

BETASERON KIT Non-Preferred Specialty

QL PA

COPAXONE KIT Preferred Specialty QL

EXTAVIA KIT Non-Preferred Specialty

QL PA

GILENYA CAPS Non-Preferred Specialty

QL PA

REBIF REBIDOSE TITRATION PACK SOLN Preferred Specialty QL

REBIF REBIDOSE SOLN Preferred Specialty QL

REBIF TITRATION PACK SOLN Preferred Specialty QL

REBIF SOLN Preferred Specialty QL

TECFIDERA STARTER PACK MISC Preferred Specialty QL

TECFIDERA CPDR Preferred Specialty QL

THALOMID CAPS Preferred Specialty QL




Limits

TYSABRI CONC Medical Benefit-Non-Preferred

Specialty

PA

Immunosuppressive Agents

ASTAGRAF XL CP24 Non-Preferred Specialty

ST

ATGAM INJ Medical Benefit

AZASAN TABS Non-Preferred Brand

azathioprine TABS Generic

BENLYSTA SOLR Medical Benefit-Preferred

Specialty

PA

CELLCEPT SUSR Preferred Brand

CELLCEPT CAPS Non-Preferred Brand

CELLCEPT TABS Non-Preferred Brand

cyclosporine modified CAPS Generic

cyclosporine modified SOLN Generic

CYCLOSPORINE MODIFIED CAPS Preferred Brand

cyclosporine CAPS Generic

gengraf CAPS Generic

gengraf SOLN Generic

IMURAN TABS Non-Preferred Brand

mycophenolate mofetil CAPS Generic

mycophenolate mofetil TABS Generic

MYFORTIC TBEC Non-Preferred Brand QL

NEORAL CAPS Non-Preferred Brand

NEORAL SOLN Non-Preferred Brand

NULOJIX SOLR Medical Benefit-Non-Preferred

Specialty

PA

PROGRAF CAPS Non-Preferred Brand

PROGRAF SOLN Medical Benefit-Preferred

Specialty

RAPAMUNE SOLN Preferred Specialty QL

RAPAMUNE TABS Preferred Specialty QL

RAPAMUNE TABS Non-Preferred Specialty

QL

SANDIMMUNE CAPS Non-Preferred Brand

SANDIMMUNE SOLN Non-Preferred Brand

SANDIMMUNE SOLN Medical Benefit

SIMULECT SOLR Medical Benefit

sirolimus TABS Preferred Specialty QL

tacrolimus CAPS Generic

ZORTRESS TABS Preferred Brand

ZORTRESS TABS Preferred Specialty QL

Other Miscellaneous Therapeutic Agents




Limits

AMPYRA TB12 Non-Preferred Specialty

QL PA

ARCALYST SOLR Preferred Specialty QL

BOTOX SOLR Medical Benefit-Preferred

Specialty

PA

CARNITOR SOLN Non-Preferred Brand

CARNITOR TABS Non-Preferred Brand

CARNITOR SOLN Medical Benefit

CARTICEL IMPL Medical Benefit

COENZYME Q10 POWD Preferred Brand

coenzyme q-10 CAPS Excluded

DYSPORT SOLR Medical Benefit-Preferred

Specialty

PA

ELMIRON CAPS Preferred Brand QL

EUFLEXXA SOLN Medical Benefit-Preferred

Specialty

HYALGAN SOLN Medical Benefit-Non-Preferred

Specialty

PA

KUVAN TBSO Preferred Specialty QL

levocarnitine SOLN Generic

levocarnitine TABS Generic

levocarnitine SOLN Medical Benefit

MYOBLOC SOLN Medical Benefit-Preferred

Specialty

PA

ORTHOVISC SOLN Medical Benefit-Non-Preferred

Specialty

PA

PROCYSBI CPDR Excluded

RIMSO-50 SOLN Medical Benefit

SENSIPAR TABS Preferred Specialty QL

SUPARTZ SOLN Medical Benefit-Non-Preferred

Specialty

PA

SYNVISC ONE SOSY Medical Benefit-Non-Preferred

Specialty

PA

SYNVISC SOSY Medical Benefit-Non-Preferred

Specialty

PA

XEOMIN SOLR Medical Benefit-Preferred

Specialty

PA

Protective Agents




Limits

dexrazoxane SOLR Medical Benefit

ETHYOL SOLR Medical Benefit-Preferred

Specialty

mesna SOLN Medical Benefit

MESNEX TABS Preferred Specialty QL

ZINECARD SOLR Medical Benefit

Oxytocics

methylergonovine maleate TABS Generic

methylergonovine maleate SOLN Medical Benefit

Radioactive Agents

XOFIGO SOLN Medical Benefit-Non-Preferred

Specialty

Respiratory Tract Agents


ACCOLATE TABS Non-Preferred Brand

cromolyn sodium NEBU Generic

GASTROCROM CONC Preferred Brand

montelukast sodium CHEW Generic

montelukast sodium TABS Generic

SINGULAIR PACK Preferred Brand

SINGULAIR CHEW Non-Preferred Brand

SINGULAIR TABS Non-Preferred Brand

zafirlukast TABS Generic

ZYFLO CR TB12 Non-Preferred Brand ST

ZYFLO TABS Non-Preferred Brand ST

Antitussives

benzonatate CAPS Generic

bromfed dm SYRP Generic

cheratussin ac SYRP Generic

cheratussin dac SOLN Generic

hydrocodone polistirex/chlorpheniramine polistirex LQCR Generic

hydrocodone/homatropine SYRP Generic

hydromet SYRP Generic

promethazine/codeine SYRP Generic

promethazine/dextromethorphan SYRP Generic

REZIRA SOLN Excluded

TESSALON PERLES CAPS Non-Preferred Brand

tussigon TABS Preferred Brand

TUSSIONEX PENNKINETIC EXTENDED RELEASE

LQCR Non-Preferred Brand

VITUZ SOLN Excluded

ZUTRIPRO SOLN Excluded

Cystic Fibrosis Transmembrane Conductance Regulator Modulators




Limits

KALYDECO TABS Preferred Specialty QL PA

Expectorants

donatussin LIQD Non-Preferred Brand

phenylephrine/guaifenesin LIQD Generic

Mucolytic Agents

HYPER-SAL NEBU Preferred Brand QL

PULMOZYME SOLN Preferred Specialty QL PA

sodium chloride NEBU Generic

Phosphodiesterase Type 4 Inhibitors

DALIRESP TABS Non-Preferred Brand PA

Respiratory Tract Agents, Miscellaneous

ARALAST NP SOLR Medical Benefit-Preferred

Specialty

PA

GLASSIA SOLN Medical Benefit-Preferred

Specialty

PA

XOLAIR SOLR Medical Benefit-Preferred

Specialty

PA

ZEMAIRA SOLR Medical Benefit-Preferred

Specialty

PA

Serums, Toxoids and Vaccines

Serums

ANASCORP SOLR Medical Benefit-Preferred

Specialty

CARIMUNE NANOFILTERED SOLR Medical Benefit-Preferred

Specialty

PA

FLEBOGAMMA DIF SOLN Medical Benefit-Preferred

Specialty

PA

FLEBOGAMMA SOLN Medical Benefit-Preferred

Specialty

PA

GAMASTAN S/D INJ Medical Benefit

GAMMAGARD LIQUID SOLN Medical Benefit-Preferred

Specialty

PA

GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR Medical Benefit-Preferred

Specialty

PA

GAMMAGARD S/D SOLR Medical Benefit-Preferred

Specialty

PA

GAMUNEX SOLN Medical PA




Limits

Benefit-Preferred Specialty

HIZENTRA SOLN Medical Benefit-Preferred

Specialty

PA

HYPERHEP B S/D SOLN Medical Benefit

HYPERRAB S/D INJ Medical Benefit

HYPERRHO S/D INJ Medical Benefit

HYPERTET S/D INJ Medical Benefit

IMOGAM RABIES-HT INJ Medical Benefit

MICRHOGAM ULTRA-FILTERED PLUS INJ Medical Benefit

NABI-HB SOLN Medical Benefit

PRIVIGEN SOLN Medical Benefit-Preferred

Specialty

PA

RHOGAM ULTRA-FILTERED PLUS INJ Medical Benefit

RHOPHYLAC SOLN Medical Benefit

WINRHO SDF SOLN Medical Benefit

Toxoids

ADACEL SUSP Medical Benefit QL

BOOSTRIX SUSP Medical Benefit QL

DAPTACEL SUSP Medical Benefit

TENIVAC INJ Medical Benefit

TETANUS TOXOID ADSORBED SOLN Medical Benefit

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT

SUSP Medical Benefit

Vaccines

CERVARIX SUSP Medical Benefit QL

COMVAX SUSP Medical Benefit

ENGERIX-B SUSP Medical Benefit QL

FLUBLOK 2013-2014 SOLN Medical Benefit

FLUMIST QUADRIVALENT SUSP Medical Benefit

FLUZONE HIGH-DOSE PF 2013-2014 SUSP Medical Benefit

FLUZONE INTRADERMAL DEVI Excluded

FLUZONE PEDIATRIC PF 2013-2014 SUSP Excluded

FLUZONE PF 2013-2014 SUSP Medical Benefit

FLUZONE SPLIT 2013-2014 INJ Medical Benefit

GARDASIL SUSP Medical Benefit QL

HAVRIX SUSP Medical Benefit QL

IMOVAX RABIES (H.D.C.V.) INJ Medical Benefit

IPOL INACTIVATED IPV INJ Medical Benefit QL

IXIARO SUSP Excluded

JE-VAX SOLR Excluded

MEDICAL PROVIDER EZ FLU SHOT 2013-2014 KIT Excluded

MENACTRA INJ Medical Benefit QL

MENOMUNE-A/C/Y/W-135 INJ Medical Benefit QL

MENVEO SOLR Medical Benefit QL




Limits

M-M-R II W/DILUENT 10 DOSE INJ Medical Benefit QL

PEDIARIX SUSP Medical Benefit

PNEUMOVAX 23/1 DOSE INJ Medical Benefit QL

PNEUMOVAX 23/5 DOSE INJ Medical Benefit QL

PREVNAR 13 SUSP Medical Benefit QL

PROQUAD INJ Medical Benefit

RABAVERT SUSR Medical Benefit

RECOMBIVAX HB SUSP Medical Benefit QL

ROTATEQ SOLN Medical Benefit

THERACYS SUSR Medical Benefit

TICE BCG SUSR Medical Benefit

TWINRIX SUSP Medical Benefit QL

TYPHIM VI SOLN Excluded

VAQTA SUSP Medical Benefit QL

VARIVAX INJ Medical Benefit

VIVOTIF BERNA CPDR Excluded

YF-VAX INJ Excluded

ZOSTAVAX SOLR Preferred Brand QL

Skin and Mucous Membrane Preparations

Anti-infectives

ACANYA GEL Non-Preferred Brand

acne medication 10 GEL Generic

acne medication 5 GEL Generic

acticin CREA Non-Preferred Brand

acyclovir OINT Generic QL

ALTABAX OINT Non-Preferred Brand ST

BACTROBAN NASAL OINT Preferred Brand

BACTROBAN CREA Non-Preferred Brand

BACTROBAN OINT Non-Preferred Brand

BENZACLIN WITH PUMP GEL Non-Preferred Brand

BENZACLIN GEL Non-Preferred Brand

BENZAMYCIN GEL Non-Preferred Brand

BENZEFOAM FOAM Non-Preferred Brand

BPO CREAMY WASH COMPLETE PACK KIT Generic QL

BPO GEL Generic

CENTANY OINT Non-Preferred Brand

ciclopirox nail lacquer SOLN Generic

ciclopirox olamine CREA Generic

ciclopirox GEL Generic

ciclopirox SUSP Generic

CLEOCIN SUPP Preferred Brand

CLEOCIN CREA Non-Preferred Brand

CLEOCIN-T GEL Non-Preferred Brand

CLEOCIN-T LOTN Non-Preferred Brand

CLEOCIN-T SOLN Non-Preferred Brand

CLEOCIN-T SWAB Non-Preferred Brand




Limits

CLINDAGEL GEL Non-Preferred Brand

clindamycin phosphate CREA Generic

clindamycin phosphate GEL Generic

clindamycin phosphate LOTN Generic

clindamycin phosphate SOLN Generic

clindamycin phosphate SWAB Generic

clindamycin/benzoyl peroxide GEL Generic

clotrimazole/betamethasone dipropionate CREA Generic

clotrimazole/betamethasone dipropionate LOTN Generic

clotrimazole CREA Generic

clotrimazole SOLN Generic

clotrimazole TROC Generic

DENAVIR CREA Preferred Brand

DESQUAM-X WASH LIQD Non-Preferred Brand

DUAC GEL Non-Preferred Brand

econazole nitrate CREA Generic

ECOZA FOAM Non-Preferred Brand QL

ERTACZO CREA Non-Preferred Brand

ery PADS Generic

erythromycin/benzoyl peroxide GEL Generic

erythromycin GEL Generic

erythromycin SOLN Generic

EURAX CREA Preferred Brand

EURAX LOTN Preferred Brand

EXELDERM CREA Non-Preferred Brand ST

EXELDERM SOLN Non-Preferred Brand ST

GENTAMICIN SULFATE CREA Generic

GENTAMICIN SULFATE OINT Generic

GYNAZOLE-1 CREA Non-Preferred Brand

ketoconazole CREA Generic

ketoconazole SHAM Generic

KLARON LOTN Non-Preferred Brand

LAMISIL SPRAY SOLN Non-Preferred Brand

lavoclen-4 acne wash kit KIT Generic

lavoclen-8 acne wash kit KIT Generic

lindane LOTN Generic

lindane SHAM Generic

LOPROX GEL Non-Preferred Brand

LOTRISONE CREA Non-Preferred Brand

malathion LOTN Generic

MENTAX CREA Non-Preferred Brand

METROCREAM CREA Non-Preferred Brand

METROGEL GEL Non-Preferred Brand

METROGEL-VAGINAL GEL Non-Preferred Brand

METROLOTION LOTN Non-Preferred Brand

metronidazole vaginal GEL Generic




Limits

metronidazole CREA Generic

metronidazole GEL Generic

metronidazole LOTN Generic

mexar wash LIQD Generic

mupirocin CREA Generic

mupirocin OINT Generic

NAFTIN CREA Non-Preferred Brand ST

NAFTIN GEL Non-Preferred Brand

NATROBA SUSP Non-Preferred Brand ST

NIZORAL SHAM Non-Preferred Brand

NORITATE CREA Preferred Brand

nystatin CREA Generic

nystatin OINT Generic

nystop POWD Generic

oscion cleanser LOTN Generic

OVACE PLUS WASH LIQD Non-Preferred Brand

OVACE WASH LIQD Non-Preferred Brand

OXISTAT CREA Preferred Brand

OXISTAT LOTN Preferred Brand

panoxyl wash LIQD Generic

PENLAC NAIL LACQUER SOLN Non-Preferred Brand

permethrin CREA Generic

permethrin LOTN Excluded

RIAX FOAM Non-Preferred Brand QL

selenium sulfide LOTN Generic

SELENIUM SULFIDE SHAM Generic

SELRX SHAM Non-Preferred Brand QL

SELSUN SHAMPOO LOTN Non-Preferred Brand

SILVADENE CREA Non-Preferred Brand

silver sulfadiazine CREA Generic

SKLICE LOTN Non-Preferred Brand

sodium sulfacetamide wash LIQD Generic

sulfacetamide sodium SUSP Generic

SULFAMYLON CREA Non-Preferred Brand

SULFAMYLON PACK Non-Preferred Brand

TERAZOL 3 SUPP Non-Preferred Brand

TERAZOL 7 CREA Non-Preferred Brand

terconazole CREA Generic

terconazole SUPP Generic

ULESFIA LOTN Preferred Brand

vandazole GEL Generic

VYTONE CREA Non-Preferred Brand QL

XERESE CREA Non-Preferred Brand ST

XOLEGEL GEL Non-Preferred Brand ST

ZOVIRAX CREA Preferred Brand QL ST

ZOVIRAX OINT Non-Preferred Brand QL




Limits


ACLOVATE CREA Non-Preferred Brand

alclometasone dipropionate CREA Generic

alclometasone dipropionate OINT Generic

amcinonide CREA Generic

AMCINONIDE LOTN Preferred Brand

AMCINONIDE OINT Preferred Brand

ANUSOL-HC SUPP Non-Preferred Brand

APEXICON E CREA Generic ST

aquanil hc LOTN Generic

augmented betamethasone dipropionate CREA Generic

augmented betamethasone dipropionate GEL Generic

augmented betamethasone dipropionate LOTN Generic

augmented betamethasone dipropionate OINT Generic

betamethasone dipropionate CREA Generic

betamethasone dipropionate LOTN Generic

betamethasone dipropionate OINT Generic

betamethasone valerate CREA Generic

betamethasone valerate FOAM Generic

betamethasone valerate LOTN Generic

betamethasone valerate OINT Generic

CAPEX SHAM Non-Preferred Brand ST

clobetasol propionate emollient FOAM Generic

clobetasol propionate CREA Generic

clobetasol propionate FOAM Generic

clobetasol propionate GEL Generic

clobetasol propionate LOTN Generic

clobetasol propionate OINT Generic

clobetasol propionate SHAM Generic

clobetasol propionate SOLN Generic

CLOBEX LIQD Non-Preferred Brand

CLOBEX LOTN Non-Preferred Brand

CLOBEX SHAM Non-Preferred Brand

CLODERM PUMP CREA Non-Preferred Brand

CLODERM CREA Non-Preferred Brand

CORDRAN SP CREA Non-Preferred Brand

CORDRAN TAPE TAPE Preferred Brand

CORDRAN LOTN Non-Preferred Brand

CORTANE-B LOTN Non-Preferred Brand

CORTENEMA ENEM Non-Preferred Brand

CORTIFOAM FOAM Preferred Brand

CORTISPORIN CREA Preferred Brand

CORTISPORIN OINT Preferred Brand

CUTIVATE CREA Non-Preferred Brand

CUTIVATE OINT Non-Preferred Brand

DERMA-SMOOTHE/FS BODY OIL Non-Preferred Brand




Limits

DERMA-SMOOTHE/FS SCALP OIL Non-Preferred Brand

DESONATE GEL Non-Preferred Brand ST

desonide CREA Generic

desonide LOTN Generic

desonide OINT Generic

desoximetasone CREA Generic

desoximetasone GEL Generic

desoximetasone OINT Generic

DIFLORASONE DIACETATE CREA Generic

diflorasone diacetate OINT Generic

DIPROLENE AF CREA Non-Preferred Brand

DIPROLENE LOTN Non-Preferred Brand

DIPROLENE OINT Non-Preferred Brand

ELOCON CREA Non-Preferred Brand

ELOCON LOTN Non-Preferred Brand

ELOCON OINT Non-Preferred Brand

EPIFOAM FOAM Preferred Brand

fluocinolone acetonide body OIL Generic

fluocinolone acetonide scalp OIL Generic

fluocinolone acetonide CREA Generic

fluocinolone acetonide OINT Generic

fluocinolone acetonide SOLN Generic

fluocinonide CREA Generic

fluocinonide GEL Generic

fluocinonide OINT Generic

fluocinonide SOLN Generic

fluticasone propionate CREA Generic

fluticasone propionate OINT Generic

halobetasol propionate CREA Generic

halobetasol propionate OINT Generic

HALOG CREA Non-Preferred Brand ST

HALOG OINT Non-Preferred Brand ST

hydrocortisone butyrate CREA Generic

hydrocortisone butyrate OINT Generic

hydrocortisone butyrate SOLN Generic

hydrocortisone valerate CREA Generic

hydrocortisone valerate OINT Generic

hydrocortisone CREA Generic

hydrocortisone ENEM Generic

hydrocortisone LOTN Generic

hydrocortisone OINT Generic

LOCOID LIPOCREAM CREA Non-Preferred Brand

LOCOID CREA Non-Preferred Brand

LOCOID OINT Non-Preferred Brand

LOCOID SOLN Non-Preferred Brand

LUXIQ FOAM Non-Preferred Brand




Limits

mometasone furoate CREA Generic

mometasone furoate OINT Generic

mometasone furoate SOLN Generic

nystatin/triamcinolone CREA Generic

nystatin/triamcinolone OINT Generic

OLUX FOAM Non-Preferred Brand

OLUX-E FOAM Non-Preferred Brand

oralone PSTE Non-Preferred Brand

PANDEL CREA Non-Preferred Brand

PRAMOSONE CREA Preferred Brand

PRAMOSONE LOTN Preferred Brand

PRAMOSONE OINT Preferred Brand

prednicarbate CREA Generic

prednicarbate OINT Generic

proctosol hc CREA Generic

TACLONEX OINT Non-Preferred Brand ST

TACLONEX SUSP Non-Preferred Brand ST

TEMOVATE GEL Non-Preferred Brand

TEMOVATE OINT Non-Preferred Brand

TEMOVATE SOLN Non-Preferred Brand

TOPICORT CREA Non-Preferred Brand

TOPICORT GEL Non-Preferred Brand

TOPICORT LIQD Non-Preferred Brand

TOPICORT OINT Non-Preferred Brand

triamcinolone acetonide CREA Generic

triamcinolone acetonide LOTN Generic

triamcinolone acetonide OINT Generic

triamcinolone acetonide PSTE Generic

triamcinolone in orabase PSTE Generic

ULTRAVATE X KIT Non-Preferred Brand

ULTRAVATE CREA Non-Preferred Brand

VANOS CREA Non-Preferred Brand ST

VANOXIDE-HC LOTN Non-Preferred Brand

VERDESO FOAM Non-Preferred Brand ST

WESTCORT OINT Non-Preferred Brand

Antipruritics and Local Anesthetics

ANALPRAM-HC SINGLES CREA Non-Preferred Brand

ANALPRAM-HC LOTN Preferred Brand

ANALPRAM-HC CREA Non-Preferred Brand

ETHYL CHLORIDE/MIST AERO Generic

hydrocortisone acetate/pramoxine CREA Generic

lidocaine hcl jelly GEL Generic

lidocaine hcl SOLN Generic

lidocaine/prilocaine CREA Generic

lidocaine OINT Generic

lidocaine PTCH Generic PA




Limits

LIDODERM PTCH Non-Preferred Brand PA

phenazopyridine hcl TABS Generic

PROCTOFOAM HC FOAM Preferred Brand QL

PRUDOXIN CREA Non-Preferred Brand

PYRIDIUM TABS Non-Preferred Brand

URELIEF PLUS TABS Generic

ZONALON CREA Non-Preferred Brand ST

Astringents

DOMEBORO PACK Excluded

DRYSOL SOLN Non-Preferred Brand

hypercare SOLN Generic

XERAC AC SOLN Non-Preferred Brand ST

Cell Stimulants and Proliferants

ATRALIN GEL Non-Preferred Brand ST

avita CREA Non-Preferred Brand

avita GEL Non-Preferred Brand

KEPIVANCE SOLR Medical Benefit

RETIN-A MICRO PUMP GEL Non-Preferred Brand

RETIN-A MICRO GEL Non-Preferred Brand

RETIN-A CREA Non-Preferred Brand

RETIN-A GEL Non-Preferred Brand

tretinoin microsphere pump GEL Generic

tretinoin microsphere GEL Generic

tretinoin CREA Generic

tretinoin GEL Generic

TRETIN-X KIT Non-Preferred Brand ST

Depigmenting and Pigmenting Agents

ELDOPAQUE FORTE CREA Non-Preferred Brand

hydroquinone CREA Generic

LUSTRA CREA Non-Preferred Brand

melpaque hp CREA Generic

OXSORALEN ULTRA CAPS Preferred Brand

TRI-LUMA CREA Non-Preferred Brand ST

Emollients, Demulcents, and Protectants

ammonium lactate CREA Generic

ammonium lactate LOTN Generic

HPR PLUS/MB HYDROGEL KIT Excluded

HPR PLUS FOAM Excluded

HPR FOAM Excluded

LAC-HYDRIN CREA Non-Preferred Brand

LAC-HYDRIN LOTN Non-Preferred Brand

Keratolytic Agents

prascion fc PADS Generic

prascion ra with sunscreens CREA Generic

SALEX CREAM KIT Non-Preferred Brand

SALEX LOTION KIT Non-Preferred Brand




Limits

SALEX SHAM Non-Preferred Brand

salicylic acid cream KIT Generic

salicylic acid lotion KIT Generic

salicylic acid CREA Generic

salicylic acid LOTN Generic

salicylic acid SHAM Generic

SALVAX FOAM Non-Preferred Brand

sodium sulfacetamide/sulfur LOTN Generic

sulfacetamide sodium/sulfur cleanser EMUL Generic

SUMADAN KIT KIT Non-Preferred Brand

SUMADAN WASH LIQD Non-Preferred Brand

urea CREA Generic

urea GEL Generic

urea LOTN Generic

UTOPIC CREA Non-Preferred Brand QL

Keratoplastic Agents

COAL TAR SOLN Preferred Brand

Skin and Mucous Membrane Agents, Misc

ABSORICA CAPS Non-Preferred Specialty

ST

acitretin CAPS Preferred Specialty

ACZONE GEL Non-Preferred Brand ST

adapalene CREA Generic

adapalene GEL Generic

ALDARA CREA Non-Preferred Brand

amnesteem CAPS Generic

AZELEX CREA Preferred Brand QL

calcipotriene OINT Generic QL

calcipotriene SOLN Generic

calcitrene OINT Generic QL

CARAC CREA Preferred Brand

claravis CAPS Generic

CONDYLOX GEL Preferred Brand

CONDYLOX SOLN Non-Preferred Brand

DIFFERIN GEL Preferred Brand

DIFFERIN CREA Non-Preferred Brand

DIFFERIN GEL Non-Preferred Brand

DIFFERIN LOTN Non-Preferred Brand

DOVONEX CREA Preferred Brand

EFUDEX CREA Non-Preferred Brand

ELIDEL CREA Preferred Brand

EPIDUO GEL Non-Preferred Brand

FABIOR FOAM Non-Preferred Brand QL

FINACEA GEL Non-Preferred Brand

finasteride TABS Excluded

FLECTOR PTCH Preferred Brand ST




Limits

FLUOROPLEX CREA Preferred Brand

fluorouracil CREA Generic

fluorouracil SOLN Generic

imiquimod CREA Generic

LATISSE SOLN Excluded

minocycline hcl er TB24 Generic

MIRVASO GEL Non-Preferred Brand QL

ORACEA CPDR Non-Preferred Brand ST

PENNSAID SOLN Non-Preferred Brand ST

PICATO GEL Non-Preferred Brand QL ST

podofilox SOLN Generic

PROTOPIC OINT Preferred Brand

QUTENZA KIT Medical Benefit-Non-Preferred

Specialty

PA

RECTIV OINT Non-Preferred Brand QL

REGRANEX GEL Preferred Specialty ST

SANTYL OINT Non-Preferred Brand

SOLODYN TB24 Non-Preferred Brand ST

SORIATANE CAPS Non-Preferred Specialty

QL

SORILUX FOAM Non-Preferred Brand

STELARA SOLN Preferred Specialty PA

TARGRETIN GEL Preferred Specialty QL PA

TAZORAC CREA Preferred Brand

TAZORAC GEL Preferred Brand

VALCHLOR GEL Preferred Specialty QL PA

vasolex OINT Generic

VECTICAL OINT Preferred Brand ST

VELTIN GEL Non-Preferred Brand

VOLTAREN GEL Non-Preferred Brand QL

zenatane CAPS Generic

ZIANA GEL Non-Preferred Brand

ZYCLARA CREA Non-Preferred Brand ST

Smooth Muscle Relaxants

Genitourinary Smooth Muscle Relaxants

DETROL LA CP24 Non-Preferred Brand QL ST

DETROL TABS Non-Preferred Brand

DITROPAN XL TB24 Non-Preferred Brand

ENABLEX TB24 Preferred Brand

flavoxate hcl TABS Generic

GELNIQUE GEL Non-Preferred Brand ST

MYRBETRIQ TB24 Non-Preferred Brand ST

oxybutynin chloride er TB24 Generic

oxybutynin chloride SYRP Generic

oxybutynin chloride TABS Generic




Limits

OXYTROL PTTW Excluded

SANCTURA XR CP24 Non-Preferred Brand

SANCTURA TABS Non-Preferred Brand

tolterodine tartrate TABS Generic

TOVIAZ TB24 Non-Preferred Brand QL ST

trospium chloride er CP24 Generic

trospium chloride TABS Generic

VESICARE TABS Preferred Brand

Respiratory Smooth Muscle Relaxants

ELIXOPHYLLIN ELIX Non-Preferred Brand

THEO-24 CP24 Preferred Brand

theophylline er TB12 Generic

theophylline er TB24 Generic

Vitamins

Multivitamin Preparations

CAVAN PRENATAL/EC CALCIUM TBEC Generic

CITRANATAL ASSURE MISC Non-Preferred Brand

CITRANATAL HARMONY CAPS Non-Preferred Brand

COMPLETE NATAL DHA MISC Generic

COMPLETENATE CHEW Generic

DUET DHA BALANCED MISC Preferred Brand

folbee plus TABS Preferred Brand

GESTICARE DHA MISC Preferred Brand

INATAL ADVANCE TABS Generic

INATAL GT TABS Generic

INATAL ULTRA TABS Generic

INFANATE BALANCE CAPS Non-Preferred Brand

MISSION PRENATAL HP TABS Preferred Brand

MISSION PRENATAL/FOLIC ACID TABS Preferred Brand

MISSION PRENATAL TABS Preferred Brand

multi vitamin/fluoride CHEW Generic

multi-vit/fluoride SOLN Generic

MULTI-VIT/IRON/FLUORIDE SOLN Generic

multivitamin with fluoride CHEW Generic

multivitamin/fluoride CHEW Generic

multivitamins/fluoride CHEW Generic

M-VIT TABS Generic

MYNATAL ADVANCE TABS Generic

MYNATAL PLUS TABS Generic

MYNATAL ULTRACAPLET TABS Generic

MYNATAL-Z TABS Generic

MYNATE 90 PLUS TBCR Generic

NEEVO DHA CAPS Non-Preferred Brand

NESTABS ABC MISC Non-Preferred Brand

OB-NATAL ONE CAPS Generic

PNV FOLIC ACID + IRON MULTIVITAMIN TABS Generic




Limits

PNV-FIRST CAPS Generic

PR NATAL 400 EC MISC Generic

PR NATAL 400 MISC Generic

PR NATAL 430 EC MISC Generic

PR NATAL 430 MISC Generic

PREFERA OB TABS Non-Preferred Brand

PREFERAOB ONE CAPS Non-Preferred Brand

PRENAFIRST TABS Generic

PRENAPLUS TABS Generic

PRENATABS FA TABS Generic

PRENATABS OBN TABS Generic

PRENATABS RX TABS Generic

PRENATAL 19 CHEW Non-Preferred Brand

PRENATAL 19 TABS Non-Preferred Brand

PRENATAL AD TABS Generic

PRENATAL AND IRON TABS Generic

PRE-NATAL FORMULA TABS Generic

PRENATAL FORTE TABS Generic

PRENATAL LOW IRON TABS Generic

PRENATAL PLUS TABS Generic

PRENATAL VITAMINS TABS Generic

PRENATAL TABS Generic

PRENATE AM TABS Non-Preferred Brand

PROVIDA OB CAPS Non-Preferred Brand

SELECT-OB CHEW Generic

TARON EC CALCIUM MISC Generic

TARON-PREX CAPS Preferred Brand

TL-CARE DHA CAPS Generic

TRIADVANCE TABS Generic

TRICARE PRENATAL COMPLEAT MISC Non-Preferred Brand

TRICARE PRENATAL DHA ONE CAPS Non-Preferred Brand

TRICARE TABS Generic

TRIMESIS RX TABS Generic

TRINATAL RX 1 TABS Generic

TRINATE TABS Preferred Brand

TRIVEEN-DUO DHA MISC Generic

TRI-VIT/FLUORIDE/IRON SOLN Generic

tri-vit/fluoride SOLN Generic

tri-vitamin/fluoride SOLN Generic

ULTRA TABS TABS Generic

urosex TABS Preferred Brand

VINATE AZ TABS Generic

VINATE DHA CAPS Non-Preferred Brand

VINATE GT TABS Generic

VINATE IC CAPS Generic

VINATE M TABS Generic




Limits

VINATE ONE TABS Generic

VINATE PN CARE TABS Generic

VINATE ULTRA TABS Generic

vitacel TABS Generic

VITAFOL-OB TABS Preferred Brand

VITAFOL-ONE CAPS Non-Preferred Brand

VITAFOL-PN TABS Preferred Brand

VOL-TAB RX TABS Generic

VP-HEME ONE CAPS Generic

Vitamin B Complex

cyanocobalamin SOLN Generic

folbee TABS Generic

folbic TABS Generic

folic acid TABS Generic

FOLIC ACID SOLN Medical Benefit

FOLTX TABS Non-Preferred Brand

LMTHF/PYRIDOXINE HCL/CYANOCOBALAMIN TABS Generic

NASCOBAL SOLN Preferred Brand

NIACOR TABS Generic

Vitamin D

calcitriol CAPS Generic

calcitriol SOLN Generic

calcitriol SOLN Medical Benefit

DRISDOL CAPS Non-Preferred Brand

HECTOROL CAPS Preferred Brand

paricalcitol CAPS Generic

ROCALTROL CAPS Non-Preferred Brand

ROCALTROL SOLN Non-Preferred Brand

vitamin d CAPS Generic

vitamin d TABS Generic

vitamin d3 CAPS Generic

vitamin d3 LIQD Generic

ZEMPLAR CAPS Non-Preferred Brand

Vitamin K Activity

MEPHYTON TABS Preferred Brand

list of covered drugs - priority health/media/documents/individual/2015... · list of covered drugs...

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