PA Drug Name Generic Name PA Summary Name

Epaned enalapril ACE Inhibitors and Combinations

Perindopril perindopril ACE Inhibitors and Combinations

Prestalia perindopril/amlodipine ACE Inhibitors and Combinations

Qbrelis lisinopril ACE Inhibitors and Combinations

Trandolapril/Verapamil ER by Greenstone trandolapril/verapamil ER ACE Inhibitors and Combinations

Absorica/LD, Amnesteem, Claravis,

Isotretinoin, Myorisan, Zenataneisotretinoin Acne Agents, Oral

Acanya clindamycin/benzoyl peroxide Acne and Rosacea Agents, Topical

Aczone dapsone Acne and Rosacea Agents, Topical

Aklief trifarotene Acne and Rosacea Agents, Topical

Altreno, Avita, Tretinoin, Retin-A Micro tretinoin Acne and Rosacea Agents, Topical

Amzeeq, Zilxi minocycline Acne and Rosacea Agents, Topical

Arazlo, Fabior, Tazorac tazarotene Acne and Rosacea Agents, Topical

Azelex, Finacea azelaic acid Acne and Rosacea Agents, Topical

Clindamycin, Clindacin, Evoclin clindamycin Acne and Rosacea Agents, Topical

Clindamycin 1%/Benzoyl Peroxide 5%,

Neuac, Onextonclindamycin/benzoyl peroxide Acne and Rosacea Agents, Topical

Differin, Adapalene adapalene Acne and Rosacea Agents, Topical

Adapalene/Benzoyl Peroxide, Epiduo Forte adapalene/benzoyl peroxide Acne and Rosacea Agents, Topical

Ery Pad, erythromycin pad erythromycin Acne and Rosacea Agents, Topical

Erythromycin/Benzoyl Peroxide erythromycin/benzoyl peroxide Acne and Rosacea Agents, Topical

Metronidazole, Noritate, Rosadan metronidazole Acne and Rosacea Agents, Topical

Soolantra ivermectin Acne and Rosacea Agents, Topical

Ziana tretinoin/clindamycin Acne and Rosacea Agents, Topical

BP 10-1%, Sulfacetamide Sodium/Sulfur,

Sumaxinsodium sulfacetamide/sulfur Acne and Rosacea Agents, Topical

Sulfacetamide sodium sulfacetamide sodium Acne and Rosacea Agents, Topical

Tekturna aliskiren Aliskiren and Combinations

Tekturna HCT aliskiren/HCTZ Aliskiren and Combinations

Donepezil 23 mg donepezil Alzheimer's Agents

Memantine oral solution memantine Alzheimer's Agents

Prior Authorization Drug Criteria Cross Reference

Memantine ER, Namenda XR Titration Pak memantine extended-release Alzheimer's Agents

Namzaric, Titration Pak memantine/donepezil Alzheimer's Agents

Exservan, Tiglutik riluzole Amyotrophic Lateral Sclerosis Agents

Arymo ER, Kadian, Morphabond ER,

Morphine ER capsulesmorphine ER Analgesics, Narcotics Long

Belbuca buprenorphine Analgesics, Narcotics Long

Fentanyl Patch 37.5, 62.5, 87.5 mcg/hour fentanyl Analgesics, Narcotics Long

Hydromorphone ER hydromorphone ER Analgesics, Narcotics Long

Hysingla ER, Zohydro ER hydrocodone ER Analgesics, Narcotics Long

Levorphanol levorphanol Analgesics, Narcotics Long

Nucynta ER tapentadol ER Analgesics, Narcotics Long

OxyContin, Xtampza ER oxycodone ER Analgesics, Narcotics Long

Oxymorphone ER oxymorphone ER Analgesics, Narcotics Long

Acetaminophen/Caffeine/Dihydrocodeine acetaminophen/caffeine/dihydrocodeine Analgesics, Narcotics Short

Benzhydrocodone/Acetaminophen benzhydrocodone/acetaminophen Analgesics, Narcotics Short

Butalbital/Acetaminophen/Caffeine/Codeine butalbital/acetaminophen/caffeine/codeine Analgesics, Narcotics Short

Butalbital/Aspirin/Caffeine/Codeine butalbital/aspirin/caffeine/codeine Analgesics, Narcotics Short

Butorphanol Nasal Spray QLL butorphanol Analgesics, Narcotics Short

Codeine codeine Analgesics, Narcotics Short

Dilaudid Oral Liquid, Hydromorphone Rectal

Suppositoryhydromorphone Analgesics, Narcotics Short

Hydrocodone/Ibuprofen, Ibudone hydrocodone/ibuprofen Analgesics, Narcotics Short

Meperidine meperidine Analgesics, Narcotics Short

Morphine Rectal Suppository morphine Analgesics, Narcotics Short

Nalocet, Primlev, Prolate oxycodone/acetaminophen Analgesics, Narcotics Short

Nucynta tapentadol Analgesics, Narcotics Short

Oxaydo, Oxycodone QLL, Oxycodone

Concentrate Oral Solutionoxycodone Analgesics, Narcotics Short

Oxycodone/Aspirin oxycodone/aspirin Analgesics, Narcotics Short

Oxycodone/Ibuprofen oxycodone/ibuprofen Analgesics, Narcotics Short

Oxymorphone oxymorphone Analgesics, Narcotics Short

Qdolo tramadol Analgesics, Narcotics Short

Diflunisal diflunisal Analgesics, Salicylates

Salsalate salsalate Analgesics, Salicylates

Testosterone Injection testosterone cypionate Androgenic Agents, Injectable

Testosterone Injection, Xyosted testosterone enanthate Androgenic Agents, Injectable

Anadrol-50 oxymetholone Androgenic Agents, Oral

Danazol danazol Androgenic Agents, Oral

Jatenzo testosterone undecanoate Androgenic Agents, Oral

Methitest, Methyltestosterone methyltestosterone Androgenic Agents, Oral

Oxandrolone oxandrolone Androgenic Agents, Oral

Androderm, Androgel, Striant, Testosterone

Trandermaltestosterone Androgenic Agents, Topical

Candesartan candesartan Angiotensin Receptor Blockers and Combinations

Edarbi azilsartan Angiotensin Receptor Blockers and Combinations

Eprosartan eprosartan Angiotensin Receptor Blockers and Combinations

Micardis, Telmisartan telmisartan Angiotensin Receptor Blockers and Combinations

Amlodipine/Valsartan amlodipine/valsartan Angiotensin Receptor Blockers and Combinations

Amlodipine/Valsartan/HCTZ amlodipine/valsartan/HCTZ Angiotensin Receptor Blockers and Combinations

Amlodipine/olmesartan amlodipine/olmesartan Angiotensin Receptor Blockers and Combinations

Entresto sacubitril/valsartan Angiotensin Receptor Blockers and Combinations

Tribenzor olmesartan/amlodipine/HCTZ Angiotensin Receptor Blockers and Combinations

Candesartan/HCTZ candesartan/HCTZ Angiotensin Receptor Blockers and Combinations

Edarbyclor azilsartan/HCTZ Angiotensin Receptor Blockers and Combinations

Micardis, Telmisartan/HCTZ telmisartan/HCTZ Angiotensin Receptor Blockers and Combinations

Telmisartan/Amlodipine, Twynsta telmisartan/amlodipine Angiotensin Receptor Blockers and Combinations

Albendazole albendazole Anthelmintics

Emverm mebendazole Anthelmintics

Stromectol ivermectin Anthelmintics

Oralair mixed grass pollen allergen extract Antiallergens, Oral

Palforziapeanut [Arachis hypogaea] allergen powder-

dnfpAntiallergens, Oral

Multaq dronedarone Antiarrhythmics, Oral

Dificid fidaxomicin Antibiotics, GI

Paromomycin paromomycin Antibiotics, GI

Xifaxan rifamixin Antibiotics, GI

Arikayce amikacin liposome inhalation suspension Antibiotics, Inhaled

Cayston aztreonam inhalation solution Antibiotics, Inhaled

Tobi Podhaler, Tobramycin Nebulized tobramycin Antibiotics, Inhaled

Mupirocin Cream mupirocin Antibiotics, Topical

Neo-Synalar neomycin/fluocinolone Antibiotics, Topical

Neo-Synalar Kit neomycin/fluocinolone/emollient cream Antibiotics, Topical

Xepi ozenoxacin Antibiotics, Topical

Cleocin Ovules, Clindamycin Vaginal Cream

(7-day)clindamycin Antibiotics, Vaginal

Solosec secnidazole Antibiotics, Vaginal

Chlordiazepoxide/Clidinium chlordiazepoxide/clidinium Anticholinergics-Antispasmodics

Cuvposa, Glycate, Glycopyrrolate Injection glycopyrrolate Anticholinergics-Antispasmodics

Methscopolamine methscopolamine Anticholinergics-Antispasmodics

Proprantheline proprantheline Anticholinergics-Antispasmodics

Savaysa edoxaban Anticoagulants

Fondaparinux fondaparinux Anticoagulants

Fragmin Syringes dalteparin Anticoagulants

Diacomit stiripentol Anticonvulsants

Valtoco Nasal Spray diazepam Anticonvulsants

Epidiolex cannabidiol Anticonvulsants

Vimpat Injection lacosamide Anticonvulsants

Aptiom eslicarbazepine Anticonvulsants

Banzel rufinamide Anticonvulsants

Briviact brivaracetam Anticonvulsants

Clobazam oral suspension, Sympazan clobazam Anticonvulsants

Equetro carbamazepine extended-release Anticonvulsants

Felbamate felbamate Anticonvulsants

Fintepla fenfluramine Anticonvulsants

Fycompa perampanel Anticonvulsants

Gabitril, Tiagabine tiagabine Anticonvulsants

Lamictal Kits/ODT, Lamotrigine ER/ODT/kits lamotrigine Anticonvulsants

Elepsia XR, Levetiracetam ER levetiracetam extended-release Anticonvulsants

Lyrica CR pregabalin extended-release Anticonvulsants

Nayzilam midazolam Anticonvulsants

Oxtellar XR oxcarbazepine Anticonvulsants

Qudexy XR, Topiramate ER, Trokendi XR topiramate extended-release Anticonvulsants

Sabril vigabatrin Anticonvulsants

Stavzor, Valproic Acid Capsules valproic acid Anticonvulsants

Xcopri cenobamate Anticonvulsants

Brisdelle, Paxil Suspension, Pexeva paroxetine Antidepressants

Escitalopram Oral Solution escitalopram Antidepressants

Fluoxetine 10 mg, 20 mg Tablets fluoxetine Antidepressants

Fluoxetine 90 mg Delayed-Release fluoxetine DR Antidepressants

Fluoxetine [PMDD], Sarafem fluoxetine [PMDD] Antidepressants

Fluvoxamine ER fluvoxamine extended-release Antidepressants

Paroxetine ER paroxetine extended-release Antidepressants

Desvenlafaxine ER desvenlafaxine extended-release Antidepressants

Drizalma, Duloxetine 40 mg duloxetine Antidepressants

Fetzima levomilnacipran Antidepressants

Savella milnacipran Antidepressants

Trintellix (previously Brintellix) vortioxetine Antidepressants

Venlafaxine ER Tablets venlafaxine extended-release Antidepressants

Nefazodone nefazodone Antidepressants

Trazodone 300 mg trazodone Antidepressants

Viibryd viladazone Antidepressants

Emsam selegiline Antidepressants

Marplan isocarboxazid Antidepressants

Phenylzine phenylzine Antidepressants

Tranylcypromine tranylcypromine Antidepressants

Imipramine Capsules imipramine pamoate Antidepressants

Protriptyline protriptyline Antidepressants

Trimipramine trimipramine Antidepressants

Aplenzin, Forfivo XL bupropion extended-release Antidepressants

Maprotiline maprotiline Antidepressants

Spravato esketamine Antidepressants

Alogliptin, Nesina alogliptin Antidiabetic Agents

Alogliptin/Metformin alogliptin/metformin Antidiabetic Agents

Alogliptin/Pioglitazone alogliptin/pioglitazone Antidiabetic Agents

Janumet XR sitagliptin/metformin ER Antidiabetic Agents

Jentadueto XR linagliptin/metformin ER Antidiabetic Agents

Fortamet, Metformin ER (generic Fortamet),

Riomet ERmetformin ER Antidiabetic Agents

Glyxambi empagliflozin/linagliptin Antidiabetic Agents

Invokamet XR canagliflozin/metformin ER Antidiabetic Agents

Qtern dapagliflozin/saxagliptin Antidiabetic Agents

Segluromet ertugliflozin/metformin Antidiabetic Agents

Steglatro ertugliflozin Antidiabetic Agents

Steglujan ertugliflozin/sitagliptin Antidiabetic Agents

Synjardy, Synjardy XR empaglifozin/metformin, ER Antidiabetic Agents

Trijardy XR empagliflozin/linagliptin/metformin ER Antidiabetic Agents

Tolbutamide tolbutamide Antidiabetic Agents

Avandia rosiglitazone Antidiabetic Agents

Pioglitazone/Glimepride pioglitazone/glimepiride Antidiabetic Agents

Pioglitazone/Metformin pioglitazone/metformin Antidiabetic Agents

Symlin Pen pramlintide acetate Antidiabetic Agents

Adlyxin lixisenatide Antidiabetic Agents

Bydureon BCise exenatide ER Antidiabetic Agents

Cycloset bromocriptine Antidiabetic Agents

Ozempic, Rybelsus semaglutide Antidiabetic Agents

Soliqua insulin glargine/lixisenatide Antidiabetic Agents

Trulicity dulaglutide Antidiabetic Agents

Xultophy insulin degludec/liraglutide Antidiabetic Agents

Alosetron alosetron Antidiarrheals

Motofen difenoxin/atropine Antidiarrheals

Mytesi crofelemer Antidiarrheals

Opium Tincture opium tincture Antidiarrheals

Viberzi eluxadoline Antidiarrheals

Akynzeo netupitant/palonosetron Antiemetic/Antivertigo Agents

Anzemet dolasetron Antiemetic/Antivertigo Agents

Compro prochlorperazine Antiemetic/Antivertigo Agents

Dimenhydrinate Injection dimenhydrinate Antiemetic/Antivertigo Agents

Dronabinol, Syndros dronabinol Antiemetic/Antivertigo Agents

Emend Suspension aprepitant Antiemetic/Antivertigo Agents

Gimoti metoclopramide nasal spray Antiemetic/Antivertigo Agents

Granisetron, Sancuso granisetron Antiemetic/Antivertigo Agents

Metoclopramide ODT metoclopramide Antiemetic/Antivertigo Agents

Ondansetron Injection, Zuplenz ondansetron Antiemetic/Antivertigo Agents

Promethazine 50 mg Suppository promethazine Antiemetic/Antivertigo Agents

Trimethobenzamide trimethobenzamide Antiemetic/Antivertigo Agents

Varubi rolapitant Antiemetic/Antivertigo Agents

Tranexamic Acid tranexamic acid Antifibrinolytic Agents

Fluconazole Injection fluconazole Antifungals, Injectable

Ambisome amphotericin B liposome Antifungals, Injectable

Cancidas caspofungin Antifungals, Injectable

Voriconazole Injection voriconazole Antifungals, Injectable

Cresemba isavuconazonium Antifungals, Oral

Flucytosine flucytosine Antifungals, Oral

Griseofulvin griseofulvin Antifungals, Oral

Lamisil Granules terbinafine Antifungals, Oral

Noxafil posaconazole Antifungals, Oral

Itraconazole, Omnel, Sporanox Solution Itraconazole Antifungals, Oral

Oravig miconazole Antifungals, Oral

Vfend Suspension voriconazole Antifungals, Oral

Bensal HP salicylic acid Antifungals, Topical

Ciclopirox, Ciclodan Kit, Loprox Kit ciclopirox Antifungals, Topical

Clotrimazole/Betamethasone Lotion clotrimazole/betamethasone Antifungals, Topical

Extina, Ketoconazole Foam , Ketodan Kit ketoconazole Antifungals, Topical

Jublia efinaconazole Antifungals, Topical

Kerydin tavaborole Antifungals, Topical

Luzu luliconazole Antifungals, Topical

Naftifine Cream, Naftin Gel naftifine Antifungals, Topical

Nystatin/Triamcinolone Cream nystatin/triamcinolone Antifungals, Topical

Vusion miconazole/zinc oxide/petrolatum Antifungals, Topical

Clarinex-D desloratadine/pseudoephedrine Antihistamines

Clarinex Syrup, Desloratadine desloratadine Antihistamines

Karbinal ER, Ryvent carbinoxamine ER Antihistamines

Levocetirizine Solution levocetirizine Antihistamines

Ryvent carbinoxamine Antihistamines

Xenical orlistat Antihyperlipidemics, Other

Saxenda liraglutide Antihyperlipidemics, Other

Clonidine TTS clonidine TTS Antihypertensives, Sympatholytics

Colchicine QLL, Colchicine Tablets, Gloperba colchicine Antihyperuricemics

Febuxostat febuxostat Antihyperuricemics

Krintafel tafenoquine Antimalarials

Atovaquone/Proguanil, Malarone atovaquone/proguanil Antimalarials

Coartem artemether/lumefantrine Antimalarials

Quinine Sulfate quinine sulfate Antimalarials

Aimovig erenumab-aooe Antimigraine Agents, Other

Ajovy fremanezumab-vfrm Antimigraine Agents, Other

Nurtec ODT rimegepant Antimigraine Agents, Other

Emgality galcanezumab-gnlm Antimigraine Agents, Other

Reyvow lasmiditan Antimigraine Agents, Other

Ubrelvy ubrogepant Antimigraine Agents, Other

Almotriptan almotriptan Antimigraine Agents, Triptans

Dihydroergotamine, Migranal dihydroergotamine mesylate Antimigraine Agents, Triptans

Eletriptan eletriptan Antimigraine Agents, Triptans

Ergomar ergotamine Antimigraine Agents, Triptans

Frova frovatriptan Antimigraine Agents, Triptans

Migergot ergotamine/caffeine Antimigraine Agents, Triptans

Nazatriptan nazatriptan Antimigraine Agents, Triptans

Onzetra Xsail, Sumatriptan Injection,

Tosymra, Zembrace sumatriptan Antimigraine Agents, Triptans

Treximet sumatriptan/naproxen Antimigraine Agents, Triptans

Zolmitriptan, Zomig, Zomig ZMT zolmitriptan Antimigraine Agents, Triptans

Pretomanid pretomanid Antimycobacterium Agents

Sirturo bedaquiline Antimycobacterium Agents

Eurax crotamiton Antiparasitics, Topical

Ivermectin ivermectin Antiparasitics, Topical

Lindane lindane Antiparasitics, Topical

Malathion, Ovide malathion Antiparasitics, Topical

Natroba, Spinosad spinosad Antiparasitics, Topical

Apokyn, Kynmobi apomorphine Antiparkinson Agents

Carbidopa/Levodopa ODT, Rytary carbidopa/levodopa Antiparkinson Agents

Gocovri amantadine extended-release Antiparkinson Agents

Inbrija levodopa Antiparkinson Agents

Mirapex ER, Pramipexole ER pramipexole Antiparkinson Agents

Neupro rotigotine Antiparkinson Agents

Nourianz istradefylline Antiparkinson Agents

Ropinirole ER ropinirole Antiparkinson Agents

Tolcapone tolcapone Antiparkinson Agents

Xadago safinamide Antiparkinson Agents

Zelapar selegiline Antiparkinson Agents

Zontivity vorapaxar Antiplatelet Drugs

Benznidazole benznidazole Antiprotozoals

Daraprim pyrimethamine Antiprotozoals

Lampit nifurtimox Antiprotozoals

Flagyl 375 mg, Metronidazole 375 mg metronidazole Antiprotozoals

Nitazoxanide Nitazoxanide Antiprotozoals

Doxepin Cream, Prudoxin, Zonalon doxepin Antipruritics, Topical

Calcipotriene ointment, Sorilux calcipotriene Antipsoriatic Agents

Calcipotriene/betamethasone, Enstilar,

Taclonexcalcipotriene/betamethasone Antipsoriatic Agents

Calcitriol, Vectical calcitriol Antipsoriatic Agents

Methoxsalen methoxsalen Antipsoriatic Agents

Cytovene Injection, Ganciclovir Injection ganciclovir Antivirals, General

Prevymis letermovir Antivirals, General

Valcyte Powder, Valganciclovir Powder valganciclovir Antivirals, General

Valacyclovir QLL valacyclovir Antivirals, Oral

Sitavig acyclovir Antivirals, Oral

Xofluza baloxivir Antivirals, Oral

Acyclovir Ointment acyclovir Antivirals, Topical

Denavir penciclovir Antivirals, Topical

Xerese acyclovir/hydrocortisone Antivirals, Topical

Meprobamate meprobamate Anxiolytics Benzodiazepines and Barbiturates

Alprazolam ER, ODT, Concentrate alprazolam Anxiolytics Benzodiazepines and Barbiturates

Clonazepam ODT clonazepam Anxiolytics Benzodiazepines and Barbiturates

Clorazepate clorazepate Anxiolytics Benzodiazepines and Barbiturates

Oxazepam oxazepam Anxiolytics Benzodiazepines and Barbiturates

Midazolam midazolam Anxiolytics Benzodiazepines and Barbiturates

Temazepam 7.5 mg, 22.5 mg temazepam Anxiolytics Benzodiazepines and Barbiturates

Triazolam triazolam Anxiolytics Benzodiazepines and Barbiturates

Amytal amobarbital Anxiolytics Benzodiazepines and Barbiturates

Seconal secobarbital Anxiolytics Benzodiazepines and Barbiturates

Bevespi Aerosphere glycopyrrolate/formoterol Asthma and COPD Agents

Duaklir Pressair aclidinium/formotoerol Asthma and COPD Agents

Incruse Ellipta umeclidinium Asthma and COPD Agents

Lonhala Magnair glycopyrrolate Asthma and COPD Agents

Spiriva Respimat tiotropium Asthma and COPD Agents

Tudorza Pressair aclidinium Asthma and COPD Agents

Yupelri revefenacin Asthma and COPD Agents

Albuterol Inhalation 0.021%, 0.042% albuterol Asthma and COPD Agents

Albuterol Tablets albuterol Asthma and COPD Agents

Brovana aformoterol Asthma and COPD Agents

Levalbuterol, Xopenex HFA levalbuterol Asthma and COPD Agents

Metaproterenol metaproterenol Asthma and COPD Agents

Perforomist formoterol Asthma and COPD Agents

ProAir Digihaler and Respiclick albuterol Asthma and COPD Agents

Striverdi Respimat oladaterol Asthma and COPD Agents

Terbutaline terbutaline Asthma and COPD Agents

Alvesco ciclesonide Asthma and COPD Agents

Armonair Digihaler fluticasone propionate Asthma and COPD Agents

Arnuity Ellipta fluticasone furoate Asthma and COPD Agents

Asmanex Twisthaler/HFA mometasone Asthma and COPD Agents

Qvar Redihaler beclomethasone Asthma and COPD Agents

AirDuo, Fluticasone/Salmeterol fluticasone/salmeterol Asthma and COPD Agents

Breo Ellipta fluticasone/vilanterol Asthma and COPD Agents

Breztri Aerosphere budesonide/glycopyrrolate/formoterol Asthma and COPD Agents

Trelegy Ellipta fluticasone/umeclidinium/vilanterol Asthma and COPD Agents

Daliresp roflumilast Asthma and COPD Agents

Abilify Maintena, Aripiprazole,

Aristada/Aristada Initioaripiprazole Atypical Antipsychotics

Caplyta lumateperone Atypical Antipsychotics

Clozapine, Clozapine ODT, Versacloz clozapine Atypical Antipsychotics

Fanapt iloperidone Atypical Antipsychotics

Invega Sustenna, Invega Trinza, Paliperidone paliperidone Atypical Antipsychotics

Latuda lurasidone Atypical Antipsychotics

Nuplazid pimavanserin Atypical Antipsychotics

Olanzapine, Zyprexa Relprevv olanzapine Atypical Antipsychotics

Olanzapine/Fluoxetine olanzapine/fluoxetine Atypical Antipsychotics

Quetiapine IR and ER quetiapine Atypical Antipsychotics

Rexulti brexpiprazole Atypical Antipsychotics

Risperdal Consta, Risperidone risperidone Atypical Antipsychotics

Secuado, Asenapine asenapine Atypical Antipsychotics

Vraylar cariprazine Atypical Antipsychotics

Ziprasidone ziprasidone Atypical Antipsychotics

Amoxicillin/Clavulanate chewable tablets,

250/125 mg tabletsamoxicillin/clavulanate Augmentin Products

Amoxicillin/Clavulanate ER amoxicillin/clavulanate extended-release Augmentin Products

Amoxicillin/clavulanate 250-62.5 mg/5 ml,

Augmentin 125-31.25 mg/5 mLamoxicillin/clavulanate Augmentin Products

Aztreonam injection, Azactam Injection aztreonam Aztreonam

Bystolic nebivolol Beta Blockers

Coreg CR carvedilol extended-release Beta Blockers

Corzide nadolol/bendroflurmethiazide Beta Blockers

Innopran XL propranolol extended-release Beta Blockers

Metoprolol/Hydrochlorothiazide metoprolol/hydrochlorothiazide Beta Blockers

Sotylize sotalol Beta Blockers

Timolol timolol Beta Blockers

Cholestyramine, cholestyramine lite,

Prevalite powder packetscholestyramine Bile Acid Sequestrants

Colestid and colestipol granules and packets colestipol Bile Acid Sequestrants

Welchol colesevelam Bile Acid Sequestrants

Chenodal chenodiol Bile Salts

Cholbam cholic acid Bile Salts

Ocaliva obeticholic acid Bile Salts

Reltone ursodiol Bile Salts

Arcalyst rilonacept Biologic Immunomodulators

Benlysta Subcutaneous belimumab Biologic Immunomodulators

Enbrel etanercept Biologic Immunomodulators

Humira adalimumab Biologic Immunomodulators

Ilaris canakinumab Biologic Immunomodulators

Xeljanz tofacitinib Biologic Immunomodulators

Xeljanz XR tofacitinib extended-release Biologic Immunomodulators

Actemra Subcutaneous tocilizumab Biologic Immunomodulators

Cimzia certolizumab Biologic Immunomodulators

Cosentyx secukinumab Biologic Immunomodulators

Dupixent dupilumab Biologic Immunomodulators

Enspryng satralizumab-mwge Biologic Immunomodulators

Fasenra Pen benralizumab Biologic Immunomodulators

Kevzara sarilumab Biologic Immunomodulators

Kineret anakinra Biologic Immunomodulators

Nucala Pen mepolizumab Biologic Immunomodulators

Olumiant baricitinib Biologic Immunomodulators

Orencia Subcutaneous abatacept Biologic Immunomodulators

Otezla apremilast Biologic Immunomodulators

Rinvoq upadacitinib Biologic Immunomodulators

Siliq brodalumab Biologic Immunomodulators

Simponi golimumab Biologic Immunomodulators

Skyrizi risankizumab Biologic Immunomodulators

Stelara ustekinumab Biologic Immunomodulators

Taltz ixekizumab Biologic Immunomodulators

Tremfya guselkumab Biologic Immunomodulators

Vesicare LS solifenacin Bladder Relaxant Preparations

Darifenacin darifenacin Bladder Relaxant Preparations

Flavoxate flavoxate Bladder Relaxant Preparations

Gelnique oxybutunin Bladder Relaxant Preparations

Myrbetriq mirabegron Bladder Relaxant Preparations

Tolterodine IR, Tolterodine ER tolterodine Bladder Relaxant Preparations

Trospium IR, Trospium ER trospium Bladder Relaxant Preparations

Actonel 5 mg and 30 mg, Atelvia,

Risedronaterisedronate Bone Resorption Suppression and Related Agents

Alendronate Oral Solution alendronate Bone Resorption Suppression and Related Agents

Forteo teriparatide Bone Resorption Suppression and Related Agents

Fosamax Plus D alendronate with vitamin D Bone Resorption Suppression and Related Agents

Ibandronate ibandronate Bone Resorption Suppression and Related Agents

Miacalcin Injection calcitonin-salmon Bone Resorption Suppression and Related Agents

Risedronate Delayed-Release risedronate DR Bone Resorption Suppression and Related Agents

Tymlos abaloparatide Bone Resorption Suppression and Related Agents

Cardura XL doxazosin BPH Agents

Cialis 2.5 mg, 5 mg tadalafil BPH Agents

Dutasteride/Tamsulosin dutasteride/tamsulosin BPH Agents

Rapaflo silodosin BPH Agents

Nymalize nimodipine Calcium Channel Blockers

Isradipine isradipine Calcium Channel Blockers

Katerzia amlodipine Calcium Channel Blockers

Nisoldipine ER nisoldipine ER Calcium Channel Blockers

Diltiazem CD 360 mg, Matzim LA diltiazem ER Calcium Channel Blockers

Verapamil ER PM verapamil ER Calcium Channel Blockers

Capecitabine capecitabine Capecitabine

Carbaglu carglumic acid Carbaglu

Doribax doripenem Carbapenems

Meropenem meropenem Carbapenems

Meropenem/Sodium Chloride meropenem/sodium chloride Carbapenems

Primaxin, Imipenem/Cilastin imipenem/cilastin Carbapenems

Celestone Soluspan betamethasone Celestone Soluspan

Cefadroxil Tablets cefadroxil Cephalosporins and Related Antibiotics

Cephalexin 750 mg and Tablets cephalexin Cephalosporins and Related Antibiotics

Cefaclor ER, Suspension cefaclor Cephalosporins and Related Antibiotics

Cefixime, Suprax cefixime Cephalosporins and Related Antibiotics

Cefpodoxime cefpodoxime Cephalosporins and Related Antibiotics

Avycaz ceftazidime/avibactam Cephalosporins, Injectable

Teflaro ceftaroline Cephalosporins, Injectable

Zerbaxa ceftolozane/tazobactam Cephalosporins, Injectable

Depen Titratabs penicillamine Chelating Agents

Deferasirox Granules deferasirox Chelating Agents

Ferriprox deferiprone Chelating Agents

Fulphila, Neulasta, Nyvepria, Udenyca,

Ziextenzo pegfilgrastim Colony Stimulating Factors

Granix tbo filgrastrim Colony Stimulating Factors

Leukine sargramostim Colony Stimulating Factors

Neupogen, Nivestym, Zarxio filgrastim Colony Stimulating Factors

Amethia, Amethia Lo, Amethyst, Camrese,

Camrese Lo, Quartette, Twirla, Tyblume,

generics

levonorgestrel/ethinyl estradiol Contraceptives

Annovera segesterone acetate/ethinyl estradiol Contraceptives

Aranelle, Leena, generics norethindrone /ethinyl estradiol Contraceptives

Balcoltralevonorgestrel/ethinyl estradiol/ferrous

biglycinateContraceptives

Generics, Safyraldrospirenone/ ethinyl estradiol/

levomefolate calciumContraceptives

Gianvi, Ocella, Zarah, generics drospirenone/ethinyl estradiol/ Contraceptives

Layolis FE, Wymza FE, genericsnorethindrone acetate/ethinyl

estradiol/ferrous fumarateContraceptives

Lo Loestrin FE, Minastrin 24 FEnorethindrone acetate/ethinyl

estradiol/ferrous fumarateContraceptives

Natazia estradiol valerate/dienogest Contraceptives

Nextstellis drospirenone/estetrol Contraceptives

Phexxi lactic acid/citric acid/potassium bitartrate Contraceptives

Slynd drospirenone Contraceptives

Tri-Lo Estaryll, Tri-Lo Marzia, Tri-Lo Sprintec,

genericsnorgestimate/ethinyl estradiol Contraceptives

Xulane, generics norelgestromin/ethinyl estradiol Contraceptives

Zovia 1/50E, generics ethinyl estradiol/ethynodiol Contraceptives

Corlanor ivabradine Corlanor

Analpram-HC Cream,

Hydrocortisone/Pramoxine, Procorthydrocortisone acetate/pramoxine Corticosteroid Combinations

Alkindi Sprinkle hydrocortisone Corticosteroids, Oral

Emflaza deflazacort Corticosteroids, Oral

Hemady, Taperdex dexamethasone Corticosteroids, Oral

Millipred, Prednisolone ODT, 10mg/5mL,

20mg/5mLprednisolone Corticosteroids, Oral

Ortikos budesonide extended-release Corticosteroids, Oral

Rayos prednisone delayed-release Corticosteroids, Oral

Augmented Betamethasone augmented betamethasone Corticosteroids, Topical

Clobetasol, Clobex Shampoo, Clodan Kit,

Olux-Eclobetasol Corticosteroids, Topical

Ultravate X Kit halobetasol/lactic acid Corticosteroids, Topical

Bryhali, Halobetasol Aerosol and Ointment,

Ultravate Lotionhalobetasol Corticosteroids, Topical

Apexicon E, Diflorasone Diacetate diflorasone diacetate Corticosteroids, Topical

Alclometasone Dipropionate alclometasone dipropionate Corticosteroids, Topical

Cloderm, Clocortolone Pivalate clocortolone pivalate Corticosteroids, Topical

Prednicarbate prednicarbate Corticosteroids, Topical

Fluticasone fluticasone Corticosteroids, Topical

Halog halcinonide Corticosteroids, Topical

Mometasone Furoate mometasone furoate Corticosteroids, Topical

Hydrocortisone Butyrate hydrocortisone butyrate Corticosteroids, Topical

Betamethasone Dipropionate betamethasone dipropionate Corticosteroids, Topical

Luxiq, Betamethasone Valerate betamethasone valerate Corticosteroids, Topical

Pandel hydrocortisone probutate Corticosteroids, Topical

Capex, Synalar/Kit, Fluocinolone Acetonide fluocinolone acetonide Corticosteroids, Topical

Texacort hydrocortisone Corticosteroids, Topical

Amcinonide amcinonide Corticosteroids, Topical

Topicort, Desoximetasone desoximetasone Corticosteroids, Topical

Trianex augmented triamcinolone Corticosteroids, Topical

Fluocinonide fluocinonide Corticosteroids, Topical

Desonide, Desonate desonide Corticosteroids, Topical

Cordran Tape, Flurandrenolide flurandrenolide Corticosteroids, Topical

Beser Kit fluticasone propionate/emollient cream Corticosteroids, Topical

Kenalog, Triamcinolone Acetonide triamcinolone acetonide Corticosteroids, Topical

Crinone progesterone Crinone

Bronchitol mannitol Cystic Fibrosis, Oral

Kalydeco ivacaftor Cystic Fibrosis, Oral

Orkambi lumacaftor/ivacaftor Cystic Fibrosis, Oral

Symdeko tezacaftor/ivacaftor and ivacaftor Cystic Fibrosis, Oral

Triktaftaelexacaftor/tezacaftor/ivacaftor and

ivacaftor) Cystic Fibrosis, Oral

Cystadrops, Cystaran, Procysbi cysteamine Cystine Depleting Agents

Abbott Test Strips blood glucose test strips Diabetic Supplies Insulin Pens

Humalog Pens insulin lispro Diabetic Supplies Insulin Pens

Humulin Pens, Novolin Pens insulin Diabetic Supplies Insulin Pens

Insulin Aspart Pens insulin aspart Diabetic Supplies Insulin Pens

Insulin Aspart/Aspart Protamine Pens insulin aspart/aspart protamine Diabetic Supplies Insulin Pens

Insulin Lispro Pens insulin lispro Diabetic Supplies Insulin Pens

Insulin Lispro/Lispro Protamine Pens insulin lispro/lispro protamine Diabetic Supplies Insulin Pens

Insulin Syringes insulin syringes Diabetic Supplies Insulin Pens

Lancet Device and Lancets lancets Diabetic Supplies Insulin Pens

Novolog Pens insulin aspart Diabetic Supplies Insulin Pens

Pen Needles pen needles Diabetic Supplies Insulin Pens

Precision Ketone Test Strips ketone test strips Diabetic Supplies Insulin Pens

Apidra Pens insulin glulisine Diabetic Supplies Insulin Pens

Baqsimi, Gvoke glucagon Diabetic Supplies Insulin Pens

Basaglar, Semglee, Toujeo Pens insulin glargine Diabetic Supplies Insulin Pens

Fiasp Pens insulin aspart with niacinamide Diabetic Supplies Insulin Pens

Lyumjev Pens insulin lispro-aabc Diabetic Supplies Insulin Pens

Tresiba Pens insulin degludec Diabetic Supplies Insulin Pens

Zegalogue dasiglucagon Diabetic Supplies Insulin Pens

Carospir spirinolactone suspension Diuretics

Eplerenone eplerenone Diuretics

Ethacrynic Acid ethacryinic acid Diuretics

Triamterene triamterene Diuretics

Egrifta tesamorelin Egrifta

Elaprase idursulfase Elaprase

Aralast-NP alpha-1 proteinase inhibitor Enzyme Inhibitors, Systemic

Glassia alpha-1 proteinase inhibitor Enzyme Inhibitors, Systemic

Prolastin-C alpha-1 proteinase inhibitor Enzyme Inhibitors, Systemic

Zemaira alpha-1 proteinase inhibitor Enzyme Inhibitors, Systemic

Zokinvy lonafarnib Enzyme Inhibitors, Systemic

Cerdelga eliglustat Enzyme Replacement, Gauchers Disease

Cerezyme imiglucerase Enzyme Replacement, Gauchers Disease

Elelyso taliglucerase Enzyme Replacement, Gauchers Disease

VPRIV velaglucerase Enzyme Replacement, Gauchers Disease

Epinephrine injection generics EXCEPT by

Mylan, EpiPen, Symjepiepinephrine Epinephrine Injection

Epogen, Procrit, Retacrit epoetin alfa Erythropoiesis Stimulating Proteins

Aranesp darbepoetin alfa Erythropoiesis Stimulating Proteins

Mircera methoxy polyethylene glycol-epoetin beta Erythropoiesis Stimulating Proteins

Bijuva estradiol/progesterone Estrogen Agents, Oral - Transdermal

Norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol Estrogen Agents, Oral - Transdermal

Divigel, Elestrin estradiol topical gel Estrogen Agents, Oral - Transdermal

Estradiol Patch, Minivelle estradiol transdermal patch Estrogen Agents, Oral - Transdermal

Duavee conjugated estrogen/bazedoxifene Estrogen Agents, Oral - Transdermal

Osphena ospemifene Estrogen Agents, Oral - Transdermal

Etoposide, Etopophos, Toposar etoposide Etoposide

Galafold migalastat Fabry Disease Agents

Antara, Fenofibrate, Fenoglide, Triglide fenofibrate Fibric Acid Derivatives

Fenofibric Acid fenofibric acid Fibric Acid Derivatives

Fenofibric Acid DR fenofibric acid delayed-release Fibric Acid Derivatives

Firmagon degarelix Firmagon

Baxdela delafloxacin Fluoroquinolones

Levofloxacin oral solution, injection levofloxacin Fluoroquinolones

Gattex teduglitide Gattex

Amitiza lubiprostone GI Motility, Chronic

Kristalose lactulose GI Motility, Chronic

Linzess linaclotide GI Motility, Chronic

Motegrity prucalopride GI Motility, Chronic

Movantik naloxegol GI Motility, Chronic

Relistor methylnaltrexone GI Motility, Chronic

Symproic naldemedine GI Motility, Chronic

Trulance plecanatide GI Motility, Chronic

Dalvance dalbavancin Glycopeptides

Firvanq vancomycin Glycopeptides

Vibativ telavancin Glycopeptides

Genotropin, Humatrope, Norditropin,

Nutropin AQ, Omnitrope, Saizen, Zomacton,

Zorbtive

somatotropin (recombinant) Growth Hormone

Pylerabismuth subcitrate/metronidazole/

tetracyclineH Pylori Treatment

Amoxicillin/Clarithromycin/Lansoprazole amoxicillin/clarithromycin/ lansoprazole H Pylori Treatment

Omeclamox amoxicillin/clarithromycin/omeprazole H Pylori Treatment

Talicia omeprazole/amoxicillin/rifabutin H Pylori Treatment

Famotidine Oral Suspenion famotidine H2 Antagonists

Nizatidine Capsules, Oral Solution nizatidine H2 Antagonists

Orladeyo berotralstat HAE Treatments

Cinryze, Ruconest C1 esterase inhibitor HAE Treatments

Takhzyro lanadelumab HAE Treatments

Adynovate, Eloctate, Esperoct, Jivi, Kovaltry,

Recombinatefactor VIII recombinant Hemophilia Treatment

Alprolix, Idelvion, Ixinity, Rebinyn, Rixubis factor IX recombinant Hemophilia Treatment

Humate-P von Willebrand factor complex human Hemophilia Treatment

Vonvedi von Willebrand factor recombinant Hemophilia Treatment

FEIBA antiinhibitor factor complex Hemophilia Treatment

Hemlibra emicizumab Hemophilia Treatment

Novoseven RT, Sevenfact factor VIIa recombinant Hemophilia Treatment

Tretten factor VIII A-subunit recombinant Hemophilia Treatment

Adefovir adefovir Hepatitis B Agents

Vemlidy tenofovir alafenamide Hepatitis B Agents

Mavyret glecaprevir/pibrentasvir Hepatitis C Agents

Sofosbuvir/Velpatasvir sofosbuvir/velpatasvir Hepatitis C Agents

Vosevi sofosbuvir/velpatasvir/voxilaprevir Hepatitis C Agents

Harvoni, Ledipasvir/Sofosbuvir ledipasvir/sofosbuvir Hepatitis C Agents

Sovaldi sofosbuvir Hepatitis C Agents

Zepatier elbasvir/grazoprevir Hepatitis C Agents

Ribapak ribavirin Hepatitis C Agents

Tegsedi inotersen Hereditary Transthyretin Amloidosis Agents

Edurant rilpivirine HIV-AIDS

Evotaz atazanavir/cobicistat HIV-AIDS

Isentress/Isentress HD raltegravir HIV-AIDS

Odefseyemtricitabine/rilpivirine/tenofovir

alafenamideHIV-AIDS

Prezcobix darunavir/cobicistat HIV-AIDS

Prezista darunavir HIV-AIDS

Tivicay PD dolutegravir HIV-AIDS

Tybost cobicistat HIV-AIDS

Abacivir/Lamivudine/Zidovudine abacivir/lamivudine/zidovudine HIV-AIDS

Aptivus tipranavir HIV-AIDS

Complera emtricitabine/rilpivirine/tenofovir HIV-AIDS

Crixivan indinavir HIV-AIDS

Delstrigodoravirine/lamivudine/tenofovir disoproxil

fumurateHIV-AIDS

Dovato dolutegravir/lamivudine HIV-AIDS

Fuzeon enfuvirtide HIV-AIDS

Intelence etavirine HIV-AIDS

Invirase saquinavir HIV-AIDS

Lexiva fosamprenavir HIV-AIDS

Nevirapine ER nevirapine extended-release HIV-AIDS

Norvir Powder and Solution ritonavir HIV-AIDS

Pifeltro doravirine HIV-AIDS

Reyataz Powder atazanavir HIV-AIDS

Rukobia fostemsavir HIV-AIDS

Selzentry maraviroc HIV-AIDS

Stribildelvitegravir/cobicistat/emtricitabine/tenofovi

r disoproxil fumarateHIV-AIDS

Symfi/Symfi Loefavirenz/lamivudine/tenofovir disoproxil

fumarateHIV-AIDS

Temixyslamivudine/tenofovir disoproxil fumarate

HIV-AIDS

Vitekta elvitegravir HIV-AIDS

HP Acthar Gel respiratory corticotropin injection HP Acthar Gel

Amphadase bovine hyaluronidase Hyaluronidase

Hylenex recombinant hyaluronidase Hyaluronidase

Vitrase ovine hyaluronidase Hyaluronidase

Qbrexza glycopyrronium Hyperhidrosis Agents

Lokelma sodium zirconium cyclosilicate Hyperkalemia Agents

Veltassa patiromer Hyperkalemia Agents

Natpara parathyroid hormone Hyperparathyroid Agents

Afrezza insulin inhaled Hypoglycemics, Insulin and Related Agents

Apidra vials insulin glulisine Hypoglycemics, Insulin and Related Agents

Fiasp vials insulin aspart with niacinamide Hypoglycemics, Insulin and Related Agents

Lyumjev vials insulin lispro-aabc Hypoglycemics, Insulin and Related Agents

Novolin vials insulin regular/isophane Hypoglycemics, Insulin and Related Agents

Semglee vials insulin glargine Hypoglycemics, Insulin and Related Agents

Tresiba vials insulin degludec Hypoglycemics, Insulin and Related Agents

Crysvita burosumab-twza Hypophosphatemia Treatments

Imcivree setmelanotide Imcrivree

CytoGam cytomegalovirus immune globulin Immune Globulins

Bivigam, Carimune, Cutaquig, Cuvitru,

Flebogamma, Gamastan, Gammagard,

Gammaked, Gammaplex, Gamunex,

Hizentra, Hyqvia, Octagam, Panzyga, Privigin,

Xembify

immune globulin Immune Globulins

HepaGam B hepatitis B immune globulin Immune Globulins

Sylatron peginterferon alfa-2b Immunomodulators, Antineoplastic

Lupkynis voclosporin Immunomodulators, Lupus

Cellcept suspension, mycophenolic mofetil

suspensionmycophenolic mofetil Immunosuppressives, Oral

Astagraf XL, Envarsus XR tacrolimus ER Immunosuppressives, Oral

Prograf Granules tacrolimus for oral suspension Immunosuppressives, Oral

Zortress everolimus Immunosuppressives, Oral

Increlex mecasermin Increlex

Invanz ertapenem Invanz

Feriva 21-7 and FA iron vitamin Iron, Oral

Infed iron dextran Iron, Parenteral

Venofer iron sucrose Iron, Parenteral

Feraheme ferumoxytol Iron, Parenteral

Injectafer ferric carboxymaltose Iron, Parenteral

Monoferric ferric derisomal Iron, Parenteral

Sodium Ferric Gluconate Complex sodium ferric gluconate complex Iron, Parenteral

Salex, Salicylic Acid Foam/Gel salicylic acid Keratolytics

Uream Cream urea Keratolytics

Keveyis dichlorphenamide Keveyis

Firdase, Ruzurgi amifampridine Lambert-Eaton Myasthenic Syndrome Agents

Lanoxin 0.0625mg, 0.1875mg digoxin Lanoxin

Clenpiq, Prepopik sodium picosulfate, magnesium, citric acid Laxatives and Cathartics

Gavilyte-H polyethylene glycol, electrolytes, bisacodyl Laxatives and Cathartics

Plenvupolyethylene glycol, sodium, ascorbic acid,

potassiumLaxatives and Cathartics

Suprep sodium, potassium, magnesium Laxatives and Cathartics

Montelukast Granules montelukast Leukotriene Modifiers

Zafirlukast zafirlukast Leukotriene Modifiers

Zileuton ER zileuton extended-release Leukotriene Modifiers

Zyflo zileuton Leukotriene Modifiers

Cubicin, Daptomycin 350 mg daptomycin Lipopeptides

Juxtapid lomitapide Lipotropics, Other

Nexletol bempedoic acid Lipotropics, Other

Nexlizet bempedoic acid and ezetimibe Lipotropics, Other

Praluent alirocumab Lipotropics, Other

Repatha evolocumab Lipotropics, Other

Vascepa icosapent ethyl Lipotropics, Other

Ezetimibe/Simvasting 10/80 mg ezetimibe/simvastatin Lipotropics, Statins

Simvastatin 80mg simvastatin Lipotropics, Statins

Altoprev lovastatin Lipotropics, Statins

Amlodipine/Atorvastatin amlodipine/atorvastatin Lipotropics, Statins

Ezallor rosuvastatin Lipotropics, Statins

Fluvastatin fluvastatin Lipotropics, Statins

Livalo, Zypitamag pitavastatin Lipotropics, Statins

Erythromycin Oral erythromycin Macrolides-Ketolides

Makena hydroxyprogesterone caproate Makena

Megace ES, Megestrol ES megestrol acetate Megace ES

Otrexup, Rasuvo, Reditrex, Xatmep methotrexate Methotrexate

Milrinone milrinone Milrinone

Bupap, Butalbital/Acetaminophen 50-300 mg butalbital/acetaminophen Miscellaneous Analgesics

Butalbital/Acetaminophen/Caffeine

Capsules, Zebutal butalbital/acetaminophen/caffeine Miscellaneous Analgesics

Conzip, Tramadol ER tramadol ER Miscellaneous Analgesics

Austedo deutetrabenazine Movement Disorder Agents

Ingrezza valbenazine Movement Disorder Agents

Tetrabenazine tetrabenazine Movement Disorder Agents

Mozobil plerixafor Mozobil

Dalfampridine dalfampridine Multiple Sclerosis Agents

Aubagio teriflunamide Multiple Sclerosis Agents

Bafiertam monomethyl fumarate Multiple Sclerosis Agents

Betaseron, Extavia interferon beta-1b Multiple Sclerosis Agents

Copaxone 40mg, Glatiramer 20mg glatiramer Multiple Sclerosis Agents

Gilenya fingolimod Multiple Sclerosis Agents

Kesimpta ofatumumab Multiple Sclerosis Agents

Mavenclad cladribine Multiple Sclerosis Agents

Mayzent siponimod Multiple Sclerosis Agents

Plegridy peginterferon beta-1a Multiple Sclerosis Agents

Rebif interferon beta-1a Multiple Sclerosis Agents

Vumerity diroximel fumarate Multiple Sclerosis Agents

Zeposia ozanimod Multiple Sclerosis Agents

Myalept metreleptin Myalept

Narcotic Fill Limit n/a Narcotic Fill Limit

Xyrem sodium oxybate Narcolepsy Agents

Xywavcalcium/magnesium/potassium/sodium

oxybatesNarcolepsy Agents

Azelastine 0.15% azelastine Nasal Antihistamines

Dymista azelastine/fluticasone Nasal Antihistamines

Olopatadine 0.6% olopatadine Nasal Antihistamines

Beconase AQ, Qnasl beclomethasone Nasal Steroids

Budesonide budesonide Nasal Steroids

Flunisolide flunisolide Nasal Steroids

Mometasone Furoate mometasone furoate Nasal Steroids

Omnaris, Zetonna ciclesonide Nasal Steroids

Veramyst fluticasone furoate Nasal Steroids

Xhance fluticasone propionate Nasal Steroids

Droxidopa droxidopa Neurogenic Orthostatic Hypotension Agents

Gralise, Horizant gabapentin Neuropathic Pain

Lidoderm, Lidocaine Patch, Lidocaine

Ointment lidocaine Neuropathic Pain

Cambia, Zipsor diclofenac potassium NSAIDs and COX II

Celecoxib celecoxib NSAIDs and COX II

Diclofenac/Misoprostol diclofenac/misoprostol NSAIDs and COX II

Diclofenac ER, Zorvolex diclofenac NSAIDs and COX II

Duexis ibuprofen/famotidine NSAIDs and COX II

Etodolac ER etodolac NSAIDs and COX II

Fenoprofen, Nalfon fenoprofen NSAIDs and COX II

Indomethacin ER indomethacin NSAIDs and COX II

Ketoprofen IR, ER ketoprofen NSAIDs and COX II

Meclofenamate meclofenamate NSAIDs and COX II

Mefenamic Acid mefenamic acid NSAIDs and COX II

Naprelan, Naproxen CR, DR, Oral Suspension naproxen NSAIDs and COX II

Oxaprozin oxaprozin NSAIDs and COX II

Relafen DS nabumetone NSAIDs and COX II

Sprix ketorolac NSAIDs and COX II

Tolmetin tolmetin NSAIDs and COX II

Vimovo naproxen/esomeprazole NSAIDs and COX II

Vivlodex meloxicam NSAIDs and COX II

Diclofenac Patch, Diclofenac Solution, Licart,

Pennsaid 2%diclofenac NSAIDs, Topical

Nuedexta dextromethorphan/quinidine Nuedexta

Dojolvi triheptanoin Nutritionals, Triglycerides

Bynfezia, Mycapssa, Octreotide octreotide Octreotide and Related Agents

Isturisa osilodrostat Octreotide and Related Agents

Korlym mifepristone Octreotide and Related Agents

Sandostatin LAR octreotide ER Octreotide and Related Agents

Xermelo telotristat Octreotide and Related Agents

Signifor pasireotide Octreotide and Related Agents

Signifor LAR pasireotide ER Octreotide and Related Agents

Somatuline Depot lanreotide ER Octreotide and Related Agents

Somavert pegvisomant Octreotide and Related Agents

Ibrance Capsules palbociclib Oncology, Oral - Breast

Kisqali riociclib Oncology, Oral - Breast

Kisqali Femara riociclib/letrozole Oncology, Oral - Breast

Nerlynx neratinib Oncology, Oral - Breast

Phesgo pertuzumab/trastuzumab/hyaluronidase Oncology, Oral - Breast

Pigray alpelisib Oncology, Oral - Breast

Talzenna talazoparib Oncology, Oral - Breast

Tukysa tucatinib Oncology, Oral - Breast

Verzenio abemaciclib Oncology, Oral - Breast

Bosulif bosutinib Oncology, Oral - Hematologic

Brukinsa zanubrutinib Oncology, Oral - Hematologic

Calquence acalabrutinib Oncology, Oral - Hematologic

Copiktra duvelisib Oncology, Oral - Hematologic

Daurismo glasdegib Oncology, Oral - Hematologic

Farydak panobinostat Oncology, Oral - Hematologic

Iclusig ponatinib Oncology, Oral - Hematologic

Idhifa enasidenib Oncology, Oral - Hematologic

Imbruvica ibrutinib Oncology, Oral - Hematologic

Inqovi decitabine/cedazuridine Oncology, Oral - Hematologic

Inrebic fedratinib Oncology, Oral - Hematologic

Ninlaro ixazomib Oncology, Oral - Hematologic

Onureg azacitidine Oncology, Oral - Hematologic

Pomalyst pomalidomide Oncology, Oral - Hematologic

Purixan mercaptopurine Oncology, Oral - Hematologic

Rydapt midostaurin Oncology, Oral - Hematologic

Sprycel dasatinib Oncology, Oral - Hematologic

Tasigna nilotinib Oncology, Oral - Hematologic

Tibsovo ivosidenib Oncology, Oral - Hematologic

Ukoniq umbralisib Oncology, Oral - Hematologic

Venclexta venetoclax Oncology, Oral - Hematologic

Xpovio selinexor Oncology, Oral - Hematologic

Zolinza vorinostat Oncology, Oral - Hematologic

Zydelig idelalisib Oncology, Oral - Hematologic

Alecensa alectinib Oncology, Oral - Lung

Alunbrig brigatinib Oncology, Oral - Lung

Erlotinib erlotinib Oncology, Oral - Lung

Gavreto pralsetinib Oncology, Oral - Lung

Gilotrif afatinib Oncology, Oral - Lung

Iressa gefitinib Oncology, Oral - Lung

Lobrena lorlatinib Oncology, Oral - Lung

Lumakras sotorasib Oncology, Oral - Lung

Retevmo selpercatinib Oncology, Oral - Lung

Rozlytrek entrectinib Oncology, Oral - Lung

Tabrecta capmatinib Oncology, Oral - Lung

Tagrisso osimertinib Oncology, Oral - Lung

Tepmetko tepotinib Oncology, Oral - Lung

Vizimpro dacomitinib Oncology, Oral - Lung

Xalkori crizotinib Oncology, Oral - Lung

Zykadia ceritinib Oncology, Oral - Lung

Ayvakit avapritinib Oncology, Oral - Other

Balversa larotrectinib Oncology, Oral - Other

Cometriq cabozantinib Oncology, Oral - Other

Koselugo selumetinib Oncology, Oral - Other

Lonsurf trifluridine/tipiracil Oncology, Oral - Other

Nexavar sorafenib Oncology, Oral - Other

Pemazyre pemigatinib Oncology, Oral - Other

Qinlock ripretinib Oncology, Oral - Other

Stivarga regorafenib Oncology, Oral - Other

Tazverik tazemetostat Oncology, Oral - Other

Temozolomide temozolomide Oncology, Oral - Other

Truseltiq infigratinib Oncology, Oral - Other

Turalio pexidartinib Oncology, Oral - Other

Vitrakvi larotrectinib Oncology, Oral - Other

Caprelsa vandetanib Oncology, Oral - Other

Lynparza olaparib Oncology, Oral - Ovarian

Rubraca rucaparib Oncology, Oral - Ovarian

Zejula niraparib Oncology, Oral - Ovarian

Abiraterone, Yonsa, Zytiga abiraterone Oncology, Oral - Prostate

Erleada apalutamide Oncology, Oral - Prostate

Nubeqa darolutamide Oncology, Oral - Prostate

Orgovyx relugolix Oncology, Oral - Prostate

Xtandi capsules enzalutamide Oncology, Oral - Prostate

Afinitor, Afinitor Disperz everolimus Oncology, Oral - Renal

Cabometyx cabozantinib Oncology, Oral - Renal

Fotivda tivozanib Oncology, Oral - Renal

Inlyta axitinib Oncology, Oral - Renal

Lenvima levatinib Oncology, Oral - Renal

Sutent sunitinib Oncology, Oral - Renal

Votrient pazopanib Oncology, Oral - Renal

Braftovi encorafenib Oncology, Oral - Skin

Cotellic cobimetinib Oncology, Oral - Skin

Erivedge vismodegib Oncology, Oral - Skin

Mekinist trametinib Oncology, Oral - Skin

Mektovi binimetinib Oncology, Oral - Skin

Odomzo sonidegib Oncology, Oral - Skin

Tafinlar dabrafenib Oncology, Oral - Skin

Zelboraf vemurafenib Oncology, Oral - Skin

AzaSite azithromycin Ophthalmic Antibiotics

Bacitracin bacitracin Ophthalmic Antibiotics

Besivance besifloxacin Ophthalmic Antibiotics

Gatifloxacin Ophthalmic gatifloxacin Ophthalmic Antibiotics

Levofloxacin Ophthalmic levofloxacin Ophthalmic Antibiotics

Moxeza moxifloxacin Ophthalmic Antibiotics

Natacyn natamycin Ophthalmic Antibiotics

Neomycin/Polymyxin B/Gramicidin neomycin/polymyxin B/gramicidin Ophthalmic Antibiotics

Lotemax Gel, Lotemax SM Gel loteprednol Ophthlamics, Antiinflammatories

Acuvail ketorolac Ophthlamics, Antiinflammatories

Bromfenac, Bromsite, Prolensa bromfenac Ophthlamics, Antiinflammatories

Nevanac nepafanac Ophthlamics, Antiinflammatories

Cequa, Restatis Multidose cyclosporine Ophthalmics, Antiinflammatory Immunomodulators

Eysuvis loteprednol Ophthalmics, Antiinflammatory Immunomodulators

Zirgan ganciclovir Ophthalmic Antivirals

Apraclonidine 0.5% apraclonidine Ophthalmics, Glaucoma Agents

Brimonidine P 0.15% brimonidine Ophthalmics, Glaucoma Agents

Simbrinza brinzolamide/brimonidine Ophthalmics, Glaucoma Agents

Istalol, Timoptic Ocudose timolol Ophthalmics, Glaucoma Agents

Combigan 10mL timolol/brimonidine Ophthalmics, Glaucoma Agents

Cosopt PF timolol/dorzolamide Ophthalmics, Glaucoma Agents

Azopt brinzolamide Ophthalmics, Glaucoma Agents

Pilocarpine pilocarpine Ophthalmics, Glaucoma Agents

Bimatoprost 0.03% bimatoprost Ophthalmics, Glaucoma Agents

Vyzulta latanoprostene bunod Ophthalmics, Glaucoma Agents

Xelpros latanoprost emulsion Ophthalmics, Glaucoma Agents

Zioptan tafluprost Ophthalmics, Glaucoma Agents

Rhopressa netarsudil Ophthalmics, Glaucoma Agents

Rocklatan netarsudil/latanoprost Ophthalmics, Glaucoma Agents

Blephamide SOP sulfacetamide/prednisolone ointment Ophthalmic Steroid-Antibiotic Combinations

Neomycin/Polymyxin

B/Bacitracin/Hydrocortisone

neomycin/polymyxin

B/bacitracin/hydrocortisoneOphthalmic Steroid-Antibiotic Combinations

Neomycin/Polymyxin B/Hydrocortisone neomycin/polymyxin B/hydrocortisone Ophthalmic Steroid-Antibiotic Combinations

TobraDex ST, Tobramycin/Dexamethasone tobramycin/dexamethasone Ophthalmic Steroid-Antibiotic Combinations

Alocril nedocromil sodium Ophthalmics for Allergic Conjuctivitis

Alomide lodoxamide tromethamine Ophthalmics for Allergic Conjuctivitis

Azelastine azelastine Ophthalmics for Allergic Conjuctivitis

Epinastine epinastine Ophthalmics for Allergic Conjuctivitis

Lastacaft alcaftadine Ophthalmics for Allergic Conjuctivitis

Olopatadine, Pataday olopatadine Ophthalmics for Allergic Conjuctivitis

Zerviate cetirizine Ophthalmics for Allergic Conjuctivitis

Oxervate cenegermin-bkbj Ophthalmics for Neurotrophic Keratitis

Narcan Nasal Spray naloxone Opiate Dependence Agents

Lucemyra lofexidine Opiate Dependence Agents

Zubsolv buprenorphine/naloxone Opiate Dependence Agents

Orfadin Suspension nitisinone Orfadin

Ciprofloxacin Otic ofloxacin Otic Antibiotics

Otovel ciprofloxacin/fluocinolone Otic Antibiotics

Linezolid, Zyvox linezolid Oxazolidinones

Sivextro tedizolid Oxazolidinones

Palynziq pegvaliase-pqpz Palyzniq

Pancreaze, Pertzye, Viokace pancrelipase Pancreatic Enzymes

Panretin alitretinoin PanretinKabiven, Perikabiven amino acid/electrolytes/dextrose/lipid Parenteral Nutrition Products

Clinolipid, Intralipid, Omegaven, Smoflipid lipid emulsion Parenteral Nutrition Products

Metyrosine metyrosine Pheochromocytoma Agents

Phenoxybenzamine phenoxybenzamine Pheochromocytoma Agents

Auryxia ferric citrate Phosphate Binders

Calcium Acetate Tablets, Phoslyra calcium acetate Phosphate BindersFosrenol Powder, Lanthanum Carbonate lanthanum carbonate Phosphate BindersRenvela Tablets, Sevelamer Carbonate

Powdersevelamer carbonate Phosphate Binders

Sevelamer Hydrochloride 400 mg sevelamer hydrochloride Phosphate Binders

Velphoro sucroferric oxyhyroxide Phosphate Binders

Oriahnn elagolix/estradiol/norethindrone Pituitary Suppressive Agents, LHRH

Orilissa elagolix Pituitary Suppressive Agents, LHRH

Fensolvi, Lupron Depot, Lupron Depot-Ped leuprolide Pituitary Suppressive Agents, LHRH

Xenleta lefamulin Pleuromutilin Antibiotics

Oxlumo lumasiran Primary Hyperoxaluria Agents

Aciphex Sprinkles, Raberprazole rabeprazole Proton Pump Inhibitors

Dexilant dexlansoprazole Proton Pump Inhibitors

Esomeprazole Rx esomeprazole Proton Pump Inhibitors

Lansoprazole Rx, Prevacid Rx Solutab lansoprazole Proton Pump Inhibitors

Prilosec Rx Powder for Oral Suspension omeprazole Proton Pump Inhibitors

Omeprazole/Sodium Bicarbonate Rx, Zegerid

Rx Powderomeprazole/sodium bicarbonate Proton Pump Inhibitors

Protonix Pak pantoprazole Proton Pump Inhibitors

Adempas riociguat Pulmonary Arterial Hypertension Agents

Epoprostenol, Flolan epoprostenol Pulmonary Arterial Hypertension Agents

Opsumit macitentan Pulmonary Arterial Hypertension Agents

Orenitram, Remodulin, Tyvaso trepostinil Pulmonary Arterial Hypertension Agents

Revatio Suspension, Sildenafil 20 mg sildenafil Pulmonary Arterial Hypertension Agents

Tadalafil 20 mg tadalafil Pulmonary Arterial Hypertension Agents

Tracleer for Oral Suspension bosentan Pulmonary Arterial Hypertension Agents

Uptravi selexipag Pulmonary Arterial Hypertension Agents

Ventavis iloprost Pulmonary Arterial Hypertension Agents

Esbriet pirfenidone Pulmonary Fibrosis Agents

Ofev nintedinab Pulmonary Fibrosis Agents

Pyridostigmine pyridostigmine Pyridostigmine

Pyridostigmine Extended-Release pyridostigmine extended-release Pyridostigmine

Ranolazine ranolazine Ranolazine

Ravicti glycerol phenylbutyrate Ravicti

Sodium Phenylbutyrate Powder sodium phenylbutyrate Ravicti

Rectiv nitroglycerin Rectiv

Regranex becaplermin Regranex

Santyl collagenase Santyl

Belsomra suvorexant Sedative Hypnotics

Dayvigo lemborexant Sedative Hypnotics

Edular, Zolpidem Sublingual zolpidem Sedative Hypnotics

Rozerem ramelteon Sedative Hypnotics

Hetlioz and Hetlioz LQ tasimelteon Sedative Hypnotics

Serostim somatotropin(recombinant) Serostim

Endari l-glutamine Sickle Cell Agents

Oxbryta voxelotor Sickle Cell Agents

Sicklos hydroxyurea tablets Sickle Cell Agents

Amrix cyclobenzaprine ER Skeletal Muscle Relaxants

Carisoprodol 250 mg carisoprodol Skeletal Muscle Relaxants

Carisoprodol/Aspirin/Codeine carisoprodol/aspirin/codeine Skeletal Muscle Relaxants

Cyclobenzaprine 7.5 mg cyclobenzaprine Skeletal Muscle Relaxants

Norgesic Forte orphenadrine/aspirin/caffeine Skeletal Muscle Relaxants

Ozobax baclofen Skeletal Muscle Relaxants

Tizanidine capsules, Zanaflex Capsules tizanidine Skeletal Muscle Relaxants

Evrysdi risdiplam Spinal Muscular Atrophy

Adzenys XR, Amphetamine ER oral

suspension, Dyanavel XR, Evekeoamphetamine Stimulants and Related Agents

Adderall XR,

Amphetamine/Dextroamphetamine IR,

Mydayis

amphetamine/dextroamphetamine IR/ER Stimulants and Related Agents

Dextroamphetamine IR/ER, Zenzedi dextroamphetamine IR/ER Stimulants and Related Agents

Adhansia XR, Aptensio XR, Concerta,

Cotempla XR, Daytrana, Jornay PM,

Methylin, Methylphenidate IR/ER, Quillichew

ER, Quillivant XR, Ritalin LA 10 mg

methylphenidate IR/ER Stimulants and Related Agents

Armodafinil armodafinil Stimulants and Related Agents

Atomoxetine atomoxetine Stimulants and Related Agents

Clonidine ER clonidine ER Stimulants and Related Agents

Desoxyn, Methamphetamine methamphetamine Stimulants and Related Agents

Dexmethylphenidate IR/ER, Focalin XR dexmethylphenidate IR/ER Stimulants and Related Agents

Guanfacine ER guanfacine ER Stimulants and Related Agents

Modafinil modafinil Stimulants and Related Agents

Sunosi solriamfetol Stimulants and Related Agents

Vyvanse lisdexamfetamine Stimulants and Related Agents

Wakix pitolisant Stimulants and Related Agents

Strensiq asfotase alfa Strensiq

Sulfadiazine sulfadiazine Sulfonamides

Synagis palivizumab Synagis

Synribo omacetaxine Synribo

Demeclocycline demeclocycline Tetracyclines

Doryx, Doryx MCP, Doxycycline Hyclate DR doxycycline hyclate delayed-release Tetracyclines

Doxycycline Hyclate IR 75, 150 mg tablets doxycycline hyclate immediate-release Tetracyclines

Doxycycline Monohydrate 75 mg and 150 mg

capsulesdoxycycline monohydrate Tetracyclines

Doxycycline [rosacea] DR, Oracea doxycycline [rosacea] delayed-release Tetracyclines

Minocycline IR tablets, Minocycline ER,

Minolira, Solodynminocycline Tetracyclines

Morgidox Kit doxycycline and cleanser Tetracyclines

Nuzyra omadacycline Tetracyclines

Thiola EC tiopronin delayed-release Thiola

Doptelet avatrombopag Thrombopoiesis Stimulating Proteins

Mulpleta lusutrombopag Thrombopoiesis Stimulating Proteins

Promacta eltrombopag Thrombopoiesis Stimulating Proteins

Tavalisse fostamatinib Thrombopoiesis Stimulating Proteins

Nplate romisplostim Thrombopoiesis Stimulating Proteins

Levothyroxine Injection, Thyquidity, Tirosint levothyroxine Thyroid Hormones

Liothyronine Injection liothyronine Thyroid Hormones

Bupropion [smoking deterrent] bupropion SR Tobacco Cessation

Nicotrol Inhaler, Nicotrol Nasal Spray nicotine Tobacco Cessation

Valchlor mechlorethamine Topical Antineoplastic and Genital Warts Therapy

Diclofenac 3% Gel diclofenac Topical Antineoplastic and Genital Warts Therapy

Picato ingenol mebutate Topical Antineoplastic and Genital Warts Therapy

Podofilox Solution podofilox Topical Antineoplastic and Genital Warts Therapy

Veregen sinecatechins Topical Antineoplastic and Genital Warts Therapy

Zyclara imiquimod Topical Antineoplastic and Genital Warts Therapy

Tacrolimus Ointment tacrolimus Topical Immunomodulators

Actiq, Fentanyl Oral Lozenges fentanyl oral lozenges Transmucosal Fentanyl

Fentora fentanyl buccal tablets Transmucosal Fentanyl

Lazanda fentanyl nasal spray Transmucosal Fentanyl

Subsys fentanyl sublingual spray Transmucosal Fentanyl

Trelstar Depot, Trelstar LA triptorelin pamoate Trelstar

Tygacil tigecycline Tygacil

Mesalamine DR mesalamine delayed-release Ulcerative Colitis Agents

Mesalamine Rectal Enema, SFRowasa mesalamine Ulcerative Colitis Agents

Giazo balsalazide Ulcerative Colitis Agents

Uceris budesonide Ulcerative Colitis Agents

Methenamine hippurate methenamine hippurate Urinary Antiinfectives

Nitrofurantoin Suspension nitrofurantoin Urinary Antiinfectives

Urimar-T, Urogesic Blue hyoscamine combination Urinary Antiinfectives

Potassium Citrate ER, Urocit-K potassium citrate Urocit-K

Femring QLL, Imvexxy estradiol Vaginal Estrogen Preparations

Intrarosa prasterone Vaginal Estrogen Preparations

BiDil isosorbide dinitrate/hydralazine HCl Vasodilators, Coronary

GoNitro, Nitroglycerin Spray nitroglycerin Vasodilators, Coronary

Verquvo vericiguat Vasodilators, Coronary

Jynarque tolvaptan Vasopressor Receptor Antagonists

Vecamyl mecamylamine Vecamyl

Vimizim elosulfase alfa Vimizim

Doxercalciferol doxercalciferol Vitamin D and ESRD Products

Paricalcitol 4 mcg paricalcitol Vitamin D and ESRD Products

Rayaldee calcifediol Vitamin D and ESRD Products

Sensipar cinacalet Vitamin D and ESRD Products

Aluminum Hydroxide aluminum hydroxide Vitamin D and ESRD Products

Calcium Carbonate calcium carbonate Vitamin D and ESRD Products

Calcium Lactate calcium lactate Vitamin D and ESRD Products

Docusate Calcium docusate calcium Vitamin D and ESRD Products

Docusate Sodium docusate sodium Vitamin D and ESRD Products

Magnebind calcium carbonate/magnesium carbonate Vitamin D and ESRD Products

Magnesium Carbonate magnesium carbonate Vitamin D and ESRD Products

Niacin niacin Vitamin D and ESRD Products

Pyridoxine pyridoxine Vitamin D and ESRD Products

Sodium Bicarbonate sodium bicarbonate Vitamin D and ESRD Products

Thiamine Hydrochloride thiamine hydrochloride Vitamin D and ESRD Products

Dialyvite, Nephplex Rx, Nephron FA, Renal,

Reno Caps, Triphrocaps, Virt-Caps, Virt-Vite

Plus, Vital-D Rx, VP-Vite Rx

vitamin B complex/folic acid and/or zinc Vitamin D and ESRD Products

Vyndaqel, Vyndamax tafamidis Vyndaqel-Vyndamax

Xospata gilteritinib Xospata