2017 Humana Drug List

2017Humana Drug List

2017 Rx4 Traditional DrugList

Humana.com

2017Rx4TC

Please read: This documentcontains information about thedrugs we cover in this plan.

PDL0075B

This is a list of covered drugs

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http://apps.humana.com/marketing/documents.asp?file=2841202

2 - FORMULARY Updated 09/2016

Welcome to HumanaWThis Humana Drug List (formulary) is effective as of January 1, 2017 for employer plans, members, and healthcareproviders. This is an all-inclusive list and may change throughout the year.What is the Drug List?The Drug List is a list of covered medicines selected by Humana.* Humana will cover the medicines in the Drug List aslong as the medicine is medically necessary, the prescription is filled at a Humana network pharmacy and other planrules are followed.

If you have this insurance through your employer and live in Texas or Louisiana: You will continue to use the 2016version of this Drug List until your plan's renewal date in 2017. You can find that Drug List at Humana.com/DrugList.How do I use the formulary?Medicines are listed in the Drug List alphabetically.Prescription medicines are grouped into one of four levels – Level 1, Level 2, Level 3, or Level 4. Generic medicineshave the same active ingredients as brand medicines and are prescribed for the same reasons. The FDA requiresgenerics to be safe and work the same as brand name medicines. Generic medicines often cost much less.• Level One – Includes low-cost generic and brand-name medicines.• Level Two – Includes higher-cost generic and brand-name medicines.• Level Three – Includes high-cost, mostly brand-name medicines. These medicines may have generic or

brand-name alternatives in Levels 1 or 2.• Level Four – Includes highest-costs medicines.• *Specialty Medicines: High-cost/high-technology medicines that can often only be obtained at specialty

pharmacies. Please visit Humana.com and log into MyHumana to view specific prescription drug benefits,including copayments or cost-share, limitations and exclusions; OR refer to your Certificate of Coverage/Insuranceor Summary Plan Description/Policy of Insurance.

Please note:If your medicine isn't included in this printed list of covered medicines, you should visit Humana.com following theinstructions below to see if your medicine is covered.• For some medicines not listed below, medical coverage may apply.• If Humana doesn't cover your medicine, your health care provider can ask Humana for approval. Generally,

Humana will only approve a request if a covered medicine wouldn't work as well OR would have a negative effecton your health.

• Some covered medicines may have additional requirements or limits on coverage, such as requiring your healthcare provider to get advance approval from Humana in order to be covered under your pharmacy plan (also

coverage.known as prior authorization). Please follow the instructions on page 3 to get information on specific medicine

Can the formulary change?Yes. The Humana Pharmacy & Therapeutics (P&T) Committee reviews and updates the Drug List regularly. Newmedicines are added as needed, and medicines that are deemed unsafe by the Food and Drug Administration (FDA) ora drug's manufacturer are immediately removed.We will communicate changes to the Drug List to members, by mail, based on the Drug List notification requirementsestablished by each state. Members can view the most up-to-date Drug List on Humana.com.

How much will I pay for covered medicines?The amount of money you pay often depends on which drug level your medicine falls within the Drug List andwhether you fill your prescription at a network pharmacy. Please refer to your Certificate of Coverage/ Summary PlanDescription/Policy of Insurance or call the number on the back of your Humana ID card to reach customer care to findout more about your pharmacy coverage.For specific coverage and cost information for existing members:• Visit Humana.com and log into MyHumana• Access the drug search tool through "Drug Pricing Tool" under "Tools & Resources" at the bottom of the page.• Search for your medicine by name or by your condition.• Please note: MyHumana only shows benefits as of the date of log in. Depending on your plan, you should wait

until after your plan's 2017 renewal date to see your new benefit information.Are there any restrictions on my coverage?Some covered medicines may have additional requirements or limits on coverage. These requirements and limitsmay include:

FORMULARY Updated 09/2016 - 3

• Prior authorization (PA): Some medicines need to be approved in advance to be covered under your pharmacyplan. For these medicines to be covered, your health care provider must get approval from Humana. Your planbenefits won't cover this medicine without prior authorization. You may pay the entire cost of the medicine if youbuy it without first getting a prior authorization.

• Quantity limits (QL): You may have a limit on how much you can get of some medicines at one time. These limitscan be placed on some medicines because of safety or health care concerns and help prevent misuse of thesemedicines. If your prescription is over the limit there are two choices:– You can get the amount of medicine that's covered by your plan, and then pay out-of-pocket for any medicine

that's over the limit.Or

– If your health care provider thinks you need more than the amount allowed, he or she can ask for priorauthorization from Humana for the amount of the drug that goes over the limit.

• Step therapy (ST): Sometimes there's more than one medicine that works to treat a health condition. Somemedicines may cost less but still work for you. Before a prescription is filled for a medicine that costs more, youmay be asked to try at least one other medicine first.

Talk to your health care provider if your medicine has an additional requirement. Ask your health care provider tocontact Humana Clinical Pharmacy Review (HCPR) to ask for approval for a medicine that requires prior authorization,quantity limit, or step therapy. Your health care provider can contact HCPR at 1-800-555-2546 between 8 a.m. – 8 p.m.EST, Monday – Friday to request an approval. Please allow 24-48 hours for Humana to review and provide a responseback to your health care provider.You can find out if your medicine has any additional requirements or limits by looking in the formulary that begins onpage 5.What if my medicine is not on the formulary?You can use the drug search tool by signing into MyHumana at Humana.com to view alternatives for your medicine.You can access the drug search tool through "Drug Pricing" under "Plan Tools" at the bottom of the page.

Your health care provider can ask Humana to make an exception. Generally, Humana will only approve a request if acovered medicine wouldn't work as well OR would have a negative effect on your health. To ask for an approval, yourhealth care provider can contact HCPR at 1-800-555-2546 between 8 a.m. – 8 p.m. EST, Monday – Friday.

WFor More InformationWFor more detailed information about your Humana prescription drug coverage, please review your Certificate ofInsurance/Summary Plan Description/Policy of Insurance and other plan materials.If you have questions:• If you're thinking about enrolling in a Humana plan, please call Customer Care number listed in your enrollment

materials• If you're already enrolled in a Humana plan, please call the number on the back of your Humana member ID card• For more information about drug coverage, call 1-800-833-6917 (TTY: 711), Monday – Thursday, 7 a.m. - 7 p.m., or

Friday 7 a.m. – 6 p.m. CST, to speak to a Customer Care representative.

W


2017 Rx4 Traditional Drug ListWThe Drug List that begins on the next page provides coverage information about some of the medicines coveredby Humana.How to read your formularyThe first column of the chart lists medicine names in alphabetical order. Brand-name medicines are listed in UPPERCASE and generic medicines are listed in lower case. Next to the medicine name you may see the following indicatorsto tell you about additional coverage information for that medicine:MM – Maintenance medicines are taken long-term such as medicines you take for high cholesterol, mental health, orhigh blood pressure. Coverage may be different by plan and you may be required to fill your prescriptions using yourplan's mail-delivery pharmacy.SP – Specialty medicines are typically high-cost/high-technology medicines that can often only be obtained atspecialty pharmacies. Specialty medicine coverage may be different by plan.ACA – Affordable Care Act $0 Preventive Medication Coverage. These medicines are available to you at no cost. Youmust have a prescription from your health care provider and fill the medication at an in-network pharmacy for us toprocess a claim for preventive medicines or products under your pharmacy plan. This list may not apply to allhealthcare plans and may change over time. Some restrictions may apply.LD – This medicine is limited distribution and may not be available at all in-network pharmacies, please call HumanaCustomer Service at 1-800-833-6917 for additional information. This list may not be all inclusive and is subject tochange

The third column shows the utilization management requirements for the medicine. Utilization managementrequirements mean that Humana may have special rules for covering that medicine. These can include priorauthorization, quantity limits, or step therapy requirements. The quantity limit for each medicine is based on safety or

more details on these requirements for your plan.

The second column lists the drug level. See page 2 for more details on the drug levels in your plan.

health care concerns and whether your health care provider prescribes a supply for 30, 60, or 90 days. See page 3 for


for PDL007

DRUG NAME DRUG LEVEL

UTILIZATIONMANAGEMENT

REQUIREMENTS1ST TIER UNIFINE PENTIPS 29 GAUGE X 1/2" NEEDLE 11ST TIER UNIFINE PENTIPS 31 GAUGE X 1/4" NEEDLE 11ST TIER UNIFINE PENTIPS 31 GAUGE X 3/16" NEEDLE 11ST TIER UNIFINE PENTIPS 31 GAUGE X 5/16" NEEDLE 11ST TIER UNIFINE PENTIPS 32 GAUGE X 5/32" NEEDLE 11ST TIER UNIFINE PENTIPS PLUS 29 GAUGE X 1/2" NEEDLE MM 11ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 1/4" NEEDLE MM 11ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 3/16" NEEDLE MM 11ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 5/16" NEEDLE 11ST TIER UNIFINE PENTIPS PLUS 32 GAUGE X 5/32" NEEDLE MM 11ST TIER UNILET COMFORTOUCH LANCET 28 GAUGE MM 11ST TIER UNILET COMFORTOUCH LANCET 30 GAUGE MM 12TEK CONTROL (HIGH-NORMAL) SOLUTION 32TEK GLUCOSE/BLOOD PRESSURE KIT 3 ST8-MOP 10 MG CAPSULE 3abacavir 300 mg tablet 2 QLabacavir-lamivudine-zidov tab 4 QLABILIFY 1 MG/ML SOLUTION MM 4 QL,PAABILIFY 10 MG TABLET MM 4 QL,PAABILIFY 15 MG TABLET MM 4 QL,PAABILIFY 2 MG TABLET MM 4 QL,PAABILIFY 20 MG TABLET MM 4 QL,PAABILIFY 30 MG TABLET MM 4 QL,PAABILIFY 5 MG TABLET MM 4 QL,PAABILIFY DISCMELT 10 MG TABLET MM 4 QL,PAABILIFY DISCMELT 15 MG TABLET MM 4 QL,PAABSORICA 10 MG CAPSULE 4 QL,STABSORICA 20 MG CAPSULE 4 QL,STABSORICA 25 MG CAPSULE 4 QL,STABSORICA 30 MG CAPSULE 4 QL,STABSORICA 35 MG CAPSULE 4 QL,STABSORICA 40 MG CAPSULE 4 QL,STABSTRAL 100 MCG SUBLINGUAL TABLET 4 QL,PAABSTRAL 200 MCG SUBLINGUAL TABLET 4 QL,PAABSTRAL 300 MCG SUBLINGUAL TABLET 4 QL,PAABSTRAL 400 MCG SUBLINGUAL TABLET 4 QL,PAABSTRAL 600 MCG SUBLINGUAL TABLET 4 QL,PAABSTRAL 800 MCG SUBLINGUAL TABLET 4 QL,PAacamprosate calc dr 333 mg tab MM 3 QLACANYA 1.2 %-2.5 % TOPICAL GEL WITH PUMP 2acarbose 100 mg tablet MM 2acarbose 25 mg tablet MM 2acarbose 50 mg tablet MM 2ACCOLATE 10 MG TABLET MM 3 QLACCOLATE 20 MG TABLET MM 3 QLACCU-CHEK AVIVA CONNECT METER MM 1ACCU-CHEK AVIVA CONTROL SOLN SOLUTION 3ACCU-CHEK AVIVA PLUS METER MM 1ACCU-CHEK AVIVA PLUS TEST STRIPS MM 1 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSACCU-CHEK AVIVA TEST STRIPS MM 1 QLACCU-CHEK CMFRT CURVE SOLN 1ACCU-CHEK CMFRT CURVE SOLN 3ACCU-CHEK CMFRT CURVE SOLN 1ACCU-CHEK CMFRT CURVE STRIP MM 1 QLACCU-CHEK COMPACT BLUE CONTROL, MID-HIGH SOLUTION 3ACCU-CHEK COMPACT PLUS CARE KIT MM 1ACCU-CHEK COMPACT PLUS CONTROL SOLUTION 3ACCU-CHEK COMPACT PLUS TEST STRIPS MM 1 QLACCU-CHEK COMPACT TEST STRIPS MM 1 QLACCU-CHEK FASTCLIX MM 1ACCU-CHEK FASTCLIX KIT MM 1ACCU-CHEK MULTICLIX LANCET MM 1ACCU-CHEK MULTICLIX LANCET KIT MM 1ACCU-CHEK NANO MM 1ACCU-CHEK SAFE-T-PRO 23 GAUGE MM 1ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE MM 1ACCU-CHEK SMARTVIEW CONTROL SOLUTION 3ACCU-CHEK SMARTVIEW TEST STRIPS MM 1 QLACCU-CHEK SOFTCLIX LANCET DEV MM 1ACCU-CHEK SOFTCLIX LANCETS MM 1ACCU-CHEK SOFTCLIX LANCING DEVICE+LANCETS KIT MM 1ACCU-CHEK VOICEMATE KIT MM 1ACCUPRIL 10 MG TABLET MM 3ACCUPRIL 20 MG TABLET MM 3ACCUPRIL 40 MG TABLET MM 3ACCUPRIL 5 MG TABLET MM 3ACCURETIC 10 MG-12.5 MG TABLET MM 3ACCURETIC 20 MG-12.5 MG TABLET MM 3ACCURETIC 20 MG-25 MG TABLET MM 3ACCUTREND GLUCOSE CONTROL SOLUTION 3ACCUTREND GLUCOSE STRIPS MM 1 QLACE AEROSOL CLOUD ENHANCER SPACER 1acebutolol 200 mg capsule MM 1acebutolol 400 mg capsule MM 1ACEON 4 MG TABLET MM 3ACEON 8 MG TABLET MM 3acetamin-codein 300-30 mg/12.5 2 QLacetaminop-codeine 120-12 mg/5 2 QLacetaminop-codeine 120-12 mg/5 2 QLacetaminophen-cod #2 tablet 2 QLacetaminophen-cod #3 tablet 2 QLacetaminophen-cod #4 tablet 2 QLacetasol hc 1 %-2 % ear drops 3acetazolamide 125 mg tablet MM 3acetazolamide 250 mg tablet MM 3acetazolamide er 500 mg cap MM 3 QLacetic acid 2% ear solution 2acetic acid-aluminum drops 3acetylcysteine 10% vial 3acetylcysteine 20% vial 3ACIPHEX 20 MG TABLET,DELAYED RELEASE MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSACIPHEX SPRINKLE 10 MG CAPSULE,DELAYED RELEASE SPRINKLE MM 3 QL,STACIPHEX SPRINKLE 5 MG CAPSULE,DELAYED RELEASE SPRINKLE MM 3 QL,STacitretin 10 mg capsule 4 PAacitretin 17.5 mg capsule 4 PAacitretin 25 mg capsule 4 PAACTEMRA 162 MG/0.9 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PAACTHAR H.P. 80 UNIT/ML INJECTION GEL SP,LD * QL,PAACTI-LANCE LANCETS 17 GAUGE MM 1ACTI-LANCE LANCETS 23 GAUGE MM 1ACTI-LANCE LANCETS 28 GAUGE MM 1ACTICLATE 150 MG TABLET SP * QL,STACTICLATE 75 MG TABLET SP * QL,STACTIGALL 300 MG CAPSULE MM 4ACTIMMUNE 100 MCG (2 MILLION UNIT)/0.5 ML SUBCUTANEOUS SOLUTION SP,LD * QL,PAACTIQ 1,200 MCG LOZENGE ON A HANDLE 4 QL,PAACTIQ 1,600 MCG LOZENGE ON A HANDLE 4 QL,PAACTIQ 200 MCG LOZENGE ON A HANDLE 4 QL,PAACTIQ 400 MCG LOZENGE ON A HANDLE 4 QL,PAACTIQ 600 MCG LOZENGE ON A HANDLE 4 QL,PAACTIQ 800 MCG LOZENGE ON A HANDLE 4 QL,PAACTIVE FE 75 MG IRON-1,250 MCG TABLET 3ACTIVE OB 20 MG IRON-1 MG-320 MG CAPSULE 3ACTIVELLA 0.5 MG-0.1 MG TABLET MM 3ACTIVELLA 1 MG-0.5 MG TABLET MM 3ACTONEL 150 MG TABLET MM 3 QLACTONEL 30 MG TABLET 3 QLACTONEL 35 MG TABLET MM 3 QLACTONEL 5 MG TABLET MM 3 QLACTOPLUS MET 15 MG-500 MG TABLET MM 4 QL,STACTOPLUS MET 15 MG-850 MG TABLET MM 4 QL,STACTOPLUS MET XR 15 MG-1,000 MG TABLET,EXTENDED RELEASE MM 4 QL,STACTOPLUS MET XR 30 MG-1,000 MG TABLET,EXTENDED RELEASE MM 4 QL,STACTOS 15 MG TABLET MM 3 QLACTOS 30 MG TABLET MM 3 QLACTOS 45 MG TABLET MM 3 QLACULAR 0.5 % EYE DROPS 3 STACULAR LS 0.4 % EYE DROPS 3 STACUVAIL (PF) 0.45 % EYE DROPS IN A DROPPERETTE 3 STacyclovir 200 mg capsule MM 2acyclovir 200 mg/5 ml susp MM 3acyclovir 400 mg tablet MM 2acyclovir 5% ointment 3 PAacyclovir 800 mg tablet MM 2ACZONE 5 % TOPICAL GEL 4 STACZONE 7.5 % TOPICAL GEL WITH PUMP 4 STADALAT CC 30 MG TABLET,EXTENDED RELEASE MM 3 QLADALAT CC 60 MG TABLET,EXTENDED RELEASE MM 3 QLADALAT CC 90 MG TABLET,EXTENDED RELEASE MM 3 QLadapalene 0.1% cream 3adapalene 0.1% gel 3adapalene 0.1% lotion 3 STadapalene 0.3% gel 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSadapalene 0.3% gel pump 3ADASUVE 10 MG BREATH ACTIVATED SP * QL,PAADCIRCA 20 MG TABLET SP * QL,PAADDERALL 10 MG TABLET 3 QLADDERALL 12.5 MG TABLET 3 QLADDERALL 15 MG TABLET 3 QLADDERALL 20 MG TABLET 3 QLADDERALL 30 MG TABLET 3 QLADDERALL 5 MG TABLET 3 QLADDERALL 7.5 MG TABLET 3 QLADDERALL XR 10 MG CAPSULE,EXTENDED RELEASE 3 QLADDERALL XR 15 MG CAPSULE,EXTENDED RELEASE 3 QLADDERALL XR 20 MG CAPSULE,EXTENDED RELEASE 3 QLADDERALL XR 25 MG CAPSULE,EXTENDED RELEASE 3 QLADDERALL XR 30 MG CAPSULE,EXTENDED RELEASE 3 QLADDERALL XR 5 MG CAPSULE,EXTENDED RELEASE 3 QLadefovir dipivoxil 10 mg tab SP *ADEMPAS 0.5 MG TABLET SP,LD * QL,PAADEMPAS 1 MG TABLET SP,LD * QL,PAADEMPAS 1.5 MG TABLET SP,LD * QL,PAADEMPAS 2 MG TABLET SP,LD * QL,PAADEMPAS 2.5 MG TABLET SP,LD * QL,PAADJUSTABLE LANCING DEVICE MM 3ADOXA 150 MG CAPSULE 4 QL,STADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO-INJECTOR 3ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR 3 QLADVAIR DISKUS 100 MCG-50 MCG/DOSE POWDER FOR INHALATION MM 2 QLADVAIR DISKUS 250 MCG-50 MCG/DOSE POWDER FOR INHALATION MM 2 QLADVAIR DISKUS 500 MCG-50 MCG/DOSE POWDER FOR INHALATION MM 2 QLADVAIR HFA 115 MCG-21 MCG/ACTUATION AEROSOL INHALER MM 2 QLADVAIR HFA 230 MCG-21 MCG/ACTUATION AEROSOL INHALER MM 2 QLADVAIR HFA 45 MCG-21 MCG/ACTUATION AEROSOL INHALER MM 2 QLadvanced eye health 250 mg-2.5 mg-0.5 mg capsule 2advanced eye health 500 mg-5 mg-1 mg capsule 2ADVANCED GLUCOSE METER MM 3 STADVANCED GLUCOSE METER TEST STRIPS MM 3 QL,STADVANCED LANCING DEVICE KIT MM 1ADVANCED TRAVEL LANCETS 28 GAUGE MM 1ADVANCED TRAVEL LANCETS 30 GAUGE MM 1ADVICOR 1,000 MG-20 MG TABLET MM 3 QL,STADVICOR 1,000 MG-40 MG TABLET MM 3 QL,STADVICOR 500 MG-20 MG TABLET MM 3 QL,STADVICOR 750 MG-20 MG TABLET MM 3 QL,STADVOCATE BLOOD GLUCOSE MONITOR MM 3 STADVOCATE CONTROL SOLUTION HIGH 3ADVOCATE DUO DEVICE 3 STADVOCATE DUO METER KIT 3 STADVOCATE LANCET 26 GAUGE MM 1ADVOCATE LANCET 30 GAUGE MM 1ADVOCATE LANCING DEVICE MM 1ADVOCATE LOW CONTROL SOLUTION 3ADVOCATE PEN NEEDLES 29 GAUGE X 1/2" 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSADVOCATE PEN NEEDLES 31 GAUGE X 3/16" 1ADVOCATE PEN NEEDLES 31 GAUGE X 5/16" 1ADVOCATE RAPID-SAFE LANCING DEVICE MM 3ADVOCATE REDI-CODE DUO METER 3 STADVOCATE REDI-CODE GLUCOSE MONITOR MM 3 STADVOCATE REDI-CODE GLUCOSE MONITOR KIT MM 3 STADVOCATE REDI-CODE STRIPS MM 3 QL,STADVOCATE REDI-CODE+ MM 3 STADVOCATE REDI-CODE+ CTRL HIGH SOLUTION 3ADVOCATE REDI-CODE+ CTRL LOW SOLUTION 3ADVOCATE REDI-CODE+ STRIPS MM 3 QL,STADVOCATE SYRINGES 0.3 ML 29 GAUGE X 1/2" MM 1ADVOCATE SYRINGES 0.3 ML 30 GAUGE X 5/16" MM 1ADVOCATE SYRINGES 0.3 ML 31 GAUGE X 5/16" MM 1ADVOCATE SYRINGES 0.5 ML 29 GAUGE X 1/2" MM 1ADVOCATE SYRINGES 0.5 ML 31 GAUGE X 5/16" MM 1ADVOCATE SYRINGES 1 ML 29 GAUGE X 1/2" MM 1ADVOCATE SYRINGES 1 ML 30 GAUGE X 5/16" MM 1ADVOCATE SYRINGES 1 ML 31 GAUGE X 5/16" MM 1ADVOCATE SYRINGES 1/2 ML 30 GAUGE X 5/16" MM 1ADVOCATE TEST STRIPS MM 3 QL,STADZENYS XR-ODT 12.5 MG EXTENDED RELEASE DISINTEGRATING TABLET 3 QL,STADZENYS XR-ODT 15.7 MG EXTENDED RELEASE DISINTEGRATING TABLET 3 QL,STADZENYS XR-ODT 18.8 MG EXTENDED RELEASE DISINTEGRATING TABLET 3 QL,STADZENYS XR-ODT 3.1 MG EXTENDED RELEASE DISINTEGRATING TABLET 3 QL,STADZENYS XR-ODT 6.3 MG EXTENDED RELEASE DISINTEGRATING TABLET 3 QL,STADZENYS XR-ODT 9.4 MG EXTENDED RELEASE DISINTEGRATING TABLET 3 QL,STAEROCHAMBER MINI 1AEROCHAMBER MV SPACER 1AEROCHAMBER PLUS FLOW-VU 3AEROCHAMBER PLUS FLOW-VU,LARGE MASK 1AEROCHAMBER PLUS FLOW-VU,MEDIUM MASK 1AEROCHAMBER PLUS FLOW-VU,SMALL MASK 2AEROCHAMBER PLUS Z STAT LARGE MASK 1AEROCHAMBER PLUS Z STAT MEDIUM MASK 2AEROCHAMBER PLUS Z STAT SMALL MASK 1AEROCHAMBER PLUS Z STAT SPACER 1AEROCHAMBER WITH FLOWSIGNAL 1AEROCHAMBER Z-STAT PLUS-FLOW SIGNAL 2AEROGEAR ACTION ASTHMA KIT 1AEROSPAN 80 MCG/ACTUATION HFA AEROSOL INHALER MM 3 QL,STAEROTRACH PLUS SPACER 1AEROVENT PLUS SPACER 2afeditab cr 30 mg tablet,extended release MM 2 QLafeditab cr 60 mg tablet,extended release MM 2 QLAFINITOR 10 MG TABLET SP * QL,PAAFINITOR 2.5 MG TABLET SP * QL,PAAFINITOR 5 MG TABLET SP * QL,PAAFINITOR 7.5 MG TABLET SP * QL,PAAFINITOR DISPERZ 2 MG TABLET FOR ORAL SUSPENSION SP * QL,PAAFINITOR DISPERZ 3 MG TABLET FOR ORAL SUSPENSION SP * QL,PAAFINITOR DISPERZ 5 MG TABLET FOR ORAL SUSPENSION SP * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSAFLURIA 2016-2017 (PF) 45 MCG(15 MCG X 3)/0.5 ML INTRAMUSCULAR SYRINGE 3AFLURIA 2016-2017 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSION 3AFLURIA QUAD 2016-2017 (PF) 60 MCG/0.5 ML INTRAMUSCULAR SYRINGE 3AFLURIA QUAD 2016-2017 60 MCG/0.5 ML INTRAMUSCULAR SUSPENSION 3AFREZZA 4 UNIT (30)/8 UNIT (60) CARTRIDGE WITH INHALER 3 QL,PAAFREZZA 4 UNIT (60)/8 UNIT (30) CARTRIDGE WITH INHALER 3 QL,PAAFREZZA 4 UNIT (90)/8 UNIT (90) CARTRIDGE WITH INHALER 3 QL,PAAFREZZA 4 UNIT CARTRIDGE WITH INHALER 3 QL,PAAFREZZA 8 UNIT (60)/12 UNIT (30) CARTRIDGE WITH INHALER 3 QL,PAAGAMATRIX AMP GLUCOSE MONITORING SYSTEM MM 3 STAGAMATRIX AMP TEST STRIPS MM 3 QL,STAGAMATRIX CONTROL HIGH SOLUTION 3AGAMATRIX CONTROL NORM-HI SOLUTION 3AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED RELEASE MM 3 STAGRYLIN 0.5 MG CAPSULE MM 4airshield 2,000 unit-1,000 mg-30 unit effervescent tablet 2airshield 5,000 unit-1,000 mg-30 unit effervescent tablet 2ak-poly-bac eye ointment 1AKNE-MYCIN 2% OINTMENT 3AKTEN (PF) 3.5 % EYE GEL 3AKYNZEO 300 MG-0.5 MG CAPSULE 4 QL,PAALA-CORT 1 % TOPICAL CREAM 3ALA-SCALP 2 % LOTION 4alagesic lq oral solution 3 QLALBENZA 200 MG TABLET 3albuterol 2.5 mg/0.5 ml sol MM 1albuterol 5 mg/ml solution MM 1albuterol sul 0.63 mg/3 ml sol MM 1albuterol sul 1.25 mg/3 ml sol MM 1albuterol sul 2.5 mg/3 ml soln MM 1albuterol sulf 2 mg/5 ml syrup MM 2albuterol sulfate 2 mg tab MM 3albuterol sulfate 4 mg tab MM 3albuterol sulfate er 4 mg tab MM 3albuterol sulfate er 8 mg tab MM 3ALCAINE 0.5 % EYE DROPS 3alclometasone dipr 0.05% oint 3alclometasone dipro 0.05% crm 3ALCOHOL 70% SWABS 3ALCOHOL PADS 3ALCOHOL PREP PADS 3ALCOHOL PREP SWABS 3ALCOHOL WIPES 3ALDACTAZIDE 25 MG-25 MG TABLET MM 3ALDACTAZIDE 50 MG-50 MG TABLET MM 3ALDACTONE 100 MG TABLET MM 3ALDACTONE 25 MG TABLET MM 3ALDACTONE 50 MG TABLET MM 3ALDARA 5 % TOPICAL CREAM PACKET 4 QLALECENSA 150 MG CAPSULE SP,LD * QL,PAalendronate sod 70 mg/75 ml MM 3 QLalendronate sodium 10 mg tab MM 1 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSalendronate sodium 35 mg tab MM 1 QLalendronate sodium 40 mg tab MM 1 QLalendronate sodium 5 mg tablet MM 1 QLalendronate sodium 70 mg tab MM 1 QLalfuzosin hcl er 10 mg tablet MM 1 QLALINIA 100 MG/5 ML ORAL SUSPENSION 3 QLALINIA 500 MG TABLET 3 QLALKERAN 2 MG TABLET 2 QLALLERGIST SYRINGE 1 ML 26 GAUGE X 1/2" 1ALLERGIST SYRINGE 1 ML 26 X 3/8" 1ALLERGIST SYRINGE 1 ML 27 X 1/2" 1ALLERGIST TRAY 1/2 ML 27GX3/8" 1/2 ML 27 X 3/8" SYRINGE 1ALLERGIST TRAY INTRADERMAL BEVEL 1 ML 26 GAUGE X 1/2" SYRINGE 1ALLERGIST TRAY INTRADERMAL BEVEL 1 ML 26 X 3/8" SYRINGE 1ALLERGIST TRAY INTRADERMAL BEVEL 1 ML 27 GAUGE X 3/8" SYRINGE 1ALLERGIST TRAY REGULAR BEVEL 1 ML 27 GAUGE X 3/8" SYRINGE 1allopurinol 100 mg tablet MM 1allopurinol 300 mg tablet MM 1ALLZITAL 25 MG-325 MG TABLET 4 QLalmotriptan malate 12.5 mg tab 3 QL,STalmotriptan malate 6.25 mg tab 3 QL,STALOCRIL 2 % EYE DROPS 3 STalogliptin 12.5 mg tablet MM 3 QLalogliptin 25 mg tablet MM 3 QLalogliptin 6.25 mg tablet MM 3 QLalogliptin-metformin 12.5-1000 MM 3 QLalogliptin-metformin 12.5-500 MM 3 QLalogliptin-pioglit 12.5-15 mg MM 3 QLalogliptin-pioglit 12.5-30 mg MM 3 QLalogliptin-pioglit 12.5-45 mg MM 3 QLalogliptin-pioglit 25-15 mg tb MM 3 QLalogliptin-pioglit 25-30 mg tb MM 3 QLalogliptin-pioglit 25-45 mg tb MM 3 QLALOMIDE 0.1 % EYE DROPS 3ALORA 0.025 MG/24 HR TRANSDERMAL PATCH MM 3 QLALORA 0.05 MG/24 HR TRANSDERMAL PATCH MM 3 QLALORA 0.075 MG/24 HR TRANSDERMAL PATCH MM 3 QLALORA 0.1 MG/24 HR TRANSDERMAL PATCH MM 3 QLalosetron hcl 0.5 mg tablet MM 4 QL,PAalosetron hcl 1 mg tablet MM 4 QL,PAALPHAGAN P 0.1 % EYE DROPS MM 3 STALPHAGAN P 0.15 % EYE DROPS MM 3 STalprazolam 0.25 mg tablet 1 QLalprazolam 0.5 mg tablet 1 QLalprazolam 1 mg tablet 1 QLalprazolam 2 mg tablet 1 QLalprazolam er 0.5 mg tablet 2 QLalprazolam er 1 mg tablet 2 QLalprazolam er 2 mg tablet 2 QLalprazolam er 3 mg tablet 2 QLalprazolam intensol 1 mg/ml oral concentrate 1alprazolam odt 0.25 mg tab 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSalprazolam odt 0.5 mg tab 3alprazolam odt 1 mg tab 3alprazolam odt 2 mg tab 3ALREX 0.2 % EYE DROPS,SUSPENSION 3 STALSUMA 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 3 QLALTABAX 1 % TOPICAL OINTMENT 3ALTACE 1.25 MG CAPSULE MM 3ALTACE 10 MG CAPSULE MM 3ALTACE 2.5 MG CAPSULE MM 3ALTACE 5 MG CAPSULE MM 3altavera (28) 0.15 mg-0.03 mg tablet MM 1ALTERNATE SITE LANCET 26 GAUGE MM 1ALTERNATE SITE LANCING DEVICE MM 1ALTOPREV 20 MG TABLET,EXTENDED RELEASE MM 4 QL,STALTOPREV 40 MG TABLET,EXTENDED RELEASE MM 4 QL,STALTOPREV 60 MG TABLET,EXTENDED RELEASE MM 4 QL,STALVESCO 160 MCG/ACTUATION AEROSOL INHALER MM 3 QL,STALVESCO 80 MCG/ACTUATION AEROSOL INHALER MM 3 QL,STalyacen 1/35 (28) 1 mg-35 mcg tablet MM 1alyacen 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM 1ALZ 10 MG-100 MG-65 MG-600 MG TABLET,EXTENDED RELEASE 3amabelz 0.5 mg-0.1 mg tablet MM 3amabelz 1 mg-0.5 mg tablet MM 3amantadine 100 mg capsule MM 3amantadine 100 mg tablet MM 3amantadine 50 mg/5 ml solution MM 1AMARYL 1 MG TABLET MM 3AMARYL 2 MG TABLET MM 3AMARYL 4 MG TABLET MM 3AMBIEN 10 MG TABLET 3 QL,STAMBIEN 5 MG TABLET 3 QL,STAMBIEN CR 12.5 MG TABLET,EXTENDED RELEASE 3 QL,STAMBIEN CR 6.25 MG TABLET,EXTENDED RELEASE 3 QL,STamcinonide 0.1% cream 3amcinonide 0.1% lotion 3amcinonide 0.1% ointment 3AMERGE 1 MG TABLET 3 QL,STAMERGE 2.5 MG TABLET 3 QL,STamethia 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack 1 QLamethia lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MM 1 QLamethyst 90 mcg-20 mcg tablet MM 1AMICAR 1,000 MG TABLET 4AMICAR 250 MG/ML (25 %) ORAL SOLUTION 4AMICAR 500 MG TABLET 4amiloride hcl 5 mg tablet MM 2amiloride hcl-hctz 5-50 mg tab MM 1aminocaproic acid 1,000 mg tab 4aminocaproic acid 25% solution 4aminocaproic acid 500 mg tab 4AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS SOLUTION 3AMINOSYN 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTION 3AMINOSYN II 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTION 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSAMINOSYN M 3.5 % INTRAVENOUS SOLUTION 3AMINOSYN-HBC 7% INTRAVENOUS SOLUTION 3amiodarone hcl 100 mg tablet MM 1amiodarone hcl 200 mg tablet MM 1amiodarone hcl 400 mg tablet MM 1AMITIZA 24 MCG CAPSULE MM 2 QLAMITIZA 8 MCG CAPSULE MM 2 QLamitriptyline hcl 10 mg tab MM 1amitriptyline hcl 100 mg tab MM 1amitriptyline hcl 150 mg tab MM 1amitriptyline hcl 25 mg tab MM 1amitriptyline hcl 50 mg tab MM 1amitriptyline hcl 75 mg tab MM 1amlod-valsa-hctz 10-160-12.5mg MM 3 QL,STamlod-valsa-hctz 10-160-25 mg MM 3 QL,STamlod-valsa-hctz 10-320-25 mg MM 3 QL,STamlod-valsa-hctz 5-160-12.5 mg MM 3 QL,STamlod-valsa-hctz 5-160-25 mg MM 3 QL,STamlodipine besylate 10 mg tab MM 1 QLamlodipine besylate 2.5 mg tab MM 1 QLamlodipine besylate 5 mg tab MM 1 QLamlodipine-atorvast 10-10 mg MM 3 QLamlodipine-atorvast 10-20 mg MM 3 QLamlodipine-atorvast 10-40 mg MM 3 QLamlodipine-atorvast 10-80 mg MM 3 QLamlodipine-atorvast 2.5-10 mg MM 3 QLamlodipine-atorvast 2.5-20 mg MM 3 QLamlodipine-atorvast 2.5-40 mg MM 3 QLamlodipine-atorvast 5-10 mg MM 3 QLamlodipine-atorvast 5-20 mg MM 3 QLamlodipine-atorvast 5-40 mg MM 3 QLamlodipine-atorvast 5-80 mg MM 3 QLamlodipine-benazepril 10-20 mg MM 1 QLamlodipine-benazepril 10-40 mg MM 1 QLamlodipine-benazepril 2.5-10 MM 1 QLamlodipine-benazepril 5-10 mg MM 1 QLamlodipine-benazepril 5-20 mg MM 1 QLamlodipine-benazepril 5-40 mg MM 1 QLamlodipine-valsartan 10-160 mg MM 3 QL,STamlodipine-valsartan 10-320 mg MM 3 QL,STamlodipine-valsartan 5-160 mg MM 3 QL,STamlodipine-valsartan 5-320 mg MM 3 QL,STammonium lactate 12% cream 2ammonium lactate 12% lotion 2amnesteem 10 mg capsule 4 QLamnesteem 20 mg capsule 4 QLamnesteem 40 mg capsule 4 QLamox-clav 200-28.5 mg tab chew 2amox-clav 200-28.5 mg/5 ml sus 2amox-clav 250-125 mg tablet 2amox-clav 250-62.5 mg/5 ml sus 2amox-clav 400-57 mg tab chew 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSamox-clav 400-57 mg/5 ml susp 2amox-clav 500-125 mg tablet 2amox-clav 600-42.9 mg/5 ml sus 2amox-clav 875-125 mg tablet 2amox-clav er 1,000-62.5 mg tab 3amoxapine 100 mg tablet MM 2amoxapine 150 mg tablet MM 2amoxapine 25 mg tablet MM 2amoxapine 50 mg tablet MM 2amoxicillin 125 mg tab chew 2amoxicillin 125 mg/5 ml susp 2amoxicillin 200 mg/5 ml susp 2amoxicillin 250 mg capsule 2amoxicillin 250 mg tab chew 2amoxicillin 250 mg/5 ml susp 2amoxicillin 400 mg/5 ml susp 2amoxicillin 500 mg capsule 2amoxicillin 500 mg tablet 2amoxicillin 875 mg tablet 2amoxicillin er 775 mg tablet 2ampicillin 125 mg/5 ml susp 2ampicillin 250 mg capsule 2ampicillin 250 mg/5 ml susp 2ampicillin 500 mg capsule 2AMPYRA 10 MG TABLET,EXTENDED RELEASE SP,LD * QL,PAAMRIX 15 MG CAPSULE,EXTENDED RELEASE 4 QL,PAAMRIX 30 MG CAPSULE,EXTENDED RELEASE 4 QL,PAAMTURNIDE 150-5-12.5 MG TAB MM 3 QLAMTURNIDE 300-10-12.5 MG TAB MM 3 QLAMTURNIDE 300-10-25 MG TAB MM 3 QLAMTURNIDE 300-5-12.5 MG TAB MM 3 QLAMTURNIDE 300-5-25 MG TAB MM 3 QLANAFRANIL 25 MG CAPSULE MM 4ANAFRANIL 50 MG CAPSULE MM 4ANAFRANIL 75 MG CAPSULE MM 4anagrelide hcl 0.5 mg capsule MM 3anagrelide hcl 1 mg capsule MM 3ANALPRAM HC 1% CREAM SINGLES 3ANALPRAM HC 2.5% LOTION 3ANALPRAM-HC 1 %-1 % RECTAL CREAM 3ANALPRAM-HC 2.5 %-1 % LOTION 3ANAPROX 275 MG TABLET MM 3ANAPROX DS 550 MG TABLET MM 3ANASPAZ 0.125 MG DISINTEGRATING TABLET MM 3anastrozole 1 mg tablet MM 1 QLANCOBON 250 MG CAPSULE 3ANCOBON 500 MG CAPSULE 3ANDRODERM 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 3 QL,STANDRODERM 4 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM 3 QL,STANDROGEL 1 % 12.5 MG PER PUMP ACTUATION (1.25 GRAM GEL) TRANSDERMALMM

3 QL,ST

ANDROGEL 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSANDROGEL 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKET MM 3 QL,STANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKET MM 2 QLANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKET MM 2 QLANDROGEL 20.25 MG/1.25 GRAM (1.62 %) TRANSDERMAL GEL PUMP MM 2 QLANDROID 10 MG CAPSULE MM 4ANGELIQ 0.25 MG-0.5 MG TABLET MM 3ANGELIQ 0.5 MG-1 MG TABLET MM 3ANORO ELLIPTA 62.5 MCG-25 MCG/ACTUATION POWDER FOR INHALATION MM 2 QLANTABUSE 250 MG TABLET MM 3ANTABUSE 500 MG TABLET MM 3ANTARA 30 MG CAPSULE MM 3 QL,STANTARA 90 MG CAPSULE MM 3 QL,STANTI-ALLERGY FORMULA 100 MG-100 MG-50 MG TABLET 3ANUSOL-HC 2.5 % RECTAL CREAM 3ANZEMET 100 MG TABLET 4 QLANZEMET 50 MG TABLET 4 QLapexicon e 0.05 % topical cream 4 STAPIDRA 100 UNIT/ML SUBCUTANEOUS SOLUTION MM 3 STAPIDRA SOLOSTAR 100 UNIT/ML SUBCUTANEOUS INSULIN PEN MM 3 STAPLENZIN 174 MG TABLET,EXTENDED RELEASE MM 4 QL,STAPLENZIN 348 MG TABLET,EXTENDED RELEASE MM 4 QL,STAPLENZIN 522 MG TABLET,EXTENDED RELEASE MM 4 QL,STAPOKYN 10 MG/ML SUBCUTANEOUS CARTRIDGE SP,LD * QLapraclonidine hcl 0.5% drops 3apri 0.15 mg-0.03 mg tablet MM 1APRISO 0.375 GRAM CAPSULE,EXTENDED RELEASE MM 2 QLAPTENSIO XR 10 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTENSIO XR 15 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTENSIO XR 20 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTENSIO XR 30 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTENSIO XR 40 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTENSIO XR 50 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTENSIO XR 60 MG CAPSULE,EXTENDED RELEASE SPRINKLE 3 QL,STAPTIOM 200 MG TABLET MM 4 QL,PAAPTIOM 400 MG TABLET MM 4 QL,PAAPTIOM 600 MG TABLET MM 4 QL,PAAPTIOM 800 MG TABLET MM 4 QL,PAAPTIVUS 100 MG/ML ORAL SOLUTION SP * QLAPTIVUS 250 MG CAPSULE SP * QLAQUA LANCE LANCING DEVICE MM 1aranelle (28) 0.5 mg/1 mg/0.5 mg-35 mcg tablet MM 1ARANESP 10 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 100 MCG/0.5 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 100 MCG/ML (IN POLYSORBATE) INJECTION SP * QL,PAARANESP 150 MCG/0.3 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 150 MCG/0.75 ML (IN POLYSORBATE) INJECTION SP * QL,PAARANESP 200 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 200 MCG/ML (IN POLYSORBATE) INJECTION SP * QL,PAARANESP 25 MCG/0.42 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 25 MCG/ML (IN POLYSORBATE) INJECTION SP * QL,PAARANESP 300 MCG/0.6 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 300 MCG/ML (IN POLYSORBATE) INJECTION SP * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSARANESP 40 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 40 MCG/ML (IN POLYSORBATE) INJECTION SP * QL,PAARANESP 500 MCG/ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 60 MCG/0.3 ML (IN POLYSORBATE) INJECTION SYRINGE SP * QL,PAARANESP 60 MCG/ML (IN POLYSORBATE) INJECTION SP * QL,PAARAVA 10 MG TABLET MM 4 QLARAVA 20 MG TABLET MM 4 QLarbinoxa 4 mg tablet 3arbinoxa 4 mg/5 ml oral liquid 3ARCALYST 220 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PAARCAPTA NEOHALER 75 MCG CAPSULE WITH INHALATION DEVICE MM 3 QL,STARGINAID 4.5 GRAM-156 MG/9.2 GRAM ORAL POWDER PACKET 3ARGINAID EXTRA 6 GRAM-4.5 GRAM-250 MG ORAL LIQUID 3ARICEPT 10 MG TABLET MM 3 QL,STARICEPT 23 MG TABLET MM 3 QL,STARICEPT 5 MG TABLET MM 3 QL,STARICEPT ODT 10 MG TABLET MM 3 QL,STARIMIDEX 1 MG TABLET MM 3 QLaripiprazole 1 mg/ml solution MM 3 QLaripiprazole 10 mg tablet MM 3 QLaripiprazole 15 mg tablet MM 3 QLaripiprazole 2 mg tablet MM 3 QLaripiprazole 20 mg tablet MM 3 QLaripiprazole 30 mg tablet MM 3 QLaripiprazole 5 mg tablet MM 3 QLaripiprazole odt 10 mg tablet MM 4 QLaripiprazole odt 15 mg tablet MM 4 QLARIXTRA 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE 4 QLARIXTRA 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE 4 QLARIXTRA 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE 4 QLARIXTRA 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE 4 QLarmodafinil 150 mg tablet MM 4 QL,PAarmodafinil 200 mg tablet MM 4 QL,PAarmodafinil 250 mg tablet MM 4 QL,PAarmodafinil 50 mg tablet MM 4 QL,PAARMOUR THYROID 120 MG TABLET MM 3ARMOUR THYROID 15 MG TABLET MM 3ARMOUR THYROID 180 MG TABLET MM 3ARMOUR THYROID 240 MG TABLET MM 3ARMOUR THYROID 30 MG TABLET MM 3ARMOUR THYROID 300 MG TABLET MM 3ARMOUR THYROID 60 MG TABLET MM 3ARMOUR THYROID 90 MG TABLET MM 3ARNUITY ELLIPTA 100 MCG/ACTUATION POWDER FOR INHALATION 2 QLARNUITY ELLIPTA 200 MCG/ACTUATION POWDER FOR INHALATION 2 QLAROMASIN 25 MG TABLET MM 4 QLARTHROTEC 50 MG-200 MCG TABLET,FILM-COATED MM 4 STARTHROTEC 75 75 MG-200 MCG TABLET,FILM-COATED MM 4 STasa-butalb-caff-cod #3 capsule 3 QLASACOL HD 800 MG TABLET,DELAYED RELEASE MM 4 QL,STascomp with codeine 30 mg-50 mg-325 mg-40 mg capsule 3 QLashlyna 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack 1 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSASMANEX HFA 100 MCG/ACTUATION AEROSOL INHALER 3 QL,STASMANEX HFA 200 MCG/ACTUATION AEROSOL INHALER 3 QL,STASMANEX TWISTHALER 110 MCG (30 DOSES) BREATH ACTIVATED MM 3 QL,STASMANEX TWISTHALER 110 MCG (7 DOSES) BREATH ACTIVATED MM 3 QL,STASMANEX TWISTHALER 220 MCG (120 DOSES) BREATH ACTIVATED MM 3 QL,STASMANEX TWISTHALER 220 MCG (14 DOSES) BREATH ACTIVATED MM 3 QL,STASMANEX TWISTHALER 220 MCG (30 DOSES) BREATH ACTIVATED MM 3 QL,STASMANEX TWISTHALER 220 MCG (60 DOSES) BREATH ACTIVATED MM 3 QL,STaspirin-caff-dihydrocodein cap 3 QLaspirin-dipyridam er 25-200 mg MM 3 STASSURE 4 CONTROL SOLUTION COMBO PACK 3ASSURE 4 STRIPS MM 3 QL,STASSURE COMFORT 28G LANCETS MM 1ASSURE DOSE NORMAL CONTROL SOLUTION 3ASSURE DOSE NORMAL-HIGH CONTROL SOLUTION 3ASSURE HAEMOLANCE PLUS 18 GAUGE MM 3ASSURE HAEMOLANCE PLUS 21 GAUGE MM 3ASSURE HAEMOLANCE PLUS 25 GAUGE MM 3ASSURE HAEMOLANCE PLUS 28 GAUGE MM 3ASSURE ID INSULIN SAFETY 0.5 ML 29 GAUGE X 1/2" SYRINGE MM 1ASSURE ID INSULIN SAFETY 1 ML 29 GAUGE X 1/2" SYRINGE MM 2ASSURE LANCE 25 GAUGE MM 3ASSURE LANCE 28 GAUGE MM 3ASSURE LANCE PLUS 21 GAUGE MM 3ASSURE LANCE PLUS 25 GAUGE MM 3ASSURE LANCE PLUS 30 GAUGE MM 3ASSURE PLATINUM MM 3 STASSURE PLATINUM STRIPS MM 3 QL,STASSURE PRISM CONTROL 1-2 SOLUTION 3ASSURE PRISM MULTI METER MM 3 STASSURE PRISM MULTI STRIP MM 3 QL,STASSURE PRO TEST STRIPS MM 3 QL,STASTAGRAF XL 0.5 MG CAPSULE,EXTENDED RELEASE 3ASTAGRAF XL 1 MG CAPSULE,EXTENDED RELEASE 3ASTAGRAF XL 5 MG CAPSULE,EXTENDED RELEASE 3astaxanthin 4 mg softgel 2ASTEPRO 0.15 % (205.5 MCG) NASAL SPRAY MM 4 QL,STASTHMAPACK CHILDREN'S KIT 1ATABEX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE 1ATACAND 16 MG TABLET MM 3 QL,STATACAND 32 MG TABLET MM 3 QL,STATACAND 4 MG TABLET MM 3 QL,STATACAND 8 MG TABLET MM 3 QL,STATACAND HCT 16 MG-12.5 MG TABLET MM 3 QL,STATACAND HCT 32 MG-12.5 MG TABLET MM 3 QL,STATACAND HCT 32 MG-25 MG TABLET MM 3 QL,STATELVIA 35 MG TABLET,DELAYED RELEASE MM 3 QLatenolol 100 mg tablet MM 1atenolol 25 mg tablet MM 1atenolol 50 mg tablet MM 1atenolol-chlorthalidone 100-25 MM 1atenolol-chlorthalidone 50-25 MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSATIVAN 0.5 MG TABLET 4 QLATIVAN 1 MG TABLET 4 QLATIVAN 2 MG TABLET 4 QLatorvastatin 10 mg tablet MM 1 QLatorvastatin 20 mg tablet MM 1 QLatorvastatin 40 mg tablet MM 1 QLatorvastatin 80 mg tablet MM 1 QLatovaquone 750 mg/5 ml susp 4 QLatovaquone-proguanil 250-100 3 QLatovaquone-proguanil 62.5-25 3 QLATRALIN 0.05 % TOPICAL GEL 4 STATRIPLA 600 MG-200 MG-300 MG TABLET SP * QLatropine 1% eye drops MM 1ATROVENT 0.03% SPRAY MM 3 QLATROVENT 0.06% SPRAY MM 3 QLATROVENT HFA 17 MCG/ACTUATION AEROSOL INHALER MM 3 QL,STAUBAGIO 14 MG TABLET SP,LD * QL,PAAUBAGIO 7 MG TABLET SP,LD * QL,PAaubra 0.1 mg-20 mcg tablet MM 1AUGMENTIN 125 MG-31.25 MG/5 ML ORAL SUSPENSION 3AUGMENTIN 250 MG-62.5 MG/5 ML ORAL SUSPENSION 3AUGMENTIN 500 MG-125 MG TABLET 3AUGMENTIN 875 MG-125 MG TABLET 3AUGMENTIN ES-600 600 MG-42.9 MG/5 ML ORAL SUSPENSION 3AUGMENTIN XR 1,000 MG-62.5 MG TABLET,EXTENDED RELEASE 3AURYXIA 210 MG IRON TABLET SP * QLAUTO-LANCET MINI MM 1AUTOJECT 2 INJECTION DEVICE SUBCUTANEOUS INSULIN PEN 3AUTOLET IMPRESSION LANCING DEVICE KIT MM 3AUTOLET LANCING DEVICE MM 1AUTOLET PLUS LANCING DEVICE MM 3AUTOPEN 1 TO 16 UNITS SUBCUTANEOUS 3AUTOPEN 1 TO 21 UNITS SUBCUTANEOUS 3AUTOPEN 2 TO 32 UNITS SUBCUTANEOUS 3AUTOPEN 2 TO 42 UNITS SUBCUTANEOUS 3AUVI-Q 0.15 MG AUTO-INJECTOR 3 STAUVI-Q 0.3 MG AUTO-INJECTOR 3 QL,STAVALIDE 150 MG-12.5 MG TABLET MM 3 QL,STAVALIDE 300 MG-12.5 MG TABLET MM 3 QL,STAVANDAMET 2 MG-1,000 MG TABLET MM 3 QLAVANDAMET 2 MG-500 MG TABLET MM 3 QLAVANDAMET 4 MG-500 MG TABLET MM 3 QLAVANDARYL 4 MG-1 MG TABLET MM 3 QLAVANDARYL 4 MG-2 MG TABLET MM 3 QLAVANDARYL 4 MG-4 MG TABLET MM 3 QLAVANDARYL 8 MG-4 MG TABLET MM 3 QLAVANDIA 2 MG TABLET MM 3 QLAVANDIA 4 MG TABLET MM 3 QLAVANDIA 8 MG TABLET MM 3 QLAVAPRO 150 MG TABLET MM 3 QL,STAVAPRO 300 MG TABLET MM 3 QL,STAVAPRO 75 MG TABLET MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSAVC VAGINAL 15 % CREAM 4AVELOX 400 MG TABLET 3AVELOX ABC PACK 400 MG TABLET 3aviane 0.1 mg-20 mcg tablet MM 1avidoxy 100 mg tablet 2AVINZA 120 MG CAPSULE 4 QL,STAVINZA 30 MG CAPSULE 4 QL,STAVINZA 45 MG CAPSULE 4 QL,STAVINZA 60 MG CAPSULE 4 QL,STAVINZA 75 MG CAPSULE 4 QL,STAVINZA 90 MG CAPSULE 4 QL,STAVITA 0.025 % TOPICAL CREAM 4AVITA 0.025 % TOPICAL GEL 4AVODART 0.5 MG CAPSULE MM 3 QL,STAVONEX (WITH ALBUMIN) 30 MCG INTRAMUSCULAR KIT SP * QL,PAAVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR SP * QL,PAAVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN KIT SP * QL,PAAVONEX 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE SP * QL,PAAVONEX 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT SP * QL,PAAXERT 12.5 MG TABLET 3 QL,STAXERT 6.25 MG TABLET 3 QL,STAXIRON 30 MG/ACTUATION (1.5 ML) TRANSDERM SOLUTION IN METERED PUMP MM 3 QL,STAYGESTIN 5 MG TABLET MM 3AZASAN 100 MG TABLET MM 3AZASAN 75 MG TABLET MM 3AZASITE 1 % EYE DROPS 2 QLazathioprine 50 mg tablet 2azelastine 0.1% (137 mcg) spry MM 2 QLazelastine 0.15% nasal spray MM 3 QLazelastine hcl 0.05% drops 2AZELEX 20 % TOPICAL CREAM 4AZILECT 0.5 MG TABLET MM 3 PAAZILECT 1 MG TABLET MM 3 PAazithromycin 1 gm pwd packet 2azithromycin 100 mg/5 ml susp 2azithromycin 200 mg/5 ml susp 2azithromycin 250 mg tablet 2azithromycin 500 mg tablet 2azithromycin 600 mg tablet 2 QLAZOPT 1 % EYE DROPS,SUSPENSION MM 3 QL,STAZOR 10 MG-20 MG TABLET MM 3 QL,STAZOR 10 MG-40 MG TABLET MM 3 QL,STAZOR 5 MG-20 MG TABLET MM 3 QL,STAZOR 5 MG-40 MG TABLET MM 3 QL,STAZULFIDINE 500 MG TABLET MM 3 QLAZULFIDINE EN-TABS 500 MG TABLET,DELAYED RELEASE MM 3 QLazurette (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM 1b-12 compliance 1,000 mcg/ml injection kit 2b-12 kit 1,000 mcg/ml injection kit 2BABY'S ONLY DAIRY 2 GRAM-80 KCAL/17 GRAM ORAL POWDER 3BABY'S ONLY ORG LACTORELIEF 2 GRAM-80 KCAL/17 GRAM ORAL POWDER 3BABY'S ONLY ORGANIC DAIRY 2 GRAM-80 KCAL/17 GRAM ORAL POWDER 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSBABY'S ONLY ORGANIC DAIRY WHEY 2 GRAM-80 KCAL/17 GRAM ORAL POWDER 3BABY'S ONLY ORGANIC SOY 2 GRAM-80 KCAL/17.5 GRAM ORAL POWDER 3bacitracin 500 unit/gm ophth 3bacitracin-polymyxin eye oint 2baclofen 10 mg tablet MM 2 QLbaclofen 20 mg tablet MM 2 QLBACTRIM 400 MG-80 MG TABLET 3BACTRIM DS 800 MG-160 MG TABLET 3BACTROBAN 2 % TOPICAL CREAM 3BACTROBAN 2% OINTMENT 3BACTROBAN NASAL 2 % OINTMENT 3bal-care dha 27 mg-1 mg-430 mg tablet-capsule,delayed release 3BAL-CARE DHA ESSENTIAL 27 MG IRON-1 MG-374 MG TABLET,CAPSULE,DELAY REL 3balanced nutritional oral liquid 2balanced nutritional plus oral liquid 2balsalazide disodium 750 mg cp 3 QLbalziva (28) 0.4 mg-35 mcg tablet MM 1BANZEL 200 MG TABLET MM 4 QL,PABANZEL 40 MG/ML ORAL SUSPENSION MM 4 QL,PABANZEL 400 MG TABLET MM 4 QL,PABARACLUDE 0.05 MG/ML ORAL SOLUTION SP * QLBARACLUDE 0.5 MG TABLET SP * QL,STBARACLUDE 1 MG TABLET SP * QL,STBD 1 ML SYRINGE-NEEDLE 25GX5/8 1BD ALCOHOL SWABS 3BD ALLERGIST TRAY REG BEVEL 1 ML 26 GAUGE X 1/2" SYRINGE 1BD ALLERGIST TRAY REG BEVEL 1 ML 27 X 1/2" SYRINGE 1BD ALLERGIST TRAY REG BEVEL 1/2 ML 27 X 1/2" 1BD AUTOSHIELD DUO PEN NEEDLE 30 GAUGE X 3/16" 1BD AUTOSHIELD PEN NEEDLE 29 GAUGE X 3/16" MM 1BD AUTOSHIELD PEN NEEDLE 29 GAUGE X 5/16" MM 1BD BLUNT NEEDLE 18GX1-1/2" 1BD ECLIPSE LUER-LOK 1 ML 30 GAUGE X 1/2" SYRINGE MM 2BD ECLIPSE NEEDLE 18GX1 1/2" 1BD ECLIPSE SYRINGE 3 ML 22GX1" 1BD FILTER NEEDLE-5 MICRON 19 X 1 1/2" 1BD INSULIN PEN NEEDLE UF MINI 31 GAUGE X 3/16" 1BD INSULIN PEN NEEDLE UF ORIGINAL 29 GAUGE X 1/2" 1BD INSULIN PEN NEEDLE UF SHORT 31 GAUGE X 5/16" 1BD INSULIN SYR 1 ML 25GX5/8" MM 2BD INSULIN SYR 1 ML 28GX1/2" MM 2BD INSULIN SYRINGE 1 ML 25 GAUGE X 5/8" MM 2BD INSULIN SYRINGE 1 ML 25 X 1" MM 2BD INSULIN SYRINGE 1 ML 26 X 1/2" MM 2BD INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2BD INSULIN SYRINGE HALF UNIT 0.3 ML 31 GAUGE X 15/64" MM 2BD INSULIN SYRINGE HALF UNIT 0.3 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE MICRO-FINE 0.3 ML 28 MM 2BD INSULIN SYRINGE MICRO-FINE 1 ML 28 GAUGE X 1/2" MM 2BD INSULIN SYRINGE MICRO-FINE 1/2 ML 28 GAUGE X 1/2" MM 2BD INSULIN SYRINGE SAFETY-LOK 1 ML 29 GAUGE X 1/2" MM 2BD INSULIN SYRINGE SLIP TIP 1 ML MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSBD INSULIN SYRINGE ULT-FINE II 0.3 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE ULT-FINE II 0.5 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE ULT-FINE II 1 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 30 GAUGE X 1/2" MM 2BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 31 GAUGE X 15/64" MM 2BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE ULTRA-FINE 0.5 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE ULTRA-FINE 1 ML 29 GAUGE X 1/2" MM 2BD INSULIN SYRINGE ULTRA-FINE 1 ML 30 GAUGE X 1/2" MM 2BD INSULIN SYRINGE ULTRA-FINE 1 ML 31 GAUGE X 15/64" MM 2BD INSULIN SYRINGE ULTRA-FINE 1 ML 31 GAUGE X 5/16" MM 2BD INSULIN SYRINGE ULTRA-FINE 1/2 ML 30 GAUGE X 1/2" MM 2BD INSULIN SYRINGE ULTRA-FINE 1/2 ML 31 GAUGE X 15/64" MM 2BD INTEGRA INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2BD INTEGRA SYRINGE 3 ML 25 GAUGE X 1" 1BD LANCET DEVICE MM 1BD LANCETS 33G MM 1BD LO-DOSE MICRO-FINE IV 0.3 ML 28 GAUGE X 1/2" SYRINGE MM 2BD LO-DOSE MICRO-FINE IV 1/2 ML 28 GAUGE X 1/2" SYRINGE MM 2BD LO-DOSE ULTRA-FINE 0.3 ML 29 GAUGE X 1/2" SYRINGE MM 2BD LO-DOSE ULTRA-FINE 0.5 ML 29 GAUGE X 1/2" SYRINGE MM 2BD LUER-LOK 5 ML SYRINGE 1BD LUER-LOK SYRINGE 1 ML MM 1BD MICROTAINER LANCET 21 GAUGE MM 1BD MICROTAINER LANCET 30 GAUGE MM 1BD SAFETYGLIDE ALLERGIST TRAY 1 ML 27 X 1/2" SYRINGE 1BD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2BD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2BD SAFETYGLIDE INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2BD SAFETYGLIDE INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2BD SAFETYGLIDE INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2BD SAFETYGLIDE SYRINGE 1 ML 27 GAUGE X 5/8" MM 2BD SLIP TIP 60 ML SYRINGE 1BD SYRINGE 30 ML 1BD SYRINGE GLASS 3 ML 1BD ULTRA FINE LANCETS 33 GAUGE MM 1BD ULTRA-FINE II LANCETS 30 GAUGE MM 1BD ULTRA-FINE NANO PEN NEEDLES 32 GAUGE X 5/32" 1BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY MM 3 QL,STbekyree (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM 1BELBUCA 150 MCG BUCCAL FILM 3 QL,PABELBUCA 300 MCG BUCCAL FILM 3 QL,PABELBUCA 450 MCG BUCCAL FILM 3 QL,PABELBUCA 600 MCG BUCCAL FILM 3 QL,PABELBUCA 75 MCG BUCCAL FILM 3 QL,PABELBUCA 750 MCG BUCCAL FILM 3 QL,PABELBUCA 900 MCG BUCCAL FILM 3 QL,PABELSOMRA 10 MG TABLET 3 QL,STBELSOMRA 15 MG TABLET 3 QL,STBELSOMRA 20 MG TABLET 3 QL,STBELSOMRA 5 MG TABLET 3 QL,STbenazepril hcl 10 mg tablet MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSbenazepril hcl 20 mg tablet MM 1benazepril hcl 40 mg tablet MM 1benazepril hcl 5 mg tablet MM 1benazepril-hctz 10-12.5 mg tab MM 2benazepril-hctz 20-12.5 mg tab MM 2benazepril-hctz 20-25 mg tab MM 2benazepril-hctz 5-6.25 mg tab MM 2BENECALORIE 7.5 KCAL/ML ORAL LIQUID 3BENICAR 20 MG TABLET MM 3 QL,STBENICAR 40 MG TABLET MM 3 QL,STBENICAR 5 MG TABLET MM 3 QL,STBENICAR HCT 20 MG-12.5 MG TABLET MM 3 QL,STBENICAR HCT 40 MG-12.5 MG TABLET MM 3 QL,STBENICAR HCT 40 MG-25 MG TABLET MM 3 QL,STBENTYL 10 MG CAPSULE 3BENTYL 20 MG TABLET 3BENZACLIN 1 %-5 % TOPICAL GEL 4BENZACLIN PUMP 1 %-5 % TOPICAL GEL 4BENZAMYCIN 3 %-5 % TOPICAL GEL 4BENZAMYCINPAK 3 %-5 % TOPICAL GEL 4benzonatate 100 mg capsule 3benzonatate 150 mg capsule 3benzonatate 200 mg capsule 3benztropine mes 0.5 mg tab MM 1benztropine mes 1 mg tablet MM 1benztropine mes 2 mg tablet MM 1BEPREVE 1.5 % EYE DROPS 3 QL,STBESIVANCE 0.6 % EYE DROPS,SUSPENSION 2BETADINE OPHTHALMIC PREP 5 % SOLUTION 3BETAGAN 0.5 % EYE DROPS MM 3betamethasone dp 0.05% crm 2betamethasone dp 0.05% lot 2betamethasone dp 0.05% oint 2betamethasone dp aug 0.05% crm 2betamethasone dp aug 0.05% gel 3betamethasone dp aug 0.05% lot 3betamethasone dp aug 0.05% oin 2betamethasone va 0.1% cream 2betamethasone va 0.1% lotion 3betamethasone valer 0.1% ointm 2betamethasone valer 0.12% foam 3 STBETAPACE 120 MG TABLET MM 3BETAPACE 160 MG TABLET MM 3BETAPACE 240 MG TABLET MM 3BETAPACE 80 MG TABLET MM 3BETAPACE AF 120 MG TABLET MM 3BETAPACE AF 160 MG TABLET MM 3BETAPACE AF 80 MG TABLET MM 3BETASERON 0.3 MG SUBCUTANEOUS KIT SP * QL,PABETASERON 0.3 MG SUBCUTANEOUS SOLUTION SP * QL,PAbetaxolol 10 mg tablet MM 2betaxolol 20 mg tablet MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSbetaxolol hcl 0.5% eye drop MM 3bethanechol 10 mg tablet 2bethanechol 25 mg tablet 2bethanechol 5 mg tablet 2bethanechol 50 mg tablet 2BETHKIS 300 MG/4 ML SOLUTION FOR NEBULIZATION SP,LD * QL,PABETIMOL 0.25 % EYE DROPS MM 3 STBETIMOL 0.5 % EYE DROPS MM 3 STBETOPTIC S 0.25 % EYE DROPS,SUSPENSION MM 3 STBEVESPI AEROSPHERE 9 MCG-4.8 MCG HFA AEROSOL INHALER 3 QL,PAbexarotene 75 mg capsule SP * QL,PABEYAZ 3 MG-0.02 MG-0.451 MG (24) TABLET MM 2BG-STAR GLUCOSE TEST STRIPS MM 3 QL,STBIAXIN 250 MG TABLET 3BIAXIN 250 MG/5 ML ORAL SUSPENSION 3BIAXIN 500 MG TABLET 3bicalutamide 50 mg tablet MM 1 QLBIDIL 20 MG-37.5 MG TABLET MM 2 QLBIFERA RX 22 MG-6 MG-1 MG-25 MCG TABLET 2BILTRICIDE 600 MG TABLET 3bimatoprost 0.03% eye drops MM 3 QLBINOSTO 70 MG EFFERVESCENT TABLET MM 3 QL,STbioflex 500 mg-50 mg-25 mg-40 mg tablet 2BIONIME RIGHTEST GM300 SYSTEM KIT MM 3 STBIONIME RIGHTEST TEST STRIPS MM 3 QL,STbiotalan clear 1,000 mg-800 mcg-10 mg/15 ml oral liquid 2BIOTIN 100+10 800 MCG-195 MG TABLET 3biotin plus keratin 10,000 mcg-100 mg tablet 2bisoprolol fumarate 10 mg tab MM 1bisoprolol fumarate 5 mg tab MM 1bisoprolol-hctz 10-6.25 mg tab MM 1bisoprolol-hctz 2.5-6.25 mg tb MM 1bisoprolol-hctz 5-6.25 mg tab MM 1BLEPH-10 10 % EYE DROPS 3BLEPHAMIDE 10 %-0.2 % EYE DROPS,SUSPENSION 3BLEPHAMIDE S.O.P. 10 %-0.2 % EYE OINTMENT 3blisovi 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM 1blisovi fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM 1blisovi fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM 1BLOOD GLUCOSE CONTROL SOLUTION 3BLOOD GLUCOSE MONITORING KIT MM 3 STBLOOD GLUCOSE TEST STRIPS MM 3 QL,STBONIVA 150 MG TABLET MM 3 QLBOOST 0.04 GRAM-1 KCAL/ML ORAL LIQUID 3boost breeze nutritional 0.04 gram-1.05 kcal/ml oral liquid 2BOOST CALORIE SMART 0.07 GRAM-0.8 KCAL/ML ORAL LIQUID 3BOOST CALORIE SMART ORAL LIQUID 3BOOST COMPACT ORAL LIQUID 3BOOST HIGH PROTEIN 0.06 GRAM-1 KCAL/ML ORAL LIQUID 3boost kid essentials 0.03 gram-1 kcal/ml oral liquid 2BOOST KID ESSENTIALS 0.04 GRAM-1.5 KCAL/ML ORAL LIQUID 3BOOST KID ESSENTIALS WITH FIBER 0.04 GRAM-1.5 KCAL/ML ORAL LIQUID 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSBOOST PLUS 0.06 GRAM-1.5 KCAL/ML ORAL LIQUID 3BOOST VHC 0.09 GRAM-2.25 KCAL/ML ORAL LIQUID 3BOSULIF 100 MG TABLET SP,LD * QL,PABOSULIF 500 MG TABLET SP,LD * QL,PAbp folinatal plus b tablet 2BRAIN MIGHT-DHA-CO Q10 140 MG-10 MG-10 MG TABLET 3BREAKFAST ESSENTIALS 41 GRAM-240 KCAL/237 ML ORAL LIQUID 3BREATHERITE MDI SPACER 1BREATHERITE RIGID SPACER AND MASK 1BREATHERITE RIGID SPACER AND MASK, ADULT 1BREATHERITE RIGID SPACER AND MASK, CHILD 1BREATHERITE RIGID SPACER AND MASK, INFANT 1BREATHERITE RIGID SPACER AND MASK, SMALL CHILD 1BREATHERITE VALVED MDI CHAMBER SPACER 1BREATHERITE VALVED MDI SPACER 1BREATHERITE WITH MASK, LARGE 1BREATHERITE WITH MASK, MEDIUM 1BREATHERITE WITH MASK, SMALL 1BREEZE 2 CONTROL SOLUTION, HIGH 3BREEZE 2 CONTROL SOLUTION, LOW 3BREEZE 2 CONTROL SOLUTION, NORMAL 3BREEZE 2 METER MM 3 STBREEZE 2 TEST STRIPS MM 3 QL,STBREO ELLIPTA 100 MCG-25 MCG/DOSE POWDER FOR INHALATION MM 2 QLBREO ELLIPTA 200 MCG-25 MCG/DOSE POWDER FOR INHALATION 2 QLBREVICON (28) 0.5 MG-35 MCG TABLET MM 3briellyn 0.4 mg-35 mcg tablet MM 1BRIGHT BEGINNINGS SOY 0.03 GRAM-1 KCAL/ML ORAL LIQUID 3BRILINTA 60 MG TABLET 2 QLBRILINTA 90 MG TABLET MM 2 QLbrimonidine 0.2% eye drop MM 1brimonidine tartrate 0.15% drp MM 3BRINTELLIX 10 MG TABLET MM 3 QL,STBRINTELLIX 20 MG TABLET MM 3 QL,STBRINTELLIX 5 MG TABLET MM 3 QL,STBRISDELLE 7.5 MG CAPSULE 4 QL,STBRIVIACT 10 MG TABLET SP * QL,PABRIVIACT 10 MG/ML ORAL SOLUTION SP * QL,PABRIVIACT 100 MG TABLET SP * QL,PABRIVIACT 25 MG TABLET SP * QL,PABRIVIACT 50 MG TABLET SP * QL,PABRIVIACT 75 MG TABLET SP * QL,PAbromfed dm 2 mg-30 mg-10 mg/5 ml syrup 3bromfenac sodium 0.09% eye drp 3 QL,STbromocriptine 2.5 mg tablet MM 3bromocriptine 5 mg capsule MM 3bromphenir-pseudoephed-dm syr 3BROVANA 15 MCG/2 ML SOLUTION FOR NEBULIZATION MM 4 QL,PAbudesonide 0.25 mg/2 ml susp MM 3 QLbudesonide 0.5 mg/2 ml susp MM 3 QLbudesonide 1 mg/2 ml inh susp MM 3budesonide 32 mcg nasal spray MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSbudesonide ec 3 mg capsule 4BULLSEYE MINI SAFETY LANCETS 21 GAUGE MM 1BULLSEYE MINI SAFETY LANCETS 25 GAUGE MM 1BULLSEYE MINI SAFETY LANCETS 28 GAUGE MM 1bumetanide 0.5 mg tablet MM 2bumetanide 1 mg tablet MM 2bumetanide 2 mg tablet MM 2BUNAVAIL 2.1 MG-0.3 MG BUCCAL FILM 3 QL,PABUNAVAIL 4.2 MG-0.7 MG BUCCAL FILM 3 QL,PABUNAVAIL 6.3 MG-1 MG BUCCAL FILM 3 QL,PAbupap 50 mg-300 mg tablet 4 QLBUPHENYL 0.94 GRAM/GRAM ORAL POWDER SP *BUPHENYL 500 MG TABLET SP *buprenorphin-naloxon 8-2 mg sl 3 QL,PAbuprenorphine 2 mg tablet sl 3 QL,PAbuprenorphine 8 mg tablet sl 3 QL,PAbuprenorphn-naloxn 2-0.5 mg sl 3 QL,PAbuproban 150 mg tablet 2 QLbupropion hcl 100 mg tablet MM 2 QLbupropion hcl 75 mg tablet MM 2 QLbupropion hcl sr 100 mg tablet MM 2 QLbupropion hcl sr 150 mg tablet MM 2 QLbupropion hcl sr 150 mg tablet 2 QLbupropion hcl sr 200 mg tablet MM 2 QLbupropion hcl xl 150 mg tablet MM 2 QLbupropion hcl xl 300 mg tablet MM 2 QLbuspirone hcl 10 mg tablet MM 1buspirone hcl 15 mg tablet MM 1buspirone hcl 30 mg tablet MM 1buspirone hcl 5 mg tablet MM 1buspirone hcl 7.5 mg tablet MM 1butalb-acetamin-caff 50-300-40 3 QLbutalb-acetamin-caff 50-325-40 2 QLbutalb-acetaminoph-caff-codein 3 QLbutalb-caff-acetaminoph-codein 3 QLbutalbit-acetaminophen-caff cp 2 QLbutalbital compound with codeine 30 mg-50 mg-325 mg-40 mg capsule 3 QLbutalbital-acetaminophn 50-325 2 QLbutalbital-asa-caffeine cap 3 QLBUTISOL 30 MG TABLET 3BUTISOL SODIUM 50 MG TABLET 3butorphanol 10 mg/ml spray 3 QLBUTRANS 10 MCG/HOUR TRANSDERMAL PATCH 3 QL,STBUTRANS 15 MCG/HOUR TRANSDERMAL PATCH 3 QL,STBUTRANS 20 MCG/HOUR TRANSDERMAL PATCH 3 QL,STBUTRANS 5 MCG/HOUR TRANSDERMAL PATCH 3 QL,STBUTRANS 7.5 MCG/HOUR TRANSDERMAL PATCH 3 QL,STBYDUREON 2 MG SUBCUTANEOUS EXTENDED RELEASE SUSPENSION MM 3 QL,STBYDUREON 2 MG/0.65 ML SUBCUTANEOUS PEN INJECTOR MM 3 QL,STBYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR MM 3 QL,STBYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR MM 3 QL,STBYSTOLIC 10 MG TABLET MM 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSBYSTOLIC 2.5 MG TABLET MM 3 QLBYSTOLIC 20 MG TABLET MM 3 QLBYSTOLIC 5 MG TABLET MM 3 QLBYVALSON 5 MG-80 MG TABLET 3 QL,STc-nate dha 28 mg-1 mg-200 mg capsule 2cabergoline 0.5 mg tablet MM 3 QLCABOMETYX 20 MG TABLET SP,LD * QL,PACABOMETYX 40 MG TABLET SP,LD * QL,PACABOMETYX 60 MG TABLET SP,LD * QL,PACADEAU DHA 29 MG IRON-1 MG-150 MG CAPSULE 3CADUET 10 MG-10 MG TABLET MM 3 QLCADUET 10 MG-20 MG TABLET MM 3 QLCADUET 10 MG-40 MG TABLET MM 3 QLCADUET 10 MG-80 MG TABLET MM 3 QLCADUET 2.5 MG-10 MG TABLET MM 3 QLCADUET 2.5 MG-20 MG TABLET MM 3 QLCADUET 2.5 MG-40 MG TABLET MM 3 QLCADUET 5 MG-10 MG TABLET MM 3 QLCADUET 5 MG-20 MG TABLET MM 3 QLCADUET 5 MG-40 MG TABLET MM 3 QLCADUET 5 MG-80 MG TABLET MM 3 QLCAFERGOT 1 MG-100 MG TABLET 3caffeine cit 60 mg/3 ml oral 4CALAN 120 MG TABLET MM 3CALAN 80 MG TABLET MM 3 QLCALAN SR 120 MG TABLET,EXTENDED RELEASE MM 3 QLCALAN SR 180 MG TABLET,EXTENDED RELEASE MM 3 QLCALAN SR 240 MG TABLET,EXTENDED RELEASE MM 3 QLcalcipotriene 0.005% cream 3 QLcalcipotriene 0.005% ointment 4 STcalcipotriene 0.005% solution 3 QLcalcipotriene-betameth dp oint 4 QL,STcalcitonin-salmon 200 units sp MM 2 QLcalcitrene 0.005 % topical ointment 4 STcalcitriol 0.25 mcg capsule MM 2calcitriol 0.5 mcg capsule MM 2calcitriol 1 mcg/ml solution MM 2calcitriol 3 mcg/g ointment 4 QLcalcium acetate 667 mg gelcap MM 3calcium acetate 667 mg tablet MM 3calcium pnv 28 mg-1 mg-250 mg capsule 3CAMBIA 50 MG ORAL POWDER PACKET 4 QL,STcamila 0.35 mg tablet MM 1CAMPRAL DR 333 MG TABLET MM 3 QLcamrese 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack 1 QLcamrese lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MM 1 QLCANASA 1,000 MG RECTAL SUPPOSITORY MM 2 QLcandesartan cilexetil 16 mg tb MM 3 QLcandesartan cilexetil 32 mg tb MM 3 QLcandesartan cilexetil 4 mg tab MM 3 QLcandesartan cilexetil 8 mg tab MM 3 QLcandesartan-hctz 16-12.5 mg tb MM 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTScandesartan-hctz 32-12.5 mg tb MM 3 QLcandesartan-hctz 32-25 mg tab MM 3 QLCANTIL 25 MG TABLET 3capacet 50 mg-325 mg-40 mg capsule 2 QLcapecitabine 150 mg tablet SP * QL,PAcapecitabine 500 mg tablet SP * QL,PACAPEX 0.01 % SHAMPOO 2CAPITAL WITH CODEINE 120 MG-12 MG/5 ML ORAL SUSPENSION 4 QLCAPRELSA 100 MG TABLET SP,LD * QL,PACAPRELSA 300 MG TABLET SP,LD * QL,PAcaptopril 100 mg tablet MM 3captopril 12.5 mg tablet MM 3captopril 25 mg tablet MM 3captopril 50 mg tablet MM 3captopril-hctz 25-15 mg tablet MM 3captopril-hctz 25-25 mg tablet MM 3captopril-hctz 50-15 mg tablet MM 3captopril-hctz 50-25 mg tablet MM 3CARAC 0.5 % TOPICAL CREAM 4CARAFATE 1 GRAM TABLET MM 3CARAFATE 100 MG/ML ORAL SUSPENSION MM 3CARBAGLU 200 MG DISPERSIBLE TABLET SP,LD * PAcarbamazepine 100 mg tab chew MM 2carbamazepine 100 mg/5 ml susp MM 3carbamazepine 200 mg tablet MM 2carbamazepine er 100 mg cap MM 3carbamazepine er 100 mg tablet MM 3 QLcarbamazepine er 200 mg cap MM 3carbamazepine er 200 mg tablet MM 3 QLcarbamazepine er 300 mg cap MM 3carbamazepine er 400 mg tablet MM 3 QLCARBATROL 100 MG CAPSULE, EXTENDED RELEASE MM 3CARBATROL 200 MG CAPSULE, EXTENDED RELEASE MM 3CARBATROL 300 MG CAPSULE, EXTENDED RELEASE MM 3carbidopa 25 mg tablet MM 3carbidopa-levo 10-100 mg odt MM 3carbidopa-levo 25-100 mg odt MM 3carbidopa-levo 25-250 mg odt MM 3carbidopa-levo er 25-100 tab MM 2carbidopa-levo er 50-200 tab MM 2carbidopa-levodopa 10-100 tab MM 1carbidopa-levodopa 25-100 tab MM 1carbidopa-levodopa 25-250 tab MM 1carbidopa-levodopa-enta 100 mg MM 3carbidopa-levodopa-enta 125 mg MM 3carbidopa-levodopa-enta 150 mg MM 3carbidopa-levodopa-enta 200 mg MM 3carbidopa-levodopa-enta 50 mg MM 3carbidopa-levodopa-enta 75 mg MM 3carbinoxamine 4 mg/5 ml liquid 3carbinoxamine maleate 4 mg tab 3CARDIOVID PLUS 600 MG-20 MG-500 MCG-800 MCG CAPSULE 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCARDIZEM 120 MG TABLET MM 4CARDIZEM 30 MG TABLET MM 4CARDIZEM 60 MG TABLET MM 4CARDIZEM CD 120 MG CAPSULE,EXTENDED RELEASE MM 4 QLCARDIZEM CD 180 MG CAPSULE,EXTENDED RELEASE MM 4 QLCARDIZEM CD 240 MG CAPSULE,EXTENDED RELEASE MM 4 QLCARDIZEM CD 300 MG CAPSULE,EXTENDED RELEASE MM 4 QLCARDIZEM CD 360 MG CAPSULE,EXTENDED RELEASE MM 4 QLCARDIZEM LA 120 MG TABLET,EXTENDED RELEASE MM 4 QLCARDIZEM LA 180 MG TABLET,EXTENDED RELEASE MM 4 QLCARDIZEM LA 240 MG TABLET,EXTENDED RELEASE MM 4 QLCARDIZEM LA 300 MG TABLET,EXTENDED RELEASE MM 4 QLCARDIZEM LA 360 MG TABLET,EXTENDED RELEASE MM 4 QLCARDIZEM LA 420 MG TABLET,EXTENDED RELEASE MM 4 QLCARDURA 1 MG TABLET MM 3CARDURA 2 MG TABLET MM 3CARDURA 4 MG TABLET MM 3CARDURA 8 MG TABLET MM 3CARDURA XL 4 MG TABLET,EXTENDED RELEASE MM 3 QLCARDURA XL 8 MG TABLET,EXTENDED RELEASE MM 3 QLCAREFINE PEN NEEDLE 29 GAUGE X 1/2" 1CAREFINE PEN NEEDLE 30 GAUGE X 5/16" 1CAREFINE PEN NEEDLE 31 GAUGE X 1/4" 1CAREFINE PEN NEEDLE 31 GAUGE X 5/16" 1CAREFINE PEN NEEDLE 32 GAUGE X 1/4" 1CAREFINE PEN NEEDLE 32 GAUGE X 3/16" 1CAREFINE PEN NEEDLE 32 GAUGE X 5/32" 1CARELANCE ULTIMATE COMFORT LANCING DEVICE MM 3CAREONE LANCING DEVICE MM 1CAREONE THIN LANCET MM 1CAREONE ULTRA THIN LANCET MM 1CARESENS CONTROL A NORMAL SOLUTION 3CARESENS LANCETS 30 GAUGE MM 3CARESENS N MM 3 STCARESENS N TEST STRIPS MM 3 QL,STCARESENS N VOICE MM 3 STCARESENS N VOICE KIT MM 3 STCARESENS PREMIUM COMFORT LANCING DEVICE MM 3carisoprodl-aspirin 200-325 mg 3carisoprodol 250 mg tablet 3 QLcarisoprodol 350 mg tablet 2carisoprodol-aspirin-codein tb 3 QLCARNITOR (SUGAR-FREE) 100 MG/ML ORAL SOLUTION MM 3CARNITOR 100 MG/ML ORAL SOLUTION MM 3CARNITOR 330 MG TABLET MM 3carteolol hcl 1% eye drops MM 1cartia xt 120 mg capsule,extended release MM 2 QLcartia xt 180 mg capsule,extended release MM 2 QLcartia xt 240 mg capsule,extended release MM 2 QLcartia xt 300 mg capsule,extended release MM 2 QLcarvedilol 12.5 mg tablet MM 1carvedilol 25 mg tablet MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTScarvedilol 3.125 mg tablet MM 1carvedilol 6.25 mg tablet MM 1CASODEX 50 MG TABLET MM 3 QLCATAFLAM 50 MG TABLET 3CATAPRES 0.1 MG TABLET MM 3CATAPRES 0.2 MG TABLET MM 3CATAPRES 0.3 MG TABLET MM 3CATAPRES-TTS-1 0.1 MG/24 HR TRANSDERMAL PATCH MM 3 QLCATAPRES-TTS-2 0.2 MG/24 HR TRANSDERMAL PATCH MM 3 QLCATAPRES-TTS-3 0.3 MG/24 HR TRANSDERMAL PATCH MM 3 QLCAYA CONTOURED 60 MM-85 MM VAGINAL DIAPHRAGM 4CAYSTON 75 MG/ML SOLUTION FOR NEBULIZATION SP,LD * QL,PAcaziant (28) 0.1 mg/0.125 mg/0.15 mg-25 mcg tablet MM 1CEDAX 180 MG/5 ML ORAL SUSPENSION 4CEDAX 400 MG CAPSULE 4cefaclor 125 mg/5 ml susp 3cefaclor 250 mg capsule 3cefaclor 250 mg/5 ml susp 3cefaclor 375 mg/5 ml suspen 3cefaclor 500 mg capsule 3cefaclor er 500 mg tablet 3cefadroxil 1 gm tablet 3cefadroxil 250 mg/5 ml susp 2cefadroxil 500 mg capsule 2cefadroxil 500 mg/5 ml susp 2cefdinir 125 mg/5 ml susp 2cefdinir 250 mg/5 ml susp 2cefdinir 300 mg capsule 2cefditoren pivoxil 200 mg tab 3cefditoren pivoxil 400 mg tab 3cefixime 100 mg/5 ml susp 3cefixime 200 mg/5 ml susp 3cefpodoxime 100 mg tablet 3cefpodoxime 100 mg/5 ml susp 3cefpodoxime 200 mg tablet 3cefpodoxime 50 mg/5 ml susp 3cefprozil 125 mg/5 ml susp 2cefprozil 250 mg tablet 2cefprozil 250 mg/5 ml susp 2cefprozil 500 mg tablet 2ceftibuten 180 mg/5 ml susp 3ceftibuten 400 mg capsule 3CEFTIN 125 MG/5 ML ORAL SUSPENSION 3CEFTIN 250 MG TABLET 3CEFTIN 250 MG/5 ML ORAL SUSPENSION 3CEFTIN 500 MG TABLET 3cefuroxime axetil 250 mg tab 2cefuroxime axetil 500 mg tab 2CELEBREX 100 MG CAPSULE MM 3 QL,STCELEBREX 200 MG CAPSULE MM 3 QL,STCELEBREX 400 MG CAPSULE MM 3 QL,STCELEBREX 50 MG CAPSULE MM 3 QL,STcelecoxib 100 mg capsule MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTScelecoxib 200 mg capsule MM 3 QL,STcelecoxib 400 mg capsule MM 3 QL,STcelecoxib 50 mg capsule MM 3 QL,STCELEXA 10 MG TABLET MM 3 QLCELEXA 20 MG TABLET MM 3 QLCELEXA 40 MG TABLET MM 3 QLCELLCEPT 200 MG/ML ORAL SUSPENSION 4CELLCEPT 250 MG CAPSULE 4 QLCELLCEPT 500 MG TABLET 4 QLCELONTIN 300 MG CAPSULE MM 3CENTANY 2 % TOPICAL OINTMENT 3centratex 106 mg iron-1 mg capsule 1cephalexin 125 mg/5 ml susp 2cephalexin 250 mg capsule 2cephalexin 250 mg tablet 2cephalexin 250 mg/5 ml susp 2cephalexin 500 mg capsule 2cephalexin 500 mg tablet 2cephalexin 750 mg capsule 2CERDELGA 84 MG CAPSULE SP,LD * QL,PACESAMET 1 MG CAPSULE 3 QL,PAcetirizine hcl 1 mg/ml soln MM 3 QLcevimeline hcl 30 mg capsule MM 3chateal 0.15 mg-0.03 mg tablet MM 1CHEMET 100 MG CAPSULE 4CHENODAL 250 MG TABLET SP,LD *chewables multivitamins-a,b,d,e,k,zn 1,000 unit-800 mcg tablet 3chlordiazepo-amitriptyl 5-12.5 MM 3chlordiazepox-amitriptyl 10-25 MM 3chlordiazepoxide 10 mg capsule 2 QLchlordiazepoxide 25 mg capsule 2 QLchlordiazepoxide 5 mg capsule 2 QLchlorhexidine 0.12% rinse 2chloroquine ph 250 mg tablet MM 2chloroquine ph 500 mg tablet MM 2chlorothiazide 250 mg tablet MM 1chlorothiazide 500 mg tablet MM 1chlorpromazine 10 mg tablet MM 3chlorpromazine 100 mg tablet MM 3chlorpromazine 200 mg tablet MM 3chlorpromazine 25 mg tablet MM 3chlorpromazine 50 mg tablet MM 3chlorpropamide 100 mg tablet MM 3chlorpropamide 250 mg tablet MM 3chlorthalidone 25 mg tablet MM 1chlorthalidone 50 mg tablet MM 1chlorzoxazone 500 mg tablet 1CHOICE DM CLARUS NORMAL CONTROL SOLUTION 3CHOICEDM CLARUS MM 3 STCHOICEDM CLARUS STRIPS MM 3 QL,STCHOLBAM 250 MG CAPSULE SP * QL,PACHOLBAM 50 MG CAPSULE SP * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTScholestyramine light 4 gram oral powder MM 3cholestyramine light 4 gram powder for susp in a packet MM 3cholestyramine packet MM 3cholestyramine powder MM 3choline citrate 650 mg tablet 2choline mag trisal liquid 1ciclodan 0.77 % topical cream 2ciclopirox 0.77% cream 2ciclopirox 0.77% gel 3ciclopirox 0.77% topical susp 2ciclopirox 1% shampoo 3ciferex 3,775 unit-1 mg capsule 3cilostazol 100 mg tablet MM 1cilostazol 50 mg tablet MM 1CILOXAN 0.3 % EYE DROPS 3CILOXAN 0.3 % EYE OINTMENT 3cimetidine 200 mg tablet MM 3cimetidine 300 mg tablet MM 3cimetidine 300 mg/5 ml soln MM 1cimetidine 400 mg tablet MM 3cimetidine 800 mg tablet MM 3CIMZIA 400 MG/2 ML (200 MG/ML X 2) SUBCUTANEOUS SYRINGE KIT SP * QL,PACIMZIA STARTER KIT 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT SP * QL,PACINQAIR 10 MG/ML INTRAVENOUS SOLUTION SP,LD * PACIPRO 250 MG TABLET 3CIPRO 250 MG/5 ML ORAL SUSPENSION 3CIPRO 500 MG TABLET 3CIPRO 500 MG/5 ML ORAL SUSPENSION 3CIPRO HC 0.2 %-1 % EAR DROPS,SUSPENSION 3 STCIPRO XR 1,000 MG TABLET,EXTENDED RELEASE 3CIPRO XR 500 MG TABLET,EXTENDED RELEASE 3CIPRODEX 0.3 %-0.1 % EAR DROPS,SUSPENSION 3ciprofloxacin 0.2% otic soln 3ciprofloxacin 0.3% eye drop 2ciprofloxacin 250 mg/5 ml susp 3ciprofloxacin 500 mg/5 ml susp 3ciprofloxacin er 1,000 mg tab 3ciprofloxacin er 500 mg tablet 3ciprofloxacin hcl 100 mg tab 2ciprofloxacin hcl 250 mg tab 2ciprofloxacin hcl 500 mg tab 2ciprofloxacin hcl 750 mg tab 2citalopram hbr 10 mg tablet MM 1 QLcitalopram hbr 10 mg/5 ml soln MM 2citalopram hbr 20 mg tablet MM 1 QLcitalopram hbr 40 mg tablet MM 1 QLCITRANATAL (DUAL-IRON) 27 MG IRON-1 MG-50 MG TABLET 3CITRANATAL 90 DHA (ALGAL OIL) 90 MG IRON-1 MG-50 MG-300 MG ORAL PACK 3CITRANATAL ASSURE 35 MG IRON-1 MG-50 MG-300 MG ORAL PACK 3CITRANATAL B-CALM (FE GLUC) 20 MG IRON-1 MG-25 MG/25 MG TABLETS 3CITRANATAL DHA (ALGAL OIL) 27 MG IRON-1 MG-50 MG-250 MG ORAL PACK 3CITRANATAL DHA PACK 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCITRANATAL HARMONY(IRON CARB-FUM) 27 MG IRON-1 MG-50 MG-260 MGCAPSULE

3

CITRANATAL RX TABLET 3CLA 1,000 MG CAPSULE 3claravis 10 mg capsule 4 QL,STclaravis 20 mg capsule 4 QL,STclaravis 30 mg capsule 4 QL,STclaravis 40 mg capsule 4 QL,STCLARINEX 2.5 MG/5 ML (0.5 MG/ML) SYRUP MM 3 QL,STCLARINEX 5 MG TABLET MM 3 QL,STCLARINEX-D 12 HOUR 2.5 MG-120 MG TABLET,EXTENDED RELEASE 3 QL,STclarithromycin 125 mg/5 ml sus 3clarithromycin 250 mg tablet 2clarithromycin 250 mg/5 ml sus 3clarithromycin 500 mg tablet 2clarithromycin er 500 mg tab 3clemastine 0.5 mg/5 ml syrup 3clemastine fum 2.68 mg tab 3CLEOCIN 100 MG VAGINAL SUPPOSITORY 3CLEOCIN 150 MG CAPSULE 3CLEOCIN 2 % VAGINAL CREAM 3CLEOCIN 300 MG CAPSULE 3CLEOCIN 75 MG CAPSULE 3CLEOCIN 75 MG/5 ML ORAL SOLUTION 3CLEOCIN T 1 % LOTION 3CLEOCIN T 1 % SOLUTION 3CLEOCIN T 1 % TOPICAL GEL 3CLEOCIN T 1 % TOPICAL SWAB 3CLEVER CHEK BLOOD GLUCOSE MM 3 STCLEVER CHEK BLOOD GLUCOSE SYST KIT MM 3 STCLEVER CHEK LANCETS 30 GAUGE MM 1CLEVER CHOICE BLOOD GLUCOSE SYSTEM MM 3 STCLEVER CHOICE HOLDING CHAMBER-LARGE MASK 3CLEVER CHOICE LEVEL 1 CONTROL SOLUTION 3CLEVER CHOICE LEVEL 2 CONTROL SOLUTION 3CLEVER CHOICE LEVEL 3 CONTROL SOLUTION 3CLEVER CHOICE MICRO MM 3 STCLEVER CHOICE MICRO TEST STRIP MM 3 QL,STCLEVER CHOICE MINI BLOOD GLUCOSE MONITOR MM 3 STCLEVER CHOICE PRO BLOOD GLUCOSE MONITOR MM 3 STCLEVER CHOICE PRO BLOOD GLUCOSE MONITOR STRIPS MM 3 QL,STCLEVER CHOICE TALK BLOOD GLUCOSE SYSTEM MM 3 STCLEVER CHOICE TALK TEST STRIPS MM 3 QL,STCLEVER CHOICE TEST STRIPS MM 3 QL,STCLEVER CHOICE VOICE+ TEST STRIPS MM 3 QL,STCLICKFINE 31 GAUGE X 1/4" NEEDLE 1CLICKFINE 31 GAUGE X 5/16" NEEDLE 1CLICKFINE 32 GAUGE X 5/32" NEEDLE 1CLIMARA 0.025 MG/24 HR TRANSDERMAL PATCH MM 3 QLCLIMARA 0.0375 MG/24 HR TRANSDERMAL PATCH MM 3 QLCLIMARA 0.05 MG/24 HR TRANSDERMAL PATCH MM 3 QLCLIMARA 0.06 MG/24 HR TRANSDERMAL PATCH MM 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCLIMARA 0.075 MG/24 HR TRANSDERMAL PATCH MM 3 QLCLIMARA 0.1 MG/24 HR TRANSDERMAL PATCH MM 3 QLCLIMARA PRO 0.045 MG-0.015 MG/24 HR TRANSDERMAL PATCH MM 3 QLclind ph-benzoyl perox 1.2-5% 3clinda-benzoyl perox 1-5% pump 3clinda-tretinoin 1.2%-0.025% 3 STclindacin etz 1 % topical swab 2clindacin p 1 % topical swab 2CLINDAGEL 1 % TOPICAL 4 STclindamycin 2% vaginal cream 3clindamycin 75 mg/5 ml soln 3clindamycin hcl 150 mg capsule 2clindamycin hcl 300 mg capsule 2clindamycin hcl 75 mg capsule 2clindamycin pediatric 75 mg/5 ml oral solution 3clindamycin ph 1% gel 3clindamycin ph 1% solution 3clindamycin phos 1% pledget 2clindamycin phosp 1% lotion 3clindamycin phosphate 1% foam 3 STclindamycin-benzoyl perox 1-5% 3CLINDESSE 2 % VAGINAL CREAM,EXTENDED RELEASE 3CLINIMIX 2.75 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX 4.25 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX 4.25 % IN 20 % DEXTROSE (SULFITE-FREE) INTRAVENOUS SOLUTION 3CLINIMIX 4.25 % IN 25 % DEXTROSE (SULFITE-FREE) INTRAVENOUS SOLUTION 3CLINIMIX 4.25 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX 5 % IN 15 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX 5 % IN 20 % DEXTROSE (SULFITE-FREE) INTRAVENOUS SOLUTION 3CLINIMIX 5 % IN 25 % DEXTROSE SULFITE-FREE INTRAVENOUS SOLUTION 3CLINIMIX E 2.75 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 2.75 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 4.25 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 4.25 % IN 25 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 4.25 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 5 % IN 15 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 5 % IN 20 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3CLINIMIX E 5 % IN 25 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION 3clobetasol 0.05% cream 3clobetasol 0.05% gel 3clobetasol 0.05% ointment 3clobetasol 0.05% shampoo 3clobetasol 0.05% solution 3clobetasol 0.05% topical lotn 3clobetasol emollient 0.05% crm 3clobetasol emulsion 0.05% foam 3clobetasol prop 0.05% foam 3clobetasol prop 0.05% spray 3 STCLOBEX 0.05 % LOTION 4 STCLOBEX 0.05 % SHAMPOO 4 STCLOBEX 0.05 % TOPICAL SPRAY 4 STclocortolone pivalate 0.1% crm 3clodan 0.05 % shampoo 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCLODERM 0.1 % TOPICAL CREAM 4 STclomipramine 25 mg capsule MM 4clomipramine 50 mg capsule MM 4clomipramine 75 mg capsule MM 4clonazepam 0.125 mg dis tab MM 2clonazepam 0.25 mg odt MM 2clonazepam 0.5 mg dis tablet MM 2clonazepam 0.5 mg tablet MM 1clonazepam 1 mg dis tablet MM 2clonazepam 1 mg tablet MM 1clonazepam 2 mg odt MM 2clonazepam 2 mg tablet MM 1clonidine 0.1 mg/day patch MM 3 QLclonidine 0.2 mg/day patch MM 3 QLclonidine 0.3 mg/day patch MM 3 QLclonidine hcl 0.1 mg tablet MM 1clonidine hcl 0.2 mg tablet MM 1clonidine hcl 0.3 mg tablet MM 1clonidine hcl er 0.1 mg tablet MM 3 QL,STclopidogrel 300 mg tablet 3 QLclopidogrel 75 mg tablet MM 1 QLclorazepate 15 mg tablet 2clorazepate 3.75 mg tablet 2clorazepate 7.5 mg tablet 2clorpres 0.1 mg-15 mg tablet MM 3clorpres 0.2 mg-15 mg tablet MM 3clorpres 0.3 mg-15 mg tablet MM 3clotrimazole 1% cream 2clotrimazole 1% solution 2clotrimazole 10 mg troche 2clotrimazole-betamethasone crm 2clotrimazole-betamethasone lot 3clozapine 100 mg tablet MM 3clozapine 200 mg tablet MM 3clozapine 25 mg tablet MM 3clozapine 50 mg tablet MM 3clozapine odt 100 mg tablet MM 3clozapine odt 12.5 mg tablet MM 3clozapine odt 150 mg tablet MM 3clozapine odt 200 mg tablet MM 3clozapine odt 25 mg tablet MM 3CLOZARIL 100 MG TABLET MM 4CLOZARIL 25 MG TABLET MM 4CO-BALAMIN 200 MG-5 MG-0.8 MG-400 MG CAPSULE 3CO-VERATROL 200 MG-5 MG-0.8 MG-400 MG CAPSULE 3COAGUCHEK LANCETS MM 1COARTEM 20 MG-120 MG TABLET 3 QLcoconut oil 1,000 mg softgel 2codeine sulfate 15 mg tablet 3 QLcodeine sulfate 30 mg tablet 3 QLcodeine sulfate 30 mg/5 ml sol 3 QLcodeine sulfate 60 mg tablet 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCOLAZAL 750 MG CAPSULE 4 QL,STcolchicine 0.6 mg capsule 3 QL,STcolchicine 0.6 mg tablet MM 3 QL,STCOLCRYS 0.6 MG TABLET MM 3 QLCOLESTID 1 GRAM TABLET MM 3COLESTID 5 GRAM ORAL GRANULES MM 3COLESTID 5 GRAM ORAL PACKET MM 3COLESTID FLAVORED 5 GRAM ORAL GRANULES MM 3COLESTID FLAVORED 7.5 GRAM PACKET MM 3colestipol hcl granules MM 3colestipol hcl granules packet MM 3colestipol micronized 1 gm tab MM 2COLLAGEN PLUS VITAMIN C 125 MG-740 MG CAPSULE 3colocort 100 mg/60 ml enema 3COLOR LANCETS 21 GAUGE MM 1COLY-MYCIN S 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION 3COLYTE WITH FLAVOR PACKS 3 STCOLYTE WITH FLAVOR PACKS 240 GRAM-22.72 G-6.72 G-5.84 G ORAL SOLUTION 3 STCOMBIGAN 0.2 %-0.5 % EYE DROPS MM 2 QLCOMBIPATCH 0.05 MG-0.14 MG/24 HR TRANSDERMAL MM 3 QLCOMBIPATCH 0.05 MG-0.25 MG/24 HR TRANSDERMAL MM 3 QLCOMBIVENT RESPIMAT 20 MCG-100 MCG/ACTUATION SOLUTION FOR INHALATIONMM

3 QL,ST

COMBIVIR 150 MG-300 MG TABLET 4 QLCOMETRIQ 100 MG/DAY (80 MG X 1-20 MG X 1) CAPSULES SP,LD * QL,PACOMETRIQ 140 MG/DAY (80 MG X 1-20 MG X 3) CAPSULES SP,LD * QL,PACOMETRIQ 60 MG/DAY (20 MG X 3/DAY) CAPSULES SP,LD * QL,PACOMFORT EZ LANCETS 21 GAUGE MM 2COMFORT EZ LANCETS 23 GAUGE MM 2COMFORT EZ LANCETS 28 GAUGE MM 2COMFORT EZ PEN NEEDLES 31 GAUGE X 1/4" 2COMFORT EZ PEN NEEDLES 31 GAUGE X 3/16" 2COMFORT EZ PEN NEEDLES 31 GAUGE X 5/16" 2COMFORT EZ PEN NEEDLES 32 GAUGE X 1/4" 2COMFORT EZ PEN NEEDLES 32 GAUGE X 3/16" 2COMFORT EZ PEN NEEDLES 32 GAUGE X 5/16" 2COMFORT EZ PEN NEEDLES 32 GAUGE X 5/32" 2COMFORT EZ PEN NEEDLES 33 GAUGE X 1/4" 2COMFORT EZ PEN NEEDLES 33 GAUGE X 3/16" 2COMFORT EZ PEN NEEDLES 33 GAUGE X 5/16" 2COMFORT EZ PEN NEEDLES 33 GAUGE X 5/32" 2COMFORT EZ SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 0.3 ML 30 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2COMFORT EZ SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2COMFORT EZ SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2COMFORT EZ SYRINGE 1 ML 28 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 1 ML 29 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 1 ML 30 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 1 ML 30 GAUGE X 5/16" MM 2COMFORT EZ SYRINGE 1 ML 31 GAUGE X 5/16" MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCOMFORT EZ SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 1/2 ML 30 GAUGE X 1/2" MM 2COMFORT EZ SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2COMFORT LANCETS MM 3COMFORT POINT PEN NDL 31GX1/3" 1COMFORT POINT PEN NDL 31GX1/6" 2COMPACT SPACE CHAMBER 1COMPACT SPACE CHAMBER PLUS 2COMPACT SPACE CHAMBER-LRG MASK 1COMPACT SPACE CHAMBER-MED MASK 1COMPACT SPACE CHAMBER-SM MASK 1COMPAZINE 10 MG TABLET 3COMPAZINE 25 MG RECTAL SUPPOSITORY 3COMPAZINE 5 MG TABLET 3COMPLEAT MODIFIED LIQUID 3COMPLEAT ORAL LIQUID 3compleat pediatric 0.03 gram-1 kcal/ml oral liquid 2COMPLEAT PEDIATRIC FORMULA 3compleat pediatric reduced calorie 0.03 gram-0.6 kcal/ml oral liquid 2COMPLERA 200 MG-25 MG-300 MG TABLET SP * QLcomplete natal dha 29 mg-1 mg-250 mg oral pack 2complete nutritional drink 0.04 gram-1.05 kcal/ml oral liquid 2completenate 29 mg-1 mg chewable tablet 1compro 25 mg rectal suppository 3COMTAN 200 MG TABLET MM 3 QLCONCEPT DHA 35 MG-1 MG-200 MG CAPSULE 3CONCEPT OB 85 MG-1 MG CAPSULE 3CONCERTA 18 MG TABLET,EXTENDED RELEASE 3 QL,STCONCERTA 27 MG TABLET,EXTENDED RELEASE 3 QL,STCONCERTA 36 MG TABLET,EXTENDED RELEASE 3 QL,STCONCERTA 54 MG TABLET,EXTENDED RELEASE 3 QL,STCONDYLOX 0.5 % TOPICAL GEL 3CONDYLOX 0.5 % TOPICAL SOLUTION 3constulose 10 gram/15 ml oral solution MM 1CONTOUR CONTROL SOLUTION, HIGH 3CONTOUR CONTROL SOLUTION, LOW 3CONTOUR CONTROL SOLUTION, NORMAL 3CONTOUR LINK KIT MM 3 STCONTOUR METER MM 3 STCONTOUR METER KIT MM 3 STCONTOUR NEXT EZ METER MM 3 STCONTOUR NEXT EZ METER KIT MM 3 STCONTOUR NEXT LEVEL 1 CONTROL SOLUTION 3CONTOUR NEXT LEVEL 2 CONTROL SOLUTION 3CONTOUR NEXT LINK KIT MM 3 STCONTOUR NEXT METER MM 3 STCONTOUR NEXT STRIPS MM 3 QL,STCONTOUR NEXT USB METER MM 3 STCONTOUR TEST STRIPS MM 3 QL,STCONTROL G3 STRIPS MM 3 QL,STCONTROL MONITORING SYSTEM KIT MM 3 STCONTROL TEST STRIPS MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCONZIP 100 MG CAPSULE,EXTENDED RELEASE (25-75) 3 QL,STCONZIP 200 MG CAPSULE,EXTENDED RELEASE (25-75) 3 QL,STCONZIP 300 MG CAPSULE, EXTENDED RELEASE 3 QL,STCOOL BLOOD GLUCOSE METER MM 3 STCOOL BLOOD GLUCOSE METER KIT MM 3 STCOOL CONTROL A SOLUTION 3COOL CONTROL B SOLUTION 3COOL GLUCOSE TEST STRIP MM 3 QL,STCOPAXONE 20 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PACOPAXONE 40 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PACOPEGUS 200 MG TABLET 4 QLCORDARONE 200 MG TABLET MM 3CORDRAN 0.05 % LOTION 4 STCORDRAN 0.05 % TOPICAL CREAM 4 STCORDRAN 0.05 % TOPICAL OINTMENT 4 STCOREG 12.5 MG TABLET MM 3COREG 25 MG TABLET MM 3COREG 3.125 MG TABLET MM 3COREG 6.25 MG TABLET MM 3COREG CR 10 MG CAPSULE, EXTENDED RELEASE MM 3 QLCOREG CR 20 MG CAPSULE, EXTENDED RELEASE MM 3 QLCOREG CR 40 MG CAPSULE, EXTENDED RELEASE MM 3 QLCOREG CR 80 MG CAPSULE, EXTENDED RELEASE MM 3 QLCORGARD 20 MG TABLET MM 3CORGARD 40 MG TABLET MM 3CORGARD 80 MG TABLET MM 3CORLANOR 5 MG TABLET 3 QL,PACORLANOR 7.5 MG TABLET 3 QL,PAcormax 0.05 % scalp solution 2COROMEGA 650 MG-1,000 UNIT/2.5 GRAM ORAL PACKET 3CORTEF 10 MG TABLET MM 3CORTEF 20 MG TABLET MM 3CORTEF 5 MG TABLET MM 3CORTENEMA 100 MG/60 ML 3CORTIFOAM 10 % (80 MG) RECTAL 4cortisone 25 mg tablet 3CORTISPORIN 1 % TOPICAL OINTMENT 3CORTISPORIN 3.5 MG/G-10,000 UNIT/G-0.5 % TOPICAL CREAM 3CORTISPORIN-TC EAR SUSPENSION 3corvita 150 150 mg-1.25 mg-120 mg-10 mg tablet 2CORVITE 150 150 MG IRON-1 MG TABLET 3CORVITE FE 150 MG IRON-1 MG TABLET 3CORVITE FE TABLET 3CORZIDE 40 MG-5 MG TABLET MM 3CORZIDE 80 MG-5 MG TABLET MM 3COSENTYX (2 SYRINGES) 300 MG (150 MG/ML) SUBCUTANEOUS SP,LD * QL,PACOSENTYX 150 MG/ML SUBCUTANEOUS SYRINGE SP,LD * QL,PACOSENTYX PEN (2 PENS) 300 MG (150 MG/ML) SUBCUTANEOUS SP,LD * QL,PACOSENTYX PEN 150 MG/ML SUBCUTANEOUS SP,LD * QL,PACOSOPT (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE MM 3 QL,STCOSOPT 22.3 MG-6.8 MG/ML EYE DROPS MM 3 QL,STCOTELLIC 20 MG TABLET SP,LD * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSCOUMADIN 1 MG TABLET MM 3COUMADIN 10 MG TABLET MM 3COUMADIN 2 MG TABLET MM 3COUMADIN 2.5 MG TABLET MM 3COUMADIN 3 MG TABLET MM 3COUMADIN 4 MG TABLET MM 3COUMADIN 5 MG TABLET MM 3COUMADIN 6 MG TABLET MM 3COUMADIN 7.5 MG TABLET MM 3covaryx 1.25 mg-2.5 mg tablet MM 3covaryx h.s. 0.625 mg-1.25 mg tablet MM 3COZAAR 100 MG TABLET MM 3 QL,STCOZAAR 25 MG TABLET MM 3 QL,STCOZAAR 50 MG TABLET MM 3 QL,STCREON 12,000-38,000-60,000 UNIT CAPSULE,DELAYED RELEASE MM 2CREON 24,000-76,000-120,000 UNIT CAPSULE,DELAYED RELEASE MM 2CREON 3,000-9,500-15,000 UNIT CAPSULE,DELAYED RELEASE MM 2CREON 36,000-114,000-180,000 UNIT CAPSULE,DELAYED RELEASE MM 2CREON 6,000-19,000-30,000 UNIT CAPSULE,DELAYED RELEASE MM 2CRESEMBA 186 MG CAPSULE 4 PACRESTOR 10 MG TABLET MM 3 QL,STCRESTOR 20 MG TABLET MM 3 QL,STCRESTOR 40 MG TABLET MM 3 QL,STCRESTOR 5 MG TABLET MM 3 QL,STCRINONE 4 % VAGINAL GEL 3 QLCRIXIVAN 200 MG CAPSULE 3 QLCRIXIVAN 400 MG CAPSULE 3 QLcromolyn 100 mg/5 ml oral conc 4cromolyn 20 mg/2 ml neb soln MM 3cromolyn 4% eye drops 1cryselle (28) 0.3 mg-30 mcg tablet MM 1CUPRIMINE 250 MG CAPSULE MM 4CURITY ALCOHOL SWABS 3CUROSURF 120 MG/1.5 ML INTRATRACHEAL SUSPENSION 3CUROSURF 240 MG/3 ML INTRATRACHEAL SUSPENSION 3CUTIVATE 0.05 % LOTION 4CUTIVATE 0.05 % TOPICAL CREAM 3CUVPOSA 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION MM,LD 3cvs glucose 40% gel 3cyanocobalamin 1,000 mcg/ml MM 2 QLcyclafem 1/35 (28) 1 mg-35 mcg tablet MM 1cyclafem 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM 1CYCLESSA (28) 0.1 MG/0.125 MG/0.15 MG-25 MCG TABLET MM 3cyclobenzaprine 10 mg tablet 1cyclobenzaprine 5 mg tablet 1cyclobenzaprine 7.5 mg tablet 3 QL,PACYCLOGYL 0.5 % EYE DROPS MM 3CYCLOGYL 1 % EYE DROPS MM 3CYCLOGYL 2 % EYE DROPS MM 3CYCLOMYDRIL 0.2 %-1 % EYE DROPS MM 2cyclopentolate 0.5% eye drops MM 3cyclopentolate 1% eye drops MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTScyclopentolate hcl 2% drops MM 1cyclophosphamide 25 mg capsule 4 QLcyclophosphamide 50 mg capsule 4 QLcycloserine 250 mg capsule 3CYCLOSET 0.8 MG TABLET MM 3 QL,STcyclosporine 100 mg capsule 3 QLcyclosporine 100 mg/ml soln 3cyclosporine 25 mg capsule 3cyclosporine modified 100 mg 3 QLcyclosporine modified 25 mg 3cyclosporine modified 50 mg 3CYMBALTA 20 MG CAPSULE,DELAYED RELEASE MM 3 QLCYMBALTA 30 MG CAPSULE,DELAYED RELEASE MM 3 QLCYMBALTA 60 MG CAPSULE,DELAYED RELEASE MM 3 QLcyproheptadine 2 mg/5 ml syrup MM 2cyproheptadine 4 mg tablet MM 2cyred 0.15 mg-0.03 mg tablet MM 1CYSTADANE 1 GRAM/1.7 ML ORAL POWDER SP,LD *CYSTAGON 150 MG CAPSULE MM,LD 3CYSTAGON 50 MG CAPSULE MM,LD 3CYSTARAN 0.44 % EYE DROPS SP,LD * QL,PACYSTEX CRANBERRY 1,937 MG-188 MG/15 ML ORAL LIQUID 3CYTOMEL 25 MCG TABLET MM 3CYTOMEL 5 MCG TABLET MM 3CYTOMEL 50 MCG TABLET MM 3CYTOTEC 100 MCG TABLET MM 3CYTOTEC 200 MCG TABLET MM 3CYTOTINE 1.5 GRAM/15 ML ORAL LIQUID 3cytra k crystals 3,300 mg-1,002 mg oral packet 3d-amphetamine er 10 mg capsule 3 QLd-amphetamine er 15 mg capsule 3 QLd-amphetamine er 5 mg capsule 3 QLD.H.E.45 1 MG/ML INJECTION SOLUTION 4DAFLONEX-XL 200 MG-500 MG-500 MG-100 MG TABLET 3DAKLINZA 30 MG TABLET SP * QL,PADAKLINZA 60 MG TABLET SP * QL,PADAKLINZA 90 MG TABLET SP * QL,PADALIRESP 500 MCG TABLET MM 3 QLdanazol 100 mg capsule 3danazol 200 mg capsule 3danazol 50 mg capsule 3DANTRIUM 25 MG CAPSULE MM 3DANTRIUM 50 MG CAPSULE MM 3dantrolene sodium 100 mg cap MM 3dantrolene sodium 25 mg cap MM 3dantrolene sodium 50 mg cap MM 3dapsone 100 mg tablet MM 2dapsone 25 mg tablet MM 2DARAPRIM 25 MG TABLET 3darifenacin er 15 mg tablet MM 3 QL,STdarifenacin er 7.5 mg tablet MM 3 QL,STdasetta 1/35 (28) 1 mg-35 mcg tablet MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSdasetta 7/7/7 (28) 0.5 mg(7)/0.75 mg(7)/1 mg(7)-35 mcg tablet MM 1DAYPRO 600 MG TABLET MM 3daysee 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack 1 QLDAYTRANA 10 MG/9 HR DAILY PATCH 3 QLDAYTRANA 15 MG/9 HR DAILY PATCH 3 QLDAYTRANA 20 MG/9 HR DAILY PATCH 3 QLDAYTRANA 30 MG/9 HR DAILY PATCH 3 QLDDAVP 0.1 MG TABLET MM 4 QLDDAVP 0.1 MG/ML (REFRIGERATE) NASAL SOLUTION MM 4DDAVP 0.2 MG TABLET MM 4 QLDDAVP 10 MCG/SPRAY (0.1 ML) NASAL SPRAY AEROSOL MM 4 QLDDAVP 4 MCG/ML INJECTION SOLUTION 4deblitane 0.35 mg tablet MM 1DELTASONE 20 MG TABLET 3delyla (28) 0.1 mg-20 mcg tablet MM 1DELZICOL 400 MG CAPSULE (DR TABLETS INSIDE) 4 QL,STDELZICOL DR 400 MG CAPSULE MM 4 QL,STDEMADEX 10 MG TABLET MM 3DEMADEX 100 MG TABLET MM 3DEMADEX 20 MG TABLET MM 3DEMADEX 5 MG TABLET MM 3demeclocycline 150 mg tablet 4demeclocycline 300 mg tablet 4DEMEROL 100 MG TABLET 3 QLDEMEROL 50 MG TABLET 3 QLDEMSER 250 MG CAPSULE 4DENAVIR 1 % TOPICAL CREAM 4 PADEPAKENE 250 MG CAPSULE MM 4DEPAKENE 250 MG/5 ML ORAL SOLUTION MM 4DEPAKOTE 125 MG TABLET,DELAYED RELEASE MM 3DEPAKOTE 250 MG TABLET,DELAYED RELEASE MM 3DEPAKOTE 500 MG TABLET,DELAYED RELEASE MM 3DEPAKOTE ER 250 MG TABLET,EXTENDED RELEASE MM 3DEPAKOTE ER 500 MG TABLET,EXTENDED RELEASE MM 3DEPAKOTE SPRINKLES 125 MG CAPSULE MM 3DEPEN TITRATABS 250 MG TABLET MM,SP 4DEPO-PROVERA 150 MG/ML INTRAMUSCULAR SUSPENSION 3 QLDEPO-PROVERA 150 MG/ML INTRAMUSCULAR SYRINGE 3 QLDEPO-SUBQ PROVERA 104 104 MG/0.65 ML SUBCUTANEOUS SYRINGE MM 4 QLDEPO-TESTOSTERONE 100 MG/ML INTRAMUSCULAR OIL MM 3DEPO-TESTOSTERONE 200 MG/ML INTRAMUSCULAR OIL MM 3DERMA-SMOOTHE/FS BODY OIL 0.01 % 3DERMA-SMOOTHE/FS SCALP OIL 0.01 % 3 STDERMATOP 0.1 % TOPICAL CREAM 4DERMATOP 0.1 % TOPICAL OINTMENT 4DERMOTIC OIL 0.01 % EAR DROPS 3DESCOVY 200 MG-25 MG TABLET SP * QLdesipramine 10 mg tablet MM 3desipramine 100 mg tablet MM 3desipramine 150 mg tablet MM 3desipramine 25 mg tablet MM 3desipramine 50 mg tablet MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSdesipramine 75 mg tablet MM 3desloratadine 2.5 mg odt MM 3 QL,STdesloratadine 5 mg odt MM 3 QL,STdesloratadine 5 mg tablet MM 3 QLdesmopressin 0.01% solution MM 3 QLdesmopressin 0.1 mg/ml sol MM 3desmopressin 10 mcg/0.1 ml spr MM 3 QLdesmopressin 40 mcg/10 ml vial 4desmopressin acetate 0.1 mg tb MM 3 QLdesmopressin acetate 0.2 mg tb MM 3 QLDESOGEN 0.15 MG-0.03 MG TABLET MM 3desogestr-eth estrad eth estra MM 1desogestrel-ethinyl estrad tab MM 1DESONATE 0.05 % TOPICAL GEL 3desonide 0.05% cream 3desonide 0.05% lotion 3desonide 0.05% ointment 3DESOWEN 0.05 % LOTION 4DESOWEN 0.05 % TOPICAL CREAM 4desoximetasone 0.05% cream 3desoximetasone 0.05% gel 3desoximetasone 0.05% ointment 3desoximetasone 0.25% cream 3desoximetasone 0.25% ointment 3DESOXYN 5 MG TABLET 3 QLdesvenlafaxine er 100 mg tab MM 3 QL,STdesvenlafaxine er 100 mg tab MM 3 QL,STdesvenlafaxine er 50 mg tab MM 3 QL,STdesvenlafaxine er 50 mg tablet MM 3 QL,STdesvenlafaxine fum er 100 mg MM 3 QL,STdesvenlafaxine fum er 50 mg MM 3 QL,STDETROL 1 MG TABLET MM 3 QLDETROL 2 MG TABLET MM 3 QLDETROL LA 2 MG CAPSULE,EXTENDED RELEASE MM 3 QLDETROL LA 4 MG CAPSULE,EXTENDED RELEASE MM 3 QLdexamethasone 0.1% eye drop 2dexamethasone 0.5 mg tablet 1dexamethasone 0.5 mg/5 ml elx 2dexamethasone 0.5 mg/5 ml liq 2dexamethasone 0.75 mg tablet 1dexamethasone 1 mg tablet 1dexamethasone 1.5 mg tablet 1dexamethasone 2 mg tablet 1dexamethasone 4 mg tablet 1dexamethasone 6 mg tablet 1dexamethasone intensol 1 mg/ml drops (concentrate) 2DEXATRIM NATURAL 600 MG-100 MG-250 MCG TABLET 3DEXCOM G4 RECEIVER MM 4 PADEXCOM G4 RECEIVER PEDIATRIC MM 4 PADEXCOM G4 RECEIVER WITH SHARE (PEDIATRIC) MM 4 PADEXCOM G4 RECEIVER WITH SHARE KIT MM 4 PADEXCOM G4 TRANSMITTER DEVICE MM 4 PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSDEXCOM G5 RECEIVER 4 PADEXCOM G5 TRANSMITTER DEVICE 4 PADEXCOM G5-G4 SENSOR DEVICE MM 4 PADEXEDRINE 10 MG TABLET 3 QLDEXEDRINE 5 MG TABLET 3 QLDEXEDRINE SPANSULE 10 MG CAPSULE,EXTENDED RELEASE 4 QLDEXEDRINE SPANSULE 15 MG CAPSULE,EXTENDED RELEASE 4 QLDEXEDRINE SPANSULE 5 MG CAPSULE,EXTENDED RELEASE 4 QLDEXILANT 30 MG CAPSULE, DELAYED RELEASE MM 3 QL,STDEXILANT 60 MG CAPSULE, DELAYED RELEASE MM 3 QL,STdexmethylphenidate 10 mg tab 2 QLdexmethylphenidate 2.5 mg tab 2 QLdexmethylphenidate 5 mg tab 2 QLdexmethylphenidate er 10 mg cp 3 QL,STdexmethylphenidate er 15 mg cp 3 QL,STdexmethylphenidate er 20 mg cp 3 QL,STdexmethylphenidate er 30 mg cp 3 QL,STdexmethylphenidate er 40 mg cp 3 QL,STdexmethylphenidate er 5 mg cap 3 QL,STDEXPAK 10 DAY 1.5 MG (35 TABS) TABLETS IN A DOSE PACK 4DEXPAK 13 DAY 1.5 MG (51 TABS) TABLETS IN A DOSE PACK 4DEXPAK 6 DAY 1.5 MG (21 TABS) TABLETS IN A DOSE PACK 4dextroamp-amphet er 10 mg cap 3 QL,STdextroamp-amphet er 15 mg cap 3 QL,STdextroamp-amphet er 20 mg cap 3 QL,STdextroamp-amphet er 25 mg cap 3 QL,STdextroamp-amphet er 30 mg cap 3 QL,STdextroamp-amphet er 5 mg cap 3 QL,STdextroamp-amphetam 12.5 mg tab 2 QLdextroamp-amphetam 7.5 mg tab 2 QLdextroamp-amphetamin 10 mg tab 2 QLdextroamp-amphetamin 15 mg tab 2 QLdextroamp-amphetamin 20 mg tab 2 QLdextroamp-amphetamin 30 mg tab 2 QLdextroamp-amphetamine 5 mg tab 2 QLdextroamphetamine 10 mg tab 3 QLdextroamphetamine 5 mg tab 3 QLdextroamphetamine 5 mg/5 ml 3 QLDIABETA 1.25 MG TABLET MM 3DIABETA 2.5 MG TABLET MM 3DIABETA 5 MG TABLET MM 3diabetic support formula 167 mcg-100 mcg-83 mcg tablet 2DIAMOX SEQUELS 500 MG CAPSULE,EXTENDED RELEASE MM 3 QLDIASTAT 2.5 MG RECTAL KIT 4DIASTAT ACUDIAL 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT 4DIASTAT ACUDIAL 5 MG-7.5 MG-10 MG RECTAL KIT 4DIATRUE CONTROL SOLUTION HIGH 3DIATRUE CONTROL SOLUTION LOW 3DIATRUE CONTROL SOLUTION NORMAL 3DIATRUE PLUS BLOOD GLUCOSE METER SYSTEM MM 3 STDIATRUE PLUS TEST STRIP MM 3 QL,STdiazepam 10 mg rectal gel syst 3diazepam 10 mg tablet 2 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSdiazepam 2 mg tablet 2 QLdiazepam 2.5 mg rectal gel sys 3diazepam 20 mg rectal gel syst 3diazepam 5 mg tablet 2 QLdiazepam 5 mg/5 ml oral soln 2 QLdiazepam 5 mg/5 ml solution 2 QLdiazepam 5 mg/ml oral conc 2 QLdiazepam intensol 5 mg/ml oral concentrate 2 QLDIBENZYLINE 10 MG CAPSULE SP *DICLEGIS 10 MG-10 MG TABLET,DELAYED RELEASE 3 QLdiclofenac 0.1% eye drops 2diclofenac 1.5% topical soln MM 3 PAdiclofenac pot 50 mg tablet 2diclofenac sod ec 25 mg tab MM 2diclofenac sod ec 50 mg tab MM 2diclofenac sod ec 75 mg tab MM 2diclofenac sod er 100 mg tab MM 2diclofenac sodium 1% gel MM 2 STdiclofenac sodium 3% gel 4 PAdiclofenac-misoprost 50-200 tb MM 3 STdiclofenac-misoprost 75-200 tb MM 3 STdicloxacillin 250 mg capsule 2dicloxacillin 500 mg capsule 2dicyclomine 10 mg capsule 1dicyclomine 10 mg/5 ml soln 2dicyclomine 20 mg tablet 1didanosine dr 125 mg capsule 3 QLdidanosine dr 200 mg capsule 3 QLdidanosine dr 250 mg capsule 3 QLdidanosine dr 400 mg capsule 3 QLDIFFERIN 0.1 % LOTION 4 STDIFFERIN 0.1 % TOPICAL CREAM 4 STDIFFERIN 0.1 % TOPICAL GEL 4 STDIFFERIN 0.3 % TOPICAL GEL 4 STDIFFERIN 0.3 % TOPICAL GEL WITH PUMP 4 STDIFICID 200 MG TABLET 4 QL,STdiflorasone 0.05% cream 3 STdiflorasone 0.05% ointment 4 STDIFLUCAN 10 MG/ML ORAL SUSPENSION 3DIFLUCAN 100 MG TABLET 3DIFLUCAN 150 MG TABLET 3DIFLUCAN 200 MG TABLET 3DIFLUCAN 40 MG/ML ORAL SUSPENSION 3DIFLUCAN 50 MG TABLET 3diflunisal 500 mg tablet MM 3digitek 125 mcg tablet MM 2 QLdigitek 250 mcg tablet MM 2digox 125 mcg tablet MM 2 QLdigox 250 mcg tablet MM 2digoxin 0.05 mg/ml solution MM 2digoxin 125 mcg tablet MM 2 QLdigoxin 250 mcg tablet MM 2dihydrocodein-acetaminoph-caff 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSdihydroergotamine 1 mg/ml am 4dihydroergotamine 4 mg/ml spry 4 QLDILANTIN 30 MG CAPSULE MM 3DILANTIN EXTENDED 100 MG CAPSULE MM 3DILANTIN INFATABS 50 MG CHEWABLE TABLET MM 3DILANTIN-125 125 MG/5 ML ORAL SUSPENSION MM 3DILATRATE-SR 40 MG CAPSULE,EXTENDED RELEASE MM 2DILAUDID 1 MG/ML ORAL LIQUID 3 QLDILAUDID 2 MG TABLET 3 QLDILAUDID 4 MG TABLET 3 QLDILAUDID 8 MG TABLET 3 QLdilt-xr 120 mg capsule, extended release MM 2 QLdilt-xr 180 mg capsule, extended release MM 2 QLdilt-xr 240 mg capsule, extended release MM 2 QLdiltiazem 120 mg tablet MM 1diltiazem 12hr er 120 mg cap MM 2diltiazem 12hr er 60 mg cap MM 2diltiazem 12hr er 90 mg cap MM 2diltiazem 24hr er 120 mg cap MM 2 QLdiltiazem 24hr er 180 mg cap MM 2 QLdiltiazem 24hr er 240 mg cap MM 2 QLdiltiazem 24hr er 300 mg cap MM 2 QLdiltiazem 24hr er 360 mg cap MM 2 QLdiltiazem 30 mg tablet MM 1diltiazem 60 mg tablet MM 1diltiazem 90 mg tablet MM 1diltiazem er 120 mg capsule MM 2 QLdiltiazem er 180 mg capsule MM 2 QLdiltiazem er 180 mg tablet MM 2 QLdiltiazem er 240 mg capsule MM 2 QLdiltiazem er 240 mg tablet MM 2 QLdiltiazem er 300 mg tablet MM 2 QLdiltiazem er 360 mg tablet MM 2 QLdiltiazem er 420 mg tablet MM 2 QLdiltiazem hcl er 120 mg cap MM 2 QLdiltiazem hcl er 180 mg cap MM 2 QLdiltiazem hcl er 240 mg cap MM 2 QLdiltiazem hcl er 300 mg cap MM 2 QLdiltiazem hcl er 360 mg cap MM 2 QLdiltiazem hcl er 420 mg cap MM 2 QLDIOVAN 160 MG TABLET MM 3 QL,STDIOVAN 320 MG TABLET MM 3 QL,STDIOVAN 40 MG TABLET MM 3 QL,STDIOVAN 80 MG TABLET MM 3 QL,STDIOVAN HCT 160 MG-12.5 MG TABLET MM 3 QL,STDIOVAN HCT 160 MG-25 MG TABLET MM 3 QL,STDIOVAN HCT 320 MG-12.5 MG TABLET MM 3 QL,STDIOVAN HCT 320 MG-25 MG TABLET MM 3 QL,STDIOVAN HCT 80 MG-12.5 MG TABLET MM 3 QL,STDIPENTUM 250 MG CAPSULE MM 4 QL,STdiphenhydramine 12.5 mg/5 ml 3diphenoxylat-atrop 2.5-0.025/5 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSdiphenoxylate-atrop 2.5-0.025 2DIPROLENE 0.05 % LOTION 3DIPROLENE 0.05 % TOPICAL OINTMENT 3DIPROLENE AF 0.05 % TOPICAL CREAM 3dipyridamole 25 mg tablet MM 1dipyridamole 50 mg tablet MM 1dipyridamole 75 mg tablet MM 1DISALCID 500 MG TABLET 3DISALCID 750 MG TABLET 3DISKETS 40 MG SOLUBLE TABLET 2 QLdisopyramide 100 mg capsule MM 3disopyramide 150 mg capsule MM 3disulfiram 250 mg tablet MM 3disulfiram 500 mg tablet MM 3DITROPAN XL 10 MG TABLET,EXTENDED RELEASE MM 3 QLDITROPAN XL 15 MG TABLET,EXTENDED RELEASE MM 3 QLDITROPAN XL 5 MG TABLET,EXTENDED RELEASE MM 3 QLDIURIL 250 MG/5 ML ORAL SUSPENSION MM 3divalproex sod dr 125 mg tab MM 1divalproex sod dr 250 mg tab MM 1divalproex sod dr 500 mg tab MM 1divalproex sod er 250 mg tab MM 3divalproex sod er 500 mg tab MM 3divalproex sodium 125 mg cap MM 3DIVIGEL 0.25 MG (0.1 %) TRANSDERMAL GEL PACKET MM 3DIVIGEL 0.5 MG (0.1 %) TRANSDERMAL GEL PACKET MM 3DIVIGEL 1 MG (0.1 %) TRANSDERMAL GEL PACKET MM 3dofetilide 125 mcg capsule 3 QLdofetilide 250 mcg capsule 3 QLdofetilide 500 mcg capsule 3 QLDOLOPHINE 10 MG TABLET 2 QLDOLOPHINE 5 MG TABLET 2 QLdonepezil hcl 10 mg tablet MM 1 QLdonepezil hcl 23 mg tablet MM 3 QL,STdonepezil hcl 5 mg tablet MM 1 QLdonepezil hcl odt 10 mg tablet MM 1 QLdonepezil hcl odt 5 mg tablet MM 1 QLDORAL 15 MG TABLET 3 QLDORYX 200 MG TABLET,DELAYED RELEASE 4 QL,STDORYX 50 MG TABLET,DELAYED RELEASE 4 QL,STDORYX DR 150 MG TABLET 4 QL,STDORYX MPC 120 MG TABLET, DELAYED RELEASE 4 QL,STdorzolamide hcl 2% eye drops MM 1 QLdorzolamide-timolol eye drops MM 1 QLdothelle dha 35 mg-1 mg-200 mg capsule 3DOVONEX 0.005 % TOPICAL CREAM 4 QLdoxazosin mesylate 1 mg tab MM 1doxazosin mesylate 2 mg tab MM 1doxazosin mesylate 4 mg tab MM 1doxazosin mesylate 8 mg tab MM 1doxepin 10 mg capsule MM 1doxepin 10 mg/ml oral conc MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSdoxepin 100 mg capsule MM 1doxepin 150 mg capsule MM 1doxepin 25 mg capsule MM 1doxepin 5% cream 4doxepin 50 mg capsule MM 1doxepin 75 mg capsule MM 1doxercalciferol 0.5 mcg cap MM 4doxercalciferol 1 mcg capsule MM 4doxercalciferol 2.5 mcg cap MM 4doxycycline 25 mg/5 ml susp 3doxycycline hyc dr 100 mg tab 3 QLdoxycycline hyc dr 150 mg tab 3 QLdoxycycline hyc dr 200 mg tab 4 QL,STdoxycycline hyc dr 50 mg tab 4 QL,STdoxycycline hyc dr 75 mg tab 3 QLdoxycycline hyclate 100 mg cap 3 QLdoxycycline hyclate 100 mg tab 3doxycycline hyclate 20 mg tab 3doxycycline hyclate 50 mg cap 3doxycycline ir-dr 40 mg cap 4 QLdoxycycline mono 100 mg cap 2 QLdoxycycline mono 100 mg tablet 2doxycycline mono 150 mg cap 4 QLdoxycycline mono 150 mg tablet 3doxycycline mono 50 mg cap 2 QLdoxycycline mono 50 mg tablet 2doxycycline mono 75 mg capsule 4 QLdoxycycline mono 75 mg tablet 2DRISDOL 50,000 UNIT CAPSULE MM 3dronabinol 10 mg capsule 3 QL,PAdronabinol 2.5 mg capsule 3 QL,PAdronabinol 5 mg capsule 3 QL,PADROPLET LANCETS 30 GAUGE MM 1DROPLET LANCING DEVICE MM 3DROPLET PEN NEEDLE 29 GAUGE X 1/2" 1DROPLET PEN NEEDLE 29 GAUGE X 3/8" 1DROPLET PEN NEEDLE 31 GAUGE X 1/4" 1DROPLET PEN NEEDLE 31 GAUGE X 3/16" 1DROPLET PEN NEEDLE 31 GAUGE X 5/16" 1DROPLET PEN NEEDLE 32 GAUGE X 1/4" 1DROPLET PEN NEEDLE 32 GAUGE X 3/16" 1DROPLET PEN NEEDLE 32 GAUGE X 5/16" 1DROPLET PEN NEEDLE 32 GAUGE X 5/32" 1drospirenone-ee 3-0.02 mg tab MM 1drospirenone-ee 3-0.03 mg tab MM 1DROXIA 200 MG CAPSULE MM 3DROXIA 300 MG CAPSULE MM 3DROXIA 400 MG CAPSULE MM 3DRY EYE OMEGA BENEFITS 560 MG-1,680MG-1,000 UNIT/5ML ORAL LIQUID 3DRY EYE OMEGA BENEFITS 667 MG-250 UNIT CAPSULE 3DUAC 1.2 % (1 % BASE)-5 % TOPICAL GEL 3DUAVEE 0.45 MG-20 MG TABLET MM 3 QL,PADUET DHA 400 EC COMBO PACK 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSDUET DHA 430 EC COMBO PACK 3DUET DHA 430 MG COMBO PACK 3DUET DHA BALANCED 25 MG IRON-1 MG-267 MG-233 MG ORAL PACK 3DUET DHA WITH OMEGA-3 25 MG IRON-1 MG-400 MG ORAL PACK 3DUETACT 30 MG-2 MG TABLET MM 3 QL,STDUETACT 30 MG-4 MG TABLET MM 3 QL,STDUEXIS 800 MG-26.6 MG TABLET MM 4 QL,STDULERA 100 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER MM 3 QL,STDULERA 200 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER MM 3 QL,STduloxetine hcl dr 20 mg cap MM 2 QLduloxetine hcl dr 30 mg cap MM 2 QLduloxetine hcl dr 40 mg cap 3 QLduloxetine hcl dr 60 mg cap MM 2 QLduocal oral powder 2DURAGESIC 100 MCG/HR TRANSDERMAL PATCH 4 QLDURAGESIC 12 MCG/HR TRANSDERMAL PATCH 4 QLDURAGESIC 25 MCG/HR TRANSDERMAL PATCH 4 QLDURAGESIC 50 MCG/HR TRANSDERMAL PATCH 4 QLDURAGESIC 75 MCG/HR TRANSDERMAL PATCH 4 QLDUREZOL 0.05 % EYE DROPS 2DURLAZA 162.5 MG CAPSULE,EXTENDED RELEASE 3 QL,PAdutasteride 0.5 mg capsule MM 3 QLdutasteride-tamsulosin 0.5-0.4 MM 3 QL,STDUTOPROL 100 MG-12.5 MG TABLET,EXTENDED RELEASE MM 3 QLDUTOPROL 25 MG-12.5 MG TABLET,EXTENDED RELEASE MM 3 QLDUTOPROL 50 MG-12.5 MG TABLET,EXTENDED RELEASE MM 3 QLDYANAVEL XR 2.5 MG/ML ORAL 24 HR EXTENDED RELEASE SUSPENSION 3 QL,STDYAZIDE 37.5 MG-25 MG CAPSULE MM 3DYMISTA 137 MCG-50 MCG/SPRAY NASAL SPRAY MM 3 QL,STDYRENIUM 100 MG CAPSULE MM 3DYRENIUM 50 MG CAPSULE MM 3DYZBAC TABLET 3E-Z JECT LANCETS MM 3E-Z JECT LANCETS 26 GAUGE MM 1E-Z JECT LANCETS 30 GAUGE MM 1E-Z JECT LANCETS 33 GAUGE MM 1E-Z JECT THIN LANCETS 28 GAUGE MM 1E-Z SPACER 2E.E.S. 400 MG TABLET 4E.E.S. GRANULES 200 MG/5 ML ORAL SUSPENSION 4EASIVENT HOLDING CHAMBER 3EASIVENT MASK LARGE 3EASIVENT MASK MEDIUM 3EASIVENT MASK SMALL 3EASY CLICK LANCING DEVICE MM 1EASY COMFORT INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2EASY COMFORT INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2EASY COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 1/2" MM 2EASY COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2EASY COMFORT INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2EASY COMFORT INSULIN SYRINGE 1/2 ML 30 GAUGE X 1/2" MM 2EASY COMFORT INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSEASY COMFORT LANCETS 30 GAUGE MM 1EASY COMFORT PEN NEEDLES 31 GAUGE X 1/4" 2EASY COMFORT PEN NEEDLES 31 GAUGE X 3/16" 1EASY COMFORT PEN NEEDLES 31 GAUGE X 5/16" 2EASY COMFORT PEN NEEDLES 32 GAUGE X 5/32" 3EASY MINI EJECT LANCING DEVICE MM 3EASY PLUS BLOOD GLUCOSE KIT MM 3 STEASY PLUS GLUCOSE SYSTEM MM 3 STEASY PLUS II BLOOD GLUCOSE METER MM 3 STEASY PLUS II HIGH CONTROL SOLUTION 3EASY PLUS II LOW CONTROL SOLUTION 3EASY PLUS II TEST STRIPS MM 3 QL,STEASY PLUS STRIPS MM 3 QL,STEASY STEP BLOOD GLUCOSE METER MM 3 STEASY STEP BLOOD GLUCOSE SYSTEM KIT MM 3 STEASY STEP HIGH CONTROL SOLN SOLUTION 3EASY STEP LOW CONTROL SOLUTION 3EASY STEP NORMAL CONTROL SOLN SOLUTION 3EASY STEP STRIPS MM 3 QL,STEASY TALK BLOOD GLUCOSE METER MM 3 STEASY TALK GLUCOSE SYSTEM KIT MM 3 STEASY TALK GLUCOSE TEST STRIPS MM 3 QL,STEASY TALK HIGH CONTROL SOLUTION 3EASY TALK LOW CONTROL SOLUTION 3EASY TOUCH 29 GAUGE X 1/2" NEEDLE 1EASY TOUCH 31 GAUGE X 1/4" NEEDLE 1EASY TOUCH 31 GAUGE X 3/16" NEEDLE 1EASY TOUCH 31 GAUGE X 5/16" NEEDLE 1EASY TOUCH 32 GAUGE X 1/4" NEEDLE 1EASY TOUCH 32 GAUGE X 3/16" NEEDLE 1EASY TOUCH 32 GAUGE X 5/32" NEEDLE 3EASY TOUCH ALCOHOL PREP PADS 3EASY TOUCH FLIPLOCK INSULIN 1 ML 29 GAUGE X 1/2" SYRINGE MM 2EASY TOUCH FLIPLOCK INSULIN 1 ML 31 GAUGE X 5/16" SYRINGE MM 2EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 30 GAUGE X 1/2" MM 2EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2EASY TOUCH GLUCOSE MONITOR MM 3 STEASY TOUCH HIGH-LOW CONTROL SOLUTION 3EASY TOUCH INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SAFETY SYRINGE 0.5 ML 30 GAUGE X 5/16" MM 2EASY TOUCH INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SAFETY SYRINGE 1 ML 30 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 0.3 ML 30 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2EASY TOUCH INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2EASY TOUCH INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2EASY TOUCH INSULIN SYRINGE 1 ML 27 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1 ML 30 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSEASY TOUCH INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2EASY TOUCH INSULIN SYRINGE 1/2 ML 27 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1/2 ML 30 GAUGE X 1/2" MM 2EASY TOUCH INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2EASY TOUCH LANCETS 26 GAUGE MM 3EASY TOUCH LANCETS 28 GAUGE MM 1EASY TOUCH LANCETS 30 GAUGE MM 3EASY TOUCH LANCETS 32 GAUGE MM 3EASY TOUCH LANCING DEVICE MM 3EASY TOUCH LUER LOCK INSULIN 1 ML SYRINGE MM 2EASY TOUCH SAFETY LANCETS 21 GAUGE MM 1EASY TOUCH SAFETY LANCETS 23 GAUGE MM 1EASY TOUCH SAFETY LANCETS 26 GAUGE MM 1EASY TOUCH SAFETY LANCETS 28 GAUGE MM 1EASY TOUCH SAFETY LANCETS 30 GAUGE MM 1EASY TOUCH SAFETY LANCETS 32 GAUGE MM 1EASY TOUCH SHEATHLOCK INSULIN 1 ML 29 GAUGE X 1/2" SYRINGE MM 2EASY TOUCH SHEATHLOCK INSULIN 1 ML 30 GAUGE X 5/16" SYRINGE MM 2EASY TOUCH SHEATHLOCK INSULIN 1 ML 31 GAUGE X 5/16" SYRINGE MM 2EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 30 GAUGE X 1/2" MM 2EASY TOUCH TEST STRIP MM 3 QL,STEASY TOUCH TWIST LANCETS 26 GAUGE MM 1EASY TOUCH TWIST LANCETS 28 GAUGE MM 1EASY TOUCH TWIST LANCETS 30 GAUGE MM 1EASY TOUCH TWIST LANCETS 32 GAUGE MM 1EASY TOUCH TWIST LANCETS 33 GAUGE MM 1EASY TOUCH UNI-SLIP 1 ML SYRINGE MM 4EASY TRAK BLOOD GLUCOSE METER MM 3 STEASY TRAK GLUCOSE SYSTEM KIT MM 3 STEASY TRAK GLUCOSE TEST STRIPS MM 3 QL,STEASY TRAK HIGH CONTROL SOLUTION 3EASY TRAK LOW CONTROL SOLUTION 3EASY TRAK NORMAL CONTROL SOLUTION 3EASY TWIST AND CAP LANCETS 28 GAUGE MM 1EASYGLUCO METER KIT MM 3 STEASYGLUCO MONITORING SYSTEM KIT MM 3 STEASYGLUCO PLUS KIT MM 3 STEASYGLUCO PLUS NORMAL CONTROL SOLUTION 3EASYGLUCO PLUS STRIPS MM 3 QL,STEASYGLUCO TEST STRIPS MM 3 QL,STEASYGLUCO TEST STRIPS 3 QL,STEASYMAX 15 LEVEL 1 SOLUTION 3EASYMAX 15 LEVEL 2 SOLUTION 3EASYMAX 15 STRIPS MM 3 QL,STEASYMAX L BLOOD GLUCOSE METER MM 3 STEASYMAX LOW CONTROL SOLUTION 3EASYMAX NG KIT MM 3 STEASYMAX NG METER MM 3 STEASYMAX NORMAL CONTROL SOLUTION 3EASYMAX STRIPS MM 3 QL,STEASYMAX V SPEAKING BLOOD GLUCOSE SYSTEM MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSEASYMAX V2 BLOOD GLUCOSE METER MM 3 STEASYMAX V2 GLUCOSE SYSTEM KIT MM 3 STEC MATRIXX 100 MG-100 MG TABLET 3EC-NAPROSYN 375 MG TABLET,DELAYED RELEASE MM 3EC-NAPROSYN 500 MG TABLET,DELAYED RELEASE MM 3ECLIPSE NEEDLE 23 GAUGE X 1" 1ECLIPSE NEEDLE 25 X 5/8" 1ECLIPSE NEEDLE 27 GAUGE X 1/2" 1ECLIPSE SYRINGE 3 ML 21 GAUGE X 1" 1ECLIPSE SYRINGE 3 ML 25 GAUGE X 1" 1econazole nitrate 1% cream 3ECOZA 1 % TOPICAL FOAM 3ed-spaz 0.125 mg disintegrating tablet MM 2EDARBI 40 MG TABLET MM 3 QL,STEDARBI 80 MG TABLET MM 3 QL,STEDARBYCLOR 40 MG-12.5 MG TABLET MM 3 QL,STEDARBYCLOR 40 MG-25 MG TABLET MM 3 QL,STEDECRIN 25 MG TABLET MM 4EDLUAR 10 MG SUBLINGUAL TABLET 3 QL,STEDLUAR 5 MG SUBLINGUAL TABLET 3 QL,STEDURANT 25 MG TABLET SP * QLeemt 1.25 mg-2.5 mg tablet MM 3eemt hs 0.625 mg-1.25 mg tablet MM 3EFFER-K 10 MEQ EFFERVESCENT TABLET MM 3EFFER-K 20 MEQ EFFERVESCENT TABLET MM 3effer-k 25 meq effervescent tablet MM 3EFFEXOR XR 150 MG CAPSULE,EXTENDED RELEASE MM 3 QLEFFEXOR XR 37.5 MG CAPSULE,EXTENDED RELEASE MM 3 QLEFFEXOR XR 75 MG CAPSULE,EXTENDED RELEASE MM 3 QLEFFIENT 10 MG TABLET MM 2 QLEFFIENT 5 MG TABLET MM 2 QLEFUDEX 5 % TOPICAL CREAM 4EGG-PRO ORAL POWDER 3EGRIFTA 1 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PAEGRIFTA 2 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PAELDEPRYL 5 MG CAPSULE MM 3ELEMENT BLOOD GLUCOSE METER KT MM 3 STELEMENT COMPACT GLUCOSE METER MM 3 STELEMENT COMPACT HIGH CONTROL SOLUTION 3ELEMENT COMPACT NORMAL CONTROL SOLUTION 3ELEMENT COMPACT TEST STRIPS MM 3 QL,STELEMENT COMPACT V GLUCOSE METER MM 3 STELEMENT HIGH CONTROL SOLUTION 3ELEMENT LOW CONTROL SOLUTION 3ELEMENT NORMAL CONTROL SOLUTION 3ELEMENT PLUS BLOOD GLUCOSE KIT MM 3 STELEMENT TEST STRIPS MM 3 QL,STELESTAT 0.05 % EYE DROPS 3 QL,STELESTRIN 0.87 GRAM/ACTUATION (0.06%) TRANSDERMAL GEL PUMP MM 4 QL,STELIDEL 1 % TOPICAL CREAM 2ELIGARD 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE SP * QL,PAELIGARD 30 MG (4 MONTH) SUBCUTANEOUS SYRINGE SP * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSELIGARD 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE SP * QL,PAELIGARD 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE SP * QL,PAELIMITE 5 % TOPICAL CREAM 3elinest 0.3 mg-30 mcg tablet MM 1eliphos 667 mg tablet MM 3ELIQUIS 2.5 MG TABLET MM 2 QLELIQUIS 5 MG TABLET MM 2 QLelite-ob 28 mg-1.25 mg-200 mg capsule 2elite-ob 400 35 mg-5 mg-1.2 mg-400 mg capsule 2ELIXOPHYLLIN 80 MG/15 ML ORAL ELIXIR MM 4ELLA 30 MG TABLET 2 QLELMIRON 100 MG CAPSULE 4 QLELOCON 0.1 % TOPICAL CREAM 3ELOCON 0.1 % TOPICAL LOTION (SOLUTION) 3ELOCON 0.1 % TOPICAL OINTMENT 3EMADINE 0.05 % EYE DROPS 3 STEMBEDA 100 MG-4 MG CAPSULE, EXTEND RELEASE, ORAL ONLY 2 QLEMBEDA 20 MG-0.8 MG CAPSULE, EXTEND RELEASE, ORAL ONLY 2 QLEMBEDA 30 MG-1.2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY 2 QLEMBEDA 50 MG-2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY 2 QLEMBEDA 60 MG-2.4 MG CAPSULE, EXTEND RELEASE, ORAL ONLY 2 QLEMBEDA 80 MG-3.2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY 2 QLEMBRACE BLOOD GLUCOSE KIT MM 3 STEMBRACE BLOOD GLUCOSE SYSTEM MM 3 STEMBRACE BLOOD GLUCOSE SYSTEM STRIPS MM 3 QL,STEMBRACE EVO BLOOD GLUCOSE KIT MM 3 STEMBRACE EVO LEVEL 1 SOLUTION 3EMBRACE EVO LEVEL 2 SOLUTION 3EMBRACE EVO TEST STRIPS MM 3 QL,STEMBRACE GLUCOSE CONTROL HIGH SOLUTION 3EMBRACE GLUCOSE CONTROL LOW SOLUTION 3EMBRACE LANCETS 30 GAUGE MM 3EMBRACE PRO BLOOD GLUCOSE METER MM 3 STEMBRACE PRO SOLUTION 3EMBRACE PRO TEST STRIPS MM 3 QL,STEMCYT 140 MG CAPSULE 3 QLEMEND 125 MG (1)-80 MG (2) CAPSULES IN A DOSE PACK 3 QL,PAEMEND 125 MG (25 MG/ML FINAL CONC.) ORAL SUSPENSION 3 QL,PAEMEND 125 MG CAPSULE 3 QL,PAEMEND 40 MG CAPSULE 3 QL,PAEMEND 80 MG CAPSULE 3 QL,PAEMLA CREAM 3emoquette 0.15 mg-0.03 mg tablet MM 1EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM 4 QLEMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM 4 QLEMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM 4 QLEMTRIVA 10 MG/ML ORAL SOLUTION 3 QLEMTRIVA 200 MG CAPSULE 3 QLemverm 100 mg chewable tablet 4ENABLEX 15 MG TABLET,EXTENDED RELEASE MM 3 QL,STENABLEX 7.5 MG TABLET,EXTENDED RELEASE MM 3 QL,STenalapril maleate 10 mg tab MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSenalapril maleate 2.5 mg tab MM 1enalapril maleate 20 mg tab MM 1enalapril maleate 5 mg tablet MM 1enalapril-hctz 10-25 mg tablet MM 1enalapril-hctz 5-12.5 mg tab MM 1ENBRACE HR 1.5 MG IRON-8.73 MG-6.4 MG CAPSULE,IMMED AND DELAY RELEASE 3ENBREL 25 MG (1 ML) SUBCUTANEOUS SOLUTION SP * QL,PAENBREL 25 MG/0.5 ML (0.51 ML) SUBCUTANEOUS SYRINGE SP * QL,PAENBREL 50 MG/ML (0.98 ML) SUBCUTANEOUS SYRINGE SP * QL,PAENBREL SURECLICK 50 MG/ML (0.98 ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PAendocet 10 mg-325 mg tablet 2 QLendocet 2.5 mg-325 mg tablet 2 QLendocet 5 mg-325 mg tablet 2 QLendocet 7.5 mg-325 mg tablet 2 QLendodan 4.8355-325 mg tablet 2 QLENFAGROW NEXT STEP 0.03 GRAM-0.5 KCAL/ML ORAL LIQUID 3ENFAGROW NEXT STEP 0.03 GRAM-0.7 KCAL/ML ORAL LIQUID 3ENFAGROW PREMIUM TODDLER POWD 3ENFAGROW TODDLER NEXT STEP 6 GRAM-160 KCAL/36 GRAM ORAL POWDER 3ENJUVIA 0.3 MG TABLET MM 3ENJUVIA 0.45 MG TABLET MM 3ENJUVIA 0.625 MG TABLET MM 3ENJUVIA 0.9 MG TABLET MM 3ENJUVIA 1.25 MG TABLET MM 3ENLITE GLUCOSE SENSOR DEVICE MM 3 PAENLITE SYSTEM MM 3 PAenoxaparin 100 mg/ml syringe 3 QLenoxaparin 120 mg/0.8 ml syr 3 QLenoxaparin 150 mg/ml syringe 3 QLenoxaparin 30 mg/0.3 ml syr 3 QLenoxaparin 300 mg/3 ml vial 3 QLenoxaparin 40 mg/0.4 ml syr 3 QLenoxaparin 60 mg/0.6 ml syr 3 QLenoxaparin 80 mg/0.8 ml syr 3 QLenpresse 50-30 (6)/75-40(5)/125-30(10) tablet MM 1enskyce 0.15 mg-0.03 mg tablet MM 1ENSTILAR 0.005 %-0.064 % TOPICAL FOAM SP * QL,PAensure active clear oral liquid 2ensure active heart health oral liquid 2ensure active high protein oral liquid 2ensure active light oral liquid 2ensure active muscle health oral liquid 2ensure active protein-muscle oral liquid 2ensure compact oral liquid 2ENSURE COMPLETE 0.05 GRAM-1.5 KCAL/ML ORAL LIQUID 3ENSURE ENLIVE 0.08 GRAM-1.5 KCAL/ML ORAL LIQUID 3ensure high protein oral liquid 2ensure high protein-muscle oral liquid 2ENSURE MUSCLE HEALTH LIQUID 3ensure muscle health oral liquid 2ensure oral liquid 2ENSURE ORAL POWDER 3ENSURE ORIGINAL 0.04 GRAM-1.05 KCAL/ML ORAL LIQUID 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSensure original oral liquid 2ENSURE PLUS 0.05 GRAM-1.5 KCAL/ML ORAL LIQUID 3ENSURE PUDDING 3entacapone 200 mg tablet MM 3 QLentecavir 0.5 mg tablet SP * QLentecavir 1 mg tablet SP * QLENTEREG 12 MG CAPSULE 4 QLENTOCORT EC 3 MG CAPSULE,DELAYED,EXTENDED RELEASE 4ENTRESTO 24 MG-26 MG TABLET 2 QL,PAENTRESTO 49 MG-51 MG TABLET 2 QL,PAENTRESTO 97 MG-103 MG TABLET 2 QL,PAenulose 10 gram/15 ml oral solution MM 1ENVARSUS XR 0.75 MG TABLET,EXTENDED RELEASE 3ENVARSUS XR 1 MG TABLET,EXTENDED RELEASE 3ENVARSUS XR 4 MG TABLET,EXTENDED RELEASE 3eo28 splash oral liquid 2EPANED 1 MG/ML ORAL SOLUTION MM 3EPCLUSA 400 MG-100 MG TABLET SP * QL,PAEPIDUO 0.1 %-2.5 % TOPICAL GEL 4 STEPIDUO 0.1 %-2.5 % TOPICAL GEL WITH PUMP 4 STEPIDUO FORTE 0.3 %-2.5 % TOPICAL GEL WITH PUMP 4 STEPIFOAM 1 %-1 % TOPICAL 4epinastine hcl 0.05% eye drops 2 QLepinephrine 0.15 mg auto-injct 3epinephrine 0.3 mg auto-inject 3 QLEPIPEN 2-PAK 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR 2 QLEPIPEN JR 2-PAK 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR 2 QLepitol 200 mg tablet MM 2EPIVIR 10 MG/ML ORAL SOLUTION 3 QLEPIVIR 150 MG TABLET 3 QLEPIVIR 300 MG TABLET 3 QLEPIVIR HBV 100 MG TABLET 3 QLEPIVIR HBV 25 MG/5 ML (5 MG/ML) ORAL SOLUTION 3 QLeplerenone 25 mg tablet MM 3eplerenone 50 mg tablet MM 3EPOGEN 10,000 UNIT/ML INJECTION SOLUTION SP * QL,PAEPOGEN 2,000 UNIT/ML INJECTION SOLUTION SP * QL,PAEPOGEN 20,000 UNIT/2 ML INJECTION SOLUTION SP * QL,PAEPOGEN 20,000 UNIT/ML INJECTION SOLUTION SP * QL,PAEPOGEN 3,000 UNIT/ML INJECTION SOLUTION SP * QL,PAEPOGEN 4,000 UNIT/ML INJECTION SOLUTION SP * QL,PAeprosartan mesylate 600 mg tab MM 3 QL,STEPZICOM 600 MG-300 MG TABLET SP * QLeql child's omega-3 gummies 2EQUETRO 100 MG CAPSULE, EXTENDED RELEASE MM 3EQUETRO 200 MG CAPSULE, EXTENDED RELEASE MM 3EQUETRO 300 MG CAPSULE, EXTENDED RELEASE MM 3ergoloid mesylates 1 mg tab MM 4ERGOMAR 2 MG SUBLINGUAL TABLET 3ERIVEDGE 150 MG CAPSULE SP,LD * QL,PAerrin 0.35 mg tablet MM 1ERTACZO 2 % TOPICAL CREAM 4 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSery pads 2 % topical swab 3ERY-TAB 250 MG TABLET,DELAYED RELEASE 4ERY-TAB 333 MG TABLET,DELAYED RELEASE 4ERY-TAB 500 MG TABLET,DELAYED RELEASE 4ERYGEL 2 % TOPICAL 3ERYPED 200 200 MG/5 ML ORAL SUSPENSION 4ERYPED 400 400 MG/5 ML ORAL SUSPENSION 4ERYTHROCIN (AS STEARATE) 250 MG TABLET 4erythromycin 0.5% eye ointment 2erythromycin 2% gel 3erythromycin 2% pledgets 3erythromycin 2% solution 2erythromycin 250 mg filmtab 4erythromycin 500 mg filmtab 4erythromycin ec 250 mg cap 4erythromycin es 400 mg tab 4erythromycin-benzoyl gel 3ESBRIET 267 MG CAPSULE SP,LD * QL,PAESCAVITE 7.5 MG IRON-0.25 MG FLUOR. CHEWABLE TABLET 3ESCAVITE D 6 MG IRON-0.25 MG FLUORIDE CHEW TABLET,IMMEDIATE - DELAYED 3ESCAVITE LQ 6 MG IRON-0.25 MG FLUORIDE/ML ORAL DROPS 3escitalopram 10 mg tablet MM 1 QLescitalopram 20 mg tablet MM 1 QLescitalopram 5 mg tablet MM 1 QLescitalopram oxalate 5 mg/5 ml MM 3 QLESGIC 50 MG-325 MG-40 MG CAPSULE 3 QLESGIC 50 MG-325 MG-40 MG TABLET 3 QLESOMEPRAZOLE DR 49.3 MG CAP MM 3 QL,STesomeprazole mag dr 20 mg cap MM 3 QLesomeprazole mag dr 40 mg cap MM 3 QLestarylla 0.25 mg-35 mcg tablet MM 1estazolam 1 mg tablet 2 QLestazolam 2 mg tablet 2 QLESTRACE 0.01% (0.1 MG/GRAM) VAGINAL CREAM MM 3ESTRACE 0.5 MG TABLET MM 3ESTRACE 1 MG TABLET MM 3ESTRACE 2 MG TABLET MM 3estradiol 0.025 mg patch MM 3 QLestradiol 0.0375 mg patch MM 3 QLestradiol 0.0375 mg/day patch MM 2 QLestradiol 0.05 mg patch MM 3 QLestradiol 0.05 mg/day patch MM 2 QLestradiol 0.06 mg/day patch MM 2 QLestradiol 0.075 mg patch MM 3 QLestradiol 0.075 mg/day patch MM 2 QLestradiol 0.1 mg patch MM 3 QLestradiol 0.1 mg/day patch MM 2 QLestradiol 0.5 mg tablet MM 1estradiol 1 mg tablet MM 1estradiol 2 mg tablet MM 1estradiol tds 0.025 mg/day MM 2 QLestradiol-noreth 0.5-0.1 mg tb MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSestradiol-noreth 1-0.5 mg tab MM 3ESTRING 2 MG VAGINAL 3 QLestro vital nutrients x-str 15 unit-0.2 mg tablet 2estro vital nutrients x-str 30 unit-400 mcg tablet 2estroblend 500 mcg-1,000 unit-20 mcg tablet 2ESTROGEL 1.25 GRAM/ACTUATION (0.06%) TRANSDERMAL GEL PUMP 3 QLestrogen-methyltestos h.s. tab MM 3estrogen-methyltestosterone tb MM 3estronatural 15 unit-0.2 mg-40 mg tablet 2estropipate 0.625(0.75 mg) tab MM 1estropipate 1.25(1.5 mg) tab MM 1estropipate 2.5(3 mg) tab MM 1estroplus 15 unit-0.2 mg-40 mg tablet 2ESTROSTEP FE-28 1-20 (5)/1-30(7)/1MG-35MCG(9) TABLET MM 3eszopiclone 1 mg tablet 2 QLeszopiclone 2 mg tablet 2 QLeszopiclone 3 mg tablet 2 QLethacrynic acid 25 mg tablet MM 4ethambutol hcl 100 mg tablet MM 3ethambutol hcl 400 mg tablet MM 3ethosuximide 250 mg capsule MM 3ethosuximide 250 mg/5 ml soln MM 3etidronate disodium 200 mg tab MM 2etidronate disodium 400 mg tab MM 2etodolac 200 mg capsule MM 2etodolac 300 mg capsule MM 2etodolac 400 mg tablet MM 2etodolac 500 mg tablet MM 2etodolac er 400 mg tablet MM 3etodolac er 500 mg tablet MM 3etodolac er 600 mg tablet MM 3etoposide 50 mg capsule SP * QLEURAX 10 % LOTION 3EURAX 10 % TOPICAL CREAM 3EVAMIST 1.53 MG/SPRAY (1.7 %) TRANSDERMAL SPRAY 3EVEKEO 10 MG TABLET 4 QLEVEKEO 5 MG TABLET 4 QLEVENCARE G2 MM 3 STEVENCARE G2 SOLUTION 3EVENCARE G2 STRIPS MM 3 QL,STEVENCARE G3 CONTROL SOLUTION 3EVENCARE G3 GLUCOSE METER KIT MM 3 STEVENCARE G3 TEST STRIPS MM 3 QL,STEVENCARE KIT MM 3 STEVENCARE MINI GLUCOSE CONTROL SOLUTION 3EVENCARE MINI GLUCOSE TEST STRIPS MM 3 QL,STEVENCARE MINI MONITOR SYSTEM MM 3 STEVENCARE SOLUTION 3EVENCARE TEST STRIPS MM 3 QL,STEVISTA 60 MG TABLET MM 3 QLEVOCLIN 1 % TOPICAL FOAM 4 STEVOLUTION BLOOD GLUCOSE METER KIT MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSEVOLUTION NORMAL CONTROL SOLUTION 3EVOLUTION TEST STRIPS MM 3 QL,STEVOTAZ 300 MG-150 MG TABLET SP * QLEVOXAC 30 MG CAPSULE MM 3EVZIO 0.4 MG/0.4 ML INJECTION,AUTO-INJECTOR SP * QLEXALGO ER 12 MG TABLET,EXTENDED RELEASE 4 QL,STEXALGO ER 16 MG TABLET,EXTENDED RELEASE 4 QL,STEXALGO ER 32 MG TABLET,EXTENDED RELEASE 4 QL,STEXALGO ER 8 MG TABLET,EXTENDED RELEASE 4 QL,STEXEL INSULIN 0.3 ML 29 GAUGE X 1/2" SYRINGE MM 2EXEL INSULIN 1 ML 27 GAUGE X 1/2" SYRINGE MM 2EXEL INSULIN 1 ML 30 GAUGE X 5/16" SYRINGE MM 2EXEL INSULIN 1/2 ML 28 GAUGE X 1/2" SYRINGE MM 2EXEL INSULIN 1/2 ML 30 GAUGE X 5/16" SYRINGE MM 2EXEL INSULIN SYRN 27G-1/2 ML MM 2EXELDERM 1 % TOPICAL CREAM 4 STEXELDERM 1 % TOPICAL SOLUTION 4 STEXELON 1.5 MG CAPSULE MM 3 QLEXELON 3 MG CAPSULE MM 3 QLEXELON 4.5 MG CAPSULE MM 3 QLEXELON 6 MG CAPSULE MM 3 QLEXELON PATCH 13.3 MG/24 HOUR TRANSDERMAL MM 3 QLEXELON PATCH 4.6 MG/24 HR TRANSDERMAL MM 3 QLEXELON PATCH 9.5 MG/24 HR TRANSDERMAL MM 3 QLexemestane 25 mg tablet MM 3 QLEXFORGE 10 MG-160 MG TABLET MM 3 QL,STEXFORGE 10 MG-320 MG TABLET MM 3 QL,STEXFORGE 5 MG-160 MG TABLET MM 3 QL,STEXFORGE 5 MG-320 MG TABLET MM 3 QL,STEXFORGE HCT 10 MG-160 MG-12.5 MG TABLET MM 3 QL,STEXFORGE HCT 10 MG-160 MG-25 MG TABLET MM 3 QL,STEXFORGE HCT 10 MG-320 MG-25 MG TABLET MM 3 QL,STEXFORGE HCT 5 MG-160 MG-12.5 MG TABLET MM 3 QL,STEXFORGE HCT 5 MG-160 MG-25 MG TABLET MM 3 QL,STEXJADE 125 MG DISPERSIBLE TABLET SP,LD * QL,PAEXJADE 250 MG DISPERSIBLE TABLET SP,LD * QL,PAEXJADE 500 MG DISPERSIBLE TABLET SP,LD * QL,PAEXTAVIA 0.3 MG SUBCUTANEOUS KIT SP * QL,PAEXTAVIA 0.3 MG SUBCUTANEOUS SOLUTION SP * QL,PAEXTINA 2 % TOPICAL FOAM 4 STextra-virt plus dha 29 mg iron-1.25 mg-55 mg capsule 2EYE OMEGA ADVANTAGE 550 MG-250 UNIT-2.5 MG-0.5 MG CAPSULE 3EZ FLU 16-17(FLUZON QD PED)(PF) 30 MCG(7.5 MCG X4)/0.25 ML IM SYR KIT 3EZ FLU 2016-17 (AFLURIA)(PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRINGE KIT 3EZ FLU 2016-17 (FLUVIRIN)(PF) 45 MCG(15 MCG X 3)/0.5 ML IM SYRINGE KIT 3EZ SMART CONTROL SOLUTION 3EZ SMART LANCETS 28 GAUGE MM 1EZ SMART PLUS SYSTEM KIT MM 3 STEZ SMART PLUS TEST STRIPS MM 3 QL,STEZ SMART SYSTEM KIT MM 3 STEZ SMART TEST STRIPS MM 3 QL,STfabb 2.2 mg-25 mg-1 mg tablet 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSFABIOR 0.1 % TOPICAL FOAM 4 STFACTIVE 320 MG TABLET 3falessa 1 mg tablet 3falmina (28) 0.1 mg-20 mcg tablet MM 1famciclovir 125 mg tablet 2 QLfamciclovir 250 mg tablet 2 QLfamciclovir 500 mg tablet 2 QLfamotidine 20 mg tablet MM 2famotidine 40 mg tablet MM 2famotidine 40 mg/5 ml susp MM 2FAMVIR 125 MG TABLET 4 QLFAMVIR 250 MG TABLET 3 QLFAMVIR 500 MG TABLET 4 QLFANAPT 1 MG TABLET MM 4 QL,PAFANAPT 10 MG TABLET MM 4 QL,PAFANAPT 12 MG TABLET MM 4 QL,PAFANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK 4 QL,PAFANAPT 2 MG TABLET MM 4 QL,PAFANAPT 4 MG TABLET MM 4 QL,PAFANAPT 6 MG TABLET MM 4 QL,PAFANAPT 8 MG TABLET MM 4 QL,PAFARESTON 60 MG TABLET SP * QLFARXIGA 10 MG TABLET MM 3 QL,STFARXIGA 5 MG TABLET MM 3 QL,STFARYDAK 10 MG CAPSULE SP,LD * QL,PAFARYDAK 15 MG CAPSULE SP,LD * QL,PAFARYDAK 20 MG CAPSULE SP,LD * QL,PAFAZACLO 100 MG DISINTEGRATING TABLET MM 3FAZACLO 12.5 MG DISINTEGRATING TABLET MM 3FAZACLO 150 MG DISINTEGRATING TABLET MM 3FAZACLO 200 MG DISINTEGRATING TABLET MM 3FAZACLO 25 MG DISINTEGRATING TABLET MM 3fe 90 plus tablet 2fe c plus 100 mg-250 mg-25 mcg-1 mg tablet 1felbamate 400 mg tablet MM 4felbamate 600 mg tablet MM 4felbamate 600 mg/5 ml susp MM 4FELBATOL 400 MG TABLET MM 4FELBATOL 600 MG TABLET MM 4FELBATOL 600 MG/5 ML ORAL SUSPENSION MM 4FELDENE 10 MG CAPSULE MM 3FELDENE 20 MG CAPSULE MM 3felodipine er 10 mg tablet MM 2 QLfelodipine er 2.5 mg tablet MM 2 QLfelodipine er 5 mg tablet MM 2 QLFEMARA 2.5 MG TABLET MM 4 QLFEMCAP 22 MM VAGINAL DEVICE 4FEMCAP 26 MM VAGINAL DEVICE 4FEMCAP 30 MM VAGINAL DEVICE 4FEMCON FE 0.4 MG-35 MCG (21)/75 MG (7) CHEWABLE TABLET MM 3FEMHRT LOW DOSE 0.5 MG-2.5 MCG TABLET MM 3FEMRING 0.05 MG/24 HR VAGINAL 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSFEMRING 0.1 MG/24 HR VAGINAL 3 QLfenofibrate 120 mg tablet MM 3 QL,STfenofibrate 130 mg capsule MM 3 QL,STfenofibrate 134 mg capsule MM 2 QLfenofibrate 145 mg tablet MM 2 QLfenofibrate 150 mg capsule MM 3 QL,STfenofibrate 160 mg tablet MM 2 QLfenofibrate 200 mg capsule MM 2 QLfenofibrate 40 mg tablet MM 3 QL,STfenofibrate 43 mg capsule MM 3 QL,STfenofibrate 48 mg tablet MM 2 QLfenofibrate 50 mg capsule MM 3 QL,STfenofibrate 54 mg tablet MM 2 QLfenofibrate 67 mg capsule MM 2 QLfenofibric acid 105 mg tablet MM 3 QL,STfenofibric acid 35 mg tablet MM 3 QL,STfenofibric acid dr 135 mg cap MM 3 QL,STfenofibric acid dr 45 mg cap MM 3 QL,STFENOGLIDE 120 MG TABLET MM 3 QL,STFENOGLIDE 40 MG TABLET MM 3 QL,STfenoprofen 200 mg capsule 3fenoprofen 400 mg capsule MM 3fenoprofen 600 mg tablet MM 3FENORTHO 200 MG CAPSULE 3FENORTHO 400 MG CAPSULE MM 3fentanyl 100 mcg/hr patch 3 QLfentanyl 12 mcg/hr patch 3 QLfentanyl 25 mcg/hr patch 3 QLfentanyl 37.5 mcg/hr patch 3 QLfentanyl 50 mcg/hr patch 3 QLfentanyl 62.5 mcg/hr patch 3 QLfentanyl 75 mcg/hr patch 3 QLfentanyl 87.5 mcg/hr patch 3 QLfentanyl cit otfc 1,200 mcg 4 QL,PAfentanyl cit otfc 1,600 mcg 4 QL,PAfentanyl citrate otfc 200 mcg 4 QL,PAfentanyl citrate otfc 400 mcg 4 QL,PAfentanyl citrate otfc 600 mcg 4 QL,PAfentanyl citrate otfc 800 mcg 4 QL,PAFENTORA 100 MCG BUCCAL TABLET, EFFERVESCENT 4 QL,PAFENTORA 200 MCG BUCCAL TABLET, EFFERVESCENT 4 QL,PAFENTORA 400 MCG BUCCAL TABLET, EFFERVESCENT 4 QL,PAFENTORA 600 MCG BUCCAL TABLET, EFFERVESCENT 4 QL,PAFENTORA 800 MCG BUCCAL TABLET, EFFERVESCENT 4 QL,PAFERIVA 21-7 TABLET 75 MG IRON-1 MG-175 MG TABLET 3FERIVA 75 MG IRON-1 MG-175 MG CAPSULE,EXTENDED RELEASE 3FERIVA FA (SUMALATE) 110 MG-1 MG-175 MG-12 MCG CAPSULE 3FERIVA FA CAPSULE 3ferocon 110 mg-0.5 mg capsule 1FERRALET 90 DUAL-IRON DELIVERY 90 MG-1 MG-12 MCG-50 MG TABLET 2ferraplus 90 90 mg-1 mg-12 mcg-120 mg-50mg tablet 2ferrex 150 forte 150 mg-25 mcg-1 mg capsule 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSferrex 150 forte plus 150 mg-60 mg-25 mcg-1 mg capsule 2ferrex 28 151 mg-200 mg-1 mg-0.8 mg tablet 2FERRIPROX 100 MG/ML ORAL SOLUTION SP,LD * QL,PAFERRIPROX 500 MG TABLET SP,LD * QL,PAferrocite plus 106 mg iron-1 mg tablet 1ferrogels forte 460 mg-60 mg-0.01 mg-1 mg capsule 1FETZIMA 120 MG CAPSULE,EXTENDED RELEASE MM 3 QL,PAFETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK 3 QL,PAFETZIMA 20 MG CAPSULE,EXTENDED RELEASE MM 3 QL,PAFETZIMA 40 MG CAPSULE,EXTENDED RELEASE MM 3 QL,PAFETZIMA 80 MG CAPSULE,EXTENDED RELEASE MM 3 QL,PAFEXMID 7.5 MG TABLET 3 QL,PAFIBERSOURCE HN ORAL LIQUID 3FIBRICOR 105 MG TABLET MM 3 QLFIBRICOR 35 MG TABLET MM 3 QLFIFTY50 2.0 GLUCOSE METER MM 3 STFIFTY50 GLUCOSE CONTROL SOLN 3FIFTY50 PEN 31G X 3/16" NEEDLE 1FIFTY50 PEN NEEDLE 32G X 1/4" 1FIFTY50 RESERVOIR 1.8 ML MISC MM 2FIFTY50 RESERVOIR 3 ML MISC MM 2FIFTY50 SAFETY SEAL LANCETS 30 GAUGE MM 1FIFTY50 SAFETY SEAL LANCETS 32 GAUGE MM 1FIFTY50 TEST STRIP MM 3 QL,STFILTER NEEDLE 5 MICRON 1FILTER NEEDLE 5 MICRON 3FINACEA 15 % TOPICAL FOAM 2FINACEA 15 % TOPICAL GEL 2finasteride 5 mg tablet MM 1 QLFINE 30 UNIVERSAL LANCETS 30 GAUGE MM 1FINGERSTIX LANCETS MM 3fioricet 50 mg-300 mg-40 mg capsule 3 QLFIORICET WITH CODEINE 50 MG-300 MG-40 MG-30 MG CAPSULE 3 QLFIORINAL 50 MG-325 MG-40 MG CAPSULE 3 QLFIORINAL-CODEINE #3 30 MG-50 MG-325 MG-40 MG CAPSULE 4 QLFIRAZYR 30 MG/3 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PAFIRMAGON 2 X 120 MG VIALS 4 QL,PAFIRMAGON 80 MG VIAL 4 QL,PAFIRMAGON KIT WITH DILUENT SYRINGE 120 MG SUBCUTANEOUS SOLUTION 4 QL,PAFIRMAGON KIT WITH DILUENT SYRINGE 80 MG SUBCUTANEOUS SOLUTION 4 QL,PAFIRST CHOICE LANCETS THIN MM 1FLAGYL 250 MG TABLET 3FLAGYL 375 MG CAPSULE 3FLAGYL 500 MG TABLET 3FLAGYL ER 750 MG TABLET,EXTENDED RELEASE 3FLAREX 0.1 % EYE DROPS,SUSPENSION 3 STflavoxate hcl 100 mg tablet MM 3flax, fish and borage oil 400 mg-5 unit capsule 2flecainide acetate 100 mg tab MM 2flecainide acetate 150 mg tab MM 2flecainide acetate 50 mg tab MM 2FLECTOR 1.3 % TRANSDERMAL 12 HOUR PATCH 3 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSFLEXGEN 500 MG-50 MG-25 MG-40 MG TABLET 3FLEXICHAMBER SPACER 3FLO-PRED 16.7(15) MG/5 ML SUSP 3FLOMAX 0.4 MG CAPSULE MM 3 QLFLONASE 0.05% NASAL SPRAY MM 3 QL,STFLOVENT DISKUS 100 MCG/ACTUATION POWDER FOR INHALATION MM 2 QLFLOVENT DISKUS 250 MCG/ACTUATION POWDER FOR INHALATION MM 2 QLFLOVENT DISKUS 50 MCG/ACTUATION POWDER FOR INHALATION MM 2 QLFLOVENT HFA 110 MCG/ACTUATION AEROSOL INHALER MM 2 QLFLOVENT HFA 220 MCG/ACTUATION AEROSOL INHALER MM 2 QLFLOVENT HFA 44 MCG/ACTUATION AEROSOL INHALER MM 2 QLFLOWTUSS 2.5 MG-200 MG/5 ML ORAL SOLUTION 3FLOXIN 0.3 % EAR DROPS 3 STFLUAD 2016-17 65YR UP(PF)45 MCG(15 MCGX3)/0.5 ML INTRAMUSCULAR SYRINGE 3FLUARIX QUAD 2016-2017 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE 3FLUBLOK 2016-2017 (PF) 135 MCG (45 MCG X 3)/0.5 ML IM SOLUTION 3FLUCELVAX QUAD 2016-2017 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE 3fluconazole 10 mg/ml susp 2fluconazole 100 mg tablet 2fluconazole 150 mg tablet 2fluconazole 200 mg tablet 2fluconazole 40 mg/ml susp 2fluconazole 50 mg tablet 2flucytosine 250 mg capsule 2flucytosine 500 mg capsule 2fludrocortisone 0.1 mg tablet MM 1FLULAVAL QUAD 2016-2017 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE 3FLULAVAL QUAD 2016-2017 60 MCG (15 MCG X 4)/0.5 ML IM SUSPENSION 3FLUMADINE 100 MG TABLET 3FLUMIST QUAD 2016-2017 10EXP6.5-7.5 FF UNIT/0.2 ML NASAL SPRAY SYRINGE 3flunisolide 0.025% spray MM 2 QLfluocinolone 0.01% body oil 3fluocinolone 0.01% cream 3fluocinolone 0.01% scalp oil 3fluocinolone 0.01% solution 3fluocinolone 0.025% cream 3fluocinolone 0.025% ointment 3fluocinolone oil 0.01% ear drp 3fluocinonide 0.05% cream 3fluocinonide 0.05% gel 3fluocinonide 0.05% ointment 3fluocinonide 0.05% solution 3fluocinonide 0.1% cream 4 STfluocinonide-e 0.05 % topical cream 3fluorometholone 0.1% drops 3FLUOROPLEX 1 % TOPICAL CREAM 4fluorouracil 0.5% cream 4fluorouracil 2% topical soln 3fluorouracil 5% cream 3fluorouracil 5% top solution 3fluoxetine 20 mg/5 ml solution MM 1fluoxetine dr 90 mg capsule MM 3 QLfluoxetine hcl 10 mg capsule MM 1 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSfluoxetine hcl 10 mg tablet MM 3 QLfluoxetine hcl 20 mg capsule MM 1 QLfluoxetine hcl 20 mg tablet MM 3 QLfluoxetine hcl 40 mg capsule MM 1 QLfluoxetine hcl 60 mg tablet MM 3 QLfluphenazine 1 mg tablet MM 1fluphenazine 10 mg tablet MM 1fluphenazine 2.5 mg tablet MM 1fluphenazine 2.5 mg/5 ml elix MM 1fluphenazine 5 mg tablet MM 1fluphenazine 5 mg/ml conc 1flurandrenolide 0.05% cream 4 STflurazepam 15 mg capsule 2 QLflurazepam 30 mg capsule 2 QLflurbiprofen 0.03% eye drop 1flurbiprofen 100 mg tablet MM 1flurbiprofen 50 mg tablet MM 1flutamide 125 mg capsule MM 3 QLfluticasone prop 0.005% oint 2fluticasone prop 0.05% cream 2fluticasone prop 0.05% lotion 3fluticasone prop 50 mcg spray MM 2 QLfluvastatin er 80 mg tablet MM 3 QL,STfluvastatin sodium 20 mg cap MM 3 QLfluvastatin sodium 40 mg cap MM 3 QLFLUVIRIN 2016-17 (PF) 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SYRINGE 3FLUVIRIN 2016-2017 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSION 3fluvoxamine er 100 mg capsule MM 3 QLfluvoxamine er 150 mg capsule MM 3 QLfluvoxamine maleate 100 mg tab MM 1 QLfluvoxamine maleate 25 mg tab MM 1 QLfluvoxamine maleate 50 mg tab MM 1 QLFLUZONE HIGH-DOSE 2016-2017 (PF) 180 MCG/0.5 ML INTRAMUSCULAR SYRINGE 3FLUZONE INTRADERM QUAD 2016-17 (PF) 36 MCG/0.1 ML INTRADERMAL SYRINGE 3FLUZONE QUAD 2016-17(PF) 60 MCG(15 MCGX4)/0.5 ML INTRAMUSCULAR SYRINGE 3FLUZONE QUAD 2016-2017 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SUSPENSION 3FLUZONE QUAD 2016-2017 60 MCG (15 MCG X 4)/0.5 ML IM SUSPENSION 3FLUZONE QUAD PEDI 2016-17 (PF) 30 MCG (7.5 MCG X 4)/0.25 ML IM SYRINGE 3FML FORTE 0.25 % EYE DROPS,SUSPENSION 3 STFML LIQUIFILM 0.1 % EYE DROPS,SUSPENSION 3 STFML S.O.P. 0.1 % EYE OINTMENT 3 STfocalgin 90 dha 90 mg iron-1 mg-50 mg-300 mg oral pack 2focalgin ca 35 mg iron-1 mg-50 mg-300 mg oral pack 3focalgin dss 90 mg-1 mg-12 mcg-50 mg tablet 3FOCALIN 10 MG TABLET 3 QLFOCALIN 2.5 MG TABLET 3 QLFOCALIN 5 MG TABLET 3 QLFOCALIN XR 10 MG CAPSULE,EXTENDED RELEASE 3 QL,STFOCALIN XR 15 MG CAPSULE,EXTENDED RELEASE 3 QL,STFOCALIN XR 20 MG CAPSULE,EXTENDED RELEASE 3 QL,STFOCALIN XR 25 MG CAPSULE,EXTENDED RELEASE 3 QL,STFOCALIN XR 30 MG CAPSULE,EXTENDED RELEASE 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSFOCALIN XR 35 MG CAPSULE,EXTENDED RELEASE 3 QL,STFOCALIN XR 40 MG CAPSULE,EXTENDED RELEASE 3 QL,STFOCALIN XR 5 MG CAPSULE,EXTENDED RELEASE 3 QL,STfolbecal 1 mg-200 mg-75 mg-12 mcg tablet,extended release 1folbee 2.5 mg-25 mg-1 mg tablet 3folbee plus 5 mg tablet 3folbee plus 5 mg-1.5 mg-25 mg tablet 3FOLET DHA 38 MG-1 MG-50 MG-350 MG ORAL PACK 3FOLET ONE 38 MG IRON-1 MG-25 MG-225 MG CAPSULE 3folic acid 1 mg tablet MM 1folic acid-vit b6-vit b12 tab 3folivane-f 125 mg-1 mg-40 mg-3 mg capsule 1folivane-ob 85 mg-1 mg capsule 1folivane-plus 125 mg-1 mg capsule 1folivane-prx dha nf capsule 2folplex 2.2 2.2 mg-25 mg-0.5 mg tablet 3FOLTRATE 0.5 MG-1 MG TABLET 3fondaparinux 10 mg/0.8 ml syr 4 QLfondaparinux 2.5 mg/0.5 ml syr 4 QLfondaparinux 5 mg/0.4 ml syr 4 QLfondaparinux 7.5 mg/0.6 ml syr 4 QLFORA D10 KIT 3 STFORA D10 STRIPS MM 3 QL,STFORA D15 DEVICE 3 STFORA D15G STRIPS MM 3 QL,STFORA D20 KIT MM 3 STFORA D20 STRIPS MM 3 QL,STFORA D40 DEVICE 3 STFORA D40-G31 TEST STRIPS MM 3 QL,STFORA G20 KIT MM 3 STFORA G20 STRIPS MM 3 QL,STFORA G30A MM 3 STFORA G30A STRIPS MM 3 QL,STFORA GD50 BLOOD GLUCOSE SYSTEM MM 3 STFORA GD50 TEST STRIPS MM 3 QL,STFORA HIGH CONTROL SOLUTION 3FORA LANCING DEVICE MM 1FORA LOW CONTROL SOLUTION 3FORA NORMAL CONTROL SOLUTION 3FORA TEST N'GO TEST STRIPS MM 3 QL,STFORA TEST N'GO VOICE METER MM 3 STFORA TEST STRIP MM 3 QL,STFORA TN'G VOICE METER MM 3 STFORA TN'G VOICE TEST STRIPS MM 3 QL,STFORA V10 KIT MM 3 STFORA V10 STRIPS MM 3 QL,STFORA V12 BLOOD GLUCOSE SYSTEM MM 3 STFORA V12 BLOOD GLUCOSE SYSTEM KIT MM 3 STFORA V12 GLUCOSE STRIPS MM 3 QL,STFORA V20 KIT MM 3 STFORA V20 STRIPS MM 3 QL,STFORA V30A MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSFORA V30A KIT MM 3 STFORA V30A STRIPS MM 3 QL,STFORACARE GD20 GLUCOSE METER MM 3 STFORACARE GD20 STRIPS MM 3 QL,STFORACARE GD40 STRIPS MM 3 QL,STFORACARE GD40A GLUCOSE METER MM 3 STFORACARE GD40B GLUCOSE METER MM 3 STFORACARE GDH HIGH CONTROL SOLUTION 3FORACARE GDH LOW CONTROL SOLUTION 3FORACARE GDH NORMAL CONTROL SOLUTION 3FORACARE LANCETS 30 GAUGE MM 1FORADIL AEROLIZER 12 MCG CAPSULE WITH INHALATION DEVICE MM 3 QL,STFORFIVO XL 450 MG TABLET,EXTENDED RELEASE MM 3 QL,STFORTAMET 1,000 MG TABLET,EXTENDED RELEASE MM 4 QL,STFORTAMET 500 MG TABLET,EXTENDED RELEASE MM 4 QL,STFORTEO 20 MCG/DOSE (600 MCG/2.4 ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PAFORTESTA 10 MG/0.5 GRAM/ACTUATION TRANSDERMAL GEL PUMP MM 3 QL,STFORTICAL 200 UNIT/ACTUATION NASAL SPRAY MM 3 QLFORTISCARE BLOOD GLUCOSE SYSTEM KIT MM 3 STFORTISCARE GLUCOSE TEST STRIPS MM 3 QL,STFORTISCARE HIGH SOLUTION 3FORTISCARE LOW SOLUTION 3FORTISCARE NORMAL SOLUTION 3FOSAMAX 70 MG TABLET MM 3 QL,STFOSAMAX PLUS D 70 MG-2,800 UNIT TABLET MM 3 QL,STFOSAMAX PLUS D 70 MG-5,600 UNIT TABLET MM 3 QL,STfosinopril sodium 10 mg tab MM 1fosinopril sodium 20 mg tab MM 1fosinopril sodium 40 mg tab MM 1fosinopril-hctz 10-12.5 mg tab MM 2fosinopril-hctz 20-12.5 mg tab MM 2FOSRENOL 1,000 MG CHEWABLE TABLET MM 4 STFOSRENOL 1,000 MG ORAL POWDER PACKET 4 STFOSRENOL 500 MG CHEWABLE TABLET MM 4 STFOSRENOL 750 MG CHEWABLE TABLET MM 4 STFOSRENOL 750 MG ORAL POWDER PACKET 4 STFRAGMIN 10,000 ANTI-XA UNIT/ML SUBCUTANEOUS SYRINGE 4 QLFRAGMIN 12,500 ANTI-XA UNIT/0.5 ML SUBCUTANEOUS SYRINGE 4 QLFRAGMIN 15,000 ANTI-XA UNIT/0.6 ML SUBCUTANEOUS SYRINGE 4 QLFRAGMIN 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE 4 QLFRAGMIN 2,500 ANTI-XA UNIT/0.2 ML SUBCUTANEOUS SYRINGE 4 QLFRAGMIN 25,000 ANTI-XA UNIT/ML SUBCUTANEOUS SOLUTION 4 QLFRAGMIN 5,000 ANTI-XA UNIT/0.2 ML SUBCUTANEOUS SYRINGE 4 QLFRAGMIN 7,500 ANTI-XA UNIT/0.3 ML SUBCUTANEOUS SYRINGE 4 QLFREAMINE HBC 6.9 % INTRAVENOUS SOLUTION 3FREESTYLE CONTROL SOLUTION 3FREESTYLE FLASH SYSTEM KIT MM 3 STFREESTYLE FREEDOM KIT MM 3 STFREESTYLE FREEDOM LITE KIT MM 3 STFREESTYLE INSULINX METER MM 3 STFREESTYLE INSULINX STRIPS MM 3 QL,STFREESTYLE INSULINX TEST STRIPS MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSFREESTYLE LANCETS 28 GAUGE MM 3FREESTYLE LITE METER KIT MM 3 STFREESTYLE LITE STRIPS MM 3 QL,STFREESTYLE NAVIGATOR GLUCOSE SENSOR DEVICE MM 3 PAFREESTYLE PRECISION 0.5 ML 31 GAUGE X 5/16" SYRINGE MM 2FREESTYLE PRECISION 1 ML 30 GAUGE X 5/16" SYRINGE MM 2FREESTYLE PRECISION 1 ML 31 GAUGE X 5/16" SYRINGE MM 2FREESTYLE PRECISION 1/2 ML 30 GAUGE X 5/16" SYRINGE MM 2FREESTYLE PRECISION NEO METER MM 3 STFREESTYLE PRECISION NEO STRIPS MM 3 QL,STFREESTYLE SIDEKICK II KIT MM 3 STFREESTYLE SYSTEM KIT MM 3 STFREESTYLE TEST STRIPS MM 3 QL,STFREESTYLE UNISTIK 2 MM 3FROVA 2.5 MG TABLET 3 QL,STfrovatriptan succ 2.5 mg tab 3 QL,STFULYZAQ 125 MG TABLET,DELAYED RELEASE 4 QL,PAFURADANTIN 25 MG/5 ML ORAL SUSPENSION 3 QLfurosemide 10 mg/ml solution MM 1furosemide 20 mg tablet MM 1furosemide 40 mg tablet MM 1furosemide 40 mg/5 ml soln MM 1furosemide 80 mg tablet MM 1FUSION PLUS 130 MG IRON-1,250 MCG CAPSULE 2FUZEON 90 MG SUBCUTANEOUS SOLUTION SP * QLfyavolv 0.5 mg-2.5 mcg tablet MM 3fyavolv 1 mg-5 mcg tablet MM 3FYCOMPA 0.5 MG/ML ORAL SUSPENSION 4 QL,PAFYCOMPA 10 MG TABLET MM 4 QL,PAFYCOMPA 12 MG TABLET MM 4 QL,PAFYCOMPA 2 MG (7)-4 MG (7) TABLETS IN A DOSE PACK 4 QL,PAFYCOMPA 2 MG TABLET MM 4 QL,PAFYCOMPA 4 MG TABLET MM 4 QL,PAFYCOMPA 6 MG TABLET MM 4 QL,PAFYCOMPA 8 MG TABLET MM 4 QL,PAgabapentin 100 mg capsule MM 2 QLgabapentin 250 mg/5 ml soln MM 3 QLgabapentin 250 mg/5 ml soln MM 3 QLgabapentin 300 mg capsule MM 2 QLgabapentin 300 mg/6 ml soln MM 3 QLgabapentin 400 mg capsule MM 2 QLgabapentin 600 mg tablet MM 2 QLgabapentin 800 mg tablet MM 2 QLGABITRIL 12 MG TABLET MM 4GABITRIL 16 MG TABLET MM 4GABITRIL 2 MG TABLET MM 4GABITRIL 4 MG TABLET MM 4 QLgalantamine 4 mg/ml oral soln MM 3 QLgalantamine er 16 mg capsule MM 3 QLgalantamine er 24 mg capsule MM 3 QLgalantamine er 8 mg capsule MM 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSgalantamine hbr 12 mg tablet MM 3 QLgalantamine hbr 4 mg tablet MM 3 QLgalantamine hbr 8 mg tablet MM 3 QLGALZIN 25 MG (ZINC) CAPSULE 3GALZIN 50 MG (ZINC) CAPSULE 3garamycin 0.3% eye drops 2GASTROCROM 100 MG/5 ML ORAL CONCENTRATE 4gatifloxacin 0.5% eye drops 3 QLGATTEX 30-VIAL 5 MG SUBCUTANEOUS KIT SP,LD * QL,PAGATTEX ONE-VIAL 5 MG SUBCUTANEOUS KIT SP,LD * QL,PAgavilyte-c 240 gram-22.72 gram-6.72 gram-5.84 gram oral solution 2gavilyte-g 236 gram-22.74 gram-6.74 gram-5.86 gram oral solution 2gavilyte-h and bisacodyl 5 mg-210 gram oral kit 3gavilyte-n 420 gram oral solution 2GDRIVE KIT MM 3 STGE100 BLOOD GLUCOSE SYSTEM KIT MM 3 STGE100 BLOOD GLUCOSE TEST STRIP MM 3 QL,STGE100 CONTROL SOLUTION NORMAL 3GELNIQUE 10 % (100 MG/GRAM) TRANSDERMAL GEL PACKET MM 3 QL,STGELNIQUE 3% GEL MM 3 QL,STgemfibrozil 600 mg tablet MM 1 QLGENERESS FE 0.8 MG-25 MCG (24)/75 MG (4) CHEWABLE TABLET MM 3generlac 10 gram/15 ml oral solution MM 1gengraf 100 mg capsule 3 QLgengraf 100 mg/ml oral solution 3gengraf 25 mg capsule 3gengraf 50 mg capsule 3GENOTROPIN 12 MG/ML (36 UNIT/ML) SUBCUTANEOUS CARTRIDGE SP * QL,PAGENOTROPIN 5 MG/ML (15 UNIT/ML) SUBCUTANEOUS CARTRIDGE SP * QL,PAGENOTROPIN MINIQUICK 0.2 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 0.4 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 0.6 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 0.8 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 1 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 1.2 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 1.4 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 1.6 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 1.8 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENOTROPIN MINIQUICK 2 MG/0.25 ML SUBCUTANEOUS SYRINGE SP * QL,PAGENSTRIP TEST STRIP MM 3 QL,STgentak 0.3 % (3 mg/gram) eye ointment 2gentamicin 0.1% cream 2gentamicin 0.1% ointment 2gentamicin 0.3% eye drops 2gentamicin 0.3% eye ointment 2GENULTIMATE TEST STRIPS MM 3 QL,STGENVOYA 150 MG-150 MG-200 MG-10 MG TABLET SP * QLGEODON 20 MG CAPSULE MM 4 QLGEODON 40 MG CAPSULE MM 4 QLGEODON 60 MG CAPSULE MM 4 QLGEODON 80 MG CAPSULE MM 4 QLgerm defense pm tablet 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSGESTICARE DHA COMBO PACK 2GIALAX 17 GRAM/SCOOP ORAL KIT 4gianvi (28) 3 mg-20 mcg tablet MM 1GIAZO 1.1 GRAM TABLET 4 QL,PAgildagia 0.4 mg-35 mcg tablet MM 1gildess 1.5/30 (21) 1.5 mg-30 mcg tablet MM 1gildess 1/20 (21) 1 mg-20 mcg tablet MM 1gildess 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM 1gildess fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM 1gildess fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM 1GILENYA 0.5 MG CAPSULE SP * QL,PAGILOTRIF 20 MG TABLET SP,LD * QL,PAGILOTRIF 30 MG TABLET SP,LD * QL,PAGILOTRIF 40 MG TABLET SP,LD * QL,PAglatopa 20 mg/ml subcutaneous syringe SP * QL,PAGLEEVEC 100 MG TABLET SP * QL,PAGLEEVEC 400 MG TABLET SP * QL,PAGLEOSTINE 10 MG CAPSULE 3 QLGLEOSTINE 100 MG CAPSULE 3 QLGLEOSTINE 40 MG CAPSULE 3 QLGLEOSTINE 5 MG CAPSULE 3 QLglimepiride 1 mg tablet MM 1glimepiride 2 mg tablet MM 1glimepiride 4 mg tablet MM 1glipizide 10 mg tablet MM 1glipizide 5 mg tablet MM 1glipizide er 10 mg tablet MM 1glipizide er 2.5 mg tablet MM 1glipizide er 5 mg tablet MM 1glipizide-metformin 2.5-250 mg MM 2glipizide-metformin 2.5-500 mg MM 2glipizide-metformin 5-500 mg MM 2GLUCAGEN DIAGNOSTIC KIT 1 MG/ML INJECTION 3GLUCAGEN DIAGNOSTIC KIT 1 MG/ML INJECTION 3GLUCAGEN HYPOKIT 1 MG INJECTION 3GLUCAGON EMERGENCY KIT (HUMAN-RECOMB) 1 MG INJECTION 3GLUCO NAVII GLUCOSE MONITOR KIT MM 3 STGLUCO NAVII TEST STRIP MM 3 QL,STGLUCOCARD 01 HIGH-NORMAL CONTROL SOLUTION 3GLUCOCARD 01 METER KIT MM 3 STGLUCOCARD 01 NORMAL CONTROL SOLUTION 3GLUCOCARD 01 SENSOR PLUS STRIPS MM 3 QL,STGLUCOCARD 01-MINI METER KIT MM 3 STGLUCOCARD EXPRESSION MM 3 STGLUCOCARD EXPRESSION KIT MM 3 STGLUCOCARD EXPRESSION SOLUTION 3GLUCOCARD EXPRESSION STRIPS MM 3 QL,STGLUCOCARD SHINE METER MM 3 STGLUCOCARD SHINE METER KIT MM 3 STGLUCOCARD SHINE SOLUTION 3GLUCOCARD SHINE TEST STRIPS MM 3 QL,STGLUCOCARD VITAL KIT MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSGLUCOCARD VITAL SENSOR STRIPS MM 3 QL,STGLUCOCARD VITAL TEST STRIPS MM 3 QL,STGLUCOCOM BLOOD GLUCOSE KIT MM 3 STGLUCOCOM CONTROL HIGH SOLUTION 3GLUCOCOM CONTROL NORMAL SOLUTION 3GLUCOCOM GLUCOSE STRIPS MM 3 QL,STGLUCOCOM LANCETS 28 GAUGE MM 1GLUCOCOM LANCETS 30 GAUGE MM 1GLUCOCOM LANCETS 33 GAUGE MM 1GLUCOLET 2 LANCING DEVICE MM 3GLUCOLET 2 LANCING DEVICE MM 3GLUCOPHAGE 1,000 MG TABLET MM 3 STGLUCOPHAGE 500 MG TABLET MM 3 STGLUCOPHAGE 850 MG TABLET MM 3 STGLUCOPHAGE XR 500 MG TABLET,EXTENDED RELEASE MM 3 QL,STGLUCOPHAGE XR 750 MG TABLET,EXTENDED RELEASE MM 3 QL,STGLUCOSE CONTROL SOLUTION 3GLUCOSE KETONE CONTROL SOLN SOLUTION 3glucose liquid 3GLUCOSOURCE LANCING DEVICE MM 3GLUCOTROL 10 MG TABLET MM 3GLUCOTROL 5 MG TABLET MM 3GLUCOTROL XL 10 MG TABLET,EXTENDED RELEASE MM 3GLUCOTROL XL 2.5 MG TABLET,EXTENDED RELEASE MM 3GLUCOTROL XL 5 MG TABLET,EXTENDED RELEASE MM 3GLUCOVANCE 2.5 MG-500 MG TABLET MM 3GLUCOVANCE 5 MG-500 MG TABLET MM 3GLUMETZA 1,000 MG TABLET,EXTENDED RELEASE MM 4 QL,STGLUMETZA 500 MG TABLET,EXTENDED RELEASE MM 4 QL,STglyburid-metformin 1.25-250 mg MM 1glyburide 1.25 mg tablet MM 1glyburide 2.5 mg tablet MM 1glyburide 5 mg tablet MM 1glyburide micro 1.5 mg tab MM 1glyburide micro 3 mg tablet MM 1glyburide micro 6 mg tablet MM 1glyburide-metformin 2.5-500 mg MM 1glyburide-metformin 5-500 mg MM 1glycopyrrolate 1 mg tablet 2glycopyrrolate 2 mg tablet 2GLYCOTROL 500 MCG-400 MCG-10 MG-400 MG CAPSULE 3glydo 2 % mucous membrane jelly in applicator 2GLYNASE 1.5 MG TABLET MM 3GLYNASE 3 MG TABLET MM 3GLYNASE 6 MG TABLET MM 3GLYSET 100 MG TABLET MM 3GLYSET 25 MG TABLET MM 3GLYSET 50 MG TABLET MM 3GLYXAMBI 10 MG-5 MG TABLET 3 QL,PAGLYXAMBI 25 MG-5 MG TABLET 3 QL,PAGM100 KIT MM 3 STGM100 STRIPS MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSGMATE CONTROL SOLUTION, HIGH 3GMATE CONTROL SOLUTION, NORMAL 3GMATE LANCETS 30 GAUGE MM 3GMATE LANCING DEVICE MM 3GMATE SMART METER MM 3 STGMATE SMART STARTER KIT MM 3 STGMATE TEST STRIPS MM 3 QL,STGMATE VOICE METER MM 3 STGMATE VOICE STARTER KIT MM 3 STGOLYTELY 227.1 GRAM-21.5 GRAM-6.36 GRAM ORAL POWDER PACKET 4GOLYTELY 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM ORAL SOLUTION 4GRALISE 30-DAY STARTER PACK 300 MG (9)-600 MG (69) TABLET,EXT. RELEASE 3 QL,STGRALISE 300 MG TABLET,EXTENDED RELEASE 3 QL,STGRALISE 600 MG TABLET,EXTENDED RELEASE 3 QL,STgranisetron hcl 1 mg tablet 2 QLGRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP * QL,PAGRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE SP * QL,PAGRIFULVIN V 500 MG TABLET 3GRIS-PEG (ULTRAMICROSIZE) 125 MG TABLET 3GRIS-PEG (ULTRAMICROSIZE) 250 MG TABLET 3griseofulvin 125 mg/5 ml susp 3griseofulvin micro 500 mg tab 3griseofulvin ultra 125 mg tab 3griseofulvin ultra 250 mg tab 3guanfacine 1 mg tablet MM 1guanfacine 2 mg tablet MM 1guanfacine hcl er 1 mg tablet MM 2 QLguanfacine hcl er 2 mg tablet MM 2 QLguanfacine hcl er 3 mg tablet MM 2 QLguanfacine hcl er 4 mg tablet MM 2 QLguanidine hcl 125 mg tablet 3GUARDIAN REAL-TIME GLUCOSE MONITOR MM 3 PAgynazole-1 2 % vaginal cream 3hair,skin and nails 3.3 mg iron-25 mcg tablet 2HAIR,SKIN,NAILS WITH BIOTIN 7.5 MG-7.5 UNIT-1,250 MCG CHEWABLE TABLET 3HAIR-SKIN-NAILS (VIT C-BIOTIN) 50 MG-1,250 MCG CHEWABLE TABLET 3HALCION 0.25 MG TABLET 3 QLhalobetasol prop 0.05% cream 3halobetasol prop 0.05% ointmnt 3HALOG 0.1 % TOPICAL CREAM 4 STHALOG 0.1 % TOPICAL OINTMENT 4 SThaloperidol 0.5 mg tablet MM 2haloperidol 1 mg tablet MM 2haloperidol 10 mg tablet MM 2haloperidol 2 mg tablet MM 2haloperidol 20 mg tablet MM 2haloperidol 5 mg tablet MM 2haloperidol lac 2 mg/ml conc MM 2HARVONI 90 MG-400 MG TABLET SP * QL,PAHEALTHPRO GLUCOSE MONITOR MM 3 STHEALTHPRO HIGH-LOW CONTROL SOLUTION 3HEALTHPRO TEST STRIPS MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSHEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MM 3HEALTHY ACCENTS UNIFINE PENTIP 29 GAUGE X 1/2" NEEDLE MM 1HEALTHY ACCENTS UNIFINE PENTIP 31 GAUGE X 1/4" NEEDLE 1HEALTHY ACCENTS UNIFINE PENTIP 31 GAUGE X 3/16" NEEDLE 1HEALTHY ACCENTS UNIFINE PENTIP 31 GAUGE X 5/16" NEEDLE 1HEALTHY ACCENTS UNIFINE PENTIP 32 GAUGE X 5/32" NEEDLE 1HEALTHY ACCENTS UNILET LANCET 30 GAUGE MM 1heather 0.35 mg tablet MM 1hecoria 0.5 mg capsule 3hecoria 1 mg capsule 3hecoria 5 mg capsule 3 QLHECTOROL 0.5 MCG CAPSULE MM 4HECTOROL 1 MCG CAPSULE MM 4HECTOROL 2.5 MCG CAPSULE MM 4HEMANGEOL 4.28 MG/ML ORAL SOLUTION 3hematinic plus vit/minerals 106 mg iron-1 mg tablet 1hematinic/folic acid 324 mg (106 mg iron)-1 mg tablet 1HEMATOGEN 200 MG (66 MG)-10 MCG-250 MG CAPSULE 2hematogen fa 200 mg-250 mg-0.01 mg-1 mg capsule 1hematogen forte 460 mg-60 mg-0.01 mg-1 mg capsule 2HEMATRON 50 MG IRON-1 MG/5 ML ORAL LIQUID 2HEMATRON-AF 150 MG-1 MG-50 MG TABLET,EXTENDED RELEASE 3hemax caplet 2hemenatal ob + dha 28 mg iron-6 mg iron-1 mg oral pack 2hemenatal ob 28 mg-6 mg-1 mg tablet 3hemetab 22 mg-6 mg-1 mg-25 mcg tablet 2HEMOCYTE-F 324 MG (106 MG IRON)-1 MG TABLET 3HEMOCYTE-PLUS 106 MG IRON-1 MG CAPSULE 3heparin 1,000 unit/10 (100/ml) 4heparin 10 unit/10 ml (1/ml) 4heparin 100 unit/10 ml (10/ml) 4heparin 100 unit/10 ml (10/ml) 4heparin 2,000 unit/2 ml vial 4heparin 30,000 unit/30 ml vial 4heparin 40,000 units/4 ml vial 4heparin 500 unit/5 ml (100/ml) 4heparin 500 unit/5 ml (100/ml) 4heparin flush 10 units/ml syr 4heparin lock 100 unit/ml intravenous solution 4heparin lock flush (porcine) (pf) 10 unit/ml intravenous syringe 4heparin lock flush (porcine) (pf) 100 unit/ml intravenous syringe 4heparin lock flush 10 unit/ml intravenous solution 4heparin lock flush 10 unit/ml intravenous syringe 4heparin lock flush 100 unit/ml 4heparin lock flush 100 unit/ml 4heparin sod 20,000 unit/ml vl 4heparin sod 5,000 unit/ 0.5 ml 4heparin sod 5,000 unit/0.5 ml 4heparin sod 5,000 unit/ml syr 4heparin sod 5,000 unit/ml vial 4heparin-ns 30 units/3 ml syrng 4HEPATAMINE 8% INTRAVENOUS SOLUTION 3HEPSERA 10 MG TABLET SP *ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSHETLIOZ 20 MG CAPSULE SP,LD * QL,PAHEXALEN 50 MG CAPSULE SP * QLhi-cal oral liquid 2high-protein nutritional shake oral liquid 2HIPREX 1 GRAM TABLET 3HIZENTRA 1 GRAM/5 ML (20 %) SUBCUTANEOUS SOLUTION SP,LD * PAHIZENTRA 10 GRAM/50 ML (20 %) SUBCUTANEOUS SOLUTION SP,LD * PAHIZENTRA 2 GRAM/10 ML (20 %) SUBCUTANEOUS SOLUTION SP,LD * PAHIZENTRA 4 GRAM/20 ML (20 %) SUBCUTANEOUS SOLUTION SP,LD * PAHORIZANT ER 300 MG TABLET,EXTENDED RELEASE MM 4 QL,PAHORIZANT ER 600 MG TABLET,EXTENDED RELEASE MM 4 QL,PAHUMALOG 100 UNIT/ML SUBCUTANEOUS CARTRIDGE MM 3 QL,STHUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION MM 3 QL,STHUMALOG KWIKPEN 100 UNIT/ML SUBCUTANEOUS MM 3 STHUMALOG KWIKPEN 200 UNIT/ML (3 ML) SUBCUTANEOUS 3 STHUMALOG MIX 50-50 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM 3 STHUMALOG MIX 50-50 KWIKPEN 100 UNIT/ML SUBCUTANEOUS PEN MM 3 STHUMALOG MIX 75-25 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM 3 STHUMALOG MIX 75-25 KWIKPEN 100 UNIT/ML SUBCUTANEOUS INSULIN PEN MM 3 STHUMAPEN LUXURA HD SUBCUTANEOUS 3HUMATROPE 12 MG (36 UNIT) INJECTION CARTRIDGE SP * QL,PAHUMATROPE 24 MG (72 UNIT) INJECTION CARTRIDGE SP * QL,PAHUMATROPE 5 MG (15 UNIT) SOLUTION FOR INJECTION SP * QL,PAHUMATROPE 6 MG (18 UNIT) INJECTION CARTRIDGE SP * QL,PAHUMIRA 10 MG/0.2 ML SUBCUTANEOUS SYRINGE KIT SP * QL,PAHUMIRA 20 MG/0.4 ML SUBCUTANEOUS SYRINGE KIT SP * QL,PAHUMIRA 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KIT SP * QL,PAHUMIRA PEDIATRIC CROHN'S STARTER 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KITSP

* QL,PA

HUMIRA PEN 40 MG/0.8 ML SUBCUTANEOUS SP * QL,PAHUMIRA PEN CROHN'S-ULC COLITIS-HIDR SUP STARTER 40 MG/0.8 ML SUB-Q KIT SP * QL,PAHUMIRA PEN PSORIASIS-UVEITIS STARTER 40 MG/0.8 ML SUBCUTANEOUS KIT SP * QL,PAHUMULIN 70/30 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM 3 STHUMULIN 70/30 KWIKPEN 100 UNIT/ML (70-30) SUBCUTANEOUS MM 3 STHUMULIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM 3 STHUMULIN N KWIKPEN 100 UNIT/ML (3 ML) SUBCUTANEOUS MM 3 STHUMULIN R 100 UNIT/ML INJECTION SOLUTION MM 3 STHUMULIN R U-500 (CONCENTRATED) INSULIN 500 UNIT/ML SUBCUTANEOUS SOLNMM

4 ST

HUMULIN R U-500 (CONCENTRATED) KWIKPEN 500 UNIT/ML (3 ML)SUBCUTANEOUS

4 ST

HYCAMTIN 0.25 MG CAPSULE SP,LD * QLHYCAMTIN 1 MG CAPSULE SP,LD * QLHYCET 7.5 MG-325 MG/15 ML ORAL SOLUTION 3 QLHYCOFENIX 2.5 MG-30 MG-200 MG/5 ML ORAL SOLUTION 3hydralazine 10 mg tablet MM 1hydralazine 100 mg tablet MM 1hydralazine 25 mg tablet MM 1hydralazine 50 mg tablet MM 1HYDREA 500 MG CAPSULE MM 3hydrochlorothiazide 12.5 mg cp MM 1hydrochlorothiazide 12.5 mg tb MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTShydrochlorothiazide 25 mg tab MM 1hydrochlorothiazide 50 mg tab MM 1hydrocod-cpm-pseudoep 5-4-60/5 3hydrocod-homatrop 5-1.5 mg tab 3hydrocodon-acetamin 7.5-325/15 3 QLhydrocodon-acetaminoph 2.5-325 2 QLhydrocodon-acetaminoph 7.5-300 3 QLhydrocodon-acetaminoph 7.5-325 2 QLhydrocodon-acetaminophen 5-300 3 QLhydrocodon-acetaminophen 5-325 2 QLhydrocodon-acetaminophn 10-300 3 QLhydrocodon-acetaminophn 10-325 2 QLhydrocodone-acetamin 10-325/15 3 QLhydrocodone-acetamin 2.5-167/5 3 QLhydrocodone-acetamin 5-163/7.5 3 QLhydrocodone-chlorphen er susp 3hydrocodone-homatropine syrup 3hydrocodone-homatropine syrup 3hydrocodone-ibuprofen 10-200 2 QLhydrocodone-ibuprofen 2.5-200 2 QLhydrocodone-ibuprofen 5-200 mg 2 QLhydrocodone-ibuprofen 7.5-200 2 QLhydrocort buty 0.1% lipo cream 3hydrocortison-acetic acid soln 3hydrocortisone 0.1% soln 3hydrocortisone 1% absorbase 1hydrocortisone 1% cream 2hydrocortisone 1% ointment 1hydrocortisone 10 mg tablet MM 2hydrocortisone 100 mg/60 ml 3hydrocortisone 2.5% cream 3hydrocortisone 2.5% cream 1hydrocortisone 2.5% lotion 2hydrocortisone 2.5% ointment 1hydrocortisone 20 mg tablet MM 2hydrocortisone 5 mg tablet MM 2hydrocortisone buty 0.1% cream 3hydrocortisone butyr 0.1% oint 3hydrocortisone val 0.2% cream 3hydrocortisone val 0.2% ointmt 3hydromet 5 mg-1.5 mg/5 ml syrup 3hydromorphone 1 mg/ml solution 3 QLhydromorphone 2 mg tablet 2 QLhydromorphone 3 mg suppos 3 QLhydromorphone 4 mg tablet 2 QLhydromorphone 8 mg tablet 2 QLhydromorphone hcl er 12 mg tab 4 QL,SThydromorphone hcl er 16 mg tab 4 QL,SThydromorphone hcl er 32 mg tab 4 QL,SThydromorphone hcl er 8 mg tab 4 QL,SThydroxocobalamin 1,000 mcg/ml 2hydroxychloroquine 200 mg tab MM 3hydroxyurea 500 mg capsule MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTShydroxyzine 10 mg/5 ml soln 1hydroxyzine hcl 10 mg tablet 1hydroxyzine hcl 25 mg tablet 1hydroxyzine hcl 50 mg tablet 1hydroxyzine pam 100 mg cap 1hydroxyzine pam 25 mg cap 1hydroxyzine pam 50 mg cap 1hyoscyamine 0.125 mg odt MM 2hyoscyamine 0.125 mg tab sl MM 2hyoscyamine 0.125 mg/5 ml elix MM 2hyoscyamine 0.125 mg/ml drop MM 2hyoscyamine er 0.375 mg tab MM 3hyoscyamine sulf 0.125 mg tab MM 2hyosyne 0.125 mg/5 ml oral elixir MM 2hyosyne 0.125 mg/ml oral drops MM 2HYPER-SAL 3.5 % SOLUTION FOR NEBULIZATION 3HYPER-SAL 7 % SOLUTION FOR NEBULIZATION 3HYPOLANCE AST LANCING KIT MM 3hyprost capsule 2HYQVIA 10 GRAM/100 ML (10 %) SUBCUTANEOUS SOLUTION SP,LD * PAHYQVIA 2.5 GRAM/25 ML (10 %) SUBCUTANEOUS SOLUTION SP,LD * PAHYQVIA 20 GRAM/200 ML (10 %) SUBCUTANEOUS SOLUTION SP,LD * PAHYQVIA 30 GRAM/300 ML (10 %) SUBCUTANEOUS SOLUTION SP,LD * PAHYQVIA 5 GRAM/50 ML (10 %) SUBCUTANEOUS SOLUTION SP,LD * PAHYQVIA HY COMPONENT 1,600 UNIT/10 ML SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA HY COMPONENT 2,400 UNIT/15 ML SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA HY COMPONENT 200 UNIT/1.25 ML SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA HY COMPONENT 400 UNIT/2.5 ML SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA HY COMPONENT 800 UNIT/5 ML SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA IG COMPONENT 10 GRAM/100 ML (10 %) SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA IG COMPONENT 2.5 GRAM/25 ML (10 %) SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA IG COMPONENT 20 GRAM/200 ML (10 %) SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA IG COMPONENT 30 GRAM/300 ML (10 %) SUBCUTANEOUS SOLUTION LD 4 PAHYQVIA IG COMPONENT 5 GRAM/50 ML (10 %) SUBCUTANEOUS SOLUTION LD 4 PAHYSINGLA ER 100 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYSINGLA ER 120 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYSINGLA ER 20 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYSINGLA ER 30 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYSINGLA ER 40 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYSINGLA ER 60 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYSINGLA ER 80 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 4 QL,STHYZAAR 100 MG-12.5 MG TABLET MM 3 QL,STHYZAAR 100 MG-25 MG TABLET MM 3 QL,STHYZAAR 50 MG-12.5 MG TABLET MM 3 QL,STibandronate sodium 150 mg tab MM 2 QLIBG-STAR BLOOD GLUCOSE SYSTEM MM 3 STIBRANCE 100 MG CAPSULE SP,LD * QL,PAIBRANCE 125 MG CAPSULE SP,LD * QL,PAIBRANCE 75 MG CAPSULE SP,LD * QL,PAIBUDONE 10 MG-200 MG TABLET 3 QLibudone 5 mg-200 mg tablet 3 QLibuprofen 100 mg/5 ml susp MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSibuprofen 400 mg tablet MM 1ibuprofen 600 mg tablet MM 1ibuprofen 800 mg tablet MM 1ICAR-C PLUS 100 MG-250 MG-25 MCG-1 MG TABLET 2ICLUSIG 15 MG TABLET SP,LD * QL,PAICLUSIG 45 MG TABLET SP,LD * QL,PAICTOTEST TABLET,NON-ORAL 3iferex 150 forte 150 mg-25 mcg-1 mg capsule 1ILEVRO 0.3 % EYE DROPS,SUSPENSION 2ILOTYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT 2imatinib mesylate 100 mg tab SP * QL,PAimatinib mesylate 400 mg tab SP * QL,PAIMBRUVICA 140 MG CAPSULE SP,LD * QL,PAIMDUR ER 120 MG TABLET MM 3IMDUR ER 30 MG TABLET MM 3IMDUR ER 60 MG TABLET MM 3imipramine hcl 10 mg tablet MM 1imipramine hcl 25 mg tablet MM 1imipramine hcl 50 mg tablet MM 1imipramine pamoate 100 mg cap MM 3imipramine pamoate 125 mg cap MM 3imipramine pamoate 150 mg cap MM 3imipramine pamoate 75 mg cap MM 3imiquimod 5% cream packet 3 QLIMITREX 100 MG TABLET 3 QL,STIMITREX 20 MG/ACTUATION NASAL SPRAY 3 QL,STIMITREX 25 MG TABLET 3 QL,STIMITREX 5 MG/ACTUATION NASAL SPRAY 3 QL,STIMITREX 50 MG TABLET 3 QL,STIMITREX 6 MG/0.5 ML SUBCUTANEOUS SOLUTION 3 QLIMITREX STATDOSE KIT REFILL 4 MG/0.5 ML SUBCUTANEOUS CARTRIDGE 4 QLIMITREX STATDOSE KIT REFILL 6 MG/0.5 ML SUBCUTANEOUS CARTRIDGE 4 QLIMITREX STATDOSE PEN 4 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 4 QLIMITREX STATDOSE PEN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 4 QLIMPAVIDO 50 MG CAPSULE SP * QLIMURAN 50 MG TABLET 3inatal advance 90 mg-1 mg-50 mg tablet 3inatal ultra 90 mg-1 mg-50 mg tablet 3INCIVEK 375 MG TABLET SP * QLINCONTROL ALCOHOL PADS 3INCONTROL LANCING DEVICE MM 1INCONTROL PEN NEEDLE 29 GAUGE X 1/2" 1INCONTROL PEN NEEDLE 31 GAUGE X 1/4" 1INCONTROL PEN NEEDLE 31 GAUGE X 3/16" 1INCONTROL PEN NEEDLE 31 GAUGE X 5/16" 1INCONTROL PEN NEEDLE 32 GAUGE X 5/32" 1INCONTROL SUPER THIN LANCETS 30 GAUGE MM 1INCONTROL ULTRA THIN LANCETS 28 GAUGE MM 1INCRELEX 10 MG/ML SUBCUTANEOUS SOLUTION SP,LD * QL,PAINCRUSE ELLIPTA 62.5 MCG/ACTUATION POWDER FOR INHALATION 2 QLindapamide 1.25 mg tablet MM 1indapamide 2.5 mg tablet MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSINDERAL LA 120 MG CAPSULE,EXTENDED RELEASE MM 4INDERAL LA 160 MG CAPSULE,EXTENDED RELEASE MM 4INDERAL LA 60 MG CAPSULE,EXTENDED RELEASE MM 4INDERAL LA 80 MG CAPSULE,EXTENDED RELEASE MM 4INDERAL XL 120 MG CAPSULE,EXTENDED RELEASE MM 4INDERAL XL 80 MG CAPSULE,EXTENDED RELEASE MM 4INDOCIN 25 MG/5 ML ORAL SUSPENSION 3INDOCIN 50 MG RECTAL SUPPOSITORY 4indomethacin 25 mg capsule 2indomethacin 50 mg capsule 2indomethacin er 75 mg capsule 3INFANATE BALANCE SOFTGEL 3infanate plus softgel 2INFASURF 35 MG/ML INTRATRACHEAL SUSPENSION 3INFINITY CONTROL SOLUTION HIGH 3INFINITY CONTROL SOLUTION LOW 3INFINITY CONTROL SOLUTION NORMAL 3INFINITY METER KIT MM 3 STINFINITY STARTER KIT MM 3 STINFINITY TEST STRIPS MM 3 QL,STINJECT EASE LANCETS 28 GAUGE MM 1INJECT EASE LANCETS 30 GAUGE MM 1INLYTA 1 MG TABLET SP,LD * QL,PAINLYTA 5 MG TABLET SP,LD * QL,PAINNOPRAN XL 120 MG CAPSULE,EXTENDED RELEASE MM 4INNOPRAN XL 80 MG CAPSULE,EXTENDED RELEASE MM 4INSPIRACHAMBER SPACER 3INSPIRACHAMBER WITH MASK-LARGE 3INSPIRACHAMBER WITH MASK-MED 3INSPIRACHAMBER WITH MASK-SMALL 3INSPRA 25 MG TABLET MM 3INSPRA 50 MG TABLET MM 3INSULIN 1 ML SYRINGE MM 2INSULIN 1/2 ML SYRINGE MM 2INSULIN 3/10 ML SYRINGE MM 2INSULIN SYRIN 0.3 ML 30GX1/2" MM 2INSULIN SYRIN 0.3 ML 31GX5/16" MM 2INSULIN SYRIN 0.5 ML 30GX1/2" MM 2INSULIN SYRIN 0.5 ML 31GX5/16" MM 2INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2INSULIN SYRINGE 1 ML 30GX1/2" MM 2INSULIN SYRINGE 1 ML 31GX5/16" MM 2INSULIN SYRINGE MICROFINE 0.3 ML 28 GAUGE X 1/2" MM 2INSULIN SYRINGE MICROFINE 1 ML 27 GAUGE X 5/8" MM 2INSULIN SYRINGE MICROFINE 1/2 ML 28 GAUGE X 1/2" MM 2INSULIN SYRINGE U100 1 ML MM 2INSULIN SYRINGE ULTRAFINE 0.5 ML 29 GAUGE X 1/2" MM 2INSUPEN 29 GAUGE X 1/2" NEEDLE 1INSUPEN 30 GAUGE X 5/16" NEEDLE 1INSUPEN 31 GAUGE X 1/4" NEEDLE 1INSUPEN 31 GAUGE X 5/16" NEEDLE 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSINSUPEN 32 GAUGE X 1/4" NEEDLE 1INSUPEN 32 GAUGE X 5/16" NEEDLE 1INSUPEN 32 GAUGE X 5/32" NEEDLE 1INSUPEN 33 GAUGE X 5/32" NEEDLE 1INTEGRA F 125 MG-1 MG-40 MG-3 MG CAPSULE 2INTEGRA PLUS 125 MG-1 MG CAPSULE 2INTEGRA SYRINGE 3 ML 21 GAUGE X 1" 1INTELENCE 100 MG TABLET SP * QLINTELENCE 200 MG TABLET SP * QLINTELENCE 25 MG TABLET SP * QLINTERLINK SYRINGE AND CANNULA 15 X 10 ML 1INTERMEZZO 1.75 MG SUBLINGUAL TABLET 3 QL,STINTERMEZZO 3.5 MG SUBLINGUAL TABLET 3 QL,STINTRON A 10 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP,LD * QL,PAINTRON A 10 MILLION UNIT/ML INJECTION SOLUTION SP,LD * QL,PAINTRON A 18 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP,LD * QL,PAINTRON A 50 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP,LD * QL,PAINTRON A 6 MILLION UNIT/ML INJECTION SOLUTION SP,LD * QL,PAintrovale 0.15 mg-30 mcg tablets,3 month dose pack 1 QLINTUNIV ER 1 MG TABLET,EXTENDED RELEASE MM 3 QL,STINTUNIV ER 2 MG TABLET,EXTENDED RELEASE MM 3 QL,STINTUNIV ER 3 MG TABLET,EXTENDED RELEASE MM 3 QL,STINTUNIV ER 4 MG TABLET,EXTENDED RELEASE MM 3 QL,STINVACARE LANCETS 30 GAUGE MM 1INVEGA 1.5 MG TABLET,EXTENDED RELEASE MM 4 QL,PAINVEGA 3 MG TABLET,EXTENDED RELEASE MM 4 QL,PAINVEGA 6 MG TABLET,EXTENDED RELEASE MM 4 QL,PAINVEGA 9 MG TABLET,EXTENDED RELEASE MM 4 QL,PAINVIRASE 200 MG CAPSULE SP * QLINVIRASE 500 MG TABLET SP * QLINVOKAMET 150 MG-1,000 MG TABLET 2 QLINVOKAMET 150 MG-500 MG TABLET 2 QLINVOKAMET 50 MG-1,000 MG TABLET 2 QLINVOKAMET 50 MG-500 MG TABLET 2 QLINVOKANA 100 MG TABLET MM 2 QLINVOKANA 300 MG TABLET MM 2 QLIOPIDINE 0.5 % EYE DROPS 3IOPIDINE 1 % EYE DROPS IN A DROPPERETTE 3iprat-albut 0.5-3(2.5) mg/3 ml MM 1ipratropium 0.03% spray MM 1 QLipratropium 0.06% spray MM 1 QLipratropium br 0.02% soln MM 1irbesartan 150 mg tablet MM 1 QLirbesartan 300 mg tablet MM 1 QLirbesartan 75 mg tablet MM 1 QLirbesartan-hctz 150-12.5 mg tb MM 1 QLirbesartan-hctz 300-12.5 mg tb MM 1 QLIRENKA 40 MG CAPSULE,DELAYED RELEASE 3 QLIRESSA 250 MG TABLET SP,LD * QL,PAiron ag-ps-asc-b12-fa-thre-suc 2IROSPAN 24/6 65 MG-65 MG-1,000 MCG (24) TABLET 2ISENTRESS 100 MG CHEWABLE TABLET SP * QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSISENTRESS 100 MG ORAL POWDER PACKET MM,SP 4 QLISENTRESS 25 MG CHEWABLE TABLET SP * QLISENTRESS 400 MG TABLET SP * QLisochron 40 mg tablet,extended release MM 2isoniazid 100 mg tablet MM 1isoniazid 300 mg tablet MM 1isoniazid 50 mg/5 ml solution MM 3ISOPTO CARPINE 1 % EYE DROPS MM 2ISOPTO CARPINE 2 % EYE DROPS MM 2ISOPTO CARPINE 4 % EYE DROPS MM 2ISORDIL 40 MG TABLET MM 4ISORDIL TITRADOSE 5 MG TABLET MM 4isosorbide dn 10 mg tablet MM 2isosorbide dn 20 mg tablet MM 2isosorbide dn 30 mg tablet MM 2isosorbide dn 5 mg tablet MM 2isosorbide dn er 40 mg tablet MM 3isosorbide mn 10 mg tablet MM 1isosorbide mn 20 mg tablet MM 1isosorbide mn er 120 mg tab MM 1isosorbide mn er 30 mg tablet MM 1isosorbide mn er 60 mg tablet MM 1ISOSOURCE 1.5 CAL 0.07 GRAM-1.5 KCAL/ML LIQUID FOR TUBE FEED 3ISOSOURCE HN ORAL LIQUID 3isradipine 2.5 mg capsule MM 3isradipine 5 mg capsule MM 3ISTALOL 0.5 % EYE DROPS MM 3itraconazole 100 mg capsule 3 QLivermectin 3 mg tablet 2JADENU 180 MG TABLET SP,LD * QL,PAJADENU 360 MG TABLET SP,LD * QL,PAJADENU 90 MG TABLET SP,LD * QL,PAJAKAFI 10 MG TABLET SP,LD * QL,PAJAKAFI 15 MG TABLET SP,LD * QL,PAJAKAFI 20 MG TABLET SP,LD * QL,PAJAKAFI 25 MG TABLET SP,LD * QL,PAJAKAFI 5 MG TABLET SP,LD * QL,PAJALYN 0.5 MG-0.4 MG CAPSULE, EXTENDED RELEASE MM 3 QL,STjantoven 1 mg tablet MM 1jantoven 10 mg tablet MM 1jantoven 2 mg tablet MM 1jantoven 2.5 mg tablet MM 1jantoven 3 mg tablet MM 1jantoven 4 mg tablet MM 1jantoven 5 mg tablet MM 1jantoven 6 mg tablet MM 1jantoven 7.5 mg tablet MM 1JANUMET 50 MG-1,000 MG TABLET MM 2 QLJANUMET 50 MG-500 MG TABLET MM 2 QLJANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE MM 2 QLJANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE MM 2 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSJANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE MM 2 QLJANUVIA 100 MG TABLET MM 2 QLJANUVIA 25 MG TABLET MM 2 QLJANUVIA 50 MG TABLET MM 2 QLJARDIANCE 10 MG TABLET 2 QLJARDIANCE 25 MG TABLET 2 QLJAZZ WIRELESS 2 METER KIT MM 3 STjencycla 0.35 mg tablet MM 1JENTADUETO 2.5 MG-1,000 MG TABLET MM 2 QLJENTADUETO 2.5 MG-500 MG TABLET MM 2 QLJENTADUETO 2.5 MG-850 MG TABLET MM 2 QLJENTADUETO XR 2.5 MG-1,000 MG TABLET, EXTENDED RELEASE 2 QLJENTADUETO XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE 2 QLjevantique lo 0.5 mg-2.5 mcg tablet MM 3JEVITY 1.2 CAL 0.06 GRAM-1.2 KCAL/ML ORAL LIQUID 3JEVITY 1.5 CAL 0.06 GRAM-1.5 KCAL/ML ORAL LIQUID 3jinteli 1 mg-5 mcg tablet MM 3jolessa 0.15 mg-30 mcg tablets,3 month dose pack 1 QLjolivette 0.35 mg tablet MM 1juleber 0.15 mg-0.03 mg tablet MM 1junel 1.5/30 (21) 1.5 mg-30 mcg tablet MM 1junel 1/20 (21) 1 mg-20 mcg tablet MM 1junel fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM 1junel fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM 1junel fe 24 1 mg-20 mcg (24)/75 mg (4) tablet MM 1JUXTAPID 10 MG CAPSULE SP,LD * QL,PAJUXTAPID 20 MG CAPSULE SP,LD * QL,PAJUXTAPID 30 MG CAPSULE SP,LD * QL,PAJUXTAPID 40 MG CAPSULE SP,LD * QL,PAJUXTAPID 5 MG CAPSULE SP,LD * QL,PAJUXTAPID 60 MG CAPSULE SP,LD * QL,PAk-effervescent 25 meq tablet MM 2k-pax 20 gram-400 mcg oral powder 2k-pax immune booster 24 gram-240 kcal/65 gram oral powder 2K-PHOS NO 2 305 MG-700 MG TABLET 3K-PHOS ORIGINAL 500 MG SOLUBLE TABLET 2K-PHOS-NEUTRAL 250 MG TABLET 3k-sol 20 meq/15 ml oral liquid MM 3k-sol 40 meq/15 ml oral liquid MM 3K-TAB 10 MEQ TABLET,EXTENDED RELEASE MM 2K-TAB 20 MEQ TABLET,EXTENDED RELEASE MM 2K-TAB 8 MEQ TABLET,EXTENDED RELEASE MM 2KADIAN 10 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 100 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 20 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 200 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 30 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 40 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 50 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 60 MG CAPSULE,EXTENDED RELEASE 4 QL,STKADIAN 80 MG CAPSULE,EXTENDED RELEASE 4 QL,STkaitlib fe 0.8 mg-25 mcg (24)/75 mg (4) chewable tablet MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSKALETRA 100 MG-25 MG TABLET SP * QLKALETRA 200 MG-50 MG TABLET SP * QLKALETRA 400 MG-100 MG/5 ML ORAL SOLUTION SP *KALYDECO 150 MG TABLET SP,LD * QL,PAKALYDECO 50 MG ORAL GRANULES IN PACKET SP,LD * QL,PAKALYDECO 75 MG ORAL GRANULES IN PACKET SP,LD * QL,PAKAPVAY 0.1 MG TABLET,EXTENDED RELEASE MM 3 QL,STKARBINAL ER 4 MG/5 ML ORAL SUSPENSION,EXTENDED RELEASE 3kariva (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM 1KAZANO 12.5 MG-1,000 MG TABLET MM 3 QLKAZANO 12.5 MG-500 MG TABLET MM 3 QLKEFLEX 250 MG CAPSULE 3KEFLEX 500 MG CAPSULE 3KEFLEX 750 MG CAPSULE 3kelnor 1/35 (28) 1 mg-35 mcg tablet MM 1KENALOG 0.147 MG/GRAM TOPICAL AEROSOL 4 STKEPPRA 1,000 MG TABLET MM 4KEPPRA 100 MG/ML ORAL SOLUTION MM 4 QLKEPPRA 250 MG TABLET MM 4KEPPRA 500 MG TABLET MM 4KEPPRA 750 MG TABLET MM 4KEPPRA XR 500 MG TABLET,EXTENDED RELEASE MM 4KEPPRA XR 750 MG TABLET,EXTENDED RELEASE MM 4KETEK 300 MG TABLET 4KETEK 400 MG TABLET 4ketoconazole 2% cream 2ketoconazole 2% foam 4 STketoconazole 2% shampoo 2ketoconazole 200 mg tablet 2ketodan 2% foam 3 STketoprofen 50 mg capsule MM 1ketoprofen 75 mg capsule MM 1ketoprofen er 200 mg capsule MM 3ketorolac 0.4% ophth solution 2ketorolac 0.5% ophth solution 2ketorolac 10 mg tablet 2 QLKEVEYIS 50 MG TABLET LD 4 QL,PAKHEDEZLA 100 MG TABLET,EXTENDED RELEASE MM 4 QL,STKHEDEZLA 50 MG TABLET,EXTENDED RELEASE MM 4 QL,STkids omega-3 with dha 25 mg-5 mg-113.5 mg chewable tablet 2kimidess (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM 1KINERET 100 MG/0.67 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PAKINNEY BRAND LANCETS 23 GAUGE MM 1kionex (with sorbitol) 15 gram-19.3 gram/60 ml oral suspension 3kionex oral powder 3KITABIS PAK 300 MG/5 ML SOLUTION FOR NEBULIZATION SP,LD * QL,PAKLARON 10 % LOTION (SUSPENSION) 4klofensaid ii 1.5 % topical drops MM 3KLONOPIN 0.5 MG TABLET MM 3KLONOPIN 1 MG TABLET MM 3KLONOPIN 2 MG TABLET MM 3KLOR-CON 10 MEQ TABLET,EXTENDED RELEASE MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSklor-con 20 meq oral packet MM 3KLOR-CON 8 MEQ TABLET,EXTENDED RELEASE MM 2klor-con m10 meq tablet,extended release MM 1KLOR-CON M15 MEQ TABLET,EXTENDED RELEASE MM 2klor-con m20 meq tablet,extended release MM 1klor-con sprinkle 10 meq capsule,extended release MM 2klor-con sprinkle 8 meq capsule,extended release MM 2KLOR-CON/25 MEQ ORAL PACKET MM 3klor-con/ef 25 meq effervescent tablet MM 2KOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE MM 3 QLKOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE MM 3 QLKOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE MM 3 QLKORLYM 300 MG TABLET SP,LD * QL,PAKOSHER PRENATAL PLUS IRON 30 MG-1 MG TABLET 3KRISTALOSE 10 GRAM ORAL PACKET MM 3KRISTALOSE 20 GRAM ORAL PACKET MM 3KROGER PEN NEEDLES 29G 1kurvelo 0.15 mg-0.03 mg tablet MM 1KUVAN 100 MG ORAL POWDER PACKET SP,LD * PAKUVAN 100 MG SOLUBLE TABLET SP,LD * PAKUVAN 500 MG ORAL POWDER PACKET SP,LD * PAKYNAMRO 200 MG/ML SUBCUTANEOUS SYRINGE SP,LD * QL,PAl-cysteine 50 mg/ml vial 2l-methyl-mc 6 mg-5 mg-50 mg-1 mg tablet 3l-methylfolate 15 mg tablet 3l-methylfolate 7.5 mg tablet 3l-methylfolate calcium 15 mg 3l-methylfolate calcium 7.5 mg 3labetalol hcl 100 mg tablet MM 2labetalol hcl 200 mg tablet MM 2labetalol hcl 300 mg tablet MM 2lactulose 10 gm/15 ml solution MM 1lactulose 10 gm/15 ml solution MM 1lactulose 20 gm/30 ml solution MM 1LAMICTAL 100 MG TABLET MM 4LAMICTAL 150 MG TABLET MM 4LAMICTAL 2 MG DISPER TABLET 4LAMICTAL 200 MG TABLET MM 4LAMICTAL 25 MG CHEWABLE DISPERSIBLE TABLET MM 4 QLLAMICTAL 25 MG TABLET MM 4LAMICTAL 5 MG CHEWABLE DISPERSIBLE TABLET MM 4 QLLAMICTAL ODT 100 MG DISINTEGRATING TABLET MM 4 STLAMICTAL ODT 200 MG DISINTEGRATING TABLET MM 4 STLAMICTAL ODT 25 MG DISINTEGRATING TABLET MM 4 STLAMICTAL ODT 50 MG DISINTEGRATING TABLET MM 4 STLAMICTAL ODT STARTER (BLUE) 25 MG (21)-50 MG (7) TABLET,DISINTEGRATING 4 STLAMICTAL ODT STARTER (GREEN) 50 MG (42)-100 MG (14) TABLET,DISINTEGRAT 4 STLAMICTAL ODT STARTER(ORANGE) 25 MG(14)-50 MG(14)-100 MG(7) TAB,DISINT 4 STLAMICTAL STARTER (BLUE) KIT 25 MG (35) TABLETS IN A DOSE PACK 4LAMICTAL STARTER (GREEN) KIT 25 MG (84)-100 MG (14) TABLETS, DOSE PACK 4LAMICTAL STARTER (ORANGE) KIT 25 MG (42)-100 MG (7) TABLETS, DOSE PACK 4LAMICTAL XR 100 MG TABLET,EXTENDED RELEASE MM 4ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSLAMICTAL XR 200 MG TABLET,EXTENDED RELEASE MM 4LAMICTAL XR 25 MG TABLET,EXTENDED RELEASE MM 4LAMICTAL XR 250 MG TABLET,EXTENDED RELEASE MM 4LAMICTAL XR 300 MG TABLET,EXTENDED RELEASE MM 4LAMICTAL XR 50 MG TABLET,EXTENDED RELEASE MM 4LAMICTAL XR STARTER (BLUE) 25 MG (21)-50 MG (7) TABLET,EXTEND RELEASE 4LAMICTAL XR STARTER (GREEN) 50 MG(14)-100 MG(14)-200 MG(7) TAB,EXT.REL 4LAMICTAL XR STARTER (ORANGE) 25 MG(14)-50 MG(14)-100 MG(7) TAB,EXT.REL 4LAMISIL 125 MG GRANULES PACKET 3 QLLAMISIL 187.5 MG GRANULES PACK 3 QLlamivudine 10 mg/ml oral soln 3 QLlamivudine 150 mg tablet 3 QLlamivudine 300 mg tablet 3 QLlamivudine hbv 100 mg tablet 3 QLlamivudine-zidovudine tablet 3 QLlamotrigine 100 mg tablet MM 1lamotrigine 150 mg tablet MM 1lamotrigine 200 mg tablet MM 1lamotrigine 25 mg disper tab MM 2 QLlamotrigine 25 mg tablet MM 1lamotrigine 25 mg tb start kit 3lamotrigine 5 mg disper tablet MM 2 QLlamotrigine er 100 mg tablet MM 3lamotrigine er 200 mg tablet MM 3lamotrigine er 25 mg tablet MM 3lamotrigine er 250 mg tablet MM 3lamotrigine er 300 mg tablet MM 3lamotrigine er 50 mg tablet MM 3lamotrigine odt 100 mg tablet MM 3 STlamotrigine odt 200 mg tablet MM 3 STlamotrigine odt 25 mg tablet MM 3 STlamotrigine odt 50 mg tablet MM 3 STlamotrigine odt kit (blue) 4 STlamotrigine odt kit (green) 4 STlamotrigine odt kit (orange) 4 STLANCETS, SUPER THIN MM 1LANCETS,THIN MM 1LANCETS,THIN 23 GAUGE MM 1LANCETS,THIN 28 GAUGE MM 1LANCETS,ULTRA THIN MM 1LANCETS,ULTRA THIN 26 GAUGE MM 1LANCING DEVICE MM 1LANCING DEVICE WITH LANCETS MM 1LANCING SYSTEM MM 1LANOXIN 125 MCG TABLET MM 2 QLLANOXIN 187.5 MCG TABLET MM 3 QLLANOXIN 250 MCG TABLET MM 2LANOXIN 62.5 MCG TABLET MM 3 QLlansoprazol-amoxicil-clarithro 4lansoprazole dr 15 mg capsule MM 2 QLlansoprazole dr 30 mg capsule MM 2 QLLANTUS 100 UNIT/ML SUBCUTANEOUS SOLUTION MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSLANTUS SOLOSTAR 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN MM 2LANZO LANCING DEVICE KIT MM 1larin 1.5/30 (21) 1.5 mg-30 mcg tablet MM 1larin 1/20 (21) 1 mg-20 mcg tablet MM 1larin 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM 1larin fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM 1larin fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM 1larissia 0.1 mg-20 mcg tablet MM 1LASIX 20 MG TABLET MM 3LASIX 40 MG TABLET MM 3LASIX 80 MG TABLET MM 3LASTACAFT 0.25 % EYE DROPS 3 STlatanoprost 0.005% eye drops MM 1 QLLATUDA 120 MG TABLET MM 4 QL,PALATUDA 20 MG TABLET MM 4 QL,PALATUDA 40 MG TABLET MM 4 QL,PALATUDA 60 MG TABLET MM 4 QL,PALATUDA 80 MG TABLET MM 4 QL,PALAYOLIS FE 0.8 MG-25 MCG (24)/75 MG (4) CHEWABLE TABLET MM 3LAZANDA 100 MCG/SPRAY NASAL SPRAY 4 QL,PALAZANDA 300 MCG/SPRAY NASAL SPRAY 4 QL,PALAZANDA 400 MCG/SPRAY NASAL SPRAY 4 QL,PALEADER PEN NEEDLES 12MM 29G 1LEADER PEN NEEDLES 31G 1leena 28 0.5 mg/1 mg/0.5 mg-35 mcg tablet MM 1leflunomide 10 mg tablet MM 3 QLleflunomide 20 mg tablet MM 3 QLLENVIMA 10 MG/DAY (10 MG X 1/DAY) CAPSULE SP,LD * QL,PALENVIMA 14 MG/DAY(10 MG X 1-4 MG X 1) CAPSULE SP,LD * QL,PALENVIMA 18 MG/DAY (10 MG X 1 AND 4 MG X 2) CAPSULE SP,LD * QL,PALENVIMA 20 MG/DAY (10 MG X 2) CAPSULE SP,LD * QL,PALENVIMA 24 MG PER DAY (10 MG X 2 AND 4 MG X 1) CAPSULE SP,LD * QL,PALENVIMA 8 MG/DAY (4 MG X 2) CAPSULE SP,LD * QL,PALESCOL 20 MG CAPSULE MM 3 QL,STLESCOL 40 MG CAPSULE MM 3 QL,STLESCOL XL 80 MG TABLET,EXTENDED RELEASE MM 3 QL,STlessina 0.1 mg-20 mcg tablet MM 1LETAIRIS 10 MG TABLET SP,LD * QL,PALETAIRIS 5 MG TABLET SP,LD * QL,PAletrozole 2.5 mg tablet MM 1 QLleucovorin calcium 10 mg tab 3leucovorin calcium 15 mg tab 3leucovorin calcium 25 mg tab 3leucovorin calcium 5 mg tab 3LEUKERAN 2 MG TABLET 3 QLLEUKINE 250 MCG SOLUTION FOR INJECTION SP * QL,PAleuprolide 1 mg/0.2 ml vial 3 QL,PAleuprolide 2wk 1 mg/0.2 ml kit 3 QL,PAlevalbuterol 0.31 mg/3 ml sol MM 3levalbuterol 0.63 mg/3 ml sol MM 3levalbuterol 1.25 mg/3 ml sol MM 3levalbuterol conc 1.25 mg/0.5 MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSLEVAQUIN 25 MG/ML SOLUTION 3LEVAQUIN 250 MG TABLET 3LEVAQUIN 500 MG TABLET 3LEVAQUIN 750 MG TABLET 3LEVATOL 20 MG TABLET MM 3LEVBID 0.375 MG TABLET,EXTENDED RELEASE MM 4LEVEMIR 100 UNIT/ML SUBCUTANEOUS SOLUTION MM 2LEVEMIR FLEXPEN 100 UNITS/ML MM 2LEVEMIR FLEXTOUCH 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN MM 2levetiracetam 1,000 mg tablet MM 2levetiracetam 100 mg/ml soln MM 2 QLlevetiracetam 250 mg tablet MM 2levetiracetam 500 mg tablet MM 2levetiracetam 500 mg/5 ml soln MM 2levetiracetam 750 mg tablet MM 2levetiracetam er 500 mg tablet MM 2levetiracetam er 750 mg tablet MM 2LEVO-T 100 MCG TABLET MM 2LEVO-T 112 MCG TABLET MM 2LEVO-T 125 MCG TABLET MM 2LEVO-T 137 MCG TABLET MM 2LEVO-T 150 MCG TABLET MM 2LEVO-T 175 MCG TABLET MM 2LEVO-T 200 MCG TABLET MM 2LEVO-T 25 MCG TABLET MM 2LEVO-T 300 MCG TABLET MM 2LEVO-T 50 MCG TABLET MM 2LEVO-T 75 MCG TABLET MM 2LEVO-T 88 MCG TABLET MM 2levobunolol 0.5% eye drops MM 1levocarnitine 100 mg/ml soln MM 3levocarnitine 330 mg tablet MM 3levocetirizine 2.5 mg/5 ml sol MM 3 QLlevocetirizine 5 mg tablet MM 3 QLlevofloxacin 0.5% eye drops 3levofloxacin 25 mg/ml solution 3levofloxacin 250 mg tablet 2levofloxacin 500 mg tablet 2levofloxacin 750 mg tablet 2levomefolate dha 27 mg-400 mcg-1.13 mg-250 mg capsule 3levomefolate-algal 15 mg cap 3levomefolate-algal 7.5 mg cap 3levonest (28) 50-30 (6)/75-40(5)/125-30(10) tablet MM 1levono-e estrad 0.10-0.02-0.01 MM 1 QLlevono-e estrad 0.15-0.03-0.01 1 QLlevonor-eth estra 0.09-0.02 mg MM 1levonor-eth estrad 0.1-0.02 mg MM 1levonor-eth estrad 0.15-0.03 MM 1levonor-eth estrad 0.15-0.03 1 QLlevonor-eth estrad triphasic MM 1levonorgestrel 0.75 mg tablet 1levonorgestrel 1.5 mg tablet 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSlevora-28 0.15 mg-0.03 mg tablet MM 1levorphanol 2 mg tablet 3 QLlevothyroxine 100 mcg tablet MM 1levothyroxine 112 mcg tablet MM 1levothyroxine 125 mcg tablet MM 1levothyroxine 137 mcg tablet MM 1levothyroxine 150 mcg tablet MM 1levothyroxine 175 mcg tablet MM 1levothyroxine 200 mcg tablet MM 1levothyroxine 25 mcg tablet MM 1levothyroxine 300 mcg tablet MM 1levothyroxine 50 mcg tablet MM 1levothyroxine 75 mcg tablet MM 1levothyroxine 88 mcg tablet MM 1LEVOXYL 100 MCG TABLET MM 1LEVOXYL 112 MCG TABLET MM 1LEVOXYL 125 MCG TABLET MM 1LEVOXYL 137 MCG TABLET MM 1LEVOXYL 150 MCG TABLET MM 1LEVOXYL 175 MCG TABLET MM 1LEVOXYL 200 MCG TABLET MM 1LEVOXYL 25 MCG TABLET MM 1LEVOXYL 50 MCG TABLET MM 1LEVOXYL 75 MCG TABLET MM 1LEVOXYL 88 MCG TABLET MM 1LEVSIN 0.125 MG TABLET MM 4LEVSIN/SL 0.125 MG SUBLINGUAL TABLET MM 4LEVULAN 20 % TOPICAL SOLUTION 4LEXAPRO 10 MG TABLET MM 3 QLLEXAPRO 20 MG TABLET MM 3 QLLEXAPRO 5 MG TABLET MM 3 QLLEXAPRO 5 MG/5 ML ORAL SOLUTION MM 3 QLLEXIVA 50 MG/ML ORAL SUSPENSION SP * QLLEXIVA 700 MG TABLET SP * QLLIALDA 1.2 GRAM TABLET,DELAYED RELEASE MM 2 QLLIBERTY BLOOD GLUCOSE MONITOR MM 1LIBERTY LEVEL 1 GLUCOSE CONTROL LOW SOLUTION 3LIBERTY LEVEL 2 GLUCOSE CONTROL NORMAL SOLUTION 3LIBERTY TEST STRIPS MM 1 QLLIBRAX (WITH CLIDINIUM) 5 MG-2.5 MG CAPSULE 4lidocaine 2% viscous soln 1lidocaine 5% ointment 3lidocaine 5% patch 3 QL,PAlidocaine hcl 2% jelly 2lidocaine hcl 2% jelly 2lidocaine hcl 4% solution 4lidocaine hcl 4% solution 4lidocaine viscous 2 % mucosal solution 2lidocaine-prilocaine cream 2LIDODERM 5 % TOPICAL PATCH 3 QL,PALILETTA 18.6 MCG/24 HOUR (3 YEARS) INTRAUTERINE DEVICE SP *lindane 1% lotion 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSlindane 1% shampoo 3linezolid 100 mg/5 ml susp 4 QLlinezolid 600 mg tablet 4 QLLINZESS 145 MCG CAPSULE MM 2 QLLINZESS 290 MCG CAPSULE MM 2 QLliothyronine sod 25 mcg tab MM 2liothyronine sod 5 mcg tab MM 2liothyronine sod 50 mcg tab MM 2LIPITOR 10 MG TABLET MM 3 QL,STLIPITOR 20 MG TABLET MM 3 QL,STLIPITOR 40 MG TABLET MM 3 QL,STLIPITOR 80 MG TABLET MM 3 QL,STLIPOFEN 150 MG CAPSULE MM 3 QL,STLIPOFEN 50 MG CAPSULE MM 3 QL,STlipotriad dry eye 700 mg-320 mg capsule,delayed release 2LIPTRUZET 10-10 MG TABLET MM 3 QLLIPTRUZET 10-20 MG TABLET MM 3 QLLIPTRUZET 10-40 MG TABLET MM 3 QLLIPTRUZET 10-80 MG TABLET MM 3 QLLIQUID HOPE ORAL 3liquid nutrition oral 2liquid nutrition plus oral 2lisinopril 10 mg tablet MM 1lisinopril 2.5 mg tablet MM 1lisinopril 20 mg tablet MM 1lisinopril 30 mg tablet MM 1lisinopril 40 mg tablet MM 1lisinopril 5 mg tablet MM 1lisinopril-hctz 10-12.5 mg tab MM 1lisinopril-hctz 20-12.5 mg tab MM 1lisinopril-hctz 20-25 mg tab MM 1LISTER-V 24 MG-21 MG CAPSULE 3LITE TOUCH INSULIN PEN NEEDLES 29 GAUGE X 1/2" 2LITE TOUCH INSULIN PEN NEEDLES 31 GAUGE X 1/4" 2LITE TOUCH INSULIN PEN NEEDLES 31 GAUGE X 3/16" 2LITE TOUCH INSULIN PEN NEEDLES 31 GAUGE X 5/16" 2LITE TOUCH INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2LITE TOUCH INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2LITE TOUCH INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2LITE TOUCH INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2LITE TOUCH INSULIN SYRINGE 1 ML 28 GAUGE MM 2LITE TOUCH INSULIN SYRINGE 1 ML 29 GAUGE MM 2LITE TOUCH INSULIN SYRINGE 1 ML 30 GAUGE X 7/16" MM 2LITE TOUCH INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2LITE TOUCH INSULIN SYRINGE 1/2 ML 28 GAUGE MM 2LITE TOUCH INSULIN SYRINGE 1/2 ML 29 MM 2LITE TOUCH INSULIN SYRINGE 1/2 ML 30 GAUGE MM 2LITE TOUCH LANCETS 30 GAUGE MM 1LITE TOUCH LANCETS 33 GAUGE MM 1LITE TOUCH LANCING DEVICE MM 3LITE TOUCH-MEDIUM MASK 1LITEAIRE MDI CHAMBER 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSLITETOUCH-LARGE MASK 1LITETOUCH-SMALL MASK 1LITHATE 20 MG CAPSULE 3LITHATE 5 MG CAPSULE 3lithium 8 meq/5 ml solution MM 1lithium carbonate 150 mg cap MM 1lithium carbonate 300 mg cap MM 1lithium carbonate 300 mg tab MM 1lithium carbonate 600 mg cap MM 1lithium carbonate er 300 mg tb MM 1lithium carbonate er 450 mg tb MM 1LITHOBID 300 MG TABLET,EXTENDED RELEASE MM 3LITHOSTAT 250 MG TABLET 2LIVALO 1 MG TABLET MM 2 QL,STLIVALO 2 MG TABLET MM 2 QL,STLIVALO 4 MG TABLET MM 2 QL,STLO LOESTRIN FE 1 MG-10 MCG (24)/10 MCG (2) TABLET MM 2LOCOID 0.1 % LOTION 4 STLOCOID 0.1 % TOPICAL CREAM 4 STLOCOID 0.1 % TOPICAL OINTMENT 4 STLOCOID 0.1 % TOPICAL SOLUTION 4 STLOCOID LIPOCREAM 0.1 % TOPICAL 4 STLODOSYN 25 MG TABLET MM 4LOESTRIN 1.5/30 (21) 1.5 MG-30 MCG TABLET MM 3LOESTRIN 1/20 (21) 1 MG-20 MCG TABLET MM 3LOESTRIN FE 1.5/30 (28-DAY) 1.5 MG-30 MCG (21)/75 MG (7) TABLET MM 3LOESTRIN FE 1/20 (28-DAY) 1 MG-20 MCG (21)/75 MG (7) TABLET MM 3lofibra 134 mg capsule MM 3 QLlofibra 160 mg tablet MM 3 QLlofibra 200 mg capsule MM 3 QLlofibra 54 mg tablet MM 3 QLlofibra 67 mg capsule MM 3 QLlomedia 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM 1LOMOTIL 2.5 MG-0.025 MG TABLET 3LOMUSTINE 10 MG CAPSULE 3 QLLOMUSTINE 100 MG CAPSULE 3 QLLOMUSTINE 40 MG CAPSULE 3 QLLONSURF 15 MG-6.14 MG TABLET SP,LD * QL,PALONSURF 20 MG-8.19 MG TABLET SP,LD * QL,PAloperamide 2 mg capsule MM 2LOPID 600 MG TABLET MM 3 QLlopreeza 0.5 mg-0.1 mg tablet MM 3lopreeza 1 mg-0.5 mg tablet MM 3LOPRESSOR 100 MG TABLET MM 3LOPRESSOR 50 MG TABLET MM 3LOPRESSOR HCT 50 MG-25 MG TABLET MM 3LOPROX (AS OLAMINE) 0.77 % TOPICAL CREAM 3LOPROX 1 % SHAMPOO 4lorazepam 0.5 mg tablet 2 QLlorazepam 1 mg tablet 2 QLlorazepam 2 mg tablet 2 QLlorazepam 2 mg/ml oral concent 2 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSlorazepam intensol 2 mg/ml oral concentrate 1 QLlorcet (hydrocodone) 5 mg-325 mg tablet 3 QLlorcet hd 10 mg-325 mg tablet 3 QLlorcet plus 7.5 mg-325 mg tablet 3 QLlortab 10 mg-325 mg tablet 3 QLlortab 5 mg-325 mg tablet 3 QLlortab 7.5 mg-325 mg tablet 3 QLlortab elixir 10 mg-300 mg/15 ml oral solution 3 QLloryna (28) 3 mg-20 mcg tablet MM 1LORZONE 375 MG TABLET 3 QL,STLORZONE 750 MG TABLET 3 QL,STlosartan potassium 100 mg tab MM 1 QLlosartan potassium 25 mg tab MM 1 QLlosartan potassium 50 mg tab MM 1 QLlosartan-hctz 100-12.5 mg tab MM 1 QLlosartan-hctz 100-25 mg tab MM 1 QLlosartan-hctz 50-12.5 mg tab MM 1 QLLOSEASONIQUE 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK MM 3 QLLOTEMAX 0.5 % EYE DROPS,SUSPENSION 3 STLOTEMAX 0.5 % EYE GEL DROPS 3 STLOTEMAX 0.5 % EYE OINTMENT 3 STLOTENSIN 20 MG TABLET MM 3LOTENSIN 40 MG TABLET MM 3LOTENSIN HCT 10 MG-12.5 MG TABLET MM 3LOTENSIN HCT 20 MG-12.5 MG TABLET MM 3LOTENSIN HCT 20 MG-25 MG TABLET MM 3LOTREL 10 MG-20 MG CAPSULE MM 3 QLLOTREL 10 MG-40 MG CAPSULE MM 3 QLLOTREL 2.5-10 MG CAPSULE MM 3 QLLOTREL 5 MG-10 MG CAPSULE MM 3 QLLOTREL 5 MG-20 MG CAPSULE MM 3 QLLOTREL 5 MG-40 MG CAPSULE MM 3 QLLOTRISONE 1 %-0.05 % TOPICAL CREAM 3LOTRONEX 0.5 MG TABLET MM 4 QL,PALOTRONEX 1 MG TABLET MM 4 QL,PAlovastatin 10 mg tablet MM 1 QLlovastatin 20 mg tablet MM 1 QLlovastatin 40 mg tablet MM 1 QLLOVAZA 1 GRAM CAPSULE MM 3 QL,STLOVENOX 100 MG/ML SUBCUTANEOUS SYRINGE 4 QLLOVENOX 120 MG/0.8 ML SUBCUTANEOUS SYRINGE 4 QLLOVENOX 150 MG/ML SUBCUTANEOUS SYRINGE 4 QLLOVENOX 30 MG/0.3 ML SUBCUTANEOUS SYRINGE 4 QLLOVENOX 300 MG/3 ML SUBCUTANEOUS SOLUTION 4 QLLOVENOX 40 MG/0.4 ML SUBCUTANEOUS SYRINGE 4 QLLOVENOX 60 MG/0.6 ML SUBCUTANEOUS SYRINGE 4 QLLOVENOX 80 MG/0.8 ML SUBCUTANEOUS SYRINGE 4 QLlow-ogestrel (28) 0.3 mg-30 mcg tablet MM 1loxapine 10 mg capsule MM 2loxapine 25 mg capsule MM 2loxapine 5 mg capsule MM 2loxapine 50 mg capsule MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSLUFYLLIN 200 MG TABLET MM 3LUFYLLIN-400 TABLET MM 3lugols 5 % oral solution 3lugols 5 %-10 % topical solution 3lukaid gla for asthma emulsion 2LUMIGAN 0.01 % EYE DROPS MM 2 QLLUNESTA 1 MG TABLET 3 QL,STLUNESTA 2 MG TABLET 3 QL,STLUNESTA 3 MG TABLET 3 QL,STLUPANETA PACK (1 MONTH) 3.75 MG IM SYRINGE AND 5 MG (30) TABLETS,KIT SP * QL,PALUPANETA PACK (3 MONTH) 11.25 MG IM SYRINGE AND 5 MG (90) TABLETS,KIT SP * QL,PAlutera (28) 0.1 mg-20 mcg tablet MM 1LUVOX CR 100 MG CAPSULE MM 4 QLLUXIQ 0.12 % TOPICAL FOAM 3 STLUZU 1 % TOPICAL CREAM 4 QL,STLYNPARZA 50 MG CAPSULE SP,LD * QL,PALYRICA 100 MG CAPSULE MM 3 QLLYRICA 150 MG CAPSULE MM 3 QLLYRICA 20 MG/ML ORAL SOLUTION MM 3 QLLYRICA 200 MG CAPSULE MM 3 QLLYRICA 225 MG CAPSULE MM 3 QLLYRICA 25 MG CAPSULE MM 3 QLLYRICA 300 MG CAPSULE MM 3 QLLYRICA 50 MG CAPSULE MM 3 QLLYRICA 75 MG CAPSULE MM 3 QLLYSIPLEX PLUS TABLET 3LYSODREN 500 MG TABLET SP *LYSTEDA 650 MG TABLET MM 3 QLlyza 0.35 mg tablet MM 1M-VIT 27 MG-1 MG TABLET 2macnatal cn dha 28 mg-1 mg-50 mg-250 mg capsule 2MACROBID 100 MG CAPSULE 3MACRODANTIN 100 MG CAPSULE 3MACRODANTIN 25 MG CAPSULE 3MACRODANTIN 50 MG CAPSULE 3mafenide acetate 50 gm powd pk 3MAGELLAN INSULIN SAFETY SYRINGE 0.3 ML 29 X 1/2" MM 2MAGELLAN INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2MAGELLAN INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" MM 2MAGELLAN INSULIN SAFETY SYRINGE 1 ML 30 GAUGE X 5/16" MM 2MAGELLAN SYRINGE 0.3 ML 30 X 5/16" MM 2MAGELLAN SYRINGE 0.5 ML 30 GAUGE X 5/16" MM 2MAGELLAN SYRINGE 1 ML 27 GAUGE X 1/2" 2MALARONE 250 MG-100 MG TABLET 3 QLMALARONE PEDIATRIC 62.5 MG-25 MG TABLET 3 QLmalathion 0.5% lotion 3maprotiline 25 mg tablet MM 3maprotiline 50 mg tablet MM 3maprotiline 75 mg tablet MM 3MARINOL 10 MG CAPSULE 4 QL,PAMARINOL 2.5 MG CAPSULE 4 QL,PAMARINOL 5 MG CAPSULE 4 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmarlissa 0.15 mg-0.03 mg tablet MM 1MARNATAL-F 60 MG IRON-1 MG CAPSULE 3MARPLAN 10 MG TABLET MM 3MATULANE 50 MG CAPSULE SP,LD *matzim la 180 mg tablet,extended release MM 3 QLmatzim la 240 mg tablet,extended release MM 3 QLmatzim la 300 mg tablet,extended release MM 3 QLmatzim la 360 mg tablet,extended release MM 3 QLmatzim la 420 mg tablet,extended release MM 3 QLMAVIK 1 MG TABLET MM 3MAVIK 2 MG TABLET MM 3MAVIK 4 MG TABLET MM 3MAXALT 10 MG TABLET 3 QL,STMAXALT 5 MG TABLET 3 QL,STMAXALT-MLT 10 MG DISINTEGRATING TABLET 3 QL,STMAXALT-MLT 5 MG DISINTEGRATING TABLET 3 QL,STMAXARON FORTE 150 MG IRON-200 MG-250 MCG TABLET 2MAXFE (FOLATE-DOCUSATE) 160 MG IRON-1 MG-60 MCG TABLET 2MAXI-COMFORT INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 1MAXI-COMFORT INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 1MAXIDEX 0.1 % EYE DROPS,SUSPENSION 3 STMAXILIFE RICE 50 MG CAPSULE 3MAXIMUM DAILY GREEN 5 MG-133 MCG TABLET 3MAXINATE 20 MG-0.8 MG TABLET 3MAXITROL 3.5 MG/G-10,000 UNIT/G-0.1 % EYE OINTMENT 3MAXITROL 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS,SUSPENSION 3MAXZIDE 75 MG-50 MG TABLET MM 3MAXZIDE-25MG 37.5 MG-25 MG TABLET MM 3MEBOLEX TABLET 3meclizine 12.5 mg tablet 2meclizine 25 mg tablet 2meclofenamate 100 mg capsule MM 3meclofenamate 50 mg capsule MM 3MEDI-LANCE LANCETS MM 1MEDISENSE COMBO PACK 3MEDISENSE CONTROLS 1-HI 1-LO COMBO PACK 3MEDISENSE GLUCOSE KETONE COMBO PACK 3MEDISENSE MID CONTROL SOLUTION 3MEDISENSE THIN LANCETS MM 1MEDISENSE THIN LANCETS 28 GAUGE MM 1MEDLANCE PLUS LANCETS 21 GAUGE MM 1MEDLANCE PLUS LANCETS 25 GAUGE MM 1MEDLANCE PLUS LANCETS 30 GAUGE MM 1MEDPOINT NORMAL CONTROL SOLUTION 3MEDROL (PAK) 4 MG TABLETS IN A DOSE PACK 3MEDROL 16 MG TABLET 3MEDROL 2 MG TABLET 3MEDROL 32 MG TABLET 3MEDROL 4 MG TABLET 3MEDROL 8 MG TABLET 3medroxyprogesterone 10 mg tab MM 1medroxyprogesterone 150 mg/ml 1 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmedroxyprogesterone 2.5 mg tab MM 1medroxyprogesterone 5 mg tab MM 1mefenamic acid 250 mg capsule 3mefloquine hcl 250 mg tablet MM 2MEGACE 400 MG/10 ML (40 MG/ML) ORAL SUSPENSION MM 3MEGACE ES 625 MG/5 ML ORAL SUSPENSION MM 4 STMEGAVITE 18 MG IRON-800 MCG-150 MG TABLET 3MEGAVITE GOLDEN YEARS 55+ 800 MCG-150 MG-25 MG TABLET 3megestrol 20 mg tablet 1megestrol 40 mg tablet 1megestrol 625 mg/5 ml susp MM 4megestrol acet 40 mg/ml susp MM 2megestrol acet 400 mg/10 ml MM 2MEKINIST 0.5 MG TABLET SP,LD * QL,PAMEKINIST 2 MG TABLET SP,LD * QL,PAmeloxicam 15 mg tablet MM 1 QLmeloxicam 7.5 mg tablet MM 1 QLmeloxicam 7.5 mg/5 ml susp MM 3 QLmemantine 5-10 mg titration pk 3 QLmemantine hcl 10 mg tablet MM 2 QLmemantine hcl 2 mg/ml solution MM 3 QLmemantine hcl 5 mg tablet MM 2 QLMENEST 0.3 MG TABLET MM 3MENEST 0.625 MG TABLET MM 3MENEST 1.25 MG TABLET MM 3MENEST 2.5 MG TABLET MM 3MENOSTAR 14 MCG/24 HR TRANSDERMAL PATCH MM 3 QLMENTAX 1 % TOPICAL CREAM 3meperidine 100 mg tablet 2 QLmeperidine 50 mg tablet 2 QLmeperidine 50 mg/5 ml solution 2 QLMEPHYTON 5 MG TABLET 4meprobamate 200 mg tablet 3meprobamate 400 mg tablet 3MEPRON 750 MG/5 ML ORAL SUSPENSION 4 QLmercaptopurine 50 mg tablet 3 QLmesalamine 4 gm/60 ml enema MM 3 QLmesalamine 800 mg dr tablet MM 4 QL,STMESNEX 400 MG TABLET SP *MESTINON 60 MG TABLET MM 4MESTINON 60 MG/5 ML SYRUP MM 4MESTINON TIMESPAN 180 MG TABLET,EXTENDED RELEASE MM 4METADATE CD 10 MG CAPSULE,EXTENDED RELEASE 3 QL,STMETADATE CD 20 MG CAPSULE,EXTENDED RELEASE 3 QL,STMETADATE CD 30 MG CAPSULE,EXTENDED RELEASE 3 QL,STMETADATE CD 40 MG CAPSULE,EXTENDED RELEASE 3 QL,STMETADATE CD 50 MG CAPSULE,EXTENDED RELEASE 3 QL,STMETADATE CD 60 MG CAPSULE,EXTENDED RELEASE 3 QL,STmetadate er 20 mg tablet,extended release 2 QLmetafolbic 6 mg-5 mg-50 mg-1 mg tablet 3metaproterenol 10 mg tablet MM 1metaproterenol 10 mg/5 ml syr MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmetaproterenol 20 mg tablet MM 1metaxall 800 mg tablet 3 QLmetaxalone 400 mg tablet 3 QLmetaxalone 800 mg tablet 3 QLMETER-CHECK SOLUTION 3metformin er 1,000 mg osm-tab MM 3 QL,STmetformin hcl 1,000 mg tablet MM 1metformin hcl 500 mg tablet MM 1metformin hcl 850 mg tablet MM 1metformin hcl er 1,000 mg tab MM 4 QL,STmetformin hcl er 500 mg osm-tb MM 3 QL,STmetformin hcl er 500 mg tablet MM 1 QLmetformin hcl er 500 mg tablet MM 4 QL,STmetformin hcl er 750 mg tablet MM 1 QLmethadone 10 mg/5 ml solution 2 QLmethadone 10 mg/ml oral conc 2 QLmethadone 40 mg tablet dispr 2 QLmethadone 5 mg/5 ml solution 2 QLmethadone hcl 10 mg tablet 2 QLmethadone hcl 5 mg tablet 2 QLmethadone intensol 10 mg/ml oral concentrate 2 QLMETHADOSE 10 MG/ML ORAL CONCENTRATE 3 QLmethadose 40 mg soluble tablet 2 QLmethamphetamine 5 mg tablet 4 QLMETHAZEL 1 MG-50 MG-2.5 MG-25 MG-50 MG CAPSULE 3methazolamide 25 mg tablet MM 3methazolamide 50 mg tablet MM 3methenamine hipp 1 gm tablet 3methergine 0.2 mg tablet 3methimazole 10 mg tablet MM 1methimazole 5 mg tablet MM 1METHITEST 10 MG TABLET MM 3methocarbamol 500 mg tablet 2methocarbamol 750 mg tablet 2methotrexate 2.5 mg tablet MM 2methotrexate 50 mg/2 ml vial 2methotrexate 50 mg/2 ml vial 2methoxsalen 10 mg capsule SP *methscopolamine brom 2.5 mg tb 3methscopolamine brom 5 mg tab 3methyclothiazide 5 mg tablet MM 2methyldopa 250 mg tablet MM 1methyldopa 500 mg tablet MM 1methyldopa-hctz 250-15 mg tab MM 3methyldopa-hctz 250-25 mg tab MM 3methylergonovine 0.2 mg tablet 3METHYLIN 10 MG CHEWABLE TABLET 3 QLMETHYLIN 10 MG/5 ML ORAL SOLUTION 3 QLMETHYLIN 2.5 MG CHEWABLE TABLET 3 QLMETHYLIN 5 MG CHEWABLE TABLET 3 QLMETHYLIN 5 MG/5 ML ORAL SOLUTION 3 QLmethylphenidate 10 mg chew tab 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmethylphenidate 10 mg tablet 2 QLmethylphenidate 10 mg/5 ml sol 3 QLmethylphenidate 2.5 mg chew tb 3 QLmethylphenidate 20 mg tablet 2 QLmethylphenidate 5 mg chew tab 3 QLmethylphenidate 5 mg tablet 2 QLmethylphenidate 5 mg/5 ml soln 3 QLmethylphenidate cd 10 mg cap 3 QLmethylphenidate cd 20 mg cap 3 QLmethylphenidate cd 30 mg cap 3 QLmethylphenidate cd 40 mg cap 3 QLmethylphenidate cd 50 mg cap 3 QLmethylphenidate cd 60 mg cap 3 QLmethylphenidate er 10 mg tab 2 QLmethylphenidate er 18 mg tab 3 QL,STmethylphenidate er 20 mg tab 2 QLmethylphenidate er 27 mg tab 3 QL,STmethylphenidate er 36 mg tab 3 QL,STmethylphenidate er 54 mg tab 3 QL,STmethylphenidate la 20 mg cap 3 QLmethylphenidate la 30 mg cap 3 QLmethylphenidate la 40 mg cap 3 QLmethylprednisolone 16 mg tab 2methylprednisolone 32 mg tab 2methylprednisolone 4 mg dosepk 2methylprednisolone 4 mg tablet 2methylprednisolone 8 mg tab 2methyltestosterone 10 mg cap MM 4metipranolol 0.3% eye drops MM 1metoclopramide 10 mg tablet 1metoclopramide 5 mg tablet 1metoclopramide 5 mg/5 ml soln 1metoclopramide hcl odt 10 mg 3 QLmetoclopramide hcl odt 5 mg tb 3 QLmetolazone 10 mg tablet MM 2metolazone 2.5 mg tablet MM 2metolazone 5 mg tablet MM 2METOPIRONE 250 MG CAPSULE 3metoprolol succ er 100 mg tab MM 2 QLmetoprolol succ er 200 mg tab MM 2 QLmetoprolol succ er 25 mg tab MM 2 QLmetoprolol succ er 50 mg tab MM 2 QLmetoprolol tartrate 100 mg tab MM 1metoprolol tartrate 25 mg tab MM 1metoprolol tartrate 37.5 mg tb 2metoprolol tartrate 50 mg tab MM 1metoprolol tartrate 75 mg tab 2metoprolol-hctz 100-25 mg tab MM 2metoprolol-hctz 100-50 mg tab MM 2metoprolol-hctz 50-25 mg tab MM 2METOZOLV ODT 5 MG DISINTEGRATING TABLET 3 QLMETROCREAM 0.75 % TOPICAL 3 STMETROGEL 1 % TOPICAL 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSMETROGEL 1 % TOPICAL GEL WITH PUMP 3 STMETROGEL VAGINAL 0.75 % 4METROLOTION 0.75 % TOPICAL 3 STmetronidazole 0.75% cream 3metronidazole 0.75% lotion 3metronidazole 250 mg tablet 2metronidazole 375 mg capsule 3metronidazole 500 mg tablet 2metronidazole topical 0.75% gl 3metronidazole topical 1% gel 3metronidazole topical 1% gel 3metronidazole vaginal 0.75% gl 3mexiletine 150 mg capsule MM 3mexiletine 200 mg capsule MM 3mexiletine 250 mg capsule MM 3MIACALCIN 200 UNIT/ACTUATION NASAL SPRAY MM 3 QLMIACALCIN 200 UNIT/ML INJECTION SOLUTION 4 QLMICARDIS 20 MG TABLET MM 3 QL,STMICARDIS 40 MG TABLET MM 3 QL,STMICARDIS 80 MG TABLET MM 3 QL,STMICARDIS HCT 40 MG-12.5 MG TABLET MM 3 QL,STMICARDIS HCT 80 MG-12.5 MG TABLET MM 3 QL,STMICARDIS HCT 80 MG-25 MG TABLET MM 3 QL,STmiconazole-3 200 mg vaginal suppository 2MICRO BLOOD GLUCOSE STRIPS MM 3 QL,STMICRO THIN LANCETS 33 GAUGE MM 1MICROCHAMBER SPACER 3MICRODOT BLOOD GLUCOSE MONITORING SYSTEM MM 3 STMICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT MM 3 STMICRODOT BLOOD GLUCOSE MONITORING SYSTEM STRIPS MM 3 QL,STMICRODOT HIGH-LOW CONTROL SOLUTION 3MICRODOT NORMAL CONTROL SOLUTION 3MICRODOT XTRA BLOOD GLUCOSE STRIPS MM 3 QL,STmicrogestin 1.5/30 (21) 1.5 mg-30 mcg tablet MM 1microgestin 1/20 (21) 1 mg-20 mcg tablet MM 1MICROGESTIN 24 FE 1 MG-20 MCG (24)/75 MG (4) TABLET MM 3microgestin fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM 1microgestin fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM 1MICROLET 2 LANCING DEVICE KIT MM 3MICROLET LANCET MM 3MICROSPACER 1MICROZIDE 12.5 MG CAPSULE MM 3midazolam hcl 2 mg/ml syrup 2midodrine hcl 10 mg tablet 3midodrine hcl 2.5 mg tablet 3midodrine hcl 5 mg tablet 3migergot 2 mg-100 mg rectal suppository 4miglitol 100 mg tablet MM 3miglitol 25 mg tablet MM 3miglitol 50 mg tablet MM 3MIGRANAL 0.5 MG/PUMP ACT. (4 MG/ML) NASAL SPRAY 4 QL,STMILLIPRED 10 MG/5 ML ORAL SOLUTION 4ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmillipred 5 mg tablet 3millipred dp 5 mg (21 tabs) tablets in a dose pack 3millipred dp 5 mg (48 tabs) tablets in a dose pack 3mimvey 1 mg-0.5 mg tablet MM 3mimvey lo 0.5 mg-0.1 mg tablet MM 3MINASTRIN 24 FE 1 MG-20 MCG (24)/75 MG (4) CHEWABLE TABLET MM 2MINI LANCING DEVICE MM 1MINI ULTRA-THIN II 31 GAUGE X 3/16" NEEDLE 1MINI WRIGHT PEAK FLOW METER 1MINI-WRIGHT PEAK FLOW METER 1MINILINK REAL-TIME TRANSMITTER DEVICE MM 3 PAMINIMED SYRINGE RESERVOIR 3 ML MM 2MINIPRESS 1 MG CAPSULE MM 3MINIPRESS 2 MG CAPSULE MM 3MINIPRESS 5 MG CAPSULE MM 3minitran 0.1 mg/hr transdermal 24 hour patch MM 3 QLminitran 0.2 mg/hr transdermal 24 hour patch MM 3 QLminitran 0.4 mg/hr transdermal 24 hour patch MM 3 QLminitran 0.6 mg/hr transdermal 24 hour patch MM 3 QLMINIVELLE 0.025 MG/24 HR TRANSDERMAL PATCH MM 3 QLMINIVELLE 0.0375 MG/24 HR TRANSDERMAL PATCH MM 3 QLMINIVELLE 0.05 MG/24 HR TRANSDERMAL PATCH MM 3 QLMINIVELLE 0.075 MG/24 HR TRANSDERMAL PATCH MM 3 QLMINIVELLE 0.1 MG/24 HR TRANSDERMAL PATCH MM 3 QLMINOCIN 100 MG CAPSULE 4MINOCIN 50 MG CAPSULE 4MINOCIN 75 MG CAPSULE 4minocycline 100 mg capsule 2minocycline 50 mg capsule 2minocycline 75 mg capsule 2minocycline er 135 mg tablet 3 QL,PAminocycline er 45 mg tablet 3 QL,PAminocycline er 90 mg tablet 3 QL,PAminocycline hcl 100 mg tablet 3minocycline hcl 50 mg tablet 3minocycline hcl 75 mg tablet 3minoxidil 10 mg tablet MM 1minoxidil 2.5 mg tablet MM 1MINUS WEIGHT PLUS ENERGY 50 MG-5 MG-6 MG-5 MG-707.5 MG CAPSULE 3MIRAPEX 0.125 MG TABLET MM 3MIRAPEX 0.25 MG TABLET MM 3MIRAPEX 0.5 MG TABLET MM 3MIRAPEX 0.75 MG TABLET MM 3MIRAPEX 1 MG TABLET MM 3MIRAPEX 1.5 MG TABLET MM 3MIRAPEX ER 0.375 MG TABLET,EXTENDED RELEASE MM 3 QL,PAMIRAPEX ER 0.75 MG TABLET,EXTENDED RELEASE MM 3 QL,PAMIRAPEX ER 1.5 MG TABLET,EXTENDED RELEASE MM 3 QL,PAMIRAPEX ER 2.25 MG TABLET,EXTENDED RELEASE MM 3 QL,PAMIRAPEX ER 3 MG TABLET,EXTENDED RELEASE MM 3 QL,PAMIRAPEX ER 3.75 MG TABLET,EXTENDED RELEASE MM 3 QL,PAMIRAPEX ER 4.5 MG TABLET,EXTENDED RELEASE MM 3 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSMIRCERA 100 MCG/0.3 ML INJECTION SYRINGE SP * QL,PAMIRCERA 200 MCG/0.3 ML INJECTION SYRINGE SP * QL,PAMIRCERA 50 MCG/0.3 ML INJECTION SYRINGE SP * QL,PAMIRCERA 75 MCG/0.3 ML INJECTION SYRINGE SP * QL,PAMIRCETTE (28) 0.15 MG-0.02 MG (21)/0.01 MG (5) TABLET MM 3MIRENA 20 MCG/24 HR (5 YEARS) INTRAUTERINE DEVICE SP,LD *mirtazapine 15 mg odt MM 3 QLmirtazapine 15 mg tablet MM 1 QLmirtazapine 30 mg odt MM 3 QLmirtazapine 30 mg tablet MM 1 QLmirtazapine 45 mg odt MM 3 QLmirtazapine 45 mg tablet MM 1 QLmirtazapine 7.5 mg tablet MM 1MIRVASO 0.33 % TOPICAL GEL MM 4 STMIRVASO 0.33 % TOPICAL GEL WITH PUMP 4 STmisoprostol 100 mcg tablet MM 2misoprostol 200 mcg tablet MM 2MISTASSIST DEVICE 4MITIGARE 0.6 MG CAPSULE 3 QL,STMOBIC 15 MG TABLET MM 3 QLMOBIC 7.5 MG TABLET MM 3 QLMOBIC 7.5 MG/5 ML SUSPENSION MM 3 QLmodafinil 100 mg tablet MM 3 QL,PAmodafinil 200 mg tablet MM 3 QL,PAmoderiba 200 mg tablet 3 QLmoderiba dose pack 200 mg (7)-400 mg (7) tablets 3 QLmoderiba dose pack 400 mg (7)-400 mg (7) tablets 3 QLmoderiba dose pack 600 mg (7)-400 mg (7) tablets 3 QLmoderiba dose pack 600 mg (7)-600 mg (7) tablets 3 QLMODICON (28) 0.5 MG-35 MCG TABLET MM 3moexipril hcl 15 mg tablet MM 2moexipril hcl 7.5 mg tablet MM 2moexipril-hctz 15-12.5 mg tab MM 2moexipril-hctz 15-25 mg tablet MM 2moexipril-hctz 7.5-12.5 mg tab MM 2molindone hcl 10 mg tablet 3 QL,PAmolindone hcl 25 mg tablet 3 QL,PAmolindone hcl 5 mg tablet 3 QL,PAmometasone furoate 0.1% cream 2mometasone furoate 0.1% oint 2mometasone furoate 0.1% soln 2mometasone furoate 50 mcg spry MM 3 QL,STMONAGHAN Z STAT ANTI-STATIC VALVED HOLDING CHAMBER SPACER 1MONAGHAN Z STAT CHAMBER-LARGE MASK 1MONAGHAN Z STAT CHAMBER-MEDIUM MASK 1MONAGHAN Z STAT CHAMBER-SMALL MASK 1mondoxyne nl 100 mg capsule 3 QLmondoxyne nl 50 mg capsule 3 QLmondoxyne nl 75 mg capsule 3 QLmono-linyah 0.25 mg-35 mcg tablet MM 1MONODOX 100 MG CAPSULE 4 QL,STMONODOX 50 MG CAPSULE 4 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSMONODOX 75 MG CAPSULE 4 QL,STmonogen oral powder 2MONOJECT BLOOD COLLECTION 20 X 1 1/2" NEEDLE 1MONOJECT BLOOD COLLECTION 20 X 1" NEEDLE 1MONOJECT BLOOD COLLECTION 21 X 1" NEEDLE 1MONOJECT BLOOD COLLECTION 22 GAUGE X 1" NEEDLE 1MONOJECT CONTROL SYRINGE LUER LOCK 12 ML 3MONOJECT HYPODERMIC NEEDLES 22 GAUGE X 1 1/2" 1MONOJECT HYPODERMIC NEEDLES 22 GAUGE X 1" 1MONOJECT HYPODERMIC NEEDLES 23 GAUGE X 1" 1MONOJECT HYPODERMIC NEEDLES 23 GAUGE X 1/2" 1MONOJECT HYPODERMIC NEEDLES 25 GAUGE X 1 1/2" 1MONOJECT HYPODERMIC NEEDLES 25 GAUGE X 1" 1MONOJECT HYPODERMIC NEEDLES 25 X 5/8" 1MONOJECT HYPODERMIC NEEDLES 26 GAUGE X 1 1/2" 1MONOJECT HYPODERMIC NEEDLES 27 GAUGE X 1/2" 1MONOJECT HYPODERMIC NEEDLES 30 GAUGE X 3/4" 1MONOJECT INSULIN SAFETY SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2MONOJECT INSULIN SAFETY SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2MONOJECT INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2MONOJECT INSULIN SAFETY SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2MONOJECT INSULIN SAFETY SYRINGE 29 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2MONOJECT INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2MONOJECT INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2MONOJECT INSULIN SYRINGE 1 ML MM 1MONOJECT INSULIN SYRINGE 1 ML 25 GAUGE X 5/8" MM 2MONOJECT INSULIN SYRINGE 1 ML 27 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2MONOJECT INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2MONOJECT INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2MONOJECT INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2MONOJECT LUER-LOCK TIP 12 ML SYRINGE 2MONOJECT MAGELLAN SYRINGE 1 ML 25 GAUGE X 1" 1MONOJECT MAGELLAN SYRINGE 1 ML 25 GAUGE X 5/8" 1MONOJECT MAGELLAN SYRINGE 3 ML 20 GAUGE X 1" 1MONOJECT PHARMACY TRAY REGULAR TIP 1 ML SYRINGE 1monoject prefill (pf) 10 unit/ml intravenous syringe 4MONOJECT REGULAR LUER 12 ML SYRINGE 2MONOJECT SAFETY SYRINGES 1MONOJECT SAFETY SYRINGES 12 ML 21 X 1 1/2" 1MONOJECT SAFETY SYRINGES 3 ML 21 GAUGE X 1" 1MONOJECT SAFETY SYRINGES 3 ML 22 GAUGE X 1 1/2" 1MONOJECT SAFETY SYRINGES 6 ML 1MONOJECT SMARTIP CANNULA 12 ML SYRINGE 1MONOJECT SMARTIP CANNULA 3 ML SYRINGE 1MONOJECT SMARTIP CANNULA 6 ML SYRINGE 1MONOJECT SYRINGE 1/2 ML 28 GAUGE MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSMONOJECT SYRINGE 12 ML 2MONOJECT SYRINGE 3 ML 2MONOJECT SYRINGE 6 ML 2MONOJECT SYRINGE 6 ML 20 X 1 1/2" 2MONOJECT SYRINGE 6 ML 21 X 1 1/2" 2MONOJECT SYRINGE 6 ML 21 X 1" 2MONOJECT SYRINGE 6 ML 22 X 1 1/2" 2MONOJECT TB LUER LOK 1 ML SYRINGE 1MONOJECT TUBERCULIN SYRINGE 1 ML 1MONOJECT ULTRA COMFORT INSULIN 1/2 ML 28 GAUGE SYRINGE MM 2MONOLET LANCETS 21 GAUGE MM 1MONOLET THIN LANCETS 28 GAUGE MM 1mononessa (28) 0.25 mg-35 mcg tablet MM 1montelukast sod 10 mg tablet MM 1 QLmontelukast sod 4 mg granules MM 3 QLmontelukast sod 4 mg tab chew MM 1 QLmontelukast sod 5 mg tab chew MM 1 QLMONUROL 3 GRAM ORAL PACKET 3morgidox 100 mg capsule 4 QLmorgidox 50 mg capsule 4morphine sulf 10 mg suppos 3 QLmorphine sulf 10 mg/5 ml soln 2 QLmorphine sulf 100 mg/5 ml soln 2 QLmorphine sulf 20 mg suppos 3 QLmorphine sulf 20 mg/5 ml soln 2 QLmorphine sulf 30 mg suppos 3 QLmorphine sulf 5 mg suppos 3 QLmorphine sulf er 100 mg tablet 2 QLmorphine sulf er 15 mg tablet 2 QLmorphine sulf er 200 mg tablet 2 QLmorphine sulf er 30 mg tablet 2 QLmorphine sulf er 60 mg tablet 2 QLmorphine sulfate er 10 mg cap 4 QL,STmorphine sulfate er 100 mg cap 4 QL,STmorphine sulfate er 120 mg cap 4 QL,STmorphine sulfate er 20 mg cap 4 QL,STmorphine sulfate er 30 mg cap 4 QL,STmorphine sulfate er 30 mg cap 4 QL,STmorphine sulfate er 45 mg cap 4 QL,STmorphine sulfate er 50 mg cap 4 QL,STmorphine sulfate er 60 mg cap 4 QL,STmorphine sulfate er 60 mg cap 4 QL,STmorphine sulfate er 75 mg cap 4 QL,STmorphine sulfate er 80 mg cap 4 QL,STmorphine sulfate er 90 mg cap 4 QL,STmorphine sulfate ir 15 mg tab 2 QLmorphine sulfate ir 30 mg tab 2 QLMOTOFEN 1 MG-0.025 MG TABLET 3MOVANTIK 12.5 MG TABLET 3 QL,PAMOVANTIK 25 MG TABLET 3 QL,PAMOVIPREP 100 G-7.5 G-2.691 G-4.7 G ORAL POWDER PACKET 3 STMOXATAG 775 MG TABLET,EXTENDED RELEASE 3MOXEZA 0.5 % EYE DROPS 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmoxifloxacin hcl 400 mg tablet 3MS CONTIN 100 MG TABLET,EXTENDED RELEASE 4 QLMS CONTIN 15 MG TABLET,EXTENDED RELEASE 4 QLMS CONTIN 200 MG TABLET,EXTENDED RELEASE 4 QLMS CONTIN 30 MG TABLET,EXTENDED RELEASE 4 QLMS CONTIN 60 MG TABLET,EXTENDED RELEASE 4 QLMULTAQ 400 MG TABLET MM 4 QLMULTI-LANCET DEVICE MM 3MULTI-LANCET DEVICE 2 KIT MM 1multi-vit with fluoride and iron 0.25 mg-10 mg/ml oral drops 3 QLmulti-vitamin with fluoride 0.25 mg/ml oral drops 3multi-vitamin with fluoride 0.5 mg chewable tablet 3 QLmulti-vitamin with fluoride 0.5 mg/ml oral drops 3multi-vitamin with fluoride 1 mg chewable tablet 3 QLmultigen 70 mg-150 mg-10 mcg-2 mg-75mg tablet 2multigen folic 70 mg-150 mg-10 mcg-1 mg-2 mg tablet 2multigen plus 151 mg-60 mg-10 mcg-1 mg tablet 2multivitamin with fluoride 0.5 mg chewable tablet 3 QLmultivitamins with fluoride 0.25 mg chewable tablet 3 QLmultivitamins with fluoride 0.5 mg chewable tablet 3 QLmultivitamins with fluoride 1 mg chewable tablet 3 QLmupirocin 2% cream 3mupirocin 2% ointment 2mv-iron fum-asp-asc-b12-fa-suc 2mv-iron-asc-b12-thre-suc-stom 2MVC-FLUORIDE 0.25 MG CHEWABLE TABLET 3 QLMVC-FLUORIDE 0.5 MG CHEWABLE TABLET 3 QLMVC-FLUORIDE 1 MG CHEWABLE TABLET 3 QLMYALEPT 5 MG/ML (FINAL CONCENTRATION) SUBCUTANEOUS SOLUTION SP,LD * QL,PAMYAMBUTOL 400 MG TABLET MM 3MYCOBUTIN 150 MG CAPSULE 4mycophenolate 200 mg/ml susp 3mycophenolate 250 mg capsule 2 QLmycophenolate 500 mg tablet 2 QLmycophenolic acid dr 180 mg tb 3mycophenolic acid dr 360 mg tb 3MYDRIACYL 1 % EYE DROPS MM 3myferon 150 forte 150 mg-25 mcg-1 mg capsule 1MYFORTIC 180 MG TABLET,DELAYED RELEASE 4MYFORTIC 360 MG TABLET,DELAYED RELEASE 4MYGLUCOHEALTH CONTROL SOLUTION 3MYGLUCOHEALTH KIT MM 3 STMYGLUCOHEALTH LANCETS 30 GAUGE MM 1MYGLUCOHEALTH STRIPS MM 3 QL,STMYKIDZ IRON FL SUSPENSION 3MYLERAN 2 MG TABLET 2 QLMYNATAL 65 MG-1 MG CAPSULE 1mynatal 90 mg-1 mg-50 mg tablet 1mynatal advance 90 mg-1 mg-50 mg tablet 1mynatal plus 65 mg-1 mg tablet 1mynatal-z 65 mg-1 mg tablet 1mynate 90 plus 90 mg iron-1 mg tablet,extended release 1mynephrocaps 1 mg capsule 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSmynephron 1 mg capsule 3MYOCALM 25 MG-50 MG-20 MG TABLET 3myorisan 10 mg capsule 4 QLmyorisan 20 mg capsule 4 QLmyorisan 30 mg capsule 4 QLmyorisan 40 mg capsule 4 QLMYRBETRIQ 25 MG TABLET,EXTENDED RELEASE MM 3 QLMYRBETRIQ 50 MG TABLET,EXTENDED RELEASE MM 3 QLMYSOLINE 250 MG TABLET MM 4MYSOLINE 50 MG TABLET MM 4myzilra 50-30 (6)/75-40(5)/125-30(10) tablet MM 1nabumetone 500 mg tablet MM 1nabumetone 750 mg tablet MM 1nac 500 mg capsule 2nac 600 mg capsule 2nac 600 mg capsule 2nadolol 20 mg tablet MM 3nadolol 40 mg tablet MM 3nadolol 80 mg tablet MM 3nadolol-bendroflu 40-5 mg tab MM 3nadolol-bendroflu 80-5 mg tab MM 3naftifine hcl 1% cream 3naftifine hcl 2% cream 3NAFTIN 1 % TOPICAL GEL 4 STNAFTIN 1% CREAM 4 STNAFTIN 2 % TOPICAL CREAM 4 STNAFTIN 2 % TOPICAL GEL 4 STNALFON 400 MG CAPSULE MM 3naloxone 0.4 mg/ml syringe 4naloxone 0.4 mg/ml vial 4naloxone 2 mg/2 ml syringe 4naltrexone 50 mg tablet 2NAMENDA 10 MG TABLET MM 3 QL,STNAMENDA 2 MG/ML ORAL SOLUTION MM 3 QL,STNAMENDA 5 MG TABLET MM 3 QL,STNAMENDA TITRATION PAK 5 MG-10 MG TABLETS IN A DOSE PACK 3 QL,STNAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 2 QLNAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 2 QLNAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 2 QLNAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 2 QLNAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK 2 QLNAMZARIC 14 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE 2 QL,STNAMZARIC 21 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE 2 QL,STNAMZARIC 28 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE 2 QL,STNAMZARIC 7 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE 2 QL,STnaphazoline 0.1% eye drops 1NAPRELAN CR 375 MG TAB,EXTENDED RELEASE 24 HR MPHASE MM 4 QL,STNAPRELAN CR 500 MG TAB,EXTENDED RELEASE 24 HR MPHASE MM 4 QL,STNAPRELAN CR 750 MG TAB,EXTENDED RELEASE 24 HR MPHASE MM 4 QL,STNAPROSYN 125 MG/5 ML ORAL SUSPENSION MM 3NAPROSYN 250 MG TABLET MM 3NAPROSYN 375 MG TABLET MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSNAPROSYN 500 MG TABLET MM 3naproxen 125 mg/5 ml suspen MM 2naproxen 250 mg tablet MM 1naproxen 375 mg tablet MM 1naproxen 500 mg tablet MM 1naproxen dr 375 mg tablet MM 1naproxen dr 500 mg tablet MM 1naproxen sod cr 375 mg tablet MM 4 QL,STnaproxen sod cr 500 mg tablet MM 4 QL,STnaproxen sodium 275 mg tab MM 2naproxen sodium 550 mg tab MM 2naratriptan hcl 1 mg tablet 2 QLnaratriptan hcl 2.5 mg tablet 2 QLNARCAN 4 MG/ACTUATION NASAL SPRAY 3 QLNARDIL 15 MG TABLET MM 3NASCOBAL 500 MCG/SPRAY NASAL SPRAY MM 3NASONEX 50 MCG/ACTUATION SPRAY MM 3 QL,STNATACHEW (FE BIS-GLYCINATE) 28 MG IRON-1 MG TABLET 3NATACYN 5 % EYE DROPS,SUSPENSION 3natalvirt 90 dha combo pack 2natalvirt ca combo pack 2natalvirt flt tablet 2NATALVIT TABLET 1NATAZIA 3 MG/2 MG-2 MG/2 MG-3 MG/1 MG TABLET MM 2nateglinide 120 mg tablet MM 2nateglinide 60 mg tablet MM 2NATELLE ONE 28 MG-1 MG-250 MG CAPSULE 3NATESTO 5.5 MG/0.122 GRAM PER ACTUATION NASAL GEL PUMP 3 QL,STNATPARA 100 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP,LD * QL,PANATPARA 25 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP,LD * QL,PANATPARA 50 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP,LD * QL,PANATPARA 75 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP,LD * QL,PANATROBA 0.9 % TOPICAL SUSPENSION 3 QLNATROL OMEGA-3 25 MG-5 MG-113.5 MG-5 MG CHEWABLE TABLET 3NATURE-THROID 113.75 MG TABLET MM 3NATURE-THROID 130 MG TABLET MM 3NATURE-THROID 146.25 MG TABLET MM 3NATURE-THROID 16.25 MG TABLET MM 3NATURE-THROID 162.5 MG TABLET MM 3NATURE-THROID 195 MG TABLET MM 3NATURE-THROID 260 MG TABLET MM 3NATURE-THROID 32.5 MG TABLET MM 3NATURE-THROID 325 MG TABLET MM 3NATURE-THROID 48.75 MG TABLET MM 3NATURE-THROID 65 MG TABLET MM 3NATURE-THROID 81.25 MG TABLET MM 3NATURE-THROID 97.5 MG TABLET MM 3NEBUPENT 300 MG SOLUTION FOR INHALATION 3NEBUSAL 6 % SOLUTION FOR NEBULIZATION 3necon 0.5/35 (28) 0.5 mg-35 mcg tablet MM 1necon 1/35 (28) 1 mg-35 mcg tablet MM 1necon 1/50 (28) 1 mg-50 mcg tablet MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSnecon 10/11 (28) 0.5 mg-35 mcg(10)/1 mg-35 mcg(11) tablet MM 1necon 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM 1NEEVODHA (WITH ALGAL OIL) 27 MG IRON-1.13 MG-581.92 MG CAPSULE 3nefazodone hcl 100 mg tablet MM 3nefazodone hcl 150 mg tablet MM 3nefazodone hcl 200 mg tablet MM 3nefazodone hcl 250 mg tablet MM 3nefazodone hcl 50 mg tablet MM 3neo-bacit-poly-hc eye ointment 3neo-polycin 3.5 mg-400 unit-10,000 unit/g eye ointment 2neo-polycin hc 3.5 mg-400-10,000 unit/g-1 % eye ointment 3NEO-SYNALAR 0.5 % (0.35 % BASE)-0.025 % TOPICAL CREAM 4 STneomy-polymyxin b 40 mg/ml amp 4neomyc-bacit-polymix eye oint 2neomyc-polym-dexamet eye ointm 2neomyc-polym-dexameth eye drop 2neomyc-polym-gramicid eye drop 2neomycin 500 mg tablet 2neomycin-poly-hc eye drops 3neomycin-polymyxin-hc ear soln 2neomycin-polymyxin-hc ear susp 2NEORAL 100 MG CAPSULE 3 QLNEORAL 100 MG/ML ORAL SOLUTION 3NEORAL 25 MG CAPSULE 3neosporin (neo-polym-gramicid) 1.75mg-10,000 unit-0.025mg/ml eye drops 3NEOSPORIN GU IRRIGANT 40 MG-200,000 UNIT/ML 3NEPHRAMINE 5.4 % INTRAVENOUS SOLUTION 3NEPHROCAPS QT 1 MG-1,750 UNIT DISINTEGRATING TABLET 3NEPHRON FA 66.6 MG-75 MG-1 MG TABLET 2NEPTAZANE 25 MG TABLET MM 2NEPTAZANE 50 MG TABLET MM 2NESINA 12.5 MG TABLET MM 3 QLNESINA 25 MG TABLET MM 3 QLNESINA 6.25 MG TABLET MM 3 QLNESTABS 32 MG-1,000 MCG TABLET 2NESTABS ABC 32 MG IRON-1 MG-120 MG-180 MG ORAL PACK 3NESTABS DHA 32 MG-1,000 MCG-230 MG ORAL PACK 2neuac 1.2 % (1 % base)-5 % topical gel 3NEULASTA 6 MG/0.6 ML SUBCUTANEOUS SYRINGE SP * QL,PANEULASTA 6 MG/0.6 ML WITH WEARABLE SUBCUTANEOUS INJECTOR SP * QL,PANEUMEGA 5 MG VIAL SP * QLNEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE SP * QL,PANEUPOGEN 300 MCG/ML INJECTION SOLUTION SP * QL,PANEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE SP * QL,PANEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION SP * QL,PANEUPRO 1 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 4 QL,PANEUPRO 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 4 QL,PANEUPRO 3 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 4 QL,PANEUPRO 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 4 QL,PANEUPRO 6 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 4 QL,PANEUPRO 8 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM 4 QL,PANEUREPA 1 GRAM CAPSULE 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSNEURONTIN 100 MG CAPSULE MM 3 QL,STNEURONTIN 250 MG/5 ML ORAL SOLUTION MM 3 QL,STNEURONTIN 300 MG CAPSULE MM 3 QL,STNEURONTIN 400 MG CAPSULE MM 3 QL,STNEURONTIN 600 MG TABLET MM 3 QL,STNEURONTIN 800 MG TABLET MM 3 QL,STNEUTEK 2TEK TEST STRIPS MM 3 QL,STNEVANAC 0.1 % EYE DROPS,SUSPENSION 3 STnevirapine 200 mg tablet 1 QLnevirapine 50 mg/5 ml susp 2 QLnevirapine er 100 mg tablet 3 QLnevirapine er 400 mg tablet 3 QLnewgen 32 mg-1,000 mcg tablet 3NEXA PLUS 29 MG IRON-1.25 MG-55 MG CAPSULE 3NEXAVAR 200 MG TABLET SP,LD * QL,PANEXIUM 20 MG CAPSULE,DELAYED RELEASE MM 3 QL,STNEXIUM 40 MG CAPSULE,DELAYED RELEASE MM 3 QL,STNEXIUM PACKET 10 MG GRANULES DELAYED RELEASE FOR SUSP MM 3 QL,STNEXIUM PACKET 2.5 MG GRANULES DELAYED RELEASE FOR SUSP MM 3 QL,STNEXIUM PACKET 20 MG GRANULES DELAYED RELEASE FOR SUSP MM 3 QL,STNEXIUM PACKET 40 MG GRANULES DELAYED RELEASE FOR SUSP MM 3 QL,STNEXIUM PACKET 5 MG GRANULES DELAYED RELEASE FOR SUSP MM 3 QL,STNEXPLANON 68 MG SUBDERMAL IMPLANT SP,LD *niacin er 1,000 mg tablet MM 3 PAniacin er 500 mg tablet MM 3 PAniacin er 750 mg tablet MM 3 PAniacin-azelaic ac-turmer-fa-b6-zn-cu 700 mg-500 mcg-8 mg-12 mg tablet 2niacor 500 mg tablet MM 2NIASPAN 1,000 MG TABLET,EXTENDED RELEASE MM 3 PANIASPAN 500 MG TABLET,EXTENDED RELEASE MM 3 PANIASPAN 750 MG TABLET,EXTENDED RELEASE MM 3 PANICADAN 800 MG-10 MG-100 MG-500 MCG TABLET 3nicardipine 20 mg capsule MM 3nicardipine 30 mg capsule MM 3NICAZEL 600 MG-5 MG-10 MG-5 MG-1.5 MG TABLET 3NICAZEL FORTE 700 MG-500 MCG-8 MG-12 MG TABLET 3nifedical xl 30 mg tablet,extended release MM 2 QLnifedical xl 60 mg tablet,extended release MM 2 QLnifedipine 10 mg capsule MM 3nifedipine 20 mg capsule MM 3nifedipine er 30 mg tablet MM 2 QLnifedipine er 30 mg tablet MM 2 QLnifedipine er 60 mg tablet MM 2 QLnifedipine er 60 mg tablet MM 2 QLnifedipine er 90 mg tablet MM 2 QLnifedipine er 90 mg tablet MM 2 QLnikki (28) 3 mg-20 mcg tablet MM 1NILANDRON 150 MG TABLET SP * QLnilutamide 150 mg tablet SP * QLnimodipine 30 mg capsule 4NINLARO 2.3 MG CAPSULE SP,LD * QL,PANINLARO 3 MG CAPSULE SP,LD * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSNINLARO 4 MG CAPSULE SP,LD * QL,PAnisoldipine er 17 mg tablet MM 3 QLnisoldipine er 20 mg tablet MM 3 QLnisoldipine er 25.5 mg tablet MM 3 QLnisoldipine er 30 mg tablet MM 3 QLnisoldipine er 34 mg tablet MM 3 QLnisoldipine er 40 mg tablet MM 3 QLnisoldipine er 8.5 mg tablet MM 3 QLNITRO-BID 2 % TRANSDERMAL OINTMENT MM 2NITRO-DUR 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH MM 3 QLNITRO-DUR 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH MM 3 QLNITRO-DUR 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH MM 3 QLNITRO-DUR 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH MM 3 QLNITRO-DUR 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH MM 3 QLNITRO-DUR 0.8 MG/HR TRANSDERMAL 24 HOUR PATCH MM 3 QLnitrofurantoin 25 mg/5 ml susp 3 QLnitrofurantoin mcr 100 mg cap 2nitrofurantoin mcr 25 mg cap 2nitrofurantoin mcr 50 mg cap 2nitrofurantoin mono-mcr 100 mg 2nitroglycerin 0.1 mg/hr patch MM 2 QLnitroglycerin 0.2 mg/hr patch MM 2 QLnitroglycerin 0.3 mg tablet sl MM 1nitroglycerin 0.4 mg tablet sl MM 1nitroglycerin 0.4 mg/hr patch MM 2 QLnitroglycerin 0.6 mg tablet sl MM 1nitroglycerin 0.6 mg/hr patch MM 2 QLnitroglycerin 400 mcg spray MM 3nitroglycerin lingual 0.4 mg MM 3NITROLINGUAL 400 MCG/SPRAY MM 3NITROMIST 400 MCG/SPRAY TRANSLINGUAL AEROSOL MM 3NITROSTAT 0.3 MG SUBLINGUAL TABLET MM 1NITROSTAT 0.4 MG SUBLINGUAL TABLET MM 1NITROSTAT 0.6 MG SUBLINGUAL TABLET MM 1niva-plus 27 mg-1 mg tablet 1nizatidine 15 mg/ml solution MM 3nizatidine 150 mg capsule MM 3nizatidine 300 mg capsule MM 3NIZORAL 2 % SHAMPOO 3NO-STICK GLUCOSE TEST STRIPS MM 3NOR-QD 0.35 MG TABLET MM 3nora-be 0.35 mg tablet MM 1NORCO 10 MG-325 MG TABLET 3 QLNORCO 5 MG-325 MG TABLET 3 QLNORCO 7.5 MG-325 MG TABLET 3 QLNORDITROPIN FLEXPRO 10 MG/1.5 ML (6.7 MG/ML) SUBCUTANEOUS PEN INJECTORSP

* QL,PA

NORDITROPIN FLEXPRO 15 MG/1.5 ML (10 MG/ML) SUBCUTANEOUS PEN INJECTORSP

* QL,PA

NORDITROPIN FLEXPRO 30 MG/3 ML (10 MG/ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PANORDITROPIN FLEXPRO 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PANORDITROPIN NORDIFLEX 30 MG/3 SP * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSnoreth-estrad-fe 1-0.02(21)-75 MM 1noreth-estrad-fe 1-0.02(24)-75 MM 1norethin-estra-fe 0.8-0.025 mg MM 1norethin-eth estrad 1 mg-5 mcg MM 3norethind-eth estrad 0.5-2.5 MM 3norethind-eth estrad 1-0.02 mg MM 1norethindrone 0.35 mg tablet MM 1norethindrone 5 mg tablet MM 2norg-ee 0.18-0.215-0.25/0.025 MM 1norg-ee 0.18-0.215-0.25/0.035 MM 1norg-ethin estra 0.25-0.035 mg MM 1NORINYL 1+35 (28) 1 MG-35 MCG TABLET MM 3NORINYL 1+50-28 TABLET MM 2NORITATE 1 % TOPICAL CREAM 4 STnorlyroc 0.35 mg tablet MM 1NORM-JECT SYRINGE 1NOROXIN 400 MG TABLET 3NORPACE 100 MG CAPSULE MM 3NORPACE 150 MG CAPSULE MM 3NORPACE CR 100 MG CAPSULE,EXTENDED RELEASE MM 3NORPACE CR 150 MG CAPSULE,EXTENDED RELEASE MM 3NORPRAMIN 10 MG TABLET MM 3NORPRAMIN 100 MG TABLET MM 3NORPRAMIN 150 MG TABLET MM 3NORPRAMIN 25 MG TABLET MM 3NORPRAMIN 50 MG TABLET MM 3NORPRAMIN 75 MG TABLET MM 3NORTHERA 100 MG CAPSULE SP,LD * QL,PANORTHERA 200 MG CAPSULE SP,LD * QL,PANORTHERA 300 MG CAPSULE SP,LD * QL,PAnortrel 0.5/35 (28) 0.5 mg-35 mcg tablet MM 1nortrel 1/35 (21) 1 mg-35 mcg tablet MM 1nortrel 1/35 (28) 1 mg-35 mcg tablet MM 1nortrel 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM 1nortriptyline 10 mg/5 ml sol MM 2nortriptyline hcl 10 mg cap MM 1nortriptyline hcl 25 mg cap MM 1nortriptyline hcl 50 mg cap MM 1nortriptyline hcl 75 mg cap MM 1NORVASC 10 MG TABLET MM 3 QLNORVASC 2.5 MG TABLET MM 3 QLNORVASC 5 MG TABLET MM 3 QLNORVIR 100 MG CAPSULE 3 QLNORVIR 100 MG TABLET 3 QLNORVIR 80 MG/ML ORAL SOLUTION 3 QLNOURISH ORAL LIQUID 3NOVA MAX BLOOD GLUCOSE METER MM 3 STNOVA MAX GLUCOSE CONTROL SOLUTION 3NOVA MAX GLUCOSE TEST STRIPS MM 3 QL,STNOVA SAFETY LANCETS 23 GAUGE MM 1NOVA SAFETY LANCETS 28 GAUGE MM 1NOVA SUREFLEX LANCETS MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSNOVAMAX PLUS GLU-KET SOLUTION 3NOVASOURCE RENAL LIQUID 3NOVOFINE 30 30 GAUGE X 1/3" NEEDLE 1NOVOFINE 32 32 GAUGE X 1/4" NEEDLE 1NOVOFINE AUTOCOVER 30 GAUGE X 1/3" NEEDLE MM 1NOVOFINE PLUS 32 GAUGE X 1/6" NEEDLE 1NOVOLIN 70/30 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM 2NOVOLIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM 2NOVOLIN R 100 UNIT/ML INJECTION SOLUTION MM 2NOVOLOG 100 UNIT/ML SUBCUTANEOUS SOLUTION MM 2NOVOLOG FLEXPEN 100 UNIT/ML SUBCUTANEOUS MM 2NOVOLOG MIX 70-30 100 UNIT/ML SUBCUTANEOUS SOLUTION MM 2NOVOLOG MIX 70-30 FLEXPEN 100 UNIT/ML SUBCUTANEOUS PEN MM 2NOVOLOG PENFILL 100 UNIT/ML SUBCUTANEOUS CARTRIDGE MM 2NOVOPEN ECHO SUBCUTANEOUS 3NOVOTWIST 30 GAUGE X 1/3" NEEDLE 1NOVOTWIST 32 GAUGE X 1/5" NEEDLE 1NOXAFIL 100 MG TABLET,DELAYED RELEASE 4 QL,PANOXAFIL 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION 4 QL,PAnp thyroid 30 mg tablet MM 1np thyroid 60 mg tablet MM 1np thyroid 90 mg tablet MM 1NUCYNTA 100 MG TABLET 4 QL,STNUCYNTA 50 MG TABLET 4 QL,STNUCYNTA 75 MG TABLET 4 QL,STNUCYNTA ER 100 MG TABLET,EXTENDED RELEASE 4 QL,STNUCYNTA ER 150 MG TABLET,EXTENDED RELEASE 4 QL,STNUCYNTA ER 200 MG TABLET,EXTENDED RELEASE 4 QL,STNUCYNTA ER 250 MG TABLET,EXTENDED RELEASE 4 QL,STNUCYNTA ER 50 MG TABLET,EXTENDED RELEASE 4 QL,STNUEDEXTA 20 MG-10 MG CAPSULE 2 QLnulev 0.125 mg disintegrating tablet MM 3NULYTELY WITH FLAVOR PACKS 420 GRAM ORAL SOLUTION 3NUPLAZID 17 MG TABLET SP * QL,PAnutra pro high protein oral powder 2nutrafit oral liquid 2nutrafit plus oral liquid 2NUTRAMENT ORAL LIQUID 3NUTREN 1.0 ORAL LIQUID 3NUTREN 1.5 ORAL LIQUID 3NUTREN 2.0 ORAL LIQUID 3NUTREN REPLETE ORAL LIQUID 3NUTRESTORE 5 GRAM ORAL POWDER PACKET 3nutri-drink oral liquid 2nutrition plus oral liquid 2nutritional drink oral liquid 2nutritional drink plus oral liquid 2nutritional shake 0.04 gram-0.93 kcal/ml oral liquid 2nutritional shake 0.04 gram-1.05 kcal/ml oral liquid 2nutritional shake oral liquid 2nutritional shake plus 0.05 gram-1.5 kcal/ml oral liquid 2nutritional shake plus oral liquid 2nutritional supplement (lactose-free) oral liquid 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSnutritional supplement liq 2nutritional supplement plus 2NUTROPIN AQ 10 MG/2 ML (5 MG/ML) SUBCUTANEOUS CARTRIDGE SP * QL,PANUTROPIN AQ 20 MG/2ML PEN CART SP * QL,PANUTROPIN AQ NUSPIN 10 MG/2 ML (5 MG/ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PANUTROPIN AQ NUSPIN 20 MG/2 ML (10 MG/ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PANUTROPIN AQ NUSPIN 5 MG/2 ML (2.5 MG/ML) SUBCUTANEOUS PEN INJECTOR SP * QL,PANUVARING 0.12 MG -0.015 MG/24 HR VAGINAL MM 2 QLNUVESSA 1.3 % VAGINAL GEL 3NUVIGIL 150 MG TABLET MM 4 QL,PANUVIGIL 200 MG TABLET MM 4 QL,PANUVIGIL 250 MG TABLET MM 4 QL,PANUVIGIL 50 MG TABLET MM 4 QL,PAnyamyc 100,000 unit/gram topical powder 2NYMALIZE 60 MG/20 ML ORAL SOLUTION 4 QLnystatin 100,000 unit/gm cream 2nystatin 100,000 unit/gm powd 2nystatin 100,000 unit/ml susp 2nystatin 100,000 units/gm oint 2nystatin 150,000,000 units pwd 3 QLnystatin 50,000,000 units pwd 3 QLnystatin 500,000 unit oral tab 2nystatin 500,000,000 units pwd 3 QLnystatin-triamcinolone cream 3nystatin-triamcinolone ointm 3nystop 100,000 unit/gram topical powder 2O-CAL FA 66 MG-1 MG TABLET 1O-CAL PRENATAL 15 MG IRON-1,000 MCG TABLET 1OB COMPLETE 50 MG IRON-1.25 MG TABLET 3OB COMPLETE GOLD 27.5 MG IRON-1 MG CAPSULE 3OB COMPLETE ONE 40 MG-10 MG-1 MG-300 MG CAPSULE 3OB COMPLETE PETITE 35 MG IRON-5 MG IRON-1 MG CAPSULE 3OB COMPLETE PREMIER 30 MG-20 MG-1 MG TABLET 3OB COMPLETE WITH DHA 30 MG IRON-10 MG IRON-1 MG CAPSULE 3OBREDON 2.5 MG-200 MG/5 ML ORAL SOLUTION 3obstetrix dha 29 mg iron-1 mg-50 mg tablet-capsule,delayed release 2OBSTETRIX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE 1obstetrix one 38 mg iron-1 mg-25 mg-225 mg capsule 3OBTREX DHA 29 MG IRON-1 MG-50 MG TABLET-CAPSULE,DELAYED RELEASE 2OBTREX PRENATAL CAPLET 1OCALIVA 10 MG TABLET SP,LD * QL,PAOCALIVA 5 MG TABLET SP,LD * QL,PAOCEAN BLUE PRENATAL DHA 312 MG-250 MG-18 MG CAPSULE 3ocella 3 mg-0.03 mg tablet MM 1octreotide 1,000 mcg/ml vial SP * PAoctreotide acet 100 mcg/ml syr SP * PAoctreotide acet 100 mcg/ml vl SP * PAoctreotide acet 200 mcg/ml vl SP * PAoctreotide acet 50 mcg/ml syr SP * PAoctreotide acet 50 mcg/ml vial SP * PAoctreotide acet 500 mcg/ml syr SP * PAoctreotide acet 500 mcg/ml vl SP * PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSOCUFEN 0.03 % EYE DROPS 3 STOCUFLOX 0.3 % EYE DROPS 3ODEFSEY 200 MG-25 MG-25 MG TABLET SP * QLODOMZO 200 MG CAPSULE SP * QL,PAOFEV 100 MG CAPSULE SP,LD * QL,PAOFEV 150 MG CAPSULE SP,LD * QL,PAofloxacin 0.3% ear drops 3ofloxacin 0.3% eye drops 3ofloxacin 400 mg tablet 2ogestrel (28) 0.5 mg-50 mcg tablet MM 1olanzapine 10 mg tablet MM 1 QLolanzapine 15 mg tablet MM 1 QLolanzapine 2.5 mg tablet MM 1 QLolanzapine 20 mg tablet MM 1 QLolanzapine 5 mg tablet MM 1 QLolanzapine 7.5 mg tablet MM 1 QLolanzapine odt 10 mg tablet MM 3 QLolanzapine odt 15 mg tablet MM 3 QLolanzapine odt 20 mg tablet MM 3 QLolanzapine odt 5 mg tablet MM 3 QLolanzapine-fluoxetine 12-25 mg MM 3 QLolanzapine-fluoxetine 12-50 mg MM 3 QLolanzapine-fluoxetine 3-25 mg MM 3 QLolanzapine-fluoxetine 6-25 mg MM 3 QLolanzapine-fluoxetine 6-50 mg MM 3 QLOLEPTRO ER 150 MG TABLET,EXTENDED RELEASE MM 3 QL,PAOLEPTRO ER 300 MG TABLET,EXTENDED RELEASE MM 3 QL,PAolopatadine 665 mcg nasal spry 3 QL,STolopatadine hcl 0.1% eye drops 3 STOLUX 0.05 % TOPICAL FOAM 4 STOLUX-E 0.05 % TOPICAL FOAM 3 STOLYSIO 150 MG CAPSULE SP * QL,PAOMECLAMOX-PAK 20 MG-500 MG-500 MG (40) ORAL PACK 4omega-3 + vitamin d3 31.25 mg-117 mg-100 unit chewable tablet 2omega-3 ethyl esters 1 gm cap MM 3 QLOMEGA-3 FISH OIL 300 MG-1,000 MG CAPSULE 3omega-3 gummies 2omeprazole dr 10 mg capsule MM 1 QLomeprazole dr 20 mg capsule MM 1 QLomeprazole dr 40 mg capsule MM 1 QLomeprazole-bicarb 20-1,100 cap MM 3 QL,STomeprazole-bicarb 20-1,680 pkt 4 QL,STomeprazole-bicarb 40-1,100 cap MM 3 QL,STomeprazole-bicarb 40-1,680 pkt 4 QL,STOMNARIS 50 MCG NASAL SPRAY MM 3 QL,STOMNIPRED 1 % EYE DROPS,SUSPENSION 3 STOMNITROPE 10 MG/1.5 ML (6.7 MG/ML) SUBCUTANEOUS CARTRIDGE SP * QL,PAOMNITROPE 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS CARTRIDGE SP * QL,PAOMNITROPE 5.8 MG SUBCUTANEOUS SOLUTION SP * QL,PAON CALL EXPRESS CONTROL SOLUTION 3ON CALL EXPRESS METER MM 3 STON CALL EXPRESS METER KIT MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSON CALL EXPRESS TEST STRIP MM 3 QL,STON CALL LANCET 30 GAUGE MM 3ON CALL LANCING DEVICE MM 3ON CALL PLUS CONTROL SOLUTION 3ON CALL PLUS LANCET 30 GAUGE MM 3ON CALL PLUS LANCING DEVICE MM 3ON CALL PLUS METER MM 3 STON CALL PLUS METER KIT MM 3 STON CALL PLUS TEST STRIP MM 3 QL,STON CALL VIVID CONTROL SOLUTION 3ON CALL VIVID METER MM 3 STON CALL VIVID METER KIT MM 3 STON CALL VIVID PAL BLOOD GLUCOSE METER MM 3 STON CALL VIVID PAL BLOOD GLUCOSE METER KIT MM 3 STON CALL VIVID TEST STRIP MM 3 QL,STON-THE-GO LANCETS 30 GAUGE MM 1ondansetron 4 mg/5 ml solution 3 QLondansetron hcl 24 mg tablet 2 QLondansetron hcl 4 mg tablet 2 QLondansetron hcl 8 mg tablet 2 QLondansetron odt 4 mg tablet 2 QLondansetron odt 8 mg tablet 2 QLone daily 300 mg-18 mg-400 mcg-50 mg tablet 2one daily women's metabolism 300 mg-18 mg-400 mcg-50 mg tablet 2ONETOUCH DELICA LANCETS 30 GAUGE MM 3ONETOUCH DELICA LANCETS 33 GAUGE MM 3ONETOUCH DELICA LANCING DEVICE KIT MM 3ONETOUCH FINEPOINT 25G LANCETS MM 3ONETOUCH SURESOFT LANCING DEVICES MM 3ONETOUCH ULTRA CONTROL SOLUTION 3ONETOUCH ULTRA TEST STRIPS MM 3 QL,STONETOUCH ULTRA2 KIT MM 3 STONETOUCH ULTRALINK SYSTEM MM 3 STONETOUCH ULTRAMINI KIT MM 3 STONETOUCH ULTRASOFT LANCETS MM 1ONETOUCH VERIO FLEX METER MM 3 STONETOUCH VERIO FLEX START KIT MM 3 STONETOUCH VERIO HIGH CONTROL SOLUTION 3ONETOUCH VERIO IQ METER MM 3 STONETOUCH VERIO IQ METER KIT MM 3 STONETOUCH VERIO MID CONTROL SOLUTION 3ONETOUCH VERIO STRIPS MM 3 QL,STONETOUCH VERIO SYNC KIT MM 3 STONETOUCH VERIO SYSTEM MM 3 STONEXTON 1.2 % (1 % BASE)-3.75 % TOPICAL GEL WITH PUMP 2ONFI 10 MG TABLET MM 4 QL,PAONFI 2.5 MG/ML ORAL SUSPENSION MM 4 QL,PAONFI 20 MG TABLET MM 4 QL,PAONGLYZA 2.5 MG TABLET MM 3 QLONGLYZA 5 MG TABLET MM 3 QLONZETRA XSAIL 11 MG POWDER FOR NASAL INHALATION 3 QL,STOPANA 10 MG TABLET 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSOPANA 5 MG TABLET 3 QLOPANA ER 10 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLOPANA ER 15 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLOPANA ER 20 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLOPANA ER 30 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLOPANA ER 40 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLOPANA ER 5 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLOPANA ER 7.5 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE 2 QLopium tincture 10 mg/ml 4 QLOPSUMIT 10 MG TABLET SP,LD * QL,PAOPTICHAMBER ADULT MASK-LARGE 1OPTICHAMBER DIAMOND VHC SPACER 3OPTICHAMBER DIAMOND VHC WITH LARGE MASK 2OPTICHAMBER DIAMOND VHC WITH MEDIUM MASK 2OPTICHAMBER DIAMOND VHC WITH SMALL MASK 2OPTIUM EZ STRIPS MM 3 QL,STOPTIUM TEST STRIPS MM 3 QL,STOPTIVAR 0.05% DROPS 3 STOPTUMRX KIT MM 3 STOPTUMRX METER MM 3 STOPTUMRX SOLUTION 3OPTUMRX STRIPS MM 3 QL,STORACEA 40 MG CAPSULE,IMMEDIATE - DELAY RELEASE 4 QL,SToralone 0.1 % dental paste 2orange chicken-carrots-brown rice oral liquid 2ORAP 1 MG TABLET MM 3ORAP 2 MG TABLET MM 3ORAPRED ODT 10 MG DISINTEGRATING TABLET 3ORAPRED ODT 15 MG DISINTEGRATING TABLET 3ORAPRED ODT 30 MG DISINTEGRATING TABLET 3ORAVIG 50 MG BUCCAL TABLET 3 QLORENCIA 125 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PAORENCIA CLICKJECT 125 MG/ML SUBCUTANEOUS AUTO-INJECTOR SP * QL,PAORENITRAM 0.125 MG TABLET,EXTENDED RELEASE SP,LD * QL,PAORENITRAM 0.25 MG TABLET,EXTENDED RELEASE SP,LD * QL,PAORENITRAM 1 MG TABLET,EXTENDED RELEASE SP,LD * QL,PAORENITRAM 2.5 MG TABLET,EXTENDED RELEASE SP,LD * QL,PAORFADIN 10 MG CAPSULE SP,LD *ORFADIN 2 MG CAPSULE SP,LD *ORFADIN 20 MG CAPSULE SP *ORFADIN 4 MG/ML ORAL SUSPENSION SP,LD *ORFADIN 5 MG CAPSULE SP,LD *ORGANIC PEDIASMART 7 GRAM-237 KCAL/52 GRAM ORAL POWDER 3ORKAMBI 200 MG-125 MG TABLET SP,LD * QL,PAorphenadrine comp forte tab 3orphenadrine er 100 mg tablet 2orsythia 0.1 mg-20 mcg tablet MM 1ortho d 3,775 unit-1 mg capsule 3ORTHO EVRA PATCH MM 3 QLORTHO MICRONOR 0.35 MG TABLET MM 3ORTHO TRI-CYCLEN (28) 0.18 MG(7)/0.215 MG(7)/0.25 MG(7)-35 MCG TABLET MM 3ORTHO TRI-CYCLEN LO (28) 0.18 MG/0.215 MG/0.25 MG-25 MCG TABLET MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSORTHO-CEPT 28 DAY TABLET MM 3ORTHO-CYCLEN (28) 0.25 MG-35 MCG TABLET MM 3ORTHO-NOVUM 1/35 (28) 1 MG-35 MCG TABLET MM 3ORTHO-NOVUM 7/7/7 (28) 0.5 MG/0.75 MG/1 MG-35 MCG TABLET MM 3oscimin 0.125 mg disintegrating tablet MM 2oscimin 0.125 mg tablet MM 2oscimin sl 0.125 mg sublingual tablet MM 2oscimin sr 0.375 mg tablet,extended release MM 2OSENI 12.5 MG-15 MG TABLET MM 3 QLOSENI 12.5 MG-30 MG TABLET MM 3 QLOSENI 12.5 MG-45 MG TABLET MM 3 QLOSENI 25 MG-15 MG TABLET MM 3 QLOSENI 25 MG-30 MG TABLET MM 3 QLOSENI 25 MG-45 MG TABLET MM 3 QLosmolite 1 cal oral liquid 2osmolite 1.2 cal oral liquid 2osmolite 1.5 cal oral liquid 2OSMOPREP 1.5 GRAM (1.102-0.398) TABLET 3 STOSTERA 500 UNIT-500 MCG-90 MG-370 MG TABLET 3OTEZLA 30 MG TABLET SP,LD * QL,PAOTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG(19) TABLETS IN A DOSE PACK SP,LD * QL,PAOTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG(47) TABLETS IN A DOSE PACK SP,LD * QL,PAOTIPRIO 6 % (6 MG/0.1 ML) INTRATYMPANIC SUSPENSION 4OTOVEL 0.3 %-0.025 % (0.25 ML) EAR SOLUTION 3 STOTREXUP (PF) 10 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 12.5 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 15 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 17.5 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 20 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 22.5 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 25 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PAOTREXUP (PF) 7.5 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR SP * QL,PAOVCON-35 (28) 0.4 MG-35 MCG TABLET MM 3OVIDE 0.5 % LOTION 3oxaprozin 600 mg caplet MM 3OXAYDO 5 MG TABLET,ORAL ONLY (NOT FEEDING TUBES) 3 QL,PAOXAYDO 7.5 MG TABLET,ORAL ONLY (NOT FOR FEEDING TUBES) 3 QL,PAoxazepam 10 mg capsule 2oxazepam 15 mg capsule 2oxazepam 30 mg capsule 2oxcarbazepine 150 mg tablet MM 2oxcarbazepine 300 mg tablet MM 2oxcarbazepine 300 mg/5 ml susp MM 3oxcarbazepine 600 mg tablet MM 2OXECTA 5 MG TABLET 3 QL,PAOXECTA 7.5 MG TABLET 3 QL,PAoxiconazole nitrate 1% cream 4 STOXISTAT 1 % LOTION 4 STOXISTAT 1 % TOPICAL CREAM 4 STOXSORALEN 1 % LOTION 4OXSORALEN ULTRA 10 MG CAPSULE SP *OXTELLAR XR 150 MG TABLET,EXTENDED RELEASE MM 4 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSOXTELLAR XR 300 MG TABLET,EXTENDED RELEASE MM 4 QL,STOXTELLAR XR 600 MG TABLET,EXTENDED RELEASE MM 4 QL,SToxybutynin 5 mg tablet MM 1oxybutynin 5 mg/5 ml syrup MM 1oxybutynin cl er 10 mg tablet MM 2 QLoxybutynin cl er 15 mg tablet MM 2 QLoxybutynin cl er 5 mg tablet MM 2 QLoxycodon 10 mg/0.5 ml oral syr 3 QLoxycodon-acetaminophen 2.5-325 2 QLoxycodon-acetaminophen 7.5-325 2 QLoxycodone hcl 10 mg tablet 2 QLoxycodone hcl 100 mg/5 ml soln 3 QLoxycodone hcl 15 mg tablet 2 QLoxycodone hcl 20 mg tablet 2 QLoxycodone hcl 30 mg tablet 2 QLoxycodone hcl 5 mg capsule 3 QLoxycodone hcl 5 mg tablet 2 QLoxycodone hcl 5 mg/5 ml soln 2 QLoxycodone hcl er 10 mg tablet 3 QL,PAoxycodone hcl er 15 mg tablet 4 QL,PAoxycodone hcl er 20 mg tablet 3 QL,PAoxycodone hcl er 30 mg tablet 4 QL,PAoxycodone hcl er 40 mg tablet 3 QL,PAoxycodone hcl er 60 mg tablet 4 QL,PAoxycodone hcl er 80 mg tablet 4 QL,PAoxycodone-acetaminophen 10-325 2 QLoxycodone-acetaminophen 5-325 2 QLoxycodone-acetaminophn 5-325/5 2 QLoxycodone-aspirin 4.8355-325 2 QLoxycodone-ibuprofen 5-400 tab 2 QLOXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAOXYCONTIN 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAOXYCONTIN 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAOXYCONTIN 30 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAOXYCONTIN 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAOXYCONTIN 60 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAOXYCONTIN 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 4 QL,PAoxymorphone hcl 10 mg tablet 3 QLoxymorphone hcl 5 mg tablet 3 QLoxymorphone hcl er 10 mg tab 3 QL,SToxymorphone hcl er 15 mg tab 3 QL,SToxymorphone hcl er 20 mg tab 3 QL,SToxymorphone hcl er 30 mg tab 3 QL,SToxymorphone hcl er 40 mg tab 3 QL,SToxymorphone hcl er 5 mg tablet 3 QL,SToxymorphone hcl er 7.5 mg tab 3 QL,STOXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH MM 3 QL,STPACERONE 100 MG TABLET MM 2pacerone 200 mg tablet MM 1PACERONE 400 MG TABLET MM 2paire ob plus dha 22 mg-6 mg-1 mg-200 mg oral pack 2paliperidone er 1.5 mg tablet MM 4 QL,PApaliperidone er 3 mg tablet MM 4 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSpaliperidone er 6 mg tablet MM 4 QL,PApaliperidone er 9 mg tablet MM 4 QL,PAPAMELOR 10 MG CAPSULE MM 4PAMELOR 25 MG CAPSULE MM 4PAMELOR 50 MG CAPSULE MM 4PAMELOR 75 MG CAPSULE MM 4PAMINE 2.5 MG TABLET 2PANCREAZE 10,500-25,000-43,750 UNIT CAPSULE,DELAYED RELEASE MM 4 STPANCREAZE 16,800-40,000-70,000 UNIT CAPSULE,DELAYED RELEASE MM 4 STPANCREAZE 21,000-37,000-61,000 UNIT CAPSULE,DELAYED RELEASE MM 4 STPANCREAZE 4,200-10,000-17,500 UNIT CAPSULE,DELAYED RELEASE MM 4 STpancrelipase dr 5,000 unit cap MM 2PANDEL 0.1 % TOPICAL CREAM 3PANRETIN 0.1 % TOPICAL GEL SP *pantoprazole sod dr 20 mg tab MM 1 QLpantoprazole sod dr 40 mg tab MM 1 QLPARADIGM REAL-TIME TRANSMITTER AND SENSOR MM 3 PAPARADIGM RESERVOIR 1.8 ML MM 3PARADIGM RESERVOIR 3 ML MM 3PARAFON FORTE DSC 500 MG TABLET 3PARAGARD T 380A 380 SQUARE MM INTRAUTERINE DEVICE MM,SP,LD 4paregoric liquid 3PAREMYD 1 %-0.25 % EYE DROPS MM 3paricalcitol 1 mcg capsule MM 3 QLparicalcitol 2 mcg capsule MM 3 QLparicalcitol 4 mcg capsule MM 3 QLPARLODEL 2.5 MG TABLET MM 3PARLODEL 5 MG CAPSULE MM 3PARNATE 10 MG TABLET MM 3 QLparoex oral rinse 0.12 % mouthwash 2paromomycin 250 mg capsule 3paroxetine er 12.5 mg tablet MM 3 QLparoxetine er 25 mg tablet MM 3 QLparoxetine er 37.5 mg tablet MM 3 QLparoxetine hcl 10 mg tablet MM 1 QLparoxetine hcl 20 mg tablet MM 1 QLparoxetine hcl 30 mg tablet MM 1 QLparoxetine hcl 40 mg tablet MM 1 QLPASER 4 GRAM GRANULES DELAYED-RELEASE PACKET MM 3PATADAY 0.2 % EYE DROPS 2PATANASE 0.6 % NASAL SPRAY 3 QL,STPATANOL 0.1 % EYE DROPS 3 STPAXIL 10 MG TABLET MM 3 QLPAXIL 10 MG/5 ML ORAL SUSPENSION MM 3PAXIL 20 MG TABLET MM 3 QLPAXIL 30 MG TABLET MM 3 QLPAXIL 40 MG TABLET MM 3 QLPAXIL CR 12.5 MG TABLET,EXTENDED RELEASE MM 3 QLPAXIL CR 25 MG TABLET,EXTENDED RELEASE MM 3 QLPAXIL CR 37.5 MG TABLET,EXTENDED RELEASE MM 3 QLPAZEO 0.7 % EYE DROPS 2PCE 333 MG PARTICLES IN TABLET 4ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSPCE 500 MG PARTICLES IN TABLET 4PEDIAPRED 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLUTION 3PEDIASURE 0.03 GRAM-1 KCAL/ML ORAL LIQUID 3PEDIASURE 0.06 GRAM-1.5 KCAL/ML ORAL LIQUID 3PEDIASURE ENTERAL 0.03 GRAM-1 KCAL/ML ORAL LIQUID 3PEDIASURE ENTERAL WITH FIBER 1.0 0.03 GRAM-1 KCAL/ML ORAL LIQUID 3PEDIASURE SHAKE MIX 6 GRAM-170 KCAL/38 GRAM ORAL POWDER 3PEDIASURE SIDEKICKS 0.03 GRAM-0.6 KCAL/ML ORAL LIQUID 3PEDIASURE SIDEKICKS CLEAR 0.03 GRAM-0.6 KCAL/ML ORAL LIQUID 3PEDIASURE WITH FIBER 0.03 GRAM-1 KCAL/ML ORAL LIQUID 3PEDIASURE WITH FIBER 0.06 GRAM-1.5 KCAL/ML ORAL LIQUID 3pediatric balanced nutrition 0.03 gram-1 kcal/ml oral liquid 2pediatric drink with fiber 0.03 gram-1 kcal/ml oral liquid 2peg 3350 electrolyte soln 2peg 3350-electrolyte solution 2peg-3350 and electrolytes soln 2peg-3350 with flavor packs 420 gram oral solution 2PEGANONE 250 MG TABLET MM 2PEGASYS 180 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP * QL,PAPEGASYS 180 MCG/ML SUBCUTANEOUS SOLUTION SP * QL,PAPEGASYS PROCLICK 135 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAPEGASYS PROCLICK 180 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAPEGINTRON 120 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON 150 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON 50 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON 80 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON REDIPEN 120 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON REDIPEN 150 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON REDIPEN 50 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEGINTRON REDIPEN 80 MCG/0.5 ML SUBCUTANEOUS KIT SP * QL,PAPEN NEEDLE 29 GAUGE X 1/2" 1PEN NEEDLE 30 GAUGE X 5/16" 1PEN NEEDLE 31 GAUGE X 1/4" 1PEN NEEDLE 31 GAUGE X 3/16" 1PEN NEEDLE 31 GAUGE X 5/16" 1PEN NEEDLE 32 GAUGE X 5/32" 1PEN NEEDLE 32G X 5/32" 1PEN NEEDLES 6MM 31G 1penicillin vk 125 mg/5 ml soln 2penicillin vk 250 mg tablet 2penicillin vk 250 mg/5 ml soln 2penicillin vk 500 mg tablet 2PENLET PLUS BLOOD SAMPLER KIT MM 3PENNSAID 1.5% SOLUTION MM 3 PAPENNSAID 20 MG/GRAM/ACTUATION (2 %) TOPICAL SOLN IN METERED-DOSE PUMP 4 PAPENTASA 250 MG CAPSULE,CONTROLLED RELEASE MM 4 QLPENTASA 500 MG CAPSULE,CONTROLLED RELEASE MM 4 QLpentazocine-naloxone tablet 3 QLPENTIPS 31 GAUGE X 3/16" NEEDLE 1PENTIPS 31 GAUGE X 5/16" NEEDLE 1PENTIPS 32 GAUGE X 5/32" NEEDLE 1PENTIPS PEN NEEDLE 29 GAUGE X 1/2" 1PENTIPS PEN NEEDLE 31 GAUGE X 1/4" 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSpentoxifylline er 400 mg tab MM 1PEPCID 20 MG TABLET MM 4PEPCID 40 MG TABLET MM 4PEPCID 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION MM 3PEPTAMEN 1.5 CAL WITH PREBIO1 ORAL LIQUID 3PEPTAMEN 1.5 ORAL LIQUID 3PEPTAMEN JUNIOR 1.5 WITH PREBIO1 ORAL LIQUID 3PEPTAMEN ORAL LIQUID 3PEPTAMEN W-PREBIO1 ORAL LIQUID 3PERCOCET 10 MG-325 MG TABLET 4 QLPERCOCET 2.5 MG-325 MG TABLET 4 QLPERCOCET 5 MG-325 MG TABLET 4 QLPERCOCET 7.5 MG-325 MG TABLET 4 QLPERCODAN 4.8355-325 MG TABLET 3 QLPERFOROMIST 20 MCG/2 ML SOLUTION FOR NEBULIZATION MM 4 QL,PAPERIDEX 0.12 % MOUTHWASH 3perindopril erbumine 2 mg tab MM 1perindopril erbumine 4 mg tab MM 1perindopril erbumine 8 mg tab MM 1periogard 0.12 % mouthwash 2permethrin 5% cream 3perphen-amitrip 2 mg-10 mg tab MM 3perphen-amitrip 2 mg-25 mg tab MM 3perphen-amitrip 4 mg-10 mg tab MM 3perphen-amitrip 4 mg-25 mg tab MM 3perphen-amitrip 4 mg-50 mg tab MM 3perphenazine 16 mg tablet MM 3perphenazine 2 mg tablet MM 3perphenazine 4 mg tablet MM 3perphenazine 8 mg tablet MM 3PERSANTINE 25 MG TABLET MM 3PERSANTINE 50 MG TABLET MM 3PERSANTINE 75 MG TABLET MM 3PERTZYE 16,000-57,500-60,500 UNIT CAPSULE,DELAYED RELEASE MM 4 STPERTZYE 8,000-28,750 UNIT-30,250 UNIT CAPSULE,DELAYED RELEASE MM 4 STPEXEVA 10 MG TABLET MM 3 QL,STPEXEVA 20 MG TABLET MM 3 QL,STPEXEVA 30 MG TABLET MM 3 QL,STPEXEVA 40 MG TABLET MM 3 QL,STPFLEX INSPIRATORY TRAINER DEVICE 1PHARMACIST CHOICE 30G LANCETS MM 1PHARMACIST CHOICE BLOOD GLUCOSE SYSTEM MM 3 STPHARMACIST CHOICE GLUCOSE TEST STRIPS MM 3 QL,STPHASEAL PROTECTOR 13 MM DEVICE 1PHASEAL PROTECTOR 20 MM DEVICE 1PHASEAL PROTECTOR 28 MM DEVICE 1phenadoz 12.5 mg rectal suppository 3phenadoz 25 mg rectal suppository 3phenazopyridine 100 mg tab 3phenazopyridine 200 mg tab 3phenelzine sulfate 15 mg tab MM 3PHENERGAN 12.5 MG RECTAL SUPPOSITORY 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSPHENERGAN 25 MG RECTAL SUPPOSITORY 3PHENERGAN 50 MG RECTAL SUPPOSITORY 3phenobarbital 100 mg tablet MM 2 QLphenobarbital 15 mg tablet MM 2 QLphenobarbital 16.2 mg tablet MM 2 QLphenobarbital 20 mg/5 ml elix MM 3 QLphenobarbital 30 mg tablet MM 2 QLphenobarbital 32.4 mg tablet MM 2 QLphenobarbital 60 mg tablet MM 2 QLphenobarbital 64.8 mg tablet MM 2 QLphenobarbital 97.2 mg tablet MM 2 QLphenoxybenzamine hcl 10 mg cap SP *phenylephrine 10% eye drops 3phenylephrine 2.5% eye drop 3PHENYTEK 200 MG CAPSULE MM 3PHENYTEK 300 MG CAPSULE MM 3phenytoin 100 mg/4 ml susp MM 2phenytoin 125 mg/5 ml susp MM 2phenytoin 50 mg tablet chew MM 2phenytoin sod ext 100 mg cap MM 2phenytoin sod ext 200 mg cap MM 2phenytoin sod ext 300 mg cap MM 1philith 0.4 mg-35 mcg tablet MM 1phlexy-vits oral packet 2PHOSLO 667 MG CAPSULE MM 3 STPHOSLYRA 667 MG (169 MG CALCIUM)/5 ML ORAL SOLUTION MM 3phospha 250 neutral 250 mg tablet 2PHOSPHOLINE IODIDE 0.125 % EYE DROPS MM 3PHYSICIANS EZ USE B-12 1,000 MCG/ML INJECTION KIT 3phytonadione 1 mg/0.5 ml syr 4PICATO 0.015 % TOPICAL GEL 3 QLPICATO 0.05 % TOPICAL GEL 3 QLpilocarpine 1% eye drops MM 2pilocarpine 2% eye drops MM 2pilocarpine 4% eye drops MM 2pilocarpine hcl 5 mg tablet MM 3pilocarpine hcl 7.5 mg tablet MM 3pimozide 1 mg tablet MM 3pimozide 2 mg tablet MM 3pimtrea (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM 1pindolol 10 mg tablet MM 2pindolol 5 mg tablet MM 2pioglitazone hcl 15 mg tablet MM 1 QLpioglitazone hcl 30 mg tablet MM 1 QLpioglitazone hcl 45 mg tablet MM 1 QLpioglitazone-glimepiride 30-2 MM 3 QL,STpioglitazone-glimepiride 30-4 MM 3 QL,STpioglitazone-metformin 15-500 MM 3 QLpioglitazone-metformin 15-850 MM 3 QLpirmella 0.5/0.75/1 mg-35 mcg tablet MM 1pirmella 1 mg-35 mcg tablet MM 1piroxicam 10 mg capsule MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSpiroxicam 20 mg capsule MM 2pivot 1.5 cal oral liquid 2PLAN B ONE-STEP 1.5 MG TABLET 3PLAQUENIL 200 MG TABLET MM 3PLAVIX 300 MG TABLET 3 QLPLAVIX 75 MG TABLET MM 3 QLPLEGRIDY 125 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP,LD * QL,PAPLEGRIDY 125 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PAPLEGRIDY 63 MCG/0.5 ML-94 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP,LD * QL,PAPLEGRIDY 63 MCG/0.5 ML-94 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PAPLETAL 100 MG TABLET MM 3PLETAL 50 MG TABLET MM 3PNEUMOVAX 23 25 MCG/0.5 ML INJECTION SOLUTION 4PNEUMOVAX 23 25 MCG/0.5 ML INJECTION SYRINGE 4pnv 29-1 29 mg iron-1 mg tablet 1pnv folic acid + iron tablet 1pnv ob+dha 27 mg-1 mg-50 mg-250 mg oral pack 2pnv-dha + docusate 27 mg-1.25 mg-55 mg-300 mg capsule 2pnv-dha 27 mg-1 mg-300 mg capsule 2pnv-ferrous fumarate 29 mg-docu 25 mg-fa 1 mg tablet 1pnv-omega 28 mg-1 mg-300 mg capsule 2pnv-select 27 mg-1 mg tablet 3pnv-total softgel 3pnv-vp-u 106.5 mg-1 mg capsule 1POCKET CHAMBER SPACER 1PODIAPN 35 MG-5 MG-2 MG-300 MG CAPSULE 3podofilox 0.5% topical soln 3poly-iron 150 forte 150 mg-25 mcg-1 mg capsule 1polycin 500 unit-10,000 unit/gram eye ointment 2polyethylene glycol 3350 powd 2 QLpolyethylene glycol 3350 powd 2 QLpolymyxin b-tmp eye drops 1POLYTRIM 10,000 UNIT-1 MG/ML EYE DROPS 3POMALYST 1 MG CAPSULE SP,LD * QL,PAPOMALYST 2 MG CAPSULE SP,LD * QL,PAPOMALYST 3 MG CAPSULE SP,LD * QL,PAPOMALYST 4 MG CAPSULE SP,LD * QL,PAPONSTEL 250 MG CAPSULE 3PORTAGEN POWDER 3portia 0.15 mg-0.03 mg tablet MM 1pot citrate-citric acid packet 3POTABA 500 MG CAPSULE MM 3potassium 25 meq tablet eff MM 1potassium citrate er 10 meq tb MM 3potassium citrate er 15 meq tb MM 3potassium citrate er 5 meq tab MM 3potassium cl 10% (20 meq/15 ml MM 3potassium cl 20 meq packet MM 3potassium cl 20% (40 meq/15 ml MM 3potassium cl 25 meq tab eff MM 2potassium cl er 10 meq capsule MM 2potassium cl er 10 meq tablet MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSpotassium cl er 10 meq tablet MM 2potassium cl er 20 meq tablet MM 2potassium cl er 20 meq tablet MM 2potassium cl er 8 meq capsule MM 2potassium cl er 8 meq tablet MM 2POTIGA 200 MG TABLET MM 4 PAPOTIGA 300 MG TABLET MM 4 PAPOTIGA 400 MG TABLET MM 4 PAPOTIGA 50 MG TABLET MM 4 PApr natal 400 29 mg-1 mg-400 mg oral pack 2pr natal 400 ec 29 mg-1 mg-400 mg tablet-capsule,delayed release 2pr natal 430 29 mg-1 mg-430 mg oral pack 1pr natal 430 ec 29 mg-1 mg-430 mg tablet-capsule,delayed release 2PRADAXA 110 MG CAPSULE 3 QLPRADAXA 150 MG CAPSULE MM 3 QLPRADAXA 75 MG CAPSULE MM 3 QLPRALUENT PEN 150 MG/ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAPRALUENT PEN 75 MG/ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAPRALUENT SYRINGE 150 MG/ML SUBCUTANEOUS SP * QL,PAPRALUENT SYRINGE 75 MG/ML SUBCUTANEOUS SP * QL,PApramipexole 0.125 mg tablet MM 1pramipexole 0.25 mg tablet MM 1pramipexole 0.5 mg tablet MM 1pramipexole 0.75 mg tablet MM 1pramipexole 1 mg tablet MM 1pramipexole 1.5 mg tablet MM 1pramipexole er 0.375 mg tablet MM 3 QL,PApramipexole er 0.75 mg tablet MM 3 QL,PApramipexole er 1.5 mg tablet MM 3 QL,PApramipexole er 2.25 mg tablet MM 3 QL,PApramipexole er 3 mg tablet MM 3 QL,PApramipexole er 3.75 mg tablet MM 3 QL,PApramipexole er 4.5 mg tablet MM 3 QL,PAPRAMOSONE 1 %-1 % LOTION 3PRAMOSONE 1 %-1 % TOPICAL CREAM 3PRAMOSONE 2.5 %-1 % LOTION 3PRANDIMET 1 MG-500 MG TABLET MM 3PRANDIMET 2 MG-500 MG TABLET MM 3PRANDIN 0.5 MG TABLET MM 3PRANDIN 1 MG TABLET MM 3PRANDIN 2 MG TABLET MM 3PRAVACHOL 20 MG TABLET MM 3 QL,STPRAVACHOL 40 MG TABLET MM 3 QL,STPRAVACHOL 80 MG TABLET MM 3 QL,STpravastatin sodium 10 mg tab MM 2 QLpravastatin sodium 20 mg tab MM 2 QLpravastatin sodium 40 mg tab MM 2 QLpravastatin sodium 80 mg tab MM 2 QLprazosin 1 mg capsule MM 2prazosin 2 mg capsule MM 2prazosin 5 mg capsule MM 2PRECISION GLUCOSE CONTROL SOLN COMBO PACK 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSPRECISION GLUCOSE/KETONE CONTR COMBO PACK 3PRECISION METER MM 3 STPRECISION PCX PLUS TEST STRIPS MM 3 QL,STPRECISION PCX TEST STRIPS MM 3 QL,STPRECISION POINT OF CARE TEST STRIPS MM 3 QL,STPRECISION Q-I-D TEST STRIPS MM 3 QL,STPRECISION XTRA MONITOR MM 3 STPRECISION XTRA TEST STRIPS MM 3 QL,STPRECOSE 100 MG TABLET MM 3PRECOSE 25 MG TABLET MM 3PRECOSE 50 MG TABLET MM 3PRED FORTE 1 % EYE DROPS,SUSPENSION 3 STPRED MILD 0.12 % EYE DROPS,SUSPENSION 3 STPRED-G 0.3 %-1 % EYE DROPS,SUSPENSION 3PRED-G S.O.P. 0.3 %-0.6 % EYE OINTMENT 3prednicarbate 0.1% cream 3prednicarbate 0.1% ointment 3prednisolone 15 mg/5 ml soln 2prednisolone 15 mg/5 ml syrup 2prednisolone 5 mg/5 ml soln 2prednisolone ac 1% eye drop 3prednisolone odt 10 mg tablet 3prednisolone odt 15 mg tablet 3prednisolone odt 30 mg tablet 3prednisolone sod 1% eye drop 2prednisolone sod ph 25 mg/5 ml 2prednisone 1 mg tablet 1prednisone 10 mg tab dose pack 1prednisone 10 mg tablet 1prednisone 2.5 mg tablet 1prednisone 20 mg tablet 1prednisone 5 mg tablet 1prednisone 5 mg tablet 1prednisone 5 mg/5 ml solution 2prednisone 50 mg tablet 1prednisone intensol 5 mg/ml oral concentrate 3PREFERA-OB 28 MG-6 MG-1 MG TABLET 2PREFERA-OB ONE 22 MG-6 MG-1 MG-200 MG CAPSULE 2PREFERA-OB PLUS DHA 28 MG IRON-6 MG IRON-1 MG ORAL PACK 2PREFERRED PLUS SYRINGE 0.5 ML MM 2PREFERRED PLUS SYRINGE 1 ML MM 2PREFEST 1 MG (15)/1 MG-0.09 MG (15) TABLET MM 3prefol-dha capsule 1PRELONE 15 MG/5 ML SYRUP 2PREMARIN 0.3 MG TABLET MM 3PREMARIN 0.45 MG TABLET MM 3PREMARIN 0.625 MG TABLET MM 3PREMARIN 0.625 MG/GRAM VAGINAL CREAM MM 3PREMARIN 0.9 MG TABLET MM 3PREMARIN 1.25 MG TABLET MM 3PREMIUM BLOOD GLUCOSE MONITORING SYSTEM MM 3 STPREMIUM V10 MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSPREMIUM V10 STRIPS MM 3 QL,STPREMPHASE 0.625 MG(14)/0.625 MG-5MG(14) TABLET MM 3PREMPRO 0.3 MG-1.5 MG TABLET MM 3PREMPRO 0.45 MG-1.5 MG TABLET MM 3PREMPRO 0.625 MG-2.5 MG TABLET MM 3PREMPRO 0.625 MG-5 MG TABLET MM 3PRENA1 CHEW 1.4 MG CHEW TABLET,IMMEDIATE - DELAYED RELEASE 3prena1 pearl 30 mg-1.4 mg-200 mg capsule,immediate - delay release 3prena1 plus combo pack 2prena1 softgel 2prena1 true 30 mg iron-1.4 mg-300 mg oral pack 3prenaissance 29 mg-1.25 mg-55 mg-325 mg capsule 2prenaissance 90 dha combo pack 2prenaissance balance softgel 3prenaissance dha combo pack 2prenaissance next 1.2 mg-40 mg-124.1 mg-100 mg tablet 3PRENAISSANCE NEXT-B TABLET 3prenaissance plus 28 mg-1 mg-50 mg-250 mg capsule 2prenaissance promise combo pck 2prenaplus tablet 1PRENATA 29 MG IRON-1 MG CHEWABLE TABLET 1PRENATABS FA 29 MG-1 MG TABLET 2PRENATABS RX 29 MG IRON-1 MG TABLET 2prenatal 19 (with docusate) 29 mg iron-1 mg-25 mg tablet 1prenatal 19 29 mg iron-1 mg chewable tablet 1prenatal ad tablet 1prenatal low iron 27 mg-1 mg tablet 1prenatal plus (calcium carbonate) 27 mg iron-1 mg tablet 1prenatal plus 29 mg iron-1 mg tablet 1prenatal vitamins plus low iron 27 mg iron-1 mg tablet 1prenatal-u 106.5 mg-1 mg capsule 1PRENATE AM 1 MG-500 MG TABLET 3PRENATE CHEWABLE 1 MG TABLET 3PRENATE DHA (FERROUS ASPARTO GLYCINATE) 18 MG IRON-1 MG-300 MGCAPSULE

3

PRENATE DHA 28 MG IRON-1 MG-300 MG CAPSULE 3PRENATE ELITE (IRON ASPARTO GLYCINATE) 20 MG IRON-1 MG TABLET 3PRENATE ELITE 26 MG IRON-1 MG TABLET 3PRENATE ENHANCE 28 MG IRON-1 MG-400 MG CAPSULE 3PRENATE ESSENTIAL (IRON ASPARTO GLYCINATE) 18 MG IRON-1 MG-300 MG CAP 3PRENATE ESSENTIAL 29 MG IRON-1 MG-300 MG CAPSULE 3PRENATE MINI (FERROUS ASPARTO GLYCINATE) 18 MG-1 MG-350 MG CAPSULE 3PRENATE MINI 29 MG IRON-1 MG-350 MG CAPSULE 3PRENATE PIXIE 10 MG IRON-1 MG-200 MG CAPSULE 3PRENATE RESTORE 27 MG IRON-1 MG-400 MG CAPSULE 3PRENATE STAR 20 MG IRON-1 MG TABLET 3preplus 27 mg iron-1 mg tablet 1PREPOPIK 10 MG-3.5 GRAM-12 GRAM ORAL POWDER PACKET 3 STPREQUE 10 15 MG IRON-0.5 MG-25 MG TABLET 2PRESSURE ACTIVATED LANCETS 21 GAUGE MM 1PRESSURE ACTIVATED LANCETS 28 GAUGE MM 1PRESTALIA 14 MG-10 MG TABLET 3 STPRESTALIA 3.5 MG-2.5 MG TABLET 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSPRESTALIA 7 MG-5 MG TABLET 3 STPRESTO PRO BLOOD GLUCOSE METER MM 3 STpretab 29 mg-1 mg tablet 3PREVACID 15 MG CAPSULE,DELAYED RELEASE MM 3 QL,STPREVACID 30 MG CAPSULE,DELAYED RELEASE MM 3 QL,STPREVACID SOLUTAB 15 MG DELAYED RELEASE,DISINTEGRATING TABLET MM 3 QL,STPREVACID SOLUTAB 30 MG DELAYED RELEASE,DISINTEGRATING TABLET MM 3 QL,STprevalite 4 gram oral powder MM 3prevalite 4 gram powder for susp in a packet MM 3previfem 0.25 mg-35 mcg tablet MM 1PREVNAR 13 (PF) 0.5 ML INTRAMUSCULAR SYRINGE 4PREVPAC 500 MG-500 MG-30 MG ORAL PACK 4PREZCOBIX 800 MG-150 MG TABLET SP * QLPREZISTA 100 MG/ML ORAL SUSPENSION SP * QLPREZISTA 150 MG TABLET SP * QLPREZISTA 400 MG TABLET SP * QLPREZISTA 600 MG TABLET SP * QLPREZISTA 75 MG TABLET SP * QLPREZISTA 800 MG TABLET SP * QLPRIFTIN 150 MG TABLET 3PRILOSEC 10 MG ORAL SUSPENSION,DELAYED RELEASE MM 3 QLPRILOSEC 2.5 MG ORAL SUSPENSION,DELAYED RELEASE MM 3 QLPRILOSEC DR 10 MG CAPSULE MM 3 QL,STPRILOSEC DR 20 MG CAPSULE MM 3 QL,STPRILOSEC DR 40 MG CAPSULE MM 3 QL,STprimaquine 26.3 mg tablet MM 2PRIMEAIRE SPACER 1primidone 250 mg tablet MM 1primidone 50 mg tablet MM 1primlev 10 mg-300 mg tablet 4 QLprimlev 5 mg-300 mg tablet 4 QLprimlev 7.5 mg-300 mg tablet 4 QLPRIMSOL 50 MG/5 ML ORAL SOLUTION 3PRINIVIL 10 MG TABLET MM 3PRINIVIL 20 MG TABLET MM 3PRINIVIL 5 MG TABLET MM 3PRISTIQ 100 MG TABLET,EXTENDED RELEASE MM 3 QLPRISTIQ 25 MG TABLET,EXTENDED RELEASE 3 QLPRISTIQ 50 MG TABLET,EXTENDED RELEASE MM 3 QLPRO COMFORT ALCOHOL PADS 3PRO COMFORT LANCETS 30 GAUGE MM 1PROAIR HFA 90 MCG/ACTUATION AEROSOL INHALER MM 3 QL,STPROAIR RESPICLICK 90 MCG/ACTUATION BREATH ACTIVATED 3 QL,STprobenecid 500 mg tablet MM 2probenecid-colchicine tabs 2PROCALAMINE 3% INTRAVENOUS SOLUTION 3PROCARDIA 10 MG CAPSULE MM 3PROCARDIA XL 30 MG TABLET,EXTENDED RELEASE MM 3 QLPROCARDIA XL 60 MG TABLET,EXTENDED RELEASE MM 3 QLPROCARDIA XL 90 MG TABLET,EXTENDED RELEASE MM 3 QLprocentra 5 mg/5 ml oral solution 4 QLPROCHAMBER 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSprochlorperazine 10 mg tab 2prochlorperazine 25 mg supp 3prochlorperazine 5 mg tablet 2PROCRIT 10,000 UNIT/ML INJECTION SOLUTION SP * QL,PAPROCRIT 2,000 UNIT/ML INJECTION SOLUTION SP * QL,PAPROCRIT 20,000 UNIT/2 ML INJECTION SOLUTION SP * QL,PAPROCRIT 20,000 UNIT/ML INJECTION SOLUTION SP * QL,PAPROCRIT 3,000 UNIT/ML INJECTION SOLUTION SP * QL,PAPROCRIT 4,000 UNIT/ML INJECTION SOLUTION SP * QL,PAPROCRIT 40,000 UNIT/ML INJECTION SOLUTION SP * QL,PAprocto-med hc 2.5 % rectal cream 3procto-pak 1 % rectal cream 2PROCTOFOAM HC 1 %-1 % 3proctosol hc 2.5 % rectal cream 3proctozone-hc 2.5 % rectal cream 3PROCYSBI 25 MG CAPSULE,DELAYED RELEASE SPRINKLE SP,LD * QL,PAPROCYSBI 75 MG CAPSULE,DELAYED RELEASE SPRINKLE SP,LD * QL,PAPRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM MM 3 STPRODIGY AUTOCODE METER KIT MM 3 STPRODIGY CONTROL SOLUTION, LOW 3PRODIGY CONTROL SOLUTION,HIGH 3PRODIGY INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2PRODIGY INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2PRODIGY INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2PRODIGY LANCETS 26 GAUGE MM 1PRODIGY LANCETS 28 GAUGE MM 1PRODIGY LANCING DEVICE MM 1PRODIGY NO CODING STRIPS MM 3 QL,STPRODIGY POCKET METER KIT MM 3 STPRODIGY TWIST TOP LANCET 28 GAUGE MM 1PRODIGY VOICE GLUCOSE METER KIT MM 3 STPROFERRIN-FORTE 12 MG-1 MG TABLET 2progesterone 100 mg capsule MM 2progesterone 200 mg capsule MM 2PROGLYCEM 50 MG/ML ORAL SUSPENSION MM 4PROGRAF 0.5 MG CAPSULE 4PROGRAF 1 MG CAPSULE 4PROGRAF 5 MG CAPSULE 4 QLPROLENSA 0.07 % EYE DROPS 4 QL,STPROMACTA 12.5 MG TABLET SP,LD * QL,PAPROMACTA 25 MG TABLET SP,LD * QL,PAPROMACTA 50 MG TABLET SP,LD * QL,PAPROMACTA 75 MG TABLET SP,LD * QL,PApromethazine 12.5 mg suppos 3promethazine 12.5 mg tablet 2promethazine 25 mg suppository 3promethazine 25 mg tablet 2promethazine 50 mg suppository 3promethazine 50 mg tablet 2promethazine 6.25 mg/5 ml syrp 2promethazine vc 6.25 mg-5 mg/5 ml syrup 3promethazine vc-codeine 6.25 mg-5 mg-10 mg/5 ml syrup 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSpromethazine-codeine syrup 3promethazine-dm syrup 3promethazine-pe-codeine syrup 3promethazine-phenylephrine syr 3promethegan 12.5 mg rectal suppository 3promethegan 25 mg rectal suppository 3promethegan 50 mg rectal suppository 3PROMETRIUM 100 MG CAPSULE MM 3PROMETRIUM 200 MG CAPSULE MM 3promote oral liquid 2PROMOTE WITH FIBER ORAL LIQUID 3propafenone hcl 150 mg tablet MM 2propafenone hcl 225 mg tab MM 2propafenone hcl 300 mg tab MM 2propafenone hcl er 225 mg cap MM 3propafenone hcl er 325 mg cap MM 3propafenone hcl er 425 mg cap MM 3propantheline 15 mg tablet 2proparacaine 0.5% eye drops 2propranolol 10 mg tablet MM 1propranolol 20 mg tablet MM 1propranolol 20 mg/5 ml soln MM 2propranolol 40 mg tablet MM 1propranolol 40 mg/5 ml soln MM 2propranolol 60 mg tablet MM 1propranolol 80 mg tablet MM 1propranolol er 120 mg capsule MM 3propranolol er 160 mg capsule MM 3propranolol er 60 mg capsule MM 3propranolol er 80 mg capsule MM 3propranolol-hctz 40-25 mg tab MM 2propranolol-hctz 80-25 mg tab MM 2propylthiouracil 50 mg tablet MM 2PROSCAR 5 MG TABLET MM 3 QL,STPROSIGHT WITH LUTEIN 60 MG-30 UNIT-6 MG CAPSULE 3PROSTATE PQ 500 MG-250 MG TABLET 3protein nutritional shake oral liquid 2PROTONIX 20 MG TABLET,DELAYED RELEASE MM 3 QL,STPROTONIX 40 MG GRANULES DELAYED-RELEASE PACKET MM 3 QLPROTONIX 40 MG TABLET,DELAYED RELEASE MM 3 QL,STPROTOPIC 0.03 % TOPICAL OINTMENT 3PROTOPIC 0.1 % TOPICAL OINTMENT 3protriptyline hcl 10 mg tablet MM 3protriptyline hcl 5 mg tablet MM 3PROVENTIL HFA 90 MCG/ACTUATION AEROSOL INHALER MM 3 QL,STPROVERA 10 MG TABLET MM 3PROVERA 2.5 MG TABLET MM 3PROVERA 5 MG TABLET MM 3PROVIDA DHA 32 MG-1.25 MG-110 MG CAPSULE 3PROVIDA OB 40 MG IRON-1.25 MG CAPSULE 2PROVIGIL 100 MG TABLET MM 4 QL,PAPROVIGIL 200 MG TABLET MM 4 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSPROXEED PLUS 200 MCG-1 GRAM-0.5 GRAM-50 MG ORAL POWDER PACKET 3PROZAC 10 MG CAPSULE MM 4 QLPROZAC 20 MG CAPSULE MM 4 QLPROZAC 40 MG CAPSULE MM 4 QLPROZAC WEEKLY 90 MG CAPSULE,DELAYED RELEASE MM 3 QLPRUDOXIN 5 % TOPICAL CREAM 4psorcon 0.05 % topical cream 3 STPULMICORT 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION MM 4 QL,STPULMICORT 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION MM 4 QL,STPULMICORT 1 MG/2 ML SUSPENSION FOR NEBULIZATION MM 4 STPULMICORT FLEXHALER 180 MCG/ACTUATION BREATH ACTIVATED MM 3 QL,STPULMICORT FLEXHALER 90 MCG/ACTUATION BREATH ACTIVATED MM 3 QL,STpulmosal 7 % solution for nebulization 3PULMOZYME 1 MG/ML SOLUTION FOR INHALATION SP * QLPUREFE OB PLUS 106 MG IRON-1 MG CAPSULE 3PUREFE PLUS 106 MG IRON-1 MG CAPSULE 3purevit dualfe plus 162 mg-115.2 mg (106 mg)-1 mg capsule 1PURINETHOL 50 MG TABLET 3 QLPURIXAN 20 MG/ML ORAL SUSPENSION SP,LD * QLPUSH BUTTON SAFETY LANCETS 28 GAUGE MM 1pv complete nutrition liquid 2pv complete nutrition liquid 2pv complete nutrition plus liq 2PV INSULIN SYRINGE 0.5 ML MM 2PV INSULIN SYRINGE 0.5 ML MM 2PV INSULIN SYRINGE 1 ML MM 2PV INSULIN SYRINGE 1 ML MM 2PV TRUETRACK SMART SYS STRIPS MM 1 QLPYLERA 140 MG-125 MG-125 MG CAPSULE 4 QLpyrazinamide 500 mg tablet MM 3PYRIDIUM 100 MG TABLET 3PYRIDIUM 200 MG TABLET 3pyridostigmine br 60 mg tablet MM 2pyridostigmine er 180 mg tab MM 4QBRELIS 1 MG/ML ORAL SOLUTION 3 QLQNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY 3 QL,STQNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY MM 3 QL,STQUALAQUIN 324 MG CAPSULE 3 QL,PAQUARTETTE 0.15 MG-20 MCG/0.15 MG-25 MCG TABLETS,3 MONTH DOSE PACK MM 2 QLquasense 0.15 mg-30 mcg tablets,3 month dose pack 1 QLquazepam 15 mg tablet 3 QLQUDEXY XR 100 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 3 QL,STQUDEXY XR 150 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 3 QL,STQUDEXY XR 200 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 3 QL,STQUDEXY XR 25 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 3 QL,STQUDEXY XR 50 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM 3 QL,STQUESTRAN 4 GRAM ORAL POWDER MM 3QUESTRAN 4 GRAM POWDER FOR SUSP IN A PACKET MM 3QUESTRAN LIGHT 4 GRAM ORAL POWDER MM 3quetiapine fumarate 100 mg tab MM 1 QLquetiapine fumarate 200 mg tab MM 1 QLquetiapine fumarate 25 mg tab MM 1 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSquetiapine fumarate 300 mg tab MM 1 QLquetiapine fumarate 400 mg tab MM 1 QLquetiapine fumarate 50 mg tab MM 1 QLQUFLORA PEDIATRIC 0.25MG FLUORIDE (0.55 MG) CHEWABLE TABLET 3QUFLORA PEDIATRIC 0.5 MG FLUORIDE (1.1 MG) CHEWABLE TABLET 3QUFLORA PEDIATRIC 1 MG FLUORIDE (2.2 MG) CHEWABLE TABLET 3QUFLORA PEDIATRIC DROPS 0.25 MG FLUORIDE (0.55 MG)/ML ORAL 3QUFLORA PEDIATRIC DROPS 0.5 MG FLUORIDE (1.1 MG)/ML ORAL 3QUILLICHEW ER 20 MG CHEWABLE TABLET, EXTENDED RELEASE 3 QL,STQUILLICHEW ER 30 MG CHEWABLE TABLET, EXTENDED RELEASE 3 QL,STQUILLICHEW ER 40 MG CHEWABLE, EXTENDED RELEASE TABLET 3 QL,STQUILLIVANT XR 5 MG/ML (25 MG/5 ML) ORAL SUSPENSION,EXTEND RELEASE 24HR 3 QL,STquinapril 10 mg tablet MM 1quinapril 20 mg tablet MM 1quinapril 40 mg tablet MM 1quinapril 5 mg tablet MM 1quinapril-hctz 10-12.5 mg tab MM 2quinapril-hctz 20-12.5 mg tab MM 2quinapril-hctz 20-25 mg tab MM 2quinidine gluc er 324 mg tab MM 4quinidine sulf er 300 mg tab MM 1quinidine sulfate 200 mg tab MM 2quinidine sulfate 300 mg tab MM 2quinine sulfate 324 mg capsule 3 QL,PAquinoa-kale-hemp oral liquid 2QUINTET AC METER MM 3 STQUINTET AC STRIPS MM 3 QL,STQUINTET BLOOD GLUCOSE METER MM 3 STQUINTET GLUCOSE TEST STRIPS MM 3 QL,STQVAR 40 MCG/ACTUATION METERED AEROSOL ORAL INHALER MM 3 QL,STQVAR 80 MCG/ACTUATION METERED AEROSOL ORAL INHALER MM 3 QL,STr-natal ob 20 mg iron-1 mg-320 mg capsule 3RA BLOOD GLUCOSE MONITOR MM 3 STra pediatric nutrition drink 0.03 gram-1 kcal/ml oral liquid 2rabeprazole sod dr 20 mg tab MM 2 QLRADIOGARDASE 0.5 GRAM CAPSULE SP *raloxifene hcl 60 mg tablet MM 3 QLramipril 1.25 mg capsule MM 1ramipril 10 mg capsule MM 1ramipril 2.5 mg capsule MM 1ramipril 5 mg capsule MM 1RANEXA 1,000 MG TABLET,EXTENDED RELEASE MM 2 QL,STRANEXA 500 MG TABLET,EXTENDED RELEASE MM 2 QL,STranitidine 15 mg/ml syrup MM 1ranitidine 150 mg capsule MM 3ranitidine 150 mg tablet MM 1ranitidine 300 mg capsule MM 3ranitidine 300 mg tablet MM 1RAPAFLO 4 MG CAPSULE MM 3 QL,STRAPAFLO 8 MG CAPSULE MM 3 QL,STRAPAMUNE 0.5 MG TABLET 4RAPAMUNE 1 MG TABLET 4 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSRAPAMUNE 1 MG/ML ORAL SOLUTION 4RAPAMUNE 2 MG TABLET 4 QLRASUVO (PF) 10 MG/0.2 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 12.5 MG/0.25 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 15 MG/0.3 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 17.5 MG/0.35 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 20 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 22.5 MG/0.45 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 25 MG/0.5 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 27.5 MG/0.55 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 30 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARASUVO (PF) 7.5 MG/0.15 ML SUBCUTANEOUS AUTO-INJECTOR 4 QL,PARAVICTI 1.1 GRAM/ML ORAL LIQUID SP,LD * QL,PARAYOS 1 MG TABLET,DELAYED RELEASE 4RAYOS 2 MG TABLET,DELAYED RELEASE 4RAYOS 5 MG TABLET,DELAYED RELEASE 4RAZADYNE 12 MG TABLET MM 3 QLRAZADYNE 4 MG TABLET MM 3 QLRAZADYNE 4 MG/ML ORAL SOLUTION MM 3 QLRAZADYNE 8 MG TABLET MM 3 QLRAZADYNE ER 16 MG CAPSULE,EXTENDED RELEASE MM 3 QLRAZADYNE ER 24 MG CAPSULE,EXTENDED RELEASE MM 3 QLRAZADYNE ER 8 MG CAPSULE,EXTENDED RELEASE MM 3 QLre-gen oral liquid 2react 1.5 mg tablet 1REBETOL 200 MG CAPSULE 3 QLREBETOL 40 MG/ML ORAL SOLUTION 3 QLREBIF (WITH ALBUMIN) 22 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP * QL,PAREBIF (WITH ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP * QL,PAREBIF REBIDOSE 22 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAREBIF REBIDOSE 44 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAREBIF REBIDOSE 8.8 MCG/0.2 ML-22 MCG/0.5 ML (6) SUBCUTANEOUS PEN INJ. SP * QL,PAREBIF TITRATION PACK 8.8 MCG/0.2 ML-22 MCG/0.5 ML SUBCUTANEOUS SYRINGESP

* QL,PA

reclipsen (28) 0.15 mg-0.03 mg tablet MM 1RECTIV 0.4 % (W/W) OINTMENT 3 QLRED WINE COMPLEX 200 MG-60 MG CAPSULE 3red wine extract 200 mg-60 mg capsule 2red wine extract capsule 2RED WINE EXTRACT PLUS 60 MG-200 MG CAPSULE 3REFUAH PLUS GLUCOSE CONTROL SOLUTION 3REFUAH PLUS GLUCOSE MONITOR KIT MM 3 STREFUAH PLUS STRIPS MM 3 QL,STREGLAN 10 MG TABLET 3REGLAN 5 MG TABLET 3REGRANEX 0.01 % TOPICAL GEL 4RELENZA DISKHALER 5 MG/ACTUATION POWDER FOR INHALATION 3 QLRELI-ON INSULIN 0.3 ML SYR MM 2RELI-ON INSULIN 1 ML SYR MM 2RELIAMED LANCET 23 GAUGE MM 3RELIAMED LANCET 28 GAUGE MM 3RELIAMED LANCET 30 GAUGE MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSRELIAMED MINI LANCING DEVICE MM 3RELIAMED SAFETY SEAL LANCETS 28 GAUGE MM 1RELIAMED SAFETY SEAL LANCETS 30 GAUGE MM 1RELIAMED TWIST AND CAP LANCET 28 GAUGE MM 3RELION ALL-IN-ONE METER KIT MM 3 STRELION CONFIRM KIT MM 3 STRELION CONFIRM-MICRO STRIPS MM 3 QL,STRELION INS SYR 0.3 ML 29GX1/2" MM 2RELION INS SYR 0.3 ML 30GX5/16 MM 2RELION INS SYR 1 ML 29GX1/2" MM 2RELION INS SYR 1 ML 30GX5/16" MM 2RELION INSULIN SYR 0.5 ML MM 2RELION LANCING DEVICE MM 1RELION MICRO GLUCOSE MONITOR MM 3 STRELION MICRO GLUCOSE MONITOR KIT MM 3 STRELION NEEDLES 31 GAUGE X 1/4" 1RELION PEN NEEDLES 32 GAUGE X 5/32" 1RELION PRIME METER MM 3 STRELION PRIME TEST STRIPS MM 3 QL,STRELION SYR 0.5 ML 30GX5/16" MM 2RELION THIN 26G LANCETS MM 1RELION THIN LANCETS 26 GAUGE MM 3RELION ULTIMA STRIPS MM 3 QL,STRELION ULTRA THIN PLUS LANCETS MM 1RELISTOR 12 MG/0.6 ML KIT SP * QL,PARELISTOR 12 MG/0.6 ML SUBCUTANEOUS SOLUTION SP * QL,PARELISTOR 12 MG/0.6 ML SUBCUTANEOUS SYRINGE SP * QL,PARELISTOR 150 MG TABLET SP * QL,PARELISTOR 8 MG/0.4 ML SUBCUTANEOUS SYRINGE SP * QL,PArelnate dha 28 mg-1 mg-200 mg capsule 3RELPAX 20 MG TABLET 3 QL,STRELPAX 40 MG TABLET 3 QL,STREMERON 15 MG TABLET MM 3 QLREMERON 30 MG TABLET MM 3 QLREMERON 45 MG TABLET MM 3 QLREMERON SOLTAB 15 MG DISINTEGRATING TABLET MM 3 QLREMERON SOLTAB 30 MG DISINTEGRATING TABLET MM 3 QLREMERON SOLTAB 45 MG DISINTEGRATING TABLET MM 3 QLrena-vite rx 1 mg-60 mg-300 mcg tablet 3RENACIDIN 6.602 GRAM-3.268 GRAM/100 ML IRRIGATION SOLUTION 3RENACIDIN IRRIGATION SOLN 3RENAGEL 400 MG TABLET MM 4 STRENAGEL 800 MG TABLET MM 4 STrenal caps 1 mg capsule 3reno caps 1 mg capsule 3RENVELA 0.8 GRAM ORAL POWDER PACKET MM 2 QLRENVELA 2.4 GRAM ORAL POWDER PACKET MM 2 QLRENVELA 800 MG TABLET MM 2 QLrepaglinide 0.5 mg tablet MM 3repaglinide 1 mg tablet MM 3repaglinide 2 mg tablet MM 3repaglinide-metformin 1-500 mg MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSrepaglinide-metformin 2-500 mg MM 3REPATHA PUSHTRONEX 420 MG/3.5 ML SUBCUTANEOUS WEARABLE INJECTOR SP * QL,PAREPATHA SURECLICK 140 MG/ML SUBCUTANEOUS PEN INJECTOR SP * QL,PAREPATHA SYRINGE 140 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PAREPHRESH PRO-B 2.5 BILLION CELL CAPSULE 3REPLETE ORAL LIQUID 3reprexain 10 mg-200 mg tablet 3 QLREPREXAIN 2.5 MG-200 MG TABLET 3 QLREPREXAIN 5 MG-200 MG TABLET 3 QLREQUIP 0.25 MG TABLET MM 4 QLREQUIP 0.5 MG TABLET MM 4 QLREQUIP 1 MG TABLET MM 4 QLREQUIP 2 MG TABLET MM 4 QLREQUIP 3 MG TABLET MM 4 QLREQUIP 4 MG TABLET MM 4 QLREQUIP 5 MG TABLET MM 4 QLREQUIP XL 12 MG TABLET,EXTENDED RELEASE MM 4 QLREQUIP XL 2 MG TABLET,EXTENDED RELEASE MM 4 QLREQUIP XL 4 MG TABLET,EXTENDED RELEASE MM 4 QLREQUIP XL 6 MG TABLET,EXTENDED RELEASE MM 4 QLREQUIP XL 8 MG TABLET,EXTENDED RELEASE MM 4 QLRESCRIPTOR 100 MG DISPERSIBLE TABLET 3 QLRESCRIPTOR 200 MG TABLET 3 QLRESCULA 0.15% EYE DROPS MM 3 QL,STRESECTISOL 5 % URETHRAL SOLUTION 3reserpine 0.1 mg tablet MM 1reserpine 0.25 mg tablet MM 1RESOURCE 2.0 ORAL LIQUID 3RESOURCE THICKENUP DAIRY 0.03 GRAM-0.7 KCAL/ML ORAL LIQUID 3RESPA-AR 8 MG-90 MG-0.24 MG TABLET,EXTENDED RELEASE 3RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE MM 2 QLRESTORIL 15 MG CAPSULE 3 QLRESTORIL 22.5 MG CAPSULE 3 QLRESTORIL 30 MG CAPSULE 3 QLRESTORIL 7.5 MG CAPSULE 3 QLresveratrol plus 100 mg tablet 2RETAINE OM3 650 MG-150 MG-20 MG CAPSULE 3RETIN-A 0.01 % TOPICAL GEL 3RETIN-A 0.025 % TOPICAL CREAM 3RETIN-A 0.025 % TOPICAL GEL 3RETIN-A 0.05 % TOPICAL CREAM 3RETIN-A 0.1 % TOPICAL CREAM 3RETIN-A MICRO 0.04 % TOPICAL GEL 4 PARETIN-A MICRO 0.1 % TOPICAL GEL 4 PARETIN-A MICRO PUMP 0.04 % TOPICAL GEL 4 PARETIN-A MICRO PUMP 0.08 % TOPICAL GEL 4 PARETIN-A MICRO PUMP 0.1 % TOPICAL GEL 4 PARETROVIR 10 MG/ML INTRAVENOUS SOLUTION 4RETROVIR 10 MG/ML SYRUP 4 QLRETROVIR 100 MG CAPSULE 4 QLREVATIO 10 MG/ML ORAL SUSPENSION SP * QL,PAREVATIO 20 MG TABLET 4 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSREVEAL BLOOD GLUCOSE METER KIT MM 3 STREVEAL TEST STRIP MM 3 QL,STrevia 50 mg tablet 3REVLIMID 10 MG CAPSULE SP,LD * QL,PAREVLIMID 15 MG CAPSULE SP,LD * QL,PAREVLIMID 2.5 MG CAPSULE SP,LD * QL,PAREVLIMID 20 MG CAPSULE SP,LD * QL,PAREVLIMID 25 MG CAPSULE SP,LD * QL,PAREVLIMID 5 MG CAPSULE SP,LD * QL,PAREXULTI 0.25 MG TABLET 4 QL,PAREXULTI 0.5 MG TABLET 4 QL,PAREXULTI 1 MG TABLET 4 QL,PAREXULTI 2 MG TABLET 4 QL,PAREXULTI 3 MG TABLET 4 QL,PAREXULTI 4 MG TABLET 4 QL,PAREYATAZ 150 MG CAPSULE SP * QLREYATAZ 200 MG CAPSULE SP * QLREYATAZ 300 MG CAPSULE SP * QLREYATAZ 50 MG ORAL POWDER PACKET SP *REZIRA 60 MG-5 MG/5 ML ORAL SOLUTION 3RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK MM 2RHINOCORT AQUA NASAL SPRAY MM 3 QL,STribasphere 200 mg capsule 3 QLribasphere 200 mg tablet 3 QLribasphere 400 mg tablet 3 QLribasphere 600 mg tablet 3 QLRIBASPHERE RIBAPAK 200 MG (28)-400 MG (28) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 200 MG (7)-400 MG (7) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 400 MG (28)-400 MG (28) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 400 MG (7)-400 MG (7) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 600 MG (28)-400 MG (28) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 600 MG (28)-600 MG (28) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 600 MG (7)-400 MG (7) TABLETS IN A DOSE PACK 3 QLRIBASPHERE RIBAPAK 600 MG (7)-600 MG (7) TABLETS IN A DOSE PACK 3 QLRIBATAB 400-400 MG DOSEPACK 3 QLRIBATAB 400-600 MG DOSEPACK 3 QLRIBATAB 600-600 MG DOSEPACK 3 QLribavirin 200 mg capsule 3 QLribavirin 200 mg tablet 3 QLRIDAURA 3 MG CAPSULE MM 4rifabutin 150 mg capsule 4RIFADIN 150 MG CAPSULE 3RIFADIN 300 MG CAPSULE 3RIFAMATE 300 MG-150 MG CAPSULE 3rifampin 150 mg capsule 2rifampin 300 mg capsule 2RIFATER 50 MG-120 MG-300 MG TABLET 2RIGHTEST CONTROL SOLUTION HIGH 3RIGHTEST CONTROL SOLUTION NORMAL 3RIGHTEST GC250S CONTROL SOLUTION NORMAL 3RIGHTEST GD500 LANCING DEVICE MM 1RIGHTEST GL300 LANCETS 30 GAUGE MM 1RIGHTEST GM250S GLUCOSE METER MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSRIGHTEST GM260 GLUCOSE METER MM 3 STRIGHTEST GM550 SYSTEM KIT MM 3 STRIGHTEST GS250S TEST STRIPS MM 3 QL,STRIGHTEST GS260 TEST STRIPS MM 3 QL,STRIGHTEST GS550 TEST STRIPS MM 3 QL,STRILUTEK 50 MG TABLET 4riluzole 50 mg tablet 3rimantadine hcl 100 mg tablet 2ringers irrigation solution 3RIOMET 500 MG/5 ML ORAL SOLUTION MM 3 QLrisedronate sod dr 35 mg tab MM 3 QLrisedronate sodium 150 mg tab MM 3 QLrisedronate sodium 30 mg tab 3 QLrisedronate sodium 35 mg tab MM 3 QLrisedronate sodium 5 mg tablet MM 3 QLRISPERDAL 0.25 MG TABLET MM 3 QLRISPERDAL 0.5 MG TABLET MM 3 QLRISPERDAL 1 MG TABLET MM 3 QLRISPERDAL 1 MG/ML ORAL SOLUTION MM 3RISPERDAL 2 MG TABLET MM 3 QLRISPERDAL 3 MG TABLET MM 3 QLRISPERDAL 4 MG TABLET MM 3 QLRISPERDAL M-TAB 0.5 MG DISINTEGRATING TABLET MM 3 QLRISPERDAL M-TAB 1 MG DISINTEGRATING TABLET MM 3 QLRISPERDAL M-TAB 2 MG DISINTEGRATING TABLET MM 3 QLRISPERDAL M-TAB 3 MG DISINTEGRATING TABLET MM 3 QLRISPERDAL M-TAB 4 MG DISINTEGRATING TABLET MM 3 QLrisperidone 0.25 mg odt MM 3 QLrisperidone 0.25 mg tablet MM 1 QLrisperidone 0.5 mg odt MM 3 QLrisperidone 0.5 mg tablet MM 1 QLrisperidone 1 mg odt MM 3 QLrisperidone 1 mg tablet MM 1 QLrisperidone 1 mg/ml solution MM 2risperidone 2 mg odt MM 3 QLrisperidone 2 mg tablet MM 1 QLrisperidone 3 mg odt MM 3 QLrisperidone 3 mg tablet MM 1 QLrisperidone 4 mg odt MM 3 QLrisperidone 4 mg tablet MM 1 QLRITALIN 10 MG TABLET 3 QLRITALIN 20 MG TABLET 3 QLRITALIN 5 MG TABLET 3 QLRITALIN LA 10 MG CAPSULE,EXTENDED RELEASE 3 QL,STRITALIN LA 20 MG CAPSULE,EXTENDED RELEASE 3 QL,STRITALIN LA 30 MG CAPSULE,EXTENDED RELEASE 3 QL,STRITALIN LA 40 MG CAPSULE,EXTENDED RELEASE 3 QL,STRITALIN LA 60 MG CAPSULE,EXTENDED RELEASE 3 QL,STRITALIN SR 20 MG TABLET 3 QL,STRITEFLO AEROCHAMBER 1rivastigmine 1.5 mg capsule MM 3 QLrivastigmine 13.3 mg/24hr ptch MM 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSrivastigmine 3 mg capsule MM 3 QLrivastigmine 4.5 mg capsule MM 3 QLrivastigmine 4.6 mg/24hr patch MM 3 QLrivastigmine 6 mg capsule MM 3 QLrivastigmine 9.5 mg/24hr patch MM 3 QLrizatriptan 10 mg odt 2 QLrizatriptan 10 mg tablet 2 QLrizatriptan 5 mg odt 2 QLrizatriptan 5 mg tablet 2 QLROBAXIN 500 MG TABLET 3ROBAXIN-750 750 MG TABLET 3ROBINUL 1 MG TABLET 3ROBINUL FORTE 2 MG TABLET 3ROCALTROL 0.25 MCG CAPSULE MM 3ROCALTROL 0.5 MCG CAPSULE MM 3ROCALTROL 1 MCG/ML ORAL SOLUTION MM 3ropinirole hcl 0.25 mg tablet MM 1 QLropinirole hcl 0.5 mg tablet MM 1 QLropinirole hcl 1 mg tablet MM 1 QLropinirole hcl 2 mg tablet MM 1 QLropinirole hcl 3 mg tablet MM 1 QLropinirole hcl 4 mg tablet MM 1 QLropinirole hcl 5 mg tablet MM 1 QLropinirole hcl er 12 mg tablet MM 3 QLropinirole hcl er 2 mg tablet MM 3 QLropinirole hcl er 4 mg tablet MM 3 QLropinirole hcl er 6 mg tablet MM 3 QLropinirole hcl er 8 mg tablet MM 3 QLrosadan 0.75 % topical cream 3rosadan 0.75 % topical gel 3rosuvastatin calcium 10 mg tab MM 2 QLrosuvastatin calcium 20 mg tab MM 2 QLrosuvastatin calcium 40 mg tab MM 2 QLrosuvastatin calcium 5 mg tab MM 2 QLroweepra 500 mg tablet MM 2ROXICET 5-325 ORAL SOLUTION 2 QLROXICODONE 15 MG TABLET 3 QLROXICODONE 30 MG TABLET 3 QLROXICODONE 5 MG TABLET 3 QLROZEREM 8 MG TABLET 3 QL,STrulavite dha 27 mg-1 mg-300 mg capsule 3RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED RELEASE 3 QL,STRYTARY 36.25 MG-145 MG CAPSULE,EXTENDED RELEASE 3 QL,STRYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RELEASE 3 QL,STRYTARY 61.25 MG-245 MG CAPSULE,EXTENDED RELEASE 3 QL,STRYTHMOL 150 MG TABLET MM 3RYTHMOL 225 MG TABLET MM 3RYTHMOL SR 225 MG CAPSULE,EXTENDED RELEASE MM 3RYTHMOL SR 325 MG CAPSULE,EXTENDED RELEASE MM 3RYTHMOL SR 425 MG CAPSULE,EXTENDED RELEASE MM 3SABRIL 500 MG ORAL POWDER PACKET SP,LD * QL,PASABRIL 500 MG TABLET SP,LD * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSAFESNAP INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2SAFESNAP INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2SAFESNAP INSULIN SYRINGE 0.5 ML 30 GAUGE X 5/16" MM 2SAFESNAP INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2SAFESNAP INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2SAFETY LANCETS 21 GAUGE MM 1SAFETY LANCETS 26 GAUGE MM 3SAFETY LANCETS 28 GAUGE MM 1SAFETY SEAL LANCETS 28 GAUGE MM 1SAFETY SEAL LANCETS 30 GAUGE MM 1SAFETY-LET LANCETS 30 GAUGE MM 1SAFYRAL 3 MG-0.03 MG-0.451 MG (21/7) TABLET MM 2SAIZEN 5 MG SUBCUTANEOUS SOLUTION SP * QL,PASAIZEN 8.8 MG SUBCUTANEOUS SOLUTION SP * QL,PASAIZEN CLICK.EASY 8.8 MG/1.5 ML (FINAL CONC.) SUBCUTANEOUS CARTRIDGE SP * QL,PASALAGEN 5 MG TABLET MM 3SALAGEN 7.5 MG TABLET MM 3salmon-oats-squash oral liquid 2salsalate 500 mg tablet 3salsalate 750 mg tablet 3SAMSCA 15 MG TABLET SP,LD * QLSAMSCA 30 MG TABLET SP,LD * QLSANCUSO 3.1 MG/24 HOUR TRANSDERMAL PATCH 4 QLSANDIMMUNE 100 MG CAPSULE 3 QLSANDIMMUNE 100 MG/ML ORAL SOLUTION 3SANDIMMUNE 25 MG CAPSULE 3SANDOSTATIN 1,000 MCG/ML INJECTION SOLUTION SP * PASANDOSTATIN 100 MCG/ML INJECTION SOLUTION SP * PASANDOSTATIN 200 MCG/ML INJECTION SOLUTION SP * PASANDOSTATIN 50 MCG/ML INJECTION SOLUTION SP * PASANDOSTATIN 500 MCG/ML INJECTION SOLUTION SP * PASANTYL 250 UNIT/GRAM TOPICAL OINTMENT 4SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL TABLET MM 4 QL,PASAPHRIS (BLACK CHERRY) 2.5 MG SUBLINGUAL TABLET 4 QL,PASAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL TABLET MM 4 QL,PASARAFEM 10 MG TABLET MM 3 QLSARAFEM 20 MG TABLET MM 3 QLSAVAYSA 15 MG TABLET 3 QL,PASAVAYSA 30 MG TABLET 3 QL,PASAVAYSA 60 MG TABLET 3 QL,PASAVELLA 100 MG TABLET MM 3 QLSAVELLA 12.5 MG (5)-25 MG(8)-50MG(42) TABLETS IN A DOSE PACK 3 QLSAVELLA 12.5 MG TABLET MM 3 QLSAVELLA 25 MG TABLET MM 3 QLSAVELLA 50 MG TABLET MM 3 QLscandical oral powder 2scandishake (lactose free) packet 2scandishake oral powder 2scandishake packet 2se-natal 19 (with docusate) 29 mg iron-1 mg-25 mg tablet 1se-natal 19 29 mg iron-1 mg chewable tablet 1se-tan dha 30 mg-1 mg-310.1 mg capsule 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSse-tan plus 162 mg-115.2 mg (106 mg)-1 mg capsule 2SEASONIQUE 0.15 MG-30 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK 3 QLSECONAL SODIUM 100 MG CAPSULE 3SECTRAL 200 MG CAPSULE MM 3SECTRAL 400 MG CAPSULE MM 3SEEBRI NEOHALER 15.6 MCG CAPSULE WITH INHALATION DEVICE 3 QL,PASELECT-OB (FOLIC ACID) 29 MG-1 MG CHEWABLE TABLET 2SELECT-OB + DHA 29 MG IRON-1 MG-250 MG ORAL PACK 3SELECT-OB 29 MG IRON-1 MG CHEWABLE TABLET 3selegiline hcl 5 mg capsule MM 3selegiline hcl 5 mg tablet MM 3selenium sulfide 2.5% lotion 2SELZENTRY 150 MG TABLET SP * QLSELZENTRY 300 MG TABLET SP * QLSEMPREX-D 8 MG-60 MG CAPSULE 3SENSIPAR 30 MG TABLET MM 4 QLSENSIPAR 60 MG TABLET MM 4 QLSENSIPAR 90 MG TABLET MM 4 QLSEREVENT DISKUS 50 MCG/DOSE POWDER FOR INHALATION MM 2 QLSERNIVO 0.05 % TOPICAL SPRAY WITH PUMP SP * QL,STSEROQUEL 100 MG TABLET MM 4 QLSEROQUEL 200 MG TABLET MM 4 QLSEROQUEL 25 MG TABLET MM 4 QLSEROQUEL 300 MG TABLET MM 4 QLSEROQUEL 400 MG TABLET MM 4 QLSEROQUEL 50 MG TABLET MM 4 QLSEROQUEL XR 150 MG TABLET,EXTENDED RELEASE MM 4 QL,PASEROQUEL XR 200 MG TABLET,EXTENDED RELEASE MM 4 QL,PASEROQUEL XR 300 MG TABLET,EXTENDED RELEASE MM 4 QL,PASEROQUEL XR 400 MG TABLET,EXTENDED RELEASE MM 4 QL,PASEROQUEL XR 50 MG TABLET,EXTENDED RELEASE MM 4 QL,PASEROQUEL XR 50 MG(3)-200 MG(1)-300 MG(11) TABLET, ER 24 HR DOSE PACK 4 QL,PASEROSTIM 4 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASEROSTIM 5 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASEROSTIM 6 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PAsertraline 20 mg/ml oral conc MM 2 QLsertraline hcl 100 mg tablet MM 1 QLsertraline hcl 25 mg tablet MM 1 QLsertraline hcl 50 mg tablet MM 1 QLsetlakin 0.15 mg-30 mcg tablets,3 month dose pack 1 QLsevelamer carbonate 800 mg tab MM 4 QL,STSEVEN SYSTEM SENSOR MM 3 PASFROWASA 4 GRAM/60 ML ENEMA MM 4 QLsharobel 0.35 mg tablet MM 1SIDEKICK BLOOD GLUCOSE SYSTEM KIT MM 1SIGNIFOR 0.3 MG/ML (1 ML) SUBCUTANEOUS SOLUTION SP,LD * QL,PASIGNIFOR 0.6 MG/ML (1 ML) SUBCUTANEOUS SOLUTION SP,LD * QL,PASIGNIFOR 0.9 MG/ML (1 ML) SUBCUTANEOUS SOLUTION SP,LD * QL,PAsildenafil 20 mg tablet 3 QL,PASILENOR 3 MG TABLET 4 QL,STSILENOR 6 MG TABLET 4 QL,STSILICONE MASK - INFANT 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSILVADENE 1 % TOPICAL CREAM 3silver sulfadiazine 1% cream 1SIMBRINZA 1 %-0.2 % EYE DROPS,SUSPENSION MM 3 QL,STSIMCOR 1,000-20 MG TABLET MM 3 QL,STSIMCOR 1,000-40 MG TABLET MM 3 QL,STSIMCOR 500-20 MG TABLET MM 3 QL,STSIMCOR 500-40 MG TABLET MM 3 QL,STSIMCOR 750-20 MG TABLET MM 3 QL,STSIMILAC GO AND GROW 4 GRAM-8 GRAM-16 GRAM/150 KCAL ORAL POWDER 3SIMILAC GO AND GROW NON-GMO 4 GRAM-8 GRAM-16 GRAM/150 KCAL ORALPOWDER

3

SIMILAC GO ANDGROW SENSITIVE 4 GRAM-8 GRAM-16 GRAM/150 KCAL ORALPOWDR

3

SIMPONI 100 MG/ML SUBCUTANEOUS PEN INJECTOR SP * QL,PASIMPONI 100 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PASIMPONI 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP * QL,PASIMPONI 50 MG/0.5 ML SUBCUTANEOUS SYRINGE SP * QL,PAsimvastatin 10 mg tablet MM 1 QLsimvastatin 20 mg tablet MM 1 QLsimvastatin 40 mg tablet MM 1 QLsimvastatin 5 mg tablet MM 1 QLsimvastatin 80 mg tablet MM 1 QLSINEMET 10 MG-100 MG TABLET MM 3SINEMET 25 MG-100 MG TABLET MM 3SINEMET 25 MG-250 MG TABLET MM 3SINEMET CR 25 MG-100 MG TABLET,EXTENDED RELEASE MM 3SINEMET CR 50 MG-200 MG TABLET,EXTENDED RELEASE MM 3SINGLE-LET MISC MM 3SINGULAIR 10 MG TABLET MM 3 QLSINGULAIR 4 MG CHEWABLE TABLET MM 3 QLSINGULAIR 4 MG ORAL GRANULES IN PACKET MM 3 QLSINGULAIR 5 MG CHEWABLE TABLET MM 3 QLsirolimus 0.5 mg tablet 4sirolimus 1 mg tablet 4 QLsirolimus 2 mg tablet 4 QLSIRTURO 100 MG TABLET 4 QL,PASITAVIG 50 MG BUCCAL TABLET 3 QL,PASIVEXTRO 200 MG TABLET 4 QLSKELAXIN 800 MG TABLET 3 QLSKLICE 0.5 % LOTION 3SKYLA 14 MCG/24 HOUR (3 YEARS) INTRAUTERINE DEVICE SP,LD *SM LANCETS 21G MM 1SMART CARESENS N KIT MM 3 STSMART SENSE LANCETS 21 GAUGE MM 1SMART SENSE LANCETS 26 GAUGE MM 1SMART SENSE LANCETS 33 GAUGE MM 1SMART SENSE MONITORING SYSTEM MM 3 STSMART SENSE TEST STRIPS MM 3 QL,STSMARTDIABETES VANTAGE MM 3SMARTDIABETES VANTAGE 30G MM 3SMARTDIABETES XPRES GLUC SYST MM 3 STSMARTDIABETES XPRES TEST STRIP MM 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSMARTEST CONTROL SOLUTION 3SMARTEST EJECT KIT MM 3 STSMARTEST LANCET MM 1SMARTEST PERSONA GLUCOSE METER MM 3 STSMARTEST PERSONA STARTER KIT MM 3 STSMARTEST PRONTO GLUCOSE METER MM 3 STSMARTEST PRONTO STARTER KIT MM 3 STSMARTEST PROTEGE KIT MM 3 STSMARTEST SMART CODE METER KIT MM 3 STSMARTEST TALKING METER KIT MM 3 STSMARTEST TEST STRIPS MM 3 QL,STSMS GLUCOSE CONTROL SOL NORMAL 3sodium chloride 0.9% inhal vl 2sodium chloride 0.9% irrig. 2sodium chloride 10% vial 2sodium chloride 3% vial 2sodium chloride 7% vial 2sodium citrate 4% soln 4sodium phenylbutyrate powder SP *sodium polystyrene sulfonate (sorbitol free) 15 gram/60 ml oral susp 2SOF-SENSOR DEVICE MM 3 PASOFT TOUCH LANCETS MM 1SOLARAZE 3 % TOPICAL GEL 4 PASOLODYN 105 MG TABLET,EXTENDED RELEASE 3 QLSOLODYN 115 MG TABLET,EXTENDED RELEASE 3 QLSOLODYN 55 MG TABLET,EXTENDED RELEASE 3 QLSOLODYN 65 MG TABLET,EXTENDED RELEASE 3 QLSOLODYN 80 MG TABLET,EXTENDED RELEASE 3 QLSOLTAMOX 10 MG/5 ML ORAL SOLUTION MM,LD 3 QLSOLUS V2 AUDIBLE METER MM 3 STSOLUS V2 AUDIBLE METER KIT MM 3 STSOLUS V2 CONTROL SOLUTION, LOW 3SOLUS V2 CONTROL SOLUTION,HIGH 3SOLUS V2 LANCETS 28 GAUGE MM 1SOLUS V2 LANCETS 30 GAUGE MM 1SOLUS V2 LANCING DEVICE KIT MM 1SOLUS V2 TEST STRIPS MM 3 QL,STSOMA 250 MG TABLET 4 QLSOMA 350 MG TABLET 4SOMATULINE DEPOT 120 MG/0.5 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PASOMATULINE DEPOT 60 MG/0.2 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PASOMATULINE DEPOT 90 MG/0.3 ML SUBCUTANEOUS SYRINGE SP,LD * QL,PASOMAVERT 10 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASOMAVERT 15 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASOMAVERT 20 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASOMAVERT 25 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASOMAVERT 30 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PASONATA 10 MG CAPSULE 3 QLSONATA 5 MG CAPSULE 3 QLSOOLANTRA 1 % TOPICAL CREAM 3 STsorbitol-mannitol irrig 3SORIATANE 10 MG CAPSULE 4 PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSORIATANE 17.5 MG CAPSULE 4 PASORIATANE 25 MG CAPSULE 4 PASORILUX 0.005 % TOPICAL FOAM 4 QLsorine 120 mg tablet MM 1sorine 160 mg tablet MM 1sorine 240 mg tablet MM 1sorine 80 mg tablet MM 1sotalol 120 mg tablet MM 1sotalol 160 mg tablet MM 1sotalol 240 mg tablet MM 1sotalol 80 mg tablet MM 1sotalol af 120 mg tablet MM 1sotalol af 160 mg tablet MM 1sotalol af 80 mg tablet MM 1SOTYLIZE 5 MG/ML ORAL SOLUTION 3SOUTH AFRICAN HOODIA PLUS CAP 375 MG-87.5 MG CAPSULE 3SOVALDI 400 MG TABLET SP * QL,PASPACE CHAMBER PLUS 2SPECTRACEF 400 MG TABLET 3spinosad 0.9% topical susp 3 QLSPIRIVA RESPIMAT 1.25 MCG/ACTUATION SOLUTION FOR INHALATION 2 QLSPIRIVA RESPIMAT 2.5 MCG/ACTUATION SOLUTION FOR INHALATION 2 QLSPIRIVA WITH HANDIHALER 18 MCG AND INHALATION CAPSULES MM 2 QLspironolactone 100 mg tablet MM 1spironolactone 25 mg tablet MM 1spironolactone 50 mg tablet MM 1spironolactone-hctz 25-25 tab MM 2SPORANOX 10 MG/ML ORAL SOLUTION 4 QLSPORANOX 100 MG CAPSULE 4 QLSPORANOX PULSEPAK 100 MG CAPSULE 4 QLsprintec (28) 0.25 mg-35 mcg tablet MM 1SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION 4 QL,STSPRITAM 250 MG TABLET FOR ORAL SUSPENSION 4 QL,STSPRITAM 500 MG TABLET FOR ORAL SUSPENSION 4 QL,STSPRITAM 750 MG TABLET FOR ORAL SUSPENSION 4 QL,STSPRIX 15.75 MG/SPRAY NASAL SPRAY 4 QL,STSPRYCEL 100 MG TABLET SP * QL,PASPRYCEL 140 MG TABLET SP * QL,PASPRYCEL 20 MG TABLET SP * QL,PASPRYCEL 50 MG TABLET SP * QL,PASPRYCEL 70 MG TABLET SP * QL,PASPRYCEL 80 MG TABLET SP * QL,PASPS (WITH SORBITOL) 15 GRAM-20 GRAM/60 ML ORAL SUSPENSION 3SPS (WITH SORBITOL) 30 GRAM-40 GRAM/120 ML ENEMA 3sps 15 gm/60 ml suspension 3sps 30 gm/120 ml enema 3sps 50 gm/200 ml enema 3sronyx 0.1 mg-20 mcg tablet MM 1SSD 1 % TOPICAL CREAM 3sski 1 gram/ml oral solution MM 1STAGES MEN'S MULTI-VITAMIN 200 MCG-300 UNIT-20 MCG TABLET 3STALEVO 100 25 MG-100 MG-200 MG TABLET MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSTALEVO 125 31.25 MG-125 MG-200 MG TABLET MM 3STALEVO 150 37.5 MG-150 MG-200 MG TABLET MM 3STALEVO 200 50 MG-200 MG-200 MG TABLET MM 3STALEVO 50 12.5 MG-50 MG-200 MG TABLET MM 3STALEVO 75 18.75 MG-75 MG-200 MG TABLET MM 3STARLIX 120 MG TABLET MM 3STARLIX 60 MG TABLET MM 3stavudine 1 mg/ml solution 2 QLstavudine 15 mg capsule 2 QLstavudine 20 mg capsule 2 QLstavudine 30 mg capsule 2 QLstavudine 40 mg capsule 2 QLSTAVZOR DR 125 MG CAPSULE MM 3STAVZOR DR 250 MG CAPSULE MM 3STAVZOR DR 500 MG CAPSULE MM 3STELARA 45 MG/0.5 ML SUBCUTANEOUS SYRINGE SP * QL,PASTELARA 90 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PASTERILANCE TL 30 GAUGE MM 1STERILANCE TL 32 GAUGE MM 1STIMATE 150 MCG/SPRAY (0.1 ML) NASAL SPRAY MM,LD 4STIOLTO RESPIMAT 2.5 MCG-2.5 MCG/ACTUATION SOLUTION FOR INHALATION 2 QLSTIVARGA 40 MG TABLET SP,LD * QL,PASTRATTERA 10 MG CAPSULE MM 3 QL,PASTRATTERA 100 MG CAPSULE MM 3 QL,PASTRATTERA 18 MG CAPSULE MM 3 QL,PASTRATTERA 25 MG CAPSULE MM 3 QL,PASTRATTERA 40 MG CAPSULE MM 3 QL,PASTRATTERA 60 MG CAPSULE MM 3 QL,PASTRATTERA 80 MG CAPSULE MM 3 QL,PASTRENSIQ 100 MG/ML SUBCUTANEOUS SOLUTION SP,LD * QL,PASTRENSIQ 40 MG/ML SUBCUTANEOUS SOLUTION SP,LD * QL,PASTRIANT 30 MG BUCCAL SYSTEM,SUSTAINED RELEASE MM 3 STSTRIBILD 150 MG-150 MG-200 MG-300 MG TABLET SP * QLSTRIVERDI RESPIMAT 2.5 MCG/ACTUATION SOLUTION FOR INHALATION 2 QLSTROMECTOL 3 MG TABLET 2strong iodine 5 % oral solution 1SUBOXONE 12 MG-3 MG SUBLINGUAL FILM 3 QL,PASUBOXONE 2 MG-0.5 MG SUBLINGUAL FILM 3 QL,PASUBOXONE 4 MG-1 MG SUBLINGUAL FILM 3 QL,PASUBOXONE 8 MG-2 MG SUBLINGUAL FILM 3 QL,PASUBSYS 1,200 MCG (600 MCG/SPRAY X2) SUBLINGUAL SPRAY 4 QL,PASUBSYS 1,600 MCG (800 MCG/SPRAY X2) SUBLINGUAL SPRAY 4 QL,PASUBSYS 100 MCG/SPRAY SUBLINGUAL SPRAY 4 QL,PASUBSYS 200 MCG/SPRAY SUBLINGUAL SPRAY 4 QL,PASUBSYS 400 MCG/SPRAY SUBLINGUAL SPRAY 4 QL,PASUBSYS 600 MCG/SPRAY SUBLINGUAL SPRAY 4 QL,PASUBSYS 800 MCG/SPRAY SUBLINGUAL SPRAY 4 QL,PASUCRAID 8,500 UNIT/ML ORAL SOLUTION SP,LD *sucralfate 1 gm tablet MM 2SULAR 17 MG TABLET,EXTENDED RELEASE MM 3 QLSULAR 34 MG TABLET,EXTENDED RELEASE MM 3 QLSULAR 8.5 MG TABLET,EXTENDED RELEASE MM 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSsulf-pred 10-0.23% eye drops 1sulfacetamide 10% eye drops 2sulfacetamide 10% eye ointment 3sulfacetamide sod 10% top susp 3sulfadiazine 500 mg tablet 3sulfamethoxazole-tmp ds tablet 2sulfamethoxazole-tmp ss tablet 2sulfamethoxazole-tmp susp 2SULFAMYLON 50 GRAM TOPICAL PACKET 3SULFAMYLON 85 MG/G TOPICAL CREAM 3sulfasalazine 500 mg tablet MM 1 QLsulfasalazine dr 500 mg tab MM 2 QLSULFATRIM 200 MG-40 MG/5 ML ORAL SUSPENSION 3sulindac 150 mg tablet MM 1sulindac 200 mg tablet MM 1sumatriptan 20 mg nasal spray 3 QLsumatriptan 4 mg/0.5 ml cart 3 QLsumatriptan 4 mg/0.5 ml inject 3 QLsumatriptan 5 mg nasal spray 3 QLsumatriptan 6 mg/0.5 ml inject 3 QLsumatriptan 6 mg/0.5 ml refill 3 QLsumatriptan 6 mg/0.5 ml syrng 3 QLsumatriptan 6 mg/0.5 ml vial 3 QLsumatriptan succ 100 mg tablet 2 QLsumatriptan succ 25 mg tablet 2 QLsumatriptan succ 50 mg tablet 2 QLSUMAVEL DOSEPRO 4 MG/0.5 ML SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 QL,STSUMAVEL DOSEPRO 6 MG/0.5 ML SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 QL,STsuper omega-3 400 mg-5 unit capsule 2SUPER THIN LANCETS MM 1SUPER THIN LANCETS 28 GAUGE MM 1SUPER THIN LANCETS 30 GAUGE MM 1SUPER THIN LANCETS 33 GAUGE MM 1SUPRANE INHALATION LIQUID 3SUPRAX 100 MG CHEWABLE TABLET 3SUPRAX 100 MG/5 ML ORAL SUSPENSION 3SUPRAX 200 MG CHEWABLE TABLET 3SUPRAX 200 MG/5 ML ORAL SUSPENSION 3SUPRAX 400 MG CAPSULE 3SUPRAX 500 MG/5 ML ORAL SUSPENSION 3SUPREP BOWEL PREP KIT 17.5 GRAM-3.13 GRAM-1.6 GRAM ORAL SOLUTION 2SURE COMFORT ALCOHOL PREP PADS 3SURE COMFORT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 0.3 ML 30 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2SURE COMFORT INSULIN SYRINGE 0.3 ML 31 GAUGE X 1/4" MM 2SURE COMFORT INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2SURE COMFORT INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2SURE COMFORT INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2SURE COMFORT INSULIN SYRINGE 1 ML 31 GAUGE X 1/4" MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSURE COMFORT INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2SURE COMFORT INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 1/2 ML 30 GAUGE X 1/2" MM 2SURE COMFORT INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2SURE COMFORT INSULIN SYRINGE 1/2 ML 31 GAUGE X 1/4" MM 2SURE COMFORT INSULIN SYRINGE U-100 0.5 ML 29 GAUGE X 1/2" MM 2SURE COMFORT LANCETS 28 GAUGE MM 1SURE COMFORT LANCETS 30 GAUGE MM 1SURE COMFORT LANCING PEN MM 1SURE COMFORT PEN NEEDLE 29 GAUGE X 1/2" 1SURE COMFORT PEN NEEDLE 30 GAUGE X 5/16" 1SURE COMFORT PEN NEEDLE 31 GAUGE X 3/16" 1SURE COMFORT PEN NEEDLE 31 GAUGE X 5/16" 1SURE COMFORT PEN NEEDLE 32 GAUGE X 1/4" 1SURE COMFORT PEN NEEDLE 32 GAUGE X 5/32" 1SURE EDGE BLOOD GLUCOSE METER MM 3 STSURE EDGE GLUCOSE CONTROL SOLN 3SURE EDGE GLUCOSE CONTROL SOLN 3SURE EDGE GLUCOSE CONTROL SOLN 3SURE EDGE TEST STRIPS MM 3 QL,STSURE-FINE PEN NEEDLES 29 GAUGE X 1/2" 1SURE-FINE PEN NEEDLES 31 GAUGE X 3/16" 1SURE-FINE PEN NEEDLES 31 GAUGE X 5/16" 1SURE-JECT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2SURE-JECT INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2SURE-JECT INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2SURE-JECT INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2SURE-JECT INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2SURE-JECT INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2SURE-JECT INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2SURE-JECT INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2SURE-JECT INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2SURE-JECT INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2SURE-JECT INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2SURE-LANCE MM 1SURE-LANCE 26 GAUGE MM 1SURE-LANCE 28 GAUGE MM 1SURE-LANCE ULTRA THIN 30 GAUGE MM 1SURE-PEN LANCING DEVICE MM 1SURE-PREP ALCOHOL PREP PADS 3SURE-TEST EASYPLUS MINI METER MM 3 STSURE-TEST EASYPLUS MINI SOLUTION 3SURE-TEST EASYPLUS MINI STRIPS MM 3 QL,STSURE-TOUCH LANCET MM 1SURECHEK GLUCOSE CONTROL SOLN 3SURECHEK TEST STRIPS MM 3 QL,STSUREFLEX LANCING DEVICE MM 1SUREFLEX LANCING DEVICE WITH LANCETS KIT MM 1SURGUARD2 SAFETY 1 ML 25 GAUGE X 5/8" SYRINGE 2SURGUARD2 SAFETY 1 ML 26 GAUGE X 3/8" SYRINGE 2SURGUARD2 SAFETY 1 ML 27 GAUGE X 1/2" SYRINGE 2SURGUARD2 SAFETY 10 ML 20 GAUGE X 1 1/2" SYRINGE 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSURGUARD2 SAFETY 10 ML 20 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 18 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 18 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 19 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 19 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 20 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 20 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 21 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 21 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 22 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 22 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 23 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 23 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 25 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 25 GAUGE X 1" NEEDLE 2SURGUARD2 SAFETY 25 X 5/8" NEEDLE 2SURGUARD2 SAFETY 26 GAUGE X 1/2" NEEDLE 2SURGUARD2 SAFETY 27 GAUGE X 1/2" NEEDLE 2SURGUARD2 SAFETY 3 ML 20 GAUGE X 1 1/2" SYRINGE 2SURGUARD2 SAFETY 3 ML 20 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 3 ML 21 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 3 ML 22 GAUGE X 1 1/2" SYRINGE 2SURGUARD2 SAFETY 3 ML 22 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 3 ML 23 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 3 ML 25 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 3 ML 25 GAUGE X 5/8" SYRINGE 2SURGUARD2 SAFETY 30 GAUGE X 1 1/2" NEEDLE 2SURGUARD2 SAFETY 5 ML 20 GAUGE X 1 1/2" SYRINGE 2SURGUARD2 SAFETY 5 ML 20 GAUGE X 1" SYRINGE 2SURGUARD2 SAFETY 5 ML 21 GAUGE X 1 1/2" SYRINGE 2SURGUARD2 SAFETY SYRINGE 10 ML 21 GAUGE X 1 1/2" 2SURGUARD2 SAFETY SYRINGE 3 ML 21 GAUGE X 1 1/2" 2SURMONTIL 100 MG CAPSULE MM 4SURMONTIL 25 MG CAPSULE MM 4SURMONTIL 50 MG CAPSULE MM 4SURVANTA 25 MG/ML INTRATRACHEAL SUSPENSION 3SUSTIVA 200 MG CAPSULE SP * QLSUSTIVA 50 MG CAPSULE SP * QLSUSTIVA 600 MG TABLET SP * QLSUTENT 12.5 MG CAPSULE SP,LD * QL,PASUTENT 25 MG CAPSULE SP,LD * QL,PASUTENT 37.5 MG CAPSULE SP,LD * QL,PASUTENT 50 MG CAPSULE SP,LD * QL,PAsyeda 3 mg-0.03 mg tablet MM 1SYLATRON 200 MCG 4-PACK SP,LD * QL,PASYLATRON 200 MCG SUBCUTANEOUS KIT SP,LD * QL,PASYLATRON 300 MCG 4-PACK SP,LD * QL,PASYLATRON 300 MCG SUBCUTANEOUS KIT SP,LD * QL,PASYLATRON 600 MCG SUBCUTANEOUS KIT SP,LD * QL,PAsymax fastabs 0.125 mg disintegrating tablet MM 2symax-sl 0.125 mg sublingual tablet MM 3symax-sr 0.375 mg tablet,extended release MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSSYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER MM 2 QLSYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER MM 2 QLSYMBYAX 12 MG-25 MG CAPSULE MM 3 QLSYMBYAX 12 MG-50 MG CAPSULE MM 3 QLSYMBYAX 3 MG-25 MG CAPSULE MM 3 QLSYMBYAX 6 MG-25 MG CAPSULE MM 3 QLSYMBYAX 6 MG-50 MG CAPSULE MM 3 QLSYMLINPEN 120 2,700 MCG/2.7 ML SUBCUTANEOUS PEN INJECTOR MM 4 QLSYMLINPEN 60 1,500 MCG/1.5 ML SUBCUTANEOUS PEN INJECTOR MM 4 QLSYNALAR 0.01 % TOPICAL SOLUTION 4SYNALAR 0.025 % TOPICAL CREAM 4SYNALAR 0.025 % TOPICAL OINTMENT 4SYNALGOS-DC 356.4 MG-30 MG-16 MG CAPSULE 3 QLSYNAREL 2 MG/ML NASAL SPRAY SP * QL,PASYNERA 70 MG-70 MG PATCH 4 PASYNJARDY 12.5 MG-1,000 MG TABLET 2 QLSYNJARDY 12.5 MG-500 MG TABLET 2 QLSYNJARDY 5 MG-1,000 MG TABLET 2 QLSYNJARDY 5 MG-500 MG TABLET 2 QLSYNTHROID 100 MCG TABLET MM 2SYNTHROID 112 MCG TABLET MM 2SYNTHROID 125 MCG TABLET MM 2SYNTHROID 137 MCG TABLET MM 2SYNTHROID 150 MCG TABLET MM 2SYNTHROID 175 MCG TABLET MM 2SYNTHROID 200 MCG TABLET MM 2SYNTHROID 25 MCG TABLET MM 2SYNTHROID 300 MCG TABLET MM 2SYNTHROID 50 MCG TABLET MM 2SYNTHROID 75 MCG TABLET MM 2SYNTHROID 88 MCG TABLET MM 2SYPRINE 250 MG CAPSULE SP *TABLOID 40 MG TABLET 4 QLTACLONEX 0.005 %-0.064 % TOPICAL OINTMENT 4 QL,STTACLONEX 0.005 %-0.064 % TOPICAL SUSPENSION 4 QL,STtacrolimus 0.03% ointment 3tacrolimus 0.1% ointment 3tacrolimus 0.5 mg capsule 3tacrolimus 1 mg capsule 3tacrolimus 5 mg capsule 3 QLTAFINLAR 50 MG CAPSULE SP,LD * QL,PATAFINLAR 75 MG CAPSULE SP,LD * QL,PATAGRISSO 40 MG TABLET SP,LD * QL,PATAGRISSO 80 MG TABLET SP,LD * QL,PATALTZ AUTOINJECTOR (2 PACK) 80 MG/ML SUBCUTANEOUS SP,LD * QL,PATALTZ AUTOINJECTOR (3 PACK) 80 MG/ML SUBCUTANEOUS SP,LD * QL,PATALTZ AUTOINJECTOR 80 MG/ML SUBCUTANEOUS SP,LD * QL,PATALTZ SYRINGE (2 PACK) 80 MG/ML SUBCUTANEOUS SP,LD * QL,PATALTZ SYRINGE (3 PACK) 80 MG/ML SUBCUTANEOUS SP,LD * QL,PATALTZ SYRINGE 80 MG/ML SUBCUTANEOUS SP,LD * QL,PATAMIFLU 30 MG CAPSULE 3 QLTAMIFLU 45 MG CAPSULE 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTAMIFLU 6 MG/ML ORAL SUSPENSION 3 QLTAMIFLU 75 MG CAPSULE 3 QLtamoxifen 10 mg tablet MM 1tamoxifen 20 mg tablet MM 1tamsulosin hcl 0.4 mg capsule MM 1 QLTANDEM PLUS 162 MG-115.2 MG (106 MG)-1 MG CAPSULE 2TANZEUM 30 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR MM 3 QL,STTANZEUM 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR MM 3 QL,STTAPAZOLE 10 MG TABLET MM 3TAPAZOLE 5 MG TABLET MM 3TARCEVA 100 MG TABLET SP,LD * QL,PATARCEVA 150 MG TABLET SP,LD * QL,PATARCEVA 25 MG TABLET SP,LD * QL,PATARGADOX 50 MG TABLET SP * QL,PATARGRETIN 1 % TOPICAL GEL SP * PATARGRETIN 75 MG CAPSULE SP * QL,PAtarina fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM 1TARKA 1 MG-240 MG TABLET, EXTENDED RELEASE MM 3TARKA 2 MG-180 MG TABLET, EXTENDED RELEASE MM 3TARKA 2 MG-240 MG TABLET, EXTENDED RELEASE MM 3TARKA 4 MG-240 MG TABLET, EXTENDED RELEASE MM 3taron forte 150 mg-60 mg-25 mcg-1 mg capsule 2taron-bc tablet 2taron-c dha 35 mg-1 mg-200 mg capsule 2taron-prex prenatal-dha 30 mg iron-1.2 mg-55 mg-265mg capsule 2TART CHERRY 30 MG-250 MG-75 MG-75 MG CAPSULE 3TASIGNA 150 MG CAPSULE SP * QL,PATASIGNA 200 MG CAPSULE SP * QL,PATASMAR 100 MG TABLET MM 4 QL,PATAZORAC 0.05 % TOPICAL CREAM 4 STTAZORAC 0.05 % TOPICAL GEL 4 STTAZORAC 0.1 % TOPICAL CREAM 4 STTAZORAC 0.1 % TOPICAL GEL 4 STtaztia xt 120 mg capsule,extended release MM 2 QLtaztia xt 180 mg capsule,extended release MM 2 QLtaztia xt 240 mg capsule,extended release MM 2 QLtaztia xt 300 mg capsule,extended release MM 2 QLtaztia xt 360 mg capsule,extended release MM 2 QLTD GOLD BLOOD GLUCOSE MONITOR MM 3 STTD GOLD LEVEL 1 CONTROL SOLUTION 3TD GOLD LEVEL 2 CONTROL SOLUTION 3TD GOLD LEVEL 3 CONTROL SOLUTION 3TD GOLD TEST STRIP MM 3 QL,STTD GOLD VOICE GLUCOSE MONITOR MM 3 STTECFIDERA 120 MG (14)-240 MG (46) CAPSULE,DELAYED RELEASE SP,LD * QL,PATECFIDERA 120 MG CAPSULE,DELAYED RELEASE SP,LD * QL,PATECFIDERA 240 MG CAPSULE,DELAYED RELEASE SP,LD * QL,PATECHLITE LANCETS 25 GAUGE MM 3TECHLITE LANCETS 28 GAUGE MM 3TECHLITE LANCETS 30 GAUGE MM 1TECHLITE PEN NEEDLE 31 GAUGE X 1/4" 1TECHLITE PEN NEEDLE 31 GAUGE X 5/16" 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTECHLITE PEN NEEDLE 32 GAUGE X 1/4" 1TECHLITE PEN NEEDLE 32 GAUGE X 5/16" 1TECHLITE PEN NEEDLE 32 GAUGE X 5/32" 1TECHNIVIE 12.5 MG-75 MG-50 MG TABLET SP * QL,PATEGRETOL 100 MG/5 ML ORAL SUSPENSION MM 3TEGRETOL 200 MG TABLET MM 3TEGRETOL XR 100 MG TABLET,EXTENDED RELEASE MM 3 QLTEGRETOL XR 200 MG TABLET,EXTENDED RELEASE MM 3 QLTEGRETOL XR 400 MG TABLET,EXTENDED RELEASE MM 3 QLTEKAMLO 150 MG-10 MG TABLET MM 2 QLTEKAMLO 150 MG-5 MG TABLET MM 2 QLTEKAMLO 300 MG-10 MG TABLET MM 2 QLTEKAMLO 300 MG-5 MG TABLET MM 2 QLTEKTURNA 150 MG TABLET MM 2 QLTEKTURNA 300 MG TABLET MM 2 QLTEKTURNA HCT 150 MG-12.5 MG TABLET MM 2 QLTEKTURNA HCT 150 MG-25 MG TABLET MM 2 QLTEKTURNA HCT 300 MG-12.5 MG TABLET MM 2 QLTEKTURNA HCT 300 MG-25 MG TABLET MM 2 QLTELCARE BGM KIT MM 3 STTELCARE BLOOD GLUCOSE KIT MM 3 STTELCARE CONTROL SOLUTION 3TELCARE LANCETS 30 GAUGE MM 1TELCARE TEST STRIPS MM 3 QL,STtelmisartan 20 mg tablet MM 3 QLtelmisartan 40 mg tablet MM 3 QLtelmisartan 80 mg tablet MM 3 QLtelmisartan-amlodipine 40-10 MM 3 QL,STtelmisartan-amlodipine 40-5 mg MM 3 QL,STtelmisartan-amlodipine 80-10 MM 3 QL,STtelmisartan-amlodipine 80-5 mg MM 3 QL,STtelmisartan-hctz 40-12.5 mg tb MM 3 QL,STtelmisartan-hctz 80-12.5 mg tb MM 3 QL,STtelmisartan-hctz 80-25 mg tab MM 3 QL,STtemazepam 15 mg capsule 2 QLtemazepam 22.5 mg capsule 2 QLtemazepam 30 mg capsule 2 QLtemazepam 7.5 mg capsule 2 QLTEMODAR 100 MG CAPSULE SP * QL,PATEMODAR 140 MG CAPSULE SP * QL,PATEMODAR 180 MG CAPSULE SP * QL,PATEMODAR 20 MG CAPSULE SP * QL,PATEMODAR 250 MG CAPSULE SP * QL,PATEMODAR 5 MG CAPSULE SP * QL,PATEMOVATE 0.05 % TOPICAL CREAM 4 STTEMOVATE 0.05 % TOPICAL OINTMENT 3 STtemozolomide 100 mg capsule SP * QL,PAtemozolomide 140 mg capsule SP * QL,PAtemozolomide 180 mg capsule SP * QL,PAtemozolomide 20 mg capsule SP * QL,PAtemozolomide 250 mg capsule SP * QL,PAtemozolomide 5 mg capsule SP * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTStencon 50 mg-325 mg tablet 2 QLTENEX 1 MG TABLET MM 3TENEX 2 MG TABLET MM 3TENORETIC 100 100 MG-25 MG TABLET MM 3TENORETIC 50 50 MG-25 MG TABLET MM 3TENORMIN 100 MG TABLET MM 3TENORMIN 25 MG TABLET MM 3TENORMIN 50 MG TABLET MM 3TERAZOL 3 0.8 % VAGINAL CREAM 3TERAZOL 7 0.4 % VAGINAL CREAM 3terazosin 1 mg capsule MM 1terazosin 10 mg capsule MM 1terazosin 2 mg capsule MM 1terazosin 5 mg capsule MM 1terbutaline sulfate 2.5 mg tab MM 2terbutaline sulfate 5 mg tab MM 2terconazole 0.4% cream 2terconazole 0.8% cream 2terconazole 80 mg suppository 3TERUMO INS SYRINGE U100-1 ML MM 2TERUMO INSULIN SYRINGE 0.3 ML 30 X 3/8" MM 2TERUMO INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2TERUMO INSULIN SYRINGE 1 ML 27 GAUGE X 1/2" MM 2TERUMO INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2TERUMO INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2TERUMO INSULIN SYRINGE 1/2 ML 27 GAUGE X 1/2" MM 2TERUMO INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2TERUMO INSULIN SYRINGE 1/2 ML 30 X 3/8" MM 2TESSALON PERLES 100 MG CAPSULE 3TEST N'GO BLOOD GLUCOSE SYSTEM MM 3 STTEST N'GO TEST STRIPS MM 3 QL,STTESTIM 50 MG/5 GRAM (1 %) TRANSDERMAL GEL MM 3 QL,STTESTOPEL 75 MG IMPLANT PELLET LD 4 QL,PAtestosteron cyp 1,000 mg/10 ml MM 2testosterone 10 mg gel pump MM 3 QL,STtestosterone 12.5 mg/1.25 gram MM 3 QL,STtestosterone 25 mg/2.5 gm pkt MM 3 QL,STtestosterone 50 mg/5 gram gel MM 3 QL,STtestosterone 50 mg/5 gram pkt MM 3 QL,STtestosterone cyp 200 mg/ml MM 2testosterone enan 200 mg/ml 2TESTRED 10 MG CAPSULE MM 4tetrabenazine 12.5 mg tablet SP * QL,PAtetrabenazine 25 mg tablet SP * QL,PAtetracycline 250 mg capsule 3tetracycline 500 mg capsule 3TEV-TROPIN 5 MG VIAL SP * QL,PATEVETEN 600 MG TABLET MM 3 QL,STTEVETEN HCT 600-25 MG TAB MM 3 QL,STTEXACORT 2.5 % TOPICAL SOLUTION 4TEXAVITE LQ 7 MG-0.25 MG/ML ORAL DROPS 3THALOMID 100 MG CAPSULE SP,LD * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTHALOMID 150 MG CAPSULE SP,LD * QL,PATHALOMID 200 MG CAPSULE SP,LD * QL,PATHALOMID 50 MG CAPSULE SP,LD * QL,PATHEO-24 100 MG CAPSULE,EXTENDED RELEASE MM 3THEO-24 200 MG CAPSULE,EXTENDED RELEASE MM 3THEO-24 300 MG CAPSULE,EXTENDED RELEASE MM 3THEO-24 400 MG CAPSULE,EXTENDED RELEASE MM 3theochron 100 mg tablet,extended release MM 1theochron 200 mg tablet,extended release MM 1theochron 300 mg tablet,extended release MM 1theophylline 80 mg/15 ml soln MM 2theophylline 80 mg/15 ml soln MM 2theophylline er 100 mg tablet MM 2theophylline er 200 mg tablet MM 2theophylline er 300 mg tab MM 2theophylline er 400 mg tablet 2theophylline er 450 mg tab MM 2theophylline er 600 mg tablet 2THERA TEARS NUTRITION 150 MG-100 MG-333 MG-61 UNIT CAPSULE 3THERMAZENE 1 % TOPICAL CREAM 2thiamine 200 mg/2 ml vial 2thickenup apple honey oral liquid 2thickenup apple nectar oral liquid 2THICKENUP CRANBERRY HONEY ORAL LIQUID 3THICKENUP CRANBERRY NECTAR ORAL LIQUID 3thickenup orange honey oral liquid 2thickenup orange nectar oral liquid 2THIN LANCETS 26 GAUGE MM 1THINPRO INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2THINPRO INSULIN SYRINGE 0.3 ML 30 X 3/8" MM 2THINPRO INSULIN SYRINGE 0.3 ML 31 X 3/8" MM 2THINPRO INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2THINPRO INSULIN SYRINGE 0.5 ML 31 X 3/8" MM 2THINPRO INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2THINPRO INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2THINPRO INSULIN SYRINGE 1 ML 30 GAUGE X 3/8" MM 2THINPRO INSULIN SYRINGE 1 ML 31 X 3/8" MM 2THINPRO INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2THINPRO INSULIN SYRINGE 1/2 ML 30 X 3/8" MM 2THINSET RESERVOIR 1.8 ML MM 2THINSET RESERVOIR 3 ML MM 2THIOLA 100 MG TABLET 4thioridazine 10 mg tablet MM 2thioridazine 100 mg tablet MM 2thioridazine 25 mg tablet MM 2thioridazine 50 mg tablet MM 2thiothixene 1 mg capsule MM 2thiothixene 10 mg capsule MM 2thiothixene 2 mg capsule MM 2thiothixene 5 mg capsule MM 2THRESHOLD IMT TRAINER DEVICE 1THRESHOLD PEP DEVICE 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSthrivite-19 29 mg iron-1 mg-25 mg tablet 2THYROLAR-1 12.5 MCG-50 MCG TABLET MM 3THYROLAR-1/2 6.25 MCG-25 MCG TABLET MM 3THYROLAR-1/4 3.1 MCG-12.5 MCG TABLET MM 3THYROLAR-2 25 MCG-100 MCG TABLET MM 3THYROLAR-3 37.5 MCG-150 MCG TABLET MM 3tiagabine hcl 2 mg tablet MM 3tiagabine hcl 4 mg tablet MM 3 QLTIAZAC 120 MG CAPSULE,EXTENDED RELEASE MM 4 QLTIAZAC 180 MG CAPSULE,EXTENDED RELEASE MM 4 QLTIAZAC 240 MG CAPSULE,EXTENDED RELEASE MM 4 QLTIAZAC 300 MG CAPSULE,EXTENDED RELEASE MM 4 QLTIAZAC 360 MG CAPSULE,EXTENDED RELEASE MM 4 QLTIAZAC 420 MG CAPSULE,EXTENDED RELEASE MM 4 QLticlopidine 250 mg tablet MM 2TIGAN 300 MG CAPSULE 3TIKOSYN 125 MCG CAPSULE 3 QLTIKOSYN 250 MCG CAPSULE 3 QLTIKOSYN 500 MCG CAPSULE 3 QLtilia fe 1-20 (5)/1-30(7)/1mg-35mcg(9) tablet MM 1timolol 0.25% eye drops MM 1timolol 0.25% gel-solution MM 3timolol 0.5% eye drops MM 1timolol 0.5% gel-solution MM 3timolol maleate 10 mg tablet MM 2timolol maleate 20 mg tablet MM 2timolol maleate 5 mg tablet MM 2TIMOPTIC 0.25 % EYE DROPS MM 3TIMOPTIC 0.5 % EYE DROPS MM 3TIMOPTIC OCUDOSE (PF) 0.25 % EYE DROPS IN A DROPPERETTE MM 3TIMOPTIC OCUDOSE (PF) 0.5 % EYE DROPS IN A DROPPERETTE MM 3TIMOPTIC-XE 0.25 % EYE GEL MM 3TIMOPTIC-XE 0.5 % EYE GEL MM 3TINDAMAX 250 MG TABLET 3TINDAMAX 500 MG TABLET 3tinidazole 250 mg tablet 3tinidazole 500 mg tablet 3TIROSINT 100 MCG CAPSULE MM 3TIROSINT 112 MCG CAPSULE MM 3TIROSINT 125 MCG CAPSULE MM 3TIROSINT 13 MCG CAPSULE MM 3TIROSINT 137 MCG CAPSULE MM 3TIROSINT 150 MCG CAPSULE MM 3TIROSINT 25 MCG CAPSULE MM 3TIROSINT 50 MCG CAPSULE MM 3TIROSINT 75 MCG CAPSULE MM 3TIROSINT 88 MCG CAPSULE MM 3TIS-U-SOL PENTALYTE 800-40-20-8.75-6.25 MG/100 ML IRRIGATION SOLUTION 3TIVICAY 10 MG TABLET 4 QLTIVICAY 25 MG TABLET 4 QLTIVICAY 50 MG TABLET SP * QLTIVORBEX 20 MG CAPSULE 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTIVORBEX 40 MG CAPSULE 3 QL,STtizanidine hcl 2 mg capsule MM 3 STtizanidine hcl 2 mg tablet MM 1tizanidine hcl 4 mg capsule MM 3 STtizanidine hcl 4 mg tablet MM 1tizanidine hcl 6 mg capsule MM 3 STTL FOLATE TABLET 3tl gard rx 2.2 mg-25 mg-1 mg tablet 3tl icon 110 mg-0.5 mg capsule 2tl-care dha softgel 2tl-fluorivite chewable tablet 3tl-hem 150 150 mg-1 mg-50 mg tablet,extended release 1TL-ICARE 3.33 MG-200 MG CAPSULE 3tl-select 29 mg-1.25 mg-55 mg-325 mg capsule 2TOBI 300 MG/5 ML SOLUTION FOR NEBULIZATION SP,LD * QL,PATOBI PODHALER 28 MG CAPSULE WITH INHALATION DEVICE SP,LD * QL,PATOBI PODHALER 28 MG CAPSULES FOR INHALATION SP,LD * QL,PATOBRADEX 0.3 %-0.1 % EYE DROPS,SUSPENSION 3TOBRADEX 0.3 %-0.1 % EYE OINTMENT 3TOBRADEX ST 0.3 %-0.05 % EYE DROPS,SUSPENSION 3tobramycin 0.3% eye drops 2tobramycin 300 mg/5 ml ampule SP * QL,PAtobramycin pak 300 mg/5 ml SP * QL,PAtobramycin-dexameth ophth susp 3TOBREX 0.3 % EYE DROPS 3TOBREX 0.3 % EYE OINTMENT 3TOFRANIL 10 MG TABLET MM 3TOFRANIL 25 MG TABLET MM 3TOFRANIL 50 MG TABLET MM 3TOFRANIL-PM 100 MG CAPSULE MM 4TOFRANIL-PM 125 MG CAPSULE MM 4TOFRANIL-PM 150 MG CAPSULE MM 4TOFRANIL-PM 75 MG CAPSULE MM 4TOLAK 4 % TOPICAL CREAM 3tolazamide 250 mg tablet MM 1tolazamide 500 mg tablet MM 1tolbutamide 500 mg tablet MM 1tolcapone 100 mg tablet MM 4 QL,PAtolmetin sodium 200 mg tab MM 3tolmetin sodium 400 mg cap MM 3tolmetin sodium 600 mg tab MM 3tolterodine tart er 2 mg cap MM 3 QLtolterodine tart er 4 mg cap MM 3 QLtolterodine tartrate 1 mg tab MM 3 QLtolterodine tartrate 2 mg tab MM 3 QLtonalin cla 1,000 mg capsule 2TOOMEY SYRINGE 70 ML 1TOPAMAX 100 MG TABLET MM 4 QLTOPAMAX 15 MG SPRINKLE CAPSULE MM 4 QLTOPAMAX 200 MG TABLET MM 4 QLTOPAMAX 25 MG SPRINKLE CAPSULE MM 4 QLTOPAMAX 25 MG TABLET MM 4 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTOPAMAX 50 MG TABLET MM 4 QLTOPCARE CLICKFINE 31 GAUGE X 1/4" NEEDLE 1TOPCARE CLICKFINE 31 GAUGE X 5/16" NEEDLE 1TOPCARE ULTRA COMFORT 0.3 ML 29 GAUGE X 1/2" SYRINGE MM 2TOPCARE ULTRA COMFORT 0.3 ML 30 GAUGE X 5/16" SYRINGE MM 2TOPCARE ULTRA COMFORT 0.3 ML 31 GAUGE X 5/16" SYRINGE MM 2TOPCARE ULTRA COMFORT 0.5 ML 29 GAUGE X 1/2" SYRINGE MM 2TOPCARE ULTRA COMFORT 0.5 ML 31 GAUGE X 5/16" SYRINGE MM 2TOPCARE ULTRA COMFORT 1 ML 29 GAUGE X 1/2" SYRINGE MM 2TOPCARE ULTRA COMFORT 1 ML 30 GAUGE X 5/16" SYRINGE MM 2TOPCARE ULTRA COMFORT 1 ML 31 GAUGE X 5/16" SYRINGE MM 2TOPCARE ULTRA COMFORT 1/2 ML 30 GAUGE X 5/16" SYRINGE MM 2TOPCARE UNIVERSAL1 LANCET MM 1TOPCARE UNIVERSAL1 LANCET 33 GAUGE MM 1TOPICORT 0.05 % TOPICAL CREAM 4 STTOPICORT 0.05 % TOPICAL GEL 4 STTOPICORT 0.05 % TOPICAL OINTMENT 4 STTOPICORT 0.25 % TOPICAL CREAM 4 STTOPICORT 0.25 % TOPICAL OINTMENT 4 STTOPICORT 0.25 % TOPICAL SPRAY 4 STtopiragen 100 mg tablet MM 1 QLtopiragen 200 mg tablet MM 1 QLtopiragen 25 mg tablet MM 1 QLtopiragen 50 mg tablet MM 1 QLtopiramate 100 mg tablet MM 1 QLtopiramate 15 mg sprinkle cap MM 2 QLtopiramate 200 mg tablet MM 1 QLtopiramate 25 mg sprinkle cap MM 2 QLtopiramate 25 mg tablet MM 1 QLtopiramate 50 mg tablet MM 1 QLtopiramate er 100 mg capsule MM 3 QL,STtopiramate er 150 mg capsule MM 3 QL,STtopiramate er 200 mg capsule MM 3 QL,STtopiramate er 25 mg capsule MM 3 QL,STtopiramate er 50 mg capsule MM 3 QL,STTOPROL XL 100 MG TABLET,EXTENDED RELEASE MM 3 QLTOPROL XL 200 MG TABLET,EXTENDED RELEASE MM 3 QLTOPROL XL 25 MG TABLET,EXTENDED RELEASE MM 3 QLTOPROL XL 50 MG TABLET,EXTENDED RELEASE MM 3 QLtorsemide 10 mg tablet MM 1torsemide 100 mg tablet MM 1torsemide 20 mg tablet MM 1torsemide 5 mg tablet MM 1TOUJEO SOLOSTAR 300 UNIT/ML (1.5 ML) SUBCUTANEOUS INSULIN PEN 2TOVIAZ 4 MG TABLET,EXTENDED RELEASE MM 2 QLTOVIAZ 8 MG TABLET,EXTENDED RELEASE MM 2 QLTOZAL 3.33 MG-200 MG CAPSULE 3TRACLEER 125 MG TABLET SP,LD * QL,PATRACLEER 62.5 MG TABLET SP,LD * QL,PATRADJENTA 5 MG TABLET MM 2 QLtramadol er 100 mg tablet 3 QL,STtramadol er 200 mg tablet 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTStramadol er 300 mg tablet 3 QL,STtramadol hcl 50 mg tablet 2 QLtramadol hcl er 100 mg capsule 3 QL,STtramadol hcl er 100 mg tablet 3 QL,STtramadol hcl er 150 mg capsule 3 QL,STtramadol hcl er 200 mg capsule 3 QL,STtramadol hcl er 200 mg tablet 3 QL,STtramadol hcl er 300 mg capsule 3 QL,STtramadol hcl er 300 mg tablet 3 QL,STtramadol-acetaminophn 37.5-325 2 QLTRANDATE 100 MG TABLET MM 3TRANDATE 200 MG TABLET MM 3TRANDATE 300 MG TABLET MM 3trandolapr-verapam er 1-240 mg MM 3trandolapr-verapam er 2-180 mg MM 3trandolapr-verapam er 2-240 mg MM 3trandolapr-verapam er 4-240 mg MM 3trandolapril 1 mg tablet MM 1trandolapril 2 mg tablet MM 1trandolapril 4 mg tablet MM 1tranexamic acid 650 mg tablet MM 3 QLTRANSDERM-SCOP 1.5 MG TRANSDERMAL PATCH (1 MG OVER 3 DAYS) 3 QLTRANXENE T-TAB 3.75 MG TABLET 3TRANXENE T-TAB 7.5 MG TABLET 3tranylcypromine sulf 10 mg tab MM 3 QLTRAVATAN Z 0.004 % EYE DROPS MM 2 QLtravoprost 0.004% eye drop MM 3 QLtrazodone 100 mg tablet MM 1trazodone 150 mg tablet MM 1trazodone 300 mg tablet MM 1trazodone 50 mg tablet MM 1TRECATOR 250 MG TABLET 2TRESIBA FLEXTOUCH U-100 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN 2 QLTRESIBA FLEXTOUCH U-200 200 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN 2 QLTRETIN-X 0.0375 % TOPICAL CREAM 3 STTRETIN-X 0.075 % TOPICAL CREAM 3 STtretinoin 0.01% gel 3tretinoin 0.025% cream 3tretinoin 0.025% gel 3tretinoin 0.05% cream 3tretinoin 0.05% gel 3tretinoin 0.1% cream 3tretinoin 10 mg capsule SP * QL,PAtretinoin gel micro 0.04% pump 4 PAtretinoin gel micro 0.04% tube 4 PAtretinoin gel micro 0.1% pump 4 PAtretinoin gel micro 0.1% tube 4 PATREXALL 10 MG TABLET MM 3 QLTREXALL 15 MG TABLET MM 3 QLTREXALL 5 MG TABLET MM 3 QLTREXALL 7.5 MG TABLET MM 3 QLTREXIMET 85 MG-500 MG TABLET 4 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTREZIX 320.5 MG-30 MG-16 MG CAPSULE 3 QLtri-estarylla 0.18/0.215/0.25 mg-35 mcg(28) tablet MM 1tri-legest fe 1-20 (5)/1-30(7)/1mg-35mcg(9) tablet MM 1tri-linyah (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM 1tri-lo-estarylla 0.18 mg/0.215 mg/0.25 mg-25 mcg tablet MM 1tri-lo-marzia 0.18 mg/0.215 mg/0.25 mg-25 mcg tablet MM 1tri-lo-sprintec 0.18 mg/0.215 mg/0.25 mg-25 mcg tablet MM 1TRI-NORINYL (28) 0.5 MG/1 MG/0.5 MG-35 MCG TABLET MM 3tri-previfem (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM 1tri-sprintec (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM 1tri-tabs dha 32 mg-1,000 mcg-230 mg oral pack 2tri-vit with fluoride and iron 0.25 mg-10 mg/ml oral drops 3 QLtri-vitamin with fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops 3 QLtri-vitamin with fluoride 0.5 mg fluoride (1.1 mg)/ml oral drops 3 QLtriadvance 90 mg-1 mg-50 mg tablet 1triamcinolone 0.025% cream 1triamcinolone 0.025% lotion 2triamcinolone 0.025% oint 1triamcinolone 0.1% cream 1triamcinolone 0.1% lotion 2triamcinolone 0.1% ointment 1triamcinolone 0.1% paste 2triamcinolone 0.147 mg/g spray 3 STtriamcinolone 0.5% cream 1triamcinolone 0.5% ointment 1triamcinolone 55 mcg nasal spr MM 3 QL,STtriamterene-hctz 37.5-25 mg cp MM 1triamterene-hctz 37.5-25 mg tb MM 1triamterene-hctz 50-25 mg cap MM 1triamterene-hctz 75-50 mg tab MM 1trianex 0.05 % topical ointment 4 STtriazolam 0.125 mg tablet 2 QLtriazolam 0.25 mg tablet 2 QLTRIBENZOR 20 MG-5 MG-12.5 MG TABLET MM 3 QL,STTRIBENZOR 40 MG-10 MG-12.5 MG TABLET MM 3 QL,STTRIBENZOR 40 MG-10 MG-25 MG TABLET MM 3 QL,STTRIBENZOR 40 MG-5 MG-12.5 MG TABLET MM 3 QL,STTRIBENZOR 40 MG-5 MG-25 MG TABLET MM 3 QL,STTRICARE 27 MG IRON-1 MG TABLET 2TRICARE PRENATAL DHA ONE 27 MG-1 MG-25 MG-500 MG CAPSULE 2TRICARE PRENATAL WITH DHA 4.5 MG-1 MG-150 MG COMBO PACK,TABCHEW,AMPUL

3

tricon 110 mg-0.5 mg capsule 1TRICOR 145 MG TABLET MM 3 QLTRICOR 48 MG TABLET MM 3 QLtriderm 0.1 % topical cream 1trifluoperazine 1 mg tablet MM 2trifluoperazine 10 mg tablet MM 2trifluoperazine 2 mg tablet MM 2trifluoperazine 5 mg tablet MM 2trifluridine 1% eye drops 3trigels-f forte 460 mg-60 mg-0.01 mg-1 mg capsule 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTRIGLIDE 160 MG TABLET MM 3 QLtrihexyphenidyl 2 mg tablet MM 1trihexyphenidyl 2 mg/5 ml elx MM 2trihexyphenidyl 5 mg tablet MM 1TRILEPTAL 150 MG TABLET MM 4TRILEPTAL 300 MG TABLET MM 4TRILEPTAL 300 MG/5 ML ORAL SUSPENSION MM 3TRILEPTAL 600 MG TABLET MM 4TRILIPIX 135 MG CAPSULE,DELAYED RELEASE MM 3 QLTRILIPIX 45 MG CAPSULE,DELAYED RELEASE MM 3 QLtrilyte with flavor packets 420 gram oral solution 2trimethobenzamide 300 mg cap 2trimethoprim 100 mg tablet 2trimipramine maleate 100 mg cp MM 3trimipramine maleate 25 mg cap MM 3trimipramine maleate 50 mg cap MM 3trinatal gt 90 mg-1 mg-50 mg tablet 1trinatal rx 1 60 mg iron-1 mg tablet 1TRINATE 28 MG-1 MG TABLET 1trinessa (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM 1trinessa lo 0.18 mg/0.215 mg/0.25 mg-25 mcg tablet MM 1TRINTELLIX 10 MG TABLET MM 3 QL,STTRINTELLIX 20 MG TABLET MM 3 QL,STTRINTELLIX 5 MG TABLET MM 3 QL,STtriphrocaps 1 mg capsule 3triple vitamin with fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops 3 QLTRISTART DHA 31 MG IRON-1 MG-200 MG CAPSULE 3TRIUMEQ 600 MG-50 MG-300 MG TABLET SP * QLtriveen-duo dha 29 mg-1 mg-400 mg oral pack 2triveen-one 27 mg-1 mg-250 mg capsule 3triveen-prx rnf 26 mg-1.2 mg-55 mg-300 mg capsule 1trivora (28) 50-30 (6)/75-40(5)/125-30(10) tablet MM 1TRIZIVIR 300 MG-150 MG-300 MG TABLET 4 QLTROKENDI XR 100 MG CAPSULE, EXTENDED RELEASE MM 4 QL,STTROKENDI XR 200 MG CAPSULE, EXTENDED RELEASE MM 4 QL,STTROKENDI XR 25 MG CAPSULE,EXTENDED RELEASE MM 4 QL,STTROKENDI XR 50 MG CAPSULE, EXTENDED RELEASE MM 4 QL,STTROMBONEX 150 MG-150 MG-150 MG-150 MG-150 MG CAPSULE 3TROMBONEX-D 75 MG-375 MG-50 MG-100 MG CAPSULE 3TROPHAMINE 10 % INTRAVENOUS SOLUTION 3TROPHAMINE 6% INTRAVENOUS SOLUTION 3tropicamide 0.5% eye drops MM 2tropicamide 1% eye drops MM 2trospium chloride 20 mg tablet MM 3 QLtrospium chloride er 60 mg cap MM 3 QLTRUE METRIX AIR GLUCOSE METER MM 1TRUE METRIX AIR GLUCOSE METER KIT MM 1TRUE METRIX GLUCOSE METER MM 1TRUE METRIX GLUCOSE TEST STRIP MM 1 QLTRUE METRIX LEVEL 1 SOLUTION 3TRUE METRIX LEVEL 2 SOLUTION 3TRUE METRIX LEVEL 3 SOLUTION 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTRUE2GO BLOOD GLUCOSE SYSTEM KIT MM 1TRUECONTROL LEVEL 0 SOLUTION 3TRUECONTROL LEVEL 1 SOLUTION 3TRUEDRAW LANCING DEVICE MM 1TRUEPLUS INSULIN 0.3 ML 29 GAUGE X 1/2" SYRINGE MM 2TRUEPLUS INSULIN 0.3 ML 30 GAUGE X 5/16" SYRINGE MM 2TRUEPLUS INSULIN 0.3 ML 31 GAUGE X 5/16" SYRINGE MM 2TRUEPLUS INSULIN 0.5 ML 29 GAUGE X 1/2" SYRINGE MM 2TRUEPLUS INSULIN 0.5 ML 31 GAUGE X 5/16" SYRINGE MM 2TRUEPLUS INSULIN 1 ML 28 GAUGE X 1/2" SYRINGE MM 2TRUEPLUS INSULIN 1 ML 29 GAUGE X 1/2" SYRINGE MM 2TRUEPLUS INSULIN 1 ML 30 GAUGE X 5/16" SYRINGE MM 2TRUEPLUS INSULIN 1 ML 31 GAUGE X 5/16" SYRINGE MM 2TRUEPLUS INSULIN 1/2 ML 28 GAUGE X 1/2" SYRINGE MM 2TRUEPLUS INSULIN 1/2 ML 30 GAUGE X 5/16" SYRINGE MM 2TRUEPLUS LANCETS 26 GAUGE MM 1TRUEPLUS LANCETS 28 GAUGE MM 1TRUEPLUS LANCETS 30 GAUGE MM 1TRUEPLUS LANCETS 33 GAUGE MM 1TRUERESULT BLOOD GLUCOSE SYSTEM MM 1TRUERESULT BLOOD GLUCOSE SYSTEM KIT MM 1TRUETEST HIGH GLUCOSE CONTROL SOLUTION 3TRUETEST LOW GLUCOSE CONTROL SOLUTION 3TRUETEST NORMAL GLUCOSE CONTROL SOLUTION 3TRUETEST TEST STRIPS MM 1 QLTRUETRACK BLOOD GLUCOSE SYSTEM KIT MM 1TRUETRACK SMART SYSTEM KIT MM 1TRUETRACK TEST STRIPS MM 1 QLTRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 2 QLTRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 2 QLTRUSOPT 2 % EYE DROPS MM 3 QLtrust natal dha 29 mg-1 mg-250 mg oral pack 2TRUVADA 100 MG-150 MG TABLET 4 QLTRUVADA 133 MG-200 MG TABLET 4 QLTRUVADA 167 MG-250 MG TABLET 4 QLTRUVADA 200 MG-300 MG TABLET SP * QLTRUZONE PEAK FLOW METER 1TUBERCULIN SYRINGE 1 ML 25 GAUGE X 1" 1TUDORZA PRESSAIR 400 MCG/ACTUATION BREATH ACTIVATED MM 3 QLTUSSICAPS 10 MG-8 MG CAPSULE,EXTENDED RELEASE 4 QLTUSSICAPS 5 MG-4 MG CAPSULE,EXTENDED RELEASE 4 QLtussigon 5 mg-1.5 mg tablet 3TUSSIONEX PENNKINETIC ER 10 MG-8 MG/5 ML SUSPENSION,EXTENDED RELEASE 3TUZISTRA XR 14.7 MG-2.8 MG/5 ML ORAL SUSPENSION,EXTENDED RELEASE 3TWOCAL HN 0.08 GRAM-2 KCAL/ML ORAL LIQUID 3TWYNSTA 40 MG-10 MG TABLET MM 3 QL,STTWYNSTA 40 MG-5 MG TABLET MM 3 QL,STTWYNSTA 80 MG-10 MG TABLET MM 3 QL,STTWYNSTA 80 MG-5 MG TABLET MM 3 QL,STTYBOST 150 MG TABLET 3 QLTYKERB 250 MG TABLET SP,LD * QL,PATYLENOL-CODEINE #3 300 MG-30 MG TABLET 3 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSTYLENOL-CODEINE #4 300 MG-60 MG TABLET 3 QLTYVASO 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION SP,LD * QL,PATYVASO INSTITUTIONAL STARTER KIT 1.74 MG/2.9 ML SOLN FOR NEBULIZATIONSP,LD

* QL,PA

TYVASO REFILL KIT 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATIONSP,LD

* QL,PA

TYVASO STARTER KIT 1.74 MG/2.9 ML SOLUTION FOR NEBULIZATION SP,LD * QL,PATYZEKA 600 MG TABLET SP * QLTYZINE 0.1 % NASAL DROPS 2TYZINE 0.1 % NASAL SPRAY 2UCERIS 2 MG/ACTUATION RECTAL FOAM 3 PAUCERIS 9 MG TABLET, EXTENDED RELEASE 4 QL,PAULESFIA 5 % LOTION 3ULORIC 40 MG TABLET MM 2 QL,STULORIC 80 MG TABLET MM 2 QL,STULTI-LANCE KIT MM 3ULTI-LANCE MISC MM 3ULTICARE 0.3 ML 29 X 1/2" SYRINGE MM 2ULTICARE 0.3 ML 30 GAUGE X 1/2" SYRINGE MM 2ULTICARE 0.3 ML 30 X 5/16" SYRINGE MM 2ULTICARE 0.3 ML 31 GAUGE X 5/16" SYRINGE MM 2ULTICARE 0.5 ML 31 GAUGE X 5/16" SYRINGE MM 2ULTICARE 1 ML 25 GAUGE X 5/8" SYRINGE 2ULTICARE 1 ML 29 X 1/2" SYRINGE MM 2ULTICARE 1 ML 30 GAUGE X 1/2" SYRINGE MM 2ULTICARE 1 ML 30 GAUGE X 5/16" SYRINGE MM 2ULTICARE 1 ML 31 GAUGE X 5/16" SYRINGE MM 2ULTICARE 1.5 ML 22 GAUGE X 1 1/2" SYRINGE 2ULTICARE 1/2 ML 29 X 1/2" SYRINGE MM 2ULTICARE 1/2 ML 30 GAUGE X 1/2" SYRINGE MM 2ULTICARE 1/2 ML 30 GAUGE X 5/16" SYRINGE MM 2ULTICARE INSULIN SYRINGE 0.3 ML 31 GAUGE X 1/4" MM 2ULTICARE INSULIN SYRINGE 1 ML 31 GAUGE X 1/4" MM 2ULTICARE INSULIN SYRINGE 1/2 ML 31 GAUGE X 1/4" MM 2ULTICARE INSULIN SYRINGE HALF UNIT 0.3 ML 31 GAUGE X 1/4" MM 2ULTICARE PEN NEEDLE 29 GAUGE X 1/2" 2ULTICARE PEN NEEDLE 31 GAUGE X 1/4" 2ULTICARE PEN NEEDLE 31 GAUGE X 5/16" 2ULTICARE PEN NEEDLE 32 GAUGE X 5/32" 2ULTICARE SYR 0.5 ML 29GX1/2" MM 2ULTICARE SYRIN 0.5 ML 28GX1/2" MM 2ULTILET ALCOHOL SWAB 3ULTILET BASIC LANCETS 30 GAUGE MM 1ULTILET CLASSIC LANCETS MM 1ULTILET CLASSIC LANCETS 28 GAUGE MM 1ULTILET CLASSIC LANCETS 30 GAUGE MM 1ULTILET CLASSIC LANCETS 33 GAUGE MM 1ULTILET INSULIN SYRINGE 0.3 ML 29 GAUGE MM 2ULTILET INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2ULTILET INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2ULTILET INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2ULTILET INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSULTILET INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2ULTILET INSULIN SYRINGE 1 ML 29 GAUGE MM 2ULTILET INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2ULTILET INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2ULTILET INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2ULTILET INSULIN SYRINGE 1/2 ML 29 MM 2ULTILET INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2ULTILET LANCETS 28 GAUGE MM 1ULTILET LANCETS 30 GAUGE MM 1ULTILET LANCETS 33 GAUGE MM 1ULTILET PEN NEEDLE 29 GAUGE 1ULTILET PEN NEEDLE 32 GAUGE X 5/32" 1ULTILET SAFETY LANCETS 23 GAUGE MM 1ULTIMA MONITOR MM 3 STULTIMA TEST STRIPS MM 3 QL,STultimatecare one 27 mg-1 mg-330 mg capsule 2ultimatecare one nf 27 mg-1 mg-50 mg-500 mg capsule 2ULTRA COMFORT 3/10 ML SYR MM 2ULTRA COMFORT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 2ULTRA COMFORT INSULIN SYRINGE 0.3 ML 30 MM 2ULTRA COMFORT INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 2ULTRA COMFORT INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 28 GAUGE MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 28 GAUGE X 1/2" MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 29 GAUGE MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 7/16" MM 2ULTRA COMFORT INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 GAUGE MM 2ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 GAUGE X 1/2" MM 2ULTRA COMFORT INSULIN SYRINGE 1/2 ML 29 MM 2ULTRA COMFORT INSULIN SYRINGE 1/2 ML 30 GAUGE MM 2ULTRA COMFORT INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 GAUGE X 1/2" MM 2ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 30 GAUGE X 5/16" MM 2ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 GAUGE X 5/16" MM 2ultra men's pack 200 mcg-1,600 unit-300 mg oral pack 2ULTRA THIN II LANCETS 30 GAUGE MM 1ULTRA THIN LANCETS MM 1ULTRA THIN LANCETS 28 GAUGE MM 1ULTRA THIN LANCETS 30 GAUGE MM 1ULTRA THIN LANCETS 31 GAUGE MM 1ULTRA THIN LANCETS 33 GAUGE MM 1ULTRA THIN PLUS LANCETS 33 GAUGE MM 1ULTRA TLC LANCETS MM 3ULTRA-THIN II (SHORT) INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16" MM 1ULTRA-THIN II (SHORT) INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16" MM 1ULTRA-THIN II (SHORT) INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16" MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSULTRA-THIN II (SHORT) INSULIN SYRINGE 1 ML 30 GAUGE X 5/16" MM 1ULTRA-THIN II (SHORT) INSULIN SYRINGE 1 ML 31 GAUGE X 5/16" MM 1ULTRA-THIN II (SHORT) INSULIN SYRINGE 1/2 ML 30 GAUGE X 5/16" MM 1ULTRA-THIN II (SHORT) PEN NDL 31 GAUGE X 5/16" NEEDLE 1ULTRA-THIN II INSULIN PEN NEEDLES 29 GAUGE X 1/2" 1ULTRA-THIN II INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" MM 1ULTRA-THIN II INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2" MM 1ULTRA-THIN II INSULIN SYRINGE 1 ML 29 GAUGE X 1/2" MM 1ULTRA-THIN II LANCETS 26 GAUGE MM 1ULTRA-THIN II LANCETS 28 GAUGE MM 1ULTRACET 37.5 MG-325 MG TABLET 3 QLULTRALANCE LANCETS 26 GAUGE MM 1ULTRALANCE LANCETS 28 GAUGE MM 1ULTRAM 50 MG TABLET 3 QLULTRAM ER 100 MG TABLET 3 QL,STULTRAM ER 200 MG TABLET 3 QL,STULTRAM ER 300 MG TABLET,EXTENDED RELEASE 3 QL,STultramino oral powder 2ULTRATRAK GLUCOSE METER MM 3 STULTRATRAK GLUCOSE METER KIT MM 3 STULTRATRAK HIGH-LOW CONTROL SOLUTION 3ULTRATRAK NORMAL CONTROL SOLUTION 3ULTRATRAK STRIPS MM 3 QL,STULTRATRAK ULTIMATE MM 3 STULTRATRAK ULTIMATE SOLUTION 3ULTRATRAK ULTIMATE STRIPS MM 3 QL,STULTRAVATE 0.05 % LOTION 4ULTRAVATE 0.05 % TOPICAL CREAM 4ULTRAVATE 0.05 % TOPICAL OINTMENT 4ULTRESA DR 13,800 UNIT CAPSULE MM 3 STULTRESA DR 20,700 UNIT CAPSULE MM 3 STULTRESA DR 23,000 UNIT CAPSULE MM 3 STUNIFINE PENTIPS 29 GAUGE NEEDLE 1UNIFINE PENTIPS 29 GAUGE X 1/2" NEEDLE 1UNIFINE PENTIPS 29 GAUGE X 5/16" NEEDLE 1UNIFINE PENTIPS 30 GAUGE X 5/16" NEEDLE 1UNIFINE PENTIPS 31 GAUGE X 1/4" NEEDLE 1UNIFINE PENTIPS 31 GAUGE X 3/16" NEEDLE 1UNIFINE PENTIPS 31 GAUGE X 5/16" NEEDLE 1UNIFINE PENTIPS 32 GAUGE X 5/32" NEEDLE 1UNIFINE PENTIPS PLUS 29 GAUGE X 1/2" NEEDLE MM 1UNIFINE PENTIPS PLUS 31 GAUGE X 1/4" NEEDLE MM 1UNIFINE PENTIPS PLUS 31 GAUGE X 3/16" NEEDLE MM 1UNIFINE PENTIPS PLUS 31 GAUGE X 5/16" NEEDLE MM 1UNIFINE PENTIPS PLUS 32 GAUGE X 5/32" NEEDLE MM 1UNILET COMFORTOUCH LANCET MM 1UNILET COMFORTOUCH LANCET 26 GAUGE MM 1UNILET EXCELITE II LANCET MM 3UNILET EXCELITE LANCET MM 3UNILET GP LANCET MM 1UNILET LANCET MM 3UNILET LANCET 28 GAUGE MM 1ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSUNILET LANCET 33 GAUGE MM 1UNILET LANCETS 30 GAUGE MM 3UNILET SUPER THIN LANCETS 30 GAUGE MM 1UNIRETIC 15-12.5 TABLET MM 3UNISTIK 2 DEVICE KIT MM 3UNISTIK 2 EXTRA KIT MM 1UNISTIK 2 NORMAL LANCET AND DEVICE KIT MM 1UNISTIK 3 COMFORT DEVICE KIT MM 3UNISTIK 3 COMFORT LANCET MM 1UNISTIK 3 EXTRA LANCET 21 GAUGE MM 1UNISTIK 3 GENTLE 30 GAUGE MM 3UNISTIK 3 KIT MM 3UNISTIK 3 LANCETS 21 GAUGE MM 1UNISTIK 3 NEONATAL DEVICE KIT MM 3UNISTIK 3 NEONATAL KIT MM 3UNISTIK 3 NORMAL LANCET 23 GAUGE MM 1UNISTIK CZT LANCET 23 GAUGE MM 1UNISTIK CZT LANCET 28 GAUGE MM 1UNISTIK SAFETY 28 GAUGE MM 1UNISTIK SAFETY 30 GAUGE MM 1UNISTIK TOUCH LANCETS 21 GAUGE MM 1UNISTIK TOUCH LANCETS 23 GAUGE MM 1UNISTIK TOUCH LANCETS 28 GAUGE MM 1UNISTIK TOUCH LANCETS 30 GAUGE MM 1UNISTRIP HIGH CONTROL SOLUTION 3UNISTRIP LOW CONTROL SOLUTION 3UNISTRIP1 TEST STRIP MM 3 QL,STUNITHROID 100 MCG TABLET MM 2UNITHROID 112 MCG TABLET MM 2UNITHROID 125 MCG TABLET MM 2UNITHROID 137 MCG TABLET MM 2UNITHROID 150 MCG TABLET MM 2UNITHROID 175 MCG TABLET MM 2UNITHROID 200 MCG TABLET MM 2UNITHROID 25 MCG TABLET MM 2UNITHROID 300 MCG TABLET MM 2UNITHROID 50 MCG TABLET MM 2UNITHROID 75 MCG TABLET MM 2UNITHROID 88 MCG TABLET MM 2UNIVASC 15 MG TABLET MM 3UNIVASC 7.5 MG TABLET MM 3UNIVERSAL 1 LANCETS 21 GAUGE MM 1UNIVERSAL 1 LANCETS 26 GAUGE MM 1UNIVERSAL 1 LANCETS 30 GAUGE MM 1UNIVERSAL 1 LANCETS 33 GAUGE MM 1UPTRAVI 1,000 MCG TABLET SP,LD * QL,PAUPTRAVI 1,200 MCG TABLET SP,LD * QL,PAUPTRAVI 1,400 MCG TABLET SP,LD * QL,PAUPTRAVI 1,600 MCG TABLET SP,LD * QL,PAUPTRAVI 200 MCG (140)-800 MCG (60) TABLETS IN A DOSE PACK SP,LD * QL,PAUPTRAVI 200 MCG TABLET SP,LD * QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSUPTRAVI 400 MCG TABLET SP,LD * QL,PAUPTRAVI 600 MCG TABLET SP,LD * QL,PAUPTRAVI 800 MCG TABLET SP,LD * QL,PAURECHOLINE 10 MG TABLET 3URECHOLINE 25 MG TABLET 3URECHOLINE 5 MG TABLET 3URECHOLINE 50 MG TABLET 3urinozinc prostate formula 40 mg-17 mcg-10 mg-63 mg-33mg capsule 2UROCIT-K 10 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE MM 3UROCIT-K 15 15 MEQ (1,620 MG) TABLET,EXTENDED RELEASE MM 3UROCIT-K 5 5 MEQ (540 MG) TABLET,EXTENDED RELEASE MM 3UROQID-ACID NO.2 500 MG-500 MG TABLET 3UROXATRAL 10 MG TABLET,EXTENDED RELEASE MM 3 QLURSO 250 250 MG TABLET MM 3URSO FORTE 500 MG TABLET MM 3ursodiol 250 mg tablet MM 3ursodiol 300 mg capsule MM 3ursodiol 500 mg tablet MM 3UTI-STAT 3,875 MG/30 ML ORAL LIQUID 3UTIBRON NEOHALER 27.5 MCG-15.6 MCG CAPSULE WITH INHALATION DEVICE 3 QL,PAVAGIFEM 10 MCG VAGINAL TABLET MM 3valacyclovir hcl 1 gram tablet MM 2 QLvalacyclovir hcl 500 mg tablet MM 2 QLVALCHLOR 0.016 % TOPICAL GEL SP,LD * QL,PAVALCYTE 450 MG TABLET MM 4 QLVALCYTE 50 MG/ML ORAL SOLUTION MM 4 QLvalganciclovir 450 mg tablet MM 4 QLvalganciclovir hcl 50 mg/ml MM 4 QLVALIUM 10 MG TABLET 3 QLVALIUM 2 MG TABLET 3 QLVALIUM 5 MG TABLET 3 QLvalproic acid 250 mg capsule MM 2valproic acid 250 mg/5 ml soln MM 1valproic acid 250 mg/5 ml soln MM 1valproic acid 500 mg/10 ml sol MM 1valsartan 160 mg tablet MM 1 QLvalsartan 320 mg tablet MM 1 QLvalsartan 40 mg tablet MM 1 QLvalsartan 80 mg tablet MM 1 QLvalsartan-hctz 160-12.5 mg tab MM 1 QLvalsartan-hctz 160-25 mg tab MM 1 QLvalsartan-hctz 320-12.5 mg tab MM 1 QLvalsartan-hctz 320-25 mg tab MM 1 QLvalsartan-hctz 80-12.5 mg tab MM 1 QLVALTREX 1 GRAM TABLET MM 3 QLVALTREX 500 MG TABLET MM 3 QLvanatol lq 50 mg-325 mg-40 mg/15 ml oral solution 4 QLVANCOCIN 125 MG CAPSULE 4 QLVANCOCIN 250 MG CAPSULE 4 QLvancomycin hcl 125 mg capsule 4 QLvancomycin hcl 250 mg capsule 4 QLVANDAZOLE 0.75 % VAGINAL GEL 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSVANISHPOINT SYRINGE 1 ML 29 GAUGE X 1/2" MM 2VANISHPOINT SYRINGE 1/2 ML 30 GAUGE X 1/2" MM 2VANOS 0.1 % TOPICAL CREAM 4 STVARUBI 90 MG TABLET SP,LD * QL,PAVASCEPA 1 GRAM CAPSULE MM 3 QLVASERETIC 10 MG-25 MG TABLET MM 3VASOFLEX 500 MG-50 MG-25 MG-40 MG CAPSULE 3VASOFLEX 500 MG-50 MG-25 MG-40 MG TABLET 3VASOFLEX FORTE 150 MG-150 MG-150 MG CAPSULE 3VASOFLEX HD 150 MG-150 MG-150 MG-500 MG TABLET 3VASOTEC 10 MG TABLET MM 4VASOTEC 2.5 MG TABLET MM 4VASOTEC 20 MG TABLET MM 4VASOTEC 5 MG TABLET MM 4vecamyl 2.5 mg tablet LD 4 QLVECTICAL 3 MCG/GRAM TOPICAL OINTMENT 4 QLvelivet triphasic regimen (28) 0.1 mg/0.125 mg/0.15 mg-25 mcg tablet MM 1VELPHORO 500 MG CHEWABLE TABLET MM 4 STVELTASSA 16.8 GRAM ORAL POWDER PACKET LD 3 QL,PAVELTASSA 25.2 GRAM ORAL POWDER PACKET LD 3 QL,PAVELTASSA 8.4 GRAM ORAL POWDER PACKET LD 3 QL,PAVELTIN 1.2 %-0.025 % TOPICAL GEL 4 STvemavite-prx-2 27 mg-1.25 mg-55 mg-300 mg capsule 2vena-bal dha 27 mg-1 mg-430 mg tablet-capsule,delayed release 2venatal-fa tablet 3VENCLEXTA 10 MG TABLET SP,LD * QL,PAVENCLEXTA 100 MG TABLET SP,LD * QL,PAVENCLEXTA 50 MG TABLET SP,LD * QL,PAVENCLEXTA STARTING PACK 10 MG-50 MG-100 MG TABLETS IN A DOSE PACK SP,LD * QL,PAvenlafaxine hcl 100 mg tablet MM 1venlafaxine hcl 25 mg tablet MM 1venlafaxine hcl 37.5 mg tablet MM 1venlafaxine hcl 50 mg tablet MM 1venlafaxine hcl 75 mg tablet MM 1venlafaxine hcl er 150 mg cap MM 1 QLVENLAFAXINE HCL ER 150 MG TAB MM 3 QLVENLAFAXINE HCL ER 225 MG TAB MM 3 QLvenlafaxine hcl er 37.5 mg cap MM 1 QLVENLAFAXINE HCL ER 37.5 MG TAB MM 3 QLvenlafaxine hcl er 75 mg cap MM 1 QLVENLAFAXINE HCL ER 75 MG TAB MM 3 QLVENTAVIS 10 MCG/ML SOLUTION FOR NEBULIZATION SP,LD * QL,PAVENTAVIS 20 MCG/ML SOLUTION FOR NEBULIZATION SP,LD * QL,PAVENTOLIN HFA 90 MCG/ACTUATION AEROSOL INHALER MM 2 QLVERAMYST 27.5 MCG/ACTUATION NASAL SPRAY,SUSPENSION MM 3 QL,STverapamil 120 mg tablet MM 1verapamil 360 mg cap pellet MM 2 QLverapamil 40 mg tablet MM 1 QLverapamil 80 mg tablet MM 1 QLverapamil er 120 mg capsule MM 2 QLverapamil er 120 mg tablet MM 1 QLverapamil er 180 mg capsule MM 2 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSverapamil er 180 mg tablet MM 1 QLverapamil er 240 mg capsule MM 2 QLverapamil er 240 mg tablet MM 1 QLverapamil er pm 100 mg capsule MM 3 QLverapamil er pm 200 mg capsule MM 3 QLverapamil er pm 300 mg capsule MM 3 QLVERDESO 0.05 % TOPICAL FOAM 4verdrocet 2.5 mg-325 mg tablet 3 QLVEREGEN 15 % TOPICAL OINTMENT 4 QLVERELAN 120 MG CAPSULE,EXTENDED RELEASE MM 3 QLVERELAN 180 MG CAPSULE,EXTENDED RELEASE MM 3 QLVERELAN 240 MG CAPSULE,EXTENDED RELEASE MM 3 QLVERELAN 360 MG CAPSULE,EXTENDED RELEASE MM 3 QLVERELAN PM 100 MG CAPSULE, EXTENDED RELEASE MM 3 QLVERELAN PM 200 MG CAPSULE, EXTENDED RELEASE MM 3 QLVERELAN PM 300 MG CAPSULE, EXTENDED RELEASE MM 3 QLVERIPRED 20 20 MG/5 ML (4 MG/ML) ORAL SOLUTION 3VERSACLOZ 50 MG/ML ORAL SUSPENSION MM 3 QL,STVESICARE 10 MG TABLET MM 3 QLVESICARE 5 MG TABLET MM 3 QLvestura (28) 3 mg-20 mcg tablet MM 1VEXOL 1 % EYE DROPS,SUSPENSION 3 STVFEND 200 MG TABLET 4 QL,PAVFEND 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION 4 QL,PAVFEND 50 MG TABLET 4 QL,PAVGO 20 DEVICE 3VGO 30 DEVICE 3VGO 40 DEVICE 3VIBERZI 100 MG TABLET 3 QL,PAVIBERZI 75 MG TABLET 3 QL,PAVIBRAMYCIN 100 MG CAPSULE 3 QLVIBRAMYCIN 25 MG/5 ML ORAL SUSPENSION 3VIBRAMYCIN 50 MG/5 ML SYRUP 3vicodin 5 mg-300 mg tablet 3 QLvicodin es 7.5 mg-300 mg tablet 3 QLvicodin hp 10 mg-300 mg tablet 3 QLVICOPROFEN 7.5-200 MG TABLET 3 QLVICTOZA 2-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR MM 2 QLVICTOZA 3-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR MM 2 QLVICTRELIS 200 MG CAPSULE SP * QLVIDEX 2 GRAM PEDIATRIC 10 MG/ML (FINAL CONC.) ORAL SOLUTION 3 QLVIDEX 4 GRAM PEDIATRIC 10 MG/ML (FINAL CONC.) ORAL SOLUTION 3 QLVIDEX EC 125 MG CAPSULE,DELAYED RELEASE 3 QLVIDEX EC 200 MG CAPSULE,DELAYED RELEASE 3 QLVIDEX EC 250 MG CAPSULE,DELAYED RELEASE 3 QLVIDEX EC 400 MG CAPSULE,DELAYED RELEASE 3 QLVIEKIRA PAK 12.5 MG-75 MG-50 MG/250 MG TABLETS IN A DOSE PACK SP * QL,PAVIEKIRA XR 8.33 MG-50 MG-33.33 MG-200 MG TABLET, EXTENDED RELEASE SP * QL,PAvienva 0.1 mg-20 mcg tablet MM 1VIGAMOX 0.5 % EYE DROPS 3vigraplex tablet 2VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK 3 QL,STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSVIIBRYD 10 MG TABLET MM 3 QL,STVIIBRYD 10-20-40 MG STARTER PK 3 QL,STVIIBRYD 20 MG TABLET MM 3 QL,STVIIBRYD 40 MG TABLET MM 3 QL,STVIMOVO 375 MG-20 MG TABLET,IMMEDIATE AND DELAY RELEASE MM 4 QL,STVIMOVO 500 MG-20 MG TABLET,IMMEDIATE AND DELAY RELEASE MM 4 QL,STVIMPAT 10 MG/ML ORAL SOLUTION MM 4 QL,PAVIMPAT 100 MG TABLET MM 4 PAVIMPAT 150 MG TABLET MM 4 PAVIMPAT 200 MG TABLET MM 4 PAVIMPAT 50 MG (14)-100 MG (14) TABLETS IN A DOSE PACK 4 PAVIMPAT 50 MG TABLET MM 4 PAvinacal 27 mg-1 mg-50 mg tablet 1VINATE CARE 40 MG IRON-1 MG CHEWABLE TABLET 2vinate dha 27 mg-400 mcg-1.13 mg-250 mg capsule 2VINATE DHA RF 27 MG IRON-1.13 MG-581.28 MG CAPSULE 3vinate gt 90 mg-1 mg-50 mg tablet 1vinate ii 29 mg-1 mg tablet 1vinate m 27 mg-1 mg tablet 1vinate one 60 mg iron-1 mg tablet 1vinate pn care 30 mg-1 mg-50 mg tablet 2vinate ultra 90 mg-1 mg-50 mg tablet 1VIOKACE 10,440 UNIT-39,150 UNIT-39,150 UNIT TABLET MM 4 STVIOKACE 20,880 UNIT-78,300 UNIT-78,300 UNIT TABLET MM 4 STviorele (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM 1VIRACEPT 250 MG TABLET SP * QLVIRACEPT 625 MG TABLET SP * QLVIRAMUNE 200 MG TABLET 3 QLVIRAMUNE 50 MG/5 ML ORAL SUSPENSION 3 QLVIRAMUNE XR 100 MG TABLET,EXTENDED RELEASE 4 QLVIRAMUNE XR 400 MG TABLET,EXTENDED RELEASE 3 QLVIRAZOLE 6 GRAM SOLUTION FOR INHALATION 3 QLVIREAD 150 MG TABLET SP * QLVIREAD 200 MG TABLET SP * QLVIREAD 250 MG TABLET SP * QLVIREAD 300 MG TABLET SP * QLVIREAD 40 MG/SCOOP (40 MG/GRAM) ORAL POWDER SP * QLVIROPTIC 1 % EYE DROPS 3virt nate tablet 1virt-advance 90 mg-1 mg-50 mg tablet 1VIRT-BAL DHA COMBO PACK 3VIRT-BAL DHA PLUS COMBO PACK 3virt-c dha 35 mg-1 mg-200 mg capsule 2virt-caps 1 mg capsule 3virt-care one capsule 2virt-gard 2.2 mg-25 mg-1 mg tablet 3virt-nate 28 mg-1 mg tablet 1virt-nate dha 28 mg-1 mg-200 mg capsule 3virt-phos 250 neutral 250 mg tablet 2virt-pn 27 mg-1 mg tablet 2virt-pn dha 27 mg-1 mg-300 mg capsule 2virt-pn plus 28 mg-1 mg-300 mg capsule 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSvirt-select 29 mg-1.25 mg-55 mg-325 mg capsule 2virt-vite 2.5 mg-25 mg-1 mg tablet 3virt-vite gt 90 mg-1 mg-50 mg tablet 1VIRT-VITE PLUS 5 MG TABLET 3virtprex 26 mg-1.2 mg-55 mg-300 mg capsule 1VISTARIL 25 MG CAPSULE 3VISTARIL 50 MG CAPSULE 3VISTOGARD 10 GRAM ORAL GRANULES IN PACKET SP,LD * QLvit d2 1.25 mg (50,000 unit) MM 1VITA-RESPA 2.2 MG-25 MG-1.3 MG TABLET 3VITAFOL 65 MG-1 MG TABLET 3VITAFOL FE+ (WITH DOCUSATE) 90 MG IRON-1 MG-50 MG-200 MG CAPSULE 3VITAFOL NANO 18 MG IRON-1 MG TABLET 3VITAFOL ULTRA 29 MG IRON-1 MG-200 MG CAPSULE 3VITAFOL-OB 65 MG-1 MG TABLET 3VITAFOL-OB+DHA 65 MG-1 MG-250 MG ORAL PACK 3VITAFOL-ONE 29 MG IRON-1 MG-200 MG CAPSULE 2VITAL HIGH NITROGEN ORAL PACKET 3VITAL-D RX 1,750 UNIT-60 MG-1 MG-12.5 MG TABLET 3VITAMED MD ONE RX 30 MG IRON-1 MG-200 MG CAPSULE 2VITAMED MD PLUS RX 30 MG IRON-1 MG-300 MG ORAL PACK 2VITAMEDMD REDICHEW RX 1.4 MG CHEW TABLET,IMMEDIATE - DELAYED RELEASE 3vitamin d2 50,000 unit capsule MM 1VITAMIN D3 COMPLETE 18 MG IRON-800 MCG-150 MG TABLET 3vitamin k 1 mg/0.5 ml injection solution 4vitamin k1 10 mg/ml injection solution 4vitamins a,c,d and fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops 3 QLVITAPEARL 30 MG-1.4 MG-200 MG CAPSULE,IMMEDIATE - DELAY RELEASE 3VITATRUE 30 MG IRON-1.4 MG-300 MG ORAL PACK 3VITEKTA 150 MG TABLET SP * QLVITEKTA 85 MG TABLET SP * QLVITUZ 5 MG-4 MG/5 ML ORAL SOLUTION 3VIVA DHA 28 MG-1 MG-200 MG CAPSULE 3VIVACTIL 10 MG TABLET MM 3VIVACTIL 5 MG TABLET MM 3VIVELLE-DOT 0.025 MG/24 HR TRANSDERMAL PATCH MM 3 QLVIVELLE-DOT 0.0375 MG/24 HR TRANSDERMAL PATCH MM 3 QLVIVELLE-DOT 0.05 MG/24 HR TRANSDERMAL PATCH MM 3 QLVIVELLE-DOT 0.075 MG/24 HR TRANSDERMAL PATCH MM 3 QLVIVELLE-DOT 0.1 MG/24 HR TRANSDERMAL PATCH MM 3 QLVIVLODEX 10 MG CAPSULE 3 QL,PAVIVLODEX 5 MG CAPSULE 3 QL,PAVOCAL POINT GLUCOSE CONTROL SOLUTION 3VOCAL POINT TEST STRIP MM 3 QL,STVOCALPOINT GLUCOSE CONTROL SOLUTION 3VOGELXO 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKET MM 3 QL,STVOGELXO 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMP MM 3 QL,STVOGELXO 50 MG/5 GRAM (1 %) TRANSDERMAL GEL MM 3 QL,STvol-care rx 1 mg-60 mg-300 mcg tablet 3vol-nate 28 mg-1 mg tablet 1vol-plus 27 mg-1 mg tablet 1vol-tab rx 29 mg iron-1 mg tablet 1VOLTAREN 1 % TOPICAL GEL MM 2ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSVOLTAREN-XR 100 MG TABLET,EXTENDED RELEASE MM 4voriconazole 200 mg tablet 4 QL,PAvoriconazole 40 mg/ml susp 4 QL,PAvoriconazole 50 mg tablet 4 QL,PAVORTEX HOLDING CHAMBER 2VORTEX HOLDING CHAMBER WITH CHILD MASK 1VORTEX HOLDING CHAMBER WITH TODDLER MASK 1VORTEX VHC FROG MASK-CHILD 1VORTEX VHC LADYBUG MASK-TODDLER 1VOSOL HC EAR DROPS 3VOSPIRE ER 4 MG TABLET,EXTENDED RELEASE MM 3VOSPIRE ER 8 MG TABLET,EXTENDED RELEASE MM 3VOTRIENT 200 MG TABLET SP,LD * QL,PAVP CH ULTRA SOFTGEL 3vp-ch plus 29 mg iron-1 mg-50 mg-265 mg capsule 2vp-ch-pnv 30 mg iron-1 mg-50 mg-260 mg capsule 2vp-era ob plus tablet 3vp-ggr-b6 1.2 mg-40 mg-124.1 mg-100 mg tablet 2vp-heme ob + dha combo pack 2vp-heme ob 28 mg-6 mg-1 mg tablet 2vp-heme one 22 mg-6 mg-1 mg-200 mg capsule 2VP-PNV-DHA 28 MG IRON-1 MG-200 MG CAPSULE 3vp-vite rx 1 mg-60 mg-300 mcg tablet 3vp-zel 600 mg-5 mg-10 mg-5 mg-1.5 mg tablet 2VRAYLAR 1.5 MG (1)-3 MG (6) CAPSULES IN A DOSE PACK SP * PAVRAYLAR 1.5 MG CAPSULE SP * QL,PAVRAYLAR 3 MG CAPSULE SP * QL,PAVRAYLAR 4.5 MG CAPSULE SP * QL,PAVRAYLAR 6 MG CAPSULE SP * QL,PAVUSION 0.25 %-15 %-81.35 % TOPICAL OINTMENT 4vyfemla (28) 0.4 mg-35 mcg tablet MM 1VYTORIN 10 MG-10 MG TABLET MM 3 QL,STVYTORIN 10 MG-20 MG TABLET MM 3 QL,STVYTORIN 10 MG-40 MG TABLET MM 3 QL,STVYTORIN 10 MG-80 MG TABLET MM 3 QL,STVYVANSE 10 MG CAPSULE 2 QLVYVANSE 20 MG CAPSULE 2 QLVYVANSE 30 MG CAPSULE 2 QLVYVANSE 40 MG CAPSULE 2 QLVYVANSE 50 MG CAPSULE 2 QLVYVANSE 60 MG CAPSULE 2 QLVYVANSE 70 MG CAPSULE 2 QLwarfarin sodium 1 mg tablet MM 1warfarin sodium 10 mg tablet MM 1warfarin sodium 2 mg tablet MM 1warfarin sodium 2.5 mg tablet MM 1warfarin sodium 3 mg tablet MM 1warfarin sodium 4 mg tablet MM 1warfarin sodium 5 mg tablet MM 1warfarin sodium 6 mg tablet MM 1warfarin sodium 7.5 mg tablet MM 1WAVESENSE AMP KIT MM 3 STST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSWAVESENSE CONTROL SOLUTION 3WAVESENSE JAZZ STRIPS MM 3 QL,STWAVESENSE PRESTO MM 3 STWAVESENSE PRESTO KIT MM 3 STWAVESENSE PRESTO STRIPS MM 3 QL,STWEBCOL TOPICAL PADS 3WELCHOL 3.75 GRAM ORAL POWDER PACKET MM 4 PAWELCHOL 625 MG TABLET MM 4 PAWELLBUTRIN 100 MG TABLET MM 3 QLWELLBUTRIN 75 MG TABLET MM 3 QLWELLBUTRIN SR 100 MG TABLET,SUSTAINED-RELEASE MM 3 QLWELLBUTRIN SR 150 MG TABLET,SUSTAINED-RELEASE MM 3 QLWELLBUTRIN SR 200 MG TABLET,SUSTAINED-RELEASE MM 3 QLWELLBUTRIN XL 150 MG 24 HR TABLET, EXTENDED RELEASE MM 4 QLWELLBUTRIN XL 300 MG 24 HR TABLET, EXTENDED RELEASE MM 4 QLwera (28) 0.5 mg-35 mcg tablet MM 1WESTHROID 130 MG TABLET MM 3WESTHROID 195 MG TABLET MM 3WESTHROID 32.5 MG TABLET MM 3WESTHROID 65 MG TABLET MM 3WESTHROID 97.5 MG TABLET MM 3WIDE-SEAL DIAPHRAGM 60 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 65 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 70 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 75 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 80 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 85 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 90 MM VAGINAL 4WIDE-SEAL DIAPHRAGM 95 MM VAGINAL 4WP THYROID 113.75 MG TABLET MM 3WP THYROID 130 MG TABLET MM 3WP THYROID 16.25 MG TABLET MM 3WP THYROID 32.5 MG TABLET MM 3WP THYROID 48.75 MG TABLET MM 3WP THYROID 65 MG TABLET MM 3WP THYROID 81.25 MG TABLET MM 3WP THYROID 97.5 MG TABLET MM 3wymzya fe 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MM 1XALATAN 0.005 % EYE DROPS MM 3 QLXALKORI 200 MG CAPSULE SP,LD * QL,PAXALKORI 250 MG CAPSULE SP,LD * QL,PAXANAX 0.25 MG TABLET 3 QLXANAX 0.5 MG TABLET 3 QLXANAX 1 MG TABLET 3 QLXANAX 2 MG TABLET 3 QLXANAX XR 0.5 MG TABLET,EXTENDED RELEASE 3 QLXANAX XR 1 MG TABLET,EXTENDED RELEASE 3 QLXANAX XR 2 MG TABLET,EXTENDED RELEASE 3 QLXANAX XR 3 MG TABLET,EXTENDED RELEASE 3 QLXARELTO 10 MG TABLET 2 QLXARELTO 15 MG (42)-20 MG (9) TABLETS IN A DOSE PACK 2 QLXARELTO 15 MG TABLET MM 2 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSXARELTO 20 MG TABLET MM 2 QLXARTEMIS XR 7.5 MG-325 MG TABLET EXTENDED RELEASE, ORAL ONLY 3 QLXELJANZ 5 MG TABLET SP * QL,PAXELJANZ XR 11 MG TABLET,EXTENDED RELEASE SP * QL,PAXELODA 150 MG TABLET SP * QL,PAXELODA 500 MG TABLET SP * QL,PAXENAZINE 12.5 MG TABLET SP,LD * QL,PAXENAZINE 25 MG TABLET SP,LD * QL,PAXERESE 5 %-1 % TOPICAL CREAM 4 PAXIFAXAN 200 MG TABLET 4 QL,PAXIFAXAN 550 MG TABLET MM 4 QL,PAXIGDUO XR 10 MG-1,000 MG TABLET,EXTENDED RELEASE 3 QL,STXIGDUO XR 10 MG-500 MG TABLET,EXTENDED RELEASE 3 QL,STXIGDUO XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE 3 QL,STXIGDUO XR 5 MG-500 MG TABLET,EXTENDED RELEASE 3 QL,STXIIDRA 5 % EYE DROPS IN A DROPPERETTE 4 QL,PAXODOL 10/300 10 MG-300 MG TABLET 2 QLXODOL 5/300 5 MG-300 MG TABLET 2 QLXODOL 7.5/300 7.5 MG-300 MG TABLET 2 QLXOLEGEL 2 % TOPICAL 4 STXOPENEX 0.31 MG/3 ML SOLUTION FOR NEBULIZATION MM 4XOPENEX 0.63 MG/3 ML SOLUTION FOR NEBULIZATION MM 4XOPENEX 1.25 MG/3 ML SOLUTION FOR NEBULIZATION MM 4XOPENEX CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION MM 4XOPENEX HFA 45 MCG/ACTUATION AEROSOL INHALER MM 3 QL,STXPRES CONTROL SOLUTION NORMAL 3XTAMPZA ER 13.5 MG CAPSULE SPRINKLE 4 QL,STXTAMPZA ER 18 MG CAPSULE SPRINKLE 4 QL,STXTAMPZA ER 27 MG CAPSULE SPRINKLE 4 QL,STXTAMPZA ER 36 MG CAPSULE SPRINKLE 4 QL,STXTAMPZA ER 9 MG CAPSULE SPRINKLE 4 QL,STXTANDI 40 MG CAPSULE SP,LD * QL,PAxulane 150 mcg-35 mcg/24 hr transdermal patch MM 1 QLXURIDEN 2 GRAM ORAL GRANULES IN PACKET SP * QL,PAxydra ef 50 mg-5 mg-6 mg-5 mg-707.5 mg capsule 2xylon 10 10 mg-200 mg tablet 3 QLXYREM 500 MG/ML ORAL SOLUTION SP,LD * QL,PAXYZAL 2.5 MG/5 ML ORAL SOLUTION MM 3 QLXYZAL 5 MG TABLET MM 3 QLYASMIN (28) 3 MG-0.03 MG TABLET MM 3YAZ (28) 3 MG-20 MCG TABLET MM 3zafirlukast 10 mg tablet MM 3 QLzafirlukast 20 mg tablet MM 3 QLzaleplon 10 mg capsule 1 QLzaleplon 5 mg capsule 1 QLZAMICET 10 MG-325 MG/15 ML ORAL SOLUTION 3 QLZANAFLEX 2 MG CAPSULE MM 3 STZANAFLEX 4 MG CAPSULE MM 3 STZANAFLEX 4 MG TABLET MM 3 STZANAFLEX 6 MG CAPSULE MM 3 STZANTAC 150 MG TABLET MM 3ZANTAC 300 MG TABLET MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSzarah 3 mg-0.03 mg tablet MM 1ZARONTIN 250 MG CAPSULE MM 3ZARONTIN 250 MG/5 ML ORAL SOLUTION MM 3ZAROXOLYN 5 MG TABLET MM 3ZARXIO 300 MCG/0.5 ML INJECTION SYRINGE SP * QL,PAZARXIO 480 MCG/0.8 ML INJECTION SYRINGE SP * QL,PAzatean-ch 27 mg-1 mg-50 mg-250 mg capsule 2zatean-pn dha 27 mg-1 mg-300 mg capsule 2zatean-pn plus 28 mg-1 mg-300 mg capsule 2zatean-pn tablet 2zavara 5,750 unit-1 mg capsule 3ZAVESCA 100 MG CAPSULE SP,LD * QL,PAZEBETA 10 MG TABLET MM 3ZEBETA 5 MG TABLET MM 3ZEBUTAL 50 MG-325 MG-40 MG CAPSULE 3 QLZEGERID 20 MG-1,680 MG ORAL PACKET 4 QL,STZEGERID 20 MG-1.1 GRAM CAPSULE MM 4 QL,STZEGERID 40 MG-1,680 MG ORAL PACKET 4 QL,STZEGERID 40 MG-1.1 GRAM CAPSULE MM 4 QL,STZELAPAR 1.25 MG DISINTEGRATING TABLET MM 4ZELBORAF 240 MG TABLET SP,LD * QL,PAZEMBRACE SYMTOUCH 3 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 4 QLZEMPLAR 1 MCG CAPSULE MM 3 QLZEMPLAR 2 MCG CAPSULE MM 3 QLzenatane 10 mg capsule 4 QLzenatane 20 mg capsule 4 QLzenatane 30 mg capsule 4 QLzenatane 40 mg capsule 4 QLzenchent (28) 0.4 mg-35 mcg tablet MM 1zenchent fe 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MM 1ZENPEP 10,000-34,000-55,000 UNIT CAPSULE,DELAYED RELEASE MM 2ZENPEP 15,000-51,000-82,000 UNIT CAPSULE,DELAYED RELEASE MM 2ZENPEP 20,000-68,000-109,000 UNIT CAPSULE,DELAYED RELEASE MM 2ZENPEP 25,000-85,000-136,000 UNIT CAPSULE,DELAYED RELEASE MM 2ZENPEP 3,000-10,000-16,000 UNIT CAPSULE,DELAYED RELEASE MM 2ZENPEP 40,000-136,000-218,000 UNIT CAPSULE,DELAYED RELEASE 2ZENPEP 5,000-17,000-27,000 UNIT CAPSULE,DELAYED RELEASE MM 2zenzedi 10 mg tablet 4 QLZENZEDI 15 MG TABLET 4 QLZENZEDI 2.5 MG TABLET 4 QLZENZEDI 20 MG TABLET 4 QLZENZEDI 30 MG TABLET 4 QLzenzedi 5 mg tablet 4 QLZENZEDI 7.5 MG TABLET 4 QLzeosa chewable tablet MM 1ZEPATIER 50 MG-100 MG TABLET SP * QL,PAZERIT 1 MG/ML ORAL SOLUTION 3 QLZERIT 15 MG CAPSULE 3 QLZERIT 20 MG CAPSULE 3 QLZERIT 30 MG CAPSULE 3 QLZERIT 40 MG CAPSULE 3 QLZESTORETIC 10 MG-12.5 MG TABLET MM 3ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSZESTORETIC 20 MG-12.5 MG TABLET MM 3ZESTORETIC 20 MG-25 MG TABLET MM 3ZESTRIL 10 MG TABLET MM 3ZESTRIL 2.5 MG TABLET MM 3ZESTRIL 20 MG TABLET MM 3ZESTRIL 30 MG TABLET MM 3ZESTRIL 40 MG TABLET MM 3ZESTRIL 5 MG TABLET MM 3ZETIA 10 MG TABLET MM 2 QLZETONNA 37 MCG/ACTUATION NASAL HFA INHALER MM 3 QL,STZIAC 10 MG-6.25 MG TABLET MM 3ZIAC 2.5 MG-6.25 MG TABLET MM 3ZIAC 5 MG-6.25 MG TABLET MM 3ZIAGEN 20 MG/ML ORAL SOLUTION 4 QLZIAGEN 300 MG TABLET 4 QLZIANA 1.2 %-0.025 % TOPICAL GEL 3zidovudine 100 mg capsule 1 QLzidovudine 300 mg tablet 1 QLzidovudine 50 mg/5 ml syrup 1 QLZINBRYTA 150 MG/ML SUBCUTANEOUS SYRINGE SP * QL,PAzingiber 1.2 mg-40 mg-124.1 mg-100 mg tablet 3ZIOPTAN (PF) 0.0015 % EYE DROPS IN A DROPPERETTE MM 3 QL,STziprasidone hcl 20 mg capsule MM 3 QLziprasidone hcl 40 mg capsule MM 3 QLziprasidone hcl 60 mg capsule MM 3 QLziprasidone hcl 80 mg capsule MM 3 QLZIPSOR 25 MG CAPSULE 4 QL,STZIRGAN 0.15 % EYE GEL 3 QLZITHROMAX 1 GRAM ORAL PACKET 3ZITHROMAX 100 MG/5 ML ORAL SUSPENSION 3ZITHROMAX 200 MG/5 ML ORAL SUSPENSION 3ZITHROMAX 250 MG TABLET 3ZITHROMAX 500 MG TABLET 3ZITHROMAX 600 MG TABLET 3 QLZITHROMAX TRI-PAK 500 MG TABLET 3ZITHROMAX Z-PAK 250 MG TABLET 3ZMAX 2 GRAM/60 ML ORAL SUSPENSION,EXTENDED RELEASE 3 QLZOCOR 10 MG TABLET MM 3 QL,STZOCOR 20 MG TABLET MM 3 QL,STZOCOR 40 MG TABLET MM 3 QL,STZOCOR 5 MG TABLET MM 3 QL,STZOCOR 80 MG TABLET MM 3 QL,STZOFRAN 4 MG TABLET 3 QLZOFRAN 4 MG/5 ML ORAL SOLUTION 3 QLZOFRAN 8 MG TABLET 3 QLZOFRAN ODT 4 MG DISINTEGRATING TABLET 3 QLZOFRAN ODT 8 MG DISINTEGRATING TABLET 3 QLZOHYDRO ER 10 MG CAPSULE 4 QL,PAZOHYDRO ER 10 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE 4 QL,PAZOHYDRO ER 15 MG CAPSULE 4 QL,PAZOHYDRO ER 15 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE 4 QL,PAZOHYDRO ER 20 MG CAPSULE 4 QL,PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSZOHYDRO ER 20 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE 4 QL,PAZOHYDRO ER 30 MG CAPSULE 4 QL,PAZOHYDRO ER 30 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE 4 QL,PAZOHYDRO ER 40 MG CAPSULE 4 QL,PAZOHYDRO ER 40 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE 4 QL,PAZOHYDRO ER 50 MG CAPSULE 4 QL,PAZOHYDRO ER 50 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE 4 QL,PAZOLINZA 100 MG CAPSULE SP,LD * QL,PAzolmitriptan 2.5 mg odt 3 QL,STzolmitriptan 2.5 mg tablet 3 QL,STzolmitriptan 5 mg odt 3 QL,STzolmitriptan 5 mg tablet 3 QL,STZOLOFT 100 MG TABLET MM 3 QLZOLOFT 20 MG/ML ORAL CONCENTRATE MM 3 QLZOLOFT 25 MG TABLET MM 3 QLZOLOFT 50 MG TABLET MM 3 QLzolpidem tart 1.75 mg tab sl 3 QL,STzolpidem tart 3.5 mg tablet sl 3 QL,STzolpidem tart er 12.5 mg tab 3 QL,STzolpidem tart er 6.25 mg tab 3 QL,STzolpidem tartrate 10 mg tablet 1 QLzolpidem tartrate 5 mg tablet 1 QLZOLPIMIST 5 MG/SPRAY (0.1 ML) ORAL SPRAY 3 QL,STZOMACTON 10 MG SUBCUTANEOUS SOLUTION SP * QL,PAZOMACTON 5 MG SUBCUTANEOUS SOLUTION SP * QL,PAZOMIG 2.5 MG NASAL SPRAY 3 QLZOMIG 2.5 MG TABLET 4 QL,STZOMIG 5 MG NASAL SPRAY 3 QLZOMIG 5 MG TABLET 4 QL,STZOMIG ZMT 2.5 MG DISINTEGRATING TABLET 4 QL,STZOMIG ZMT 5 MG DISINTEGRATING TABLET 4 QL,STZONALON 5 % TOPICAL CREAM 4ZONATUSS 150 MG CAPSULE 3ZONEGRAN 100 MG CAPSULE MM 4ZONEGRAN 25 MG CAPSULE MM 4zonisamide 100 mg capsule MM 1zonisamide 25 mg capsule MM 1zonisamide 50 mg capsule MM 1ZONTIVITY 2.08 MG TABLET MM 3 QL,PAZORBTIVE 8.8 MG SUBCUTANEOUS SOLUTION SP,LD * QL,PAZORTRESS 0.25 MG TABLET 4 QL,PAZORTRESS 0.5 MG TABLET 4 QL,PAZORTRESS 0.75 MG TABLET 4 QL,PAZORVOLEX 18 MG CAPSULE 3 QL,STZORVOLEX 35 MG CAPSULE 3 QL,STzovia 1/35e (28) 1 mg-35 mcg tablet MM 1zovia 1/50e (28) 1 mg-50 mcg tablet MM 1ZOVIRAX 200 MG CAPSULE MM 3ZOVIRAX 200 MG/5 ML ORAL SUSPENSION MM 3ZOVIRAX 400 MG TABLET MM 3ZOVIRAX 5 % TOPICAL CREAM 4 PAZOVIRAX 5 % TOPICAL OINTMENT 4 PAST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization




REQUIREMENTSZOVIRAX 800 MG TABLET MM 3ZUBSOLV 1.4 MG-0.36 MG SUBLINGUAL TABLET 3 QL,PAZUBSOLV 11.4 MG-2.9 MG SUBLINGUAL TABLET 3 QL,PAZUBSOLV 2.9 MG-0.71 MG SUBLINGUAL TABLET 3 QL,PAZUBSOLV 5.7 MG-1.4 MG SUBLINGUAL TABLET 3 QL,PAZUBSOLV 8.6 MG-2.1 MG SUBLINGUAL TABLET 3 QL,PAZUPLENZ 4 MG ORAL SOLUBLE FILM 3 QL,PAZUPLENZ 8 MG ORAL SOLUBLE FILM 3 QL,PAZURAMPIC 200 MG TABLET 3 QL,PAZUTRIPRO 5 MG-4 MG-60 MG/5 ML ORAL SOLUTION 3ZYCLARA 2.5 % TOPICAL CREAM PUMP 4 QL,STZYCLARA 3.75 % TOPICAL CREAM PACKET 4 STZYCLARA 3.75 % TOPICAL CREAM PUMP 4 QL,STZYDELIG 100 MG TABLET SP,LD * QL,PAZYDELIG 150 MG TABLET SP,LD * QL,PAZYFLO 600 MG TABLET MM 4 QL,STZYFLO CR 600 MG TABLET,EXTENDED RELEASE MM 4 QL,STZYKADIA 150 MG CAPSULE SP,LD * QL,PAZYLET 0.3 %-0.5 % EYE DROPS,SUSPENSION 3 STZYLOPRIM 100 MG TABLET MM 3ZYLOPRIM 300 MG TABLET MM 3ZYMAXID 0.5 % EYE DROPS 3 QL,STZYPREXA 10 MG TABLET MM 4 QLZYPREXA 15 MG TABLET MM 4 QLZYPREXA 2.5 MG TABLET MM 4 QLZYPREXA 20 MG TABLET MM 4 QLZYPREXA 5 MG TABLET MM 4 QLZYPREXA 7.5 MG TABLET MM 4 QLZYPREXA ZYDIS 10 MG DISINTEGRATING TABLET MM 4 QLZYPREXA ZYDIS 15 MG DISINTEGRATING TABLET MM 4 QLZYPREXA ZYDIS 20 MG DISINTEGRATING TABLET MM 4 QLZYPREXA ZYDIS 5 MG DISINTEGRATING TABLET MM 4 QLZYTAZE 25 MG-500 MG CAPSULE 3ZYTIGA 250 MG TABLET SP,LD * QL,PAZYVOX 100 MG/5 ML ORAL SUSPENSION 4 QLZYVOX 600 MG TABLET 4 QLST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization

Discrimination is Against the LawHumana Insurance Company, Humana Health Plan, Inc. and all of their insurer and health plan affiliates andsubsidiaries (collectively, "Humana") complies with applicable Federal civil rights laws and does not discriminateon the basis of race, color, national origin, age, disability, or sex. Humana does not exclude people or treat themdifferently because of race, color, national origin, age, disability, or sex.

Humana:• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters– Written information in other formats

• Provides free language services to people whose primary language is not English when those services arenecessary to provide meaningful access, such as:– Qualified interpreters– Information written in other languages

If you need these services, contact Dr. Michelle Griffin, PhD.

If you believe that Humana has failed to provide these services or discriminated in another way on the basis ofrace, color, national origin, age, disability, or sex, you can file a grievance with:

Dr. Michelle M. Griffin, PhD (FACHE)Civil Rights/LEP/ADA/Section 1557 Compliance Officer: 500 W. Main Street -10th floor Louisville, Kentucky 40202Phone: 1-877-320-1235 Fax: 1-877-320-1269Email: [email protected] or [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Dr. Michelle GriffinPHD, Civil Rights/LEP/ADA/Section 1557 Compliance Officer is available to help you at the contact informationlisted above.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for CivilRights electronically through the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800–368–1019 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Humana.com

2017Rx4TC

* Not all the medicines listed on this formulary are covered by all prescription drug benefit plans. For more information about themedicines covered by your prescription drug benefit plan, copayment or coinsurance amounts, you can call the number on the back ofyour Humana member ID card or log into MyHumana, click on "Coverage, Claims & Spending" then "Pharmacy."

If your insurance is issued through the states of GA, IL, or MI, your coverage may include medicines in the following drug classes: obesityand infertility. To get more information around these state-mandated coverages, log in to MyHumana through Humana.com or callCustomer Service at 1-800-833-6917.

If your insurance is issued through the state of NC, your coverage may include medicines in the following drug classes: obesity, infertility,and sexual dysfunction. To get more information around these state-mandated coverages, log in to MyHumana throughHumana.com or call Customer Service at 1-800-833-6917.

For Commercial Fully-Insured and Individual policies issued in Texas, Louisiana, and Puerto Rico:Drug List changes are effective on a plan's renewal date.Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc.,Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License #00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. - A HealthMaintenance Organization, or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana HealthBenefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Humana Insurance of PuertoRico, Inc. License #00187-0009, or administered by Humana Insurance Company or Humana Health Plan, Inc.

Statements in languages other than English contained in the advertisement do not necessarily reflect the exact contents of the policywritten in English, because of possible linguistic differences. In the event of a dispute, the policy as written in English is considered thecontrolling authority.

For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Humana Insurance Company.

Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on thecompany providing your benefits.

Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force ordiscontinued. For costs and complete details of the coverage, call or write your Humana insurance agent or the company.

ASO products are administered by Humana Insurance Company or Humana Health Plan, Inc.

2017 Humana Drug List

Documents

Transcript of 2017 Humana Drug List