Drug Lookup Tool

List of Drugs That Require Prior Authorization

PDF Download: List of Drugs That Require Prior Authorization
Submit Drug PAs Online: Express Path
Drug Name Generic Name PA Program Disease State Submit PA or Call
Abraxane Paclitaxel Protein-Bound Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Abstral fentanyl transmucosal drug Pharmacy PA Pain For Real-Time Response, Submit PA
OR Call (800) 753-2851
Actemra Tocilizumab Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Acthar Gel Repository Corticotropin Injection Medical Management/PA Metabolic, Immune Disorders or Inherited Rare Disease For Real-Time Response, Submit PA
OR Call (866) 877-7042
Actimmune Interferon Gamma-1b,Recomb. Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Actiq fentanyl transmucosal drug Pharmacy PA Pain For Real-Time Response, Submit PA
OR Call (800) 753-2851
Adcetris Brentuximab Vedotin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Adcirca Tadalafil Pharmacy PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (800) 753-2851
Adempas Riociguat Pharmacy PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (800) 753-2851
Adrucil Fluorouracil Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Advair Diskus Fluticasone Propionate and Salmeterol Pharmacy PA Asthma/COPD For Real-Time Response, Submit PA
OR Call (800) 753-2851
Advair HFA Fluticasone Propionate and Salmeterol Pharmacy PA Asthma/COPD For Real-Time Response, Submit PA
OR Call (800) 753-2851
Advate Antihemoph.FVIII, Full Length UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Adynovate Antihemophilic Factor VIII UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Afinitor (o) Everolimus Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Alecensa (o) Alectinib Hydrochloride Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Alimta Pemetrexed Disodium Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Alkeran Melphalan HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Alphanate Antihemophilic Factor/vWF UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
AlphaNine SD Factor IX UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Alprolix Factor IX Rec, Fc Fusion Protn UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Alunbrig Brigatinib Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Amifostine Amifostine Crystalline Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ampyra Dalfampridine Pharmacy PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (800) 753-2851
Androderm topical testosterone Pharmacy PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
AndroGel topical testosterone Pharmacy PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Aralast NP Alpha-1-Proteinase Inhibitor Medical Management/PA Alpha 1 Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Aranesp Darbepoetin Alfa In Polysorbat Medical Management/PA Blood Cell Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Arcalyst Rilonacept Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Arranon Nelarabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Arzerra Ofatumumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Atralin topical tretinoin products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Aubagio Teriflunomide Pharmacy PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (800) 753-2851
Austedo Deutetrabenazine Pharmacy PA Huntington's Disease For Real-Time Response, Submit PA
OR Call (800) 753-2851
Avastin Bevacizumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Aveed injectable testosterone Medical Management/PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (866) 877-7042
Avinza class II narcotic Pharmacy PA Pain For Real-Time Response, Submit PA
OR Call (800) 753-2851
Avita topical tretinoin products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Avonex Interferon Beta-1a Medical Management/PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Axiron topical testosterone Pharmacy PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Azacitidine Azacitidine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bebulin Factor IX Cplx(Pcc)#6, 3factor UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Beleodaq Belinostat Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bendeka Bendamustine HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
BeneFIX Factor IX Human Recombinant UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Berinert C1 Esterase Inhibitor Medical Management/PA Hereditary Angioedema For Real-Time Response, Submit PA
OR Call (866) 877-7042
Betaseron Interferon Beta-1b Medical Management/PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bicnu Carmustine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bivigam Immun Glob G (IgG)/Gly/IgA 50+ Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bleomycin Sulfate Bleomycin Sulfate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Blincyto Blinatumomab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Boniva Ibandronate Sodium Medical Management/PA Osteoporosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bosulif (o) Bosutinib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Botox Onabotulinumtoxina Medical Management/PA Neuromuscular Conditions/Cosmetic For Real-Time Response, Submit PA
OR Call (866) 877-7042
Breo Ellipta Fluticasone and Vilanterol Pharmacy PA Asthma/COPD For Real-Time Response, Submit PA
OR Call (800) 753-2851
Brineura Cerliponase alfa Medical Management/PA Enzyme Deficiencies For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bunavail Buprenorphine HCl/Naloxone HCl Pharmacy PA Chemical Dependence For Real-Time Response, Submit PA
OR Call (800) 753-2851
Buprenorphine-Naloxone Buprenorphine HCl/Naloxone HCl Pharmacy PA Chemical Dependence For Real-Time Response, Submit PA
OR Call (800) 753-2851
Busulfex Busulfan Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Bydureon GLP-1 agonist Pharmacy PA Diabetes For Real-Time Response, Submit PA
OR Call (800) 753-2851
Byetta GLP-1 agonist Pharmacy PA Diabetes For Real-Time Response, Submit PA
OR Call (800) 753-2851
Cabometyx Cabozantinib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Calcium Folinate Leucovorin Calcium Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Camptosar Irinotecan HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Capecitabine Capecitabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Caprelsa Vandetanib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Carboplatin Carboplatin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Carimune NF Immun Glob G(IgG)/Sucr/IgA 50+ Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Chemet Succimer Pharmacy PA Chelating Agents For Real-Time Response, Submit PA
OR Call (800) 753-2851
Chenodal chenodiol Pharmacy PA Gallstones For Real-Time Response, Submit PA
OR Call (800) 753-2851
Cholbam Cholic Acid Pharmacy PA Gi Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Cialis tadalafil Pharmacy PA BPH For Real-Time Response, Submit PA
OR Call (800) 753-2851
Cimzia Certolizumab Pegol Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cinqair reslizumab Medical Management/PA Respiratory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cinryze C1 Esterase Inhibitor Medical Management/PA Hereditary Angioedema For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cisplatin Cisplatin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cladribine Cladribine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Clindamycin/Tretinoin Gel Clindamycin and Tretinoin Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Clolar Clofarabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cometriq Cabozantinib S-Malate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Copaxone Glatiramer Acetate Medical Management/PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Copegus, Rebetol, Ribasphere Ribavirin Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Corifact Factor XIII UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Corlanor ivabradine Pharmacy PA Heart Failure For Real-Time Response, Submit PA
OR Call (800) 753-2851
Cosentyx Secukinumab Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cosmegen Dactinomycin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cotellic Cobimetinib Fumarate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Cuvitru Immune Globulin Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cyclophosphamide Cyclophosphamide Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cyramza Ramucirumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Cytarabine Cytarabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Dacarbazine Dacarbazine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Dacogen Decitabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Daklinza daclatasvir Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Daliresp roflumilast Pharmacy PA Respiratory Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Daraprim Pyrimethamine Pharmacy PA Toxoplasmosis For Real-Time Response, Submit PA
OR Call (800) 753-2851
Darzalex Daratumumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Daunorubicin HCl Daunorubicin HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Decitabine Decitabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Delatestryl injectable testosterone Medical Management/PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (866) 877-7042
Depo - Testosterone injectable testosterone Medical Management/PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (866) 877-7042
Depocyt Cytarabine Liposome/PF Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Dexrazoxane Dexrazoxane HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Diclegis Doxylamine Succinate Pharmacy PA Nausea/Vomiting For Real-Time Response, Submit PA
OR Call (800) 753-2851
Docefrez Docetaxel Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Docetaxel Docetaxel Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Doxil Doxorubicin HCl Peg-Liposomal Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Doxorubicin HCl Doxorubicin HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Dulera Formoterol and Mometasone Pharmacy PA Asthma/COPD For Real-Time Response, Submit PA
OR Call (800) 753-2851
Dupixent Dupilumab Medical Management/PA Atopic Dermatitis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Dysport Abobotulinumtoxina Medical Management/PA Neuromuscular Conditions/Cosmetic For Real-Time Response, Submit PA
OR Call (866) 877-7042
Egrifta Tesamorelin Acetate Medical Management/PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (866) 877-7042
Eligard Leuprolide Acetate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Eliquis Apixaban Pharmacy PA Cardiovascular Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Elitek Rasburicase Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ellence Epirubicin HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Emflaza Deflazacort Pharmacy PA Duchenne Muscular Dystrophy For Real-Time Response, Submit PA
OR Call (800) 753-2851
Empliciti Elotuzumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Enbrel Etanercept Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Entresto sacubitril/valsartan Pharmacy PA Heart Failure For Real-Time Response, Submit PA
OR Call (800) 753-2851
Entyvio Vedolizumab Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Epclusa Sofosubuvir/velpatasvir Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Epirubicin HCl Epirubicin HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Epogen Epoetin Alfa Medical Management/PA Blood Cell Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Epoprostenol Sodium Epoprostenol Sodium (Glycine) Medical Management/PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (866) 877-7042
Erbitux Cetuximab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Erivedge Vismodegib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Erwinaze Asparaginase (Erwinia Chrysan) Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Esbriet Pirfenidone Pharmacy PA Idiopathic Pulmonary Fibrosis For Real-Time Response, Submit PA
OR Call (800) 753-2851
Etopophos Etoposide Phosphate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Etoposide Etoposide Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Euflexxa Hyaluronate Sodium Medical Management/PA Osteoarthritis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Exalgo class II narcotic Pharmacy PA Pain For Real-Time Response, Submit PA
OR Call (800) 753-2851
Exjade Deferasirox Pharmacy PA Iron Chelator For Real-Time Response, Submit PA
OR Call (800) 753-2851
Exondys 51 Eteplirsen Medical Management/PA Duchenne Muscular Dystrophy For Real-Time Response, Submit PA
OR Call (866) 877-7042
Extavia Interferon Beta-1b Medical Management/PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Eylea Aflibercept Medical Management/PA Ophthalmic Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Fabior topical tazarotene products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Farydak Panobinostat Lactate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Fasenra Benralizumab Medical Management/PA Asthma For Real-Time Response, Submit PA
OR Call (866) 877-7042
Faslodex Fulvestrant Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Eloctate Antihemoph.FVIII Rec, Fc Fusion UHA Internal Clinical Review N/A Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Feiba NF Anti-Inhibitor Coagulant Comp. UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Fentora fentanyl transmucosal drug Pharmacy PA Pain For Real-Time Response, Submit PA
OR Call (800) 753-2851
Ferriprox Deferiprone Pharmacy PA Iron Chelator For Real-Time Response, Submit PA
OR Call (800) 753-2851
Firazyr Icatibant Acetate Medical Management/PA Hereditary Angioedema For Real-Time Response, Submit PA
OR Call (866) 877-7042
Firmagon Degarelix Acetate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
First Testosterone topical testosterone Pharmacy PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Flebogamma DIF Immun Glob G(IgG)/Sorb/IgA 50+ Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Flolan Epoprostenol Sodium (Glycine) Medical Management/PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (866) 877-7042
Floxuridine Floxuridine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Fludarabine Phosphate Fludarabine Phosphate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Fluorouracil Fluorouracil Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Folotyn Pralatrexate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Forteo Teriparatide Medical Management/PA Osteoporosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Fortesta topical testosterone Pharmacy PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Fusilev Levoleucovorin Calcium Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gammagard Immun Glob G/Gly/Gluc/IgA 0-50 Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gammagard Liquid Immun Glob G/Gly/Gluc/IgA 0-50 Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gammagard S/D Immun Glob G/Gly/Gluc/IgA 0-50 Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gammaked Immun Glob G (IgG)/Gly/IgA 50+ Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gammaplex Immun Glob G/Sorb/Gly/IgA 0-50 Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gamunex-C Immun Glob G (IgG)/Gly/IgA 50+ Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gazyva Obinutuzumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gel-One Hyaluronate Sod, Cross-Linked Medical Management/PA Osteoarthritis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gelsyn-3 Hyaluronic Acid 0.8% Medical Management/PA Osteoarthritis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gemcitabine HCl Gemcitabine HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gemzar Gemcitabine HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Genotropin Somatropin Medical Management/PA Growth Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
GenVisc 850 Hyaluronate Sodium Medical Management/PA Osteoarthritis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gilenya Fingolimod HCl Pharmacy PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (800) 753-2851
Gilotrif (o) Afatinib Dimaleate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Glassia Alpha-1-Proteinase Inhibitor Medical Management/PA Alpha 1 Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Glatopa Glatiramer Acetate Medical Management/PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Gleevec (o) Imatinib Mesylate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Granix Tbo-Filgrastim Medical Management/PA Blood Cell Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Grastek Grass Pollen-Timothy, Standard Pharmacy PA Allergies For Real-Time Response, Submit PA
OR Call (800) 753-2851
Haegarda C1 Esterase Inhibitor Medical Management/PA Hereditary Angioedema For Real-Time Response, Submit PA
OR Call (866) 877-7042
Halaven Eribulin Mesylate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Harvoni Ledipasvir/Sofosbuvir Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Helixate FS Antihemoph.FVIII, Full Length UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Hemlibra Emicizumab UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Hemofil M Antihemophilic Factor, Human UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Herceptin Trastuzumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Hetlioz tasimelteon Pharmacy PA Sleep Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Hizentra Immun Glob G(IgG)/Pro/IgA 0-50 Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
HP Acthar Corticotropin Medical Management/PA CNS/Autonomic Disorders For Real-Time Response, Submit PA
OR Call (866) 877-7042
Humate-P Antihemophilic Factor/vWF UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Humatrope Somatropin Medical Management/PA Growth Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Humira Adalimumab Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Hyalgan Hyaluronate Sodium Medical Management/PA Osteoarthritis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Hycamtin Topotecan HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Hymovis Hyaluronic Acid injection Medical Management/PA Osteoarthritis For Real-Time Response, Submit PA
OR Call (866) 877-7042
HyQvia IgG/Hyaluronidase,Recombinant Medical Management/PA Immune Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ibrance (o) Palbociclib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Iclusig Ponatinib Hcl Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Idamycin PFS Idarubicin HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Idarubicin HCl Idarubicin HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ifex Ifosfamide Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ifosfamide Ifosfamide Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ilaris Canakinumab Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Imatinib Mesylate Imatinib Mesylate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Imbruvica Ibrutinib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Imlygic Talimogene Laherparepvec Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Increlex Mecasermin Medical Management/PA Growth Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Inflectra Infliximab-dyyb Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ingrezza Valbenazine Pharmacy PA Mental/Neuro Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Inlyta Axitinib Pharmacy PA Cancer For Real-Time Response, Submit PA
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Thalomid Thalidomide Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Theracys BCG Live Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Thiotepa Thiotepa Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Toposar Etoposide Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Topotecan HCl Topotecan HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Torisel Temsirolimus Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Totect Dexrazoxane HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Tracleer Bosentan Pharmacy PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (800) 753-2851
Travatan/Z ophthalmic prostaglandin Pharmacy PA Ophthalmic Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Treanda Bendamustine HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Trelstar Triptorelin Pamoate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Tremfya Guselkumab Medical Management/PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
tretinoin topical tretinoin products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Tretin-X topical tretinoin products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Tretten Factor XIII A-Subunit, Recomb UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Trexall Methotrexate Sodium Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Trisenox Arsenic Trioxide Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Trulicity GLP-1 agonist Pharmacy PA Diabetes For Real-Time Response, Submit PA
OR Call (800) 753-2851
Tykerb Lapatinib Ditosylate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Tymlos Abaloparatide Medical Management/PA Bone Conditions For Real-Time Response, Submit PA
OR Call (866) 877-7042
Tysabri Natalizumab Medical Management/PA Multiple Sclerosis For Real-Time Response, Submit PA
OR Call (866) 877-7042
Tyvaso Treprostinil Pharmacy PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (800) 753-2851
Unituxin Dinutuximab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Uptravi Selexipag Pharmacy PA Circulation Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Valchlor Mechlorethamine HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Valstar Valrubicin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Vantas Histrelin Ac Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Vascepa Cosapent Pharmacy PA High Blood Cholesterol For Real-Time Response, Submit PA
OR Call (800) 753-2851
Vectibix Panitumumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Velcade Bortezomib Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Veletri Epoprostenol Sodium (Arginine) Medical Management/PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (866) 877-7042
Veltin topical tretinoin products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Venclexta Venetoclax Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Ventavis Iloprost Tromethamine Pharmacy PA Pulmonary Hypertension For Real-Time Response, Submit PA
OR Call (800) 753-2851
Victoza GLP-1 agonist Pharmacy PA Diabetes For Real-Time Response, Submit PA
OR Call (800) 753-2851
Vidaza Azacitidine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Viekira Pak Ombita/Paritap/Riton/Dasabuvir Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Vinblastine Sulfate Vinblastine Sulfate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Vincasar PFS Vincristine Sulfate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Vincristine Sulfate Vincristine Sulfate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Vinorelbine Tartrate Vinorelbine Tartrate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Vogelxo Testosterone Gel Pharmacy PA Endocrine Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Vosevi Sofosbuvir/Velpatasvir Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Votrient Pazopanib Hcl Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Wilate Antihemophilic Factor/Vwf UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Xalatan ophthalmic prostaglandin Pharmacy PA Ophthalmic Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xalkori Crizotinib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xarelto Rivaroxaban Pharmacy PA Cardiovascular Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xeljanz Tofacitinib Citrate Pharmacy PA Inflammatory Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xeloda Capecitabine Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Xenazine Tetrabenazine Pharmacy PA Mental/Neuro Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xeomin Incobotulinumtoxina Medical Management/PA Neuromuscular Conditions/Cosmetic For Real-Time Response, Submit PA
OR Call (866) 877-7042
Xermelo Telotristat Ethyl Pharmacy PA Gastrointestinal Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xgeva Denosumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Xiidra Lifitegrast Pharmacy PA Ophthalmic Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xofigo Radium-223 Dichloride Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Xolair Omalizumab Medical Management/PA Asthma For Real-Time Response, Submit PA
OR Call (866) 877-7042
Xtandi Enzalutamide Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Xyntha Antihemoph.FVIII, B-Domain Del UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Xyntha Solofuse Antihemoph.FVIII, B-Domain Del UHA Internal Clinical Review Hemophilia Submit PAs to UHA Health Care Services Fax (866) 572-4384 Phone (808) 532-4006
Xyrem Sodium Oxybate Pharmacy PA Sleep Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Yervoy Ipilimumab Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Yondelis Trabectedin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zaltrap Ziv-Aflibercept Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zanosar Streptozocin Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zarxio Filgrastim-Sndz Medical Management/PA Blood Cell Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zejula Niraparib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zelboraf Vemurafenib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zemaira Alpha-1-Proteinase Inhibitor Medical Management/PA Alpha 1 Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zepatier Elbasvir/Grazoprevir Pharmacy PA Hepatitis C For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zevalin Kit For Y-90/Ibritumomab/Album Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Ziana topical tretinoin products Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zinecard Dexrazoxane HCl Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zioptan ophthalmic prostaglandin Pharmacy PA Ophthalmic Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zoladex Goserelin Acetate Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zoledronic Acid Zoledronic Acid Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zolinza Vorinostat Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zomacton Somatropin Medical Management/PA Growth Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zometa Zoledronic Acid Medical Management/PA Cancer For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zontivity Vorapaxar Pharmacy PA Cardiovascular Disorders For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zorbtive Somatropin Medical Management/PA Growth Deficiency For Real-Time Response, Submit PA
OR Call (866) 877-7042
Zovirax Acyclovir Pharmacy PA Skin Conditions For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zubsolv Buprenorphine HCl/Naloxone HCl Pharmacy PA Chemical Dependence For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zydelig Idelalisib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zykadia Ceritinib Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zytiga Abiraterone Acetate Pharmacy PA Cancer For Real-Time Response, Submit PA
OR Call (800) 753-2851
Zyvox Linezolid Pharmacy PA Infections For Real-Time Response, Submit PA
OR Call (800) 753-2851

List of Step Therapy Drugs

PDF Download: List of Step Therapy Drugs
Submit Drug PAs Online: Express Path
Medication Therapeutic Category First Line Alternative
ACANYA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ACIPHEX SPRINKLE (2018 Preferred Formulary Exclusion) ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
ACTICLATE ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
ACTONEL BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
ACTONEL PLUS CALCIUM BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
ACTOPLUS MET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ACTOPLUS MET XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ACTOS DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ACZONE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ADALAT CC HIGH BLOOD PRESSURE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER
ADAPALENE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ADDERALL XR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
ADOXA ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
ADZENXS XR ODT ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
AEROSPAN ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR
ALA-SCALP HP SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
ALCORTIN A SKIN INFECTIONS TOPICAL STEROID+MUPIROCIN
ALLZITAL PAIN GENERIC PRODUCT WITH BUTALBITAL
ALOCRIL EYE CONDITIONS CROMOLYN
ALODOX KIT ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
ALOGLIPTIN (2018 Preferred Formulary Exclusion) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ALOGLIPTIN/METFORMIN (2018 Preferred Formulary Exclusion) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ALOGLIPTIN/PIOGLITAZONE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ALOMIDE EYE CONDITIONS CROMOLYN
ALOQUIN SKIN INFECTIONS MUPIROCIN
ALREX EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
ALSUMA INJECTION MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
ALTOPREV HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
ALVESCO (2018 Preferred Formulary Exclusion) ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR
AMBIEN SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
AMBIEN CR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
AMERGE MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
AMRIX ER MUSCLE RELAXANT GENERIC CYCLOBENZAPRINE
ANAPROX PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
ANAPROX DS PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
ANDROID HORMONAL SUPPLEMENTATION GENERIC OR METHITEST
ANSAID PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
ANTARA HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
ANUSOL HC SUPPOSITORY (2018 Preferred Formulary Exclusion) INFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG), ANUCORT-HC (25 MG), GRX HICORT (25 MG), HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG)
APLENZIN DEPRESSION BUPROPION SR, BUPROPION ER
APTENSIO XR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
AQUA GLYCOLIC HC SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
ARICEPT 10MG TABLET NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
ARICEPT 23MG TABLET (BRAND OR GENERIC) NEUROLOGICAL DISORDERS ARICEPT 10 MG TABLETS (BRAND OR GENERIC) OR ARICEPT ODT 10 MG (BRAND OR GENERIC)
ARICEPT 5MG TABLET NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
ARICEPT ODT NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
ARTHROTEC PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
ASTAGRAF XL TRANSPLANT GENERIC TACROLIMUS
ATACAND (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
ATACAND HCT (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
ATELVIA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
AUBAGIO MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF
AVALIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
AVANDAMET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
AVANDARYL DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
AVANDIA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
AVAPRO HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
AVAR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AVAR LS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AVAR-E SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AVAR-E GREEN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AVAR-E LS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AVAR-E LS CREAM SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AVIDOXY KIT ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
AVODART BPH FINASTERIDE 5 MG
AXERT MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
AZELEX SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
AZOR (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
BECONASE AQ (2018 Preferred Formulary Exclusion) ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
BELBUCA PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
BELSOMRA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
BENICAR (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
BENICAR HCT (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
BENZACLIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
BENZAMYCIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
BENZAMYCIN PAK SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
BENZEFOAM SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
BENZEFOAM ULTRA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
BENZEPRO SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
BEPREVE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
BETAPACE HIGH BLOOD PRESSURE GENERIC ORAL SOTALOL
BETAPACE AF HIGH BLOOD PRESSURE GENERIC ORAL SOTALOL
BINOSTO BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
BONIVA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
BRINTELLIX DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
BRISDELLE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
BRIVIACT NEUROLOGICAL DISORDERS LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA
BUPAP (2018 Preferred Formulary Exclusion) PAIN GENERIC PRODUCT WITH BUTALBITAL
BUTRANS (2018 Preferred Formulary Exclusion) PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
BYSTOLIC HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
BYVALSON HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
CADUET HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
CALAN HIGH BLOOD PRESSURE VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER
CALAN SR HIGH BLOOD PRESSURE VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER
CAMBIA PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
CAPEX SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
CARDENE SR HIGH BLOOD PRESSURE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER
CARDURA BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN
CARDURA XL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN
CATAFLAM PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
CELEBREX PAIN BRAND OR GENERIC ORAL NSAIDS (MUST USE 2)
FOR EXAMPLE: DICLOFENAC (IR AND ER), ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
CELECOXIB PAIN BRAND OR GENERIC ORAL NSAIDS (MUST USE 2)
FOR EXAMPLE: DICLOFENAC (IR AND ER), ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
CELEXA DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
CICLODAN 8% KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT
CLARIFOAM EF SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
CLEOCIN T SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
CLINDACIN ETZ SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
CLINDACIN PAC SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
CLINDAGEL SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
CLOBEX SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
CLODAN SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
CLODERM SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
CNL 8 NAIL KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT
COLCHICINE CAPSULES (2018 Preferred Formulary Exclusion) GOUT COLCRYS, MITIGARE
COLCHICINE TABLETS (2018 Preferred Formulary Exclusion) GOUT COLCRYS, MITIGARE
COLESTID HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE
CONCERTA ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
CONZIP PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN
CORDRAN SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
COREG HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
COREG CR HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
CORGARD HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
CORZIDE HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
COZAAR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
CRESTOR HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
CUTIVATE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
CYMBALTA (2018 Preferred Formulary Exclusion) DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
DAKLINZA (2018 Preferred Formulary Exclusion) HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI
DAYPRO PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
DAYTRANA ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
DEPAKENE NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID
DEPAKOTE NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID
DEPAKOTE ER/EC/DR NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID
DEPAKOTE SPRINKLE NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID
DERMAPAK PLUS SKIN CONDITIONS ONE MED FROM RULE 1 AND ONE MED FROM RULE 2
RULE 1: GENERIC PRESCRIPTION TOPICAL BENZOYL PEROXIDE, ANTIBIOTIC, ETC CONTAINING PRODUCTS
RULE 2: GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
DERMA-SMOOTH FS SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DERMASORB HC SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DERMASORB TA SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DERMATOP SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DESONATE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DESOWEN SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DESVENLAFAXINE ER (BRAND) DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
DESVENLAFAXINE FUMARATE ER (BRAND) DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
DETROL OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
DETROL LA OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
DEXEDRINE ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
DEXILANT ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
DEXPAK 6 DAY/10 DAY/13 DAY INFLAMMATORY CONDITIONS GENERIC DEXAMETHASON TABLETS
DICLOFENAC SODIUM 1% GEL PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
DIFFERIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
DIOVAN HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
DIOVAN HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
DIPROLENE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DIPROLENE/AF SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
DISKETS PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
DITROPAN XL OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
DOLOPHINE PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
DORYX ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
DORYX MPC ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
DOXYCYCLINE 40MG CAPSULES (IR/DR) (BRAND) ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
DUAC SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
DUETACT DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
DURAGESIC PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
DURLAZA BLOOD MODIFYING TWO OTHER ASPIRIN PRODUCTS
DUTASTERIDE BPH FINASTERIDE 5 MG
DUTASTERIDE/TAMSULOSIN BPH FINASTERIDE 5 MG
DUTOPROL HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
DYMISTA ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
DYNAVEL XR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
EC-NAPROSYN PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
EDARBI HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
EDARBYCLOR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
EDLUAR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
EFFEXOR DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
EFFEXOR XR (2018 Preferred Formulary Exclusion) DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
ELESTAT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
ELIDEL SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC):
FOR EXAMPLE:
ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
ELOCON SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
EMADINE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
EMBEDA PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
ENABLEX OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
ENVARSUS XR TRANSPLANT GENERIC TACROLIMUS
EPIDUO SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
EPIDUO FORTE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ESGIC PAIN GENERIC PRODUCT WITH BUTALBITAL
ESOMEPRAZOLE STRONTIUM ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
EUCRISA SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC):
FOR EXAMPLE:
ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
EVOCLIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
EXELON PATCH NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
EXELON TABLET NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
EXFORGE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
EXFORGE HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
FARXIGA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
FELDENE PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
FENOFIBRATE CAPSULES (BRAND) HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
FENOGLIDE HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
FENOPROFEN (BRAND) PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
FETZIMA DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
FEXMID MUSCLE RELAXANT GENERIC CYCLOBENZAPRINE
FIBRICOR HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
FINACEA FOAM SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
FINACEA GEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
FINACEA PLUS KIT SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
FIORICET PAIN GENERIC PRODUCT WITH BUTALBITAL
FIORINAL PAIN GENERIC PRODUCT WITH BUTALBITAL
FIORINAL WITH CODEINE PAIN GENERIC PRODUCT WITH BUTALBITAL
FLECTOR PATCH PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
FLOMAX BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN
FLOWTUSS COUGH AND COLD GENERIC COUGH/COLD LIQUID
FLUOXETINE 60MG TABLETS DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
FOCALIN XR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
FORFIVO XL DEPRESSION BUPROPION SR, BUPROPION ER
FORTAMET (BRAND AND GENERIC) DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY)
STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC)
FOSAMAX PLUS D BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
FOSAMAX TABLETS BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE
STEP 2: ATELVIA
FROVA MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
GELNIQUE OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
GILENYA MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF
GLUCOPHAGE DIABETES METFORMIN IR
GLUCOPHAGE XR (BRAND) DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY)
STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC)
GLUMETZA (BRAND AND GENERIC) (2018 Preferred Formulary Exclusion) DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY)
STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC)
GLYXAMBI DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
GRALISE NEUROLOGICAL DISORDERS GABAPENTIN
HALOG SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
HECTOROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION
HORIZANT NEUROLOGICAL DISORDERS GABAPENTIN
HYCOFENIX COUGH AND COLD GENERIC COUGH/COLD LIQUID
HYDROMORPHONE ER PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
HYSINGLA ER PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
HYTRIN BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN
HYZAAR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
IMITREX (ORAL) MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
IMITREX INJECTION MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
IMITREX NASAL SPRAY MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
INDERAL LA (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
INDERAL XL HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
INDOCIN PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
INNOPRAN XL HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
INOVA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
INOVA 4-1 SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
INOVA 8-2 SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
INTERMEZZO SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
INTUNIV (2018 Preferred Formulary Exclusion) ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE
INVOKAMET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
INVOKANA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
IRENKA DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
JALYN BPH FINASTERIDE 5 MG
JANUMET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
JANUMET XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
JANUVIA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
JARDIANCE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
JENTADUETO DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
JENTADUETO XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
JUBLIA ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT
JUVISYNC DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
KAPVAY ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE
KAZANO (2018 Preferred Formulary Exclusion) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
KENALOG SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
KEPPRA NEUROLOGICAL DISORDERS LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA
KEPPRA XR NEUROLOGICAL DISORDERS LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA
KERYDIN ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT
KEVZARA INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR
ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA
JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA
PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC
PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC
CROHN'S DISEASE: HUMIRA
ULCERATIVE COLITIS: HUMIRA
KHEDEZLA DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
KINERET INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR
ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA
JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA
PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC
PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC
CROHN'S DISEASE: HUMIRA
ULCERATIVE COLITIS: HUMIRA
KLARON SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
KLOFENSAID II PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
KOMBIGLYZE XR (2018 Preferred Formulary Exclusion) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
LAMICTAL NEUROLOGICAL DISORDERS LAMOTRIGINE, LAMOTRIGINE XR
LAMICTAL XR NEUROLOGICAL DISORDERS LAMOTRIGINE, LAMOTRIGINE XR
LASTACAFT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
LESCOL HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
LESCOL XL HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
LETAIRIS PULMONARY HYPERTENSION TRACLEER, OPSUMIT
LEVATOL HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
LEXAPRO (2018 Preferred Formulary Exclusion) DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
LIDOCAINE-TETRACAINE 7%-7% CREAM SKIN CONDITIONS LIDOCAINE/PRILOCAINE CREAM
LIPITOR HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
LIPOFEN HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
LIVALO HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
LOCOID SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
LOCORT 7 DAY/11 DAY INFLAMMATORY CONDITIONS GENERIC DEXAMETHASON TABLETS
LOFIBRA HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
LOPRESSOR HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
LOPRESSOR HCT HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
LORZONE MUSCLE RELAXANT GENERIC CHLORZOXAZONE
LUMIGAN EYE CONDITIONS BIMATOPROST, LATANOPROST , TRAVOPROST
LUNESTA (2018 Preferred Formulary Exclusion) SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
LUVOX CR DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
LUXIQ SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
LYRICA NEUROLOGICAL DISORDERS GABAPENTIN
MAXALT MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
MAXALT MLT MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
METADATE CD ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
METHADOSE PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
METROCREAM SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
METROGEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
METROLOTION SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
MEVACOR HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
MICARDIS HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
MICARDIS HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
MINOCIN ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
MINOCIN KIT ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
MOBIC PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
MONODOX ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
MORGIDOX KIT ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
MORPHINE SULFATE CR/ER PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
MOTRIN PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
MYRBETRIQ OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
NALFON PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
NAMENDA ORAL SOLUTION NEUROLOGICAL DISORDERS MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION
NAMENDA TABLETS NEUROLOGICAL DISORDERS MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION
NAMENDA XR NEUROLOGICAL DISORDERS MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION
NAMZARIC NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
NAPRELAN PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
NAPROSYN PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
NAPROSYN EC PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
NASACORT ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
NASACORT AQ ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
NASONEX (2018 Preferred Formulary Exclusion) ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
NESINA (2018 Preferred Formulary Exclusion) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
NEUAC SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
NEURONTIN NEUROLOGICAL DISORDERS GABAPENTIN
NEXIUM ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
NORITATE SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
NORVASC HIGH BLOOD PRESSURE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER
NOVACORT SKIN CONDITIONS HYDROCORTISONE-PRAMOXINE
NVOKAMET XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
OBERDON COUGH AND COLD GENERIC COUGH/COLD LIQUID
OLEPTRO ER SLEEP DISORDERS GENERIC TRAZODONE
OLUX SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
OLUX-E SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
OLYSIO (2018 Preferred Formulary Exclusion) HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI
OMNARIS (2018 Preferred Formulary Exclusion) ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
ONEXTON SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ONGLYZA (2018 Preferred Formulary Exclusion) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
ONZETRA XSAIL MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
OPTIVAR EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
ORACEA ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
ORTHO EVRA AND BRAND ORAL CONTRACEPTIVES CONTRACEPTIVES XULANE AND GENERIC ORAL CONTRACEPTIVES
OSENI DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
OTEZLA INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR
ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA
JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA
PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC
PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC
CROHN'S DISEASE: HUMIRA
ULCERATIVE COLITIS: HUMIRA
OVACE PLUS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
OXTELLAR XR NEUROLOGICAL DISORDERS OXCARBAZEPINE
OXYCODONE ER (BRAND) (2018 Preferred Formulary Exclusion) PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
OXYMORPHONE ER PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
OXYTROL OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
PACNEX SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
PACNEX HP SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
PACNEX LP SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
PANDEL SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
PATADAY EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
PATANOL EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
PAXIL DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
PAXIL CR DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
PAZEO EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE
PEDIADERM SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
PEDIADERM TA SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
PEDIPIROX-4 NAIL KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT
PENLAC ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT
PENNSAID PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
PEXEVA DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
PLEXION SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
PLEXION SCT SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
PONSTEL PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
PR BENZOYL PEROXIDE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
PRAVACHOL HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
PRESTALIA HIGH BLOOD PRESSURE MUST USE ONE GENERIC DHP CCB AND ONE ACE-INHIBITOR (BRAND OR GENERIC)
PREVACID (2018 Preferred Formulary Exclusion) ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
PREVACID SOLUTAB (2018 Preferred Formulary Exclusion) ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
PRILOSEC ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
PRISTIQ (2018 Preferred Formulary Exclusion) DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
PROCARDIA HIGH BLOOD PRESSURE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER
PROCARDIA XL HIGH BLOOD PRESSURE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER
PROCYSBI DR URINARY DISORDERS CYSTAGON
PROSCAR BPH FINASTERIDE 5 MG
PROTOCORT SUPPOSITORY INFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG), ANUCORT-HC (25 MG), GRX HICORT (25 MG), HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG)
PROTONIX (2018 Preferred Formulary Exclusion) ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE
PROTOPIC SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC):
FOR EXAMPLE:
ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
PROZAC (2018 Preferred Formulary Exclusion) DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
PROZAC WEEKLY DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
PSORCON SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
QDEXY XR NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN
QNASAL ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
QUESTRAN HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE
QUESTRAN LIGHT HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE
QUILLICHEW ER ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
QUILLIVANT XR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
RAPAFLO BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN
RAYALDEE CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION
RAZADYNE NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
RAZADYNE ER NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)
RELISTOR CONSTIPATION REQUIRES USE OF BOTH AMITIZA AND MOVANTIK FIRST
RELPAX MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
RESCULA EYE CONDITIONS BIMATOPROST, LATANOPROST , TRAVOPROST
REVATIO ORAL SUSPENSION PULMONARY HYPERTENSION SILDENAFIL 20MG
REVATIO TABLETS PULMONARY HYPERTENSION SILDENAFIL 20MG
RHINOCORT ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
RHINOCORT AQUA ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
RIOMET DIABETES METFORMIN IR
RITALIN LA ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
RITALIN SR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
ROCALTROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION
ROCALTROL ORAL SOLUTION VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION
ROSADAN CREAM KIT SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
ROSADAN GEL KIT SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
ROSANIL SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ROSULA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ROZEREM SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
SANCTURA OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
SANCTURA XR OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
SARAFEM DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
SAVELLA PAIN/INFLAMMATION REQUIRES USE OF ANY TWO (BRAND OR GENERIC SSRIS) OR (BRAND OR GENERIC SNRIS)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: DESVENLAFAXINE ER (BRAND), DESVENLAFAXINE FUMARATE ER (BRAND), FETZIMA, IRENKA, KHEDEZLA, PRISTIQ, VENLAFAXINE IR OR ER (EFFEXOR, EFFEXOR XR), VENLAFAXINE ER (BRAND PRODUCT)
SCALACORT SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
SECTRAL HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
SERNIVO SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
SILENOR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
SITAVIG BUCCAL TABLETS VIRAL INFECTIONS GENERIC ACYCLOVIR
SOLODYN ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
SONATA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
SOOLANTRA SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL
SOVALDI (2018 Preferred Formulary Exclusion) HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI
SPIRITAM NEUROLOGICAL DISORDERS LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA
SPRIX PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
STAVZOR NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID
STRATTERA (2018 Preferred Formulary Exclusion) ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE
SULAR HIGH BLOOD PRESSURE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER
SUMADAN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
SUMADAN XLT SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
SUMAVEL DOSEPRO (2018 Preferred Formulary Exclusion) MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
SUMAXIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
SUMAXIN CP SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
SUMAXIN TS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
SYNALAR SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
SYNALAR TS KIT SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
SYNDROS NAUSEA/VOMITING AT LEAST 2 CONVENTIONAL ANTIEMETIC TREATMENT (FOR N/V ASSOCIATED WITH CANCER CHEMOTHERAPY)
SYNJARDY DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
TACROLIMUS OINTMENT(GENERIC) SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC):
FOR EXAMPLE:
ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
TARGADOX ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
TECFIDERA MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF
TEMOVATE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
TENORETIC HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
TENORMIN HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
TESTRED HORMONAL SUPPLEMENTATION GENERIC OR METHITEST
TEVETEN HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
TEVETEN HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
TEXACORT SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
TIVORBEX PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
TOPAMAX NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN
TOPAMAX SPRINKLE NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN
TOPICORT SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
TOPICORT SPRAY SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
TOPIRAMATE ER NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN
TOPROL XL HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
TOVIAZ OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
TRADJENTA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
TRAMADOL EXTENDED RELEASE PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN
TRANDATE HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
TREXIMET MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
TRIBENZOR (2018 Preferred Formulary Exclusion) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
TRICOR HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
TRIGLIDE HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
TRILEPTAL NEUROLOGICAL DISORDERS OXCARBAZEPINE
TRILIPIX HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID
TROKENDI XR NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN
TUSSICAPS COUGH AND COLD GENERIC COUGH/COLD LIQUID
TUZISTRA XR COUGH AND COLD GENERIC COUGH/COLD LIQUID
TWYNSTA HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE
ULORIC GOUT ALLOPURINOL, PROBENECID, PROBENECID/COLCHICHINE
ULTRACET PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN
ULTRAM PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN
ULTRAM ER PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN
ULTRAVATE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
ULTRAVATE X SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
UROXATROL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN
VANATOL LQ PAIN GENERIC PRODUCT WITH BUTALBITAL
VANOS SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
VANOXIDE-HC SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
VELTIN (2018 Preferred Formulary Exclusion) SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
VENLAFAXINE EXTENDED-RELEASE (BRAND) DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)
SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD
SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS
VENTAVIS PULMONARY HYPERTENSION TYVASO
VERDESO SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST
FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE
VERELAN HIGH BLOOD PRESSURE VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER
VERELAN PM HIGH BLOOD PRESSURE VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER
VESICARE OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER
VIBRAMYCIN ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE
VIIBRYD DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
VITUZ COUGH AND COLD GENERIC COUGH/COLD LIQUID
VIVLODEX PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
VOLTAREN GEL PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
VOLTAREN XR PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
VYTORIN (2018 Preferred Formulary Exclusion) HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
VYVANSE ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS
FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS
WELCHOL HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE
WELLBUTRIN SR (2018 Preferred Formulary Exclusion) DEPRESSION BUPROPION SR, BUPROPION ER
WELLBUTRIN XL DEPRESSION BUPROPION SR, BUPROPION ER
XALATAN EYE CONDITIONS BIMATOPROST, LATANOPROST , TRAVOPROST
XATMEP ONCOLOGY/INFLAMMATORY CONDITIONS METHOTREXATE TABLETS, TREXALL
XIGDUO XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC)
XTAMPZA ER PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
YOSPRALA ULCER ASPIRIN + RX PPI
ZAVESCA METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE CERDELGA
ZEBETA HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
ZEGERID (BRAND AND SELECT GENERICS) ULCER TRY 5 OTHER GENERICS. IF A PATIENT HAS TRIED THE FIRST LINE ALTERNATIVES, A COVERAGE REVIEW MUST BE COMPLETED IN ORDER TO GAIN ACCESS TO A STEP 2 DRUG.
ZEMBRACE SYMTOUCH MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
ZEMPLAR CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION
ZEPATIER (2018 Preferred Formulary Exclusion) HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI
ZETIA (2018 Preferred Formulary Exclusion) HIGH BLOOD CHOLESTEROL GENERIC HMG-COA REDUCTASE INHIBITORS* (I.E., ATORVASTATIN, ATORVASTATIN PLUS, AMLODIPINE, FLUVASTATIN, FLUVASTATIN ER, LOVASTATIN, PRAVASTATIN, ROSUVASTATIN, SIMVASTATIN)
BRAND NAME HMG-COA REDUCTASE INHIBITORS (I.E., ALTOPREV, CRESTOR, LESCOL, LESCOL XL, LIPITOR, LIVALO, MEVACOR, PRAVACHOL, ZOCOR)
BRAND NAME HMG-COA REDUCTASE INHIBITOR COMBINATION PRODUCTS (I.E., CADUET, VYTORIN)
*TRY ONE OF THESE GENERICS FIRST TO AVOID BEING TARGETED BY ANOTHER STEP THERAPY PROGRAM
ZETONNA (2018 Preferred Formulary Exclusion) ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY
ZIAC HIGH BLOOD PRESSURE GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)
ZIANA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR
ZIOPTAN (2018 Preferred Formulary Exclusion) EYE CONDITIONS BIMATOPROST, LATANOPROST , TRAVOPROST
ZIPSOR PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
ZOCOR HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN
STEP 2: LIVALO
ZOHYDRO ER PAIN - NARCOTIC MORPHINE SULFATE CONTROLLED-RELEASE TABLETS, MORPHINE SULFATE EXTENDED-RELEASE CAPSULES (GENERIC KADIAN), OXYMORPHONE EXTENDED-RELEASE TABLETS
ZOLOFT (2018 Preferred Formulary Exclusion) DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:
CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE
ZOLPIMIST SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER
ZOMIG MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
ZOMIG NASAL SPRAY MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
ZOMIG ZMT MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN
ZONACORT 7 DAY/11 DAY INFLAMMATORY CONDITIONS GENERIC DEXAMETHASON TABLETS
ZORVOLEX PAIN GENERIC NSAIDS (MUST USE TWO)
FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL
ZURAMPIC GOUT ALLOPURINOL, PROBENECID, PROBENECID/COLCHICHINE
ZYFLO ASTHMA/COPD GENERIC MONTELUKAST
ZYFLO CR (2018 Preferred Formulary Exclusion) ASTHMA/COPD GENERIC MONTELUKAST