Wellmark BlueRx Preferred Formulary

Blue Rx Preferred Formulary
EFFECTIVE 08/01/2016
INTRODUCTION
The Blue Rx Preferred formulary is a list of drugs covered under your

pharmacy benefit and developed to serve as a guide for physicians,
pharmacists, healthcare professionals and members in the selection of
cost-effective drug therapy. Wellmark recognizes that drug therapy is an
integral part of effective health management. The vast availability of
drug options, however, warrants a reasonable program for drug selection
and use.
Wellmark continually reviews new and existing drugs to ensure the

formulary remains responsive to the needs of our members and health
professionals. Criteria used to evaluate drug selection for the formulary
includes, but is not limited to safety, efficacy and cost-effectiveness data,
as well as comparison of relevant benefits of similar prescription or over-
the-counter (OTC) agents while minimizing potential duplications.
The formulary is a continually reviewed and modified document that

represents covered drugs under your pharmacy benefit. This dynamic
process does not allow this document to be completely accurate at all
times. To accommodate regular changes, an updated electronic version
of this formulary is available online at www.Wellmark.com. Wellmark
welcomes your input and feedback on the information provided in this
document.
FORMULARY OVERVIEW
The Blue Rx Preferred formulary is continually changing to reflect new

advances in drug treatment therapies and current practices of Wellmark
providers. Due to the rapidly changing environment, this process ensures
appropriate formulary review and tier placement. To continue to provide

2016 Wellmark, Inc. 1
sustainable pharmacy benefits and access to needed cost-effective
treatments, concentrated evaluation and analysis of drug products in
formularies is accomplished through this process.
Wellmark has developed the Pharmacy and Therapeutics Committee

(P&T) to ensure all drugs in the Blue Rx Preferred formulary and new
drugs approved by the United States Food and Drug Administration
(FDA) are reviewed by licensed physicians actively practicing medicine in
Iowa and South Dakota. In addition, the process allows P&T members
the opportunity to receive evidence-based clinical data and make clinical
recommendations for formulary placement and utilization management.
The entire Wellmark formulary is reviewed annually by P&T including all
new drugs approved by the FDA.
The P&T includes licensed physicians and pharmacists. These clinicians

serve in an evaluation, education and advisory capacity to the Wellmark
Pharmacy program specific to the coverage and limitations of drugs on
the Wellmark formularies. Through review and discussion, P&T votes
whether the drug or drug class is therapeutically unique, similar or
inferior to existing treatment options. In addition, the P&T makes
utilization management recommendations to Wellmark for consideration
when there are therapeutically interchangeable alternatives.
The P&T meets quarterly to evaluate drugs requested for addition to the
Wellmark formularies, reviews existing drugs in the Wellmark formularies
and establishes recommendations for utilization management.
HOW TO READ THE FORMULARY
All drugs are listed by their generic names and/or most common
proprietary (brand) name. Specific drug listings may be accessed either
by generic (in lowercase) or brand name (in uppercase) and by
therapeutic drug tier. Any drug not found in this formulary listing, or any
formulary updates published by Wellmark, shall be considered excluded
from your benefit.
Once the product is located, the following items can be viewed:

Drug Tier: Drugs are categorized within tiers on the formulary. Each tier
is assigned a cost, which is determined by the member's pharmacy
benefit plan.
Specialty Drugs (SP-P): Specialty drugs are high-cost injectable,

infused, oral or inhaled drugs for the ongoing treatment of a chronic
condition. These drugs generally require close supervision and
monitoring of the patient's drug therapy. Specialty drugs may be
categorized within tiers on the formulary or as drugs covered under your
medical benefit.
Specialty Drugs Preferred (SP-P): Drugs in this category will

process with the preferred specialty drug cost-share.
Specialty Drugs Non-Preferred (SP-NP): Drugs in this category
will process with the non-preferred specialty cost-share, and will
have a higher cost share than preferred specialty drugs.
Specialty pharmacies specialize in the delivery and clinical management

of specialty drugs. Wellmark has two preferred specialty pharmacy
providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy
Solutions. You can find more information about their services at
www.Wellmark.com.
Drug Name: This lists the generic name for the product (lowercase) OR
the brand name or common reference name for the product
(UPPERCASE).
Requirements/Limits: This lists Wellmark Pharmacy programs that

may impact a particular drug or class of drugs and are described below:
Prior Authorization (PA): This indicates a drug requires prior

authorization before it is covered under your benefit. Your health
care provider will need to contact our Pharmacy program at 1-800-
600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6
p.m. CST
Prior authorization review of prescribing guidelines will be evaluated

utilizing the established drug review criteria approved by Wellmark.
If the request does not meet the approved criteria, the request will
not be approved and alternative therapy may be recommended
along with the proper course of alternative action. A list of edits
recommended by Wellmark is available upon request. Members
should call Wellmark Customer Service at the number listed on the
back of their ID card if they have questions regarding their specific
coverage.
Medical Necessity Prior Authorization (MN-PA): This indicates

a drug requires prior authorization before it is covered under your
benefit. Your health care provider will need to contact our Pharmacy
program at 1-800-600-8065. Hours of operation are Monday -
Friday: 8 a.m. to 6 p.m. CST
The intent of formulary medical necessity prior authorization is to

confirm the appropriate coverage of the target drugs when evidence
is provided documenting a trial and failure of the preferred
formulary alternatives or a clinical reason such as expected adverse
reaction or contraindication that prevents the patient from trying
the formulary alternatives. These criteria apply to all medications
subject to formulary medical necessity not otherwise managed
through drug specific criteria. Members should call Wellmark
Customer Service at the number listed on the back of their ID card
if they have questions regarding their specific coverage.
Quantity Limits (QL): Wellmark typically covers a 30-day supply

for prescriptions per co-pay. Some drugs, however, have a quantity
limit. Amounts over the specified quantity limits are not a covered
benefit. Quantity limits are in place to ensure the drug is being used
correctly and other treatments are not appropriate. Most people
would not need to take these drugs more often than what Wellmark
allows.
No special steps are necessary by the physician or member to have

these drugs covered as long as the drugs prescribed do not exceed
quantity limits. A few drugs may also require prior authorization
(for example, Viagra). If you require one of these drugs in a larger
quantity than is allowed, your physician may make a special
request for coverage. Your physician may be asked to provide
details about your medical condition and treatment plan. After
reviewing the information, coverage will be evaluated based on
medical necessity.

Your benefits certificate, coverage manual, or policy has specific
information about your plan's prior authorization requirements.
Preventive Drugs (PV): Preventive drugs are defined by the
Internal Revenue Service. Preventive drugs are prescribed to
prevent the occurrence of a disease or condition with risk factors
such as high blood pressure, high cholesterol, diabetes, asthma,
heart attack and stroke, or to prevent the recurrence of the disease
or condition for individuals who have recovered. Preventive drugs
do not include drugs used to treat an existing illness, injury or
condition.
For some pharmacy plans that require you to pay a certain amount
before the plan coverage begins, preventive drugs may be covered
before you reach that amount. To be sure, you should read your
enrollment information to see how preventive drugs are covered
specific to your plan.
Generic Available (GA): Indicates a generic equivalent is

available for a brand name drug. In most cases, when you purchase
a brand name drug that has an FDA-approved "A"-rated generic
equivalent, Wellmark will pay only what it would have paid for the
equivalent generic drug. You will be responsible for your payment
obligation for the equivalent generic drug and any remaining cost
difference up to the maximum allowed fee for the brand name drug
HEALTH CARE REFORM PREVENTIVE DRUGS
Preventive drugs with an "A" or "B" rating in the current

recommendations of the United States Preventive Services Task Force
(USPSTF) and immunizations as recommended by the Advisory
Committee on Immunization Practices of the Centers for Disease Control
and Prevention are not associated with any cost share for members on
plans with this benefit.
A complete list of recommendations and guidelines related to preventive

services can be found at Healthcare.gov. Recommended preventive items
and services are subject to change and are subject to medical
management.

BENEFIT COVERAGE AND LIMITATIONS
This printed formulary does not define benefit coverage and limitations.
Many members have specific benefit inclusions, exclusions, copayments
or a lack of coverage, which are not reflected in the Blue Rx Essentials
formulary. Members should contact their Plan Sponsor or Wellmark
Customer Service at the number on the back of their ID card if they have
questions regarding their coverage. Please note that the formulary
process is evolutionary and changes can occur throughout the year. The
following topics may or may not be applicable depending on the
parameters of your specific benefits.
FORMULARY EXCEPTION PROCESS
Drugs not included in this list shall be considered non-formulary and are
NOT COVERED. In some instances, Wellmark will consider coverage
exceptions. Coverage of non-formulary drugs may be requested by the
health professional through an exception request for a non-formulary
prescription drug (outlined below). Generally, the following guidelines
must be documented in order for an exception to be granted:
All covered formulary drugs on any tier will be ineffective; OR

All covered formulary drugs on any tier have been ineffective; OR
All covered formulary drugs on any tier would not be as effective as
the non-formulary drug; OR
All covered formulary drugs would have adverse effects
COMMON DRUG EXCLUSIONS
Due to benefit design parameters, some plan sponsors may choose to

exclude certain drug classes. Prior authorization is generally not available
for drugs that are specifically excluded by benefit design. Common
excluded drugs may include, but are not limited to:
OTC drugs or their equivalents unless otherwise specified in the

formulary listing.
Drug products used for cosmetic purposes
Experimental drug products, or any drug product used in an
experimental manner

Replacement of a lost or stolen drug
Foreign drugs or drugs not approved by the United States Food &
Drug Administration (FDA)
GENERIC DRUG SUBSTITUTION
In most cases, Wellmark promotes the use of equally effective generic

drugs whenever possible. If a member or physician requests a brand-
name product when the prescription is filled and a generic equivalent is
available, the member will typically be required to pay the difference in
cost between the brand and the generic drug.
When a brand-name drug becomes available as a generic, the brand-

name product may move to a higher tier. Members may be required to
pay more for a prescription when a higher-tier brand-name product is
dispensed.
Members will not be responsible for the cost difference between brands
and generics when choosing one of the products listed below:
Coumadin Stavzor
Cytomel Synthroid
Depakene Tegretol/Tegretol XR
Depakote/Depakote ER Theophylline products
Dilantin Thyrolar
Equetro Tirosint
Lanoxin

LEGEND
GA Generic Available
PA Prior Authorization
PV Preventive Medication
QL Quantity Limit
SP-P Specialty Preferred
SP-NP Specialty Non-Preferred
lowercase Indicates generic availability
UPPERCASE Indicates brand availability
CONTACT INFORMATION
The Blue Rx formulary is designed to assist physicians, members and

other health care professionals in the selection of cost-effective agents.
Wellmark encourages your input and feedback on how we can assist in
improving this document and the formulary management process.
Please direct your communications to:

Wellmark Blue Cross and Blue Shield
1331 Grand Avenue
P.O. Box 9232
Des Moines, IA 50306
In addition to the Blue Rx formulary, other quick-reference guides are

available on our web site at Wellmark.com.

Wellmark Blue Rx Preferred Formulary
Requirements/
Drug Name Drug Tier Limits
ANALGESICS
COX-II INHIBITORS
CELEBREX 4 GA; QL
celecoxib 1 QL
GOUT
allopurinol 1
colchicine 1
colchicine/probenecid 1
COLCRYS 4 GA
MITIGARE 4 GA
probenecid 1
ULORIC 2 PA; QL
ZYLOPRIM 4 GA
NON-OPIOID ANALGESICS
acetaminophen/salicylamide/phenyltoloxamine 1
BUPAP 4
butalbital/acetaminophen 1
butalbital/acetaminophen/caffeine 1
butalbital/aspirin/caffeine 1
EQUAGESIC 4
ESGIC 4 GA
FIORICET 4 GA
FIORINAL 4 GA
LEVACET 4
VANATOL LQ 4
NSAIDS
ANAPROX 4 GA
ANAPROX DS 4 GA
choline/magnesium trisalicylates 1
DAYPRO 4 GA
diclofenac potassium 1
diclofenac sodium delayed-rel 1 diclofenac sodium ext-
rel 1
diflunisal 1
EC-NAPROSYN 4 GA
etodolac 1
etodolac ext-rel 1
Requirements/
FELDENE 4 GA
fenoprofen 1
flurbiprofen 1
ibuprofen 1
INDOCIN SUPP 3
INDOCIN SUSP 2
indomethacin 1
indomethacin ext-rel 1
ketoprofen 1
ketoprofen ext-rel 1
ketorolac 1
meclofenamate sodium 1
mefenamic acid 1
meloxicam 1
MOBIC 4 GA
nabumetone 1
NALFON 4
NAPRELAN 375MG, 500MG 4 GA
NAPRELAN 750MG 4
NAPROSYN 4 GA
naproxen 1
naproxen delayed-rel 1
naproxen sodium 1
naproxen sodium ext-rel 1
oxaprozin 1
piroxicam 1
PONSTEL 4 GA
salsalate 1
SPRIX 4
sulindac 1
TIVORBEX 4
tolmetin sodium 1
ZIPSOR 4
NSAIDS, COMBINATIONS
ARTHROTEC 4 GA
diclofenac/misoprostol 1
NSAIDS, TOPICAL
diclofenac sodium soln 4
FLECTOR 4
PENNSAID 4
Requirements/
REXAPHENAC 4
VOLTAREN GEL 4
OPIOID ANALGESICS
ABSTRAL 4 PA
ACTIQ 4 PA; GA
alfentanil injection 1
butalbital/acetaminophen/caffeine/codeine 1
butalbital/aspirin/caffeine/codeine 1
butorphanol nasal spray 1 QL
BUTRANS 4 QL
CAPITAL W/CODEINE 1
codeine 1
codeine/acetaminophen 1
CONZIP 4 GA
DEMEROL 4 GA
dihydrocodeine/acetaminophen/caffeine 1
dihydrocodeine/aspirin/caffeine 1
DILAUDID 4 GA
DOLOPHINE 4 GA
DURAGESIC 4 GA; QL
EMBEDA 4 QL
EXALGO 4 GA; QL
fentanyl transdermal 12mcg, 25mcg, 50mcg,
75mcg, 100mcg 1 QL
FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG,
87.5MCG 1 QL
fentanyl transmucosal lozenge 1 PA
FENTORA 4 PA
FIORICET W/CODEINE 4 GA
FIORINAL W/CODEINE 4 GA
HYCET 4 GA
hydrocodone/acetaminophen 1
hydrocodone/ibuprofen 1
hydromorphone 1
hydromorphone ext-rel 1 QL
HYDROMORPHONE SUPP 1
HYSINGLA ER 4 QL
KADIAN 10MG, 20MG, 30MG, 50MG, 60MG,
80MG, 100MG 4 GA; QL
KADIAN 40MG, 200MG 4 QL

Requirements/
LAZANDA 4
levorphanol 1
LORTAB ELIXIR 4
meperidine 1
methadone 1
METHADOSE CONCENTRATE 4 GA
morphine 1
morphine ext-rel 1 QL
morphine ext-rel beads 4 QL
morphine supp 5mg, 10mg, 20mg 1
MORPHINE SUPP 30MG 1
MS CONTIN 4 GA; QL
NORCO 4 GA
NUCYNTA 4
NUCYNTA ER 4 QL
OPANA 4 GA
OPANA ER 4 QL
OXAYDO 4
oxycodone 1
oxycodone ext-rel 2 QL
oxycodone/acetaminophen 1
oxycodone/aspirin 1
oxycodone/ibuprofen 1
OXYCONTIN 2 QL
oxymorphone 1
oxymorphone ext-rel 1 QL
pentazocine/naloxone 1
PERCOCET 4 GA
PRIMLEV 4
REPREXAIN 4 GA
ROXICET SOLN 4
ROXICODONE 4 GA
SUBSYS 4 PA
tramadol 1
tramadol ext-rel caps 100mg, 200mg, 300mg 4
TRAMADOL EXT-REL CAPS 150MG 4
tramadol ext-rel tabs 1
tramadol/acetaminophen 1
TREZIX 4 GA
TYLENOL W/CODEINE 4 GA
ULTRACET 4 GA

Requirements/
ULTRAM 4 GA
ULTRAM ER 4 GA
VICOPROFEN 4 GA
XARTEMIS XR 4 QL
ZOHYDRO ER 4 QL
ANTI-INFECTIVES
AMINOGLYCOSIDES
neomycin 1
paromomycin 1
ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN
cefadroxil 1
cephalexin 1
KEFLEX 4 GA
ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN
cefaclor 1
CEFACLOR ER 3
cefprozil 1
CEFTIN 4 GA
CEFTIN SUSP 4
cefuroxime axetil 1
ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN
CEDAX CAPS 4 GA
CEDAX SUSP 90MG/5ML 4
CEDAX SUSP 180MG/5ML 4 GA
cefdinir 1
cefditoren 3
cefixime 1
cefpodoxime 1
ceftibuten 1
ceftriaxone 1
SUPRAX 3
SUPRAX SUSP 4 GA
SUPRAX SUSP 500MG/5ML 3
ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES
azithromycin 1
BIAXIN 4 GA
Requirements/
clarithromycin 1
clarithromycin ext-rel 1
DIFICID 4
e.e.s. 400 4
ERYPED 2
erythromycin base 1
erythromycin delayed-rel 1
erythromycin ethylsuccinate 1
erythromycin stearate 1
ZITHROMAX 4 GA
ZMAX SUSP 4
ANTIBACTERIALS, FLUOROQUINOLONES
AVELOX 4 GA
CIPRO 4 GA
CIPRO XR 4 GA
ciprofloxacin 1
ciprofloxacin ext-rel 1
ciprofloxacin oral susp 1
FACTIVE 4
LEVAQUIN 4 GA
levofloxacin 1
levofloxacin oral soln 1
moxifloxacin 1
ofloxacin 1
ANTIBACTERIALS, KETOLIDES
KETEK 4
ANTIBACTERIALS, PENICILLINS
amoxicillin 1
amoxicillin/clavulanate 1
amoxicillin/clavulanate ext-rel 1
ampicillin 1
AUGMENTIN 4 GA
AUGMENTIN SUSP 4 GA
AUGMENTIN SUSP 125MG/5ML 4
AUGMENTIN XR 4 GA
dicloxacillin 1
penicillin vk 1

Requirements/
ANTIBACTERIALS, SULFONAMIDES
BACTRIM 4 GA
BACTRIM DS 4 GA
SULFADIAZINE 1
sulfamethoxazole/trimethoprim 1
ANTIBACTERIALS, TETRACYCLINES
ADOXA 4 PA; GA
demeclocycline 1
DORYX 4 PA
doxycycline hyclate 1
doxycycline hyclate delayed-rel 1 PA
doxycycline monohydrate caps 50mg, 75mg,
100mg 1
doxycycline monohydrate caps 150mg 1 PA
doxycycline monohydrate susp 1
doxycycline monohydrate tabs 1 PA
MINOCIN 4 GA
minocycline 1
minocycline ext-rel 1 PA
MONODOX 4 GA
SOLODYN 4 PA
tetracycline 1
VIBRAMYCIN CAPS, SUSP 4 GA
VIBRAMYCIN SYRUP 3
ANTIFUNGALS
ANCOBON 4 GA
BIO-STATIN 4
clotrimazole troche 1
CRESEMBA 4
DIFLUCAN 4 GA
fluconazole 1
flucytosine 1
GRIS-PEG 4 GA
griseofulvin microsize 1
griseofulvin ultramicrosize 1
itraconazole 1 PA
ketoconazole tabs 1
LAMISIL 4 GA
NOXAFIL 4

Requirements/
nystatin oral 1
ONMEL 4 PA
ORAVIG 4
SPORANOX 4 PA; GA
SPORANOX SOLN 3 PA
terbinafine 1
VFEND 4 GA
voriconazole 1
ANTIMALARIALS
ARALEN 4 GA
atovaquone/proguanil 1 PV
chloroquine 1 PV
COARTEM 4
DARAPRIM 2
MALARONE 4 GA
mefloquine 1 PV
PRIMAQUINE 1 PV
QUALAQUIN 4 GA
quinine sulfate 1
ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS
TYBOST 2
ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS
abacavir/lamivudine/zidovudine 1
ATRIPLA 2
COMBIVIR 4 GA
COMPLERA 2
DESCOVY 2
EPZICOM 3
EVOTAZ 3
GENVOYA 2
lamivudine/zidovudine 1
ODEFSEY 2
PREZCOBIX 3
STRIBILD 2
TRIUMEQ 2
TRIZIVIR 4 GA
TRUVADA 2

Requirements/
ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS
SELZENTRY 2
ANTIRETROVIRALS, FUSION INHIBITORS
FUZEON SP-P
ANTIRETROVIRALS, INTEGRASE INHIBITORS
ISENTRESS 2
ISENTRESS POWDER 3
TIVICAY 2
VITEKTA 2
ANTIRETROVIRALS, PROTEASE INHIBITORS
APTIVUS 2
APTIVUS SOLN 3
CRIXIVAN 2
INVIRASE 2
KALETRA 2
LEXIVA 2
LEXIVA SUSP 3
NORVIR 2
NORVIR SOLN 3
PREZISTA SUSP 3
PREZISTA TABS 2
REYATAZ 2
REYATAZ POWDER 3
VIRACEPT 2
ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -
NON-NUCLEOSIDE
EDURANT 2
INTELENCE 2
nevirapine 1
nevirapine ext-rel 1
RESCRIPTOR 2
SUSTIVA 2
VIRAMUNE 4 GA
VIRAMUNE XR 4 GA

Requirements/
NUCLEOSIDE
abacavir 1
didanosine 1
EMTRIVA 2
EPIVIR 4 GA
lamivudine soln, tabs 1
RETROVIR 4 GA
stavudine 1
VIDEX EC 4 GA
VIDEX SOLN 3
ZERIT 4 GA
ZIAGEN 4 GA
ZIAGEN SOLN 2
zidovudine 1
NUCLEOTIDE
VIREAD 2
VIREAD POWDER 3
ANTITUBERCULAR AGENTS
cycloserine 1
ethambutol 1
isoniazid 1
PASER GRANULES 1
PRIFTIN 3
pyrazinamide 1
RIFADIN 4 GA
rifampin 1
RIFATER 4
SIRTURO 4
TRECATOR 3
ANTIVIRALS, CMV AGENTS
VALCYTE 4 GA
VALCYTE SOLN 2
valganciclovir 1
ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B
adefovir dipivoxil 1

Requirements/
BARACLUDE SOLN 4
BARACLUDE TABS 4 GA
entecavir 1
EPIVIR HBV 4 GA
EPIVIR HBV SOLN 3
lamivudine tabs 1
TYZEKA SP-P
ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C
COPEGUS 4 GA
DAKLINZA SP-NP PA; QL
HARVONI SP-P PA; QL
OLYSIO SP-NP PA; QL
REBETOL CAPS 4 GA
REBETOL SOLN 4
ribavirin 1
SOVALDI SP-P PA; QL
TECHNIVIE SP-NP PA; QL
VIEKIRA PAK SP-NP PA; QL
ANTIVIRALS, HERPES AGENTS
acyclovir 1
famciclovir 1
FAMVIR 4 GA
SITAVIG 4
valacyclovir 1
VALTREX 4 GA
ZOVIRAX 4 GA
ANTIVIRALS, INFLUENZA AGENTS
FLUMADINE 4 GA
RELENZA 2
rimantadine 1
TAMIFLU 2
MISCELLANEOUS
ALBENZA 3
ALINIA 3
atovaquone 1
BILTRICIDE 3
CLEOCIN 4 GA
clindamycin caps, oral soln 1
Requirements/
dapsone 1
FLAGYL 4 GA
FLAGYL ER 4
FURADANTIN SUSP 4 GA
IMPAVIDO 3
ivermectin 1
linezolid 1
MACROBID 4 GA
MACRODANTIN 4 GA
MEPRON SUSP 4 GA
metronidazole 1
MONUROL 2
MYCOBUTIN 4 GA
NEBUPENT 3
nitrofurantoin 1
PRIMSOL 3
rifabutin 1
SIVEXTRO 3
STROMECTOL 4 GA
TINDAMAX 4 GA
tinidazole 1
trimethoprim 1
VANCOCIN 4 GA
vancomycin caps 1
vancomycin inj 500mg, 1000mg 1
VANCOMYCIN INJECTION 750MG 1
XIFAXAN 2
ZYVOX SUSP 4 GA
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
ALKERAN 2
CYCLOPHOSPHAMIDE CAPS 1
EMCYT SP-P
GLEOSTINE 5MG 2
GLEOSTINE 10MG, 40MG, 100MG 4
HEXALEN 2
LEUKERAN 2
MYLERAN 2
TEMODAR SP-NP GA
temozolomide SP-P
Requirements/
VALCHLOR 2
ANTIMETABOLITES
capecitabine SP-P
mercaptopurine 1
methotrexate 1
TABLOID 2
TREXALL 4
XELODA SP-NP GA
HORMONAL ANTINEOPLASTICS, ANTIANDROGENS
bicalutamide 1
flutamide 1
NILANDRON 2
XTANDI SP-P
ZYTIGA SP-P
HORMONAL ANTINEOPLASTICS, ANTIESTROGENS
FARESTON 2
SOLTAMOX 2
tamoxifen 1 PA; PV
HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS
anastrozole 1
ARIMIDEX 4 GA
AROMASIN 4 GA
exemestane 1
FEMARA 4 GA
letrozole 1
HORMONAL ANTINEOPLASTICS, PROGESTINS
megestrol acetate 1
IMMUNOMODULATORS
POMALYST SP-P
REVLIMID SP-P
THALOMID SP-P
KINASE INHIBITORS
AFINITOR SP-P QL
AFINITOR DISPERZ SP-P
ALECENSA SP-P
Requirements/
BOSULIF SP-P
CABOMETYX SP-P
CAPRELSA 2
COMETRIQ 2
COTELLIC SP-P
GILOTRIF 2
GLEEVEC SP-NP GA
IBRANCE SP-P
ICLUSIG SP-P
imatinib mesylate SP-P
IMBRUVICA SP-P
INLYTA SP-P
JAKAFI SP-P
LENVIMA 2
MEKINIST SP-P
NEXAVAR SP-P
SPRYCEL SP-P
STIVARGA SP-P
SUTENT SP-P
TAFINLAR SP-P
TAGRISSO SP-P
TARCEVA SP-P
TASIGNA SP-P
TYKERB SP-P QL
VOTRIENT SP-P
XALKORI SP-P
ZELBORAF SP-P
ZYDELIG 2
ZYKADIA SP-P
MISCELLANEOUS
bexarotene SP-P
DROXIA 3
ERIVEDGE 2
etoposide SP-P
FARYDAK SP-P
HYDREA 4 GA
hydroxyurea 1
leucovorin 1
LONSURF SP-P
LYNPARZA 2

Requirements/
LYSODREN 2
MATULANE 2
NINLARO SP-P
ODOMZO SP-P
TARGRETIN CAPS SP-NP GA
TARGRETIN GEL SP-P
tretinoin caps 1
VENCLEXTA SP-P
VISTOGARD SP-P
ZOLINZA SP-P
TOPOISOMERASE INHIBITORS
HYCAMTIN SP-P
CARDIOVASCULAR
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/benazepril 1 PV
LOTREL 4 GA
PRESTALIA 4
TARKA 4 GA
trandolapril/verapamil 1 PV
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/hydrochlorothiazide 1 PV
captopril/hydrochlorothiazide 1 PV
enalapril/hydrochlorothiazide 1 PV
fosinopril/hydrochlorothiazide 1 PV
lisinopril/hydrochlorothiazide 1 PV
LOTENSIN HCT 4 GA
moexipril/hydrochlorothiazide 1 PV
quinapril/hydrochlorothiazide 1 PV
ZESTORETIC 4 GA
ACE INHIBITORS
ACCUPRIL 4 GA
ALTACE 4 GA
benazepril 1 PV
captopril 1 PV
enalapril 1 PV
EPANED 4
fosinopril 1 PV
Requirements/
lisinopril 1 PV
LOTENSIN 4 GA
MAVIK 4 GA
moexipril 1 PV
perindopril 1 PV
PRINIVIL 4 GA
quinapril 1 PV
ramipril 1 PV
trandolapril 1 PV
VASOTEC 4 GA
ZESTRIL 4 GA
ADRENOLYTICS, CENTRAL
CATAPRES 4 GA
CATAPRES-TTS 4 GA
clonidine 1 PV
clonidine transdermal 1 PV
guanfacine 1 PV
TENEX 4 GA
ALDOSTERONE RECEPTOR ANTAGONISTS
ALDACTONE 4 GA
eplerenone 1
spironolactone 1
ALPHA BLOCKERS
CARDURA 4 GA
doxazosin 1
prazosin 1
terazosin 1
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL
BLOCKER COMBINATIONS
amlodipine/valsartan 1 PV
AZOR 4
EXFORGE 4 GA
telmisartan/amlodipine 1 PV
TWYNSTA 4 GA

Requirements/
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL
BLOCKER/DIURETIC COMBINATIONS
amlodipine/valsartan/hydrochlorothiazide 1 PV
EXFORGE HCT 4 GA
TRIBENZOR 4
ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC
COMBINATIONS
ATACAND HCT 4 GA
AVALIDE 4 GA
BENICAR HCT 4
candesartan/hydrochlorothiazide 1 PV
DIOVAN HCT 4 GA
EDARBYCLOR 4
HYZAAR 4 GA
irbesartan/hydrochlorothiazide 1 PV
losartan/hydrochlorothiazide 1 PV
MICARDIS HCT 4 GA
telmisartan/hydrochlorothiazide 1 PV
valsartan/hydrochlorothiazide 1 PV
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ATACAND 4 GA
AVAPRO 4 GA
BENICAR 4
candesartan 1 PV
COZAAR 4 GA
DIOVAN 4 GA
EDARBI 4
eprosartan 1 PV
irbesartan 1 PV
losartan 1 PV
MICARDIS 4 GA
telmisartan 1 PV
valsartan 1 PV
ANTIARRHYTHMICS
amiodarone 1 PV
BETAPACE 4 GA
disopyramide 1 PV
dofetilide 1
Requirements/
flecainide 1 PV
mexiletine 1
MULTAQ 3
NORPACE 4 GA
NORPACE CR 3
propafenone 1 PV
propafenone ext-rel 1 PV
quinidine gluconate 1
quinidine sulfate 1
quinidine sulfate ext-rel 1
RYTHMOL 4 GA
RYTHMOL SR 4 GA
sotalol 1 PV
sotalol af 1 PV
TIKOSYN 4 GA
ANTILIPEMICS, BILE ACID RESINS
cholestyramine powder 1 PV
cholestyramine powder light 1 PV
COLESTID 4 GA
colestipol 1 PV
QUESTRAN 4 GA
QUESTRAN LIGHT 4 GA
WELCHOL 4
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS
ZETIA 2 PV
ANTILIPEMICS, FIBRATES
ANTARA 4
fenofibrate caps, tabs 1 PV
fenofibric acid 1 PV
fenofibric acid delayed-rel 1 PV
FENOGLIDE 4 GA
gemfibrozil 1 PV
LIPOFEN 4 GA
LOFIBRA 4 GA
TRICOR 4 GA
TRIGLIDE 4
TRILIPIX 4 GA

Requirements/
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS
ALTOPREV 4
atorvastatin 1 PV
CRESTOR 2 PV
fluvastatin 1 PV
fluvastatin ext-rel 1
LESCOL XL 4 GA
LIPITOR 4 GA
LIVALO 2 PV
lovastatin 1 PV
MEVACOR 4 GA
PRAVACHOL 4 GA
pravastatin 1 PV
simvastatin 1 PV
VYTORIN 4
ZOCOR 4 GA
ANTILIPEMICS, MISCELLANEOUS
JUXTAPID SP-P PA; QL
KYNAMRO SP-P PA; QL
ANTILIPEMICS, NIACINS/COMBINATIONS
ADVICOR 4
niacin 4
niacin ext-rel 1 PV
NIASPAN 4 GA
SIMCOR 4
ANTILIPEMICS, PCSK9 INHIBITORS
PRALUENT SP-NP MN-PA; QL
REPATHA SP-P PA; QL
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol/chlorthalidone 1 PV
bisoprolol/hydrochlorothiazide 1 PV
CORZIDE 4 GA
DUTOPROL 4
LOPRESSOR HCT 4 GA
metoprolol/hydrochlorothiazide 1 PV
nadolol/bendroflumethiazide 1 PV

Requirements/
propranolol/hydrochlorothiazide 1 PV
ZIAC 4 GA
BETA-BLOCKERS
acebutolol 1 PV
atenolol 1 PV
betaxolol 1 PV
bisoprolol 1 PV
BYSTOLIC 4
carvedilol 1 PV
COREG 4 GA
COREG CR 4
CORGARD 4 GA
HEMANGEOL 4
INDERAL LA 4 GA
labetalol 1 PV
LEVATOL 4
LOPRESSOR 4 GA
metoprolol succinate ext-rel 1 PV
metoprolol tartrate 1 PV
nadolol 1 PV
pindolol 1 PV
propranolol 1 PV
propranolol ext-rel 1 PV
SECTRAL 4 GA
TENORMIN 4 GA
timolol 1 PV
TOPROL-XL 4 GA
TRANDATE 4 GA
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine/atorvastatin 1 PV
CADUET 4 GA
CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES
ADALAT CC 4 GA
amlodipine 1 PV
felodipine ext-rel 1 PV
isradipine 1 PV
nicardipine 1 PV
nifedipine 1 PV
nifedipine ext-rel 1 PV
Requirements/
nimodipine 1
nisoldipine ext-rel 1 PV
NYMALIZE 4
PROCARDIA 4 GA
PROCARDIA XL 4 GA
CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES
CALAN 4 GA
CALAN SR 4 GA
CARDIZEM 4 GA
CARDIZEM CD 4 GA
CARDIZEM LA 120MG 4
CARDIZEM LA 180MG, 240MG, 300MG,
360MG, 420MG 4 GA
diltiazem 1 PV
diltiazem ext-rel 1 PV
verapamil 1 PV
verapamil ext-rel 1 PV
VERELAN 4 GA
VERELAN PM 4 GA
DIGITALIS GLYCOSIDES
digoxin 1
LANOXIN 62.5MCG, 187.5MCG 4
LANOXIN 125MCG, 250MCG 4 GA
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS
TEKTURNA 4
TEKTURNA HCT 4
DIURETICS
ALDACTAZIDE 25/25 4 GA
ALDACTAZIDE 50/50 4
amiloride 1
amiloride/hydrochlorothiazide 1 PV
bumetanide 1
chlorothiazide 1 PV
chlorthalidone 1 PV
DEMADEX 4 GA
DIURIL 3
DYAZIDE 4 GA
DYRENIUM 3
Requirements/
EDECRIN 3
furosemide 1
FUROSEMIDE SOLN 8 MG/ML 4
furosemide soln 10mg/ml 1
hydrochlorothiazide 1 PV
indapamide 1 PV
LASIX 4 GA
MAXZIDE 4 GA
methyclothiazide 1 PV
metolazone 1
MICROZIDE 4 GA
spironolactone/hydrochlorothiazide 1 PV
torsemide 1
triamterene/hydrochlorothiazide 1 PV
MISCELLANEOUS
clonidine/chlorthalidone 4
CORLANOR 4
DEMSER 2
DIBENZYLINE 4 GA
hydralazine 1 PV
isoxsuprine 10mg 1
isoxsuprine 20mg 4
methyldopa 1 PV
methyldopa/hydrochlorothiazide 1 PV
midodrine 1
minoxidil 1 PV
phenoxybenzamine 1
RANEXA 3
reserpine 1 PV
NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS
ENTRESTO 3 PA; QL
NITRATE/VASODILATOR COMBINATIONS
BIDIL 4
NITRATES, ORAL
DILATRATE SR 4
ISORDIL 5MG 4 GA

Requirements/
ISORDIL 40MG 4
isosorbide dinitrate 1 PV
isosorbide dinitrate ext-rel 1 PV
isosorbide mononitrate 1 PV
isosorbide mononitrate ext-rel 1 PV
nitroglycerin caps 1 PV
NITRATES, SUBLINGUAL/TRANSLINGUAL
nitroglycerin lingual aerosol 1
nitroglycerin lingual spray 1 PV
NITROLINGUAL SPRAY 4 GA
NITROMIST 4 GA
NITROSTAT 2
NITRATES, TRANSDERMAL
NITRO-BID 3
NITRO-DUR 0.1MG, 0.2MG, 0.4MG, 0.6MG 4 GA
NITRO-DUR 0.3MG, 0.8MG 4
nitroglycerin transdermal 1 PV
PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR
ANTAGONIST
LETAIRIS SP-P PA; QL
OPSUMIT SP-P PA; QL
TRACLEER SP-P PA; QL
PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE
INHIBITOR
ADCIRCA SP-P PA; QL
REVATIO INJ SP-NP PA; GA; QL
REVATIO SUSP SP-NP PA; QL
REVATIO TABS SP-NP PA; GA; QL
sildenafil SP-P PA; QL
PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN
RECEPTOR AGONIST
UPTRAVI SP-P PA; QL
PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN
VASODILATORS
ORENITRAM SP-P PA

Requirements/
TYVASO SP-P PA; QL
VENTAVIS SP-P PA; QL
PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE
CYCLASE STIMULATORS
ADEMPAS SP-P PA; QL
CENTRAL NERVOUS SYSTEM
ANTIANXIETY, BENZODIAZEPINES
alprazolam 1
alprazolam ext-rel 1
ALPRAZOLAM INTENSOL 1
ATIVAN 4 GA
chlordiazepoxide 1
clonazepam 1 PV
clorazepate 1
diazepam 1
KLONOPIN 4 GA
lorazepam 1
NIRAVAM 4 GA
oxazepam 1
VALIUM 4 GA
XANAX 4 GA
XANAX XR 4 GA
ANTIANXIETY, MISCELLANEOUS
ANAFRANIL 4 GA
buspirone 1
clomipramine 1 PV
fluvoxamine 1 PV
fluvoxamine ext-rel 1 PA; PV
meprobamate 1
ANTICONVULSANTS
APTIOM 4
BANZEL 2 PA; PV; QL
BRIVIACT 4
carbamazepine 1 PV
carbamazepine ext-rel 1 PV
CARBATROL 4 GA

Requirements/
CELONTIN 2 PV
DEPAKENE 4 GA
DEPAKOTE 4 GA
DEPAKOTE ER 4 GA
DIASTAT 4 GA
diazepam gel 1
DILANTIN 30MG 4
DILANTIN 100MG 4 GA
DILANTIN CHEW 50MG 4 GA
DILANTIN-125 SUSP 4 GA
divalproex sodium 1 PV
divalproex sodium delayed-rel 1 PV
divalproex sodium ext-rel 1 PV
ethosuximide 1 PV
felbamate 1 PV
FELBATOL 4 GA
FYCOMPA 4
gabapentin 1
GABITRIL 2MG, 4MG 4 GA
GABITRIL 12MG, 16MG 4
KEPPRA 4 GA
KEPPRA XR 4 GA
LAMICTAL 4 GA
LAMICTAL CHEW 2MG 4
LAMICTAL CHEW 5MG, 25MG 4 GA
LAMICTAL ODT 4 GA
LAMICTAL XR 4 GA
lamotrigine 1 PV
lamotrigine ext-rel 1 PV
levetiracetam 1 PV
MYSOLINE 4 GA
NEURONTIN 4 GA
ONFI 4 PA; QL
oxcarbazepine 1 PV
OXTELLAR XR 4
PEGANONE 2 PV
phenobarbital 1 PV
PHENYTEK 4 GA
phenytoin 1 PV
phenytoin sodium extended 1 PV
POTIGA 4

Requirements/
primidone 1 PV
QUDEXY XR 4 GA
SABRIL POWDER SP-P PA; QL
SABRIL TABS SP-P QL
STAVZOR 4
TEGRETOL 4 GA
TEGRETOL-XR 100MG, 200MG, 400MG 4 GA
tiagabine 1 PV
TOPAMAX 4 GA
TOPAMAX SPRINKLE 4 GA
topiramate 1 PV
TRILEPTAL 4 GA
TROKENDI XR 4
valproic acid 1 PV
VIMPAT 2 PV
ZARONTIN 4 GA
ZONEGRAN 4 GA
zonisamide 1 PV
ANTIDEMENTIA
ARICEPT 4 GA
donepezil 1
EXELON 4 GA
galantamine 1
galantamine ext-rel 1
memantine 1
NAMENDA 4 GA
NAMENDA XR 4
rivastigmine 1
rivastigmine transdermal 1
ANTIDEPRESSANTS, MAOIS
EMSAM 3
MARPLAN 2
NARDIL 4 GA
PARNATE 4 GA
phenelzine 1 PV
tranylcypromine 1 PV
ANTIDEPRESSANTS, MISCELLANEOUS
APLENZIN 4
bupropion 1 PV
Requirements/
bupropion delayed-rel 1 PV
bupropion ext-rel (12hr) 1 PV
bupropion ext-rel (24hr) 1 PV
chlordiazepoxide/amitriptyline 1
FORFIVO XL 4
maprotiline 1 PV
mirtazapine 1 PV
nefazodone 1 PV
OLEPTRO 4
REMERON 4 GA
trazodone 1 PV
WELLBUTRIN 4 GA
WELLBUTRIN SR 4 GA
WELLBUTRIN XL 4 GA
ANTIDEPRESSANTS, SNRIS
CYMBALTA 4 GA
DESVENLAFAXINE ER 50MG, 100MG 4 PA; QL
desvenlafaxine ext-rel 50mg, 100mg 1 PA; PV; QL
duloxetine 1 PV
EFFEXOR XR 4 GA
FETZIMA 4 PA; QL
IRENKA 4
KHEDEZLA 4 PA; GA; QL
PRISTIQ 50MG, 100MG 4 PA; QL
venlafaxine 1 PV
venlafaxine ext-rel 1 PV
ANTIDEPRESSANTS, SSRIS
BRINTELLIX 4 PA
CELEXA 4 GA
citalopram 1 PV
escitalopram 1 PV
fluoxetine 1 PV
FLUOXETINE 60MG 1 PV
fluoxetine delayed-rel 1 PV
LEXAPRO 4 GA
paroxetine 1 PV
paroxetine ext-rel 1 PV
PAXIL 4 GA
PAXIL CR 4 GA
PAXIL SUSP 4
Requirements/
PEXEVA 4 PA
PROZAC 4 GA
PROZAC WEEKLY 4 GA
SARAFEM 4
sertraline 1 PV
VIIBRYD 4 PA
ZOLOFT 4 GA
ANTIDEPRESSANTS, TCAS
amitriptyline 1 PV
amoxapine 1 PV
desipramine 1 PV
doxepin 1 PV
imipramine hcl 1 PV
imipramine pamoate 1 PV
nortriptyline 1 PV
PAMELOR 4 GA
protriptyline 1 PV
SURMONTIL 25MG, 50MG 4
SURMONTIL 100MG 4 GA
TOFRANIL 4 GA
trimipramine 1 PV
ANTIPARKINSONIAN AGENTS
amantadine 1
AZILECT 2
benztropine 1
bromocriptine 1
carbidopa 1
carbidopa/levodopa 1
carbidopa/levodopa ext-rel 1
carbidopa/levodopa/entacapone 1
COMTAN 4 GA
ELDEPRYL 4 GA
entacapone 1
LODOSYN 4 GA
MIRAPEX 4 GA
MIRAPEX ER 0.375MG, 0.75MG, 1.5MG,
2.25MG, 3MG, 4.5MG 4 PA; GA
MIRAPEX ER 3.75MG 4 PA
NEUPRO 4
PARLODEL 4 GA
Requirements/
pramipexole 1
pramipexole ext-rel 1 PA
REQUIP 4 GA
REQUIP XL 4 PA; GA
ropinirole 1
ropinirole ext-rel 1 PA
selegiline 1
SINEMET 4 GA
SINEMET CR 4 GA
STALEVO 4 GA
TASMAR 4 GA
tolcapone 1
trihexyphenidyl 1
ZELAPAR 4
ANTIPSYCHOTICS, ATYPICALS
ABILIFY 4 GA
aripiprazole 1 PV
ARIPIPRAZOLE ODT 4
aripiprazole soln 1
clozapine 1 PV
CLOZARIL 4 GA
FANAPT 4 QL
FAZACLO 4 GA
GEODON 4 GA
INVEGA 4 GA
LATUDA 4
loxapine 1 PV
olanzapine 1 PV
olanzapine/fluoxetine 1
paliperidone ext-rel 1
quetiapine 1 PV
REXULTI 4 PA; QL
RISPERDAL 4 GA
RISPERDAL-M TAB 4 GA
risperidone 1 PV
SAPHRIS 4
SEROQUEL 4 GA
SEROQUEL XR 4
SYMBYAX 4 GA
VERSACLOZ 4

Requirements/
VRAYLAR 4 PA; QL
ziprasidone 1 PV
ZYPREXA 4 GA
ZYPREXA ZYDIS 4 GA
ANTIPSYCHOTICS, MISCELLANEOUS
chlorpromazine 1 PV
fluphenazine 1 PV
haloperidol 1 PV
ORAP 4 GA
perphenazine 1 PV
perphenazine/amitriptyline 1
pimozide 1
thioridazine 1 PV
thiothixene 1 PV
trifluoperazine 1 PV
ATTENTION DEFICIT HYPERACTIVITY DISORDER
ADDERALL 4 GA
ADDERALL XR 4 PA; GA
amphetamine/dextroamphetamine 1
amphetamine/dextroamphetamine ext-rel 1 PA
APTENSIO XR 4 PA
clonidine ext-rel 1 PA
CONCERTA 4 PA; GA
DAYTRANA 4 PA; QL
DEXEDRINE CR 4 PA; GA
dexmethylphenidate 1
dexmethylphenidate ext-rel 1 PA
dextroamphetamine 2.5mg, 7.5mg, 15mg,
20mg, 30mg 4
dextroamphetamine 5mg, 10mg 1
dextroamphetamine ext-rel 5mg, 10mg, 15mg 1 PA
dextroamphetamine soln 1
FOCALIN 4 GA
FOCALIN XR 5MG, 10MG, 15MG, 20MG,
30MG, 40MG 4 PA; GA
FOCALIN XR 25MG, 35MG 4 PA
guanfacine ext-rel 1
INTUNIV 4 GA; QL
KAPVAY 4 PA; GA
METADATE CD 4 PA; GA
Requirements/
methamphetamine tabs 5mg 1
METHYLIN CHEW 2.5MG, 5MG, 10MG 4 GA
METHYLIN SOLN 4 GA
methylphenidate chew 2.5mg, 5mg, 10mg 1
METHYLPHENIDATE ER 20MG, 30MG, 40MG 4 PA; GA
methylphenidate ext-rel 18mg, 27mg, 36mg,
54mg 1 PA
methylphenidate ext-rel caps 10mg, 20mg,
30mg, 40mg, 50mg, 60mg 1 PA
methylphenidate ext-rel caps 20mg, 30mg,
40mg 1 PA
methylphenidate ext-rel tabs 10mg, 20mg 1 PA
methylphenidate soln 1
methylphenidate tabs 5mg, 10mg, 20mg 1
PROCENTRA 4 GA
QUILLIVANT XR 4 PA; QL
RITALIN 4 GA
RITALIN LA 10MG, 60MG 4 PA
RITALIN LA 20MG, 30MG, 40MG 4 PA; GA
STRATTERA 2 PA; QL
VYVANSE 3 PA
FIBROMYALGIA
LYRICA 3
SAVELLA 4
HUNTINGTON'S DISEASE AGENTS
tetrabenazine SP-P QL
XENAZINE SP-NP GA; QL
HYPNOTICS, TRICYCLICS
SILENOR 4 PA
HYPNOTICS: BENZODIAZEPINES
estazolam 1
flurazepam 1
HALCION 4 GA
temazepam 1
triazolam 1
HYPNOTICS: NON-BENZODIAZEPINES
AMBIEN 4 GA
Requirements/
AMBIEN CR 4 PA; GA
BELSOMRA 4 PA; QL
BUTISOL SODIUM 3
EDLUAR 4 PA
eszopiclone 1 PA
HETLIOZ SP-P PA; QL
INTERMEZZO 4 PA; GA
LUNESTA 4 PA; GA
ROZEREM 4 PA
SECONAL 3
SONATA 4 GA
zaleplon 1
zolpidem 1
zolpidem ext-rel 1 PA
zolpidem sublingual 1 PA
ZOLPIMIST 4 PA
MIGRAINE, ERGOTAMINE DERIVATIVES
CAFERGOT 4
D.H.E. 4 GA
dihydroergotamine inj 1
dihydroergotamine nasal spray 1 QL
ERGOMAR 4
migergot supp 1
MIGRANAL 4 GA; QL
MIGRAINE, MISCELLANEOUS
isometheptene/caffeine/acetaminophen 1
isometheptene/dichloralphenazone/
acetaminophen 1
PRODRIN 4 GA
MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID
TREXIMET 4 PA; QL
MIGRAINE, SELECTIVE SEROTONIN AGONISTS
almotriptan 1 QL
ALSUMA 4 PA; QL
AMERGE 4 GA; QL
AXERT 4 GA; QL
FROVA 4 PA; GA; QL
frovatriptan 1 PA; QL
Requirements/
IMITREX 4 GA; QL
MAXALT 4 GA; QL
MAXALT-MLT 4 GA; QL
naratriptan 1 QL
RELPAX 4 PA; QL
rizatriptan 1 QL
sumatriptan 1 QL
SUMAVEL DOSEPRO 4 PA; QL
zolmitriptan 1 QL
ZOMIG 4 GA; QL
ZOMIG NASAL SPRAY 4 PA; QL
ZOMIG ZMT 4 GA; QL
MISCELLANEOUS
ergoloid mesylates 1
GUANIDINE 3
RILUTEK 4 GA
riluzole 1
MOOD STABILIZERS
EQUETRO 4
LITHIUM 3
lithium carbonate 1
lithium carbonate ext-rel 1
LITHOBID 4 GA
MULTIPLE SCLEROSIS
AMPYRA SP-P QL
AUBAGIO SP-P PA; QL
AVONEX SP-P PA; QL
AVONEX PEN SP-P PA; QL
AVONEX PREFILLED SYG SP-P PA; QL
BETASERON SP-P PA; QL
COPAXONE 20 MG SP-NP PA; GA; QL
COPAXONE 40 MG SP-NP PA; QL
EXTAVIA SP-P PA; QL
GILENYA SP-P PA; QL
glatopa 20 mg SP-P PA; QL
PLEGRIDY SP-P PA; QL
REBIF SP-P PA; QL
TECFIDERA SP-P PA; QL

Requirements/
MUSCULOSKELETAL THERAPY AGENTS
AMRIX 4
baclofen 1
carisoprodol 1
carisoprodol/aspirin 1
carisoprodol/aspirin/codeine 1
chlorzoxazone 1
cyclobenzaprine 1
DANTRIUM 4 GA
dantrolene 1
FEXMID 4 GA
LORZONE 4
metaxalone 1
methocarbamol 1
orphenadrine ext-rel 1
orphenadrine/aspirin/caffeine 1
PARAFON FORTE DSC 4 GA
ROBAXIN 4 GA
ROBAXIN-750 4 GA
SKELAXIN 4 GA
SOMA 4 GA
tizanidine 1
ZANAFLEX 4 GA
MYASTHENIA GRAVIS
MESTINON 4 GA
MESTINON SYRUP 4
MESTINON TIMESPAN 4 GA
pyridostigmine 1
pyridostigmine ext-rel 1
NARCOLEPSY/CATAPLEXY
armodafinil 1 PA; QL
modafinil 1 PA; QL
NUVIGIL 4 PA; GA; QL
PROVIGIL 4 PA; GA; QL
XYREM 2 PA; QL
PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS
acamprosate calcium 1 PV
ANTABUSE 4 GA

Requirements/
disulfiram 1 PV
PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST
naltrexone 1 PV
PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID
ANTAGONIST COMBINATIONS
buprenorphine/naloxone sublingual 1 PV
SUBOXONE 4
ZUBSOLV 4
PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS
buprenorphine sublingual 1 PV
PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT
NUEDEXTA 4
PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS
bupropion ext-rel 1
CHANTIX 3
NICOTROL INHALER 3
NICOTROL NS 3
ZYBAN 4 GA
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50 2
ANDRODERM 4 PA
ANDROGEL 1% (25MG PAK) 4 PA; GA
ANDROGEL 1% (50MG PAK) 4 PA
ANDROGEL 1% PUMP 4 PA; GA
ANDROGEL 1.62% 2 PA
ANDROXY 3
AXIRON 4 PA
DEPO-TESTOSTERONE 100MG/ML 4
DEPO-TESTOSTERONE 200MG/ML 4 GA
FORTESTA 4 PA; GA
OXANDRIN 4 GA
oxandrolone 1
STRIANT 4 PA

Requirements/
TESTIM 4 PA; GA
testosterone cypionate 1
testosterone enanthate 1
testosterone gel 1% 2 PA
testosterone gel 10mg/act 2 PA
VOGELXO 4 PA; GA
ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR
acarbose 1 PV
GLYSET 4
ANTIDIABETICS, AMYLIN ANALOGS
SYMLINPEN 2 PV
ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS
glipizide/metformin 1 PV
GLUCOVANCE 4 GA
glyburide/metformin 1 PV
ANTIDIABETICS, BIGUANIDES
FORTAMET 4 GA
GLUCOPHAGE 4 GA
GLUCOPHAGE XR 4 GA
metformin 1 PV
metformin ext-rel 1 PV
RIOMET 2
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITOR/BIGUANIDE COMBINATIONS
JANUMET 2 PV
JANUMET XR 2 PV
JENTADUETO 2 PV
KAZANO 4 MN-PA
KOMBIGLYZE XR 4 MN-PA
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITOR/INSULIN SENSITIZER COMBINATIONS
OSENI 4 MN-PA
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUVIA 2 PV

Requirements/
NESINA 4 MN-PA
ONGLYZA 4 MN-PA
TRADJENTA 2 PV
ANTIDIABETICS, INCRETIN MIMETIC AGENTS
BYDUREON 2 PV; QL
BYETTA 3 QL
TANZEUM 4 MN-PA; QL
TRULICITY 4 MN-PA; QL
VICTOZA 2 PV; QL
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE
COMBINATION
ACTOPLUS MET 4 GA
ACTOPLUS MET XR 4
pioglitazone/metformin 1 PV
ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO
pioglitazone/glimepiride 1 PV
ANTIDIABETICS, INSULIN SENSITIZERS
ACTOS 4 GA
AVANDIA 4
pioglitazone 1 PV
ANTIDIABETICS, INSULINS
AFREZZA 4 PA; QL
APIDRA 4 MN-PA
HUMALOG 4 MN-PA
HUMALOG MIX 4 MN-PA
HUMULIN 70/30 4 MN-PA
HUMULIN N 4 MN-PA
HUMULIN R 4 MN-PA
HUMULIN R U-500 2 PV
LANTUS 2 PV
LEVEMIR 2 PV
NOVOLIN 70/30 2 PV
NOVOLIN 70/30 RELION 2 PV
NOVOLIN N 2 PV
NOVOLIN N RELION 2 PV
NOVOLIN R 2 PV

Requirements/
NOVOLIN R RELION 2 PV
NOVOLOG 2 PV
NOVOLOG MIX 2 PV
ANTIDIABETICS, MEGLITINIDE
nateglinide 1 PV
PRANDIN 4 GA
repaglinide 1 PV
STARLIX 4 GA
ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS
repaglinide/metformin 1
ANTIDIABETICS, MISCELLANEOUS
CYCLOSET 4
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITOR/BIGUANIDE COMBINATIONS
INVOKAMET 4
SYNJARDY 4
XIGDUO XR 4
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITORS
FARXIGA 4
INVOKANA 3
JARDIANCE 4
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2
INHIBITOR/DPP-4 INHIBITOR COMBINATIONS
GLYXAMBI 4
ANTIDIABETICS, SULFONYLUREAS
AMARYL 4 GA
chlorpropamide 1 PV
glimepiride 1 PV
glipizide 1 PV
glipizide ext-rel 1 PV
GLUCOTROL 4 GA
GLUCOTROL XL 4 GA
glyburide 1 PV

Requirements/
glyburide micronized 1 PV
tolazamide 1 PV
tolbutamide 1 PV
ANTIDIABETICS, SUPPLIES
ACCU-CHEK BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
ALL NON-PREFERRED BLOOD GLUCOSE TEST
STRIPS 3 MN-PA; QL
ASCENSIA BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
BLOOD KETONE TEST STRIPS 2 PV
BREEZE 2 BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
CONTOUR BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
CONTOUR NEXT BLOOD GLUCOSE TEST
STRIPS 3 MN-PA; QL
FREESTYLE BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
INSULIN SYRINGES 2 PV
LANCETS 2 PV; QL
ONETOUCH BLOOD GLUCOSE TEST STRIPS 2 PV; QL
PEN NEEDLES 2 PV
PRECISION XTRA BLOOD GLUCOSE TEST
STRIPS 3 MN-PA; QL
SURE-TEST BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
TRUETEST BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
TRUETRACK BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL
URINE TEST STRIPS 2 PV
CALCIUM RECEPTOR ANTAGONISTS
SENSIPAR SP-P
CALCIUM REGULATORS, BISPHOSPHONATES
ACTONEL 4 GA
alendronate 5mg, 10mg, 35mg, 70mg 1 PV
alendronate 40mg 1
alendronate soln 4
ATELVIA 4 GA
BONIVA TABS 4 GA
etidronate 1
FOSAMAX 4 GA
FOSAMAX PLUS D 4
ibandronate 1 PV
risedronate 1 PV
risedronate delayed-rel 1 PV
Requirements/
CALCIUM REGULATORS, CALCITONINS
calcitonin nasal spray 1 PV
FORTICAL 4
MIACALCIN 4 GA
CALCIUM REGULATORS, PARATHYROID HORMONES
FORTEO SP-P
CONTRACEPTIVES, BIPHASIC
azurette 1 PV
desogestrel/ethinyl estradiol 1 PV
kariva 1 PV
kimidess 1 PV
MIRCETTE 4 GA
NECON 10/11 4
pimtrea 1 PV
viorele 1 PV
CONTRACEPTIVES, CONTINUOUS
amethyst 1
levonorgestrel/ethinyl estradiol 1
CONTRACEPTIVES, EMERGENCY CONTRACEPTION
ELLA 4
CONTRACEPTIVES, EXTENDED CYCLE
amethia 1
amethia lo 1
ashlyna 1
camrese 1
camrese lo 1
daysee 1
introvale 1
jolessa 1
LOSEASONIQUE 4 GA
QUARTETTE 4
quasense 1
SEASONIQUE 4 GA
setlakin 1

Requirements/
CONTRACEPTIVES, FOUR PHASE
NATAZIA 4
CONTRACEPTIVES, INJECTABLE
DEPO-PROVERA 4 GA
DEPO-SUBQ PROVERA 104 4
medroxyprogesterone acetate 150mg/ml 1
CONTRACEPTIVES, MONOPHASIC
altavera 1
alyacen 1
apri 1 PV
aubra 1
aviane 1
balziva 1
BEYAZ 4
BREVICON 4 GA
briellyn 1
chateal 1
cryselle 1
cyclafem 1
cyred 1 PV
dasetta 1
delyla 1
DESOGEN 4 GA
desogestrel/ethinyl estradiol 1 PV
drospirenone/ethinyl estradiol 1
elinest 1
emoquette 1 PV
enskyce 1 PV
estarylla 1
FALESSA 4
falmina 1
FEMCON FE 4 GA
GENERESS FE 4 GA
gianvi 1
gildagia 1
gildess 1 PV
gildess fe 1 PV
gildess fe 24 1
juleber 1 PV

Requirements/
junel 1 PV
junel fe 1 PV
junel fe 24 1
kelnor 1
kurvelo 1
larin 1 PV
larin fe 1 PV
larin fe 24 1
layolis fe chew 1
lessina 1
levora 1
LO LOESTRIN 4
LOESTRIN 4 GA
LOESTRIN FE 4 GA
lomedia fe 24 1
loryna 1
low-ogestrel 1
lutera 1
marlissa 1
microgestin 1 PV
microgestin fe 1 PV
microgestin fe 24 1
MINASTRIN FE 24 4
MODICON 4 GA
mono-linyah 1
mononessa 1
necon 1
necon 4
nikki 1
norethindrone/ethinyl estradiol 1 PV
norethindrone/ethinyl estradiol fe 1
norethindrone/ethinyl estradiol fe 1 PV
norethindrone/ethinyl estradiol fe chew 1
norgestimate/ethinyl estradiol 1
NORINYL 4 GA
nortrel 1
ocella 1
ogestrel 1
orsythia 1
ORTHO-CYCLEN 4 GA

Requirements/
ORTHO-NOVUM 4 GA
OVCON-35 4 GA
philith 1
pirmella 1
portia 1
previfem 1
reclipsen 1 PV
SAFYRAL 4
sprintec 1
sronyx 1
syeda 1
tarina fe 1 PV
vestura 1
vyfemla 1
wera 1
wymzya fe chew 1 PV
YASMIN 4 GA
YAZ 4 GA
zarah 1
zenchent 1
zenchent fe chew 1 PV
zovia 1
CONTRACEPTIVES, PROGESTIN ONLY
camila 1
deblitane 1
errin 1
heather 1
jencycla 1
jolivette 1
lyza 1
NOR-QD 4 GA
nora-be 1
norethindrone 1
norlyroc 1
ORTHO MICRONOR 4 GA
sharobel 1
CONTRACEPTIVES, TRANSDERMAL
xulane 1

Requirements/
CONTRACEPTIVES, TRIPHASIC
alyacen 1
aranelle 1
caziant 1 PV
cyclafem 1
CYCLESSA 4 GA
dasetta 1
enpresse 1
ESTROSTEP FE 4 GA
leena 1
myzilra 1
necon 1
norgestimate/ethinyl estradiol 1
nortrel 1
ORTHO TRI-CYCLEN 4 GA
ORTHO TRI-CYCLEN LO 4 GA
ORTHO-NOVUM 7/7/7 4 GA
pirmella 1
tilia fe 1 PV
tri-estaryll 1
tri-legest fe 1 PV
tri-linyah 1
tri-lo-sprintec 1
TRI-NORINYL 4 GA
tri-previfem 1
tri-sprintec 1
trinessa 1
trivora 1
velivet 1 PV
CONTRACEPTIVES, VAGINAL
NUVARING 3
ENDOMETRIOSIS
danazol 1
ESTROGEN/PROGESTIN, ORAL
ACTIVELLA 4 GA
ANGELIQ 4
estradiol/norethindrone 1

Requirements/
ethinyl estradiol/norethindrone 1
FEMHRT LOW DOSE 4 GA
JEVANTIQUE LO 4 GA
jinteli 1
lopreeza 1
mimvey 1
mimvey lo 1
PREFEST 4
PREMPHASE 2
PREMPRO 2
ESTROGEN/PROGESTIN, TRANSDERMAL
CLIMARA PRO 3
COMBIPATCH 3
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR
COMBINATIONS
DUAVEE 4
ESTROGENS, ORAL
covaryx 1
covaryx hs 1
eemt 1
eemt hs 1
ENJUVIA 4
esterified estrogens/methyltestosterone 1
ESTRACE 4 GA
estradiol 1
estropipate 1
MENEST 4
PREMARIN 2
ESTROGENS, TRANSDERMAL
CLIMARA 4 GA
DIVIGEL 4
ELESTRIN 4
estradiol transdermal twice weekly 1 QL
estradiol transdermal weekly 1
ESTROGEL 4
EVAMIST 4
MENOSTAR 4

Requirements/
MINIVELLE 4 QL
VIVELLE-DOT 4 GA; QL
ESTROGENS, VAGINAL
ESTRACE CREAM 2
ESTRING 3
FEMRING 4
PREMARIN CREAM 2
VAGIFEM 3
GLUCOCORTICOIDS
CORTEF 4 GA
cortisone 4
dexamethasone 1
DEXAMETHASONE INTENSOL 1
dexamethasone oral soln 0.5mg/5ml 1
DEXPAK 4
FLO-PRED 4
fludrocortisone 1
hydrocortisone 1
KENALOG INJ 4
MEDROL 4 GA
MEDROL 2MG 4
methylprednisolone 1
MILLIPRED 4
ORAPRED ODT 4 GA
PEDIAPRED 4 GA
prednisolone sodium phosphate odt, soln 1
prednisolone syrup 1
prednisone 1
PREDNISONE INTENSOL 1
RAYOS 4
VERIPRED 4
GLUCOSE ELEVATING AGENT
GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY KIT 2
HUMAN GROWTH HORMONES
GENOTROPIN SP-NP PA
HUMATROPE SP-NP PA
NORDITROPIN SP-P PA
Requirements/
NUTROPIN AQ SP-NP PA
OMNITROPE SP-NP PA
SAIZEN SP-NP PA
SEROSTIM SP-NP PA
ZOMACTON SP-NP PA
ZORBTIVE SP-NP PA
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
calcitriol caps 1
calcitriol soln 4
doxercalciferol 1
HECTOROL 4 GA
paricalcitol 1
ROCALTROL 4 GA
ZEMPLAR 4 GA
INSULIN-LIKE GROWTH FACTOR
INCRELEX SP-P
LYSOSOMAL STORAGE DISORDERS
CERDELGA SP-P
ZAVESCA SP-P
MISCELLANEOUS
cabergoline 1
CARBAGLU 4
CARNITOR 4 GA
CYSTADANE 4
KORLYM 2
levocarnitine 1
methylergonovine 1
octreotide SP-P
ORFADIN 3
ORFADIN SUSP 3
RAVICTI SP-P
SANDOSTATIN SP-NP GA
SOMAVERT SP-P
STRENSIQ SP-P
SYPRINE 3
PHENYLKETONURIA TREATMENT AGENTS
KUVAN SP-P PA
Requirements/
PHOSPHATE BINDER AGENTS
calcium acetate 1
ELIPHOS 4 GA
FOSRENOL 3
PHOSLO 4 GA
PHOSLYRA 4
RENAGEL 4
RENVELA 3
VELPHORO 4
PROGESTINS, INJECTABLE
progesterone 50mg/ml 1
PROGESTINS, ORAL
AYGESTIN 4 GA
medroxyprogesterone acetate 1
MEGACE ES 4 GA
megestrol susp 1
norethindrone acetate 1
progesterone micronized 1
PROMETRIUM 4 GA
PROVERA 4 GA
PROGESTINS, VAGINAL
CRINONE GEL 4% 3
SELECTIVE ESTROGEN RECEPTOR MODULATOR
EVISTA 4 PA; GA
OSPHENA 4
raloxifene 1 PA; PV
THYROID AGENTS, ANTITHYROID AGENTS
iodine soln strong (lugol's) 4
methimazole 1
propylthiouracil 1
SSKI 4
THYROID SUPPLEMENTS
ARMOUR THYROID 15MG, 120MG, 180MG,
240MG, 300MG 4
ARMOUR THYROID 30MG, 60MG, 90MG 4 GA

Requirements/
CYTOMEL 4 GA
levothyroxine 1
levoxyl 1
liothyronine 1
NATURE THROID 4
SYNTHROID 2 GA
thyroid tab 1
THYROLAR 4
TIROSINT 4
unithroid 1
WESTHROID 4
WP THYROID 4
VASOPRESSIN RECEPTOR ANTAGONISTS
SAMSCA 3 QL
VASOPRESSINS
DDAVP 4 GA
desmopressin 1
STIMATE 4
GASTROINTESTINAL
ANTIDIARRHEALS
diphenoxylate/atropine 1
LOMOTIL 4 GA
MOTOFEN 4
opium tincture 1
ANTIEMETICS
AKYNZEO 4
ANZEMET 2
CESAMET 2
COMPAZINE 4 GA
dronabinol 1
EMEND 2
granisetron 1
MARINOL 4 GA
metoclopramide 1
METOZOLV ODT 4 GA
ondansetron 1
ondansetron soln 1 QL
Requirements/
prochlorperazine 1
prochlorperazine supp 1
promethazine 1
promethazine supp 1
REGLAN 4 GA
SANCUSO 4 PA; QL
TIGAN 4 GA
TRANSDERM-SCOP 4
trimethobenzamide 1
VARUBI 4 QL
ZOFRAN 4 GA
ZOFRAN SOLN 4 GA; QL
ZUPLENZ 4
ANTISPASMODICS
ANASPAZ 4 GA
BELLADONNA/OPIUM SUPP 1
BENTYL 4 GA
CANTIL 2
chlordiazepoxide/clidinium 1
CUVPOSA 3
dicyclomine 1
DONNATAL 4
GASTRINEX NF 4
glycopyrrolate 1
hyoscyamine sulfate 1
hyoscyamine sulfate ext-rel 1
LEVBID 4 GA
LEVSIN 4 GA
LIBRAX 4 GA
methscopolamine 1
propantheline 1
ROBINUL 4 GA
ROBINUL FORTE 4 GA
SYMAX DUOTAB 4
CHOLELITHOLYTICS
ACTIGALL 4 GA
CHENODAL 2
URSO 250 4 GA
URSO FORTE 4 GA
ursodiol 1
Requirements/
H2-RECEPTOR ANTAGONISTS
cimetidine 1
famotidine 1
nizatidine 1
PEPCID 4 GA
ranitidine 1
ZANTAC 4 GA
INFLAMMATORY BOWEL DISEASE, ORAL AGENTS
APRISO 4
ASACOL HD 2
AZULFIDINE 4 GA
AZULFIDINE EN-TABS 4 GA
balsalazide 1
budesonide caps 1
COLAZAL 4 GA
DELZICOL 4
DIPENTUM 2
ENTOCORT EC 4 GA
GIAZO 4
LIALDA 4
PENTASA 3
sulfasalazine 1
sulfasalazine delayed-rel 1
UCERIS 4
INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS
CANASA 2
CORTIFOAM 4
hydrocortisone enema 1
mesalamine enema 1
SFROWASA 4
UCERIS FOAM 4
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION
AMITIZA 3 PA
LINZESS 4 PA
IRRITABLE BOWEL SYNDROME WITH DIARRHEA
alosetron 1
LOTRONEX 4 GA

Requirements/
VIBERZI 4
LAXATIVES/STOOL SOFTENERS
CASCARA SAGRADA 2
COLYTE/FLAVOR PACKS 4 GA
GOLYTELY 4
GOLYTELY 4 GA
KRISTALOSE 1
lactulose 1
MOVIPREP 2 PV
NULYTELY 4 GA
OSMOPREP 2 PV
peg 3350/electrolytes 1 PV
PREPOPIK 4
SUPREP 2 PV
MISCELLANEOUS
BUPHENYL 4
BUPHENYL POWDER 4 GA
CARAFATE 4 GA
CARAFATE SUSP 4
cromolyn sodium 100mg/5ml 1
ENTEREG 3
GASTROCROM 4 GA
lactulose (encephalopathy) 1
RECTIV 4
SUCRAID 2
sucralfate 1
OPIOID-INDUCED CONSTIPATION
MOVANTIK 4 PA
RELISTOR 3 PA; QL
PANCREATIC ENZYMES
CREON 2
PANCREAZE 2
PERTZYE 2
VIOKACE 2
ZENPEP 2
ZENPEP 5000 UNIT 4

Requirements/
PROSTAGLANDINS
CYTOTEC 4 GA
misoprostol 1
PROTON PUMP INHIBITORS (PPI)
ACIPHEX 4 GA; QL
ACIPHEX SPRINKLE 4 PA; QL
DEXILANT 4 PA; QL
esomeprazole 1 PA; QL
lansoprazole 1 QL
NEXIUM 4 PA; GA; QL
NEXIUM GRANULES 4 PA; QL
omeprazole 1 QL
pantoprazole 1 QL
PREVACID 4 GA; QL
PREVACID SOLUTAB 4 PA; QL
PRILOSEC 4 GA; QL
PRILOSEC POWDER 4 PA; QL
PROTONIX 4 GA; QL
PROTONIX PAK 4 PA; QL
rabeprazole 1 QL
SALIVA STIMULANTS
cevimeline 1
EVOXAC 4 GA
pilocarpine 1
SALAGEN 4 GA
STEROIDS, RECTAL
ANALPRAM-HC CREAM 4 GA
ANALPRAM-HC LOTION 4
ANUSOL-HC 4 GA
EPIFOAM 3
hydrocortisone acetate supp 1
hydrocortisone cream 1
hydrocortisone/pramoxine 1
lidazone 1
lidocaine/hydrocortisone 1
LIDOCAINE/HYDROCORTISONE GEL 1
PROCORT 3
PROCTOCORT 4 GA

Requirements/
PROCTOFOAM HC 3
ULCER THERAPY COMBINATION
lansoprazole/amoxicillin/clarithromycin 1
OMECLAMOX-PAK 4
PREVPAC 4 GA
PYLERA 4
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA

alfuzosin 1
AVODART 4 GA
CARDURA XL 4
dutasteride 1
dutasteride/tamsulosin 1
finasteride 1
FLOMAX 4 GA
JALYN 4 GA
PROSCAR 4 GA
RAPAFLO 4 QL
tamsulosin 1
UROXATRAL 4 GA
ERECTILE DYSFUNCTION, ALPROSTADIL AGENTS
CAVERJECT 4 QL
EDEX 4 QL
MUSE 4 QL
ERECTILE DYSFUNCTION, PHOSPHODIESTERASE INHIBITORS
CIALIS 4 PA; QL
LEVITRA 4 PA; QL
STAXYN 4 PA; QL
STENDRA 4 PA; QL
VIAGRA 2 PA; QL
MISCELLANEOUS
bethanechol 1
CYSTAGON 2
ELMIRON 3
LITHOSTAT 3
methenamine hippurate 1
Requirements/
methenamine mandelate 1
methenamine/hyoscyamine/methylene blue/
phenyl salicylate/benzoic acid 1
phenyl salicylate/sodium bisphosphonate 1
phenyl salicylate/sodium phosphate 1
sodium phosphate 1
ORACIT 4
phenazopyridine 1
potassium citrate 1
potassium citrate/citric acid 1
potassium citrate/sodium citrate/citric acid 1
PROCYSBI 4
PYRIDIUM 4 GA
RIMSO-50 4
SHOHLS SOLN MODIFIED 4 GA
sodium citrate/citric acid 1
THIOLA 2
UROCIT-K 4 GA
UROGESIC-BLUE 4 GA
UROQID #2 2
URINARY ANTISPASMODICS
darifenacin ext-rel 1
DETROL 4 GA
DETROL LA 4 GA
DITROPAN XL 4 GA
ENABLEX 4 GA
flavoxate 1
GELNIQUE 4
MYRBETRIQ 4
oxybutynin 1
oxybutynin ext-rel 1
tolterodine 1
tolterodine ext-rel 1
TOVIAZ 4 QL
trospium 1
trospium ext-rel 1
VESICARE 4

Requirements/
VAGINAL ANTI-INFECTIVES
AVC 4
CLEOCIN CREAM 4 GA
CLEOCIN SUPP 3
clindamycin cream 1
CLINDESSE 4
GYNAZOLE-1 4
METROGEL-VAGINAL 4 GA
metronidazole gel 0.75% 1
NUVESSA 4
TERAZOL 3 4 GA
TERAZOL 7 4 GA
terconazole cream 0.4% 1
terconazole cream 0.8% 1 PV
terconazole supp 1
HEMATOLOGIC
ANTICOAGULANTS, INJECTABLE
ARIXTRA 4 GA
enoxaparin 1
fondaparinux 1
FRAGMIN 2
LOVENOX 4 GA
ANTICOAGULANTS, ORAL
COUMADIN 2 GA; PV
ELIQUIS 2 PV
PRADAXA 2 PV
SAVAYSA 4 MN-PA
warfarin 1 PV
XARELTO 2 PV
HEMATOPOIETIC GROWTH FACTORS
ARANESP SP-P
EPOGEN SP-P
GRANIX SP-P
LEUKINE SP-P
NEULASTA SP-P
NEUPOGEN SP-P
PROCRIT SP-P

Requirements/
ZARXIO SP-P
HEMOSTATICS, SYSTEMIC
AMICAR 4
LYSTEDA 4 GA
tranexamic acid 1
HEREDITARY ANGIOEDEMA AGENTS
FIRAZYR SP-P PA
IDIOPATHIC THROMBOCYTOPENIC PURPURA
PROMACTA SP-P PA; QL
MISCELLANEOUS
CHEMET 2
cilostazol 1
EXJADE 2
FERRIPROX 4
pentoxifylline 1
PLATELET AGGREGATION INHIBITORS
AGGRENOX 4 GA
aspirin/dipyridamole ext-rel 1
BRILINTA 3
clopidogrel 1 PV
dipyridamole 1 PV
EFFIENT 3
PLAVIX 4 GA
PLATELET SYNTHESIS INHIBITORS
anagrelide 1
IMMUNOLOGIC AGENTS
ALLERGENIC EXTRACTS
GRASTEK 4 PA; QL
ORALAIR 4 PA; QL
RAGWITEK 4 PA; QL
BIOLOGIC DISEASE-MODIFYING AGENTS
ACTEMRA SP-P PA; QL
CIMZIA SP-NP PA; QL

Requirements/
ENBREL SP-P PA; QL
HUMIRA SP-P PA; QL
KINERET SP-P PA; QL
ORENCIA SP-P PA; QL
SIMPONI SP-NP PA; QL
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS)
ARAVA 4 GA
DEPEN 2
hydroxychloroquine 1
leflunomide 1
PLAQUENIL 4 GA
RHEUMATREX 2
RIDAURA 2
XELJANZ SP-P PA; QL
IMMUNOMODULATORS, INTERFERONS
ACTIMMUNE SP-P
PEGASYS SP-P PA; QL
PEGINTRON SP-P PA; QL
SYLATRON SP-P
IMMUNOMODULATORS, MISCELLANEOUS
OTEZLA SP-P PA; QL
IMMUNOSUPPRESSANTS, ANTIMETABOLITES
AZASAN 1
azathioprine 1
CELLCEPT 2 GA
IMURAN 4 GA
mycophenolate mofetil 1 PV
mycophenolate sodium delayed-rel 1 PV
MYFORTIC 4 GA
IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS
ASTAGRAF XL 2 PV
cyclosporine 1 PV
cyclosporine modified 1 PV
NEORAL 3 GA
PROGRAF 3 GA
SANDIMMUNE 3 GA
SANDIMMUNE SOLN 3
Requirements/
tacrolimus 1 PV
IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE
RAPAMUNE SOLN 2 PV
RAPAMUNE TABS 4 GA
sirolimus 1 PV
ZORTRESS SP-P
VACCINES
ACTHIB 2 PV
ADACEL 2 PV
AFLURIA 2 PV
BEXSERO 2 PV
BOOSTRIX 2 PV
CERVARIX 2 PV
DAPTACEL 2 PV
DIPHTHERIA/TETANUS TOXOID 2 PV
ENGERIX-B 2 PV
FLUARIX 2 PV
FLUBLOK 2 PV
FLUCELVAX 2 PV
FLULAVAL 2 PV
FLUVIRIN 2 PV
FLUZONE 2 PV
GARDASIL 2 PV
HAVRIX 2 PV
HIBERIX 2 PV
INFANRIX 2 PV
IPOL INACTIVATED IPV 2 PV
KINRIX 2 PV
M-M-R II 2 PV
MENACTRA 2 PV
MENHIBRIX 2 PV
MENOMUNE 2 PV
MENVEO 2 PV
PEDIARIX 2 PV
PEDVAX HIB 2 PV
PENTACEL 2 PV
PNEUMOVAX 23 2 PV
PREVNAR 13 2 PV
PROQUAD 2 PV
QUADRACEL 2 PV
Requirements/
RECOMBIVAX HB 2 PV
ROTARIX 2 PV
ROTATEQ 2 PV
TENIVAC 2 PV
TRUMENBA 2 PV
TWINRIX 2 PV
VAQTA 2 PV
VARIVAX 2 PV
ZOSTAVAX 2 PV
MISCELLANEOUS
DIAGNOSTIC PRODUCTS
CHEMSTRIP 2 PV
COMBISTIX 2 PV
HEMA-COMBISTIX 2 PV
LABSTIX 2 PV
MULTISTIX 2 PV
URISTIX 2 PV
NUTRITIONAL / SUPPLEMENTS
ELECTROLYTES, MISCELLANEOUS
K-PHOS 3
K-PHOS NEUTRAL 4 GA
K-PHOS NO 2 4
potassium/sodium phosphates 1
ELECTROLYTES, POTASSIUM
EFFER-K 4
K-TAB 4 GA
KLOR-CON M15 1
KLOR-CON/25 4
MICRO-K 4 GA
potassium bicarbonate effervescent 1
potassium bicarbonate/chloride effervescent 1
potassium chloride ext-rel 1
potassium chloride powder 1
potassium chloride soln 1
ELECTROLYTES, POTASSIUM-REMOVING AGENTS
sodium polystyrene sulfonate susp 1
Requirements/
VELTASSA SP-P
VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS
folic acid 1
VITAMINS AND MINERALS, MISCELLANEOUS
MAGNEBIND 400 4
MEPHYTON 2
VITAMINS AND MINERALS, PRENATAL VITAMINS
ACTIVE OB 2 PV
ATABEX EC 2 PV
BAL-CARE DHA 2 PV
C-NATE DHA 2 PV
CALCIUM PNV 2 PV
CITRANATAL 2 PV
CO-NATAL FA 2 PV
COMPLETE NATAL DHA 2 PV
COMPLETENATE 2 PV
CONCEPT 2 PV
DOTHELLE DHA 2 PV
DUET DHA 2 PV
elite-ob 2 PV
ENBRACE HR 2 PV
EXTRA-VIRT PLUS DHA 2 PV
FOCALGIN 2 PV
FOLCAL DHA 2 PV
FOLCAPS OMEGA 3 2 PV
FOLET 2 PV
folinatal plus b 2 PV
FOLIVANE-OB 2 PV
HEMENATAL 2 PV
inatal advance 2 PV
inatal gt 2 PV
inatal ultra 2 PV
INFANATE BALANCE 2 PV
LEVOMEFOLATE DHA 2 PV
MACNATAL CN DHA 2 PV
MARNATAL-F 2 PV
multinatal plus 2 PV
MYNATAL 2 PV
MYNATE 90 PLUS 2 PV
Requirements/
NATACHEW 2 PV
NATALVIT 2 PV
NATELLE ONE 2 PV
NEEVO DHA 2 PV
NESTABS 2 PV
NEWGEN 2 PV
NEXA PLUS 2 PV
O-CAL PRENATAL 2 PV
OB COMPLETE 2 PV
OB COMPLETE GOLD 2 PV
OBSTETRIX 2 PV
PAIRE OB 2 PV
PNV OB+DHA 2 PV
PNV TABS 29-1 2 PV
pnv-dha 2 PV
PNV-DHA+DOCUSATE 2 PV
PNV-OMEGA 2 PV
pnv-select 2 PV
PNV-TOTAL 2 PV
PNV-VP-U 2 PV
PR NATAL 2 PV
PREFERAOB 2 PV
PRENA1 2 PV
PRENAISSANCE 2 PV
PRENATA 2 PV
prenatabs fa 2 PV
prenatabs rx 2 PV
PRENATAL 2 PV
PRENATAL 19 CHEW 2 PV
PRENATAL 19 TABS 2 PV
PRENATAL VITAMINS/FERROUS FUMARATE/
DOCUSATE 2 PV
PRENATE 2 PV
PREQUE 10 2 PV
PRETAB 2 PV
PROVIDA 2 PV
PUREFE OB PLUS 2 PV
R-NATAL OB 2 PV
REDICHEW RX 2 PV
RELNATE DHA 2 PV
RULAVITE DHA 2 PV

Requirements/
SE-NATAL 19 2 PV
SE-TAN DHA 2 PV
SELECT-OB 2 PV
TARON-BC 2 PV
TARON-C DHA 2 PV
TARON-PREX 2 PV
THRIVITE 2 PV
TL FOLATE 2 PV
TL-CARE DHA 2 PV
TL-SELECT 2 PV
TRI-TABS DHA 2 PV
triadvance 2 PV
TRICARE 2 PV
TRINATAL 2 PV
trinate 2 PV
TRISTART DHA 2 PV
TRIVEEN-DUO DHA 2 PV
TRIVEEN-PRX 2 PV
ULTIMATECARE 2 PV
ultra tabs 2 PV
VEMAVITE 2 PV
VENA-BAL DHA 2 PV
VINACAL B 2 PV
VINATE 2 PV
VIRT NATE 2 PV
VIRT-ADVANCE 2 PV
VIRT-C DHA 2 PV
VIRT-CARE ONE 2 PV
VIRT-PN 2 PV
VIRT-SELECT 2 PV
VIRT-VITE GT 2 PV
VIRTPREX 2 PV
VITA-PREN 2 PV
VITAFOL 2 PV
VITAMEDMD 2 PV
VITAPEARL 2 PV
VITATRUE 2 PV
VIVA DHA 2 PV
VOL-NATE 2 PV
VOL-TAB RX 2 PV
VP-CH 2 PV

Requirements/
VP-GGR-B6 PRENATAL 2 PV
VP-HEME 2 PV
VP-PNV-DHA 2 PV
ZATEAN 2 PV
RESPIRATORY
ANAPHYLAXIS TREATMENT AGENTS

ADRENACLICK 3 GA
epinephrine inj 3
EPIPEN 2
EPIPEN JR 2
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPTA 4
COMBIVENT RESPIMAT 2
ipratropium/albuterol nebulizer soln 1
STIOLTO RESPIMAT 4
ANTICHOLINERGICS
ATROVENT HFA 2
ipratropium nebulizer soln 1
SPIRIVA HANDIHALER 2
SPIRIVA RESPIMAT 3
TUDORZA PRESSAIR 4
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
CLARINEX-D 12 HOUR 4
DECON-A 4
promethazine/phenylephrine 1
RELHIST 4
RESCON-MX 4
SEMPREX-D 4
ANTIHISTAMINES, LOW-SEDATING
levocetirizine 1
XYZAL 4 GA
ANTIHISTAMINES, NONSEDATING
CLARINEX 4 GA
CLARINEX SYRUP 4
desloratadine 1
Requirements/
ANTIHISTAMINES, SEDATING
brompheniramine 1
carbinoxamine 1
clemastine 1
cyproheptadine 1
hydroxyzine hcl 1
hydroxyzine pamoate 1
KARBINAL ER 4
RESPA-BR 3
VISTARIL 4 GA
ANTITUSSIVE COMBINATIONS, NON-OPIOID
CARBAPHEN 4
DECON-G 4
dextromethorphan/brompheniramine/
pseudoephedrine 1
dextromethorphan/brompheniramine/
pseudoephedrine 4
dextromethorphan/chlorpheniramine/
phenylephrine 4
dextromethorphan/guaifenesin/phenylephrine 1
EXACTUSS 3 GA
GILTUSS 3 GA
giltuss pediatric 1
NEOTUSS PLUS 4
NORTUSS-EX 4
PEDIATEX TDM 4
promethazine/dextromethorphan 1
TGQ DM/BPM/PSE 4
TGQ DM/CPM/PE 4
TGQ DM/GFN/PSE 4
TUSNEL 4
ANTITUSSIVE COMBINATIONS, OPIOID
FLOWTUSS 4
GILTUSS PED-C 4
HYCOFENIX 4
hydrocodone polistirex/chlorpheniramine 1
hydrocodone/chlorpheniramine/
pseudoephedrine 1
hydrocodone/homatropine 1

Requirements/
OBREDON 4
promethazine/codeine 1
promethazine/phenylephrine/codeine 1
REZIRA 4
SUTTAR-2 4 GA
SUTTAR-SF 4 GA
TUSSICAPS 4
TUSSIONEX 4 GA
TUZISTRA XR 4
VITUZ 4
ZUTRIPRO 4 GA
ANTITUSSIVES
benzonatate 1
TESSALON PERLES 4 GA
ZONATUSS 4 GA
BETA AGONISTS, INHALANTS, LONG ACTING
ARCAPTA NEOHALER 4
BROVANA 2 PV
FORADIL AEROLIZER 2 PV
PERFOROMIST 2 PV
SEREVENT DISKUS 2 PV
STRIVERDI RESPIMAT 3
BETA AGONISTS, INHALANTS, SHORT ACTING
albuterol nebulizer soln 1
levalbuterol nebulizer soln 1
metaproterenol 1
PROAIR HFA 1
PROAIR RESPICLICK 1
PROVENTIL HFA 2
VENTOLIN HFA 2
XOPENEX HFA 4 MN-PA
XOPENEX NEBULIZER 4 GA
BETA AGONISTS, ORAL AGENTS
albuterol 1
albuterol ext-rel 1
terbutaline 1
VOSPIRE ER 4 GA

Requirements/
CYSTIC FIBROSIS
CAYSTON 3
KALYDECO SP-P PA; QL
ORKAMBI SP-P PA; QL
PULMOZYME SP-P
TOBI NEBULIZER SP-NP GA
tobramycin nebulizer soln SP-P
DECONGESTANT/EXPECTORANT COMBINATIONS
phenylephrine/guaifenesin 1
LEUKOTRIENE MODIFIERS
ACCOLATE 4 GA
montelukast 1 PV
SINGULAIR 4 GA
zafirlukast 1 PV
ZYFLO 4
ZYFLO CR 4
MAST CELL STABILIZERS
cromolyn sodium nebulizer soln 1 PV
MISCELLANEOUS
acetylcysteine 1
ATROVENT NASAL 4 GA
caffeine citrate 1
dyphylline-guaifenesin 1
HYPERSAL 3.5% 4
HYPERSAL 7% 4 GA
ipratropium nasal spray 1
NEBUSAL 4
sodium chloride nebulizer soln 1
XOLAIR SP-P PA; QL
NASAL ANTIHISTAMINE/STEROID COMBINATIONS
DYMISTA 4 PA
NASAL ANTIHISTAMINES
ASTEPRO 4 GA
azelastine spray 1
olopatadine spray 1

Requirements/
PATANASE 4 GA
NASAL STEROIDS
BECONASE AQ 4 PA
flunisolide spray 1
mometasone spray 1 PA
NASONEX 4 PA; GA
OMNARIS 4 PA
QNASL 4 PA
VERAMYST 4 PA
ZETONNA 4 PA
PHOSPHODIESTERASE-4 INHIBITORS
DALIRESP 4
PULMONARY FIBROSIS AGENTS
ESBRIET SP-P PA; QL
OFEV SP-P PA; QL
STEROID INHALANTS
AEROSPAN 4 MN-PA
ALVESCO 4 MN-PA
ASMANEX 1 PV
budesonide nebulizer susp 1 PV
FLOVENT DISKUS 4 MN-PA
FLOVENT HFA 4 MN-PA
PULMICORT 4 GA
PULMICORT FLEXHALER 4 MN-PA
QVAR 1 PV
STEROID/BETA AGONIST COMBINATIONS
ADVAIR DISKUS 2 PV
ADVAIR HFA 2 PV
BREO ELLIPTA 4 PA
DULERA 2 PV
SYMBICORT 4 MN-PA
TOPICAL DECONGESTANTS
ADRENALIN 3
TYZINE 4

Requirements/
XANTHINES
ELIXOPHYLLIN 4
LUFYLLIN 3
THEO-24 1
theophylline ext-rel 1
theophylline soln 1
TOPICAL
DERMATOLOGY, ACNE: ORAL

claravis 1
myorisan 1
zenatane 1
DERMATOLOGY, ACNE: TOPICAL
ACANYA 4
ACZONE 4
adapalene 1
ATRALIN 4 PA; GA
AVAR 4
AVAR LS 4
AVAR LS CLEANSER 4 GA
AVAR-E LS 4 GA
AZELEX 4
BENZACLIN 4
BENZACLIN PUMP 4 GA
BENZAMYCIN 4 GA
BENZAMYCIN PAK 4
BENZEFOAM 4 GA
BENZIQ 4
benzoyl peroxide 1
BPO 1
CLEOCIN-T 4 GA
CLINDAGEL 4
clindamycin 1
clindamycin/benzoyl peroxide 1
DIFFERIN 4 GA
DUAC GEL 4 GA
EPIDUO 4
ERYGEL 4 GA
erythromycin gel, pads, soln 1

Requirements/
erythromycin/benzoyl peroxide 1
EVOCLIN 4 GA
KLARON 4 GA
NUOX 4
PLEXION CLEANSER, CREAM, LOTION 4 GA
PLEXION PADS 4
RETIN-A 4 PA; GA
RIAX 4
ROSULA 4
sulfacetamide lotion 1
sulfacetamide/sulfur 1
SULFOAM 4
SUMADAN WASH 4 GA
SUMAXIN 4 GA
TAZORAC 4
TRETIN-X 4
tretinoin 1 PA
VANOXIDE-HC 4
VELTIN 4 PA
ZACLIR 4
ZIANA 4 PA
DERMATOLOGY, ACTINIC KERATOSIS
CARAC 4 PA; GA
diclofenac gel 3% 1 PA
EFUDEX 4 GA
FLUOROPLEX 3 PA
fluorouracil cream 0.5% 1 PA
fluorouracil cream, drop, soln 5% 1
fluorouracil drop, soln 2% 1
LEVULAN KERASTICK 3
METVIXIA 3
PICATO 4 PA
SOLARAZE 4 PA; GA
ZYCLARA 4 PA
DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY
COMBINATIONS
CORTISPORIN CREAM 0.5% 4
CORTISPORIN OINT 1% 4
NEO-SYNALAR 4

Requirements/
DERMATOLOGY, ANTIBIOTICS
ALTABAX 4
BACTROBAN 4 GA
BACTROBAN NASAL 4
CENTANY 4
gentamicin 1
mupirocin 1
SILVADENE 4 GA
silver sulfadiazine 1
DERMATOLOGY, ANTIFUNGALS
ciclopirox 1
clotrimazole/betamethasone 1
econazole 1
ECOZA 4
ERTACZO 4
EXELDERM 4
EXTINA 4 GA
HALOTIN 1
ketoconazole 1
LOPROX SHAMPOO 4 GA
LOTRISONE 4 GA
LUZU 4
naftifine cream 1
NAFTIN CREAM 4 GA
NAFTIN GEL 4
NIZORAL 4 GA
nystatin topical 1
nystatin/triamcinolone 1
oxiconazole cream 1
OXISTAT CREAM 4 GA
OXISTAT LOTION 4
PENLAC 4 GA
VUSION 4
DERMATOLOGY, ANTIPSORIATICS, INJECTABLE
COSENTYX SP-P PA; QL
COSENTYX PEN SP-P PA; QL
DERMATOLOGY, ANTIPSORIATICS, ORAL
acitretin 1

Requirements/
methoxsalen 1
8-MOP 4
OXSORALEN-ULTRA 4 GA
SORIATANE 4 GA
DERMATOLOGY, ANTIPSORIATICS, TOPICAL
calcipotriene 1
calcitriol oint 1
DOVONEX 4 GA
DRITHO-CREME HP 4
SORILUX 4
TACLONEX OINT 4 GA
TACLONEX SUSP 4
VECTICAL 4 GA
ZITHRANOL 4
ZITHRANOL-RR 4
DERMATOLOGY, ANTISEBORRHEICS
OVACE PLUS CREAM, FOAM, LOTION 4
OVACE PLUS SHAMPOO, WASH 4 GA
OVACE WASH 4 GA
selenium sulfide 1
SELRX 4
sulfacetamide gel, shampoo, wash 1
DERMATOLOGY, ANTISEPTICS/DISINFECTANTS
triple dye soln 4
DERMATOLOGY, CORTICOSTEROID COMBINATIONS
PRAMOSONE CREAM 1-1% 1
PRAMOSONE CREAM 1-2.5% 4 GA
PRAMOSONE E 4
PRAMOSONE LOTION 1
PRAMOSONE OINT 4
pramoxine/hydrocortisone 1-2.5% 1
DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY
amcinonide cream, lotion 0.1% 1
AMCINONIDE OINT 0.1% 1
APEXICON E 4
betamethasone dipropionate augmented
cream, lotion 0.05% 1
Requirements/
betamethasone dipropionate cream,
lotion, oint 0.05% 1
desoximetasone cream, oint 0.25% 1
desoximetasone gel 0.05% 1
diflorasone 1
DIPROLENE 4 GA
DIPROLENE AF 4 GA
fluocinonide cream 0.1% 1
fluocinonide cream, gel, oint, soln 0.05% 1
fluocinonide-e cream 0.05% 1
HALOG 4
TOPICORT CREAM, OINT 0.25% 4 GA
TOPICORT GEL 0.05% 4 GA
TOPICORT SPRAY 0.25% 4
triamcinolone cream, oint 0.5% 1
VANOS 4 GA
DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY
ALA SCALP 4 GA
alclometasone 1
CAPEX 4
DERMA-SMOOTHE/FS BODY, SCALP 4 GA
DESONATE 4
desonide cream, lotion, oint 0.05% 1
DESOWEN CREAM, LOTION, OINT 0.05% 4 GA
fluocinolone acetonide cream, soln 0.01% 1
fluocinolone acetonide oil body, scalp 1
hydrocortisone cream, lotion, oint 2.5% 1
hydrocortisone lotion 2% 1
NUCORT 3
SYNALAR 4 GA
TEXACORT 4
VERDESO 4
DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY
betamethasone valerate cream, lotion,
oint 0.1% 1
betamethasone valerate foam 1
clocortolone cream 0.1% 4
CLODERM 4 GA
CORDRAN CREAM, LOTION, OINT 0.05% 4
CORDRAN TAPE 4
Requirements/
CUTIVATE CREAM, LOTION 0.05% 4 GA
desoximetasone cream, oint 0.05% 1
ELOCON CREAM, LOTION, OINT 0.1% 4 GA
fluocinolone acetonide cream, oint 0.025% 1
fluticasone cream, lotion 0.05% 1
fluticasone oint 0.005% 1
hydrocortisone butyrate cream, oint, soln 0.1% 1
hydrocortisone valerate cream, oint 0.2% 1
KENALOG SPRAY 4 GA
LOCOID CREAM, OINT, SOLN 0.1% 4 GA
LOCOID LIPOCREAM 0.1% 4 GA
LOCOID LOTION 0.1% 4
LUXIQ 4 GA
mometasone cream, oint, soln 0.1% 1
PANDEL 4
prednicarbate cream, oint 0.1% 1
SYNALAR CREAM, OINT 0.025% 4 GA
TOPICORT CREAM, OINT 0.05% 4 GA
triamcinolone cream 0.1% 1
triamcinolone cream, lotion, oint 0.1% 1
triamcinolone cream, lotion, oint 0.025% 1
triamcinolone spray 1
TRIANEX 3
DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY
betamethasone dipropionate augmented gel,
oint 0.05% 1
clobetasol cream, gel, lotion, oint, shampoo,
soln, spray 0.05% 1
clobetasol emollient cream 0.05% 1
clobetasol foam 1
CLOBEX LOTION, SHAMPOO, SPRAY 0.05% 4 GA
diflorasone oint 0.05% 1
DIPROLENE OINT 0.05% 4 GA
halobetasol cream, oint 0.05% 1
OLUX 4 GA
OLUX-E 4 GA
TEMOVATE CREAM, GEL, OINT, SOLN 0.05% 4 GA
TEMOVATE E CREAM 0.05% 4 GA
ULTRAVATE CREAM, OINT 0.05% 4 GA
ULTRAVATE LOTION 0.05% 4

Requirements/
DERMATOLOGY, EMOLLIENTS
CEM-UREA 4
GORDONS UREA 4
HYDRO 40 FOAM 4 GA
KERAFOAM 4
KERALAC 4 GA
LATRIX XM 4
RYNODERM 4
UMECTA 4
UMECTA NAIL FILM 4 GA
UMECTA PD 4
URAMAXIN 4 GA
URAMAXIN FOAM 3
urea cream 1
urea emulsion 1
urea foam 1
urea gel 1
urea lotion 1
UREA NAIL 4
urea nail gel 45% 1
urea nail susp 1
urea susp 1
UTOPIC 4
DERMATOLOGY, IMMUNOMODULATORS
ELIDEL 4
PROTOPIC 4 GA
tacrolimus oint 1
DERMATOLOGY, LOCAL ANALGESIC
lidocaine pad 5% 1
LIDODERM 4 GA
DERMATOLOGY, LOCAL ANESTHETICS
EMLA 4 GA
lidocaine oint 5% 1
lidocaine soln 4% 1
lidocaine/prilocaine 1
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir oint 1

Requirements/
ALDARA 4 PA; GA
ARZOL SILVER NITRATE APPLICATORS 4 GA
CONDYLOX GEL 4 PA
CONDYLOX SOLN 4 GA
DENAVIR 4
doxepin cream 5% 1
imiquimod 1 PA
PANRETIN 3
PODOCON 25 1
podofilox soln 0.5% 1
PRUDOXIN CREAM 5% 4 GA
SALICYLIC ACID 26% 1
salicylic acid soln 27.5% 1
SANTYL 3
silver nitrate applicators 1
SILVER NITRATE OINT, SOLN 10% 1
SILVER NITRATE SOLN 0.5%, 25%, 50% 1
SULFAMYLON CREAM 3
SULFAMYLON PAK 4 GA
TRI-CHLOR 1
VEREGEN 3 PA
VIRASAL 4 GA
XERESE 4
ZONALON CREAM 5% 4 GA
ZOVIRAX CREAM 4
ZOVIRAX OINT 4 GA
DERMATOLOGY, ROSACEA
DOXYCYCLINE DELAYED-REL 40MG 4 PA
FINACEA 4
METROCREAM 4 GA
METROGEL 4 GA
METROLOTION 4 GA
metronidazole cream, gel, lotion 0.75% 1
metronidazole gel 1% 1
MIRVASO 4
NORITATE 4
ORACEA 4 PA
DERMATOLOGY, SCABICIDES AND PEDICULICIDES
ELIMITE 4 GA
EURAX 3
Requirements/
lindane 1
malathion 1
NATROBA 4 GA
OVIDE 4 GA
permethrin 1
SKLICE 4
spinosad 4
ULESFIA 3
DERMATOLOGY, WOUND CARE PRODUCTS
REGRANEX 3
MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS
ARESTIN 2
chlorhexidine gluconate 1
DEBACTEROL 3
PERIDEX 4 GA
triamcinolone dental paste 1
viscous lidocaine 1
OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY
COMBINATIONS
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 3
MAXITROL 4 GA
neomycin/polymyxin b/bacitracin/
hydrocortisone 1
neomycin/polymyxin b/dexamethasone 1
neomycin/polymyxin b/hydrocortisone 1
PRED-G 3
PRED-G S.O.P 3
sulfacetamide/prednisolone 1
TOBRADEX OINT 3
TOBRADEX ST 4
TOBRADEX SUSP 4 GA
tobramycin/dexamethasone 1
ZYLET 3
OPHTHALMIC, ANTI-INFECTIVES
AZASITE 3
bacitracin 1

Requirements/
bacitracin/polymyxin b 1
BESIVANCE 3
BETADINE OPHTHALMIC PREP 3
BLEPH-10 4 GA
CILOXAN OINT 3
CILOXAN SOLN 4 GA
ciprofloxacin ophth 1
erythromycin oint 1
GARAMYCIN 4 GA
gatifloxacin 1
gentamicin ophth 1
levofloxacin soln 1
MOXEZA 3
neomycin/bacitracin/polymyxin b 1
neomycin/polymyxin b/gramicidin 1
OCUFLOX 4 GA
ofloxacin ophth 1
polymyxin b/trimethoprim 1
POLYTRIM 4 GA
sulfacetamide ophth 1
tobramycin soln 1
TOBREX OINT 3
TOBREX SOLN 4 GA
VIGAMOX 3
ZYMAXID 4 GA
OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL
ACULAR 4 GA
ACULAR LS 4 GA
ACUVAIL 3
bromfenac 1
diclofenac 1
flurbiprofen soln 1
ILEVRO 4
ketorolac soln 1
NEVANAC 4
PROLENSA 4
OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL
ALREX 3
dexamethasone soln 1
DUREZOL 3
Requirements/
FLAREX 3
fluorometholone 1
FML FORTE 4
FML LIQUIFILM 4 GA
FML OINT 3
LOTEMAX 3
MAXIDEX 3
OMNIPRED 3 GA
PRED FORTE 3 GA
PRED MILD 3
prednisolone acetate 1% 1
PREDNISOLONE PHOSPHATE 1% 1
VEXOL 3
OPHTHALMIC, ANTIALLERGICS
ALOCRIL 3
ALOMIDE 3
azelastine 1
BEPREVE 3
cromolyn sodium 1
ELESTAT 4 GA
EMADINE 3
epinastine 1
LASTACAFT 4
olopatadine 1
PATADAY 4
PATANOL 4 GA
PAZEO 4
OPHTHALMIC, ANTIFUNGALS
NATACYN 3
OPHTHALMIC, ANTIVIRAL
trifluridine 1
VIROPTIC 4 GA
ZIRGAN 4
OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE
BETIMOL 2
carteolol 1
ISTALOL 3
levobunolol 1
Requirements/
metipranolol 1
timolol gel soln 1
timolol soln 1
TIMOPTIC 0.25%, 0.5% 4 GA
TIMOPTIC OCUDOSE 0.25%, 0.5% 4
TIMOPTIC-XE 4 GA
OPHTHALMIC, BETA-BLOCKERS: SELECTIVE
betaxolol soln 1
BETOPTIC-S 2
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER
COMBINATIONS
COSOPT 4 GA
COSOPT PF 4
dorzolamide/timolol 1
OPHTHALMIC, CARBONIC ANHYDRASE
INHIBITOR/SYMPATHOMIMETIC COMBINATIONS
SIMBRINZA 4
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL
acetazolamide 1
acetazolamide ext-rel 1
DIAMOX SEQUELS 4 GA
methazolamide 1
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL
AZOPT 3
dorzolamide 1
TRUSOPT 4 GA
OPHTHALMIC, IMMUNOMODULATOR
RESTASIS 3
OPHTHALMIC, LOCAL ANESTHETIC
AKTEN 3
OPHTHALMIC, MISCELLANEOUS
CYSTARAN 2
LACRISERT 3

Requirements/
naphazoline 1
phenylephrine 1
proparacaine 1
tetracaine 1
OPHTHALMIC, MYDRIATICS
ATROPINE OINT 1
atropine soln 1
CYCLOGYL 0.5%, 1%, 2% 4 GA
CYCLOMYDRIL 4
cyclopentolate 1
homatropine 1
ISOPTO HOMATROPINE 2% 4
ISOPTO HOMATROPINE 5% 4 GA
ISOPTO HYOSCINE 4
tropicamide 1
OPHTHALMIC, PARASYMPATHOMIMETICS
ISOPTO CARBACHOL 4
MIOCHOL-E 4
pilocarpine soln 1
OPHTHALMIC, PROSTAGLANDINS
bimatoprost 1
latanoprost 1
LUMIGAN 2
TRAVATAN Z 4
travoprost 4
XALATAN 4 GA
ZIOPTAN 4
OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER
COMBINATIONS
COMBIGAN 4
OPHTHALMIC, SYMPATHOMIMETICS
ALPHAGAN P 0.1% 4
ALPHAGAN P 0.15% 4 GA
apraclonidine 1
brimonidine 0.15%, 0.2% 1
IOPIDINE 0.5% 4 GA

Requirements/
IOPIDINE 1% 3
PHOSPHOLINE IODIDE 3
OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS
CIPRO HC 3
CIPRODEX 3
COLY-MYCIN S 3
CORTISPORIN 4 GA
CORTISPORIN-TC 3
hydrocortisone/acetic acid 1
neomycin/polymyxin b/hydrocortisone soln 1
neomycin/polymyxin b/hydrocortisone susp 1
OTIC, ANTI-INFECTIVES
acetic acid 1
acetic acid/aluminum acetate 1
CETRAXAL 4 GA
ciprofloxacin otic 1
ofloxacin otic 1
OTIC, MISCELLANEOUS
antipyrine/benzocaine 1
antipyrine/benzocaine/polycosanol 1
CORTANE-B 4 GA
DERMOTIC 4 GA
fluocinolone acetonide oil 0.01% 1
MYOXIN 1
OTICIN HC DRO 4 GA
pramoxine/chloroxylenol 1
pramoxine/hydrocortisone/chloroxylenol 1
TREAGAN OTIC 4 GA


Wellmark BlueRx Preferred Formulary

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Wellmark BlueRx Preferred Formulary

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Blue Rx Preferred Formulary

The Blue Rx Preferred formulary is a list of drugs covered under your

Wellmark continually reviews new and existing drugs to ensure the

The formulary is a continually reviewed and modified document that

The Blue Rx Preferred formulary is continually changing to reflect new

Blue Rx Preferred Formulary

Wellmark has developed the Pharmacy and Therapeutics Committee

The P&T includes licensed physicians and pharmacists. These clinicians

HOW TO READ THE FORMULARY

Once the product is located, the following items can be viewed:

Blue Rx Preferred Formulary

Specialty Drugs (SP-P): Specialty drugs are high-cost injectable,

Specialty Drugs Preferred (SP-P): Drugs in this category will

Specialty pharmacies specialize in the delivery and clinical management

Requirements/Limits: This lists Wellmark Pharmacy programs that

Prior Authorization (PA): This indicates a drug requires prior

Prior authorization review of prescribing guidelines will be evaluated

Medical Necessity Prior Authorization (MN-PA): This indicates

The intent of formulary medical necessity prior authorization is to

Quantity Limits (QL): Wellmark typically covers a 30-day supply

No special steps are necessary by the physician or member to have

Blue Rx Preferred Formulary

Generic Available (GA): Indicates a generic equivalent is

HEALTH CARE REFORM PREVENTIVE DRUGS

Preventive drugs with an "A" or "B" rating in the current

A complete list of recommendations and guidelines related to preventive

Blue Rx Preferred Formulary

FORMULARY EXCEPTION PROCESS

All covered formulary drugs on any tier will be ineffective; OR

COMMON DRUG EXCLUSIONS

Due to benefit design parameters, some plan sponsors may choose to

OTC drugs or their equivalents unless otherwise specified in the

Blue Rx Preferred Formulary

GENERIC DRUG SUBSTITUTION

In most cases, Wellmark promotes the use of equally effective generic

When a brand-name drug becomes available as a generic, the brand-

Blue Rx Preferred Formulary

The Blue Rx formulary is designed to assist physicians, members and

Please direct your communications to:

In addition to the Blue Rx formulary, other quick-reference guides are

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary

Blue Rx Preferred Formulary