Prescription Drugs List for Prior Authorization and Step Therapy in KP, Exercises of Nursing

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Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs

ABACAVIR SULFATE SOLN 20 MG/ML ABIRATERONE ACETATE TABS 250 MG ABACAVIR SULFATE SOLN 20 MG/ML

ABACAVIR SULFATE TABS 300 MG Abstral 100 mcg sublingual tablet ABACAVIR SULFATE TABS 300 MG

ABACAVIR SULFATE-LAMIVUDINE TABS 600-300 MG acetaminophen 120 mg-codeine 12 mg/5 ABACAVIR SULFATE-LAMIVUDINE TABS 600-300 MG

ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABS 300-150-300 MG acetaminophen 300 mg-codeine 15 mg ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABS 300-150-

ABIRATERONE ACETATE TABS 250 MG acetaminophen 300 mg-codeine 30 mg ABIRATERONE ACETATE TABS 250 MG

ACARBOSE TABS 100 MG acetaminophen 300 mg-codeine 60 mg ACARBOSE TABS 100 MG

ACARBOSE TABS 25 MG

ACTEMRA ACTPEN SOAJ 162 MG/0.9ML

ACARBOSE TABS 25 MG

ACARBOSE TABS 50 MG ACTEMRA SOSY 162 MG/0.9ML ACARBOSE TABS 50 MG

ACETAMINOPHEN SOLN 10 MG/ML ACTHAR GEL 80 UNIT/ML ACETAMINOPHEN SOLN 10 MG/ML

ACETAMINOPHEN-CODEINE #2 TABS 300-15 MG ADLYXIN SOPN 20 MCG/0.2ML ACETAMINOPHEN-CODEINE #2 TABS 300-15 MG

ACETAMINOPHEN-CODEINE #3 TABS 300-30 MG

ADLYXIN STARTER PACK PNKT 10 & 20 MCG/0.2ML

ACETAMINOPHEN-CODEINE #3 TABS 300-30 MG

ACETAMINOPHEN-CODEINE #4 TABS 300-60 MG

AIMOVIG SOAJ 140 MG/ML

ACETAMINOPHEN-CODEINE #4 TABS 300-60 MG

ACETAMINOPHEN-CODEINE SOLN 120-12 MG/5ML AIMOVIG SOAJ 70 MG/ML ACETAMINOPHEN-CODEINE SOLN 120-12 MG/5ML

ACETAZOLAMIDE ER CP12 500 MG AJOVY SOAJ 225 MG/1.5ML ACETAZOLAMIDE ER CP12 500 MG

ACETAZOLAMIDE SODIUM SOLR 500 MG AJOVY SOSY 225 MG/1.5ML ACETAZOLAMIDE SODIUM SOLR 500 MG

ACETAZOLAMIDE TABS 125 MG ALECENSA CAPS 150 MG ACETAZOLAMIDE TABS 125 MG

ACETAZOLAMIDE TABS 250 MG

AMITIZA CAPS 24 MCG

ACETAZOLAMIDE TABS 250 MG

ACETIC ACID SOLN 0.25 % AMITIZA CAPS 8 MCG ACETIC ACID SOLN 0.25 %

ACETIC ACID SOLN 2 % AMPYRA TB12 10 MG ACETIC ACID SOLN 2 %

ACETIC ACID-ALUMINUM ACETATE SOLN 2 % APOKYN 10 mg/mL subcutaneous ACETIC ACID-ALUMINUM ACETATE SOLN 2 %

ACETYLCYSTEINE SOLN 10 %

ARANESP (ALBUMIN FREE) SOLN 100 MCG/ML

ACETYLCYSTEINE SOLN 10 %

ACETYLCYSTEINE SOLN 20 %

ARANESP (ALBUMIN FREE) SOLN 200 MCG/ML

ACETYLCYSTEINE SOLN 20 %

ACITRETIN CAPS 10 MG ARANESP (ALBUMIN FREE) SOLN 25 MCG/MLACITRETIN CAPS 10 MG

ACITRETIN CAPS 17.5 MG ARANESP (ALBUMIN FREE) SOLN 300 MCG/MLACITRETIN CAPS 17.5 MG

ACITRETIN CAPS 25 MG ARANESP (ALBUMIN FREE) SOLN 40 MCG/MLACITRETIN CAPS 25 MG

ACTEMRA ACTPEN SOAJ 162 MG/0.9ML

ARANESP (ALBUMIN FREE) SOLN 60 MCG/ML

ACTEMRA ACTPEN SOAJ 162 MG/0.9ML

ACTEMRA SOSY 162 MG/0.9ML

ARANESP (ALBUMIN FREE) SOSY 10 MCG/0.4ML

ACTEMRA SOSY 162 MG/0.9ML

ACYCLOVIR CAPS 200 MG ARANESP (ALBUMIN FREE) SOSY 100 MCG/0.5MLACYCLOVIR CAPS 200 MG

ACYCLOVIR SODIUM INJ 1000MG ARANESP (ALBUMIN FREE) SOSY 150 MCG/0.3MLACYCLOVIR SODIUM INJ 1000MG

ACYCLOVIR SODIUM INJ 500MG ARANESP (ALBUMIN FREE) SOSY 200 MCG/0.4MLACYCLOVIR SODIUM INJ 500MG

ACYCLOVIR SUSP 200 MG/5ML

ARANESP (ALBUMIN FREE) SOSY 25 MCG/0.42ML

ACYCLOVIR SUSP 200 MG/5ML

ACYCLOVIR TABS 400 MG

ARANESP (ALBUMIN FREE) SOSY 300 MCG/0.6ML

ACYCLOVIR TABS 400 MG

ACYCLOVIR TABS 800 MG ARANESP (ALBUMIN FREE) SOSY 40 MCG/0.4MLACYCLOVIR TABS 800 MG

ADACEL SUSP 5-2-15.5 LF-MCG/0.5 ARANESP (ALBUMIN FREE) SOSY 500 MCG/MLADACEL SUSP 5-2-15.5 LF-MCG/0.

Prescription Drug Formulary

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

ADAGEN SOLN 250 UNIT/ML

ARANESP (ALBUMIN FREE) SOSY 60 MCG/0.3ML

ADAGEN SOLN 250 UNIT/ML

ADAPALENE GEL 0.1 %

Ascomp with Codeine 30 mg-50 mg-

mg-40 mg capsule

ADAPALENE GEL 0.1 %

ADAPALENE GEL 0.3 % AUBAGIO TABS 14 MG ADAPALENE GEL 0.3 %

ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5 % AUBAGIO TABS 7 MG ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5 %

ADEFOVIR DIPIVOXIL TABS 10 MG

Auvi-Q ADEFOVIR DIPIVOXIL TABS 10 MG

ADEMPAS TABS 0.5 MG Auvi-Q 0.15 mg/0.15 mL injection,auto- ADEMPAS TABS 0.5 MG

ADEMPAS TABS 1 MG Auvi-Q 0.3 mg/0.3 mL injection, auto- ADEMPAS TABS 1 MG

ADEMPAS TABS 1.5 MG AVONEX PEN AJKT 30 MCG/0.5ML ADEMPAS TABS 1.5 MG

ADEMPAS TABS 2 MG AVONEX PREFILLED PSKT 30 MCG/0.5ML ADEMPAS TABS 2 MG

ADEMPAS TABS 2.5 MG

benzhydrocodone-acetaminophen ADEMPAS TABS 2.5 MG

ADENOSINE (DIAGNOSTIC) SOLN 3 MG/ML

butalbital 50 mg-acetaminophen 300 mg-

caffeine 40 mg-codeine 30 mg cap

ADENOSINE (DIAGNOSTIC) SOLN 3 MG/ML

ADENOSINE SOLN 12 MG/4ML

butalbital 50 mg-acetaminophen 325 mg-

caffeine 40 mg-codeine 30 mg cap

ADENOSINE SOLN 12 MG/4ML

ADENOSINE SOLN 6 MG/2ML

Butalbital Compound with Codeine 30 mg-

50 mg-325 mg-40 mg capsule

ADENOSINE SOLN 6 MG/2ML

ADRUCIL SOLN 500 MG/10ML butorphanol tartrate 1 mg/mL injection ADRUCIL SOLN 500 MG/10ML

ADULT AEROSOL MASK MISC butorphanol tartrate 10 mg/mL nasal ADVAIR HFA AERO 115-21 MCG/ACT

ADVAIR HFA AERO 115-21 MCG/ACT Butrans 10 mcg/hour transdermal patch ADVAIR HFA AERO 230-21 MCG/ACT

ADVAIR HFA AERO 230-21 MCG/ACT Butrans 15 mcg/hour transdermal patch ADVAIR HFA AERO 45-21 MCG/ACT

ADVAIR HFA AERO 45-21 MCG/ACT Butrans 20 mcg/hour transdermal patch AFIRMELLE TABS 0.1-20 MG-MCG

ADVOCATE CONTROL SOLUTION LIQD LOW Butrans 5 mcg/hour transdermal patch AFTERA TABS 1.5 MG

AEROCHAMBER Z-STAT PLUS MISC Butrans 7.5 mcg/hour transdermal patch AKOVAZ SOLN 50 MG/ML

AEROCHAMBER Z-STAT PLUS/LARGE MISC

Bydureon 2 mg subcutaneous extended

release suspension

AKYNZEO CAPS 300-0.5 MG

AEROCHAMBER Z-STAT PLUS/MEDIUM MISC Bydureon 2 mg/0.65 mL subcutaneous ALAVERT TBDP 10 MG

AEROCHAMBER Z-STAT PLUS/SMALL MISC BYDUREON BCISE AUIJ 2 MG/0.85ML ALBENDAZOLE TABS 200 MG

AEROGEAR ACTION ASTHMA KIT KIT

Byetta 10 mcg/dose(250 mcg/mL)2.4 mL

subcutaneous pen injector

ALBUMIN HUMAN SOLN 25 %

AFIRMELLE TABS 0.1-20 MG-MCG

Byetta 5 mcg/dose (250 mcg/mL)1.2 mL

subcutaneous pen injector

ALBUSTIX STRP

AFTERA TABS 1.5 MG carisoprodol-ASA-codeine 200 mg-325 ALBUTEROL SULFATE HFA AERS 108 (90 Base) MCG/A

AKOVAZ SOLN 50 MG/ML CAYSTON SOLR 75 MG ALBUTEROL SULFATE NEBU (2.5 MG/3ML) 0.083%

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

AKYNZEO CAPS 300-0.5 MG Cheratussin AC 10 mg-100 mg/5 mL oral ALBUTEROL SULFATE NEBU (5 MG/ML) 0.5%

ALAVERT TBDP 10 MG chloroquine 250 mg tablet ALBUTEROL SULFATE NEBU 2.5 MG/0.5ML

ALBENDAZOLE TABS 200 MG chloroquine 500 mg tablet ALECENSA CAPS 150 MG

ALBUMIN HUMAN SOLN 25 % CIMZIA KIT 2 X 200 MG ALENDRONATE SODIUM TABS 70 MG

ALBUSTIX STRP CIMZIA PREFILLED KIT 2 X 200 MG/ML ALIMTA SOLR 100 MG

ALBUTEROL SULFATE HFA AERS 108 (90 Base) MCG/ACT codeine sulfate 15 mg tablet ALIMTA SOLR 500 MG

ALBUTEROL SULFATE NEBU (2.5 MG/3ML) 0.083% codeine sulfate 30 mg tablet ALLEGRA ALLERGY CHILDRENS TABS 30 MG

ALBUTEROL SULFATE NEBU (5 MG/ML) 0.5% codeine sulfate 60 mg tablet ALLEGRA ALLERGY CHILDRENS TBDP 30 MG

ALBUTEROL SULFATE NEBU 2.5 MG/0.5ML ConZip 200 mg capsule,extended release ALLOPURINOL TABS 100 MG

ALECENSA CAPS 150 MG COSENTYX (300 MG DOSE) SOSY 150 MG/MLALLOPURINOL TABS 300 MG

ALENDRONATE SODIUM TABS 70 MG

COSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML

ALPROLIX SOLR 1000 UNIT

ALIMTA SOLR 100 MG COSENTYX SENSOREADY PEN SOAJ 150 MG/MLALPROLIX SOLR 2000 UNIT

ALIMTA SOLR 500 MG COSENTYX SOSY 150 MG/ML ALPROLIX SOLR 3000 UNIT

ALLEGRA ALLERGY CHILDRENS TABS 30 MG Daklinza 30 mg tablet ALPROLIX SOLR 500 UNIT

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG Daklinza 60 mg tablet ALTAFLUOR BENOX SOLN 0.25-0.4 %

ALLERGIST TRAY KIT 26G X 1/2" 1 ML Daklinza 90 mg tablet ALTAVERA TABS 0.15-30 MG-MCG

ALLERGIST TRAY KIT 27G X 3/8" 0.5 ML DALFAMPRIDINE ER TB12 10 MG ALUNBRIG TABS 30 MG

ALLERGIST TRAY KIT 27G X 3/8" 1 ML Dupixent Pen ALVESCO AERS 160 MCG/ACT

ALLOPURINOL TABS 100 MG DUPIXENT SOSY 200 MG/1.14ML ALVESCO AERS 80 MCG/ACT

ALLOPURINOL TABS 300 MG DUPIXENT SOSY 300 MG/2ML ALYACEN 1/35 TABS 1-35 MG-MCG

ALPROLIX SOLR 1000 UNIT Duragesic 50 mcg/hr transdermal patch AMANTADINE HCL CAPS 100 MG

ALPROLIX SOLR 2000 UNIT Dvorah AMANTADINE HCL SYRP 50 MG/5ML

ALPROLIX SOLR 3000 UNIT Egrifta 1 mg subcutaneous solution AMANTADINE HCL TABS 100 MG

ALPROLIX SOLR 500 UNIT Embeda 20 mg-0.8 mg capsule, extend AMBRISENTAN TABS 10 MG

ALTAFLUOR BENOX SOLN 0.25-0.4 % EMBEDA CAP CR 100-4 MG (REMOVE - NOT IN FN)AMBRISENTAN TABS 5 MG

ALTAVERA TABS 0.15-30 MG-MCG EMBEDA CAP CR 20-0.8 MG (REMOVE - NOT IN FN)AMIKACIN SULFATE INJ 500/2ML

ALUNBRIG TABS 30 MG EMBEDA CAP CR 30-1.2 MG (REMOVE - NOT IN FN)AMIKACIN SULFATE SOLN 1 GM/4ML

ALVESCO AERS 160 MCG/ACT EMBEDA CAP CR 50-2 MG (REMOVE - NOT IN FN)AMIKACIN SULFATE SOLN 500 MG/2ML

ALVESCO AERS 80 MCG/ACT EMBEDA CAP CR 60-2.4 MG (REMOVE - NOT IN FN)AMILORIDE HCL TABS 5 MG

ALYACEN 1/35 TABS 1-35 MG-MCG EMBEDA CAP CR 80-3.2 MG (REMOVE - NOT IN FN)AMILORIDE-HYDROCHLOROTHIAZIDE TABS 5-50 MG

AMANTADINE HCL CAPS 100 MG

EMFLAZA SUSP 22.75 MG/ML

AMINOCAPROIC ACID TABS 500 MG

AMANTADINE HCL SYRP 50 MG/5ML EMFLAZA TABS 18 MG AMINOPHYLLINE SOLN 25 MG/ML

AMANTADINE HCL TABS 100 MG EMFLAZA TABS 30 MG AMIODARONE HCL SOLN 150 MG/3ML

AMBRISENTAN TABS 10 MG EMFLAZA TABS 36 MG AMIODARONE HCL TABS 200 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

AMBRISENTAN TABS 5 MG

EMFLAZA TABS 6 MG

AMLODIPINE BESYLATE TABS 10 MG

AMIKACIN SULFATE INJ 500/2ML EMGALITY (300 MG DOSE) SOSY 100 MG/MLAMLODIPINE BESYLATE TABS 2.5 MG

AMIKACIN SULFATE SOLN 1 GM/4ML EMGALITY SOAJ 120 MG/ML AMLODIPINE BESYLATE TABS 5 MG

AMIKACIN SULFATE SOLN 500 MG/2ML EMGALITY SOSY 120 MG/ML AMOXICILLIN CAPS 250 MG

AMILORIDE HCL TABS 5 MG Enbrel AMOXICILLIN CAPS 500 MG

AMILORIDE-HYDROCHLOROTHIAZIDE TABS 5-50 MG

ENBREL MINI SOCT 50 MG/ML

AMOXICILLIN CHEW 125 MG

AMINOCAPROIC ACID TABS 500 MG ENBREL SOLR 25 MG AMOXICILLIN CHEW 250 MG

AMINOPHYLLINE SOLN 25 MG/ML ENBREL SOSY 25 MG/0.5ML AMOXICILLIN SUSR 125 MG/5ML

AMIODARONE HCL SOLN 150 MG/3ML ENBREL SOSY 50 MG/ML AMOXICILLIN SUSR 200 MG/5ML

AMIODARONE HCL TABS 200 MG ENBREL SURECLICK SOAJ 50 MG/ML AMOXICILLIN SUSR 250 MG/5ML

AMLODIPINE BESYLATE TABS 10 MG Endocet 10 mg-325 mg tablet AMOXICILLIN SUSR 400 MG/5ML

AMLODIPINE BESYLATE TABS 2.5 MG Endocet 5 mg-325 mg tablet AMOXICILLIN TABS 500 MG

AMLODIPINE BESYLATE TABS 5 MG Endocet 7.5 mg-325 mg tablet AMOXICILLIN TABS 875 MG

AMOXICILLIN CAPS 250 MG Epclusa AMOXICILLIN-POT CLAVULANATE CHEW 200-28.5 MG

AMOXICILLIN CAPS 500 MG Epclusa 400 mg-100 mg tablet AMOXICILLIN-POT CLAVULANATE CHEW 400-57 MG

AMOXICILLIN CHEW 125 MG

ESBRIET CAPS 267 MG

AMOXICILLIN-POT CLAVULANATE SUSR 200-28.5 MG/

AMOXICILLIN CHEW 250 MG ESBRIET TABS 267 MG AMOXICILLIN-POT CLAVULANATE SUSR 250-62.5 MG/

AMOXICILLIN SUSR 125 MG/5ML ESBRIET TABS 801 MG AMOXICILLIN-POT CLAVULANATE SUSR 400-57 MG/5M

AMOXICILLIN SUSR 200 MG/5ML Exalgo ER 8 mg tablet,extended release AMOXICILLIN-POT CLAVULANATE SUSR 600-42.9 MG/

AMOXICILLIN SUSR 250 MG/5ML Farxiga 10 mg tablet AMOXICILLIN-POT CLAVULANATE TABS 250-125 MG

AMOXICILLIN SUSR 400 MG/5ML Farxiga 5 mg tablet AMOXICILLIN-POT CLAVULANATE TABS 500-125 MG

AMOXICILLIN TABS 500 MG FASENRA PEN SOAJ 30 MG/ML AMOXICILLIN-POT CLAVULANATE TABS 875-125 MG

AMOXICILLIN TABS 875 MG FASENRA SOSY 30 MG/ML AMPHOTERICIN B SOLR 50 MG

AMOXICILLIN-POT CLAVULANATE CHEW 200-28.5 MG fentanyl (PF) 50 mcg/mL injection AMPICILLIN CAP 250MG

AMOXICILLIN-POT CLAVULANATE CHEW 400-57 MG fentanyl 100 mcg/hr transdermal patch AMPICILLIN CAPS 500 MG

AMOXICILLIN-POT CLAVULANATE SUSR 200-28.5 MG/5ML fentanyl 12 mcg/hr transdermal patch AMPICILLIN SODIUM SOLR 1 GM

AMOXICILLIN-POT CLAVULANATE SUSR 250-62.5 MG/5ML fentanyl 25 mcg/hr transdermal patch AMPICILLIN SODIUM SOLR 2 GM

AMOXICILLIN-POT CLAVULANATE SUSR 400-57 MG/5ML fentanyl 37.5 mcg/hour transdermal AMPICILLIN SODIUM SOLR 250 MG

AMOXICILLIN-POT CLAVULANATE SUSR 600-42.9 MG/5ML fentanyl 50 mcg/hr transdermal patch AMPICILLIN SODIUM SOLR 500 MG

AMOXICILLIN-POT CLAVULANATE TABS 250-125 MG fentanyl 62.5 mcg/hour transdermal AMPICILLIN SUSR 125 MG/5ML

AMOXICILLIN-POT CLAVULANATE TABS 500-125 MG fentanyl 75 mcg/hr transdermal patch AMPICILLIN SUSR 250 MG/5ML

AMOXICILLIN-POT CLAVULANATE TABS 875-125 MG fentanyl 87.5 mcg/hour transdermal AMPICILLIN-SULBACTAM SODIUM SOLR 1.5 (1-0.5) GM

AMPHOTERICIN B SOLR 50 MG Fentora 100 mcg buccal tablet, AMPICILLIN-SULBACTAM SODIUM SOLR 3 (2-1) GM

AMPICILLIN CAP 250MG Fentora 200 mcg buccal tablet, AMP-SULBACTA INJ 1.5GM

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

AMPICILLIN CAPS 500 MG

FIRDAPSE TABS 10 MG

AMP-SULBACTA INJ 3GM

AMPICILLIN SODIUM SOLR 1 GM

Genotropin 12 mg/mL (36 unit/mL)

subcutaneous cartridge

ANAGRELIDE HCL CAPS 0.5 MG

AMPICILLIN SODIUM SOLR 2 GM

Genotropin 5 mg/mL (15 unit/mL)

subcutaneous cartridge

ANAGRELIDE HCL CAPS 1 MG

AMPICILLIN SODIUM SOLR 250 MG

Genotropin MiniQuick 0.4 mg/0.25 mL

subcutaneous syringe

ANASTROZOLE TABS 1 MG

AMPICILLIN SODIUM SOLR 500 MG

Genotropin MiniQuick 0.8 mg/0.25 mL

subcutaneous syringe

APREPITANT CAPS 125 MG

AMPICILLIN SUSR 125 MG/5ML

Genotropin MiniQuick 1 mg/0.25 mL

subcutaneous syringe

APREPITANT CAPS 80 MG

AMPICILLIN SUSR 250 MG/5ML

Genotropin MiniQuick 1.6 mg/0.25 mL

subcutaneous syringe

APRI TABS 0.15-30 MG-MCG

AMPICILLIN-SULBACTAM SODIUM SOLR 1.5 (1-0.5) GM

Genotropin MiniQuick 1.8 mg/0.25 mL

subcutaneous syringe

APTIVUS CAPS 250 MG

AMPICILLIN-SULBACTAM SODIUM SOLR 3 (2-1) GM

Genotropin MiniQuick 2 mg/0.25 mL

subcutaneous syringe

APTIVUS SOLN 100 MG/ML

AMP-SULBACTA INJ 1.5GM GILENYA CAPS 0.25 MG AQUASOL A SOLN 15 MG/ML

AMP-SULBACTA INJ 3GM GILENYA CAPS 0.5 MG ARANELLE TABS 0.5/1/0.5-35 MG-MCG

ANAGRELIDE HCL CAPS 0.5 MG GLYXAMBI TABS 10-5 MG ARZOL SILVER NIT APPLICATORS MISC 75-25 %

ANAGRELIDE HCL CAPS 1 MG

GLYXAMBI TABS 25-5 MG

ASCORBIC ACID SOLN 500 MG/ML

ANASTROZOLE TABS 1 MG Guaiatussin AC 10 mg-100 mg/5 mL oral ASCRIPTIN TABS 325 MG

APREPITANT CAPS 125 MG Guaifenesin AC 10 mg-100 mg/5 mL oral ASPIRIN CHEW 81 MG

APREPITANT CAPS 80 MG Harvoni ASPIRIN-DIPYRIDAMOLE ER CP12 25-200 MG

APRI TABS 0.15-30 MG-MCG Harvoni 90 mg-400 mg tablet ATAZANAVIR SULFATE CAPS 150 MG

APTIVUS CAPS 250 MG HARVONI PACK 33.75-150 MG ATAZANAVIR SULFATE CAPS 200 MG

APTIVUS SOLN 100 MG/ML HARVONI PACK 45-200 MG ATAZANAVIR SULFATE CAPS 300 MG

AQUASOL A SOLN 15 MG/ML Humatrope 5 mg (15 unit) solution for ATENOLOL TABS 100 MG

ARANELLE TABS 0.5/1/0.5-35 MG-MCG HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8MLATENOLOL TABS 25 MG

ARZOL SILVER NIT APPLICATORS MISC 75-25 % HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML & 40MG/0.4MLATENOLOL TABS 50 MG

ASCORBIC ACID SOLN 500 MG/ML

HUMIRA PEN PNKT 40 MG/0.4ML

ATENOLOL-CHLORTHALIDONE TABS 100-25 MG

ASCRIPTIN TABS 325 MG HUMIRA PEN PNKT 40 MG/0.8ML ATENOLOL-CHLORTHALIDONE TABS 50-25 MG

ASPIRIN CHEW 81 MG HUMIRA PEN-CD/UC/HS STARTER PNKT 40 MG/0.8MLATORVASTATIN CALCIUM TABS 10 MG

ASPIRIN-DIPYRIDAMOLE ER CP12 25-200 MG HUMIRA PEN-CD/UC/HS STARTER PNKT 80 MG/0.8MLATORVASTATIN CALCIUM TABS 20 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

ASTHMAPACK FOR CHILDREN KIT

HUMIRA PEN-PS/UV/ADOL HS START PNKT 40 MG/0.8ML

ATORVASTATIN CALCIUM TABS 40 MG

ATAZANAVIR SULFATE CAPS 150 MG HUMIRA PEN-PS/UV/ADOL HS START PNKT 80 MG/0.8ML & 40MG/0.4MLATORVASTATIN CALCIUM TABS 80 MG

ATAZANAVIR SULFATE CAPS 200 MG HUMIRA PSKT 10 MG/0.1ML ATOVAQUONE SUSP 750 MG/5ML

ATAZANAVIR SULFATE CAPS 300 MG HUMIRA PSKT 10 MG/0.2ML ATOVAQUONE-PROGUANIL HCL TABS 250-100 MG

ATENOLOL TABS 100 MG HUMIRA PSKT 20 MG/0.2ML ATOVAQUONE-PROGUANIL HCL TABS 62.5-25 MG

ATENOLOL TABS 25 MG

HUMIRA PSKT 20 MG/0.4ML

ATROPINE SULFATE INJ 1MG/ML

ATENOLOL TABS 50 MG HUMIRA PSKT 40 MG/0.4ML ATROPINE SULFATE OINT 1 %

ATENOLOL-CHLORTHALIDONE TABS 100-25 MG HUMIRA PSKT 40 MG/0.8ML ATROPINE SULFATE SOLN 0.4 MG/ML

ATENOLOL-CHLORTHALIDONE TABS 50-25 MG Humira(CF) Pen Pediatric UC ATROPINE SULFATE SOLN 1 %

ATORVASTATIN CALCIUM TABS 10 MG Hycet 7.5 mg-325 mg/15 mL oral solution ATROPINE SULFATE SOSY 1 MG/10ML

ATORVASTATIN CALCIUM TABS 20 MG

Hycodan AUBRA TABS 0.1-20 MG-MCG

ATORVASTATIN CALCIUM TABS 40 MG hydrocodone 10 mg-acetaminophen 300 AUROVELA 1.5/30 TABS 1.5-30 MG-MCG

ATORVASTATIN CALCIUM TABS 80 MG hydrocodone 10 mg-acetaminophen 325 AUROVELA 1/20 TABS 1-20 MG-MCG

ATOVAQUONE SUSP 750 MG/5ML

hydrocodone 10 mg-chlorpheniramine 8

mg/5 mL oral susp extend.rel 12hr

AUROVELA FE 1.5/30 TABS 1.5-30 MG-MCG

ATOVAQUONE-PROGUANIL HCL TABS 250-100 MG hydrocodone 2.5 mg-acetaminophen 325 AUROVELA FE 1/20 TABS 1-20 MG-MCG

ATOVAQUONE-PROGUANIL HCL TABS 62.5-25 MG hydrocodone 5 mg-acetaminophen 300 AVELOX SOLN 400 MG/250ML

ATROPINE SULFATE INJ 1MG/ML hydrocodone 5 mg-acetaminophen 325 AVIANE TABS 0.1-20 MG-MCG

ATROPINE SULFATE OINT 1 %

hydrocodone 5 mg-cpm 4 mg-

pseudoephedrine 60 mg/5 mL oral

AYUNA TABS 0.15-30 MG-MCG

ATROPINE SULFATE SOLN 0.4 MG/ML hydrocodone 5 mg-ibuprofen 200 mg AZACITIDINE SUSR 100 MG

ATROPINE SULFATE SOLN 1 % hydrocodone 7.5 mg-acetaminophen 300 AZATHIOPRINE TABS 50 MG

ATROPINE SULFATE SOSY 1 MG/10ML hydrocodone 7.5 mg-acetaminophen 325 AZELAIC ACID GEL 15 %

AUBRA TABS 0.1-20 MG-MCG

hydrocodone 7.5 mg-acetaminophen 325

mg/15 mL oral solution

AZELASTINE HCL SOLN 0.1 %

AUROVELA 1.5/30 TABS 1.5-30 MG-MCG hydrocodone 7.5 mg-ibuprofen 200 mg AZITHROMYCIN PACK 1 GM

AUROVELA 1/20 TABS 1-20 MG-MCG hydrocodone bitartrate AZITHROMYCIN SOLR 500 MG

AUROVELA FE 1.5/30 TABS 1.5-30 MG-MCG hydrocodone-homatropine 5 mg-1.5 mg AZITHROMYCIN SUSR 100 MG/5ML

AUROVELA FE 1/20 TABS 1-20 MG-MCG

hydrocodone-homatropine 5 mg-1.5 mg/

mL (5 mL) syrup

AZITHROMYCIN SUSR 200 MG/5ML

AUTOPEN DEVI hydrocodone-homatropine 5 mg-1.5 mg/5 AZITHROMYCIN TABS 250 MG

AVELOX SOLN 400 MG/250ML Hydromet 5 mg-1.5 mg/5 mL syrup AZITHROMYCIN TABS 500 MG

AVIANE TABS 0.1-20 MG-MCG hydromorphone 1 mg/mL oral liquid AZITHROMYCIN TABS 600 MG

AYUNA TABS 0.15-30 MG-MCG hydromorphone 2 mg tablet AZTREONAM SOLR 1 GM

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

AZACITIDINE SUSR 100 MG hydromorphone 4 mg tablet AZTREONAM SOLR 2 GM

AZATHIOPRINE TABS 50 MG hydromorphone 8 mg tablet BACIIM SOLR 50000 UNIT

AZELAIC ACID GEL 15 % hydromorphone ER 12 mg tablet,extended BACITRACIN OINT 500 UNIT/GM

AZELASTINE HCL SOLN 0.1 % hydromorphone ER 16 mg tablet,extended BACITRACIN-POLYMYXIN B OINT 500-10000 UNIT/GM

AZITHROMYCIN PACK 1 GM hydromorphone ER 32 mg tablet,extended BACITRA-NEOMYCIN-POLYMYXIN-HC OINT 1 %

AZITHROMYCIN SOLR 500 MG hydromorphone ER 8 mg tablet,extended BACLOFEN TABS 10 MG

AZITHROMYCIN SUSR 100 MG/5ML hydroxychloroquine 200 mg tablet BACLOFEN TABS 20 MG

AZITHROMYCIN SUSR 200 MG/5ML IBRANCE CAPS 100 MG BACTERIOSTATIC WATER(BENZ ALC) SOLN

AZITHROMYCIN TABS 250 MG IBRANCE CAPS 125 MG BALSALAZIDE DISODIUM CAPS 750 MG

AZITHROMYCIN TABS 500 MG IBRANCE CAPS 75 MG BAQSIMI ONE PACK POWD 3 MG/DOSE

AZITHROMYCIN TABS 600 MG IBRANCE TABS 100 MG BARACLUDE SOLN 0.05 MG/ML

AZTREONAM SOLR 1 GM IBRANCE TABS 125 MG BENDEKA SOLN 100 MG/4ML

AZTREONAM SOLR 2 GM IBRANCE TABS 75 MG BENZONATATE CAPS 100 MG

BACIIM SOLR 50000 UNIT Ibudone 5 mg-200 mg tablet BENZTROPINE MESYLATE SOLN 1 MG/ML

BACITRACIN OINT 500 UNIT/GM ibuprofen-oxycodone 400 mg-5 mg tablet BENZTROPINE MESYLATE TABS 0.5 MG

BACITRACIN-POLYMYXIN B OINT 500-10000 UNIT/GM

ILARIS SOLN 150 MG/ML

BENZTROPINE MESYLATE TABS 1 MG

BACITRA-NEOMYCIN-POLYMYXIN-HC OINT 1 % ILUMYA SOSY 100 MG/ML BENZTROPINE MESYLATE TABS 2 MG

BACLOFEN TABS 10 MG IMBRUVICA CAPS 140 MG BETADINE OPHTHALMIC PREP SOLN 5 %

BACLOFEN TABS 20 MG IMBRUVICA CAPS 70 MG BETAMETHASONE DIPROPIONATE AUG CREA 0.05 %

BACTERIOSTATIC WATER(BENZ ALC) SOLN IMBRUVICA TABS 140 MG BETAMETHASONE DIPROPIONATE AUG GEL 0.05 %

BALSALAZIDE DISODIUM CAPS 750 MG IMBRUVICA TABS 280 MG BETAMETHASONE DIPROPIONATE AUG LOTN 0.05 %

BAQSIMI ONE PACK POWD 3 MG/DOSE IMBRUVICA TABS 420 MG BETAMETHASONE DIPROPIONATE AUG OINT 0.05 %

BARACLUDE SOLN 0.05 MG/ML IMBRUVICA TABS 560 MG BETAMETHASONE DIPROPIONATE CREA 0.05 %

BD 10ML LUER-LOK SYRINGE 22G X 1-1/2" MIS 22GX1.5" Increlex 10 mg/mL subcutaneous solution BETAMETHASONE VALERATE CREA 0.1 %

BD 3ML LUER-LOK SYRINGE 21G X 1-1/4" MIS 21GX1.25 INVOKAMET TABS 150-1000 MG BETAMETHASONE VALERATE LOTN 0.1 %

BD 3ML LUER-LOK SYRINGE/22G X 1-1/4" MIS 22GX1.

INVOKAMET TABS 150-500 MG

BETAMETHASONE VALERATE OINT 0.1 %

BD ALLERGY SYRINGE MISC 28G X 1/2" 1 ML INVOKAMET TABS 50-1000 MG BETAXOLOL HCL SOLN 0.5 %

BD AUTOSHIELD DUO MISC 30G X 5 MM INVOKAMET TABS 50-500 MG BETHANECHOL CHLORIDE TABS 10 MG

BD BLUNT FILL NEEDLE MISC 18G X 1-1/2" INVOKAMET XR TB24 150-1000 MG BETHANECHOL CHLORIDE TABS 25 MG

BD DISP NEEDLE MISC 25G X 1" INVOKAMET XR TB24 150-500 MG BETHANECHOL CHLORIDE TABS 5 MG

BD DISP NEEDLES MISC 18G X 1-1/2"

INVOKAMET XR TB24 50-1000 MG

BETHANECHOL CHLORIDE TABS 50 MG

BD DISP NEEDLES MISC 20G X 1" INVOKAMET XR TB24 50-500 MG BEXAROTENE CAPS 75 MG

BD DISP NEEDLES MISC 22G X 1-1/2" Invokana 100 mg tablet BEXSERO SUSY

BD DISP NEEDLES MISC 25G X 5/8" Invokana 300 mg tablet BICALUTAMIDE TABS 50 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

BD DISP NEEDLES MISC 27G X 1/2" Janumet 50 mg-1,000 mg tablet BICILLIN L-A SUSP 1200000 UNIT/2ML

BD DISP NEEDLES MISC 30G X 1/2" Janumet 50 mg-500 mg tablet BICILLIN L-A SUSP 2400000 UNIT/4ML

BD FILTER NEEDLE/5 MICRON MISC Janumet XR 100 mg-1,000 mg BICILLIN L-A SUSP 600000 UNIT/ML

BD HYPODERMIC NEEDLE MISC 18G X 1-1/2" Janumet XR 50 mg-1,000 mg BICNU SOLR 100 MG

BD HYPODERMIC NEEDLE MISC 20G X 1-1/2" Janumet XR 50 mg-500 mg BIKTARVY TABS 50-200-25 MG

BD HYPODERMIC NEEDLE MISC 22G X 1" Januvia 100 mg tablet BIO-D-MULSION FORTE LIQD 50 MCG/0.03ML

BD HYPODERMIC NEEDLE MISC 22G X 1-1/2" Januvia 25 mg tablet BIO-D-MULSION LIQD 10 MCG/0.03ML

BD HYPODERMIC NEEDLE MISC 25G X 1" Januvia 50 mg tablet BISOPROLOL FUMARATE TABS 10 MG

BD HYPODERMIC NEEDLE MISC 25G X 1-1/2" Jardiance 10 mg tablet BISOPROLOL FUMARATE TABS 5 MG

BD HYPODERMIC NEEDLE MISC 25G X 5/8" Jentadueto 2.5 mg-1,000 mg tablet BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 10-6.25 M

BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2" MIS 0.3/28GJentadueto 2.5 mg-500 mg tablet BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 2.5-6.25 M

BD INSULIN SYRINGE MICROFINE MISC 27G X 5/8" 1 ML Jentadueto 2.5 mg-850 mg tablet BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 5-6.25 M

BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2" MIS 0.3/28GJYNARQUE TABS 15 MG BLEOMYCIN SULFATE SOLR 15 UNIT

BD INSULIN SYRINGE MISC 25G X 1" 1 ML JYNARQUE TABS 30 MG BLEOMYCIN SULFATE SOLR 30 UNIT

BD INSULIN SYRINGE MISC 25G X 5/8" 1 ML JYNARQUE TBPK 45 & 15 MG BLEPHAMIDE SUSP 10-0.2 %

BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML

JYNARQUE TBPK 60 & 30 MG

BLISOVI FE 1.5/30 TABS 1.5-30 MG-MCG

BD INSULIN SYRINGE MISC 27G X 1/2" 1 ML JYNARQUE TBPK 90 & 30 MG BLISOVI FE 1/20 TABS 1-20 MG-MCG

BD INSULIN SYRINGE MISC U-100 1 ML Kadian 10 mg capsule,extended release BOSENTAN TABS 125 MG

BD INSULIN SYRINGE U/F MISC 30G X 1/2" 0.3 ML Kadian 20 mg capsule,extended release BOSENTAN TABS 62.5 MG

BD INSULIN SYRINGE U/F MISC 30G X 1/2" 0.5 ML Kadian 30 mg capsule,extended release BOTOX SOLR 100 UNIT

BD INSULIN SYRINGE U/F MISC 30G X 1/2" 1 ML Kadian 50 mg capsule,extended release BRIDION SOLN 200 MG/2ML

BD INSULIN SYRINGE U/F MISC 31G X 5/16" 0.3 ML Kadian 60 mg capsule,extended release BRIDION SOLN 500 MG/5ML

BD INSULIN SYRINGE U/F MISC 31G X 5/16" 0.5 ML Kadian 80 mg capsule,extended release BRILINTA TABS 60 MG

BD INSULIN SYRINGE U/F MISC 31G X 5/16" 1 ML Kaletra 100 mg-25 mg tablet BRILINTA TABS 90 MG

BD INSULIN SYRINGE U-500 MISC 31G X 6MM 0.5 ML KALETRA 100-25 MG TABLET BRIMONIDINE TARTRATE SOLN 0.2 %

BD INTEGRA INSULIN SYRINGE/U-100/1ML/29G X 1/2" MIS 1ML/29GKaletra 200 mg-50 mg tablet BROMOCRIPTINE MESYLATE CAPS 5 MG

BD LANCET ULTRAFINE 30G MISC KALETRA 200-50 MG TABLET BROMOCRIPTINE MESYLATE TABS 2.5 MG

BD LUER-LOK SYRINGE MISC 18G X 1-1/2" 3 ML Kaletra 400 mg-100 mg/5 mL oral BSS SOLN

BD LUER-LOK SYRINGE MISC 20G X 1" 10 ML KALETRA 80 MG-20 MG/ML SOLN BUDESONIDE CPEP 3 MG

BD LUER-LOK SYRINGE MISC 20G X 1" 3 ML KALETRA ORAL SOLUTION 400-100 MG/5MLBUDESONIDE SUSP 0.25 MG/2ML

BD LUER-LOK SYRINGE MISC 20G X 1" 5 ML

KALETRA TABS 100-25 MG

BUDESONIDE SUSP 0.5 MG/2ML

BD LUER-LOK SYRINGE MISC 20G X 1-1/2" 10 ML KALETRA TABS 200-50 MG BUFFERIN LOW DOSE TABS 81 MG

BD LUER-LOK SYRINGE MISC 20G X 1-1/2" 3 ML Kazano 12.5 mg-1,000 mg tablet BUPIVACAINE HCL (PF) SOLN 0.25 %

BD LUER-LOK SYRINGE MISC 20G X 1-1/2" 5 ML Kazano 12.5 mg-500 mg tablet BUPIVACAINE HCL (PF) SOLN 0.5 %

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

BD LUER-LOK SYRINGE MISC 21G X 1" 10 ML

KEVZARA SOAJ 150 MG/1.14ML

BUPIVACAINE HCL (PF) SOLN 0.75 %

BD LUER-LOK SYRINGE MISC 21G X 1" 5 ML KEVZARA SOAJ 200 MG/1.14ML BUPIVACAINE HCL SOLN 0.5 %

BD LUER-LOK SYRINGE MISC 21G X 1-1/2" 10 ML KEVZARA SOSY 150 MG/1.14ML BUPIVACAINE-EPINEPHRINE (PF) SOLN 0.25% -1:

BD LUER-LOK SYRINGE MISC 21G X 1-1/2" 3 ML KEVZARA SOSY 200 MG/1.14ML BUPIVACAINE-EPINEPHRINE (PF) SOLN 0.5% -1:

BD LUER-LOK SYRINGE MISC 21G X 1-1/2" 5 ML KINERET SOSY 100 MG/0.67ML BUTORPHANOL TARTRATE SOLN 1 MG/ML

BD LUER-LOK SYRINGE MISC 22G X 1" 3 ML Kombiglyze XR 2.5 mg-1,000 mg BUTORPHANOL TARTRATE SOLN 2 MG/ML

BD LUER-LOK SYRINGE MISC 22G X 1" 5 ML Kombiglyze XR 5 mg-1,000 mg CABERGOLINE TABS 0.5 MG

BD LUER-LOK SYRINGE MISC 22G X 1-1/2" 3 ML Kombiglyze XR 5 mg-500 mg CABOMETYX TABS 20 MG

BD LUER-LOK SYRINGE MISC 22G X 1-1/2" 5 ML Lazanda 100 mcg/spray nasal spray CABOMETYX TABS 40 MG

BD LUER-LOK SYRINGE MISC 23G X 1" 3 ML leuprolide 1 mg/0.2 mL subcutaneous kit CABOMETYX TABS 60 MG

BD LUER-LOK SYRINGE MISC 23G X 1-1/4" 10 ML

levorphanol tartrate CAFFEINE CITRATE SOLN 60 MG/3ML

BD LUER-LOK SYRINGE MISC 25G X 1" 3 ML levorphanol tartrate 2 mg tablet CALCIPOTRIENE SOLN 0.005 %

BD LUER-LOK SYRINGE MISC 25G X 1-1/2" 3 ML LINZESS CAPS 145 MCG CALCITONIN (SALMON) SOLN 200 UNIT/ACT

BD LUER-LOK SYRINGE MISC 25G X 5/8" 3 ML LINZESS CAPS 290 MCG CALCITRIOL CAPS 0.25 MCG

BD LUER-LOK SYRINGE MISC 26G X 5/8" 3 ML LINZESS CAPS 72 MCG CALCITRIOL CAPS 0.5 MCG

BD PEN NEEDLE MINI U/F MISC 31G X 5 MM

LOPINAVIR-RITONAVIR ORAL SOLUTION 400-100 MG/5ML

CALCITRIOL SOLN 1 MCG/ML

BD PEN NEEDLE ORIGINAL U/F MISC 29G X 12.7MM Lortab Elixir 10 mg-300 mg/15 mL oral CALCIUM ACETATE (PHOS BINDER) CAPS 667 MG

BD PEN NEEDLE SHORT U/F MISC 31G X 8 MM MAVENCLAD (10 TABS) TBPK 10 MG CALCIUM CHLORIDE SOLN 10 %

BD SAFETYGLIDE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML MAVENCLAD (4 TABS) TBPK 10 MG CALCIUM GLUCONATE SOLN 10 %

BD SAFETY-LOK INSULIN SYRINGE MISC 29G X 1/2" 1 ML MAVENCLAD (5 TABS) TBPK 10 MG CAMILA TABS 0.35 MG

BD SYRINGE BLUNT CANNULA 17G MISC 5 ML

MAVENCLAD (6 TABS) TBPK 10 MG

CAMPATH SOLN 30 MG/ML

BD SYRINGE LUER-LOK MISC 1 ML MAVENCLAD (7 TABS) TBPK 10 MG CAMPHOR BLOCKS GUM

BD SYRINGE LUER-LOK MISC 10 ML MAVENCLAD (8 TABS) TBPK 10 MG CAMPHOR CRYS

BD SYRINGE LUER-LOK MISC 20 ML MAVENCLAD (9 TABS) TBPK 10 MG CAMPHOR SPIRIT SPRT

BD SYRINGE LUER-LOK MISC 30 ML Mavyret 100 mg-40 mg tablet CAMPTOSAR SOLN 100 MG/5ML

BD SYRINGE LUER-LOK MISC 5 ML

Maxi-Tuss CD CAMPTOSAR SOLN 300 MG/15ML

BD SYRINGE SLIP TIP MISC 1 ML MAYZENT STARTER PACK TBPK 0.25 MG CAPECITABINE TABS 150 MG

BD SYRINGE SLIP TIP MISC 3 ML MAYZENT TABS 0.25 MG CAPECITABINE TABS 500 MG

BD SYRINGE/NEEDLE MISC 23G X 1" 3 ML MAYZENT TABS 2 MG CAPRELSA TABS 100 MG

BD SYRINGE/NEEDLE SLIP TIP MISC 26G X 5/8" 1 ML medroxyprogesterone 10 mg tablet CAPRELSA TABS 300 MG

BD TB SYRINGE MISC 25G X 5/8" 1 ML

medroxyprogesterone 150 mg/mL

intramuscular suspension

CAPTOPRIL TABS 100 MG

BD TB SYRINGE MISC 26G X 3/8" 1 ML medroxyprogesterone 2.5 mg tablet CAPTOPRIL TABS 12.5 MG

BD TB SYRINGE MISC 27G X 1/2" 0.5 ML medroxyprogesterone 5 mg tablet CAPTOPRIL TABS 25 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

BD VEO INSULIN SYR U/F 1/2UNIT MISC 31G X 15/64" 0.3 ML meperidine 100 mg tablet CAPTOPRIL TABS 50 MG

BD VEO INSULIN SYRINGE U/F MISC 31G X 15/64" 0.3 ML meperidine 50 mg tablet CARBIDOPA TABS 25 MG

BD VEO INSULIN SYRINGE U/F MISC 31G X 15/64" 0.5 ML meperidine 50 mg/5 mL oral solution CARBIDOPA-LEVODOPA ER TBCR 25-100 MG

BD VEO INSULIN SYRINGE U/F MISC 31G X 15/64" 1 ML methadone 10 mg tablet CARBIDOPA-LEVODOPA ER TBCR 50-200 MG

BENDEKA SOLN 100 MG/4ML methadone 10 mg/5 mL oral solution CARBIDOPA-LEVODOPA TABS 10-100 MG

BENZONATATE CAPS 100 MG methadone 10 mg/mL oral concentrate CARBIDOPA-LEVODOPA TABS 25-100 MG

BENZTROPINE MESYLATE SOLN 1 MG/ML methadone 5 mg tablet CARBIDOPA-LEVODOPA TABS 25-250 MG

BENZTROPINE MESYLATE TABS 0.5 MG methadone 5 mg/5 mL oral solution CARBOCAINE PRESERVATIVE-FREE SOLN 1 %

BENZTROPINE MESYLATE TABS 1 MG Methadone Intensol 10 mg/mL oral CARBOCAINE PRESERVATIVE-FREE SOLN 1.5 %

BENZTROPINE MESYLATE TABS 2 MG Methadose 10 mg/mL oral concentrate CARBOPLATIN INJ 150MG

BETADINE OPHTHALMIC PREP SOLN 5 %

MIRCERA SOSY 100 MCG/0.3ML

CARBOPLATIN INJ 450MG

BETAMETHASONE DIPROPIONATE AUG CREA 0.05 % MIRCERA SOSY 150 MCG/0.3ML CARBOPLATIN INJ 50MG

BETAMETHASONE DIPROPIONATE AUG GEL 0.05 % MIRCERA SOSY 200 MCG/0.3ML CARBOPLATIN SOLN 150 MG/15ML

BETAMETHASONE DIPROPIONATE AUG LOTN 0.05 % MIRCERA SOSY 30 MCG/0.3ML CARBOPLATIN SOLN 450 MG/45ML

BETAMETHASONE DIPROPIONATE AUG OINT 0.05 % MIRCERA SOSY 50 MCG/0.3ML CARDENE IV SOLN 20-0.86 MG/200ML-%

BETAMETHASONE DIPROPIONATE CREA 0.05 %

MIRCERA SOSY 75 MCG/0.3ML

CARDENE IV SOLN 40-0.83 MG/200ML-%

BETAMETHASONE VALERATE CREA 0.1 % morphine CARTIA XT CP24 120 MG

BETAMETHASONE VALERATE LOTN 0.1 % morphine 10 mg/5 mL oral solution CARTIA XT CP24 180 MG

BETAMETHASONE VALERATE OINT 0.1 % morphine 15 mg immediate release tablet CARTIA XT CP24 240 MG

BETAXOLOL HCL SOLN 0.5 % morphine 20 mg/5 mL (4 mg/mL) oral CARTIA XT CP24 300 MG

BETHANECHOL CHLORIDE TABS 10 MG morphine 30 mg immediate release tablet CARVEDILOL TABS 12.5 MG

BETHANECHOL CHLORIDE TABS 25 MG

morphine concentrate 100 mg/5 mL (

mg/mL) oral solution

CARVEDILOL TABS 25 MG

BETHANECHOL CHLORIDE TABS 5 MG morphine ER 10 mg capsule,extended CARVEDILOL TABS 3.125 MG

BETHANECHOL CHLORIDE TABS 50 MG morphine ER 100 mg tablet,extended CARVEDILOL TABS 6.25 MG

BEXAROTENE CAPS 75 MG morphine ER 15 mg tablet,extended CASPOFUNGIN ACETATE SOLR 70 MG

BEXSERO SUSY morphine ER 20 mg capsule,extended CATHFLO ACTIVASE SOLR 2 MG

BICALUTAMIDE TABS 50 MG morphine ER 200 mg tablet,extended CEFACLOR CAPS 250 MG

BICILLIN L-A SUSP 1200000 UNIT/2ML

morphine ER 30 mg capsule,extended

release 24 hr multiphase

CEFACLOR CAPS 500 MG

BICILLIN L-A SUSP 2400000 UNIT/4ML morphine ER 30 mg tablet,extended CEFACLOR SUSR 125 MG/5ML

BICILLIN L-A SUSP 600000 UNIT/ML morphine ER 60 mg tablet,extended CEFACLOR SUSR 250 MG/5ML

BICNU SOLR 100 MG MOTEGRITY TABS 1 MG CEFACLOR SUSR 375 MG/5ML

BIKTARVY TABS 50-200-25 MG MOTEGRITY TABS 2 MG CEFAZOLIN SODIUM SOLR 1 GM

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

BIO-D-MULSION FORTE LIQD 50 MCG/0.03ML

MOVANTIK TABS 12.5 MG

CEFAZOLIN SODIUM SOLR 10 GM

BIO-D-MULSION LIQD 10 MCG/0.03ML MOVANTIK TABS 25 MG CEFAZOLIN SODIUM-DEXTROSE SOLN 1-4 GM/50ML-%

BISOPROLOL FUMARATE TABS 10 MG MYALEPT SOLR 11.3 MG CEFDINIR CAPS 300 MG

BISOPROLOL FUMARATE TABS 5 MG Nalocet CEFDINIR SUSR 125 MG/5ML

BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 10-6.25 MG Nesina 12.5 mg tablet CEFDINIR SUSR 250 MG/5ML

BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 2.5-6.25 MG Nesina 25 mg tablet CEFEPIME HCL SOLR 1 GM

BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 5-6.25 MG NEXAVAR TABS 200 MG CEFEPIME HCL SOLR 2 GM

BLEOMYCIN SULFATE SOLR 15 UNIT NINLARO CAPS 2.3 MG CEFEPIME-DEXTROSE SOLR 1-5 GM-%(50ML)

BLEOMYCIN SULFATE SOLR 30 UNIT NINLARO CAPS 3 MG CEFEPIME-DEXTROSE SOLR 2-5 GM-%(50ML)

BLEPHAMIDE SUSP 10-0.2 % NINLARO CAPS 4 MG CEFIXIME CAPS 400 MG

BLISOVI FE 1.5/30 TABS 1.5-30 MG-MCG

Norditropin FlexPro 10 mg/1.5 mL (6.

mg/mL) subcutaneous pen injector

CEFIXIME SUSR 100 MG/5ML

BLISOVI FE 1/20 TABS 1-20 MG-MCG

Norditropin FlexPro 15 mg/1.5 mL (

mg/mL) subcutaneous pen injector

CEFIXIME SUSR 200 MG/5ML

BOSENTAN TABS 125 MG

Norditropin FlexPro 5 mg/1.5 mL (3.

mg/mL) subcutaneous pen injector

CEFOTAXIME SODIUM SOLR 1 GM

BOSENTAN TABS 62.5 MG NORVIR 100 MG POWDER PACKET CEFOXITIN SODIUM SOLR 1 GM

BOTOX SOLR 100 UNIT Norvir 100 mg tablet CEFOXITIN SODIUM SOLR 10 GM

BRIDION SOLN 200 MG/2ML Norvir 80 mg/mL oral solution CEFOXITIN SODIUM SOLR 2 GM

BRIDION SOLN 500 MG/5ML NORVIR 80 MG/ML SOLUTION CEFTAZIDIME AND DEXTROSE SOLR 1-5 GM-%(50ML)

BRILINTA TABS 60 MG

NORVIR CAP 100MG

CEFTAZIDIME AND DEXTROSE SOLR 2-5 GM-%(50ML)

BRILINTA TABS 90 MG NORVIR ORAL POWDER PACK 100 MG CEFTIN SUSR 250 MG/5ML

BRIMONIDINE TARTRATE SOLN 0.2 % NORVIR ORAL SOLUTION 80 MG/ML CEFTRIAXONE SODIUM IN DEXTROSE SOLN 20 MG/ML

BROMOCRIPTINE MESYLATE CAPS 5 MG NORVIR PACK 100 MG CEFTRIAXONE SODIUM IN DEXTROSE SOLN 40 MG/ML

BROMOCRIPTINE MESYLATE TABS 2.5 MG NORVIR TABS 100 MG CEFTRIAXONE SODIUM SOLR 1 GM

BSS SOLN

NUCALA SOAJ 100 MG/ML

CEFTRIAXONE SODIUM SOLR 10 GM

BUDESONIDE CPEP 3 MG NUCALA SOLR 100 MG CEFTRIAXONE SODIUM SOLR 2 GM

BUDESONIDE SUSP 0.25 MG/2ML NUCALA SOSY 100 MG/ML CEFTRIAXONE SODIUM SOLR 250 MG

BUDESONIDE SUSP 0.5 MG/2ML Nucynta 100 mg tablet CEFTRIAXONE SODIUM SOLR 500 MG

BUFFERIN LOW DOSE TABS 81 MG Nucynta 50 mg tablet CEFTRIAXONE SODIUM-DEXTROSE SOLR 1-3.74 GM-%(

BUPIVACAINE HCL (PF) SOLN 0.25 % Nucynta 75 mg tablet CEFTRIAXONE SODIUM-DEXTROSE SOLR 2-2.22 GM-%(

BUPIVACAINE HCL (PF) SOLN 0.5 % Nucynta ER 100 mg tablet,extended CEFUROXIME AXETIL SUS 125/5ML

BUPIVACAINE HCL (PF) SOLN 0.75 % Nucynta ER 150 mg tablet,extended CEFUROXIME AXETIL SUS 250/5ML

BUPIVACAINE HCL SOLN 0.5 % Nucynta ER 50 mg tablet,extended release CEFUROXIME AXETIL TABS 250 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

BUPIVACAINE-EPINEPHRINE (PF) SOLN 0.25% -1:

Nutropin AQ Nuspin 10 mg/2 mL (

mg/mL) subcutaneous pen injector

CEFUROXIME AXETIL TABS 500 MG

BUPIVACAINE-EPINEPHRINE (PF) SOLN 0.5% -1:

Nutropin AQ Nuspin 20 mg/2 mL (

mg/mL) subcutaneous pen injector

CEFUROXIME SODIUM SOLR 7.5 GM

BUTORPHANOL TARTRATE SOLN 1 MG/ML

Nutropin AQ Nuspin 5 mg/2 mL (2.

mg/mL) subcutaneous pen injector

CELESTONE SOLUSPAN SUSP 6 (3-3) MG/ML

BUTORPHANOL TARTRATE SOLN 2 MG/ML OCALIVA TABS 10 MG CELONTIN CAPS 300 MG

CABERGOLINE TABS 0.5 MG OCALIVA TABS 5 MG CEPHALEXIN CAPS 250 MG

CABOMETYX TABS 20 MG OFEV CAPS 100 MG CEPHALEXIN CAPS 500 MG

CABOMETYX TABS 40 MG OFEV CAPS 150 MG CEPHALEXIN SUSR 125 MG/5ML

CABOMETYX TABS 60 MG

OLUMIANT TABS 1 MG

CEPHALEXIN SUSR 250 MG/5ML

CAFFEINE CITRATE SOLN 60 MG/3ML OLUMIANT TABS 2 MG CEQUA SOLN 0.09 %

CALCIPOTRIENE SOLN 0.005 % Olysio 150 mg capsule CERALYTE 50 PACK 1.3-2.2-2.9 GM/L

CALCITONIN (SALMON) SOLN 200 UNIT/ACT

Omnitrope 10 mg/1.5 mL (6.7 mg/mL)

subcutaneous cartridge

CERALYTE 70 PACK 1.3-2.2-2.9 GM/L

CALCITRIOL CAPS 0.25 MCG

Omnitrope 5 mg/1.5 mL (3.3 mg/mL)

subcutaneous cartridge

CERALYTE 70 SOLN

CALCITRIOL CAPS 0.5 MCG Omnitrope 5.8 mg subcutaneous solution CERALYTE 90 PACK 1.3-3.4-2.9 GM/L

CALCITRIOL SOLN 1 MCG/ML Onglyza 2.5 mg tablet CERAORS 75 NATURAL PACK

CALCIUM ACETATE (PHOS BINDER) CAPS 667 MG Onglyza 5 mg tablet CERASPORT CON

CALCIUM CHLORIDE SOLN 10 % Opana 10 mg tablet CERASPORT EX1 PACK

CALCIUM GLUCONATE SOLN 10 % opium tincture 10 mg/mL (morphine) CERASPORT EX1 SOLN

CAMILA TABS 0.35 MG ORENCIA CLICKJECT SOAJ 125 MG/ML CERASPORT PACK

CAMPATH SOLN 30 MG/ML ORENCIA SOSY 125 MG/ML CERASPORT SOLN

CAMPHOR BLOCKS GUM ORENCIA SOSY 50 MG/0.4ML CERDELGA CAPS 84 MG

CAMPHOR CRYS

ORENCIA SOSY 87.5 MG/0.7ML

CEROVITE JR CHEW 18 MG

CAMPHOR SPIRIT SPRT Oseni 12.5 mg-15 mg tablet CERUBIDINE INJ 20MG

CAMPTOSAR SOLN 100 MG/5ML OTEZLA TABS 30 MG CETIRIZINE HCL CHEW 10 MG

CAMPTOSAR SOLN 300 MG/15ML OTEZLA TBPK 10 & 20 & 30 MG CETIRIZINE HCL CHEW 5 MG

CAPECITABINE TABS 150 MG OTREXUP SOAJ 10 MG/0.4ML CETIRIZINE HCL TABS 10 MG

CAPECITABINE TABS 500 MG

OTREXUP SOAJ 12.5 MG/0.4ML

CETIRIZINE HCL TABS 5 MG

CAPRELSA TABS 100 MG OTREXUP SOAJ 15 MG/0.4ML CHATEAL EQ TABS 0.15-30 MG-MCG

CAPRELSA TABS 300 MG OTREXUP SOAJ 17.5 MG/0.4ML CHERATUSSIN AC SYRP 100-10 MG/5ML

CAPTOPRIL TABS 100 MG OTREXUP SOAJ 20 MG/0.4ML CHEWABLE VITE/IRON CHILDRENS CHEW 15 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CAPTOPRIL TABS 12.5 MG

OTREXUP SOAJ 22.5 MG/0.4ML

CHLORAMPHENICOL POWD

CAPTOPRIL TABS 25 MG OTREXUP SOAJ 25 MG/0.4ML CHLOROQUINE PHOSPHATE TABS 250 MG

CAPTOPRIL TABS 50 MG oxycodone 15 mg tablet CHLOROQUINE PHOSPHATE TABS 500 MG

CARBIDOPA TABS 25 MG oxycodone 20 mg tablet CHLOROTHIAZIDE TABS 250 MG

CARBIDOPA-LEVODOPA ER TBCR 25-100 MG oxycodone 20 mg/mL oral concentrate CHLOROTHIAZIDE TABS 500 MG

CARBIDOPA-LEVODOPA ER TBCR 50-200 MG oxycodone 30 mg tablet CHLORTHALIDONE TABS 25 MG

CARBIDOPA-LEVODOPA TABS 10-100 MG oxycodone 5 mg capsule CHLORTHALIDONE TABS 50 MG

CARBIDOPA-LEVODOPA TABS 25-100 MG oxycodone 5 mg tablet CHOLESTYRAMINE PACK 4 GM

CARBIDOPA-LEVODOPA TABS 25-250 MG oxycodone 5 mg/5 mL oral solution CHOLESTYRAMINE POWD 4 GM/DOSE

CARBOCAINE PRESERVATIVE-FREE SOLN 1 %

oxycodone ER 10 mg tablet,crush

resistant,extended release 12 hr

CHOLINE MAGNESIUM TRISALICYLATE TAB 1000MG

CARBOCAINE PRESERVATIVE-FREE SOLN 1.5 %

oxycodone ER 15 mg tablet,crush

resistant,extended release 12 hr

CICLOPIROX GEL 0.77 %

CARBOPLATIN INJ 150MG

oxycodone ER 20 mg tablet,crush

resistant,extended release 12 hr

CICLOPIROX OLAMINE CREA 0.77 %

CARBOPLATIN INJ 450MG

oxycodone ER 30 mg tablet,crush

resistant,extended release 12 hr

CILOSTAZOL TABS 100 MG

CARBOPLATIN INJ 50MG

oxycodone ER 40 mg tablet,crush

resistant,extended release 12 hr

CILOSTAZOL TABS 50 MG

CARBOPLATIN SOLN 150 MG/15ML

oxycodone ER 60 mg tablet,crush

resistant,extended release 12 hr

CILOXAN OINT 0.3 %

CARBOPLATIN SOLN 450 MG/45ML

oxycodone ER 80 mg tablet,crush

resistant,extended release 12 hr

CIMDUO TABS 300-300 MG

CARDENE IV SOLN 20-0.86 MG/200ML-% OXYCODONE HCL TABS 10 MG CINACALCET HCL TABS 30 MG

CARDENE IV SOLN 40-0.83 MG/200ML-% oxycodone-acetaminophen 10 mg-325 mg CINACALCET HCL TABS 60 MG

CARTIA XT CP24 120 MG oxycodone-acetaminophen 2.5 mg-325 CINACALCET HCL TABS 90 MG

CARTIA XT CP24 180 MG oxycodone-acetaminophen 5 mg-325 mg CIPROFLOXACIN HCL SOLN 0.3 %

CARTIA XT CP24 240 MG

oxycodone-acetaminophen 5 mg-

mg/5 mL oral solution

CIPROFLOXACIN HCL TABS 100 MG

CARTIA XT CP24 300 MG oxycodone-acetaminophen 7.5 mg-325 CIPROFLOXACIN HCL TABS 250 MG

CARVEDILOL TABS 12.5 MG OxyContin 10 mg tablet,crush CIPROFLOXACIN HCL TABS 500 MG

CARVEDILOL TABS 25 MG OxyContin 15 mg tablet,crush CIPROFLOXACIN HCL TABS 750 MG

CARVEDILOL TABS 3.125 MG OxyContin 20 mg tablet,crush CIPROFLOXACIN IN D5W SOLN 200 MG/100ML

CARVEDILOL TABS 6.25 MG OxyContin 30 mg tablet,crush CIPROFLOXACIN IN D5W SOLN 400 MG/200ML

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CASPOFUNGIN ACETATE SOLR 70 MG OxyContin 40 mg tablet,crush CIPROFLOXACIN SUSR 250 MG/5ML (5%)

CATHFLO ACTIVASE SOLR 2 MG OxyContin 60 mg tablet,crush CIPROFLOXACIN SUSR 500 MG/5ML (10%)

CEFACLOR CAPS 250 MG OxyContin 80 mg tablet,crush CIPROFLOXACIN-DEXAMETHASONE SUSP 0.3-0.1 %

CEFACLOR CAPS 500 MG oxymorphone 10 mg tablet CISATRACURIUM BESYLATE (PF) SOLN 10 MG/5ML

CEFACLOR SUSR 125 MG/5ML oxymorphone 5 mg tablet CISATRACURIUM BESYLATE (PF) SOLN 200 MG/20ML

CEFACLOR SUSR 250 MG/5ML oxymorphone ER 10 mg tablet,extended CISPLATIN SOLN 100 MG/100ML

CEFACLOR SUSR 375 MG/5ML oxymorphone ER 15 mg tablet,extended CISPLATIN SOLN 200 MG/200ML

CEFAZOLIN SODIUM SOLR 1 GM oxymorphone ER 20 mg tablet,extended CISPLATIN SOLN 50 MG/50ML

CEFAZOLIN SODIUM SOLR 10 GM oxymorphone ER 30 mg tablet,extended CLADRIBINE SOLN 10 MG/10ML

CEFAZOLIN SODIUM-DEXTROSE SOLN 1-4 GM/50ML-% oxymorphone ER 40 mg tablet,extended CLAFORAN INJ 2GM

CEFDINIR CAPS 300 MG oxymorphone ER 5 mg tablet,extended CLARAVIS CAPS 10 MG

CEFDINIR SUSR 125 MG/5ML oxymorphone ER 7.5 mg tablet,extended CLARAVIS CAPS 20 MG

CEFDINIR SUSR 250 MG/5ML Ozempic CLARAVIS CAPS 30 MG

CEFEPIME HCL SOLR 1 GM Plaquenil 200 mg tablet CLARAVIS CAPS 40 MG

CEFEPIME HCL SOLR 2 GM PLEGRIDY SOPN 125 MCG/0.5ML CLARITHROMYCIN SUSR 125 MG/5ML

CEFEPIME-DEXTROSE SOLR 1-5 GM-%(50ML)

PLEGRIDY SOSY 125 MCG/0.5ML

CLARITHROMYCIN SUSR 250 MG/5ML

CEFEPIME-DEXTROSE SOLR 2-5 GM-%(50ML) PLEGRIDY STARTER PACK SOPN 63 & 94 MCG/0.5MLCLARITHROMYCIN TABS 250 MG

CEFIXIME CAPS 400 MG PLEGRIDY STARTER PACK SOSY 63 & 94 MCG/0.5MLCLARITHROMYCIN TABS 500 MG

CEFIXIME SUSR 100 MG/5ML POMALYST CAPS 1 MG CLARITIN CAPS 10 MG

CEFIXIME SUSR 200 MG/5ML POMALYST CAPS 2 MG CLARITIN CHEW 5 MG

CEFOTAXIME SODIUM SOLR 1 GM POMALYST CAPS 3 MG CLARITIN REDITABS TBDP 5 MG

CEFOXITIN SODIUM SOLR 1 GM POMALYST CAPS 4 MG CLEVIPREX EMUL 25 MG/50ML

CEFOXITIN SODIUM SOLR 10 GM PRALUENT SOPN 150 MG/ML CLEVIPREX EMUL 50 MG/100ML

CEFOXITIN SODIUM SOLR 2 GM PRALUENT SOPN 75 MG/ML CLIMARA PTWK 0.025 MG/24HR

CEFTAZIDIME AND DEXTROSE SOLR 1-5 GM-%(50ML) PRALUENT SOSY 150 MG/ML CLIMARA PTWK 0.0375 MG/24HR

CEFTAZIDIME AND DEXTROSE SOLR 2-5 GM-%(50ML)

PRALUENT SOSY 75 MG/ML

CLIMARA PTWK 0.05 MG/24HR

CEFTIN SUSR 250 MG/5ML Prolate CLIMARA PTWK 0.06 MG/24HR

CEFTRIAXONE SODIUM IN DEXTROSE SOLN 20 MG/ML promethazine 6.25 mg-codeine 10 mg/5 CLIMARA PTWK 0.075 MG/24HR

CEFTRIAXONE SODIUM IN DEXTROSE SOLN 40 MG/ML

Promethazine VC-Codeine 6.25 mg-5 mg-

10 mg/5 mL syrup

CLIMARA PTWK 0.1 MG/24HR

CEFTRIAXONE SODIUM SOLR 1 GM

Qtern CLINDAMYCIN HCL CAPS 150 MG

CEFTRIAXONE SODIUM SOLR 10 GM QTERN TABS 10-5 MG CLINDAMYCIN HCL CAPS 300 MG

CEFTRIAXONE SODIUM SOLR 2 GM RASUVO SOAJ 10 MG/0.2ML CLINDAMYCIN PALMITATE HCL SOLR 75 MG/5ML

CEFTRIAXONE SODIUM SOLR 250 MG RASUVO SOAJ 12.5 MG/0.25ML CLINDAMYCIN PHOSPHATE CREA 2 %

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CEFTRIAXONE SODIUM SOLR 500 MG

RASUVO SOAJ 15 MG/0.3ML

CLINDAMYCIN PHOSPHATE GEL 1 %

CEFTRIAXONE SODIUM-DEXTROSE SOLR 1-3.74 GM-%(50ML) RASUVO SOAJ 17.5 MG/0.35ML CLINDAMYCIN PHOSPHATE IN D5W SOLN 300 MG/50M

CEFTRIAXONE SODIUM-DEXTROSE SOLR 2-2.22 GM-%(50ML) RASUVO SOAJ 20 MG/0.4ML CLINDAMYCIN PHOSPHATE LOTN 1 %

CEFUROXIME AXETIL SUS 125/5ML RASUVO SOAJ 22.5 MG/0.45ML CLINDAMYCIN PHOSPHATE SOLN 1 %

CEFUROXIME AXETIL SUS 250/5ML RASUVO SOAJ 25 MG/0.5ML CLINDAMYCIN PHOSPHATE SOLN 300 MG/2ML

CEFUROXIME AXETIL TABS 250 MG

RASUVO SOAJ 30 MG/0.6ML

CLINDAMYCIN PHOSPHATE SOLN 600 MG/4ML

CEFUROXIME AXETIL TABS 500 MG RASUVO SOAJ 7.5 MG/0.15ML CLINDAMYCIN PHOSPHATE SOLN 900 MG/6ML

CEFUROXIME SODIUM SOLR 7.5 GM REBIF REBIDOSE SOAJ 22 MCG/0.5ML CLINDAMYCIN PHOSPHATE SWAB 1 %

CELESTONE SOLUSPAN SUSP 6 (3-3) MG/ML REBIF REBIDOSE SOAJ 44 MCG/0.5ML CLINIMIX E/DEXTROSE (5/15) SOLN 5 %

CELONTIN CAPS 300 MG REBIF REBIDOSE TITRATION PACK SOAJ 6X8.8 & 6X22 MCGCLINIMIX E/DEXTROSE (5/20) SOLN 5 %

CEPHALEXIN CAPS 250 MG

REBIF SOSY 22 MCG/0.5ML

CLINIMIX/DEXTROSE (5/15) SOLN 5 %

CEPHALEXIN CAPS 500 MG REBIF SOSY 44 MCG/0.5ML CLOBETASOL PROPIONATE CREA 0.05 %

CEPHALEXIN SUSR 125 MG/5ML REBIF TITRATION PACK SOSY 6X8.8 & 6X22 MCGCLOBETASOL PROPIONATE LOTN 0.05 %

CEPHALEXIN SUSR 250 MG/5ML RELISTOR SOLN 12 MG/0.6ML CLOBETASOL PROPIONATE OINT 0.05 %

CEQUA SOLN 0.09 % RELISTOR SOLN 8 MG/0.4ML CLOBETASOL PROPIONATE SOLN 0.05 %

CERALYTE 50 PACK 1.3-2.2-2.9 GM/L

RELISTOR TABS 150 MG

CLOBEX SPRAY LIQD 0.05 %

CERALYTE 70 PACK 1.3-2.2-2.9 GM/L REPATHA PUSHTRONEX SYSTEM SOCT 420 MG/3.5MLCLONIDINE HCL (ANALGESIA) SOLN 100 MCG/ML

CERALYTE 70 SOLN REPATHA SOSY 140 MG/ML CLONIDINE HCL TABS 0.1 MG

CERALYTE 90 PACK 1.3-3.4-2.9 GM/L REPATHA SURECLICK SOAJ 140 MG/ML CLONIDINE HCL TABS 0.2 MG

CERAORS 75 NATURAL PACK Retacrit CLONIDINE HCL TABS 0.3 MG

CERASPORT CON

RETACRIT SOLN 10000 UNIT/ML

CLONIDINE PTWK 0.1 MG/24HR

CERASPORT EX1 PACK RETACRIT SOLN 2000 UNIT/ML CLONIDINE PTWK 0.2 MG/24HR

CERASPORT EX1 SOLN RETACRIT SOLN 3000 UNIT/ML CLONIDINE PTWK 0.3 MG/24HR

CERASPORT PACK RETACRIT SOLN 4000 UNIT/ML CLOPIDOGREL BISULFATE TABS 75 MG

CERASPORT SOLN RETACRIT SOLN 40000 UNIT/ML CLOTRIMAZOLE TROC 10 MG

CERDELGA CAPS 84 MG REVLIMID CAPS 10 MG COAL TAR EXTRACT SOLN 20 %

CEROVITE JR CHEW 18 MG REVLIMID CAPS 15 MG COAL TAR LIQD

CERUBIDINE INJ 20MG REVLIMID CAPS 2.5 MG COAL TAR SOLN

CETIRIZINE HCL CHEW 10 MG REVLIMID CAPS 20 MG COAL TAR SOLN 20 %

CETIRIZINE HCL CHEW 5 MG REVLIMID CAPS 25 MG COAL TAR TAR

CETIRIZINE HCL TABS 10 MG REVLIMID CAPS 5 MG COARTEM TABS 20-120 MG

CETIRIZINE HCL TABS 5 MG Rezira 60 mg-5 mg/5 mL oral solution CODEINE PHOSPHATE/GUAIFENESIN LIQ 10-300MG

CHATEAL EQ TABS 0.15-30 MG-MCG RINVOQ TB24 15 MG CODEINE SULFATE TABS 15 MG

CHERATUSSIN AC SYRP 100-10 MG/5ML RITONAVIR 100 MG TABLET CODEINE SULFATE TABS 30 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CHEWABLE VITE/IRON CHILDRENS CHEW 15 MG

RITONAVIR TABS 100 MG

CODEINE SULFATE TABS 60 MG

CHLORAMPHENICOL POWD RoxyBond CODEINE/GUAIFENESIN TAB 10-

CHLOROQUINE PHOSPHATE TABS 250 MG RUZURGI TABS 10 MG COLCHICINE CAPS 0.6 MG

CHLOROQUINE PHOSPHATE TABS 500 MG Rybelsus COLCHICINE TABS 0.6 MG

CHLOROTHIAZIDE TABS 250 MG Saizen 5 mg subcutaneous solution COLESTIPOL HCL TABS 1 GM

CHLOROTHIAZIDE TABS 500 MG

Saizen click.easy 8.8 mg/1.51 mL (final

conc.) subcutaneous cartridge

COLISTIMETHATE SODIUM (CBA) SOLR 150 MG

CHLORTHALIDONE TABS 25 MG Segluromet COLOCORT ENEM 100 MG/60ML

CHLORTHALIDONE TABS 50 MG SEGLUROMET TABS 2.5-1000 MG COLY-MYCIN S SUSP 3.3-3-10-0.5 MG/ML

CHOLESTYRAMINE PACK 4 GM SEGLUROMET TABS 2.5-500 MG COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 MG

CHOLESTYRAMINE POWD 4 GM/DOSE

SEGLUROMET TABS 7.5-1000 MG

COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 MG & 80 M

CHOLINE MAGNESIUM TRISALICYLATE TAB 1000MG SEGLUROMET TABS 7.5-500 MG COMETRIQ (60 MG DAILY DOSE) KIT 20 MG

CICLOPIROX GEL 0.77 % Serostim 4 mg subcutaneous solution COMPLERA TABS 200-25-300 MG

CICLOPIROX OLAMINE CREA 0.77 % SILIQ SOSY 210 MG/1.5ML COMPLETE SENIOR TABS

CILOSTAZOL TABS 100 MG SIMPONI SOAJ 100 MG/ML CONTOUR NEXT TEST STRP

CILOSTAZOL TABS 50 MG

SIMPONI SOAJ 50 MG/0.5ML

CORTISONE ACETATE TABS 25 MG

CILOXAN OINT 0.3 % SIMPONI SOSY 100 MG/ML CORTROSYN SOLR 0.25 MG

CIMDUO TABS 300-300 MG SIMPONI SOSY 50 MG/0.5ML COSENTYX (300 MG DOSE) SOSY 150 MG/ML

CINACALCET HCL TABS 30 MG SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83MLCOSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML

CINACALCET HCL TABS 60 MG SOLIQUA SOPN 100-33 UNT-MCG/ML COSENTYX SENSOREADY PEN SOAJ 150 MG/ML

CINACALCET HCL TABS 90 MG

Sovaldi COSENTYX SOSY 150 MG/ML

CIPROFLOXACIN HCL SOLN 0.3 % Sovaldi 400 mg tablet COSMEGEN SOLR 0.5 MG

CIPROFLOXACIN HCL TABS 100 MG SOVALDI PACK 150 MG COTELLIC TABS 20 MG

CIPROFLOXACIN HCL TABS 250 MG SOVALDI PACK 200 MG CREON CPEP 12000-38000 UNIT

CIPROFLOXACIN HCL TABS 500 MG SPRYCEL TABS 100 MG CREON CPEP 24000-76000 UNIT

CIPROFLOXACIN HCL TABS 750 MG SPRYCEL TABS 140 MG CREON CPEP 3000-9500 UNIT

CIPROFLOXACIN IN D5W SOLN 200 MG/100ML SPRYCEL TABS 20 MG CREON CPEP 36000-114000 UNIT

CIPROFLOXACIN IN D5W SOLN 400 MG/200ML SPRYCEL TABS 50 MG CREON CPEP 6000-19000 UNIT

CIPROFLOXACIN SUSR 250 MG/5ML (5%) SPRYCEL TABS 70 MG CRIXIVAN CAPS 200 MG

CIPROFLOXACIN SUSR 500 MG/5ML (10%) SPRYCEL TABS 80 MG CRIXIVAN CAPS 400 MG

CIPROFLOXACIN-DEXAMETHASONE SUSP 0.3-0.1 %

Steglatro CROMOLYN SODIUM CONC 100 MG/5ML

CISATRACURIUM BESYLATE (PF) SOLN 10 MG/5ML Steglujan CROMOLYN SODIUM NEBU 20 MG/2ML

CISATRACURIUM BESYLATE (PF) SOLN 200 MG/20ML STELARA SOLN 45 MG/0.5ML CROMOLYN SODIUM SOLN 4 %

CISPLATIN SOLN 100 MG/100ML STELARA SOSY 45 MG/0.5ML CYANOCOBALAMIN SOLN 1000 MCG/ML

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CISPLATIN SOLN 200 MG/200ML

STELARA SOSY 90 MG/ML

CYCLAFEM 1/35 TABS 1-35 MG-MCG

CISPLATIN SOLN 50 MG/50ML Subsys 100 mcg/spray sublingual spray CYCLOBENZAPRINE HCL TABS 10 MG

CLADRIBINE SOLN 10 MG/10ML SYMPROIC TABS 0.2 MG CYCLOBENZAPRINE HCL TABS 5 MG

CLAFORAN INJ 2GM SYNJARDY TABS 12.5-1000 MG CYCLOMYDRIL SOLN 0.2-1 %

CLARAVIS CAPS 10 MG SYNJARDY TABS 12.5-500 MG CYCLOPENTOLATE HCL SOLN 0.5 %

CLARAVIS CAPS 20 MG

SYNJARDY TABS 5-1000 MG

CYCLOPENTOLATE HCL SOLN 1 %

CLARAVIS CAPS 30 MG SYNJARDY TABS 5-500 MG CYCLOPENTOLATE HCL SOLN 2 %

CLARAVIS CAPS 40 MG SYNJARDY XR TB24 10-1000 MG CYCLOPHOSPHAMIDE CAPS 25 MG

CLARITHROMYCIN SUSR 125 MG/5ML SYNJARDY XR TB24 12.5-1000 MG CYCLOPHOSPHAMIDE CAPS 50 MG

CLARITHROMYCIN SUSR 250 MG/5ML SYNJARDY XR TB24 25-1000 MG CYCLOPHOSPHAMIDE SOLR 1 GM

CLARITHROMYCIN TABS 250 MG

SYNJARDY XR TB24 5-1000 MG

CYCLOPHOSPHAMIDE SOLR 2 GM

CLARITHROMYCIN TABS 500 MG TADALAFIL TABS 2.5 MG CYCLOPHOSPHAMIDE SOLR 500 MG

CLARITIN CAPS 10 MG TADALAFIL TABS 5 MG CYCLOSPORINE CAPS 100 MG

CLARITIN CHEW 5 MG TAGRISSO TABS 40 MG CYCLOSPORINE CAPS 25 MG

CLARITIN REDITABS TBDP 5 MG TAGRISSO TABS 80 MG CYPROHEPTADINE HCL SYRP 2 MG/5ML

CLEVIPREX EMUL 25 MG/50ML

TALTZ SOAJ 80 MG/ML

CYPROHEPTADINE HCL TABS 4 MG

CLEVIPREX EMUL 50 MG/100ML TALTZ SOSY 80 MG/ML CYRAMZA SOLN 100 MG/10ML

CLIMARA PTWK 0.025 MG/24HR Tanzeum 30 mg/0.5 mL subcutaneous CYRAMZA SOLN 500 MG/50ML

CLIMARA PTWK 0.0375 MG/24HR Tanzeum 50 mg/0.5 mL subcutaneous CYRED EQ TABS 0.15-30 MG-MCG

CLIMARA PTWK 0.05 MG/24HR TECFIDERA CPDR 120 MG CYTARABINE (PF) SOLN 100 MG/ML

CLIMARA PTWK 0.06 MG/24HR

TECFIDERA CPDR 240 MG

CYTARABINE (PF) SOLN 20 MG/ML

CLIMARA PTWK 0.075 MG/24HR TECFIDERA MISC 120 & 240 MG CYTARABINE INJ 100MG

CLIMARA PTWK 0.1 MG/24HR TECHNIVIE TABS 12.5-75-50 MG CYTARABINE INJ 2GM

CLINDAMYCIN HCL CAPS 150 MG TEGSEDI SOSY 284 MG/1.5ML CYTARABINE INJ 500MG

CLINDAMYCIN HCL CAPS 300 MG Tradjenta 5 mg tablet CYTARABINE SOLN 20 MG/ML

CLINDAMYCIN PALMITATE HCL SOLR 75 MG/5ML

tramadol CYTOVENE SOLR 500 MG

CLINDAMYCIN PHOSPHATE CREA 2 % tramadol 37.5 mg-acetaminophen 325 mg CYTOXAN INJ 1GM

CLINDAMYCIN PHOSPHATE GEL 1 % tramadol 50 mg tablet CYTOXAN INJ 2GM

CLINDAMYCIN PHOSPHATE IN D5W SOLN 300 MG/50ML tramadol ER 100 mg tablet,extended CYTOXAN INJ 500MG

CLINDAMYCIN PHOSPHATE LOTN 1 % tramadol ER 100 mg tablet,extended CYTRA K CRYSTALS PACK 3300-1002 MG

CLINDAMYCIN PHOSPHATE SOLN 1 % tramadol ER 200 mg tablet,extended D3 MAXIMUM STRENGTH LIQD 125 MCG/ML

CLINDAMYCIN PHOSPHATE SOLN 300 MG/2ML tramadol ER 300 mg tablet,extended DACARBAZINE SOLR 200 MG

CLINDAMYCIN PHOSPHATE SOLN 600 MG/4ML tramadol ER 300 mg tablet,extended DANAZOL CAPS 100 MG

CLINDAMYCIN PHOSPHATE SOLN 900 MG/6ML TREMFYA SOPN 100 MG/ML DANAZOL CAPS 200 MG

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CLINDAMYCIN PHOSPHATE SWAB 1 %

TREMFYA SOSY 100 MG/ML

DANAZOL CAPS 50 MG

CLINIMIX E/DEXTROSE (5/15) SOLN 5 % Trijardy XR DANTROLENE SODIUM CAPS 100 MG

CLINIMIX E/DEXTROSE (5/20) SOLN 5 % Trintellix 10 mg tablet DANTROLENE SODIUM CAPS 25 MG

CLINIMIX/DEXTROSE (5/15) SOLN 5 % Trintellix 20 mg tablet DANTROLENE SODIUM CAPS 50 MG

CLOBETASOL PROPIONATE CREA 0.05 % Trintellix 5 mg tablet DAPSONE TABS 100 MG

CLOBETASOL PROPIONATE LOTN 0.05 %

TRULANCE TABS 3 MG

DAPSONE TABS 25 MG

CLOBETASOL PROPIONATE OINT 0.05 % Trulicity DAPTOMYCIN SOLR 500 MG

CLOBETASOL PROPIONATE SOLN 0.05 % Trulicity 0.75 mg/0.5 mL subcutaneous DARIFENACIN HYDROBROMIDE ER TB24 15 MG

CLOBEX SPRAY LIQD 0.05 % TussiCaps 10 mg-8 mg capsule,extended DARIFENACIN HYDROBROMIDE ER TB24 7.5 MG

CLONIDINE HCL (ANALGESIA) SOLN 100 MCG/ML TussiCaps 5 mg-4 mg capsule,extended DASETTA 1/35 TABS 1-35 MG-MCG

CLONIDINE HCL TABS 0.1 MG Tussigon 5 mg-1.5 mg tablet DAUNORUBICIN HCL SOLN 20 MG/4ML

CLONIDINE HCL TABS 0.2 MG Tylenol-Codeine #3 300 mg-30 mg tablet DEBLITANE TABS 0.35 MG

CLONIDINE HCL TABS 0.3 MG Tylenol-Codeine #4 300 mg-60 mg tablet DECITABINE SOLR 50 MG

CLONIDINE PTWK 0.1 MG/24HR UBRELVY TABS 100 MG DEFERASIROX TABS 360 MG

CLONIDINE PTWK 0.2 MG/24HR UBRELVY TABS 50 MG DEFERASIROX TABS 90 MG

CLONIDINE PTWK 0.3 MG/24HR Ultracet 37.5 mg-325 mg tablet DEFEROXAMINE MESYLATE SOLR 2 GM

CLOPIDOGREL BISULFATE TABS 75 MG VIBERZI TABS 100 MG DEFEROXAMINE MESYLATE SOLR 500 MG

CLOTRIMAZOLE TROC 10 MG VIBERZI TABS 75 MG DELSTRIGO TABS 100-300-300 MG

COAL TAR EXTRACT SOLN 20 % Vicodin 5 mg-300 mg tablet DEPO-MEDROL SUSP 20 MG/ML

COAL TAR LIQD Vicodin ES 7.5 mg-300 mg tablet DEPO-MEDROL SUSP 40 MG/ML

COAL TAR SOLN Vicodin HP 10 mg-300 mg tablet DEPO-PROVERA SUSP 400 MG/ML

COAL TAR SOLN 20 %

Victoza 2-Pak 0.6 mg/0.1 mL (18 mg/

mL) subcutaneous pen injector

DEPO-TESTOSTERONE SOLN 100 MG/ML

COAL TAR TAR

Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/

mL) subcutaneous pen injector

DEPO-TESTOSTERONE SOLN 200 MG/ML

COARTEM TABS 20-120 MG

Viekira Pak 12.5 mg-75 mg-50 mg/

mg tablets in a dose pack

DESCOVY TABS 200-25 MG

CODEINE PHOSPHATE/GUAIFENESIN LIQ 10-300MG Virtussin AC 10 mg-100 mg/5 mL oral DESMOPRESSIN ACE SPRAY REFRIG SOLN 0.01 %

CODEINE SULFATE TABS 15 MG Vituz 5 mg-4 mg/5 mL oral solution DESMOPRESSIN ACETATE SOL 0.01%

CODEINE SULFATE TABS 30 MG Vosevi 400 mg-100 mg-100 mg tablet DESMOPRESSIN ACETATE SOLN 4 MCG/ML

CODEINE SULFATE TABS 60 MG VOTRIENT TABS 200 MG DESMOPRESSIN ACETATE SPRAY SOLN 0.01 %

CODEINE/GUAIFENESIN TAB 10-300 VUMERITY (STARTER) CPDR 231 MG DESMOPRESSIN ACETATE TABS 0.1 MG

COLCHICINE CAPS 0.6 MG VUMERITY CPDR 231 MG DESMOPRESSIN ACETATE TABS 0.2 MG

COLCHICINE TABS 0.6 MG XELJANZ TABS 10 MG DESOGESTREL-ETHINYL ESTRADIOL TABS 0.15-30 MG-

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

COLESTIPOL HCL TABS 1 GM

XELJANZ TABS 5 MG

DESOXIMETASONE CREA 0.25 %

COLISTIMETHATE SODIUM (CBA) SOLR 150 MG XELJANZ XR TB24 11 MG DESOXIMETASONE OINT 0.25 %

COLOCORT ENEM 100 MG/60ML XELJANZ XR TB24 22 MG DEXAMETHASONE ELIX 0.5 MG/5ML

COLY-MYCIN S SUSP 3.3-3-10-0.5 MG/ML Xigduo XR DEXAMETHASONE INTENSOL CONC 1 MG/ML

COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 MG Xigduo XR 5 mg-1,000 mg tablet,extended DEXAMETHASONE SODIUM PHOSPHATE SOLN 0.1 %

COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 MG & 80 MG

XOLAIR SOLR 150 MG

DEXAMETHASONE SODIUM PHOSPHATE SOLN 10 MG/M

COMETRIQ (60 MG DAILY DOSE) KIT 20 MG XOLAIR SOSY 150 MG/ML DEXAMETHASONE SODIUM PHOSPHATE SOLN 4 MG/M

COMFORT ASSIST INSULIN SYRINGE MISC 30G X 5/16" 1 ML XOLAIR SOSY 75 MG/0.5ML DEXAMETHASONE SOLN 0.5 MG/5ML

COMPLERA TABS 200-25-300 MG XTANDI CAPS 40 MG DEXAMETHASONE TABS 0.5 MG

COMPLETE SENIOR TABS XULTOPHY SOPN 100-3.6 UNIT-MG/ML DEXAMETHASONE TABS 0.75 MG

CONTOUR NEXT TEST STRP

XYREM SOLN 500 MG/ML

DEXAMETHASONE TABS 1 MG

CORTISONE ACETATE TABS 25 MG YONSA TABS 125 MG DEXAMETHASONE TABS 1.5 MG

CORTROSYN SOLR 0.25 MG Zamicet 10 mg-325 mg/15 mL oral DEXAMETHASONE TABS 2 MG

COSENTYX (300 MG DOSE) SOSY 150 MG/ML ZEPATIER TABS 50-100 MG DEXAMETHASONE TABS 4 MG

COSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML ZOMACTON SOLR 10 MG DEXAMETHASONE TABS 6 MG

COSENTYX SENSOREADY PEN SOAJ 150 MG/ML

ZOMACTON SOLR 5 MG

DEXMEDETOMIDINE HCL IN NACL SOLN 80 MCG/20ML

COSENTYX SOSY 150 MG/ML ZORBTIVE SOLR 8.8 MG DEXMEDETOMIDINE HCL SOLN 200 MCG/2ML

COSMEGEN SOLR 0.5 MG Zutripro 5 mg-4 mg-60 mg/5 mL oral DEXRAZOXANE HCL SOLR 250 MG

COTELLIC TABS 20 MG ZYTIGA TABS 250 MG DEXTROSE 10% INJ 10%

CREON CPEP 12000-38000 UNIT ZYTIGA TABS 500 MG DEXTROSE IN LACTATED RINGERS SOLN 5 %

CREON CPEP 24000-76000 UNIT DEXTROSE SOLN 10 %

CREON CPEP 3000-9500 UNIT DEXTROSE SOLN 5 %

CREON CPEP 36000-114000 UNIT DEXTROSE SOLN 50 %

CREON CPEP 6000-19000 UNIT DEXTROSE SOLN 70 %

CRIXIVAN CAPS 200 MG DEXTROSE-NACL SOLN 5-0.2 %

CRIXIVAN CAPS 400 MG DEXTROSE-NACL SOLN 5-0.33 %

CROMOLYN SODIUM CONC 100 MG/5ML DEXTROSE-NACL SOLN 5-0.45 %

CROMOLYN SODIUM NEBU 20 MG/2ML DEXTROSE-NACL SOLN 5-0.9 %

CROMOLYN SODIUM SOLN 4 % DIALYVITE VITAMIN D3 MAX TABS 1.25 MG (50000 UT

CYANOCOBALAMIN SOLN 1000 MCG/ML DIANEAL LOW CALCIUM/1.5% DEX SOLN 344 MOSM/L

CYCLAFEM 1/35 TABS 1-35 MG-MCG DIANEAL LOW CALCIUM/2.5% DEX SOLN 395 MOSM/L

CYCLOBENZAPRINE HCL TABS 10 MG DIANEAL LOW CALCIUM/4.25% DEX SOLN 483 MOSM/

CYCLOBENZAPRINE HCL TABS 5 MG DIANEAL PD-2/1.5% DEXTROSE SOLN 346 MOSM/L

CYCLOMYDRIL SOLN 0.2-1 % DIANEAL PD-2/2.5% DEXTROSE SOLN 396 MOSM/L

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

CYCLOPENTOLATE HCL SOLN 0.5 % DIANEAL PD-2/4.25% DEXTROSE SOLN 485 MOSM/L

CYCLOPENTOLATE HCL SOLN 1 % DIASTIX STRP

CYCLOPENTOLATE HCL SOLN 2 % DIAZOXIDE SUSP 50 MG/ML

CYCLOPHOSPHAMIDE CAPS 25 MG DICLOFENAC SODIUM SOLN 0.1 %

CYCLOPHOSPHAMIDE CAPS 50 MG DICLOFENAC SODIUM TBEC 25 MG

CYCLOPHOSPHAMIDE SOLR 1 GM DICLOFENAC SODIUM TBEC 50 MG

CYCLOPHOSPHAMIDE SOLR 2 GM DICLOFENAC SODIUM TBEC 75 MG

CYCLOPHOSPHAMIDE SOLR 500 MG DICLOXACILLIN SODIUM CAPS 250 MG

CYCLOSPORINE CAPS 100 MG DICLOXACILLIN SODIUM CAPS 500 MG

CYCLOSPORINE CAPS 25 MG DICYCLOMINE HCL CAPS 10 MG

CYPROHEPTADINE HCL SYRP 2 MG/5ML DICYCLOMINE HCL SOLN 10 MG/5ML

CYPROHEPTADINE HCL TABS 4 MG DICYCLOMINE HCL SOLN 10 MG/ML

CYRAMZA SOLN 100 MG/10ML DICYCLOMINE HCL TABS 20 MG

CYRAMZA SOLN 500 MG/50ML DIDANOSINE CPDR 250 MG

CYRED EQ TABS 0.15-30 MG-MCG DIDANOSINE CPDR 400 MG

CYTARABINE (PF) SOLN 100 MG/ML DIETHYLSTILBESTROL POW

CYTARABINE (PF) SOLN 20 MG/ML DIFFERIN CREA 0.1 %

CYTARABINE INJ 100MG DIFLORASONE DIACETATE OINT 0.05 %

CYTARABINE INJ 2GM DIGOXIN SOLN 0.05 MG/ML

CYTARABINE INJ 500MG DIGOXIN SOLN 0.25 MG/ML

CYTARABINE SOLN 20 MG/ML DIGOXIN TABS 125 MCG

CYTOVENE SOLR 500 MG DIGOXIN TABS 250 MCG

CYTOXAN INJ 1GM DIHYDROERGOTAMINE MESYLATE INJ 1MG/ML

CYTOXAN INJ 2GM DIHYDROERGOTAMINE MESYLATE SOLN 1 MG/ML

CYTOXAN INJ 500MG DILANTIN CAPS 30 MG

CYTRA K CRYSTALS PACK 3300-1002 MG DILTIAZEM HCL ER COATED BEADS CP24 120 MG

D3 MAXIMUM STRENGTH LIQD 125 MCG/ML DILTIAZEM HCL ER COATED BEADS CP24 180 MG

DACARBAZINE SOLR 200 MG DILTIAZEM HCL ER COATED BEADS CP24 240 MG

DANAZOL CAPS 100 MG DILTIAZEM HCL ER COATED BEADS CP24 300 MG

DANAZOL CAPS 200 MG DILTIAZEM HCL ER CP12 120 MG

DANAZOL CAPS 50 MG DILTIAZEM HCL ER CP12 60 MG

DANTROLENE SODIUM CAPS 100 MG DILTIAZEM HCL ER CP12 90 MG

DANTROLENE SODIUM CAPS 25 MG DILTIAZEM HCL POWD

DANTROLENE SODIUM CAPS 50 MG DILTIAZEM HCL SOLN 25 MG/5ML

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

DAPSONE TABS 100 MG DILTIAZEM HCL SOLR 100 MG

DAPSONE TABS 25 MG DILTIAZEM HCL TABS 120 MG

DAPTOMYCIN SOLR 500 MG DILTIAZEM HCL TABS 30 MG

DARIFENACIN HYDROBROMIDE ER TB24 15 MG DILTIAZEM HCL TABS 60 MG

DARIFENACIN HYDROBROMIDE ER TB24 7.5 MG DILTIAZEM HCL TABS 90 MG

DASETTA 1/35 TABS 1-35 MG-MCG DILT-XR CP24 120 MG

DAUNORUBICIN HCL SOLN 20 MG/4ML DILT-XR CP24 180 MG

DEBLITANE TABS 0.35 MG DILT-XR CP24 240 MG

DECITABINE SOLR 50 MG DIMETHYL FUMARATE CPDR 120 MG

DEFERASIROX TABS 360 MG DIMETHYL FUMARATE CPDR 240 MG

DEFERASIROX TABS 90 MG DIPHENHYDRAMINE HCL SOLN 50 MG/ML

DEFEROXAMINE MESYLATE SOLR 2 GM DIPHENOXYLATE-ATROPINE LIQD 2.5-0.025 MG/5ML

DEFEROXAMINE MESYLATE SOLR 500 MG DIPHENOXYLATE-ATROPINE TABS 2.5-0.025 MG

DELSTRIGO TABS 100-300-300 MG DIPRIVAN EMUL 100 MG/10ML

DEPO-MEDROL SUSP 20 MG/ML DIPYRIDAMOLE TABS 25 MG

DEPO-MEDROL SUSP 40 MG/ML DIPYRIDAMOLE TABS 50 MG

DEPO-PROVERA SUSP 400 MG/ML DIPYRIDAMOLE TABS 75 MG

DEPO-TESTOSTERONE SOLN 100 MG/ML DISOPYRAMIDE PHOSPHATE CAPS 100 MG

DEPO-TESTOSTERONE SOLN 200 MG/ML DISOPYRAMIDE PHOSPHATE CAPS 150 MG

DESCOVY TABS 200-25 MG DISOPYRAMIDE PHOSPHATE ER CAP 150MG ER

DESMOPRESSIN ACE SPRAY REFRIG SOLN 0.01 % DOBUTAMINE HCL SOLN 250 MG/20ML

DESMOPRESSIN ACETATE SOL 0.01% DOBUTAMINE IN D5W SOLN 2 MG/ML

DESMOPRESSIN ACETATE SOLN 4 MCG/ML DOCETAXEL (NON-ALCOHOL) SOLN 160 MG/8ML

DESMOPRESSIN ACETATE SPRAY SOLN 0.01 % DOCETAXEL (NON-ALCOHOL) SOLN 20 MG/ML

DESMOPRESSIN ACETATE TABS 0.1 MG DOCETAXEL (NON-ALCOHOL) SOLN 80 MG/4ML

DESMOPRESSIN ACETATE TABS 0.2 MG DOFETILIDE CAPS 125 MCG

DESOGESTREL-ETHINYL ESTRADIOL TABS 0.15-30 MG-MCG DOFETILIDE CAPS 250 MCG

DESOXIMETASONE CREA 0.25 % DOFETILIDE CAPS 500 MCG

DESOXIMETASONE OINT 0.25 % DONEPEZIL HCL TABS 10 MG

DEVILBISS COMPACT COMPRESSOR MIS COMPRESS DONEPEZIL HCL TABS 5 MG

DEVILBISS DISPOSABLE NEBULIZER MISC DONEPEZIL HCL TBDP 10 MG

DEVILBISS PULMO-AIDE COMPRESSOR/NEBULIZER MIS COMP/NEB DONEPEZIL HCL TBDP 5 MG

DEXAMETHASONE ELIX 0.5 MG/5ML DOPAMINE HCL-DEXTROSE 5% INJ 1.6MG/ML

DEXAMETHASONE INTENSOL CONC 1 MG/ML DORZOLAMIDE HCL SOLN 2 %

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

DEXAMETHASONE SODIUM PHOSPHATE SOLN 0.1 % DORZOLAMIDE HCL-TIMOLOL MAL SOLN 22.3-6.8 MG/

DEXAMETHASONE SODIUM PHOSPHATE SOLN 10 MG/ML DOVATO TABS 50-300 MG

DEXAMETHASONE SODIUM PHOSPHATE SOLN 4 MG/ML DOXAZOSIN MESYLATE TABS 1 MG

DEXAMETHASONE SOLN 0.5 MG/5ML DOXAZOSIN MESYLATE TABS 2 MG

DEXAMETHASONE TABS 0.5 MG DOXAZOSIN MESYLATE TABS 4 MG

DEXAMETHASONE TABS 0.75 MG DOXAZOSIN MESYLATE TABS 8 MG

DEXAMETHASONE TABS 1 MG DOXORUBICIN HCL LIPOSOMAL INJ 2 MG/ML

DEXAMETHASONE TABS 1.5 MG DOXORUBICIN HCL SOLN 2 MG/ML

DEXAMETHASONE TABS 2 MG DOXORUBICIN HCL SOLR 50 MG

DEXAMETHASONE TABS 4 MG DOXY 100 SOLR 100 MG

DEXAMETHASONE TABS 6 MG DOXYCYCLINE MONOHYDRATE CAPS 100 MG

DEXMEDETOMIDINE HCL IN NACL SOLN 80 MCG/20ML DOXYCYCLINE MONOHYDRATE SUSR 25 MG/5ML

DEXMEDETOMIDINE HCL SOLN 200 MCG/2ML DOXYCYCLINE MONOHYDRATE TABS 100 MG

DEXRAZOXANE HCL SOLR 250 MG DOXYCYCLINE MONOHYDRATE TABS 50 MG

DEXTROSE 10% INJ 10% DRIPDROP HYDRATION PACK

DEXTROSE IN LACTATED RINGERS SOLN 5 % DRIPDROP ORS POW ORS

DEXTROSE SOLN 10 % DRIPDROP PACK

DEXTROSE SOLN 5 % DRONABINOL CAPS 10 MG

DEXTROSE SOLN 50 % DRONABINOL CAPS 2.5 MG

DEXTROSE SOLN 70 % DRONABINOL CAPS 5 MG

DEXTROSE-NACL SOLN 5-0.2 % DROSPIRENONE-ETHINYL ESTRADIOL TABS 3-0.03 MG

DEXTROSE-NACL SOLN 5-0.33 % DURATUSS HD ELX

DEXTROSE-NACL SOLN 5-0.45 % E.S.P. SUS 200-600

DEXTROSE-NACL SOLN 5-0.9 % ECONTRA EZ TABS 1.5 MG

DIALYVITE VITAMIN D3 MAX TABS 1.25 MG (50000 UT) ECPIRIN TBEC 325 MG

DIANEAL LOW CALCIUM/1.5% DEX SOLN 344 MOSM/L EDURANT TABS 25 MG

DIANEAL LOW CALCIUM/2.5% DEX SOLN 395 MOSM/L EFAVIRENZ CAPS 200 MG

DIANEAL LOW CALCIUM/4.25% DEX SOLN 483 MOSM/L EFAVIRENZ CAPS 50 MG

DIANEAL PD-2/1.5% DEXTROSE SOLN 346 MOSM/L EFAVIRENZ TABS 600 MG

DIANEAL PD-2/2.5% DEXTROSE SOLN 396 MOSM/L EFAVIRENZ-EMTRICITAB-TENOFOVIR TABS 600-200-3

DIANEAL PD-2/4.25% DEXTROSE SOLN 485 MOSM/L EFFER-K TBEF 25 MEQ

DIASTIX STRP ELIPHOS TABS 667 MG

DIAZOXIDE SUSP 50 MG/ML ELLA TABS 30 MG

DICLOFENAC SODIUM SOLN 0.1 % ELOCTATE SOLR 1000 UNIT

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

DICLOFENAC SODIUM TBEC 25 MG ELOCTATE SOLR 1500 UNIT

DICLOFENAC SODIUM TBEC 50 MG ELOCTATE SOLR 2000 UNIT

DICLOFENAC SODIUM TBEC 75 MG ELOCTATE SOLR 250 UNIT

DICLOXACILLIN SODIUM CAPS 250 MG ELOCTATE SOLR 3000 UNIT

DICLOXACILLIN SODIUM CAPS 500 MG ELOCTATE SOLR 4000 UNIT

DICYCLOMINE HCL CAPS 10 MG ELOCTATE SOLR 500 UNIT

DICYCLOMINE HCL SOLN 10 MG/5ML ELOCTATE SOLR 5000 UNIT

DICYCLOMINE HCL SOLN 10 MG/ML ELOCTATE SOLR 6000 UNIT

DICYCLOMINE HCL TABS 20 MG ELOCTATE SOLR 750 UNIT

DIDANOSINE CPDR 250 MG ELURYNG RING 0.12-0.015 MG/24HR

DIDANOSINE CPDR 400 MG EMCYT CAPS 140 MG

DIETHYLSTILBESTROL POW EMOQUETTE TABS 0.15-30 MG-MCG

DIFFERIN CREA 0.1 % EMTRICITABINE CAPS 200 MG

DIFLORASONE DIACETATE OINT 0.05 % EMTRICITABINE-TENOFOVIR DF TABS 200-300 MG

DIGOXIN SOLN 0.05 MG/ML EMTRIVA SOLN 10 MG/ML

DIGOXIN SOLN 0.25 MG/ML ENALAPRIL MALEATE TABS 10 MG

DIGOXIN TABS 125 MCG ENALAPRIL MALEATE TABS 2.5 MG

DIGOXIN TABS 250 MCG ENALAPRIL MALEATE TABS 20 MG

DIHYDROERGOTAMINE MESYLATE INJ 1MG/ML ENALAPRIL MALEATE TABS 5 MG

DIHYDROERGOTAMINE MESYLATE SOLN 1 MG/ML ENBREL SOLR 25 MG

DILANTIN CAPS 30 MG ENBREL SOSY 25 MG/0.5ML

DILTIAZEM HCL ER COATED BEADS CP24 120 MG ENBREL SOSY 50 MG/ML

DILTIAZEM HCL ER COATED BEADS CP24 180 MG ENBREL SURECLICK SOAJ 50 MG/ML

DILTIAZEM HCL ER COATED BEADS CP24 240 MG ENDOCET TABS 5-325 MG

DILTIAZEM HCL ER COATED BEADS CP24 300 MG ENDOCET TABS 7.5-325 MG

DILTIAZEM HCL ER CP12 120 MG ENGERIX-B SUSP 10 MCG/0.5ML

DILTIAZEM HCL ER CP12 60 MG ENGERIX-B SUSP 20 MCG/ML

DILTIAZEM HCL ER CP12 90 MG ENOXAPARIN SODIUM SOLN 100 MG/ML

DILTIAZEM HCL POWD ENOXAPARIN SODIUM SOLN 120 MG/0.8ML

DILTIAZEM HCL SOLN 25 MG/5ML ENOXAPARIN SODIUM SOLN 150 MG/ML

DILTIAZEM HCL SOLR 100 MG ENOXAPARIN SODIUM SOLN 30 MG/0.3ML

DILTIAZEM HCL TABS 120 MG ENOXAPARIN SODIUM SOLN 300 MG/3ML

DILTIAZEM HCL TABS 30 MG ENOXAPARIN SODIUM SOLN 40 MG/0.4ML

DILTIAZEM HCL TABS 60 MG ENOXAPARIN SODIUM SOLN 60 MG/0.6ML

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

DILTIAZEM HCL TABS 90 MG ENOXAPARIN SODIUM SOLN 80 MG/0.8ML

DILT-XR CP24 120 MG ENPRESSE-28 TABS 50-30/75-40/ 125-30 MCG

DILT-XR CP24 180 MG ENSKYCE TABS 0.15-30 MG-MCG

DILT-XR CP24 240 MG ENTACAPONE TABS 200 MG

DIMETHYL FUMARATE CPDR 120 MG ENTECAVIR TABS 0.5 MG

DIMETHYL FUMARATE CPDR 240 MG ENTECAVIR TABS 1 MG

DIPHENHYDRAMINE HCL SOLN 50 MG/ML ENTRESTO TABS 24-26 MG

DIPHENOXYLATE-ATROPINE LIQD 2.5-0.025 MG/5ML ENTRESTO TABS 49-51 MG

DIPHENOXYLATE-ATROPINE TABS 2.5-0.025 MG ENTRESTO TABS 97-103 MG

DIPRIVAN EMUL 100 MG/10ML EOVIST SOLN 0.25 MOL/L

DIPYRIDAMOLE TABS 25 MG EPCLUSA TABS 400-100 MG

DIPYRIDAMOLE TABS 50 MG EPINEPHRINE HCL INJ 1MG/ML

DIPYRIDAMOLE TABS 75 MG EPINEPHRINE SOAJ 0.15 MG/0.15ML

DISOPYRAMIDE PHOSPHATE CAPS 100 MG EPINEPHRINE SOAJ 0.3 MG/0.3ML

DISOPYRAMIDE PHOSPHATE CAPS 150 MG EPIPEN 2-PAK SOAJ 0.3 MG/0.3ML

DISOPYRAMIDE PHOSPHATE ER CAP 150MG ER EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML

DOBUTAMINE HCL SOLN 250 MG/20ML EPIRUBICIN HCL INJ 200MG

DOBUTAMINE IN D5W SOLN 2 MG/ML EPIRUBICIN HCL INJ 50MG

DOCETAXEL (NON-ALCOHOL) SOLN 160 MG/8ML EPIRUBICIN HCL SOLN 50 MG/25ML

DOCETAXEL (NON-ALCOHOL) SOLN 20 MG/ML ERBITUX SOLN 100 MG/50ML

DOCETAXEL (NON-ALCOHOL) SOLN 80 MG/4ML ERBITUX SOLN 200 MG/100ML

DOFETILIDE CAPS 125 MCG ERGOCALCIFEROL SOLN 200 MCG/ML

DOFETILIDE CAPS 250 MCG ERGOLOID MESYLATES TABS 1 MG

DOFETILIDE CAPS 500 MCG ERLOTINIB HCL TABS 100 MG

DONEPEZIL HCL TABS 10 MG ERLOTINIB HCL TABS 150 MG

DONEPEZIL HCL TABS 5 MG ERLOTINIB HCL TABS 25 MG

DONEPEZIL HCL TBDP 10 MG ERRIN TABS 0.35 MG

DONEPEZIL HCL TBDP 5 MG ERTAPENEM SODIUM SOLR 1 GM

DOPAMINE HCL-DEXTROSE 5% INJ 1.6MG/ML ERYTHROCIN LACTOBIONATE SOLR 500 MG

DORZOLAMIDE HCL SOLN 2 % ERYTHROMYCIN BASE CPEP 250 MG

DORZOLAMIDE HCL-TIMOLOL MAL SOLN 22.3-6.8 MG/ML ERYTHROMYCIN BASE TABS 250 MG

DOVATO TABS 50-300 MG ERYTHROMYCIN BASE TABS 500 MG

DOXAZOSIN MESYLATE TABS 1 MG ERYTHROMYCIN ETHYLSUCCINATE SUSR 200 MG/5ML

DOXAZOSIN MESYLATE TABS 2 MG ERYTHROMYCIN ETHYLSUCCINATE SUSR 400 MG/5ML

Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL

Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary

DOXAZOSIN MESYLATE TABS 4 MG ERYTHROMYCIN OINT 5 MG/GM

DOXAZOSIN MESYLATE TABS 8 MG ERYTHROMYCIN SOLN 2 %

DOXORUBICIN HCL LIPOSOMAL INJ 2 MG/ML ESMOLOL HCL SOLN 100 MG/10ML

DOXORUBICIN HCL SOLN 2 MG/ML ESTARYLLA TABS 0.25-35 MG-MCG

DOXORUBICIN HCL SOLR 50 MG ESTRACE CREA 0.1 MG/GM

DOXY 100 SOLR 100 MG ESTRADIOL CREA 0.1 MG/GM

DOXYCYCLINE MONOHYDRATE CAPS 100 MG ESTRADIOL PTTW 0.025 MG/24HR

DOXYCYCLINE MONOHYDRATE SUSR 25 MG/5ML ESTRADIOL PTTW 0.0375 MG/24HR

DOXYCYCLINE MONOHYDRATE TABS 100 MG ESTRADIOL PTTW 0.05 MG/24HR

DOXYCYCLINE MONOHYDRATE TABS 50 MG ESTRADIOL PTTW 0.075 MG/24HR

DRIPDROP HYDRATION PACK ESTRADIOL PTTW 0.1 MG/24HR

DRIPDROP ORS POW ORS ESTRADIOL TABS 0.5 MG

DRIPDROP PACK ESTRADIOL TABS 1 MG

DRONABINOL CAPS 10 MG ESTRADIOL TABS 2 MG

DRONABINOL CAPS 2.5 MG ETHACRYNATE SODIUM SOLR 50 MG

DRONABINOL CAPS 5 MG ETHAMBUTOL HCL TABS 100 MG

DROSPIRENONE-ETHINYL ESTRADIOL TABS 3-0.03 MG ETHAMBUTOL HCL TABS 400 MG

DURATUSS HD ELX ETHYNODIOL DIAC-ETH ESTRADIOL TABS 1-35 MG-MC

E.S.P. SUS 200-600 ETHYNODIOL DIAC-ETH ESTRADIOL TABS 1-50 MG-MC

EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML ETIDRONATE DISODIUM TABS 200 MG

EASY TOUCH SAFETY SYRINGE MISC 25G X 5/8" 3 ML ETODOLAC TABS 400 MG

ECONTRA EZ TABS 1.5 MG ETODOLAC TABS 500 MG

ECPIRIN TBEC 325 MG ETOMIDATE SOLN 2 MG/ML

EDURANT TABS 25 MG ETOPOSIDE CAPS 50 MG

EFAVIRENZ CAPS 200 MG EVEROLIMUS TABS 2.5 MG

EFAVIRENZ CAPS 50 MG EVEROLIMUS TABS 5 MG

EFAVIRENZ TABS 600 MG EVEROLIMUS TABS 7.5 MG

EFAVIRENZ-EMTRICITAB-TENOFOVIR TABS 600-200-300 MG EVOTAZ TABS 300-150 MG

EFFER-K TBEF 25 MEQ EXEMESTANE TABS 25 MG

ELIPHOS TABS 667 MG EXTAVIA KIT 0.3 MG

ELLA TABS 30 MG EXTRANEAL SOLN 7.5 %

ELOCTATE SOLR 1000 UNIT FABRAZYME SOLR 35 MG

ELOCTATE SOLR 1500 UNIT FALMINA TABS 0.1-20 MG-MCG

ELOCTATE SOLR 2000 UNIT FAMOTIDINE SOLN 40 MG/4ML