Molina Healthcare of Ohio Prior Authorization (PA) List

Transcription

1 Molina Healthcare of Ohio Prior Authorization (PA) List All drugs listed on the PA list require prior authorization in order to be covered. This list applies to all Molina Healthcare members, including Covered Families and Children (CFC) and Aged, Blind or Disabled (ABD) members. Molina Healthcare covers all medically-necessary, Medicaid-covered prescription medications available through the traditional fee-for-service Medicaid program but may require prior authorization differently. Some drugs, mostly injections, must be obtained from Caremark Specialty Pharmacy. After a member s drug is authorized, the member will be informed that the drug will be shipped to the member from Caremark Specialty Pharmacy. The PA process is initiated by the prescriber completing a PA form requesting the medication and faxing it to Molina Healthcare at (800) A PA form may be downloaded from the Molina Healthcare of Ohio website at The turnaround time for all prior authorization requests are within 24 hours of receiving the request with the exception of weekends and holidays. A fax will be issued to the provider once a decision has been made (both approvals and denials). If you receive a denial on a medication and wish to appeal the decision on the member s behalf, please call (800) to initiate the appeals process. Urgent requests for medication may be made by calling the Pharmacy department at (800) Branded drugs that have a generic equivalent available require PA if the brand is requested. This list does not show all of the brand name drugs that have a generic available. Brand name medications that have generic equivalents will only be dispensed in generic form unless the prescriber indicates a branded drug is necessary (DAW) and Molina Healthcare prior authorizes the drug. Step therapy and quantity limit exceptions require prior authorization. Molina Healthcare s Pharmacy department is available 8 a.m. to 6 p.m. Monday through Friday by calling (800) PRIOR AUTHORIZATION CODE: Lower Cost Alternatives = There is another drug that does the same as the Prior Authorized drug and it costs less. The alternative drugs are listed. A member can ask his or her provider if the alternative is right for the member. Step Therapy = The member must have tried another drug before the use of the drug with Prior Authorization. Clinical Review = These requests must go through clinical review. There are certain medical records, laboratory tests or certain diseases listed in order to get this medication. Duration of Therapy Limit = There is no initial Prior Authorization required. PA is only required after a certain period of time OH0616

2 Molina Healthcare of Ohio Prior Authorization (PA) List Effective July 1, 2016 DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIA 8-MOP 10 MG CAPSULE CUTANEOUS T CELL LYMPHOMA ABILIFY SOLUTION REQUIRES ABILIFY DISCMELT REQUIRES ABILIFY DISCMELT TABLET REQUIRES ABILIFY TABLET REQUIRES ABSORICA CAP REQUEST MUST GO THROUGH ABSTRAL TAB SUBLING REQUEST MUST GO THROUGH, ACANYA GEL PUMP CLINDAMYCIN/BENZOYL PEROXIDE GEL ACIDOPHILUS CAPLET REQUEST MUST GO THROUGH ACIPHEX EC 20 MG TABLET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. ACIPHEX SPRINKLE REQUEST MUST GO THROUGH ACIPHEX SPRINKLES CAP LOWER COST ALTERNATIVE USE PRILOSEC OTC, NEXIUM OTC ACTEMRA SYRINGE REQUEST MUST GO THROUGH, ACTIMMUNE 2 MILLION UNIT VI REQUEST MUST GO THROUGH, ACTIQ LOZENGE REQUEST MUST GO THROUGH ACTIVE OB SOFTGEL GENERIC PRENATAL VITAMIN WITH IRON ACTIVELLA TABLET PREMPRO ACTONEL TABLET GENERIC ALENDRONATE ACTONEL WITH CALCIUM GENERIC ALENDRONATE PLUS CALCIUM TABLET ACTOPLUS MET XR ACTOPLUS MET ACUVAIL 0.45% OPHTH DICLOFENAC, KETOROLAC OPTH SOLUTION SOLUTIO ACZONE 5% GEL CLINDAMYCIN/BENZOYL PEROXIDE GEL ADCETRIS INJECTION REQUEST MUST GO THROUGH, ADCIRCA 20 MG TABLET REQUEST MUST GO THROUGH, ADEMPAS TABLET REQUEST MUST GO THROUGH, ADRENACLICK INJ USE EPI-PEN, EPI PEN JR ADOXA TABLET DOXYCYCLINE MONO 100 MG CAP ADOXA PAK MG TABLET DOXYCYCLINE ADVAIR DISKUS REQUIRES ADVAIR HFA REQUIRES ADVICOR TABLETS NIACIN PLUS SIMVASTATIN ADVIL 200 MG LIQUI-GEL CAPS USE NAPROXEN, DICLOFENAC, ETODOLAC

3 AEROSPAN 80 MCG INHALER ASMANEX, QVAR, PULMICORT FLEXHALER AFINITOR REQUIRES AFINITOR DISPERZ 2 MG TABLE SIROLIMUS, TACROLIMUS AFINITOR TABLET REQUEST MUST GO THROUGH, AIRAVITE TABLET FOLIC ACID AFREZZA INHALATION REQUEST MUST GO THROUGH AKNE-MYCIN 2% OINTMENT CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL AKYNZEO CAPSULE LOWER COST ALTERNATIVE ONDANSETRON/ODT, GRANISETRON ALAMAST 0.1% DROPS CROMOLYN 4% EYE DROPS ALBENZA 200 MG TABLET REQUEST MUST GO THROUGH ALEVAZOL OINTMENT LOWER COST ALTERNATIVE USE CLOTRIMAZOLE ALECENSA CAPSULE CLINICAL REQUEST MUST GO THROUGH, ALINIA 100 MG/5 ML SUSPENSI ALINIA 500 MG TABLET ALLEGRA 30 MG/5 ML SUSPENSI CETIRIZINE; LORATADINE ALLEGRA ODT 30 MG TABLET CETIRIZINE; LORATADINE ALLEGRA-D TABLET CETIRIZINE; LORATADINE ALLFEN CD TABLET GUAIFENESIN-CODEINE SYRUP ALOCRIL 2% OPHTH DROPS CROMOLYN SODIUM 4% OPHTH SOL ALPHAGAN P 0.1% DROPS ALPHAGAN P 0.15% EYE DROPS ALPRAZOLAM ER TABLET ALPRAZOLAM REG. STRENGTH TABLETS ALPRAZOLAM ODT ALPRAZOLAM REG. STRENGTH TABLETS ALREX EYE DROPS FLUOROMETHOLONE, PREDNISOLONE ACETATE ALTABAX 1% OINTMENT MURIPROCIN CREAM/OINTMENT ALTOPREV TABLET SIMVASTATIN ALVESCO INHALER QVAR, PULMICORT FLEXHALER, ASMANEX AMINOSYN II 15% IV SOLUTION REQUEST MUST GO THROUGH AMITIZA CAPSULE MIRALAX, LACTULOSE AMPYRA ER 10 MG TABLET REQUEST MUST GO THROUGH, AMRIX ER CAPSULE CYCLOBENZAPRINE TABLET ANABAR CAPLET ACETOMINOPHEN PLUS ANTIHISTAMINE ANADROL-50 TABLET REQUEST MUST GO THROUGH ANDRODERM PATCH REQUEST MUST GO THROUGH, ANDROGEL ALL STRENGTHS STEP/CLINICAL REQUEST MUST GO THROUGH, REQUIRES LAB VALUES ANDROGEN PRODUCTS REQUEST MUST GO THROUGH, ANGELIQ 0.5 MG-1 MG TABLET PREMPRO ANTARA 30 MG CAPSULE FENOFIBRATE GENERIC ANTARA CAPSULE GENERIC FENOFIBRATE 54MG OR 160MG ANZEMET TABLET ONDANSETRON/ODT, GRANISETRON APIDRA 100 UNITS/ML VIAL APIDRA SOLOSTAR 100 UNITS/M APLENZIN ER TABLET WELLBUTRIN XL

4 APOKYN 30 MG/3 ML CARTRIDGE REQUEST MUST GO THROUGH, APTENSIO XR CAPSULE LOWER COST ALTERNATIVE METADATE CD, CONCERTA ARANESP INJECTION REQUEST MUST GO THROUGH, ARCALYST 220 MG INJECTION REQUEST MUST GO THROUGH, ARCAPTA NEOHALER SALMETEROL, FORMOTEROL INHALERS ARICEPT 23 MG TABLET GENERIC DONEPEZIL 20MG ARISTADA ER SUSPENSION CLINICAL REQUEST MUST GO THROUGH ARIXTRA SYRINGE REQUEST MUST GO THROUGH, ARNUITY ELLIPTA QVAR, ASMANEX TWISTHALER, PULMICORT FLEXHALER ARTHROTEC EC DICLOFENAC SODIUM PLUS MISOPROSTOL ASTAGRAF XL CAPSULE GENERIC TACROLIMUS ATACAND TABLET LOSARTAN OR ACE-INHIBITOR ATACAND HCT TABLET LOSARTAN-HCTZ ATELVIA DR 35 MG TABLET GENRIC ALENDRONATE ATGAM 50 MG/ML AMPUL REQUEST MUST GO THROUGH, AUBAGIO 14 MG TABLET REQUEST MUST GO THROUGH, AUBAGIO 7 MG TABLET REQUEST MUST GO THROUGH, AVALIDE TABLET LOSARTAN-HCTZ AVANDAMET TAB REQUEST MUST GO THROUGH AVANDARYL TABLET REQUEST MUST GO THROUGH AVANDIA TABLET REQUEST MUST GO THROUGH AVAPRO TABLET LOSARTAN OR ACE-INHIBITOR AVAR CLEANSING PADS SULFACETAMIDE/SULFUR CRM, GEL, LOTION, PADS GENERIC AVAR FOAM LOWER COST ALTERNATIVE SULFACETAMIDE/SULFUR CRM, GEL, LOTION, PADS AVELOX 400 MG TABLET OFLOXACIN, LEVOFLOXACIN AVINZA CAPSULE REQUEST MUST GO THROUGH AVODART 0.5 MG SOFTGEL FINASTERIDE (PROSCAR) AVONEX ADMIN PACK 30 MCG VL REQUEST MUST GO THROUGH, AXERT TABLET IMITREX, AMERGE AZASITE 1% EYE DROPS CIPROFLOXACIN, OFLOXACIN EYE DROPS AZELASTINE 0.05% EYE DROPS LOW COST ALTERNATIVE USE KETOTIFEN, PATADAY AZELEX 20% CREAM CLINDAMYCIN/BENZOYL PEROXIDE GEL AZILECT TABLET REQUEST MUST GO THROUGH, AZOR TABLET LOSARTAN PLUS AMLODIPINE BANZEL TABLET REQUEST MUST GO THROUGH

5 BECONASE AQ 0.042% SPRAY FLUNISOLIDE, FLUTICASONE BELBUCA FILM REQUEST MUST GO THROUGH BELSOMRA TABLETS REQUEST MUST GO THROUGH BENICAR HCT TABLET LOSARTAN-HCTZ BENICAR TABLET LOSARTAN OR ACE-INHIBITOR BENZACLIN GEL 35G PUMP CLINDAMYCIN/BENZOYL PEROXIDE GEL BENZAMYCINPAK GEL CLINDAMYCIN BENZOYL PEROXIDE GEL BENZEFOAM 5.3% EMOLLIENT BENZOYL PEROXIDE FO BENZEFOAM ULTRA 9.8% FOAM BENZOYL PEROXIDE BENZIQ 5.25% GEL BENZOYL PEROXIDE BENZIQ 5.25% WASH BENZOYL PEROXIDE BENZOYL PEROXIDE 7% WASH BENZOYL PEROXIDE BEPREVE 1.5% EYE DROPS USE KETOTIFEN, PATADAY BESIVANCE 0.6% SUSP LEVOFLOXACIN OPHTH BETASERON 0.3 MG KIT REQUEST MUST GO THROUGH, BETHKIS 300 MG/4 ML AMPULE REQUEST MUST GO THROUGH, BETHKIS NEB REQUEST MUST GO THROUGH BILTRICIDE 600 MG TABLET MEBENDAZOLE 100 MG TAB CHEW BLEPHAMIDE EYE DROPS FLUOROMETHOLONE, PREDNISOLONE ACETATE BONIVA 150 MG TABLET GENRIC ALENDRONATE BOSULIF 500 MG TABLET REQUEST MUST GO THROUGH B-PLEX TABLET FOLBEE PLUS TABLET BREO ELLIPTA INHALER REQUEST MUST GO THROUGH BREVOXYL COMPLETE PACK BENZOYL PEROXIDE BREVOXYL-4 COMPLETE PACK BENZOYL PEROXIDE BREVOXYL-8 COMPLETE PACK BENZOYL PEROXIDE BRILINTA REQUIRES BRINTELLIX TAB TRIAL OF 2 CITALOPRAM, ESCITALOPRAM, PAROXETINE, VENLAFAXINE, SERTRALINE, FLUOXETINE, BUPROPION BRISDELLE 7.5 MG CAPSULE PAROXETINE TABLETS BROMDAY 0.09% EYE DROPS DICLOFENAC, KETOROLAC OPTH SOLUTION BROVANA 15 MCG/2 ML REQUEST MUST GO THROUGH SOLUTIO BUNAVAIL FILM REQUEST MUST GO THROUGH BUPHENYL POWDER BUPHENYL 500 MG TABLET BUTISOL SODIUM 30 MG/5 ML E PHENOBARBITAL TABLET BUTISOL SODIUM TABLET PHENOBARBITAL TABLET BUTRANS PATCH USE METHADONE, MORPHINE SULF ER, OXYCODONE, HYDROCODONE/ACETAMINOPHEN BYDUREON 2 MG STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICS BYETTA DOSE PEN INJ STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICS BYSTOLIC TABLET ATENOLOL, BISOPROLOL, METOPROLOL CADUET TABLET AMLODIPINE PLUS SIMVASTATIN CAMBIA 50 MG POWDER USE NAPROXEN, DICLOFENAC, ETODOLAC PACKET CAMPRAL DR 333 MG TABLET REQUEST MUST GO THROUGH CANTIL 25 MG TABLET PROPANTHELINE, GLYCOPYRROLATE

6 CAPCOF LIQUID PROMETHAZINE VC-CODEINE SYR CAPRELSA TABLET REQUEST MUST GO THROUGH, CARBAGLU 200 MG DISPER REQUEST MUST GO THROUGH TABL CARDURA XL TABLET DOXAZOSIN, TERAZOSIN, TAMSULOSIN CARIMUNE NF 12 GM VIAL REQUEST MUST GO THROUGH, CARIMUNE NF 3 GM VIAL REQUEST MUST GO THROUGH, CARIMUNE NF 6 GM VIAL REQUEST MUST GO THROUGH, CARISOPRODOL CPD-CODEINE ORPHENADRINE COMP AND COMP-DS TABLETS TA CAVAN-EC SOD DHA VITAMINS PRENATAL VITAMINS WITH IRON CAVAN-FOLATE DHA COMBO LACTOCAL-F TABLET PACK CAVAN-HEME OB TABLET PRENATAL VITAMINS WITH IRON CAYSTON 75 MG INHAL SOLUTIO REQUEST MUST GO THROUGH, CEDAX TABLETS/SUSPENSION CEFPODOXIME PROXETIL CELEBREX CAPSULE REQUEST MUST GO THROUGH CENESTIN TABLET PREMARIN, ESTRADIOL TABLETS CERDELGA CAP REQUEST MUST GO THROUGH CEREDASE 80 UNITS/ML VIAL REQUEST MUST GO THROUGH, CEREFOLIN NAC CAPLET FOLIC ACID CERISA WASH CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL CESAMET 1 MG CAPSULE ONDANSETRON/ODT, GRANISETRON CETRAXAL 0.2% EAR SOLUTION CIPRODEX OTIC SUSPENSION CHANTIX TABLET LOWER COST ALTERNATIVE NICOTINE, BUPROPION SR CHENODAL 250 MG TABLET URSODIOL TABLET CHILD DELSYM COUGH+COLD ACETOMINOPHEN, DIPHENHYDRAMINE, PHENYLEPHRINE CHILDREN S MUCINEX GUAIFENESIN/DEXTROMETHORPHAN SYRUP CHOLBAM CAPSULE REQUEST MUST GO THROUGH CIMZIA 200 MG/ML SYRINGE KI REQUEST MUST GO THROUGH, CIPRO HC OTIC SUSPENSION CIPRODEX OTIC SUSPENSION CITRANATAL 90 DHA PACK COMPLETE-RF PRENATAL TABLET CITRANATAL ASSURE COMBO PRENATAL VITAMINS WITH IRON PAC CITRANATAL DHA PACK PRENATAL VITAMINS WITH IRON CITRANATAL HARMONY GENERIC PRENATAL VITAMINS CAPSULE CLARAVIS CAPSULE REQUEST MUST GO THROUGH CLARIFOAM EF EMOLLIENT FOAM CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL

7 CLARINEX TABLET CETIRIZINE; LORATADINE CLARINEX-D TABLET CETIRIZINE; LORATADINE CLARIS CLARIFYING WASH CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL CLARITIN REDITABS CETIRIZINE; LORATADINE CLIMARA PRO PATCH ESTRADIOL TRANSDERMAL PATCH, FEMHRT, PREMPHASE, PREMPRO CLOBEX 0.05% SPRAY TRIAMCINOLONE, BETAMETHASONE, CLOBEX 0.05% TOPICAL LOTION TRIAMCINOLONE, BETAMETHASONE, CLODAN KIT 0.05% LOWER COST ALTERNATIVE USE TRIAMCINOLONE, BETAMETHASONE, OR CLODERM 0.1% CREAM TRIAMCINOLONE, BETAMETHASONE, CLONAZEPAM 0.25 MG ODT CLONAZEPAM ORAL TABLETS CLONAZEPAM DIS TABLET CLONAZEPAM TABLETS CLONIDINE PATCH CLONIDINE TABLET CLORPRES TABLET CHLORTHALIDONE/CLONIDINE TABS COCET TABLET ACETAMINOPHEN-COD #2 TABLET COLCHICINE 0.6 MG CAPSULE LOWER COST ALTERNATIVE COLCHICINE TABLETS COLESTID TABLET/GRANULES CHOLESTYRAMINE PACKET COLY-MYCIN S EAR DROPS CORTOMYCIN EAR SUSPENSION COMETRIQ 100 MG DAILY-DOSE REQUEST MUST GO THROUGH, COMETRIQ 140 MG DAILY-DOSE REQUEST MUST GO THROUGH, COMETRIQ 60 MG DAILY-DOSE P REQUEST MUST GO THROUGH, COMPLETE NATAL DHA PRENATAL VITAMINS WITH IRON CONCEPT DHA CAPSULE PRENATAL VITAMINS WITH IRON CONEX SOLUTION LOWER COST ALTERNATIVE USE ZYRTEC OTC, CLARITIN OTC CONZIP TABLETS TRAMADOL ER COPAXONE INJECTION REQUEST MUST GO THROUGH, CORLANOR TABLET REQUST MUST GO THROUGH COREG CR CAPSULE CARVEDILOL CORTISPORIN CREAM CORTISPORIN OINT COSENTYX REQUEST MUST GO THROUGH, COSOPT PF DORZOLAMIDE/TIMOLOL OPHTH SOL COTAB AX TABLET DIMETAPP LONG-ACTING COUGH COTELLIC TABLET CLINICAL REQUEST MUST GO THROUGH, COVERA-HS ER 180 MG TABLET VERAPAMIL EXTENDED RELEASE COVERA-HS ER 240 MG TABLET VERAPAMIL EXTENDED RELEASE COVERA-HS MG TABLET VERAPAMIL EXTENDED RELEASE CRESEMBA CAPSULE FLUCONAZOLE, ITRACONAZOLE

8 CRESTOR TABLET REQUIRES CRINONE 8% GEL REQUEST MUST GO THROUGH, CUBICIN 500 MG VIAL REQUEST MUST GO THROUGH, CUTIVATE 0.05% LOTION TRIAMCINOLONE, BETAMETHASONE, CUVPOSA 1 MG/5 ML GLYCOPYRROLATE TABLETS, GENERIC DONNATAL SOLUTION CYCLIVERT MECLIZINE, DIPHENHYDRAMINE CYCLOPHOSPHAMIDE 500 MG REQUEST MUST GO THROUGH VIA CYCLOPHOSPHAMIDE CAP REQUEST MUST GO THROUGH CYMBALTA REQUIRES CYSTADANE POWDER REQUEST MUST GO THROUGH, CYTOGAM 2.5 GM/50 ML VIAL REQUEST MUST GO THROUGH, DAKLINZA TABLET REQUEST MUST GO THROUGH, DALIRESP REQUEST MUST GO THROUGH DAYTRANA PATCH METADATE CD CAPSULE DELZICOL DR 400 MG CAPSULE PENTASA, ASACOL HD DEMECLOCYCLINE TABLET DOXYCYCLINE MONO 100 MG CAP DEMSER 250 MG CAPSULE PHENTOLAMINE DENAVIR LOW COST ALTERNATIVE ABREVA DERMATOP CREAM/ OINTMENT TRIAMCINOLONE, BETAMETHASONE, DESONATE 0.05% GEL TRIAMCINOLONE, BETAMETHASONE, DESOWEN LOT DESONIDE CREAM/OINTMENT WITH GENERIC OTC CETAPHIL LOTION DESOXYN 5 MG TABLET AMPHETAMINE, DEXTROAMPHETAMINE, DESVENLAFAXINE TAB ER TRIAL OF 2 CITALOPRAM, ESCITALOPRAM, PAROXETINE, VENLAFAXINE, SERTRALINE, FLUOXETINE, BUPROPION DETROL LA CAPSULE OXYBUTYNIN/XL, TROSPIUM 20MG DEXILANT DR CAPSULE OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. DEXRAZOXANE 250 MG VIAL REQUEST MUST GO THROUGH DEXRAZOXANE 500 MG VIAL REQUEST MUST GO THROUGH DIALYVITE 3,000 TABLET DIALYVITE TABLET DIALYVITE 5000 TABLET DIALYVITE TABLET DIALYVITE SUPREME D TABLET DIALYVITE TABLET DIALYVITE WITH ZINC TABLET DIALYVITE TABLET DIATX ZN TABLET DIALYVITE TABLET DICLEGIS DR MG TABLET DOXYLAMINE AND PYRIDOXINE DIFICID TABLET REQUEST MUST GO THROUGH DIFIL-G 400 TABLET THEOPHYLLINE TABLET DILATRATE-SR 40 MG CAPSULE REQUEST MUST GO THROUGH DIOVAN HCT TABLET STEP THERAPY FAILURE ACE INHIBITOR

9 DIOVAN TABLET STEP THERAPY FAILURE ACE INHIBITOR DIPYRIDAMOLE 5 MG/ML VIAL REQUEST MUST GO THROUGH DIVIGEL 0.25 MG GEL PACKET ESTRADIOL TRANSDERMAL PATCH DIVIGEL 0.5 MG GEL PACKET ESTRADIOL TRANSDERMAL PATCH DIVIGEL 1 MG GEL PACKET ESTRADIOL TRANSDERMAL PATCH DORAL 15 MG TABLET ZOLPIDEM, ZALEPLON, TEMAZEPAM DORYX DR TABLET DOXYCYCLINE 100MG DOXYCYCLINE HYC DR 75 MG DOXYCYCLINE MONO 100 MG CAP TA DOXYCYCLINE MONO 75 MG DOXYCYCLINE MONO 100 MG CAP CAPS DRONABINOL CAPSULE REQUIRES DUAVEE TAB LOWER COST ALTERNATIVE USE PREMPRO, PREMPHASE WITH ALENDRONATE DUET DHA COMPLETE COMBO PRENATAL VITAMINS WITH IRON PAC DUETACT TABLET SULPHONYLUREA PLUS METFORMIN DUEXIS IBUPROFEN AND FAMOTIDINE DULERA INHALER STEP THERAPY QVAR, ASMANEX TWISTHALER, PULMICORT FLEXHALER DURAFLU TABLET COLD MULTI-SYMPTOM CAPLET DUTOPROL METOPROLOL/HCTZ DYLIX 100 MG/15 ML ELIXIR THEOPHYLLINE SOLUTION DYMISTA 137/50 MCG SPRAY LORATADINE PLUS FLUTICASONE OR FLUNISOLIDE DYMISTA FLUNISOLIDE, FLUTICASONE NASAL SPRAY DYNACIRC CR TABLET NIFEDIPINE; AMLODIPINE ED CHLORPED D PEDIATRIC RYNATAN PEDIATRIC ORAL SUSP DRO ED CYTE F TABLET FERROUS SULFATE 325 MG TABL EDARBI 40 LOSARTAN, ACE-INHIBITOR EDARBI 80 LOSARTAN, ACE-INHIBITOR EDARBYCLOR LOSARTAN PLUS HCTZ ED-FLEX CAPSULE ACETAMINOPHEN WITH CODEINE EDLUAR 10 MG SL TABLET ZOLPIDEM, ZALEPLON EDLUAR 5 MG SL TABLET ZOLPIDEM, ZALEPLON EFFER-K TABLET EFF K-TAB ER 10 MEQ TABLET EFFIENT TABLET REQUEST MUST GO THROUGH ELESTAT 0.05% EYE DROPS USE KETOTIFEN, PATADAY ELESTRIN 0.06% GEL ESTRADIOL TRANSDERMAL PATCH ELIDEL 1% CREAM TRIAMCINOLONE, BETAMETHASONE, ELIQUIS 2.5 MG TABLET REQUEST MUST GO THROUGH ELIQUIS 5 MG TABLET REQUEST MUST GO THROUGH EMADINE 0.05% EYE DROPS USE KETOTIFEN, PATADAY EMBEDA CAPSULE REQUEST MUST GO THROUGH, EMCYT 140 MG CAPSULE REQUEST MUST GO THROUGH, EMEND ONDANSETRON/ODT, GRANISETRON EMSAM PATCH SELEGILINE TABLETS ENABLEX TABLET OXYBUTYNIN/XL, TROSPIUM 20MG ENBRACE SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH IRON

10 ENVARSUS XR TABLET CLINICAL REQUEST MUST GO THROUGH EPIDUO FORTE GEL LOWER COST ALTERNATIVE CLINDAMYCIN/BENZOYL PEROXIDE GEL ENBREL INJECTION REQUEST MUST GO THROUGH, ENTRESTO TABLET REQUEST MUST GO THROUGH EPIDUO GEL CLINDAMYCIN/BENZOYL PEROXIDE GEL EPLERENONE TABLET SPIRONOLACTONE EPOGEN INJECTION REQUEST MUST GO THROUGH, ERTACZO 2% CREAM MICONAZOLE, CLOTRIMAZOLE CREAM ESBRIET CAPSULE REQUEST MUST GO THROUGH, ESCAVITE LQ DROPS LOWER COST ALTERNATIVE USE GENERIC MULTIVITAMIN WITH FLUORIDE AND IRON ESCITALOPRAM SOL LOWER COST ALTERNATIVE USE ESCITALOPRAM CAPSULES ESOMEPRAZOLE DR REQUEST MUST GO THROUGH ESTRADERM PATCH ESTRADIOL TRANSDERMAL PATCH ESTRASORB PACKET ESTRADIOL TRANSDERMAL PATCH ESTRING 2 MG VAGINAL RING USE PREMARIN OR ESTRACE CREAM EVAMIST 1.53 MG/SPRAY ESTRADIOL TRANSDERMAL PATCH EVEKEO TABLET LOWER COST ALTERNATIVE AMPHETAMINE/DEXTROAMPHETAMINE EVOCLIN 1% FOAM CLINDAMYCIN BENZOYL PEROXIDE GEL EVZIO INJ REQUEST MUST GO THROUGH EXALGO ER TABLET REQUEST MUST GO THROUGH EXELDERM CREAM/ SOLUTION MICONAZOLE, CLOTRIMAZOLE CREAM EXELON PATCH RIVASTIGMINE, GALANTAMINE/ER TABLETS EXELON 2 MG/ML ORAL RIVASTIGMINE, GALANTAMINE/ER TABLETS SOLUTIO EXFORGE TABLET LOSARTAN PLUS AMLODIPINE EXFORGE HCT TAB LOSARTAN-HCTZ PLUS AMLODIPINE EXJADE TABLET REQUEST MUST GO THROUGH, EXTAVIA 0.3 MG KIT REQUEST MUST GO THROUGH, EXTINA 2% FOAM MICONAZOLE, CLOTRIMAZOLE CREAM FACTIVE 320 MG TABLET CIPROFLOXACIN FABIOR 0.1% FOAM TAZAROTENE CRM/GEL FANAPT TABLET RISPERIDONE, GEODON, ZYPREXA, SEROQUEL FAZACLO ODT RISPERIDONE, CLOZAPINE FEMECAL OB TABLET PRENATAL VITAMINS WITH IRON FEMRING 0.05 MG VAGINAL RIN USE PREMARIN OR ESTRACE CREAM FEMTRACE TABLET PREMARIN, ESTRADIOL TABLETS FENTANYL CITRATE BUCCAL REQUEST MUST GO THROUGH TABLETS FENTANYL CITRATE OTFC 200 REQUEST MUST GO THROUGH M FENTANYL PATCH REQUEST MUST GO THROUGH FENTORA BUCCAL TABL REQUEST MUST GO THROUGH FERIVA 21-7 TABLET LOWER COST ALTERNATIVE GENERIC MULTIVITAMIN WITH IRON

11 FERIVA FA CAPSULE LOWER COST ALTERNATIVE GENERIC MULTIVITAMIN WITH IRON FERRALET 90 DUAL-IRON FERROUS SULFATE 325 MG TABL TABLE FERRAPLUS 90 TABLET FERROUS SULFATE 325 MG TABL FERREX 28 TABLET FERROUS SULFATE 325 MG TABL FERRIPROX TABLET REQUEST MUST GO THROUGH, FETZIMA ER CAPSULE VENLAFAXINE, SSRI FEXMID 7.5 MG TABLET TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL FEXOFENADINE 30MG, 60MG CETIRIZINE; LORATADINE HCL TABLET FIBRICOR TABLET GENERIC FENOFIBRATE 54MG OR 160MG FINACEA 15% GEL CLINDAMYCIN, ERYTHROMYCIN FINACEA PLUS KIT CLINDAMYCIN GEL FIORICET-COD C FIORINAL, FIORICET FIRAZYR SYRINGE REQUEST MUST GO THROUGH, FLAGYL ER 750 MG TABLET METRONIDAZOLE TAB 500MG &250MG FLEBOGAMMA DIF 5% VIAL REQUEST MUST GO THROUGH, FLECTOR 1.3% PATCH USE VOLTAREN GEL FLO-PRED PREDNISOLONE SOLUTION FLO-PRED ORAL SUSPENSION PREDNISOLONE ORAL SOLUTION FLOVENT INHALER ASMANEX, QVAR, PULMICORT FLEXHALER FLUOR-A-DAY TABLET FLUORITAB 1 MG TABLET CHEW, EPIFLUR 0.25, 0.5MG CHEWABLE FLUOXETINE DR 90 MG CITALOPRAM, FLUOXETINE, SERTRALINE CAPSULE FLUOXETINE HCL TABLET FLUOXETINE 10MG, 20MG, 40MG TABLET FOCALGIN 90 DHA COMBO LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH DHA PACK FOCALIN XR CAPSULE METADATE CD CAPSULE FOLAST TABLET FOLIC ACID FOLCAPS TABLET FOLIC ACID FOLGARD RX TABLET FOLIC ACID FOLIVANE-EC CALCIUM DHA PRENATAL VITAMINS WITH IRON COM FOLIVANE-OB CAPSULE COMPLETE-RF PRENATAL TABLET FOLIVANE-PRX DHA NF PRENATAL VITAMINS WITH IRON CAPSULE FORTAMET ER TABLET METFORMIN EXTENDED RELEASE FORTEO 600 MCG/2.4 ML PEN I REQUEST MUST GO THROUGH, FOSAMAX PLUS D GENRIC ALENDRONATE PLUS VIT D FOSRENOL TABLET CHEW CALCIUM ACETATE 667 MG CAPS FRAGMIN SYRINGE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA FRESHKOTE EYE DROPS REQUEST MUST GO THROUGH FROVA 2.5 MG TABLET IMITREX, AMERGE

12 FULYZAQ 125 MG DR TABLET REQUEST MUST GO THROUGH FUMATINIC ER CAPSULE FERROUS SULFATE 325 MG TABL FUZEON CONVENIENCE KIT REQUEST MUST GO THROUGH, FYCOMPA TABLET REQUEST MUST GO THROUGH GABLOFEN 10,000 MCG/20 ML V REQUEST MUST GO THROUGH GABLOFEN 40,000 MCG/20 ML V REQUEST MUST GO THROUGH GABLOFEN 50 MCG/ML REQUEST MUST GO THROUGH SYRINGE GAMASTAN S/D SYRINGE REQUEST MUST GO THROUGH, GAMASTAN S-D VIAL REQUEST MUST GO THROUGH, GAMMAGARD LIQUID 10% VIAL GAMMAGARD S-D 10 GM VL W/ST GAMMAGARD S-D 2.5 GM VL W/S REQUEST MUST GO THROUGH, REQUEST MUST GO THROUGH, REQUEST MUST GO THROUGH, GAMMAGARD S-D 5 G (IGA<1) S REQUEST MUST GO THROUGH, GAMMAGARD S-D 5 GM VL W/ SET REQUEST MUST GO THROUGH, GAMUNEX 10% VIAL REQUEST MUST GO THROUGH, GAMUNEX-C 1 GRAM/10 ML VIAL GAMUNEX-C 10 GRAM/100 ML VI GAMUNEX-C 2.5 GRAM/25 ML VI GAMUNEX-C 20 GRAM/200 ML VI GAMUNEX-C 5 GRAM/50 ML VIAL REQUEST MUST GO THROUGH, REQUEST MUST GO THROUGH, REQUEST MUST GO THROUGH, REQUEST MUST GO THROUGH, REQUEST MUST GO THROUGH, GATTEX VIAL KIT REQUEST MUST GO THROUGH, GAVILYTE-H AND BISACODYL LOWER COST ALTERNATIVE COLYTE, GOLYTELY, NULYTELY KI GELNIQUE 10% GEL SACHETS OXYBUTYNIN/XL, TROSPIUM 20MG GENVOYA TABLET CLINICAL REQUEST MUST GO THROUGH GIAZO 1.1 GM TABLET GENERIC BALSALAZIDE, PENTASA, ASACOL HD

13 GILENYA 0.5 MG CAPSULE REQUEST MUST GO THROUGH, GILOTRIF TABLET REQUEST MUST GO THROUGH, GLATOPA REQUEST MUST GO THROUGH, GLEEVEC TABLET REQUEST MUST GO THROUGH, GLUMETZA ER TABLET METFORMIN EXTENDED RELEASE GLYXAMBI TABLET REQUEST MUST GO THROUGH GRALISE GABAPENTIN GRANIX SYRINGE REQUEST MUST GO THROUGH, GRASTEK SL TAB REQUEST MUST GO THROUGH GROWTH HORMONES REQUEST MUST GO THROUGH, GUANIDINE HCL 125 MG REQUEST MUST GO THROUGH TABLET HALOG CREAM/ OINTMENT TRIAMCINOLONE, BETAMETHASONE, HARVONI REQUIRES, MEDICATION MUST BE OBTAINED FROM SPECIALTY HELIDAC THERAPY PREVPAC PATIENT PACK HEMANGEOL SOL LOWER COST ALTERNATIVE USE PROPRANOLOL SOLUTION HEMATOGEN FA SOFTGEL FERROUS SULFATE 325 MG TABL HEMATOGEN SOFTGEL FERROUS SULFATE 325 MG TABL HEMOCYTE PLUS CAPSULE FERROUS SULFATE 325 MG TABL HEMOCYTE-F TABLET FERROUS SULFATE 325 MG TABL HEMOPHILIA CLOTTING FACTORS REQUEST MUST GO THROUGH, HEPAGAM B VIAL REQUEST MUST GO THROUGH, HEPAGAM B VIAL REQUEST MUST GO THROUGH, HIZENTRA 1 GRAM/5 ML VIAL REQUEST MUST GO THROUGH, HIZENTRA 2 GRAM/10 ML VIAL REQUEST MUST GO THROUGH, HIZENTRA 4 GRAM/20 ML VIAL REQUEST MUST GO THROUGH, HORIZANT ER TABLET GABAPENTIN HUMALOG 200 UNITS/ML KWIKPEN REQUEST MUST GO THROUGH

14 HUMIRA INJECTION REQUEST MUST GO THROUGH, HYCAMTIN CAPSULE REQUEST MUST GO THROUGH, HYDROCODONE/APAP TAB LOWER COST ALTERNATIVE OXYCODONE/ACETAMINOPHEN, OXYCODONE HYDROCORT BUTY 0.1% LIPO CR HYDROCORTISONE CREAM HYPERRAB S/D SYRINGE REQUEST MUST GO THROUGH, HYPERRAB S-D VIAL REQUEST MUST GO THROUGH, HYPERRHO S-D SYRINGE REQUEST MUST GO THROUGH, HYSINGLA TABLET REQUEST MUST GO THROUGH, IBRANCE CAPSULE REQUEST MUST GO THROUGH, IBUDONE TABLET HYDROCODONE WITH IBUPROFEN TABLETS ILEVRO 0.3% OPHTH DROPS DICLOFENAC, KETOROLAC OPTH SOLUTION IMBRUVICA 140 MG CAPSULE REQUEST MUST GO THROUGH, IMIQUIMOD 5% CREAM REQUIRES PACKET IMMUNE GLOBULIN INJECTION REQUEST MUST GO THROUGH, INCIVEK REQUEST MUST GO THROUGH, INCRELEX 40 MG/4 ML VIAL REQUEST MUST GO THROUGH, INCRUSE ELLIPTA 62.5 MCG IN TUDORZA INHALER INFANATE BALANCE SOFTGEL GENERIC PRENATAL VITAMIN WITH IRON INFANATE CAP PLUS LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLET INFERGEN VIAL REQUEST MUST GO THROUGH, INLYTA REQUIRES INNOHEP 20,000 UNIT/ML VIAL REQUEST MUST GO THROUGH INNOPRAN XL CAPSULE GENERIC PROPRANOLOL ER INOVA EASY PAD BENZOYL PEROXIDE INTERMEZZO ZOLPIDEM, ZALEPLON INTRON A INJECTION REQUEST MUST GO THROUGH, INTUNIV ER TABLET GENERIC GUANFACINE INVEGA ER 1.5 MG TABLET RISPERIDONE INVEGA ER 3 MG TABLET RISPERIDONE INVEGA ER 6 MG TABLET RISPERIDONE

15 INVEGA ER 9 MG TABLET RISPERIDONE INVEGA TABLET RISPERIDONE INVEGA TRINZA CLINICAL REQUEST MUST GO THROUGH INVOKAMET TAB REQUEST MUST GO THROUGH INVOKANA TABLET METFORMIN, PIOGLITAZONE, SULFONYLUREAS, MEGLITINIDES IONSYS PATCH REQUEST MUST GO THROUGH IOPIDINE 0.5% EYE DROPS ALPHAGAN P 0.15% EYE DROPS IQUIX 1.5% EYE DROPS LEVOFLOXACIN OPHTH IRENKA CAPSULE LOWER COST ALTERNATIVE VENLAFAXINE ER CAPSULES IRESSA 250 MG TABLET CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA, MEDICATION MUST BE OBTAINED FROM SPECIALTY ISRADIPINE CAPSULE NIFEDIPINE; AMLODIPINE ISTALOL 0.5% EYE DROPS TIMOPTIC OPHTH SOLUTION JADENU TABLET REQUEST MUST GO THROUGH, JAKAFI REQUEST MUST GO THROUGH, JALYN MG CAPSULE FINASTERIDE PLUS TAMSULOSIN JANUMET XR STEP THERAPY METFORMIN THEN TRADJENTA OR JENTADUETO JANUVIA STEP THERAPY METFORMIN THEN TRADJENTA OR JENTADUETO JARDIANCE TAB STEP THERAPY METFORMIN JENTADUETO STEP THERAPY METFORMIN JUBLIA SOL 10% REQUEST MUST GO THROUGH JUVISYNC MG TABLET METFORMIN, SULFONYLUREA,PIOGLITAZON JUVISYNC MG TABLET METFORMIN, SULFONYLUREA,PIOGLITAZON JUVISYNC MG TABLET METFORMIN, SULFONYLUREA,PIOGLITAZON JUXTAPID CAPSULE REQUEST MUST GO THROUGH KADIAN MORPHINE SULFATE ER 12HR, 24 HR, METHADONE KALYDECO REQUEST MUST GO THROUGH, KAPVAY ER 0.1 MG TABLET CLONIDINE (CATAPRES) KAZANO ,000 MG TABLET STEP THERAPY USE JANUMET + METFORMIN KAZANO MG TABLET STEP THERAPY USE JANUMET + METFORMIN KEFLEX 750 MG CAPSULE CEPHALEXIN 500MG KENALOG AEROSOL SPRAY TRIAMCINOLONE, BETAMETHASONE, KEPPRA XR TABLET LEVETIRACETAM TABLET KEROL AD 45% EMULSION UREA 40% CREAM, LOTION KERYDIN TOPICAL SOLUTION LOWER COST ALTERNATIVE PENLAC, TERBINAFINE KEVEYIS TABLET REQUEST MUST GO THROUGH KINERET 100 MG/0.67 ML SYR REQUEST MUST GO THROUGH, KIONEX 15 GM/60 ML SUSPENSI CALCIUM ACETATE 667 MG CAPS KITABIS PAK REQUEST MUST GO THROUGH, KOGENATE FS VIAL

16 KORLYM REQUIRES K-PHOS #2 TABLET K-PHOS NEUTRAL TABLET K-PHOS M.F. TABLET K-PHOS NEUTRAL TABLET KUVAN REQUEST MUST GO THROUGH, KYNAMRO 200 MG/ML SYRINGE REQUEST MUST GO THROUGH LACRISERT 5 MG EYE INSERT ARTIFICIAL TEARS LAMICTAL ODT TABLET LAMOTRIGINE TABLET LAMICTAL XR TABLET LAMOTRIGINE TABLET LAMISIL GRANULES PAC TERBINAFINE HCL 250 MG TABL LANSOPRAZOLE ODT TABLET LANSOPRAZOLE DR CAPSULES LASTACAFT 0.25% EYE DROPS USE KETOTIFEN, PATADAY LATUDA ALL STRENGTHS OLANZAPINE, RISPERIDONE, ZIPRASIDONE LATUDA TABLET OLANZAPINE, RISPERIDONE, ZIPRASIDONE LENVIMA CAPSULE REQUEST MUST GO THROUGH, LESCOL CAPSULE SIMVASTATIN, ATORVASTATIN LESCOL XL 80 MG TABLET SIMVASTATIN, ATORVASTATIN LETAIRIS TABLET REQUEST MUST GO THROUGH, LEUKINE VIAL REQUEST MUST GO THROUGH, LEVATOL 20 MG TABLET ATENOLOL, BISOPROLOL, METOPROLOL LEVORPHANOL 2 MG TABLET MORPHINE SULFATE, OXYCODONE LEXAPRO TABLET/ SOLUTION CITALOPRAM, FLUOXETINE, SERTRALINE LIALDA DR TABLET ASACOL EC 400 MG TABLET LIDODERM 5% PATCH REQUEST MUST GO THROUGH LIDOVIR 4%-4% ACYCLOVIR OINTMENT LINDANE LOTION/ SHAMPOO STEP THERAPY FAILURE OF PERMETHRIN/RID LINZESS 145 MCG CAPSULE LACTULOSE, PEG LINZESS 290 MCG CAPSULE LACTULOSE, PEG LIORESAL IT 0.05 MG/1 ML AM REQUEST MUST GO THROUGH LIORESAL IT 10 MG/20 ML KIT REQUEST MUST GO THROUGH LIORESAL IT 10 MG/5 ML KIT REQUEST MUST GO THROUGH LIPOFEN CAPSULE GENERIC FENOFIBRATE 54MG OR 160MG LIPTRUZET TABLET ATORVASTATIN, SIMVASTATIN LITHOSTAT 250 MG TABLET REQUEST MUST GO THROUGH LIVALO TABLET SIMVASTATIN LMX 4 PLUS KIT LIDOCAINE OINT, LMX 4 4%CREAM LODOSYN 25 MG TABLET SINEMET CR LOFIBRA GENERIC FENOFIBRATE 54MG OR 160MG LO MINASTRIN FE TABLET CHEW GENERIC ETHINYL ESTRADIOL/ NORETHINDRONE LONSURF TABLET CLINICAL REQUEST MUST GO THROUGH LORZONE CHLORZOXAZONE 500MG, TIZANIDINE, CARISPRODOL LOTRISONE CLOTRIMAZOLE CRM SOLUTION LOTRONEX TABLET STEP THERAPY FAILURE OF METAMUCIL,PSYLLIUM, DICYCLOMINE LOVAZA 1 GM CAPSULE GENERIC FISH OIL CAPSULES LOVENOXPREFILLED SYR REQUEST MUST GO THROUGH

17 LUMIGAN EYE DROPS LATANAPROST LUMINAL 130 MG/ML REQUEST MUST GO THROUGH CARPUJECT LUNESTA TABLET ZOLPIDEM, ZALEPLON LUVOX CR CAPSULE CITALOPRAM, FLUOXETINE, SERTRALINE LUXIQ 0.12% FOAM TRIAMCINOLONE, BETAMETHASONE, LYNPARZA CAPSULE REQUEST MUST GO THROUGH, LYRICA CAPSULE GABAPENTIN MAGNACET MG TABLET OXYCODONE WITH ACETOMINOPHEN MAGNEBIND RX TABLET CALCIUM ACETATE 667 MG CAPS MARNATAL-F CAPSULE LACTOCAL-F TABLET MAXAIR AUTOHALER 0.2 MG PRO-AIR HFA AER MAXALT TABLET IMITREX, AMERGE MAXALT MLT TABLET IMITREX, AMERGE MAXIDONE MG TABLET OXYCODONE WITH ACETOMINOPHEN MAXIFED-G CD TABLET GUAIFENESIN-CODEINE SYRUP MAXIFLU CD TABLET PSEUDOEPHEDRINE, ACETOMINOPHEN TABLETS MEBARAL TABLET PHENOBARBITAL MEFENAMIC ACID 250 MG USE NAPROXEN, DICLOFENAC, ETODOLAC CAPSU MEGACE ES 625 MG/5 ML SUSP MEGESTROL ACET 40 MG/ML SUS MEKINIST TABLET REQUEST MUST GO THROUGH, M-END PE LIQUID PROMETHAZINE VC-CODEINE SYR MENEST TABLET PREMARIN, ESTRADIOL TABLETS MENTAX 1% CREAM MICONAZOLE, CLOTRIMAZOLE CREAM METANX TABLET FOLIC ACID METAXALONE 800 MG TABLET TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL METOZOLV ODT TABLET METOCLOPRAMIDE, TABLETS, SOLUTION MICARDIS HCT TABLET LOSARTAN-HCTZ MICARDIS TABLET LOSARTAN OR ACE-INHIBITOR MILLIPRED DP SOLUTION/ PREDNISOLONE DOSE PACK MINASTRIN 24 FE CHEWABLE TA GENERIC ORAL CONTRACEPTIVE WITH IRON MIRAPEX ER TABLET PRAMIPEXOLE IMMEDIATE RELEASE TABLET MOLINDONE TABLET LOWER COST ALTERNATIVE RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE MONUROL 3 GM SACHET CEPHALOSPORIN, CIPROFLOXACIN MOTOFEN TABLET REQUEST MUST GO THROUGH MOVANTIK CAPSULE LOWER COST ALTERNATIVE MIRALAX, LACTULOSE MOVIPREP POWDER KIT COLYTE, GOLYTELY, NULYTELY MOXATAG ER 775 MG TABLET AMOXICILLIN 500 MG TABLET MOXEZA 0.5% EYE DROPS CIPROFLOXACIN 0.3% EYE DROP MUCINEX COLD & SINUS GUAIFENESIN SYRUP MUCINEX COLD-FLU & SORE THROAT GUAIFENESIN/DEXTROMETHORPHAN/ PHENYLEPHRINE MYCOLOG II NYSTATIN CRM OINT

18 MYTELASE 10 MG CAPLET NEOSTIGMINE, PYRIDOSTIGMINE NAFTIN CLOTRIMAZOLE, KETOCONAZOLE TOPICAL NAFTIN 1% CREAM/GEL MICONAZOLE, CLOTRIMAZOLE CREAM NAFTIN 2% GEL CLOTRIMAZOLE CRM SOLUTION, MICONAZOLE CRM NALFON 200 MG PULVULE FENOPROFEN, OTHER GENERIC NSAIDS, NALFON CAPSULE USE NAPROXEN, DICLOFENAC, ETODOLAC NAMZARIC ER LOWER COST ALTERNATIVE MEMANTINE, DONEPEZIL NAPRELAN CR USE NAPROXEN, DICLOFENAC, ETODOLAC NASACORT AQ NASAL SPRAY FLUNISOLIDE, FLUTICASONE NASCOBAL 500 MCG NASAL CYANOCOBALAMIN 1,000 MCG/ML SPRA NASONEX 50 MCG NASAL FLUNISOLIDE, FLUTICASONE SPRAY NATACYN EYE DROPS REQUEST MUST GO THROUGH NATELLE ONE CAPSULE PRENATAL VITAMINS WITH IRON NATESTO NASAL REQUEST MUST GO THROUGH NATPARA POWDER FOR INJECTION REQUEST MUST GO THROUGH, NATROBA 0.9% TOPICAL SUSP OVIDE, PERMETHRIN, LICE TREATMENT NEEVO DHA GELCAP PRENATAL VITAMINS WITH IRON NEOBENZ MICRO CREAM/ BENZOYL PEROXIDE 5% OR 10% LOTION WASH PLUS PAC NEO-SYNALAR CREAM LOWER COST ALTERNATIVE USE TRIAMCINOLONE, BETAMETHASONE, NEPHPLEX RX TABLET FOLIC ACID NEPHROCAPS QT TABLET REQUEST MUST GO THROUGH NEPHRON FA TABLET FERROUS SULFATE 325 MG TABL NESINA 12.5 MG TABLET STEP THERAPY MUST HAVE TRIED METFORMIN, SULFONYLUREAS, PIOGLITAZONE NESINA 25 MG TABLET STEP THERAPY MUST HAVE TRIED METFORMIN, SULFONYLUREAS, PIOGLITAZONE NESINA 6.25 MG TABLET STEP THERAPY MUST HAVE TRIED METFORMIN, SULFONYLUREAS, PIOGLITAZONE NESTABS ABC PRENATAL GENERIC PRENATAL VITAMIN WITH IRON COMBO NEUAC KIT LOWER COST ALTERNATIVE USE CLINDAMYCIN/BENZOYL PEROXIDE NEULASTA 6 MG/0.6 ML SYRING REQUEST MUST GO THROUGH NEUMEGA 5 MG VIAL REQUEST MUST GO THROUGH NEUPOGEN INJECTION REQUEST MUST GO THROUGH NEVANAC 0.1% DROPTAINER DICLOFENAC, KETOROLAC OPTH SOLUTION NEXA SELECT CAPSULE PRENATAL VITAMINS WITH IRON NEXA SELECT SOFTGEL PRENATAL VITAMINS WITH IRON NEXAVAR 200 MG TABLET REQUEST MUST GO THROUGH NEXICLON SUSPENSION/ LOSARTAN OR ACE-INHIBITOR TABLET NEXICLON XR 0.09 MG/ML SUSP CLONIDINE TABLETS NEXICLON XR 0.17 MG TABLET CLONIDINE TABLETS NEXIUM OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE, NEXIUM OTC NEXIUM DR 10 MG PACKET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. NEXIUM DR 20 MG CAPSULE OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. NEXIUM DR 20 MG PACKET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.

19 NEXIUM DR 40 MG CAPSULE OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. NEXIUM DR 40 MG PACKET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. NIASPAN ER TABLET GENERIC ER NIACIN NICOTROL CARTRIDGE REQUEST MUST GO THROUGH INHALER NICOTROL NS 10 MG/ML SPRAY REQUEST MUST GO THROUGH NINLARO CAPSULE CLINICAL REQUEST MUST GO THROUGH, NOROXIN 400 MG TABLET CIPROFLOXACIN NORTHERA CAP REQUEST MUST GO THROUGH NOXAFIL 40 MG/ML FLUCONAZOLE, ITRACONAZOLE, SUSPENSION NOXAFIL DR 100 MG TABLET ITRACONAZOLE, VORICONAZOLE NUCYNTA ER TRAMADOL ER NUCYNTA TABLET TRAMADOL HCL TABLET NUEDEXTA MG CAPSULE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA NUOX GEL BENZOYL PEROXIDE 5% OR 10% LOTION NUVESSA VAGINAL GEL LOWER COST ALTERNATIVE METRONIDAZOLE GEL NUVIGIL 150 MG TABLET NARCOLEPSY, SLEEP APNEA, HYPERSOMNIA NUVIGIL 250 MG TABLET NARCOLEPSY, SLEEP APNEA, HYPERSOMNIA NUVIGIL 50 MG TABLET NARCOLEPSY, SLEEP APNEA, HYPERSOMNIA NYDAMAX 0.75% GEL METROLOTION TOPICAL 0.75%, NYMALIZE 60 MG/20 ML SOLUTI NIMODIPINE TABLETS OB COMPLETE PRENATAL VITAMINS WITH IRON OB COMPLETE PETITE SOFTGEL GENERIC PRENATAL VITAMINS ODOMZO CLINICAL REQUEST MUST GO THROUGH, OFEV CAPSULE REQUEST MUST GO THROUGH OLEPTRO ER 150 MG TABLET TRAZODONE OLEPTRO ER 300 MG TABLET TRAZODONE OLYSIO 150 MG CAPSULE REQUEST MUST GO THROUGH, OMECLAMOX-PAK COMBO PREV-PAK PACK 20(20)-500 OMEPRAZOLE-BICARB 40-1,100 OMEPRAZOLE; PLUS SODIUM BICARB. OMNARIS 50 MCG NASAL SPRAY FLUNISOLIDE, FLUTICASONE ONEXTON 1.2%-3.75% GEL LOWER COST ALTERNATIVE CLINDAMYCIN/BENZOYL PEROXIDE GEL ONEXTON GEL PUMP LOWER COST ALTERNATIVE CLINDAMYCIN/BENZOYL PEROXIDE GEL ONFI TABLET REQUEST MUST GO THROUGH ONGLYZA MUST HAVE TRIED METFORMIN, SULFONYLUREAS, PIOGLITAZONE ONMEL 200 MG TABLET ITRACONAZOLE 100 MG TABLETS ONSOLIS SOLUBLE FILM REQUEST MUST GO THROUGH OPANA TABLET OXYMORPHONE TABLETS OPANA ER TABLET REQUEST MUST GO THROUGH OPIUM TINCTURE 10 MG/ML AUTO APPROVE OPSUMIT 10 MG TABLET REQUEST MUST GO THROUGH, ORACEA 40 MG CAPSULE DOXYCYCLINE 50MG CAPSULE

20 ORALAIR REQUEST MUST GO THROUGH, ORAPRED ODT TABLET PREDNISOLONE ORAVIG 50 MG BUCCAL TABLET NYSTATIN 100,000 UNITS/ML S ORENCIA INJECTION REQUEST MUST GO THROUGH ORENCIA SYRINGE REQUEST MUST GO THROUGH, ORFADIN CAPSULE REQUEST MUST GO THROUGH ORKAMBI REQUEST MUST GO THROUGH, ORPHENADRINE COMP FORTE TAB TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL ORPHENADRINE COMP TABLET TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL OSENI MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OTREXUP AUTO-INJ REQUEST MUST GO THROUGH, OTREXUP INJ LOWER COST ALTERNATIVE METHOTREXATE INJ OVACE PLUS 10% WASH SODIUM SULFACETAMIDE WASH 10% OVACE PLUS LOT 9.8% LOWER COST ALTERNATIVE USE SODIUM SULFACETAMIDE WASH 10% OXANDROLONE 10 MG TABLET REQUEST MUST GO THROUGH OXANDROLONE 2.5 MG TABLET REQUEST MUST GO THROUGH OXECTA OXYCODONE GENERIC TABLET OXISTAT 1% CREAM/LOTION MICONAZOLE, CLOTRIMAZOLE CREAM OXSORALEN 1% LOTION REQUEST MUST GO THROUGH OXYTROL FOR WOMEN 3.9 OXYBUTYNIN/ER, TROSPIUM TABLETS MG/24 OXYCODONE-IBUPROFEN HYDROCODONE WITH IBUPROFEN TABLETS T OXYCONTIN TABLET REQUEST MUST GO THROUGH OXYMORPHONE HCL ER TAB METHADONE, MORPHINE SULF ER OXYTROL 3.9 MG/24HR PATCH OXYBUTYNIN/XL, TROSPIUM 20MG PACNEX HP 7% CLEANSING BENZOYL PEROXIDE SOLUTION PADS PACNEX LP 4.25% CLEANSING P BENZOYL PEROXIDE SOLUTION PACNEX MX 4.25% CLEANSER BENZOYL PEROXIDE SOLUTION PACNEX WASH/PADS BENZOYL PEROXIDE 5% OR 10% LOTION PAIRE OB PLUS DHA COMBO PRENATAL VITAMINS WITH IRON PAC PALGIC 4 MG TABLET CETIRIZINE; LORATADINE

21 PANDEL 0.1% CREAM TRIAMCINOLONE, BETAMETHASONE, PANRETIN 0.1% GEL TRIAMCINOLONE, BETAMETHASONE, PARCOPA ODT CARBIDOPA-LEVO MG ODT PAROXETINE CR TABLET CITALOPRAM, FLUOXETINE, SERTRALINE PATANASE 0.6% NASAL SPRAY ASTEPRO 0.15% NASAL SPRAY PATANOL 0.1% EYE DROPS USE KETOTIFEN, PATADAY PAZEO EYE DROPS LOWER COST ALTERNATIVE KETOTIFEN, PATADAY PEDIADERM AF KIT NYSTATIN CREAM, OINTMENT PEDIADERM TOPICAL TRIAMCINOLONE, BETAMETHASONE, PEDIPIROX-4 CICLOPIROX 8%/VITAMIN E KIT PEGASYS VIAL REQUEST MUST GO THROUGH, PEGINTRON INJECTION REQUEST MUST GO THROUGH, PENNSAID 1.5% SOLUTION USE VOLTAREN GEL PENTAM 300 VIAL REQUEST MUST GO THROUGH PENTAZOCIN-ACETAMINOPHN OXYCODONE WITH ACETOMINOPHEN PERFOROMIST SEREVENT PEXEVA TABLET CITALOPRAM, FLUOXETINE, SERTRALINE PHOSLYRA SOLUTION CALCIUM ACETATE 667MG TABLET PICATO REQUEST MUST GO THROUGH PLEGRIDY REQUEST MUST GO THROUGH, PLEXION CLEANSING CLOTHS CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL PNV-DHA PLUS SOFTGEL PRENATAL VITAMINS WITH IRON PNV FOLIC ACID + IRON GENERIC PRENATAL VITAMIN WITH IRON TABLET PNV-IRON TABLET LACTOCAL-F TABLET POLY IRON PN FORTE TABLET PRENATAL VITAMINS WITH IRON POMALYST 1 MG CAPSULE REQUEST MUST GO THROUGH POLY-VI-FLOR LOWER COST ALTERNATIVE USE GENERIC MULTIVITAMIN WITH FLUORIDE POMALYST 2 MG CAPSULE REQUEST MUST GO THROUGH POMALYST 3 MG CAPSULE REQUEST MUST GO THROUGH POMALYST 4 MG CAPSULE REQUEST MUST GO THROUGH POTASSIUM CL 25 MEQ TAB EFF KLOR-CON 25 MEQ PACKET POTIGA ALL STRENGTHS REQUEST MUST GO THROUGH PRADAXA CAPSULE REQUEST MUST GO THROUGH PRALUENT REQUEST MUST GO THROUGH, PRANDIMET TABLET SULPHONYLUREA PLUS METFORMIN PRASCION RA CREAM CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL PREFERA-OB PLUS DHA USE GENERIC PRENATAL VITAMIN WITH DHA COMBO P PREGNYL 10,000 UNITS VIAL REQUEST MUST GO THROUGH,

22 PRENACARE TABLET COMPLETE-RF PRENATAL TABLET PRENAISSANCE NEXT PRENATAL VITAMINS WITH MINERALS PRENAISSANCE NEXT-B TABLET PRENATAL VITAMIN GENERIC PRENATE AM TABLET GENERIC PRENATAL VITAMIN WITH IRON PRENATE DHA SOFTGEL LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLET PRENATE ESSENTIAL SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN PRENATE MINI SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN PRENATE PIXIE LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLET PRENATE SOFTGEL PRENATAL VITAMIN GENERIC PRENATE SOFTGEL/ TABLET PRENATAL VITAMINS WITH IRON PRENATE STAR TABLET LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLET PRENEXA CAPSULE PRENATAL VITAMINS WITH IRON PREQUE 10 TABLET PRENATAL VITAMINS WITH IRON PRIFTIN 150 MG TABLET REQUEST MUST GO THROUGH PRIMLEV TABLET OXYCODONE WITH ACETOMINOPHEN PRIMSOL 50 MG/5 ML ORAL SOL CEPHALOSPORIN, CIPROFLOXACIN PRISTIQ TABLET VENLAFAXINE ER CAPSULES PRIVIGEN 10% VIAL REQUEST MUST GO THROUGH, PROAIR RESPICLICK INHAL PROAIR HFA 90 MCG INHALER POW PROBARIMIN QT TABLET MULTIVITAMIN GENERIC PROCENTRA 5 MG/5 ML SOLUTIO AMPHETAMINE, DEXTROAMPHETAMINE, ADDERALL XR PROCRIT 10,000 UNITS/ML VIAL REQUEST MUST GO THROUGH, PROCRIT 2,000 UNITS/ML VIAL REQUEST MUST GO THROUGH, PROCRIT 20,000 UNITS/ML VIA REQUEST MUST GO THROUGH, PROCRIT 3,000 UNITS/ML VIAL REQUEST MUST GO THROUGH, PROCRIT 4,000 UNITS/ML VIAL REQUEST MUST GO THROUGH, PROCRIT 40,000 UNITS/ML VIA REQUEST MUST GO THROUGH, PROLENSA 0.07% EYE DROPS BROMFENAC OPHTH, KETOROLAC OPHTH PROLEUKIN 22 MILLION UNIT V REQUEST MUST GO THROUGH, PROMACTA 12.5MG REQUEST MUST GO THROUGH PROMACTA TABLET REQUEST MUST GO THROUGH PROPARACAINE 0.5% EYE TETRACAINE OPHTH SOLUTION DROPS PROQUIN XR 500 MG TABLET CIPROFLOXACIN PRO-RED AC SYRUP CODEINE, ANTIHISTAMINE, PHENYLEPHRINE COMBINATION PROSED-DS TABLET URELLE TABLET

23 PROTONIX 40 MG SUSPENSION OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. PROTOPIC OINTMENT TRIAMCINOLONE, BETAMETHASONE, PROVENTIL HFA 90 MCG PROAIR HFA 90 MCG INHALER INHALE PROVIDA DHA CAPSULE LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH DHA PROVIDA OB CAPSULE GENERIC PRENATAL VITAMIN WITH IRON PROVIGIL TABLET REQUEST MUST GO THROUGH PULMOZYME AMPUL REQUEST MUST GO THROUGH PV VITAMIN D 400 UNIT TABLET PRENATAL VITAMIN GENERIC PYLERA CAPSULE PREVPAC PATIENT PACK QNASL 80 MCG FLUTICASONE, FLUNISOLIDE NASAL SPRAY QUDEXY XR CAP LOWER COST ALTERNATIVE USE TOPIRAMATE QUFLORA PEDIATRIC LOWER COST ALTERNATIVE USE MULTIVITAMINS/FLUORIDE DROPS QUARTETTE TABLET EE/LEVONORGESTREL GENERIC QUILLIVANT XR 25 MG/5 ML SU GENERIC METHYLPHENIDATE WITH SPRINKLE CAPABILITY (METADATE CD) QUIXIN 0.5% EYE DROPS LEVOFLOXACIN OPHTH RAGWITEK SUB REQUEST MUST GO THROUGH RAPAFLO CAPSULE TAMSULOSIN, TERAZOSIN AND DOXAZOSIN. RASUVO INJ REQUEST MUST GO THROUGH REBETOL 40 MG/ML SOLUTION REQUEST MUST GO THROUGH, REBIF REBIDOSE 22 MCG/0.5 M REQUEST MUST GO THROUGH, REBIF REBIDOSE 44 MCG/0.5 M REQUEST MUST GO THROUGH, REBIF REBIDOSE TITRATION PA REQUEST MUST GO THROUGH, REBIF SYRINGE REQUEST MUST GO THROUGH, RECTIV ANUSOL HC OINTMENT REGRANEX 0.01% GEL REQUEST MUST GO THROUGH RELPAX TABLET IMITREX, AMERGE REMICADE 100 MG VIAL REQUEST MUST GO THROUGH, REMODULIN INJECTION REQUEST MUST GO THROUGH, RENAGEL TABLET CALCIUM ACETATE 667 MG CAPS RENVELA POWDER/TABLET CALCIUM ACETATE 667 MG CAPS REPATHA REQUEST MUST GO THROUGH, REPREXAIN TABLET HYDROCODONE WITH IBUPROFEN TABLETS REQUIP XL TABLET REQUIP IMMEDIATE RELEASE TABLET RESCULA 0.15% EYE DROPS LATANOPROST OPHTH SOLUTION RETIN-A MICR GEL 0.08% LOWER COST ALTERNATIVE USE TRETINOIN CREAM, GEL

24 REVATIO INJECTION AND TABLETS REQUEST MUST GO THROUGH, REVATIO SUS REQUEST MUST GO THROUGH REVLIMID 20 MG CAPSULE REQUEST MUST GO THROUGH, REVLIMID CAPSULE REQUEST MUST GO THROUGH REXULTI TABLET REQUEST MUST GO THROUGH RHINARIS NASAL GEL SODIUM CHLORIDE NASAL SOLUTION RHINOCORT AQUA NASAL FLUNISOLIDE, FLUTICASONE SPRAY RHOPHYLAC 300 MCG/2 ML SYR REQUEST MUST GO THROUGH, RIBAPAK REQUEST MUST GO THROUGH, RIBASPHERE TABLET REQUEST MUST GO THROUGH, RIBAVIRIN REQUEST MUST GO THROUGH, RIFAMATE CAPSULE RIFAMPIN 300 MG PLUS ISONIAZID RILUTEK 50 MG TABLET REQUEST MUST GO THROUGH, RITALIN LA 60MG LOWER COST ALTERNATIVE METADATE CD, CONCERTA RITALIN LA 10MG LOWER COST ALTERNATIVE METADATE CD, CONCERTA RITUXAN 10 MG/ML VIAL REQUEST MUST GO THROUGH, RIXUBIS INFUSION MEDICATION MUST BE OBTAINED FROM SPECIALTY ROSULA WASH LOWER COST ALTERNATIVE SULFACETAMIDE/SULFUR CREAM, GEL, LOTION, PADS ROVIN-A DHA PRENATAL VITAMINS WITH MINERALS ROVIN-NV DHA CAPSULE PRENATAL VITAMINS WITH IRON ROZEREM TABLET ZOLPIDEM, ZALEPLON RYBIX ODT 50 MG TABLET TRAMADOL HCL TABLET RYNATAN PEDIATRIC RYNATAN PEDIATRIC ORAL SUSP CHEWABLE RYTARY ER LOWER COST ALTERNATIVE CARBIDOPA/LEVODOPA ER TABLET RYZOLT LOWER COST ALTERNATIVE CARBIDOPA/LEVODOPA ER TABLET RYZOLT ER TABLET TRAMADOL HCL TABLET SABRIL 500 MG TABLET\ POWDER CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA SAIZEN 5 MG VIAL REQUEST MUST GO THROUGH, SAIZEN 8.8 MG CLICK.EASY CA REQUEST MUST GO THROUGH,

25 SAIZEN 8.8 MG VIAL REQUEST MUST GO THROUGH, SALKERA 6% FOAM SALICYLIC ACID 6% LOTION KI SAMSCA TABLET REQUEST MUST GO THROUGH SANCTURA 20 MG TABLET STEP THERAPY FAILURE OXYBUTYNIN/ER SANCTURA XR 60 MG CAPSULE OXYBUTYNIN/XL, TROSPIUM 20MG SANCUSO 3.1 MG/24 HR PATCH ONDANSETRON/ODT, GRANISETRON SAPHRIS TABLET SUBLING RISPERIDONE, GEODON, ZYPREXA, SEROQUEL SAVAYSA TABLET REQUST MUST GO THROUGH SAVELLA TABLET GABAPENTIN SCOPACE 0.4 MG TABLET MECLIZINE TABLET SE-CARE TABLET PRENATAL VITAMINS WITH IRON SELECT-OB CHEWABLE CAPLET LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLET SENSIPAR TABLET REQUEST MUST GO THROUGH SEROMYCIN 250 MG CAPSULE RIFAMPIN 300 MG PLUS ISONIAZID SEROQUEL XR GENERIC QUETIAPINE IR SEROSTIM INJECTION REQUEST MUST GO THROUGH, SE-TAN CAPSULE FERROUS SULFATE 325 MG TABL SIGNIFOR 0.3 MG/ML AMPULE REQUEST MUST GO THROUGH SIGNIFOR 0.6 MG/ML AMPULE REQUEST MUST GO THROUGH SIGNIFOR 0.9 MG/ML AMPULE REQUEST MUST GO THROUGH SILENOR TABLET ZOLPIDEM, ZALEPLON, TEMAZEPAM SIMBRINZA 1%-0.2% EYE DROPS DORZOLAMIDE/TIMOLOL OPHTH SIMCOR TABLET NIACIN PLUS SIMVASTATIN SIMPONI 50 MG/ML SYRINGE REQUEST MUST GO THROUGH, SIMPONI INJECTION REQUEST MUST GO THROUGH, SINGULAIR TAB/GRAN/CHEW STEP THERAPY FAILURE OF INHALED STEROID SINUS RELIEF CONGESTION & OTC DECONGESTANT/ACETOMINOPHEN PAIN SIRTURO 100 MG TABLET REQUEST MUST GO THROUGH SITAVIG TAB LOWER COST ALTERNATIVE USE ABREVA, ORAL ACYCLOVIR SIVEXTRO TAB REQUEST MUST GO THROUGH SKELID 200 MG TABLET GENRIC ALENDRONATE SOLARAZE 3% GEL CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA SOLODYN ER TABLET MINOCYCLINE 75MG, 100 MG CAPSULE SOMA 250 MG TABLET TIZANIDINE TABLET; CARISOPRODOL TABLET SOMAVERT INJECTION REQUEST MUST GO THROUGH SORIATANE CAPSULE REQUEST MUST GO THROUGH SORILUX 0.005% FOAM DOVONEX OINT, CREAM SOTYLIZE SOLUTION LOWER COST ALTERNATIVE SOTALOL TABLETS SOVALDI 400 MG TABLET REQUEST MUST GO THROUGH, SPECTRACEF DOSE PACK CEFPODOXIME PROXETIL SPIRIVA HANDIHALER TUDORZA, INCRUSE ELLIPTA

26 SPIRIVA RESPIMAT REQUEST MUST GO THROUGH SPORANOX 10 MG/ML REQUEST MUST GO THROUGH SOLUTION SPRYCEL TABLET REQUEST MUST GO THROUGH, STAVZOR DR CAPSULE DEPAKOTE ER 500 MG TABLET STIOLTO RESPIMAT TUDORZA INHALER STIMATE 1.5 MG/ML NASAL SPR REQUEST MUST GO THROUGH STIVARGA 40 MG TABLET REQUEST MUST GO THROUGH, STRATTERA CAPSULE STEP THERAPY FAILURE OF METHYLPHENIDATE, AMPHETAMINE PRODUCT STRIANT 30 MG MUCOADHESIVE CLINICAL/STEP REQUEST MUST GO THROUGH, REQUIRES LAB VALUES STRIBILD TABLETS ALL REQUEST MUST GO THROUGH STRENGTHS STRIVERDI AER RESPIMAT LOWER COST ALTERNATIVE USE SERVENT SUBOXONE TABLET REQUEST MUST GO THROUGH SUBOXONE 12 MG-3 MG SL REQUEST MUST GO THROUGH FILM SUBOXONE 4 MG-1 MG SL FILM REQUEST MUST GO THROUGH SUBSYS FENTANYL SOLUTION MORPHINE SULFATE SOLUTION SUCRAID 8,500 UNITS/ML SOLN REQUEST MUST GO THROUGH SULFAMYLON POWDER PACKET CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL SUMADAN SULFACETAMIDE SOLUTION SUMADAN SULFACETAMIDE TOPICAL LOTION SUMADAN LOTION SULFACETAMIDE SODIUM LOTION SUMAVEL DOSEPRO 6 MG/0.5 SUMATRIPTAN INJECTION, TABLETS ML SUMAXIN CP SULFACETAMIDE TOPICAL LOTION SUMAXIN PADS/WASH CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL SUMAXIN TS TOPICAL SULFACETAMIDE SOLUTION SUSPENSI SUPRAX SUSPENSION CEFPODOXIME PROXETIL SUPRAX 100 MG TABLET CHEWABLE GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME) SUPRAX 200 MG TABLET CHEWABLE GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME) SUPRAX 400 MG TABLET CEFPODOXIME PROXETIL SUPRAX CAPSULE, SUSPENSION CEFPODOXIME SUSPENSION/CAPSULES SUPREP BOWEL PREP KIT COLYTE, GOLYTELY, NULYTELY SUTENT CAPSULE REQUEST MUST GO THROUGH SYLATRON REQUEST MUST GO THROUGH, SYLVANT SOL REQUEST MUST GO THROUGH SYMBYAX CAPSULE ZYPREXA PLUS FLUOXETINE SYMLIN 0.6 MG/ML VIAL REQUEST MUST GO THROUGH SYMLINPEN PEN/VIAL STEP THERAPY FAILURE OF INSULIN THERAPY

27 SYNAGIS INJECTION REQUEST MUST GO THROUGH, SYNALGOS-DC CAPSULE CODEINE WITH ACETOMINOPHEN, SYNAREL 2 MG/ML NASAL REQUEST MUST GO THROUGH SPRAY SYNERCID 500 MG VIAL REQUEST MUST GO THROUGH SYNJARDY TABLET REQUEST MUST GO THROUGH SYPRINE 250 MG CAPSULE REQUEST MUST GO THROUGH TAFINLAR CAPSULE REQUEST MUST GO THROUGH, TAGRISSO TABLET CLINICAL REQUEST MUST GO THROUGH, TANZEUM INJ REQUEST MUST GO THROUGH TARCEVA TABLET REQUEST MUST GO THROUGH, TARON EC CALCIUM DHA PRENATAL VITAMINS WITH IRON COMB P TARON-DUO EC COMB PACK PRENATAL VITAMINS WITH IRON TARON-EC CAL TABLET PRENATAL VITAMINS WITH IRON TARON-PREX PRENATAL DHA PRENATAL VITAMINS WITH IRON CAP TASIGNA CAPSULE REQUEST MUST GO THROUGH, TECFIDERA REQUEST MUST GO THROUGH, TECHNIVIE REQUEST MUST GO THROUGH, TEKTURNA HCT TABLET STEP THERAPY FAILURE ACE/ARB TEKTURNA TABLET STEP THERAPY FAILURE ACE/ARB TEMODAR CAPSULE REQUEST MUST GO THROUGH, TEVETEN TABLET LOSARTAN OR ACE-INHIBITOR TEV-TROPIN 5 MG VIAL REQUEST MUST GO THROUGH, THALOMID CAPSULE REQUEST MUST GO THROUGH, THEROBEC TABLET FOLBEE PLUS THRIVITE 19 TABLET LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN TINDAMAX TABLET METRONIDAZOLE 250 MG TABLET TIROSINT CAPSULE GENERIC LEVOTHYROXINE TL-ASSURE + DHA PRENATAL VITAMINS WITH MINERALS TL-SELECT DHA SOFTGEL GENERIC PRENATAL VITAMINS TOBI PODHALER 28 MG INHALE REQUEST MUST GO THROUGH,

28 TOBI PODHALER INHALER REQUEST MUST GO THROUGH, TOLMETIN SODIUM 600 MG USE NAPROXEN, DICLOFENAC, ETODOLAC TAB TOPICORT 0.25% SPRAY BETAMETHASONE CRM/LOT, DESOXIMETASONE CRM TOPICORT GEL LOWER COST ALTERNATIVE USE BETAMETHASONE TOPIRAMATE CAP ER LOWER COST ALTERNATIVE USE TOPIRAMATE TOUJEO SOLOSTAR REQUEST MUST GO THROUGH TOVIAZ ER TABLET OXYBUTYNIN/XL, TROSPIUM 20MG TRACLEER TABLET REQUEST MUST GO THROUGH, TRADJENTA TABLET STEP THERAPY METFORMIN TRAVATAN Z 0.004% EYE DROP LATANAPROST TRAVOPROST 0.004% EYE DROP LATANOPROST OPHTH SOL TRESIBA FLEXTOUCH CLINICAL REQUEST MUST GO THROUGH TREXIMET MG TABLET SUMATRIPTAN AND NAPROXEN TABLETS TRIANEX OINTMENT LOWER COST ALTERNATIVE TRIAMCINOLONE, BETAMETHASONE, TRIAZ PAD/FOAM TRIAZ CLEANSER TRIBENZOR TABLET LOSARTAN-HCTZ PLUS AMLODIPINE TRICARE PRENATAL COMPLEAT P PRENATAL VITAMIN GENERIC IN WITH IRON TRICARE PRENATAL TABLET PRENATAL VITAMINS WITH IRON TRICOR TABLET GENERIC FENOFIBRATE 54MG OR 160MG TRIGLIDE TABLET GENERIC FENOFIBRATE 54MG OR 160MG TRILIPIX DR CAPSULE GENERIC FENOFIBRATE 54MG OR 160MG TRI-LUMA CREAM RETIN A CREAM/GEL TRIMESIS RX TABLET PRENATAL VITAMINS WITH IRON TRISTART DHA SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH DHA TRI-TABS DHA COMBO PACK PRENATAL VITAMIN WITH IRON TRIUMEQ TAB LOWER COST ALTERNATIVE USE EPZICOM WITH TIVICAY TROKENDI XR CAPSULE TOPIRAMATE TRULICITY INJ REQUEST MUST GO THROUGH TUSSIONEX PENNKINETIC SUSP HYDROCODONE-HOMATROPINE SYR TWINJECT AUTO-INJECT EPI PEN, EPI PEN JR TWYNSTA TABLET LOSARTAN PLUS AMLODIPINE TYGACIL 50 MG VIAL REQUEST MUST GO THROUGH, TYKERB TABLET REQUEST MUST GO THROUGH, TYVASO INHALATION SOLUTION REQUEST MUST GO THROUGH, TYZINE NOSE DROPS/ SPRAY NOSE DROPS 1%, AFRIN NASAL SPRAY TYZINE PEDIATRIC 0.05% DROP OXYMETOLAZINE NASAL SPRAY UCERIS RECTAL FOAM REQUEST MUST GO THROUGH ULESFIA 5% LOTION STEP THERAPY FAILURE OF PERMETHRIN AND RID AND MALATHION ULORIC TABLET ALLOPURINOL TABLET

29 ULTRACET TABLET TRAMADOL HCL TABLET AND ACETAMINOPHEN TAB ULTRAM ER TABLET TRAMADOL HCL TABLET ULTRAVATE 0.05% CR/OINT TRIAMCINOLONE, BETAMETHASONE, ULTRESA DR 20,700 UNIT CAPS CREON, ZENPEP, PANCREAZE ULTRESA DR 23,000 UNIT CAPS CREON, ZENPEP, PANCREAZE UREA LOTION/GEL UREA 40% CREAM, LOTION UROQID-ACID NO TB K-PHOS NEUTRAL TABLET UROXATRAL 10 MG TABLET TAMSULOSIN, TERAZOSIN AND DOXAZOSIN. UTIBRON NEOHALER CLINICAL REQUEST MUST GO THROUGH VAGIFEM 10 MCG VAGINAL TAB USE PREMARIN OR ESTRACE CREAM VALCHLOR 0.016% GEL HP STEROID CREAM VALTURNA TABLET STEP THERAPY FAILURE ACE/ARB VANATOL LQ ORAL SOLUTION LOWER COST ALTERNATIVE BUTALBITAL/APAP/CAFFEINE 50/325/40 TABLETS VANOS 0.1% CREAM TRIAMCINOLONE, BETAMETHASONE, VARUBI TABLET LOWER COST ALTERNATIVE ONDANSETRON/ODT, GRANISETRON VASCEPA 1 GM CAPSULE FENOFIBRATE 54 MG OR 160 MG, NIACIN ER. ONLY USED TO TREAT TRIGLYERIDE >500 VECAMYL TABLET METHYLPHENIDATE, CLONIDINE, PERGOLIDE VELETRI INFUSION REQUEST MUST GO THROUGH, VELTASSA POWDER PACK CLINICAL REQUEST MUST GO THROUGH VENTAVIS SOLUTI REQUEST MUST GO THROUGH, VERAMYST 27.5 MCG NASAL SPR FLUNISOLIDE, FLUTICASONE VEREGEN 15% OINTMENT REQUIRES VERELAN PM CAP PELLE VERAPAMIL EXTENDED RELEASE VERSACLOZ 50 MG/ML CLOZAPINE GENERIC SUSPENSI VESICARE TABLET OXYBUTYNIN/XL,TROSPIUM 20MG VFEND TABLET/SUSPENSION FLUCONAZOLE, ITRACONAZOLE, VICTOZA INJECTION STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICS VICTRELIS REQUEST MUST GO THROUGH, VIEKIRA REQUIRES, MEDICATION MUST BE OBTAINED FROM SPECIALTY VIGAMOX 0.5% EYE DROPS OFLOXACIN, LEVOFLOXACIN OPHTH DROPS VIIBRYD SSRI, VENLAFAXINE, BUPROPION VIIBRYD ALL STRENGTHS GENERIC SSRI, GENERIC SNRI, BUPROPION VIMOVO TABLET OMEPRAZOLE PLUS NAPROXEN VIRAMUNE XR 100 MG TABLET GENERIC IR AVAILABLE VISICOL TABLET COLYTE, GOLYTELY, NULYTELY VITAFOL NANO TABLET LOWER COST ALTERNATIVE USE MULTIVITAMINS W IRON VITAFOL ULTRA SOFTGEL MULTIVITAMIN WITH IRON VIVAGLOBIN 16% VIAL REQUEST MUST GO THROUGH, VIVELLE-DOT PATCH ESTRADIOL TRANSDERMAL PATCH VIVLODEX LOWER COST ALTERNATIVE MELOXICAM, IBUPROFEN, ETODOLAC

30 VOTRIENT 200 MG TABLET REQUEST MUST GO THROUGH VUSION OINTMENT MICONAZOLE, CLOTRIMAZOLE CREAM VYTORIN TABLET SIMVASTATIN VYVANSE CAPSULE AMPHETAMINE, DEXTROAMPHETAMINE, ADDERALL XR WELCHOL TABLET/PACKET CHOLESTYRAMINE WINRHO SDF 1,500 UNITS VIAL REQUEST MUST GO THROUGH, WINRHO SDF 15,000 UNITS VIA REQUEST MUST GO THROUGH, WINRHO SDF 2,500 UNITS VIAL REQUEST MUST GO THROUGH, WINRHO SDF 5,000 UNITS VIAL REQUEST MUST GO THROUGH, XARELTO TABLETS REQUEST MUST GO THROUGH XALKORI CAPSULE REQUEST MUST GO THROUGH, XELJANZ 5 MG TABLET REQUEST MUST GO THROUGH, XELODA TABLET REQUEST MUST GO THROUGH, XENAZINE TABLET REQUEST MUST GO THROUGH XERESE 5%-1% CREAM ABREVA CREAM XIBROM 0.09% EYE DROPS DICLOFENAC, KETOROLAC OPTH SOLUTION XIFAXAN TABLET REQUIRES XIGDUO XR TABLET REQUEST MUST GO THROUGH XODOL TABLET OXYCODONE WITH ACETOMINOPHEN XOLEGEL 2% GEL MICONAZOLE, CLOTRIMAZOLE CREAM XOLOX MG TABLET OXYCODONE WITH ACETOMINOPHEN XOPENEX CONC 1.25 MG/0.5 ML ALBUTEROL NEBULIZER SOLUTION XOPENEX HFA 45 MCG PROAIR HFA 90 MCG INHALER INHALER XOPENEX INHAL SOLUTION ALBUTEROL NEBULIZER SOLUTION XTANDI 40 MG CAPSULE REQUEST MUST GO THROUGH XYREM 500 MG/ML ORAL SOLUTI CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA XYZAL TABLET CETIRIZINE; LORATADINE ZADITOR 0.025% EYE DROPS LOW COST ALTERNATIVE USE KETOTIFEN, PATADAY ZAMICET SOLUTION HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIR ZANAFLEX CAPSULE TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL ZARXIO SOLUTION REQUEST MUST GO THROUGH, ZATEAN CAPSULE PRENATAL PLUS IRON TABLET ZAVESCA 100 MG CAPSULE REQUEST MUST GO THROUGH ZECUITY PATCH LOWER COST ALTERNATIVE SUMATRIPTAN TABS, INJECTION, NASAL SPRAY ZEGERID OTC 20-1,100 MG CAP OMEPRAZOLE; PLUS SODIUM BICARB.

31 ZELBORAF TABLET REQUEST MUST GO THROUGH, ZENZEDI TABLET USE AMPHETAMINE, DEXTROAMPHETAMINE ZETIA 10 MG TABLET REQUEST MUST GO THROUGH ZETONNA FLUNISOLIDE, FLUTICASONE NASAL SPRAY ZETONNA NASAL AEROSOL FLUTICASONE, FLUNISOLIDE NASAL SPRAY ZIANA GEL CLINDAMYCIN/BENZOYL PEROXIDE GEL ZIOPTAN LATANOPROST OPHTH SOL ZIOPTAN OPHTH SOL LATANAPROST OPHTH SOLUTION ZIPSOR 25 MG CAPSULE USE NAPROXEN, DICLOFENAC, ETODOLAC ZIRGAN 0.15% OPHTHALMIC VIROPTIC 1% EYE DROPS GEL ZIRGAN OPHTH REQUEST MUST GO THROUGH ZOLINZA 100 MG CAPSULE REQUEST MUST GO THROUGH ZOLPIDEM TART ER TABLET ZOLPIDEM, ZALEPLON ZOLPIMIST 5 MG ORAL SPRAY ZOLPIDEM, ZALEPLON ZOLVIT 10 MG-300 MG/15 ML S HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIR ZOMIG 2.5 MG NASAL SPRAY SUMATRIPTAN TAB/NASAL SPRAY, NARATRIPTAN TAB ZOMIG 5 MG NASAL SPRAY SUMATRIPTAN, NARATRIPTAN ZOMIG TABLET IMITREX, AMERGE ZOMIG ZMT TABLET IMITREX, AMERGE ZONALON 5% CREAM HYDROCORTISONE CREAM 1% ZONATUSS BENZONATATE CAPSULE 100MG OR 200MG ZONTIVITY TAB REQUEST MUST GO THROUGH ZORBTIVE 8.8 MG VIAL REQUEST MUST GO THROUGH, ZORVOLEX CAPSULE DICLOFENAC, NSAID ZOVIRAX OINTMENT, CREAM ABREVA, ORAL ACYCLOVIR ZUBSOLV TABLET REQUEST MUST GO THROUGH ZUPLENZ SOLUBLE FILM ONDANSETRON ODT TABLET ZYCLARA REQUEST MUST GO THROUGH ZYCLARA 3.75% CREAM IMIQUIMOD CREAM 5% ZYDELIG TAB REQUEST MUST GO THROUGH ZYDONE TABLET OXYCODONE WITH ACETOMINOPHEN ZYFLO 600 MG FILMTAB STEP THERAPY FAILURE OF INHALED STEROID ZYFLO CR 600 MG TABLET STEP THERAPY FAILURE OF INHALED STEROID ZYMAXID 0.5% EYE DROPS CIPROFLOXACIN 0.3% EYE DROP ZYPREXA RELPREVV CLINICAL REQUEST MUST GO THROUGH ZYTIGA TABLET REQUEST MUST GO THROUGH, ZYVOX TABLET/SUSP REQUEST MUST GO THROUGH