Molina Healthcare of Ohio Prior Authorization (PA) List

Molina Healthcare of Ohio Prior Authorization (PA) List Effective October 1, 2013 DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIA 8-MOP 10 MG CAPSULE CUTANEOUS T CELL LYMPHOMA ABSTRAL TAB SUBLING REQUEST MUST GO THROUGH, ACANYA GEL PUMP CLINDAMYCIN/BENZOYL PEROXIDE GEL ACIPHEX EC 20 MG TABLET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. ACTIMMUNE 2 MILLION UNIT VI REQUEST MUST GO THROUGH, ACTIQ LOZENGE REQUEST MUST GO THROUGH 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 ADCIRCA 20 MG TABLET REQUEST MUST GO THROUGH, ADOXA TABLET DOXYCYCLINE MONO 100 MG CAP ADOXA PAK 1-150 MG TABLET DOXYCYCLINE ADVAIR DISKUS REQUEST MUST GO THROUGH ADVICOR TABLETS NIACIN PLUS SIMVASTATIN ADVIL 200 MG LIQUI-GEL CAPS USE NAPROXEN, DICLOFENAC, ETODOLAC AFINITOR REQUIRES AFINITOR TABLET REQUEST MUST GO THROUGH, AIRAVITE TABLET FOLIC ACID AKNE-MYCIN 2% OINTMENT CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL ALAMAST 0.1% DROPS CROMOLYN 4% EYE DROPS ALBENZA 200 MG TABLET MEBENDAZOLE 100 MG TAB CHEW 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 30737OH1013

ALTABAX 1% OINTMENT MURIPROCIN CREAM/OINTMENT ALTOPREV TABLET SIMVASTATIN ALVESCO INHALER BECLOMETHASONE (QVAR), FLUTICASONE(FLOVENT) 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 AMTURNIDE TAB STEP THERAPY FAILURE ACE/ARB ANABAR CAPLET ACETOMINOPHEN PLUS ANTIHISTAMINE ANADROL-50 TABLET 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 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 APOKYN 30 MG/3 ML CARTRIDGE REQUEST MUST GO THROUGH, 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 ARIXTRA SYRINGE REQUEST MUST GO THROUGH, ARTHROTEC EC DICLOFENAC SODIUM PLUS MISOPROSTOL ASMANEX TWISTHALER BECLOMETHASONE (QVAR), FLUTICASONE(FLOVENT) 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 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 LEVOFLOXACIN OPHTH, ERYTHROMYCIN EYE OINTMENT AZELEX 20% CREAM CLINDAMYCIN/BENZOYL PEROXIDE GEL AZILECT TABLET REQUEST MUST GO THROUGH, AZOR TABLET LOSARTAN PLUS AMLODIPINE BANZEL TABLET REQUEST MUST GO THROUGH, BECONASE AQ 0.042% SPRAY FLUNISOLIDE, FLUTICASONE 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 OPTIVAR, ZADITOR, PATANOL BESIVANCE 0.6% SUSP LEVOFLOXACIN OPHTH BETASERON 0.3 MG KIT REQUEST MUST GO THROUGH, BILTRICIDE 600 MG TABLET MEBENDAZOLE 100 MG TAB CHEW BONIVA 150 MG TABLET GENRIC ALENDRONATE BOSULIF 500 MG TABLET REQUEST MUST GO THROUGH B-PLEX TABLET FOLBEE PLUS TABLET BREVOXYL COMPLETE PACK BENZOYL PEROXIDE BREVOXYL-4 COMPLETE PACK BENZOYL PEROXIDE BREVOXYL-8 COMPLETE PACK BENZOYL PEROXIDE BRILINTA REQUIRES BRILLINTA TABLETS REQUEST MUST GO THROUGH, BROMDAY 0.09% EYE DROPS DICLOFENAC, KETOROLAC OPTH SOLUTION BROVANA 15 MCG/2 ML SOLUTIO 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 METHADONE, MORPHINE SULFATE ER, KADIAN BYDUREON 2MG REQUEST MUST GO THROUGH 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 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 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 REQUEST MUST GO THROUGH CHENODAL 250 MG TABLET URSODIOL TABLET CHILDREN S MUCINEX GUAIFENESIN/DEXTROMETHORPHAN SYRUP

CICLOPIROX 8 % KIT AUTO APPROVE MEMBER ACTIVE 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 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 CLOBEX 0.05% SPRAY TRIAMCINOLONE, BETAMETHASONE, CLOBEX 0.05% TOPICAL LOTION TRIAMCINOLONE, BETAMETHASONE, 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 COLCRYS 0.6 MG TABLET STEP THERAPY FAILURE OF NSAID PROPHYLAXIS COLESTID TABLET/GRANULES CHOLESTYRAMINE PACKET COLY-MYCIN S EAR DROPS CORTOMYCIN EAR SUSPENSION COMETRIQ 100 MG DAILY- DOSE COMETRIQ 140 MG DAILY- DOSE REQUEST MUST GO THROUGH, 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 CONZIP TABLETS TRAMADOL ER COPAXONE 20 MG INJECTION KI REQUEST MUST GO THROUGH, COREG CR CAPSULE CARVEDILOL CORTISPORIN CREAM CORTISPORIN OINT COSOPT PF DORZOLAMIDE/TIMOLOL OPHTH SOL

COTAB AX TABLET DIMETAPP LONG-ACTING COUGH 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 CRESTOR TABLET SIMVASTATIN, ATORVASTATIN 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 CYMBALTA CAPSULE REQUEST MUST GO THROUGH CYSTADANE POWDER REQUEST MUST GO THROUGH, CYTOGAM 2.5 GM/50 ML VIAL 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 DERMATOP CREAM/ OINTMENT TRIAMCINOLONE, BETAMETHASONE, DESONATE 0.05% GEL TRIAMCINOLONE, BETAMETHASONE, DESOWEN 0.05% LOTION KIT TRIAMCINOLONE, BETAMETHASONE, DESOXYN 5 MG TABLET AMPHETAMINE, DEXTROAMPHETAMINE, DETROL LA CAPSULE OXYBUTYNIN/XL, TROSPIUM 20MG DETROL TABLET 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 DIFIL-G 400 TABLET THEOPHYLLINE TABLET DIOVAN HCT TABLET STEP THERAPY FAILURE ACE INHIBITOR 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 100 MG TABLET DOXYCYCLINE 100MG DORYX DR 150 MG 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 ONDANSETRON/ODT, GRANISETRON DUET DHA COMPLETE COMBO PRENATAL VITAMINS WITH IRON PAC DUETACT TABLET SULPHONYLUREA PLUS METFORMIN DUEXIS IBUPROFEN AND FAMOTIDINE DULERA INHALER CLINICAL CRITERIA FAILURE OF INHALED STEROID MAX DOSE 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 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 OPTIVAR, ZADITOR, PATANOL 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 OPTIVAR, ZADITOR, PATANOL EMCYT 140 MG CAPSULE REQUEST MUST GO THROUGH, EMEND ONDANSETRON/ODT, GRANISETRON EMSAM PATCH SELEGILINE TABLETS ENABLEX TABLET OXYBUTYNIN/XL, TROSPIUM 20MG ENBREL INJECTION 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 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 EVOCLIN 1% FOAM CLINDAMYCIN BENZOYL PEROXIDE GEL 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 FANAPT TABLET RISPERIDONE, GEODON, ZYPREXA, SEROQUEL FAZACLO ODT RISPERIDONE, CLOZAPINE FEMECAL OB TABLET PRENATAL VITAMINS WITH IRON FEMRING 0.05 MG VAGINAL USE PREMARIN OR ESTRACE CREAM RIN 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 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, FEXMID 7.5 MG TABLET TIZANIDINE TABLET; CARISOPRODOL TABLET FEXOFENADINE HCL TABLET CETIRIZINE; LORATADINE FIBRICOR TABLET GENERIC FENOFIBRATE 54MG OR 160MG FINACEA 15% GEL CLINDAMYCIN, ERYTHROMYCIN FINACEA PLUS KIT CLINDAMYCIN GEL 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 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 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 FROVA 2.5 MG TABLET IMITREX, AMERGE FULYZAQ 125 MG DR TABLET REQUEST MUST GO THROUGH FUMATINIC ER CAPSULE FERROUS SULFATE 325 MG TABL FUZEON CONVENIENCE KIT 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, GELNIQUE 10% GEL SACHETS OXYBUTYNIN/XL, TROSPIUM 20MG GIAZO 1.1 GM TABLET GENERIC BALSALAZIDE, PENTASA, ASACOL HD GILENYA 0.5 MG CAPSULE REQUEST MUST GO THROUGH, GLEEVEC TABLET REQUEST MUST GO THROUGH, GLUMETZA ER TABLET METFORMIN EXTENDED RELEASE GRALISE GABAPENTIN GROWTH HORMONES REQUEST MUST GO THROUGH, GUANIDINE HCL 125 MG REQUEST MUST GO THROUGH TABLET HALOG CREAM/ OINTMENT TRIAMCINOLONE, BETAMETHASONE, HELIDAC THERAPY PREVPAC PATIENT PACK 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 HUMIRA INJECTION REQUEST MUST GO THROUGH, HYCAMTIN CAPSULE REQUEST MUST GO THROUGH, HYPERRAB S/D SYRINGE REQUEST MUST GO THROUGH, HYPERRAB S-D VIAL REQUEST MUST GO THROUGH, HYPERRHO S-D SYRINGE REQUEST MUST GO THROUGH, HYPERRHO S-D SYRINGE REQUEST MUST GO THROUGH, IBUDONE TABLET HYDROCODONE WITH IBUPROFEN TABLETS ILEVRO 0.3% OPHTH DROPS BROMDAY, VOLTAREN OPHTH SOL IMIQUIMOD 5% CREAM PACKET IMIQUIMOD CREAM 5% IMMUNE GLOBULIN INJECTION REQUEST MUST GO THROUGH, INCIVEK REQUEST MUST GO THROUGH, INCRELEX 40 MG/4 ML VIAL REQUEST MUST GO THROUGH, 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 INVEGA ER 9 MG TABLET RISPERIDONE INVEGA TABLET RISPERIDONE IOPIDINE 0.5% EYE DROPS ALPHAGAN P 0.15% EYE DROPS IQUIX 1.5% EYE DROPS LEVOFLOXACIN OPHTH IRESSA 250 MG TABLET CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA, MEDICATION MUST BE OBTAINED FROM SPECIALTY ISENTRESS 100 MG TABLET CHE REQUEST MUST GO THROUGH ISRADIPINE CAPSULE NIFEDIPINE; AMLODIPINE ISTALOL 0.5% EYE DROPS TIMOPTIC OPHTH SOLUTION JAKAFI REQUEST MUST GO THROUGH, JALYN 0.5-0.4 MG CAPSULE FINASTERIDE PLUS TAMSULOSIN JANUMET XR SITAGLIPTIN AND METFORMIN JENTADUETO IPTIN OR SITAGLIPTIN AND METFORMIN JUVISYNC 50-10 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS SIMVASTATIN JUVISYNC 50-20 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS SIMVASTATIN JUVISYNC 50-40 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS SIMVASTATIN JUXTAPID 10 MG CAPSULE REQUEST MUST GO THROUGH JUXTAPID 20 MG CAPSULE REQUEST MUST GO THROUGH KADIAN MORPHINE SULFATE ER 12HR, 24 HR, METHADONE KAPVAY ER 0.1 MG TABLET CLONIDINE (CATAPRES) KAZANO 12.5-1,000 MG TABLET STEP THERAPY USE JANUMET + METFORMIN KAZANO 12.5-500 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 KINERET 100 MG/0.67 ML SYR REQUEST MUST GO THROUGH, KIONEX 15 GM/60 ML SUSPENSI CALCIUM ACETATE 667 MG CAPS KORLYM REQUIRES K-PHOS #2 TABLET K-PHOS NEUTRAL TABLET K-PHOS M.F. TABLET K-PHOS NEUTRAL TABLET 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 OPTIVAR, ZADITOR, PATANOL LATUDA ALL STRENGTHS OLANZAPINE, RISPERIDONE, ZIPRASIDONE LATUDA TABLET RISPERIDONE, GEODON, ZYPREXA, SEROQUEL 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 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 LORZONE CHLORZOXAZONE 500MG, TIZANIDINE, CARISPRODOL LOTRONEX TABLET STEP THERAPY FAILURE OF METAMUCIL,PSYLLIUM, DICYCLOMINE LOVAZA 1 GM CAPSULE GENERIC FISH OIL CAPSULES LOVENOXPREFILLED SYR REQUEST MUST GO THROUGH 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, 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 10-750 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 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 TABLET; CARISOPRODOL TABLET METOZOLV ODT TABLET METOCLOPRAMIDE, TABLETS, SOLUTION MICARDIS HCT TABLET LOSARTAN-HCTZ MICARDIS TABLET LOSARTAN OR ACE-INHIBITOR MILLIPRED DP SOLUTION/ PREDNISOLONE DOSE PACK MIRAPEX ER TABLET PRAMIPEXOLE IMMEDIATE RELEASE TABLET MONUROL 3 GM SACHET CEPHALOSPORIN, CIPROFLOXACIN MOVIPREP POWDER KIT HALFLYTELY-BISACODYL BOWEL 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 MYTELASE 10 MG CAPLET NEOSTIGMINE, PYRIDOSTIGMINE NAFTIN CLOTRIMAZOLE, KETOCONAZOLE TOPICAL NAFTIN 1% CREAM/GEL MICONAZOLE, CLOTRIMAZOLE CREAM NALFON 200 MG PULVULE FENOPROFEN, OTHER GENERIC NSAIDS, NALFON CAPSULE USE NAPROXEN, DICLOFENAC, ETODOLAC 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 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 NEPHPLEX RX TABLET FOLIC ACID NEPHRON FA TABLET FERROUS SULFATE 325 MG TABL NESINA 12.5 MG TABLET STEP THERAPY USE PREFERRED GLIPTINS (JANUVIA OR TRADJENTA) NESINA 25 MG TABLET STEP THERAPY USE PREFERRED GLIPTINS (JANUVIA OR TRADJENTA) NESINA 6.25 MG TABLET STEP THERAPY USE PREFERRED GLIPTINS (JANUVIA OR TRADJENTA) 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 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 DR 10 MG PACKET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. NEXIUM DR 20 MG CAPSULE OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. NEXIUM DR 20 MG PACKET OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. 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 NOROXIN 400 MG TABLET CIPROFLOXACIN NOXAFIL 40 MG/ML FLUCONAZOLE, ITRACONAZOLE, SUSPENSION NUCYNTA ER TRAMADOL ER NUCYNTA TABLET TRAMADOL HCL TABLET NUEDEXTA 20-10 MG CAPSULE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL CRITERIA NUOX GEL BENZOYL PEROXIDE 5% OR 10% LOTION 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%, OB COMPLETE PRENATAL VITAMINS WITH IRON OB COMPLETE PETITE GENERIC PRENATAL VITAMINS SOFTGEL OLEPTRO ER 150 MG TABLET TRAZODONE OLEPTRO ER 300 MG TABLET TRAZODONE OMECLAMOX-PAK COMBO PREV-PAK PACK 20(20)-500 OMEPRAZOLE-BICARB 40-1,100 OMEPRAZOLE; PLUS SODIUM BICARB. OMNARIS 50 MCG NASAL FLUNISOLIDE, FLUTICASONE SPRAY 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 ORACEA 40 MG CAPSULE DOXYCYCLINE 50MG CAPSULE ORAPRED ODT TABLET PREDNISOLONE ORAVIG 50 MG BUCCAL NYSTATIN 100,000 UNITS/ML S TABLET ORENCIA INJECTION REQUEST MUST GO THROUGH ORENCIA SYRINGE REQUEST MUST GO THROUGH, ORFADIN CAPSULE REQUEST MUST GO THROUGH

ORPHENADRINE COMP FORTE TIZANIDINE TABLET; CARISOPRODOL TABLET TAB ORPHENADRINE COMP TABLET TIZANIDINE TABLET; CARISOPRODOL TABLET OSENI 12.5-15 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI 12.5-30 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI 12.5-45 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI 25-15 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI 25-30 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE OSENI 25-45 MG TABLET STEP THERAPY USE SEPARATE GLIPTAN (JANUVIA OR TRADJENTA) PLUS PIOGLITAZONE 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 OXYCODONE-IBUPROFEN 5-400 HYDROCODONE WITH IBUPROFEN TABLETS T OXYCONTIN TABLET REQUEST MUST GO THROUGH 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 PANDEL 0.1% CREAM TRIAMCINOLONE, BETAMETHASONE, PANRETIN 0.1% GEL TRIAMCINOLONE, BETAMETHASONE, PARCOPA ODT CARBIDOPA-LEVO 25-250 MG ODT PAROXETINE CR TABLET CITALOPRAM, FLUOXETINE, SERTRALINE PATANASE 0.6% NASAL SPRAY ASTEPRO 0.15% NASAL SPRAY 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 20 MCG/2 ML ALBUTEROL NEBULIZER SOLUTION SOL PEXEVA TABLET CITALOPRAM, FLUOXETINE, SERTRALINE PHOSLYRA SOLUTION CALCIUM ACETATE 667MG TABLET PICATO IMIQUIMOD, FLOUROURACIL 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 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 PRANDIMET TABLET SULPHONYLUREA PLUS METFORMIN PRASCION RA CREAM CLINDAMYCIN SOL, CLINDAGEL, ERYTHROMYCIN GEL PREFERA-OB/ PLUS DHA PRENATAL VITAMINS WITH IRON COMBO P PREGNYL 10,000 UNITS VIAL REQUEST MUST GO THROUGH, PRENACARE TABLET COMPLETE-RF PRENATAL TABLET PRENAISSANCE NEXT PRENATAL VITAMINS WITH MINERALS PRENATE SOFTGEL/ TABLET PRENATAL VITAMINS WITH IRON 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, 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, 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 PROSED-DS TABLET URELLE TABLET PROTONIX 40 MG SUSPENSION OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE. PROTOPIC OINTMENT TRIAMCINOLONE, BETAMETHASONE, PROVENTIL HFA 90 MCG PROAIR HFA 90 MCG INHALER INHALE PROVIGIL TABLET REQUEST MUST GO THROUGH PULMICORT FLEXHALER BECLOMETHASONE (QVAR), FLUTICASONE(FLOVENT) PYLERA CAPSULE PREVPAC PATIENT PACK QNASL 80 MCG FLUTICASONE, FLUNISOLIDE NASAL SPRAY QUILLIVANT XR 25 MG/5 ML SU GENERIC METHYLPHENIDATE WITH SPRINKLE CAPABILITY (METADATE CD) QUIXIN 0.5% EYE DROPS LEVOFLOXACIN OPHTH RAPAFLO CAPSULE TAMSULOSIN, TERAZOSIN AND DOXAZOSIN. 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 REPREXAIN TABLET HYDROCODONE WITH IBUPROFEN TABLETS REQUIP XL TABLET REQUIP IMMEDIATE RELEASE TABLET RESCULA 0.15% EYE DROPS LATANOPROST OPHTH SOLUTION REVATIO INJECTION AND TABLETS REQUEST MUST GO THROUGH, REVLIMID CAPSULE REQUEST MUST GO THROUGH RHINARIS NASAL GEL SODIUM CHLORIDE NASAL SOLUTION RHINOCORT AQUA NASAL SPRAY FLUNISOLIDE, FLUTICASONE 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 CAPSULE METADATE CD CAPSULE RITUXAN 10 MG/ML VIAL REQUEST MUST GO THROUGH, 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 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, 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 SAVELLA TABLET GABAPENTIN SCOPACE 0.4 MG TABLET MECLIZINE TABLET SEA-OMEGA CAPSULE GENERIC FISH OIL CAPSULES SE-CARE TABLET PRENATAL VITAMINS WITH IRON 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 SIMCOR TABLET NIACIN PLUS SIMVASTATIN SIMPONI INJECTION REQUEST MUST GO THROUGH, SINGULAIR TAB/GRAN/CHEW STEP THERAPY FAILURE OF INHALED STEROID SINUS RELIEF CONGESTION & OTC DECONGESTANT/ACETOMINOPHEN PAIN 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 SPECTRACEF DOSE PACK CEFPODOXIME PROXETIL SPORANOX 10 MG/ML FLUCONAZOLE 10 MG/ML SUSP SOLUTION SPRYCEL TABLET REQUEST MUST GO THROUGH, STAVZOR DR CAPSULE DEPAKOTE ER 500 MG TABLET 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 STRIBILD TABLETS ALL STRENGTHS CLINICAL/STEP REQUEST MUST GO THROUGH, REQUIRES LAB VALUES REQUEST MUST GO THROUGH STROMECTOL 3 MG TABLET MEBENDAZOLE 100 MG TAB CHEW 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 SUPRAX 200 MG TABLET CHEWABLE GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME) GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME) SUPRAX 400 MG TABLET CEFPODOXIME PROXETIL SUPREP BOWEL PREP KIT HALFLYTELY-BISACODYL BOWEL SUTENT CAPSULE REQUEST MUST GO THROUGH, SYLATRON REQUEST MUST GO THROUGH, SYMBICORT INHALER 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 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 SYPRINE 250 MG CAPSULE 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 CAP PRENATAL VITAMINS WITH IRON

TASIGNA CAPSULE REQUEST MUST GO THROUGH, TEKAMLO TABLET STEP THERAPY FAILURE ACE/ARB TEKTURNA HCT TABLET STEP THERAPY FAILURE ACE/ARB TEKTURNA TABLET STEP THERAPY FAILURE ACE/ARB TEMODAR CAPSULE REQUEST MUST GO THROUGH, TEVETEN HCT TAB LOSARTAN-HCTZ TEVETEN TABLET LOSARTAN OR ACE-INHIBITOR TEV-TROPIN 5 MG VIAL REQUEST MUST GO THROUGH, THALOMID CAPSULE REQUEST MUST GO THROUGH, TINDAMAX TABLET METRONIDAZOLE 250 MG TABLET TIROSINT CAPSULE GENERIC LEVOTHYROXINE TL-ASSURE + DHA PRENATAL VITAMINS WITH MINERALS TL-SELECT DHA SOFTGEL GENERIC PRENATAL VITAMINS TOLMETIN SODIUM 600 MG USE NAPROXEN, DICLOFENAC, ETODOLAC TAB TOVIAZ ER TABLET OXYBUTYNIN/XL, TROSPIUM 20MG TRACLEER TABLET REQUEST MUST GO THROUGH, TRADJENTA TABLET SITAGLIPTIN, SAXAGLIPTIN TRAVATAN Z 0.004% EYE DROP LATANAPROST TREXIMET 85-500 MG TABLET SUMATRIPTAN AND NAPROXEN TABLETS TRIAZ PAD/FOAM TRIAZ CLEANSER TRIBENZOR TABLET LOSARTAN-HCTZ PLUS AMLODIPINE 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 TUSSIONEX PENNKINETIC HYDROCODONE-HOMATROPINE SYR SUSP TWINJECT AUTO-INJECT EPIPEN 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

ULESFIA 5% LOTION STEP THERAPY FAILURE OF PERMETHRIN AND RID AND MALATHION ULORIC TABLET ALLOPURINOL TABLET 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.2 500-500 TB K-PHOS NEUTRAL TABLET UROXATRAL 10 MG TABLET TAMSULOSIN, TERAZOSIN AND DOXAZOSIN. VAGIFEM 10 MCG VAGINAL TAB USE PREMARIN OR ESTRACE CREAM VALTURNA TABLET STEP THERAPY FAILURE ACE/ARB VANOS 0.1% CREAM TRIAMCINOLONE, BETAMETHASONE, VASCEPA 1 GM CAPSULE FENOFIBRATE 54 MG OR 160 MG, NIACIN ER. ONLY USED TO TREAT TRIGLYERIDE >500 VENLAFAXINE HCL TABLET VENLAFAXINE ER CAPSULES VENTAVIS SOLUTI REQUEST MUST GO THROUGH, VERAMYST 27.5 MCG NASAL FLUNISOLIDE, FLUTICASONE SPR VEREGEN 15% OINTMENT IMIQUIMOD CREAM VERELAN PM CAP PELLE VERAPAMIL EXTENDED RELEASE 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, 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 VISICOL TABLET HALFLYTELY-BISACODYL BOWEL VIVAGLOBIN 16% VIAL REQUEST MUST GO THROUGH, VIVELLE-DOT PATCH ESTRADIOL TRANSDERMAL PATCH 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 XELJANZ 5 MG TABLET REQUEST MUST GO THROUGH, XELODA TABLET REQUEST MUST GO THROUGH, XENAZINE TABLET REQUEST MUST GO THROUGH XERESE 5%-1% CREAM ZOVIRAX CREAM XIBROM 0.09% EYE DROPS DICLOFENAC, KETOROLAC OPTH SOLUTION XIFAXAN TABLET NEOMYCIN 500 MG TABLET XODOL TABLET OXYCODONE WITH ACETOMINOPHEN XOLEGEL 2% GEL MICONAZOLE, CLOTRIMAZOLE CREAM XOLOX 10-500 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 ZAMICET SOLUTION HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIR ZANAFLEX CAPSULE TIZANIDINE TABLET; CARISOPRODOL TABLET ZATEAN CAPSULE PRENATAL PLUS IRON TABLET ZAVESCA 100 MG CAPSULE REQUEST MUST GO THROUGH ZEGERID OTC 20-1,100 MG CAP OMEPRAZOLE; PLUS SODIUM BICARB. ZENPEP PANCREASE, CREON ZETIA 10 MG TABLET REQUEST MUST GO THROUGH 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 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 ZORBTIVE 8.8 MG VIAL REQUEST MUST GO THROUGH, ZUPLENZ SOLUBLE FILM ONDANSETRON ODT TABLET ZYCLARA IMIQUIMOD CREAM 5% ZYCLARA 3.75% CREAM IMIQUIMOD CREAM 5% 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 ZYVOX TABLET/SUSP REQUEST MUST GO THROUGH