ABC and Choices 3-Tier Rx drug list - MESSA

Updated 9/24/2021

Drug name Generic name Choices Tier ABC Tier Limits Specialty

drug?Abilify * aripiprazole 1 1 NoAbiraterone acetate 1 1 QL NoAbstral 3 3 PA, QL NoAcanya * clindamycin phos/benzoyl perox 1 1 NoAccolate * zafirlukast 1 1 QL NoAccrufer 3 3 PA, QL No

Accupril * quinapril hcl 1Free as

preventiveNo

Accuretic * quinapril/hydrochlorothiazide 1Free as

preventiveNo

Accutane capsule 1 1 No

Aceon * perindopril erbumine 1Free as

preventiveNo

Acetasol HC; Vosol HC * hydrocortisone/acetic acid 1 1 NoAcetic Acid * acetic acid 1 1 NoAciphex tablet * rabeprazole sodium 1 1 QL NoAclovate * alclometasone dipropionate 1 1 NoActemra Actpen, syringe 2 2 PA, QL YesActhar H.P. 3 3 PA, QL YesActigall * ursodiol 1 1 NoActimmune 2 2 YesActiq * fentanyl citrate 1 1 PA, QL NoActivella * estradiol/norethindrone acet 1 1 NoActonel * risedronate sodium 1 1 QL NoActoplus Met * pioglitazone hcl/metformin hcl 1 1 NoActoplus Met XR 3 3 NoActos * pioglitazone hcl 1 1 NoAcular, LS * ketorolac tromethamine 1 1 NoAcuvail 3 3 NoAcyclovir * acyclovir 1 1 NoAczone 5% * dapsone 1 1 QL No

Adacel Free as

preventiveFree as

preventiveQL No

Adalat CC; Procardia, XL * nifedipine 1Free as

preventiveNo

Adapin; Sinequan * doxepin hcl 1 1 No

Medications covered by MESSA Choices with 3-Tier Rx and MESSA ABC with 3-Tier Rx with and without mandatory mail

This list is current as of 9/23/2021. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013.

Use this list to find information about drug coverage and therapeutic options. This list is ordered alphabetically and includes generic and brand name drugs. Drugs are identified according to their tier placement; prior authorization (PA), step therapy (ST) or quantity limit (QL) requirements are noted where applicable. We encourage you to talk to your doctor to find the right drug therapies that your health plan covers. This chart contains tier information for Choices plans and ABC plans. Please refer to the appropriate column for medication details. If your 3-Tier Rx plan includes mandatory mail, please refer to the list of long-term maintenance medications requiring home delivery to see if your drug requires home delivery.

Up to 34-day supply 90-day supplySpecific preventive medications are covered 100 percent with no deductible required. Age and gender limits apply. ***ABC plans have a list of specific preventive medications in addition to those mandated by federal law.

No cost to you No cost to you

Tier 1Generics

Tier 2Most brand drugs with no generic equivalent

Tier 3Most brand drugs with a generic equivalent or therapeutic alternative

Note: The amount you pay for brand name medications varies because coinsurance is based on the price of the drug when it is filled. If you obtain a brand name drug when a Tier 1 drug is available, you will pay the Tier 3 coinsurance plus the difference in cost between the Tier 1 drug and the brand name drug. These drugs are identified with an asterisk (*) in the list below. A drug may switch from one tier to another. Up to a 90-day supply of insulin may be obtained for the same amount as a 34-day supply from any in-network provider. All over the counter (OTC) medications are excluded from coverage except the Affordable Care Act (ACA) mandated OTC medications.

$10 copayment $25 copayment

20 percent coinsurance $40 minimum - $80 maximum




https://www.messa.org/pdf/RRAList.pdf









Updated 9/24/2021


drug?Adcirca * tadalafil, Alyq 1 1 PA, QL YesAdderall * dextroamphetamine/amphetamin e 1 1 QL NoAdderall XR * dextroamphetamine/amphetamin e 1 1 QL NoAddyi 3 3 PA, QL NoAdempas 2 2 PA, QL Yes

Adipex-P * phentermine hcl 1Free as

preventiveNo

Adoxa capsule * doxycycline monohydrate 1 1 PA NoAdoxa tablet * doxycycline monohydrate 1 1 PA NoAdvair Diskus 1 1 QL NoAdvair HFA fluticasone-salmeterol, Wixela Inhub 1 1 QL NoAdzenys ER 3 3 PA, QL NoAdzenys XR-ODT 3 3 PA, QL NoAfinitor *, Disperz Everolimus 1 1 PA, QL Yes

Afluria Free as

preventiveFree as

preventiveQL No

Afluria Quad Free as

preventiveFree as

preventiveQL No

Afrezza 3 3 ST NoAggrenox * aspirin/dipyridamole 1 1 NoAgrylin * anagrelide hcl 1 1 NoAimovig 2 2 PA, QL NoAjovy 2 2 PA, QL NoAktipak 3 3 NoAkynzeo 3 3 PA, QL NoAla-Cort * hydrocortisone 1 1 NoAla-scalp HP * hydrocortisone 1 1 NoAlbenza * albendazole 1 1 QL NoAlbuterol nebulizer solution * albuterol sulfate 1 1 No

Aldactazide * spironolact/hydrochlorothiazid 1Free as

preventiveNo

Aldactazide 50/50mg 3 3 No

Aldactone * spironolactone 1Free as

preventiveNo

Aldara * imiquimod 1 1 No

Aldomet * methyldopa 1Free as

preventiveNo

Aldoril * methyldopa/hydrochlorothiazide 1Free as

preventiveNo

Alecensa 2 2 PA, QL Yes

Alesse; Levlite * levonorgestrel-ethin estradiol, afirmelleFree as

preventiveFree as

preventiveNo

Alferon N 2 2 NoAlinia * Nitazoxanide 1 1 NoAlkeran tablet * melphalan 1 1 NoAlocril 3 3 NoAlomide 3 3 NoAlora 2 2 NoAlphagan 0.2%, P 0.15% * brimonidine tartrate 1 1 NoAlphagan P 0.1% 2 2 NoAlrex 3 3 NoAlsuma * sumatriptan succinate 1 1 QL No

Altace * ramipril 1Free as

preventiveNo

Altreno 3 3 QL NoAlunbrig 2 2 PA, QL YesAlupent * metaproterenol sulfate 1 1 NoAmaryl * glimepiride 1 1 NoAmbien * zolpidem tartrate 1 1 QL NoAmbien CR * zolpidem tartrate 1 1 QL NoAmerge * naratriptan hcl 1 1 QL NoAmicar * aminocaproic acid 1 1 NoAmicar solution 2 2 NoAmitiza 2 2 QL NoAmnesteem; Claravis; Myorisan; Zenatane * isotretinoin 1 1 QL NoAmoxapine * amoxapine 1 1 NoAmoxil * amoxicillin 1 1 NoAmphetamine suspension 3 3 PA, QL No

Updated 9/24/2021


drug?Ampicillin * ampicillin trihydrate 1 1 NoAmpyra * dalfampridine 1 1 PA, QL YesAnadrol-50 3 3 NoAnafranil * clomipramine hcl 1 1 NoAnalpram-HC 1-1% cream 2 2 NoAnalpram-HC cream 2.5-1%, 1-1% * hydrocortisone/pramoxine 1 1 NoAnamantle HC * lidocaine/hydrocortisone ac 1 1 NoAnamantle HC Forte * lidocaine/hydrocortisone ac 1 1 NoAnamantle HC Kit * lidocaine/hydrocortisone ac 1 1 NoAnaprox, DS * naproxen sodium 1 1 NoAncobon * flucytosine 1 1 NoAndroderm 2 2 PA, QL NoAndrogel * testosterone 1 1 PA, QL NoAndroid, Testred * methyltestosterone 1 1 NoAngeliq 3 3 NoAnoro Ellipta 2 2 QL NoAnsaid * flurbiprofen 1 1 No

Antabuse * disulfiram 1Free as

preventiveNo

Antara * fenofibrate,micronized 1Free as

preventiveNo

Antara 30, 90mg 3 3 NoAntivert * meclizine hcl 1 1 NoApexicon E * diflorasone diacetate/emoll 1 1 NoApokyn 2 2 QL Yes

Apresoline * hydralazine hcl 1Free as

preventiveNo

Apriso * Mesalamine Er 1 1 NoAptensio XR * Methylphenidate ER 1 1 QL NoAptiom 3 3 ST, QL NoAptivus 2 2 NoArakoda 3 3 QL NoAralen * chloroquine phosphate 1 1 NoAranesp 3 3 PA YesArava * leflunomide 1 1 NoArcalyst 2 2 PA YesArcapta Neohaler 3 3 QL NoAricept 23mg * donepezil hcl 1 1 QL NoAricept 5, 10mg; ODT * donepezil hcl 1 1 NoArikayce 2 2 PA, QL Yes

Arimidex * anastrozoleFree as

preventiveFree as

preventivePA No

Aristocort; Kenalog 0.5% * triamcinolone acetonide 1 1 NoArixtra * fondaparinux sodium 1 1 NoArmonair Respiclick 3 3 QL NoArmour Thyroid * thyroid,pork 1 1 NoArmour Thyroid 15mg, 30mg, 60mg, 3 3 NoArnuity Ellipta 2 2 QL No

Aromasin * exemestaneFree as

preventiveFree as

preventivePA No

Artane * trihexyphenidyl hcl 1 1 NoArthrotec * diclofenac sodium/misoprostol 1 1 NoAsacol HD * mesalamine 1 1 NoAsmanex, HFA 2 2 QL No

Aspirin; Ecotrin 81mg, 325mg (OTC) aspirinFree as

preventiveFree as

preventiveNo

Astagraf XL 3 3 YesAstelin nasal spray * azelastine hcl 1 1 QL NoAstepro nasal spray * azelastine hcl 1 1 QL No

Atacand * candesartan cilexetil 1Free as

preventiveNo

Atacand HCT * candesartan/hydrochlorothiazid 1Free as

preventiveNo

Atarax * hydroxyzine hcl 1 1 NoAtelvia * risedronate sodium 1 1 ST, QL NoAtivan * lorazepam 1 1 NoAtralin * tretinoin 1 1 NoAtripla * Efavirenz-Emtric-Tenof Disop 1 1 No

Updated 9/24/2021


drug?Atrovent HFA 2 2 QL NoAtrovent nasal spray * ipratropium bromide 1 1 QL NoAtrovent solution * ipratropium bromide 1 1 QL NoAubagio 3 3 QL YesAugmentin 125mg-31.25mg/ml suspension 2 2 NoAugmentin, ES, XR * amoxicillin/potassium clav 1 1 NoAuralgan * aa/antipyrin/bcaine/polico1/al 1 1 No

Aurovela 24 FeFree as

preventiveFree as

preventiveNo

Auryxia 3 3 NoAustedo 3 3 PA, QL Yes

Avalide * irbesartan/hydrochlorothiazide 1Free as

preventiveNo

Avandia 3 3 No

Avapro * irbesartan 1Free as

preventiveNo

AVC 3 3 NoAvelox * moxifloxacin hcl 1 1 NoAventyl; Pamelor * nortriptyline hcl 1 1 NoAvidoxy 100mg * doxycycline monohydrate 1 1 NoAvinza * morphine sulfate 1 1 QL NoAvita gel 3 3 NoAvodart * dutasteride 1 1 NoAvonex 2 2 QL YesAxert * almotriptan malate 1 1 ST, QL NoAxid (Rx only) * nizatidine 1 1 NoAxiron * testosterone 1 1 ST, QL NoAygestin * norethindrone acetate 1 1 NoAyvakit tablet 2 2 YesAzasan 3 3 NoAzasite 3 3 NoAzelex 3 3 NoAzilect * rasagiline mesylate 1 1 NoAzopt* brinzolamide drops 1 1 No

Azor * amlodipine bes/olmesartan med 1Free as

preventiveNo

Azstarys 3 $3 PA, QL NoAzulfidine, EN-tab * sulfasalazine 1 1 NoBacitracin * bacitracin 1 1 NoBaciguent ointment 3 3 NoBaclofen * baclofen 1 1 NoBaclofen 5mg 3 3 NoBactroban ointment * mupirocin 1 1 NoBafiertam capsule 3 3 YesBalcoltra 3 3 NoBalversa tablet 3 3 YesBanzel* Rufinamide suspension 1 1 PA, QL NoBaraclude * entecavir 1 1 YesBaraclude solution 2 2 YesBasaglar Kwikpen U-100 3 3 NoBaxdela tablet 3 3 NoBeconase AQ 3 3 ST, QL NoBelbuca* buprenorphine hcl 1 1 PA, QL NoBelsomra 3 3 ST, QL NoBenadryl (Rx Only) * diphenhydramine hcl 1 1 No

Benicar * olmesartan medoxomil 1Free as

preventiveNo

Benicar HCT * olmesartan/hydrochlorothiazide 1Free as

preventiveNo

Benlysta 2 2 PA, QL YesBentyl * dicyclomine hcl 1 1 NoBenzaclin * clindamycin phos/benzoyl perox 1 1 NoBenzamycin * erythromycin/benzoyl peroxide 1 1 NoBenznidazole 2 2 QL NoBepreve* bepotastine besilate drops 1 1 NoBesivance 3 3 NoBetagan * levobunolol hcl 1 1 No

Updated 9/24/2021


drug?

Betapace, AF * sotalol hcl 1Free as

preventiveNo

Betaseron 3 3 QL YesBethkis * Tobramycin Ampul-Neb 1 1 PA, QL YesBetimol 2 2 NoBetoptic S 2 2 No

Betoptic solution * betaxolol hcl 1Free as

preventiveNo

Bevespi Aerosphere 3 3 QL NoBevyxxa tablet 3 3 QL No

Beyaz * drospir/eth estra/levomefol caFree as

preventiveFree as

preventiveNo

Biaxin, XL * clarithromycin 1 1 NoBidil 2 2 NoBiktarvy 2 2 QL NoBiltricide * praziquantel 1 1 NoBinosto 3 3 ST, QL No

Bisacodyl OTC * bisacodylFree as

preventiveFree as

preventiveQL No

Bleph-10 ointment * sulfacetamide sodium 1 1 NoBleph-10, Sodium Sulamyde drops * sulfacetamide sodium 1 1 NoBlephamide 2 2 No

Blocadren * timolol maleate 1Free as

preventiveNo

Boniva * ibandronate sodium 1 1 QL NoBonjesta 3 3 PA, QL No

Bontril * phendimetrazine tartrate 1Free as

preventiveNo

Boostrix Free as

preventiveFree as

preventiveQL No

Bosulif 2 2 PA, QL YesBraftovi 2 2 PA, QL YesBravelle 2 2 YesBreo Ellipta 2 2 QL NoBrethine * terbutaline sulfate 1 1 NoBrilinta 2 2 NoBrisdelle * paroxetine mesylate 1 1 QL NoBriviact 3 3 PA, QL NoBromday; Xibrom * bromfenac sodium 1 1 NoBromfed-DM * brompheniramine/pseudoephed/ dm 1 1 NoBronchitol capsule with device 3 3 PA, QL NoBrovana* arformoterol tartrate vial-neb 3 3 NoBryhali 3 3 QL No

Bumex * bumetanide 1Free as

preventiveNo

Bunavail 3 3 QL NoBuphenyl powder * sodium phenylbutyrate 1 1 NoBuphenyl tablet * sodium phenylbutyrate 1 1 QL NoBuprenorphine 7.5 mcg/hr patch 2 2 QL NoBupropion Hcl XL 450mg 3 3 ST, QL NoBuspar * buspirone hcl 1 1 NoButisol sodium 3 3 NoButrans * buprenorphine 2 2 QL NoButrans 7.5mcg/hr 2 2 QL NoBynfezia pen injector 3 3 PA, QL YesBystolic 2.5, 5, 10mg 3 3 ST NoBystolic 20mg 3 3 ST NoByvalson 3 3 QL NoCabometyx 2 2 PA, QL Yes

Caduet * amlodipine/atorvastatin 1Free as

preventiveQL No

Cafcit * caffeine citrate 1 1 NoCafergot * ergotamine tartrate/caffeine 1 1 QL No

Calan SR; Isoptin SR * verapamil hcl 1Free as

preventiveNo

Calciferol (Rx Only) * ergocalciferol (vitamin d2) 1 1 NoCalquence 2 2 PA, QL Yes

Updated 9/24/2021


drug?

Campral * acamprosate calcium 1Free as

preventiveNo

Canasa * mesalamine 1 1 NoCapex shampoo 2 2 No

Capoten * captopril 1Free as

preventiveNo

Capozide * captopril/hydrochlorothiazide 1Free as

preventiveNo

Caprelsa 2 2 PA, QL YesCarafate suspension 2 2 NoCarafate tablet, suspension * sucralfate 1 1 NoCarbaglu 2 2 PA YesCarbatrol * carbamazepine 1 1 No

Cardene * nicardipine hcl 1Free as

preventiveNo

Cardizem LA 120mg 3 3 No

Cardizem, CD, LA, SR * diltiazem hcl, diltiazem 24hr ER 1Free as

preventiveNo

Cardura * doxazosin mesylate 1Free as

preventiveNo

Cardura XL 3 3 NoCarnitor * levocarnitine 1 1 NoCarnitor SF* levocarnitine SF 1 1 NoCarnitor solution * levocarnitine (with sugar) 1 1 NoCarospir 3 3 NoCasodex * bicalutamide 1 1 NoCataflam * diclofenac potassium, Cataflam 1 1 No

Catapres * clonidine hcl 1Free as

preventiveNo

Catapres-TTS * clonidine 1Free as

preventiveNo

Caverject 2 2 PA, QL NoCayston 3 3 PA, QL YesCeclor, ER * cefaclor 1 1 NoCeftin * cefuroxime axetil 1 1 NoCefzil * cefprozil 1 1 NoCelebrex * celecoxib 1 1 NoCelexa * citalopram hydrobromide 1 1 NoCellcept * mycophenolate mofetil 1 1 YesCelontin 3 3 NoCequa 3 3 PA, QL NoCerdelga 3 3 PA, QL YesCesamet 3 3 NoCetraxal * ciprofloxacin hcl 1 1 NoCetrotide 2 2 YesCetylev 3 3 NoChantix 2 2 QL No

Chantix Free as

preventiveFree as

preventiveST, QL No

Chemet 2 2 NoChenodal 3 3 PA YesCheratussin AC 3 3 NoChlorzoxazone 1 1 NoCholbam 2 2 PA, QL YesChorionic Gonadotropin 3 3 PA YesCialis * tadalafil 1 1 PA, QL NoCialis 2.5mg, 5mg * tadalafil 1 1 PA, QL NoCiloxan drops * ciprofloxacin hcl 1 1 NoCiloxan ointment 2 2 NoCimduo 2 2 QL NoCimzia syringe 3 3 PA, QL YesCipro HC 3 3 NoCipro suspension * ciprofloxacin 1 1 NoCipro tablet * ciprofloxacin hcl 1 1 NoCipro XR * ciprofloxacin/ciprofloxa hcl 1 1 NoCiprodex 2 2 NoCiprofloxacin HCL- Fluocinolone 2 2 No

Updated 9/24/2021


drug?

Citrate of Magnesia OTC * magnesium citrateFree as

preventiveFree as

preventiveQL No

Clarinex * desloratadine 1 1 QL NoClarinex syrup 3 3 NoClarinex-D 3 3 QL NoClenpiq 3 3 NoCleocin capsule * clindamycin hcl 1 1 NoCleocin solution * clindamycin palmitate hcl 1 1 NoCleocin vaginal cream * clindamycin phosphate 1 1 NoCleocin vaginal ovules 3 3 NoCleocin-T, swabs * clindamycin phosphate 1 1 NoClimara * estradiol 1 1 NoClimara Pro 3 3 NoClindesse 3 3 NoClinoril * sulindac 1 1 NoClobevate; Temovate * clobetasol propionate 1 1 NoClobex, spray * clobetasol propionate 1 1 NoClocortolone pivalate 2 2 NoCloderm 2 2 NoClomid * clomiphene citrate 1 1 NoClozapine 200mg * clozapine 1 1 NoClozapine ODT * clozapine ODT 1 1 NoClozaril * clozapine 1 1 NoCoartem 2 2 NoCodeine sulfate tablet * codeine sulfate 1 1 QL NoCoditussin AC 3 3 NoCogentin * benztropine mesylate 1 1 NoColazal * balsalazide disodium 1 1 NoColbenemid * probenecid/colchicine 1 1 NoColchicine capsule 3 3 NoColchicine tablet 2 2 NoColcrys 2 2 No

Colestid * colestipol hcl 1Free as

preventiveNo

Colestid granules, packet 3 3 NoColy-Mycin S 3 3 No

Colyte * peg3350/sod sulf,bicarb,cl/kclFree as

preventiveFree as

preventiveQL No

Colyte * peg3350/sod sulf,bicarb,cl/kcl 1 1 NoCombigan 3 3 NoCombipatch 3 3 NoCombivent Respimat 2 2 NoCombivir * lamivudine/zidovudine 1 1 NoCombunox * ibuprofen/oxycodone hcl 1 1 QL NoCometriq 2 2 PA, QL Yes

Commit Lozenge OTC * nicotine polacrilexFree as

preventiveFree as

preventiveQL No

Compazine suppository * prochlorperazine 1 1 NoCompazine tablet * prochlorperazine maleate 1 1 NoComplera 2 2 QL NoComplete Natal DHA combo package 2 2Comtan * entacapone 1 1 No

Conceptrol Free as

preventiveFree as

preventiveQL No

Concerta * methylphenidate hcl 1 1 NoCondylox gel 2 2 NoCondylox solution * podofilox 1 1 NoContrave 3 3 PA, QL NoCopaxone * glatiramer acetate 1 1 QL YesCopegus * ribavirin 1 1 YesCopiktra 2 2 PA, QL YesCordarone; Pacerone * amiodarone hcl 1 1 NoCordran cream, ointment * flurandrenolide 1 1 NoCordran tape 2 2 No

Coreg CR * carvedilol phosphate 1Free as

preventiveQL No

Coreg immediate-release * carvedilol 1Free as

preventiveNo

Updated 9/24/2021


drug?

Corgard * nadolol 1Free as

preventiveNo

Corlanor 2 2 PA, QL NoCortef; Hydrocortisone * hydrocortisone 1 1 NoCortenema * hydrocortisone 1 1 NoCortifoam 3 3 NoCortisone acetate * cortisone acetate 1 1 NoCortisporin * neomycin/polymyxin b/hydrocort 1 1 NoCortisporin cream 0.5% 3 3 NoCortisporin eye drops * neomycin/polymyxin b/hydrocort 1 1 NoCortisporin eye ointment * neomycin/bacit/p-myx/hydrocort 1 1 NoCortisporin ointment 1% 3 3 No

Corzide * nadolol/bendroflumethiazide 1Free as

preventiveNo

Cosopt * dorzolamide hcl/timolol maleat 1 1 NoCosopt PF * dorzolamide/timolol/pf 1 1 NoCotellic 2 2 PA, QL YesCoumadin * warfarin sodium 1 1 NoCovaryx, H.S. * estrogen,ester/me-testosterone 1 1 NoCoverject syringe 2 2 No

Cozaar * losartan potassium 1Free as

preventiveNo

CPB WC * bromphenira/pseudoephed/codei n 1 1 NoCreon 2 2 NoCresemba capsule 2 2 QL No

Crestor * rosuvastatin calcium 1Free as

preventiveQL No

Crestor* 5mg, 10mg * rosuvastatin calciumFree as

preventiveFree as

preventiveQL No

Crinone 4% 2 2 NoCrinone 8% 2 2 NoCrotan * crotamiton 1 1 NoCutaquig vial 3 3 PA YesCutivate * fluticasone propionate, Beser 1 1 NoCuvitru 3 3 PA YesCuvposa 3 3 NoCyanocobalamin injection * cyanocobalamin (vitamin b-12) 1 1 No

Cyclessa * desogestrel-ethinyl estradiolFree as

preventiveFree as

preventiveNo

Cyclocort * amcinonide 1 1 NoCyclogyl * cyclopentolate hcl 1 1 NoCyclogyl 5ml 3 3 NoCyclomydril 3 3 NoCyclophosphamide capsule * cyclophosphamide 1 1 NoCyclophosphamide tablet 3 3 NoCycloserine 2 2 NoCycloset 3 3 PA, QL NoCymbalta * duloxetine hcl 1 1 NoCystadane 3 3 YesCystagon 2 2 YesCystaran 2 2 PA, QL YesCytomel * liothyronine sodium 1 1 NoCytotec * misoprostol 1 1 NoD.H.E.45 * dihydroergotamine mesylate 1 1 QL NoDaliresp 3 3 PA, QL NoDalmane * flurazepam hcl 1 1 QL NoDanocrine * danazol 1 1 NoDantrium * dantrolene sodium 1 1 NoDapsone * dapsone 1 1 NoDaraprim 2 2 PA YesDaurismo 3 3 PA, QL YesDaypro * oxaprozin 1 1 NoDaytrana 3 3 NoDayvigo 3 3 NoDDAVP * desmopressin acetate 1 1 NoDDAVP solution 3 3 NoDecadron ophthalmic * dexamethasone sodium phosphate 1 1 NoDeclomycin * demeclocycline hcl 1 1 No

Updated 9/24/2021


drug?Delatestryl * testosterone enanthate 1 1 NoDelestrogen * estradiol valerate 1 1 NoDelestrogen 10mg/ml 3 3 NoDelstrigo 2 2 QL NoDeltasone * prednisone 1 1 NoDelzicol* Mesalamine Dr 1 1 No

Demadex * torsemide 1Free as

preventiveNo

Demerol * meperidine hcl 1 1 QL NoDemser * metyrosine 1 1 No

Demulen * ethynodiol d-ethinyl estradiolFree as

preventiveFree as

preventiveNo

Depakene * valproic acid 1 1 NoDepakote, ER, Sprinkles * divalproex sodium 1 1 NoDepen * Penicillamine 1 1 NoDepo-estradiol 3 3 No

Depo-Provera 150mg * medroxyprogesterone acetateFree as

preventiveFree as

preventiveNo

Depo-Provera 400mg 2 2 NoDepo-subq Provera 104 2 2 NoDepo-Testosterone * testosterone cypionate 1 1 NoDepot, LA 2 2 YesDermacort, Hytone 2.5% * hydrocortisone 1 1 NoDermacort; Hytone 1% (Rx Only) * hydrocortisone 1 1 NoDerma-smoothe-FS * fluocinolone acetonide 1 1 NoDermatop * prednicarbate 1 1 NoDermotic * fluocinolone acetonide oil 1 1 NoDescovy 2 2 PA, QL NoDesferal * deferoxamine mesylate 1 1 No

Desogen; Ortho-cept * desogestrel-ethinyl estradiol, kalligaFree as

preventiveFree as

preventiveNo

Desonate * desonide, desrx gel 1 1 NoDesowen * desonide 1 1 NoDesoxyn * methamphetamine hcl 1 1 NoDesvenlafaxine ER 3 3 ST, QL NoDesyrel * trazodone hcl 1 1 NoDetrol, LA * tolterodine tartrate 1 1 NoDexedrine * dextroamphetamine sulfate 1 1 NoDexilant 3 3 ST NoDexpak * dexamethasone 1 1 NoDiabeta; Micronase * glyburide 1 1 NoDiabinese * chlorpropamide 1 1 NoDiacomit capsule and powder pack 3 3 YesDiamox, Sequels * acetazolamide 1 1 NoDiastat 2.5mg 2 2 NoDiastat 2.5mg * diazepam 1 1 NoDiastat Acudial * diazepam 1 1 No

Dibenzyline * phenoxybenzamine hcl 1Free as

preventivePA, QL No

Diclegis * doxylamine succ-pyridoxine 1 1 PA, QL NoDiclofenac Epolamine patch 3 3 PA, QL NoDicofenac capsule 3 3 PA, QL NoDicloxacillin * dicloxacillin sodium 1 1 No

Didrex * benzphetamine hcl 1Free as

preventiveNo

Didronel * etidronate disodium 1 1 QL NoDifferin 0.1% lotion 3 3 NoDifferin cream, gel * adapalene 1 1 NoDificid 3 3 QL NoDiflucan * fluconazole 1 1 NoDilantin * phenytoin 1 1 NoDilantin 30mg capsule 2 2 NoDilantin; Phenytek capsule * phenytoin sodium extended 1 1 NoDilatrate-SR 2 2 NoDilaudid * hydromorphone hcl 1 1 QL No

Diovan * valsartan 1Free as

preventiveNo

Updated 9/24/2021


drug?

Diovan HCT * valsartan/hydrochlorothiazide 1Free as

preventiveNo

Dipentum 3 3 NoDiprolene cream, lotion; AF * betamethasone/propylene glyc 1 1 NoDiprolene gel, ointment * betamethasone dipropionate/diprop A 1 1 NoDiprolene ointment* betamethasone dipropionate Augmented 1 1 NoDiprosone cream, ointment * betamethasone dipropionate 1 1 NoDiprosone lotion * betamethasone dipropionate 1 1 NoDisalcid * salsalate 1 1 NoDitropan, XL * oxybutynin chloride 1 1 No

Diuril * chlorothiazide 1Free as

preventiveNo

Diuril suspension 3 3 NoDivigel 3 3 NoDolobid * diflunisal 1 1 No

Donnatal*Phenobarbital-Hyposcyamine-Atropine-Scopolamine

1 1 No

Doptelet 3 3 PA, QL YesDoryx * doxycycline hyclate 1 1 PA NoDoryx MPC 3 3 PA NoDostinex * cabergoline 1 1 NoDovato tablet 3 3 NoDovonex * calcipotriene 1 1 NoDoxycycline IR-DR 3 3 PA NoDroxia 2 2 NoDrysol 2 2 NoDuac * clindamycin phos/benzoyl perox 1 1 NoDuavee 3 3 NoDuetact * pioglitazone hcl/glimepiride 1 1 NoDulera 2 2 QL NoDulara HFA 2 2 QL NoDuoneb * ipratropium/albuterol sulfate 1 1 QL NoDuopa 2 2 PA, QL YesDupixent 3 3 PA, QL YesDuragesic * fentanyl 1 1 QL NoDurezol 3 3 NoDuricef * cefadroxil 1 1 NoDutoprol 3 3 NoDyanavel XR 3 3 PA, QL No

Dyazide; Maxzide * triamterene/hydrochlorothiazid 1Free as

preventiveNo

Dymista * Azelastine-Fluticasone spray 3 3 PA, QL NoDynacin * minocycline hcl 1 1 No

Dynacirc * isradipine 1Free as

preventiveNo

Dyrenium * Triamterene capsule 1 1 NoE.E.S. * erythromycin ethylsuccinate 1 1 NoEC-Naproxyn * naproxen 1 1 NoEcoza 3 3 PA, QL NoEdarbi 3 3 ST, QL NoEdarbyclor 3 3 ST, QL No

Edecrin * ethacrynic acid 1Free as

preventiveNo

Edex 3 3 PA, QL NoEdluar 3 3 ST, QL NoEdurant 2 2 QL NoEffexor * venlafaxine hcl 1 1 NoEffexor XR; Venlafaxine hcl ER capsule * venlafaxine hcl 1 1 NoEffexor XR; Venlafaxine hcl ER tablet * venlafaxine hcl 1 1 NoEffient * prasugrel hcl 1 1 NoEfudex * fluorouracil 1 1 NoEgrifta 3 3 PA, QL YesElavil * amitriptyline hcl 1 1 NoEldepryl * selegiline hcl 1 1 NoElepsia XR 3 3 PA, QL NoElestat * epinastine hcl 1 1 NoElestrin 3 3 NoElidel * pimecrolimus 1 1 No

Updated 9/24/2021


drug?Elimite * permethrin 1 1 NoEliquis 2 2 QL NoElixophyllin 3 3 No

Ella Free as

preventiveFree as

preventiveQL No

Elmiron 2 2 NoElocon cream, lotion, solution * mometasone furoate 1 1 NoElocon ointment * mometasone furoate 1 1 NoEmadine 3 3 NoEmbeda 3 3 PA, QL NoEmcyt 2 2 NoEmend * aprepitant 1 1 QL NoEmend 40mg (1 pack, 5 pack) 2 2 QL NoEmend 40mg * aprepitant 1 1 QL NoEmend suspension 2 2 QL NoEmflaza 3 3 PA YesEmgality 2 2 PA, QL NoEmla * lidocaine/prilocaine 1 1 NoEmsam 3 3 PA, QL NoEmtriva * Emtricitabine 1 1 NoEmverm 3 3 QL NoEnablex * darifenacin hydrobromide 1 1 QL NoEnbrel 2 2 PA, QL YesEndometrin 2 2 No

Enduron * methyclothiazide 1Free as

preventiveNo

Enstilar 3 3 PA, QL NoEntocort EC * budesonide 1 1 NoEntresto 2 2 QL NoEnvarsus XR 3 3 YesEpaned enalapril maleate 1 1 NoEpclusa 2 2 PA, QL YesEpidiolex 3 3 PA, QL YesEpiduo * adapalene/benzoyl peroxide 1 1 NoEpiduo Forte 3 3 PA, QL NoEpifoam 2 2 NoEpinephrine auto-injector 2 2 QL NoEpipen 0.3mg auto-injector * epinephrine 1 1 QL NoEpivir * lamivudine 1 1 NoEpivir HBV * lamivudine 1 1 NoEpivir HBV solution 2 2 NoEpogen 3 3 PA YesEpzicom * abacavir sulfate/lamivudine 1 1 NoEquanil; Miltown * meprobamate 1 1 NoEquetro 3 3 NoErgoloid Mesylates * ergoloid mesylates 1 1 NoErgomar 2 2 QL NoErivedge 2 2 PA, QL YesErleada 2 2 PA, QL YesErtaczo 3 3 NoEryped 200mg/5ml 3 3 NoEryped 400mg/5ml erythromycin ethylsuccinate suspension 1 1 NoEry-tab * erythromycin base 1 1 NoEry-tab 500mg * erythromycin 1 1 NoErythromycin Base * erythromycin base 1 1 NoErythromycin Stearate * erythromycin stearate 1 1 NoErythromycin topical gel, solution, swab * erythromycin base in ethanol 1 1 NoEsbriet 2 2 PA, QL YesEsgic; Fioricet 50/325/40mg * butalb/acetaminophen/caffeine 1 1 QL NoEskalith, CR; Lithobid * lithium carbonate 1 1 NoEsomeprazole strontium 3 3 QL NoEstrace * estradiol 1 1 NoEstring 2 2 NoEstrogel 2 2 No

Estrostep Fe * norethindrone-e.estradiol-ironFree as

preventiveFree as

preventiveNo

Ethambutol * ethambutol hcl 1 1 NoEtrafon * perphenazine/amitriptyline hcl 1 1 No

Updated 9/24/2021


drug?Eucrisa 3 3 PA, QL NoEulexin * flutamide 1 1 NoEurax 2 2 NoEvamist 3 3 NoEvekeo * amphetamine sulfate 1 1 PA, QL No

Evista * raloxifene hclFree as

preventiveFree as

preventivePA, QL No

Evista * raloxifene hcl 1 1 QL NoEvotaz 2 2 QL NoEvoxac * cevimeline hcl 1 1 NoExalgo * hydromorphone hcl 1 1 QL NoExelderm 3 3 NoExelon capsule * rivastigmine tartrate 1 1 NoExelon patch * rivastigmine 1 1 No

Exforge * amlodipine besylate/valsartan 1Free as

preventiveNo

Exforge HCT * amlodipine/valsartan/hcthiazid 1Free as

preventiveNo

Exjade deferasirox 1 1 PA, QL YesExservan film 3 3 YesExtavia 3 3 QL YesExtina * ketoconazole 1 1 NoFabior 3 3 ST, QL NoFactive 3 3 NoFamvir * famciclovir 1 1 NoFanapt 3 3 ST NoFareston * toremifene citrate 1 1 NoFarxiga 2 2 QL NoFarydak 2 2 PA, QL YesFaslodex * fulvestrant 1 1 NoFazaclo * clozapine 1 1 NoFazaclo 150, 200mg 3 3 No

FC2 Female Condom Free as

preventiveFree as

preventiveQL No

Felbatol * felbamate 1 1 NoFeldene * piroxicam 1 1 NoFemara * letrozole 1 1 No

Femcon Fe * noreth-ethinyl estradiol/ironFree as

preventiveFree as

preventiveNo

FemHRT * norethindrone ac-eth estradiol 1Free as

preventiveNo

Femring 3 3 No

Fenofibric acid 1Free as

preventiveNo

Fenoglide * fenofibrate 1Free as

preventiveNo

Fenoprofen Calcium 200mg, 400mg 3 3 PA, QL NoFenortho 3 3 PA, QL NoFentora 3 3 PA, QL NoFerriprox * Deferiprone table 1 1 PA, QL YesFetzima 3 3 ST, QL NoFexmid * cyclobenzaprine hcl 1 1 NoFiasp, Flextouch, penfill 2 2 NoFinacea foam 3 3 ST, QL NoFinacea gel * azelaic acid 1 1 NoFioricet 50/300/40mg * butalb/acetaminophen/caffeine 1 1 NoFioricet w/codeine 50/300/30mg * butalbit/acetamin/caff/codeine 1 1 QL NoFioricet w/codeine 50/325/30mg * butalbit/acetamin/caff/codeine 1 1 QL NoFiorinal * butalbital/aspirin/caffeine/with codeine 1 1 NoFiorinal w/codeine * codeine/butalbital/asa/caffein 1 1 QL NoFirazyr * icatibant, Sajazir 1 1 PA, QL YesFirvanq 3 3 QL NoFlagyl * metronidazole 1 1 NoFlarex 3 3 NoFlector Patch 3 3 PA, QL NoFlexeril * cyclobenzaprine hcl 1 1 NoFlomax * tamsulosin hcl 1 1 NoFlonase (Rx Only) * fluticasone propionate 1 1 QL No

Updated 9/24/2021


drug?Florinef * fludrocortisone acetate 1 1 NoFlorone; Psorcon * diflorasone diacetate 1 1 NoFlovent HFA, Diskus 2 2 QL NoFloxin Otic * ofloxacin 1 1 NoFloxin tablet * ofloxacin 1 1 No

Fluad Free as

preventiveFree as

preventiveQL No

Fluarix Free as

preventiveFree as

preventiveQL No

Flublok Quad Free as

preventiveFree as

preventiveQL No

Flucelvax Quad Free as

preventiveFree as

preventiveQL No

Flulaval Free as

preventiveFree as

preventiveQL No

Flumadine * rimantadine hcl 1 1 No

Flumist Free as

preventiveFree as

preventiveQL No

Fluoroplex 3 3 NoFluorouracil 0.5% cream 3 3 ST, QL NoFluoxetine 60mg * fluoxetine hcl 1 1 QL NoFluphenazine decanoate * fluphenazine decanoate 1 1 NoFluphenazine liquid * fluphenazine hcl 1 1 NoFluticasone-salmeterol RespiClick 3 3 QL No

Fluzone Free as

preventiveFree as

preventiveQL No

Fluzone High-dose Free as

preventiveFree as

preventiveQL No

FML * fluorometholone 1 1 NoFML Forte, S.O.P. 2 2 NoFocalin, XR * dexmethylphenidate hcl 1 1 No

Folic Acid 0.4mg, 0.8mg (OTC) * folic acidFree as

preventiveFree as

preventiveNo

Folic Acid 1mg * folic acid 1 1 NoFollistim AQ 3 3 ST YesFortamet * metformin hcl 1 1 PA NoForteo 2 2 PA, QL YesFortesta * testosterone 1 1 ST, QL NoFosamax * alendronate sodium 1 1 QL NoFosamax Plus D 3 3 ST, QL NoFosrenol * lanthanum carbonate 1 1 NoFosrenol packet 3 3 NoFragmin 3 3 NoFrova * frovatriptan succinate 1 1 ST, QL NoFuradantin * nitrofurantoin 1 1 NoFuzeon 2 2 NoFycompa suspension 3 3 QL NoFycompa tablet 3 3 QL NoGabitril * tiagabine hcl 1 1 NoGalafold 2 2 PA, QL YesGalzin 3 3 NoGammagard liquid 3 3 PA YesGammaked 3 3 PA YesGamunex-C sub-q 3 3 PA Yesganirelix acetate syringe 1 1 NoGaramycin * gentamicin sulfate 1 1 No

Gardasil, 9* Free as

preventiveFree as

preventiveQL No

Gastrocrom * cromolyn sodium 1 1 NoGattex 2 2 PA, QL YesGelnique 3 3 ST, QL No

Generess Fe * noreth-ethinyl estradiol/ironFree as

preventiveFree as

preventiveNo

Gengraf; Neoral * cyclosporine, modified 1 1 YesGenotropin 2 2 PA YesGentamicin cream, ointment * gentamicin sulfate 1 1 NoGenvoya 2 2 QL NoGeodon * ziprasidone hcl 1 1 No

Updated 9/24/2021


drug?Gilenya 2 2 QL YesGilotrif 2 2 PA, QL YesGlassia 2 2 PA, QL YesGlatopa * glatiramer acetate 1 1 QL YesGleevec * imatinib mesylate 1 1 QL YesGleostine; Lomustine 2 2 NoGlucaGen HypoKit 2 2 NoGlucagon Emergency Kit 1 1 NoGlucophage, XR * metformin hcl 1 1 NoGlucotrol, XL * glipizide 1 1 NoGlucovance * glyburide/metformin hcl 1 1 No

Glycolax OTC * polyethylene glycol 3350Free as

preventiveFree as

preventiveQL No

Glynase * glyburide,micronized 1 1 NoGlyset * miglitol 1 1 NoGlyxambi 2 2 QL No

Golytely * peg3350/sod sulf,bicarb,cl/kclFree as

preventiveFree as

preventiveQL No

Golytely * peg3350/sod sulf,bicarb,cl/kcl 1 1 NoGolytely flavored 2 2 NoGonal-F, RFF, Redi-ject 2 2 YesGoNitro 3 3 NoGralise 3 3 ST, QL NoGranix 3 3 YesGrastek 3 3 PA, QL NoGrifulvin V * griseofulvin, microsize 1 1 NoGris-PEG * griseofulvin ultramicrosize 1 1 NoGuaitussin AC * codeine phosphate/guaifenesin 1 1 NoGuanidine hcl * guanidine hcl 1 1 NoGvoke Hypogen auto injector 2 2 NoGynazole-1 3 3 No

Gynol II * nonoxynol 9Free as

preventiveFree as

preventiveQL No

Haegarda 2 2 PA YesHalcion * triazolam 1 1 QL NoHaldol liquid * haloperidol lactate 1 1 NoHaldol tablet * haloperidol 1 1 NoHaldol vial * haloperidol decanoate 1 1 NoHalog * Halcinonide cream 1 1 NoHalog solution 3 3 NoHarvoni 3 3 PA, QL Yes

Havrix Free as

preventiveFree as

preventiveQL No

Hectorol * doxercalciferol 1 1 NoHemangeol 3 3 QL NoHeparin * heparin sodium,porcine/pf 1 1 NoHeparin sodium syringe 3 3 NoHepsera * adefovir dipivoxil 1 1 YesHetlioz 3 3 PA, QL YesHetlioz Lq 3 3 PA, QL YesHiprex/Urex * methenamine hippurate 1 1 NoHistex PD * carbinoxamine maleate 1 1 NoHizentra vial and syringe 3 3 PA YesHorizant 3 3 ST, QL NoHumatin * paromomycin sulfate 1 1 NoHumatrope 3 3 PA YesHumira 2 2 PA, QL YesHumira Pen pediatric 2 2 PA, QL YesHumulin R U-500 (all forms) 2 2 NoHycamtin capsule 2 2 YesHycet * hydrocodone/acetaminophen 1 1 QL NoHycodan * hydrocodone bit/homatrop me-br 1 1 NoHydrea * hydroxyurea 1 1 No

Hydrodiuril; Microzide * hydrochlorothiazide 1Free as

preventiveNo

Hygroton; Thalitone * chlorthalidone 1Free as

preventiveNo

Hyper-Sal 3 3 No

Updated 9/24/2021


drug?HyQvia 3 3 PA YesHysingla ER* hydrocodone tablet 1 1 PA, QL No

Hytrin * terazosin hcl 1Free as

preventiveNo

Hyzaar * losartan/hydrochlorothiazide 1Free as

preventiveNo

Ibrance 2 2 PA, QL YesIbudone * hydrocodone/ibuprofen 1 1 QL NoIbudone 5mg/200mg 3 3 QL NoIclusig 2 2 PA, QL YesIdhifa 2 2 PA, QL YesIlevro 3 3 NoIlotycin * erythromycin base 1 1 No

Imbruvica capsule; 280mg, 420mg, 560mg tablet 2 2 PA, QL Yes

Imdur; Ismo; Monoket * isosorbide mononitrate 1 1 NoImitrex * sumatriptan succinate 1 1 QL NoImitrex nasal spray * sumatriptan 1 1 QL NoImodium * loperamide hcl 1 1 NoImpavido 2 2 QL NoImuran * azathioprine 1 1 NoImvexxy 3 3 QL NoInbrija capsule 3 3 QL NoIncrelex 3 3 PA YesIncruse Ellipta 3 3 QL No

Inderal, LA * propranolol hcl 1Free as

preventiveNo

Inderide * propranolol/hydrochlorothiazid 1Free as

preventiveNo

Indocin, SR * indomethacin 1 1 NoInflamase, Forte * prednisolone sod phosphate 1 1 NoIngrezza 3 3 PA, QL YesIngrezza initiation pack 3 3 PA, QL YesInlyta 2 2 PA, QL YesInqovi tablet 2 2 Yes

Inspra * eplerenone 1Free as

preventiveNo

Insulin Lispro Junior Kwikpen 3 3 NoIntal solution * cromolyn sodium 1 1 NoIntelence * etravirine 1 1 NoIntermezzo * zolpidem tartrate 1 1 PA, QL NoIntrarosa 3 3 QL NoIntron A 2 2 Yes

Intuniv * guanfacine hcl 1Free as

preventiveQL No

Invega * paliperidone 1 1 QL NoInveltys 3 3 PA, QL NoInvirase 2 2 NoInvokamet, XR 2 2 QL NoInvokana 2 2 QL NoIopidine droperette 3 3 NoIopidine drops * apraclonidine hcl 1 1 NoIrenka * duloxetine hcl 1 1 NoIressa 2 2 PA, QL YesIsentress 2 2 NoIsentress HD 2 2 NoIsoniazid * isoniazid 1 1 NoIsopto Atropine * atropine sulfate 1 1 NoIsopto Homatropine * homatropine hbr 1 1 NoIsopto-Carpine; Pilocar * pilocarpine hcl 1 1 NoIsordil * isosorbide dinitrate 1 1 NoIsordil 40mg 3 3 No

Istalol * timolol maleate 1Free as

preventiveNo

Isturisa Tablet 3 3 PA, QL YesJadenu* Deferasirox 1 1 PA, QL YesJakafi 2 2 PA, QL YesJalyn * dutasteride/tamsulosin hcl 1 1 QL No

Updated 9/24/2021


drug?Janumet 2 2 NoJanumet XR 2 2 QL NoJanuvia 2 2 QL NoJardiance 2 2 QL NoJatenzo 3 3 PA QL NoJentadueto, XR 2 2 QL NoJornay PM capsule 3 3 PA, QL NoJuluca 3 3 QL NoJuxtapid 3 3 PA, QL YesJynarque 2 2 PA, QL YesKadian * morphine sulfate 1 1 QL NoKadian 200mg 3 3 QL NoKaletra * lopinavir/ritonavir 1 1 NoKaletra tablet 2 2 NoKalydeco 2 2 PA, QL Yes

Kapvay * clonidine hcl 1Free as

preventiveQL No

Karbinal ER 3 3 ST, QL NoKayexalate * sodium polystyrene sulfonate 1 1 NoKeflex * cephalexin 1 1 NoKenalog 0.025% cream, lotion * triamcinolone acetonide 1 1 NoKenalog 0.025% ointment, 0.05%, 0.1% * triamcinolone acetonide 1 1 NoKenalog Spray * triamcinolone acetonide 1 1 NoKeppra, XR * levetiracetam 1 1 No

Kerlone * betaxolol hcl 1Free as

preventiveNo

Ketoprofen * ketoprofen 1 1 PA, QL NoKeveyis 3 3 PA, QL YesKevzara 3 3 PA, QL YesKhedezla 3 3 ST, QL NoKineret 3 3 PA, QL YesKisqali Femara co-pack 2 2 PA, QL YesKisqali, Femara co-pack 2 2 PA, QL YesKlaron * sulfacetamide sodium 1 1 NoKlonopin, Wafer * clonazepam 1 1 NoK-Lor; Klor-Con packet * potassium chloride 1 1 NoKlor-Con M15 * potassium chloride 1 1 NoKloxxado spray 2 2 QL NoK-Lyte; Klor-con/EF * potassium bicarbonate/cit ac 1 1 NoKorlym 2 2 PA, QL YesKrintafel 2 2 QL NoKristalose 20g packet 3 3 NoK-Sol; Potassium Chloride * potassium chloride 1 1 NoK-Tab 2 2 NoK-Tab; K-Dur; Slow-K; Kaon CL; Klor-con * potassium chloride 1 1 NoKuvan * Sapropterin Dihydrochloride powder pack and tablet 2 2 PA YesKytril * granisetron hcl 1 1 QL NoLac-Hydrin * ammonium lactate 1 1 NoLacrisert 2 2 NoLactulose * lactulose 1 1 NoLamictal dose pack * lamotrigine 1 1 NoLamictal ODT, XR * lamotrigine 1 1 NoLamictal XR dose pack 3 3 NoLamictal, dispertabs * lamotrigine 1 1 NoLamisil tablet * terbinafine hcl 1 1 NoLanoxin * digoxin 1 1 NoLanoxin 62.5, 187.5mcg 3 3 NoLantus, Solostar 2 2 NoLariam * mefloquine hcl 1 1 No

Lasix * furosemide 1Free as

preventiveNo

Lastacaft 3 3 NoLatuda 3 3 ST NoLedipasvir-sofosbuvir 2 2 PA, QL YesLenvima 2 2 PA, QL Yes

Lescol, XL * fluvastatin sodium 1Free as

preventiveQL No

Updated 9/24/2021


drug?

Lescol, XL* (all strengths) * fluvastatin sodiumFree as

preventiveFree as

preventiveQL No

Letairis Ambrisentan 1 1 PA, QL YesLeucovorin tablet * leucovorin calcium 1 1 NoLeukeran 2 2 NoLeukine 2 2 YesLevalbuterol Tartrate HFA 3 3 QL NoLevaquin * levofloxacin, isotretinoin 1 1 NoLevbid * hyoscyamine sulfate 1 1 NoLevemir, Flextouch 2 2 NoLevitra * vardenafil hcl 1 1 PA, QL No

Levlen; Nordette * levonorgestrel-ethin estradiol, AyunaFree as

preventiveFree as

preventiveNo

Levorphanol Tartrate * levorphanol tartrate 1 1 QL NoLevorphanol Tartrate 3mg 3 3 QL NoLevoxyl; Synthroid * levothyroxine sodium 1 1 NoLevsin, SL * hyoscyamine sulfate 1 1 NoLexapro * escitalopram oxalate 1 1 NoLexiva * fosamprenavir calcium 1 1 NoLexiva suspension 2 2 NoLialda * mesalamine 1 1 QL NoLibrax * chlordiazepoxide/clidinium br 1 1 NoLibrium * chlordiazepoxide hcl 1 1 NoLidex * fluocinonide 1 1 QL NoLidex E * fluocinonide/emollient base 1 1 NoLidocort cream 1 1 NoLidoderm patch * lidocaine 1 1 NoLimbitrol, DS * amitriptyline/chlordiazepoxide 1 1 NoLindane * lindane 1 1 NoLinzess 2 2 QL No

Lipitor * atorvastatin calcium 1Free as

preventiveQL No

Lipitor 10mg, 20mg * atorvastatin calciumFree as

preventiveFree as

preventiveQL No

Lipofen; Fenofibrate capsule 3 3 NoLithium Citrate * lithium citrate 1 1 NoLithostat 3 3 NoLivalo 3 3 ST, QL NoLo Loestrin Fe 3 3 No

Lo/Ovral * norgestrel-ethinyl estradiolFree as

preventiveFree as

preventiveNo

Locoid cream, ointment, solution * hydrocortisone butyrate 1 1 NoLocoid Lipocream * hydrocortisone butyrate/emoll 1 1 NoLodine, XL * etodolac 1 1 NoLodosyn * carbidopa 1 1 No

Loestrin * norethindrone ac-eth estradiol, Aurovela, HaileyFree as

preventiveFree as

preventiveNo

Loestrin 24 Fe * norethindrone-e.estradiol-iron, Hailey 24 FeFree as

preventiveFree as

preventiveNo

Loestrin Fe *norethindrone-e.estradiol-iron, Aurovela Fe, Hailey Fe

Free as preventive

Free as preventive

No

Lofibra capsule * fenofibrate,micronized 1Free as

preventiveNo

Lofibra tablet * fenofibrate 1Free as

preventiveNo

Lokelma 3 3 PA, QL NoLomaira 3 3 NoLomotil * diphenoxylate hcl/atropine 1 1 NoLonhala Magnair 3 3 QL No

Loniten * minoxidil 1Free as

preventiveNo

Lonsurf 2 2 PA, QL Yes

Lopid * gemfibrozil 1Free as

preventiveNo

Lopressor * metoprolol tartrate 1Free as

preventiveNo

Lopressor HCT * metoprolol/hydrochlorothiazide 1Free as

preventiveNo

Updated 9/24/2021


drug?Loprox cream, suspension * ciclopirox olamine 1 1 NoLoprox gel, shampoo * ciclopirox 1 1 NoLorazepam intensol * lorazepam 1 1 NoLorbrena 3 3 PA, QL YesLortab solution 3 3 QL No

Loseasonique * l-norgest/e.estradiol-e.estrad, Lojaimiess tabletFree as

preventiveFree as

preventiveQL No

Lotemax * Loteprednol Etabonate 1 1 PA, QL No

Lotensin * benazepril hcl 1Free as

preventiveNo

Lotensin HCT * benazepril/hydrochlorothiazide 1Free as

preventiveNo

Lotrel * amlodipine besylate/benazepril 1Free as

preventiveNo

Lotrimin * clotrimazole 1 1 NoLotrisone * clotrimazole/betamethasone dip 1 1 NoLotronex * alosetron hcl 1 1 No

Lovaza * omega-3 acid ethyl esters 1Free as

preventiveQL No

Lovenox * enoxaparin sodium 1 1 NoLoxitane * loxapine succinate 1 1 No

Lozol * indapamide 1Free as

preventiveNo

Lucemyra 2 2 QL NoLumigan * bimatoprost 1 1 NoLumigan 0.01% 2 2 NoLunesta * eszopiclone 1 1 QL NoLupaneta Pack 3 3 YesLupron * leuprolide acetate 1 1 YesLupron Depot 3.75mg, 11.25mg 2 2 YesLupron Depot-PED 2 2 YesLuvox * fluvoxamine maleate 1 1 NoLuvox CR * fluvoxamine maleate 1 1 NoLuxiq * betamethasone valerate 1 1 NoLuzu, Luliconazole 1% cream 3 3 PA, QL No

Lybrel * levonorgestrel-ethin estradiol, dolishaleFree as

preventiveFree as

preventiveNo

Lynparza 2 2 PA, QL YesLyrica * pregabalin 1 1 PA, QL NoLyrica CR progabalin ER 3 3 PA, QL NoLysodren 2 2 NoLysteda * tranexamic acid 1 1 PA, QL NoMacrobid * nitrofurantoin monohyd/m-cryst 1 1 NoMacrodantin * nitrofurantoin macrocrystal 1 1 NoMalarone * atovaquone/proguanil hcl 1 1 NoMaprotiline hcl * maprotiline hcl 1 1 NoMarinol * dronabinol 1 1 NoMarplan 3 3 NoMatulane 2 2 YesMavenclad 3 3 Yes

Mavik * trandolapril 1Free as

preventiveNo

Mavyret 3 3 PA, QL YesMaxalt, MLT * rizatriptan benzoate 1 1 QL NoMaxidex 3 3 NoMaxitrol * neomycin/polymyxin b/dexametha 1 1 NoMayzent tablet 3 3 YesMeclomen * meclofenamate sodium 1 1 NoMedrol 2mg 3 3 NoMedrol, dose pack * methylprednisolone, methylpred dp 1 1 NoMegace, ES * megestrol acetate 1 1 NoMekinist 2 2 PA, QL YesMektovi 2 2 PA, QL YesMellaril * thioridazine hcl 1 1 No

Menactra Free as

preventiveFree as

preventiveQL No

Menest 3 3 NoMenopur 2 2 Yes

Updated 9/24/2021


drug?Menostar 3 3 NoMentax 2 2 No

Menveo Free as

preventiveFree as

preventiveQL No

Mephyton * phytonadione (vit k1) 1 1 NoMepron * atovaquone 1 1 NoMepron blister pak 2 2 NoMesnex tablet 2 2 NoMestinon syrup pyridostigmine bromide syrup 1 1 NoMestinon, Timespan * pyridostigmine bromide 1 1 NoMetadate CD * methylphenidate hcl 1 1 NoMetaglip * glipizide/metformin hcl 1 1 NoMethadone * methadone hcl 1 1 QL NoMethergine * methylergonovine maleate 1 1 QL NoMethitest 3 3 QL NoMethotrexate * methotrexate sodium 1 1 NoMethotrexate PF injection * methotrexate sodium/pf 1 1 NoMethylin, ER * methylphenidate hcl 1 1 NoMethylphenidate ER 72mg 3 3 QL NoMetozolv ODT * metoclopramide hcl 1 1 NoMetrocream, gel, lotion 0.75% * metronidazole 1 1 NoMetrogel 1% * metronidazole 1 1 NoMetrogel-Vaginal * metronidazole 1 1 No

Mevacor * lovastatin 1Free as

preventiveQL No

Mevacor* (all strengths) * lovastatinFree as

preventiveFree as

preventiveQL No

Mexitil * mexiletine hcl 1 1 NoMiacalcin injection 2 2 NoMiacalcin nasal spray * calcitonin,salmon,synthetic 1 1 No

Micardis * telmisartan 1Free as

preventiveNo

Micardis HCT * telmisartan/hydrochlorothiazid 1Free as

preventiveNo

Micro-K * potassium chloride 1 1 No

Midamor * amiloride hcl 1Free as

preventiveNo

Migergot * ergotamine tartrate/caffeine 1 1 NoMigranal * dihydroergotamine mesylate 1 1 QL No

Milk of Magnesia OTC * magnesium hydroxideFree as

preventiveFree as

preventiveQL No

Millipred solution * prednisolone sod phosphate 1 1 NoMillipred tablet, dose pack * prednisolone 1 1 No

Minastrin 24 Fe * norethindrone-e.estradiol-iron, charlotte 24 FeFree as

preventiveFree as

preventiveNo

Minipress * prazosin hcl 1Free as

preventiveNo

Minitran 3 3 NoMinivelle, Vivelle-Dot * estradiol, dotti/Lyllana transdermal patch 1 1 NoMinocin capsule * minocycline hcl 1 1 NoMirapex ER * pramipexole di-hcl 1 1 QL NoMirapex immediate-release * pramipexole di-hcl 1 1 QL NoMircera 3 3 PA, QL Yes

Mircette * desog-e.estradiol/e.estradiol, Simliya, Volnea tabletFree as

preventiveFree as

preventiveNo

Mitigare 3 3 NoM-Natal Plus tablet 1 1 NoMobic * meloxicam 1 1 No

Modicon * norethindrone-ethinyl estradFree as

preventiveFree as

preventiveNo

Moduretic * amiloride/hydrochlorothiazide 1 1 NoMolindone * molindone hcl 1 1 QL NoMonistat 3 * miconazole nitrate 1 1 NoMonodox * doxycycline monohydrate 1 1 No

Monopril * fosinopril sodium 1Free as

preventiveNo

Monopril HCT * fosinopril/hydrochlorothiazide 1Free as

preventiveNo

Updated 9/24/2021


drug?Monurol * Fosfomycin Tromethamine 1 1 NoMotofen 3 3 NoMotrin (Rx Only) * ibuprofen 1 1 NoMovantik 3 3 PA, QL NoMoviprep * Peg3350-Sod Sul-Nacl-K powder pack 1 1 NoMoxatag 3 3 NoMoxeza * Moxifloxacin drops 1 1 NoMS Contin * morphine sulfate 1 1 QL NoMSIR * morphine sulfate 1 1 QL NoMucomyst * acetylcysteine 1 1 NoMulpleta 2 2 PA, QL YesMultaq 2 2 QL NoMupirocin Calcium 1 1 NoMuse 2 2 PA, QL NoMyalept 3 3 PA, QL YesMycapssa capsule 3 3 YesMycelex Troche * clotrimazole 1 1 NoMycobutin * rifabutin 1 1 NoMycostatin * nystatin 1 1 NoMydriacyl * tropicamide 1 1 NoMyfortic * mycophenolate sodium 1 1 YesMyleran 2 2 NoMyrbetriq 3 3 PA, ST, QL NoMysoline * primidone 1 1 NoMytesi 2 2 PA, QL NoNaftin * naftifine hcl 1 1 PA, QL NoNaftin gel 3 3 PA, QL NoNalfon * fenoprofen calcium 1 1 PA, QL NoNalfon 400mg 3 3 PA, QL NoNaloxone hcl injection * naloxone hcl 1 1 NoNamenda * memantine hcl 1 1 QL NoNamenda dose pack 2 2 QL NoNamenda XR * memantine hcl 1 1 QL NoNamenda XR dose pack 3 3 QL NoNamzaric 3 3 ST, QL NoNaprosyn (Rx Only) * naproxen 1 1 NoNaprosyn suspension (Rx Only) * naproxen 1 1 NoNaprosyn tablet (Rx Only) * naproxen 1 1 NoNarcan nasal spray 2 2 QL NoNardil * phenelzine sulfate 1 1 NoNasalide * flunisolide 1 1 QL NoNasonex * mometasone furoate 1 1 ST, QL NoNatacyn 2 2 NoNatazia 3 3 NoNatesto 3 3 ST, QL NoNatpara 2 2 PA, QL YesNatroba * spinosad 1 1 NoNature-Throid * thyroid,pork 1 1 NoNavane * thiothixene 1 1 NoNayzilam spray 2 2 NoNebupent aerosol 2 2 NoNebusal 3 3 NoNeomycin * neomycin sulfate 1 1 NoNeosporin ophthalmic ointment * neomycin sulf/bacitracin/poly 1 1 NoNeosporin ophthalmic solution * neomycin/polymyxn b/gramicidin 1 1 NoNeo-Synalar 3 3 NoNeo-Synephrine * phenylephrine hcl 1 1 NoNeptazane * methazolamide 1 1 NoNerlynx 2 2 PA, QL YesNeulasta 3 3 QL YesNeupogen 3 3 YesNeupro 3 3 PA, QL NoNeurontin * gabapentin 1 1 No

Neutragard * fluoride (sodium) 1Free as

preventiveNo

Nevanac 3 3 NoNexavar 2 2 PA, QL YesNexium * esomeprazole magnesium 1 1 No

Updated 9/24/2021


drug?Nexium suspension 3 3 ST NoNexlizet 3 3 No

Niaspan * niacin 1Free as

preventiveNo

Nicorette lozenge * nicotine polacrilexFree as

preventiveFree as

preventiveQL No

Nicotine gum; Nicorette * nicotine polacrilexFree as

preventiveFree as

preventiveQL No

Nicotine patch * nicotineFree as

preventiveFree as

preventiveQL No

Nicotrol, NS 3 3 QL No

Nicotrol, NS Free as

preventiveFree as

preventiveST, QL No

Nilandron * nilutamide 1 1 PA, QL No

Nimotop * nimodipine 1Free as

preventiveNo

Ninlaro 2 2 PA, QL YesNiravam * alprazolam 1 1 NoNitro-bid ointment * nitroglycerin 1 1 NoNitro-Dur * nitroglycerin 2 2 NoNitroglycerin capsule, patch * nitroglycerin 1 1 NoNitrostat * nitroglycerin 1 1 NoNityr 3 3 PA YesNizoral * ketoconazole 1 1 NoNizoral cream, shampoo 2% * ketoconazole 1 1 NoNocdurna 3 3 PA, QL NoNoctiva 3 3 PA, QL NoNorco; Vicodin; Xodol * hydrocodone/acetaminophen 1 1 QL NoNorditropin FlexPro 2 2 PA YesNorflex * orphenadrine citrate 1 1 No

Norinyl 1/35; Ortho-novum 1/35 * norethindrone-ethinyl estrad, Nortrel, NyliaFree as

preventiveFree as

preventiveNo

Noritate 3 3 No

Normodyne * labetalol hcl 1Free as

preventiveNo

Norpace * disopyramide phosphate 1 1 NoNorpace CR 2 2 NoNorpramin * desipramine hcl 1 1 NoNorthera * Droxidopa 1 1 PA, QL Yes

Norvasc * amlodipine besylate 1Free as

preventiveNo

Norvir * ritonavir 1 1 NoNorvir capsule, solution, packet 2 2 NoNovarel 3 3 PA YesNovolin; 70/30 vial 2 2 NoNovolog, Mix (all forms) 2 2 NoNoxafil suspension 2 2 QL NoNoxafil tablet * Posaconazole tablet 1 1 QL NoNP Thyroid * thyroid,pork 1 1 NoNubain * nalbuphine hcl 1 1 QL NoNucynta, ER 3 3 PA, QL NoNuedexta 2 2 PA, QL No

Nulytely * sodium chloride/nahco3/kcl/pegFree as

preventiveFree as

preventiveQL No

Nulytely * sodium chloride/nahco3/kcl/peg 1 1 NoNulytely Soln Recon 3 3 NoNuplazid 3 3 PA, QL NoNutropin AQ Nuspin 2 2 PA Yes

Nuvaring * Eluryng, Etonosgestrel-Ethinyl EFree as

preventiveFree as

preventiveQL No

Nuvessa 3 3 NoNuvigil * armodafinil 1 1 QL NoNuzyra tablet 3 3 QL NoNymalize 3 3 QL NoNystatin * nystatin 1 1 NoNystatin w/Triamcinolone * nystatin/triamcin 1 1 NoObredon 3 3 QL NoOcaliva 2 2 PA, QL Yes

Updated 9/24/2021


drug?Ocufen * flurbiprofen sodium 1 1 NoOcuflox * ofloxacin 1 1 NoOcupress * carteolol hcl 1 1 NoOdactra 3 3 PA, QL NoOdefsey 2 2 QL NoOdomzo 2 2 PA, QL YesOfev 2 2 PA, QL YesOlumiant 3 3 PA, QL YesOlux * clobetasol propionate 1 1 No

Olux-E * clobetasol propionate/emoll/tovet emollient 1 1 No

Omeclamox-pak 3 3 NoOmnaris 3 3 ST, QL NoOmnicef * cefdinir 1 1 NoOmnitrope 3 3 PA YesOnfi * clobazam 1 1 QL NoOngentys capsule 3 3 PA, QL NoOnzetra Xsail 3 3 ST, QL NoOpana * oxymorphone hcl 1 1 QL NoOpana ER * oxymorphone hcl 1 1 PA, QL NoOpsumit 2 2 PA, QL YesOpticrom * cromolyn sodium 1 1 NoOptipranolol * metipranolol 1 1 NoOptivar * azelastine hcl 1 1 NoOracea 3 3 PA No

Oral Saline Laxative liquid OTC * sodium phosphate,mono-dibasicFree as

preventiveFree as

preventiveQL No

Oralair 3 3 PA, QL NoOralone paste * triamcinolone acetonide 1 1 NoOrap * pimozide 1 1 NoOrapred ODT * prednisolone sod phosphate 1 1 NoOrapred solution * prednisolone sod phosphate 1 1 NoOravig 3 3 QL NoOrencia Clickject, sub-q 3 3 PA, QL YesOrenitram ER 2 2 PA, QL YesOrfadin * Nitisinone 1 1 PA YesOrilissa 3 3 PA, QL NoOrinase * tolbutamide 1 1 NoOrkambi 2 2 PA, QL Yes

Ortho Evra * norelgestromin/ethin.estradiol/zafemyFree as

preventiveFree as

preventiveQL No

Ortho Micronor; Nor-QD * norethindrone, LyleqFree as

preventiveFree as

preventiveNo

Ortho Tri-Cyclen * norgestimate-ethinyl estradiol, Tri-NymyoFree as

preventiveFree as

preventiveNo

Ortho Tri-Cyclen Lo * norgestimate-ethinyl estradiol, tri-lo-miliFree as

preventiveFree as

preventiveNo

Ortho-Cyclen * norgestimate-ethinyl estradiol, NymyoFree as

preventiveFree as

preventiveNo

Ortho-Novum 7/7/7 * norethindrone-ethinyl estrad, Nortrel, NyliaFree as

preventiveFree as

preventiveNo

Osmoprep 3 3 NoOsphena 3 3 NoOtezla 2 2 PA, QL YesOtovel 2 2 NoOtrexup 3 3 PA, QL Yes

Ovcon 35 * norethindrone-ethinyl estradFree as

preventiveFree as

preventiveNo

Ovide * malathion 1 1 NoOvidrel 2 2 Yes

Ovral * norgestrel-ethinyl estradiolFree as

preventiveFree as

preventiveNo

Oxandrin * oxandrolone 1 1 PA NoOxervate 2 2 PA, QL YesOxistat * oxiconazole nitrate 1 1 PA, QL NoOxistat lotion 3 3 PA, QL NoOxsoralen-Ultra * methoxsalen 1 1 NoOxtellar XR 3 3 PA, QL No

Updated 9/24/2021


drug?Oxycodone hcl ER 3 3 PA, QL NoOxycodone immediate release, solution * oxycodone hcl 1 1 QL NoOxycontin 3 3 PA, QL NoOzempic 2 2 QL NoPalynziq 2 2 PA, QL YesPamine, Forte * methscopolamine bromide 1 1 NoPancreaze 3 3 NoPanretin 2 2 NoParafon Forte DSC 500mg * chlorzoxazone 1 1 NoParcopa * carbidopa/levodopa 1 1 NoParemyd 3 3 NoParlodel * bromocriptine mesylate 1 1 NoParnate * tranylcypromine sulfate 1 1 NoPaser 3 3 NoPataday * olopatadine hcl 1 1 NoPatanase * olopatadine hcl 1 1 QL NoPatanol * olopatadine hcl 1 1 NoPaxil * paroxetine hcl 1 1 NoPaxil CR * paroxetine hcl 1 1 NoPaxil suspension 3 3 NoPazeo 3 3 QL NoPediapred solution * prednisolone sod phosphate 1 1 NoPeganone 2 2 NoPegasys, Proclick 2 2 QL YesPeg-Intron, Redipen 2 2 QL Yes

Peg-Prep * bisac/nacl/nahco3/kcl/peg 3350Free as

preventiveFree as

preventiveQL No

Penicillin VK * penicillin v potassium 1 1 NoPenlac * ciclopirox 1 1 NoPennsaid 1.5% * diclofenac sodium 1 1 QL NoPennsaid 2% 3 3 ST, QL NoPentasa 2 2 NoPepcid (Rx Only) * famotidine 1 1 NoPercocet * oxycodone hcl/acetaminophen 1 1 QL NoPercodan * oxycodone hcl/aspirin 1 1 QL NoPerforomist * formoterol fumarate vial-neb 1 1 NoPeriactin * cyproheptadine hcl 1 1 NoPeridex * chlorhexidine gluconate 1 1 NoPeriostat * doxycycline hyclate 1 1 NoPerphenazine * perphenazine 1 1 NoPersantine * dipyridamole 1 1 NoPertzye 3 3 NoPexeva 3 3 ST NoPhenergan * promethazine hcl 1 1 NoPhenergan DM * promethazine/dextromethorphan 1 1 NoPhenergan VC * phenylephrine hcl/prometh hcl 1 1 NoPhenergan VC w/Codeine * promethazine/phenyleph/codeine 1 1 NoPhenergan w/Codeine * promethazine hcl/codeine 1 1 NoPhenobarbital * phenobarbital 1 1 NoPhoslo * calcium acetate 1 1 NoPhoslyra 3 3 NoPhospholine Iodide 2 2 NoPhrenilin 50mg/325mg * butalbital/acetaminophen 1 1 NoPhrenilin Forte * butalb/acetaminophen/caffeine 1 1 NoPicato 3 3 PA, QL NoPifeltro 2 2 QL No

Plan B One-step * levonorgestrel, After PillFree as

preventiveFree as

preventiveQL No

Plaquenil * hydroxychloroquine sulfate 1 1 NoPlavix * clopidogrel bisulfate 1 1 NoPlegridy 2 2 QL Yes

Plendil * felodipine 1Free as

preventiveNo

Plenvu 3 3 NoPletal * cilostazol 1 1 NoPlixda 3 3 No

Pneumovax 23 Free as

preventiveFree as

preventiveQL No

Updated 9/24/2021


drug?Polysporin * bacitracin/polymyxin b sulfate 1 1 NoPolytrim * polymyxin b sulf/trimethoprim 1 1 NoPomalyst 3 3 PA, QL YesPonstel * mefenamic acid 1 1 NoPosaconazole tablet (authorized generic) 2 2 NoPotassium Chloride effervescent * pot chloride/pot bicarb/cit ac 1 1 NoPradaxa 3 3 QL NoPraluent 2 2 PA, QL NoPramosone cream * hydrocortisone/pramoxine 1 1 NoPramosone ointment 2.5%-1% 3 3 NoPrandiMet * repaglinide/metformin hcl 1 1 NoPrandin * repaglinide 1 1 No

Pravachol * pravastatin sodium 1Free as

preventiveQL No

Pravachol* (all strengths) * pravastatin sodiumFree as

preventiveFree as

preventiveQL No

Precose * acarbose 1 1 NoPred Forte * prednisolone acetate 1 1 NoPred Mild 2 2 NoPred-G 3 3 NoPrednisolone solution, tablet * prednisolone 1 1 NoPrednisone * prednisone 1 1 NoPrefest 3 3 NoPregnyl 2 2 PA YesPremarin, cream, Low Dose 2 2 NoPrempro, Low Dose; Premphase 2 2 NoPrepopik 3 3 NoPrestalia 3 3 QL NoPretomanid tablet 2 2 NoPrevacid capsule (Rx Only) * lansoprazole 1 1 No

Prevident * fluoride (sodium), sodium fluoride 5000 1Free as

preventiveNo

Prevident 5000 Plus *sodium fluoride 5000, sodium fluoride sensitive, sodium fluoride enamel

1 1 No

Prevnar 13* Free as

preventiveFree as

preventiveQL No

Prevpac * lansoprazole/amoxiciln/clarith 1 1 NoPrevymis tablet 3 3 QL NoPrezcobix 2 2 QL NoPrezista 2 2 NoPriftin 3 3 NoPrilosec capsule (Rx Only) * omeprazole 1 1 NoPrilosec suspension 3 3 NoPrimaquine (branded version) 2 2 NoPrimaquine (generic version) 1 1 NoPrimsol 3 3 No

Prinivil; Zestril * lisinopril 1Free as

preventiveNo

Prinzide; Zestoretic * lisinopril/hydrochlorothiazide 1Free as

preventiveNo

Pristiq * desvenlafaxine succinate 1 1 QL NoProAir HFA; 2 2 QL NoProamatine * midodrine hcl 1 1 NoPro-Banthine * propantheline bromide 1 1 NoProbenecid * probenecid 1 1 NoProcentra * dextroamphetamine sulfate 1 1 NoProcrit 2 2 PA YesProctocort * hydrocortisone 1 1 NoProctocort suppository * hydrocortisone acetate 1 1 NoProctofoam-HC 2 2 NoProcto-pak * hydrocortisone 1 1 NoProctosol-HC suppository * hydrocortisone acetate 1 1 NoProcysbi 3 3 PA, QL YesProgesterone In Oil (inj) * progesterone 1 1 NoProglycem * Diazoxide suspension 1 1 NoPrograf * tacrolimus 1 1 YesPrograf granule packet 3 3 YesProlensa 3 3 No

Updated 9/24/2021


drug?Prolixin * fluphenazine hcl 1 1 NoPromacta 2 2 PA YesPrometrium * progesterone, micronized 1 1 NoPropylthiouracil * propylthiouracil 1 1 NoProscar * finasteride 1 1 NoProsom * estazolam 1 1 QL NoProtonix suspension 3 3 NoProtonix tablet * pantoprazole sodium 1 1 NoProtopic * tacrolimus 1 1 NoProventil HFA 3 3 QL NoProventil solution * albuterol sulfate 1 1 NoProventil albuterol sulfate 1 1 No

Provera * medroxyprogesterone acetate 1Free as

preventiveNo

Provigil * modafinil 1 1 QL NoProzac * fluoxetine hcl 1 1 QL NoProzac weekly * fluoxetine hcl 1 1 QL NoPrudoxin, Zonalon * doxepin hcl 1 1 PA, QL NoPulmicort Flexhaler 2 2 QL NoPulmicort solution * budesonide 1 1 NoPulmozyme 2 2 PA YesPurinethol * mercaptopurine 1 1 NoPurixan 3 3 YesPyrazinamide * pyrazinamide 1 1 NoQbrelis 3 3 QL NoQbrexza 2 2 PA, QL NoQnasl 3 3 ST, QL NoQsymia 3 3 PA, QL NoQtern 2 2 QL NoQualaquin * quinine sulfate 1 1 No

Quartette * l-norgest/e.estradiol-e.estradFree as

preventiveFree as

preventiveQL No

Quazepam 3 3 QL NoQudexy XR * topiramate ER 1 1 PA, QL No

Questran * cholestyramine (with sugar) 1Free as

preventiveNo

Questran Light * cholestyramine/aspartame 1Free as

preventiveNo

QuilliChew ER 3 3 PA, QL NoQuillivant XR 3 3 ST, QL NoQuinidex * quinidine sulfate 1 1 NoQuinidine Gluconate SA * quinidine gluconate 1 1 NoQuixin * levofloxacin 1 1 NoQvar RediHaler 2 2 QL NoRadiogardase 2 2 NoRagwitek 3 3 PA, QL NoRanexa * ranolazine ER 1 1 NoRapaflo * silodosin 1 1 QL NoRapamune * sirolimus 1 1 YesRasuvo 3 3 PA, QL YesRavicti 3 3 PA, QL YesRayaldee 3 3 QL NoRayos 3 3 PA, QL NoRazadyne, ER * galantamine hbr 1 1 NoRebetol * ribavirin 1 1 YesRebetol solution 2 2 YesRebif, Rebidose 2 2 QL YesRectiv 3 3 QL NoReditrex syringe 3 3 PA, QL YesReglan * metoclopramide hcl 1 1 NoRegranex 3 3 QL NoRelafen * nabumetone 1 1 NoRelcof C * codeine phosphate/guaifenesin 1 1 NoRelenza 2 2 QL NoRelexxii 3 3 QL NoRelistor tablet 3 3 PA, QL NoRelpax * eletriptan hydrobromide 1 1 ST, QL NoRemeron * mirtazapine 1 1 No

Updated 9/24/2021


drug?Renacidin 2 2 NoRenagel * sevelamer hcl 1 1 NoRenvela * sevelamer carbonate 1 1 NoRepatha 2 2 PA, QL NoRequip * ropinirole hcl 1 1 NoRequip XL * ropinirole hcl 1 1 NoRestasis 2 2 NoRestoril * temazepam 1 1 QL NoRetacrit vial 2 2 NoRetin-A; Avita * tretinoin 1 1 NoRetrovir * zidovudine 1 1 NoRevatio * sildenafil citrate 1 1 QL NoRevatio suspension 2 2 PA, QL NoRevia * naltrexone hcl 1 1 NoRevlimid 3 3 QL YesRexulti 3 3 PA, QL NoReyataz * atazanavir sulfate 1 1 NoReyataz packet 2 2 NoRhopressa 3 3 PA, QL NoRibapak; Ribatab * ribavirin 1 1 YesRibasphere Ribapak tablet * ribavirin 1 1 YesRidaura 2 2 NoRifadin * rifampin 1 1 NoRifamate 3 3 NoRifater 3 3 NoRilutek * riluzole 1 1 NoRinvoq 2 2 NoRiomet * Metformin Hcl solution 1 1 NoRiomet ER 3 3 NoRisperdal, M-Tab * risperidone 1 1 NoRitalin, LA, SR * methylphenidate hcl 1 1 NoRMS Suppository * morphine sulfate 1 1 QL NoRobaxin * methocarbamol 1 1 NoRobinul tablet, Forte * glycopyrrolate 1 1 No

Robitussin AC * codeine phosphate/guaifenesin, maxi-tuss Ac 1 1 No

Rocaltrol * calcitriol 1 1 NoRoxanol * morphine sulfate 1 1 QL NoRozorem * ramelteon 1 1 QL NoRubraca 2 2 PA, QL YesRuconest 3 3 PA, QL YesRuzurgi tablet 3 3 YesRydapt 2 2 PA, QL YesRynatan * phenylephrine/chlor-tan 1 1 NoRytary 3 3 ST, QL NoRythmol, SR * propafenone hcl 1 1 NoRyzolt * tramadol hcl 1 1 QL NoSabril packet * vigabatrin 1 1 PA, QL YesSabril tablet * vigabatrin 1 1 ST, QL Yes

Safyral * drospir/eth estra/levomefol caFree as

preventiveFree as

preventiveNo

Saizen 3 3 PA YesSaizenprep 3 3 PA YesSalagen * pilocarpine hcl 1 1 NoSamsca * tolvaptan 2 2 QL YesSanctura * trospium chloride 1 1 QL NoSanctura XR * trospium chloride 1 1 QL NoSancuso 3 3 PA, QL NoSandimmune capsule * cyclosporine 1 1 YesSandimmune solution 3 3 YesSandostatin * octreotide acetate 1 1 YesSandostatin LAR Depot 2 2 PA YesSantyl 2 2 NoSaphris* Asenapine Maleate sublingual tablets 1 1 ST, QL NoSavaysa 3 3 QL NoSavella 3 3 PA, QL NoSavella dose pack 3 3 PA NoSaxenda 3 3 PA, QL No

Updated 9/24/2021


drug?

Seasonale * levonorgestrel-ethin estradiol, icleviaFree as

preventiveFree as

preventiveQL No

Seasonique *l-norgest/e.estradiol-e.estrad, simpesse, Jaimiess tablet

Free as preventive

Free as preventive

QL No

Seconal * secobarbital sodium 1 1 No

Sectral * acebutolol hcl 1Free as

preventiveNo

Secuado patch 3 3 PA QL NoSeebri Neohaler 3 3 QL NoSegluromet 3 3 QL NoSelsun 2.5% (Rx Only) * selenium sulfide 1 1 NoSelzentry 2 2 NoSemprex-D 3 3 NoSe-Natal 19 tablet 1 1 NoSensipar 2 2 YesSerax * oxazepam 1 1 NoSerevent Diskus 2 2 QL NoSeroquel * quetiapine fumarate 1 1 NoSeroquel XR * quetiapine fumarate 1 1 QL NoSerostim 3 3 PA YesSerzone * nefazodone hcl 1 1 NoSevenfact vial 2 NoSfRowasa enema * mesalamine 1 1 No

Shingrix* Free as

preventiveFree as

preventiveQL No

Signifor 2 2 PA, QL YesSignifor LAR 3 3 PA, QL YesSiklos 3 3 PA NoSilenor * Doxepin 3 3 ST, QL NoSilvadene * silver sulfadiazine 1 1 NoSilver Nitrate * silver nitrate applicator 1 1 NoSimbrinza 3 3 NoSimponi 3 3 PA, QL YesSinemet, CR * carbidopa/levodopa 1 1 NoSingulair * montelukast sodium 1 1 QL NoSirturo 2 2 PA, QL NoSitavig 3 3 ST, QL NoSivextro 2 2 QL NoSkelaxin * metaxalone 1 1 NoSklice * Ivermectin lotion 1 1 QL NoSkyrizi pen and syringe kit 2 2 YesSodium Chloride flush syringe 1 1 NoSodium Chloride syringe 1 1 No

Sodium Fluoride 0.25mg, 0.5mg, 1mg * fluoride (sodium)Free as

preventiveFree as

preventiveNo

Sodium Fluoride 0.25mg, 0.5mg, 1mg * fluoride (sodium) 1Free as

preventiveNo

Sofosbuvir-velpatasvir 2 2 PA, QL YesSolaraze * diclofenac sodium 1 1 PA, QL NoSoliqua 100-33 3 3 PA, QL NoSoltamox 3 3 NoSolu-cortef * hydrocortisone sod succinate 1 1 NoSolu-cortef (pf) 3 3 NoSoma * carisoprodol 1 1 NoSoma * vanadom 1 1 NoSoma Compound * carisoprodol/aspirin 1 1 NoSoma Compound w/codeine * carisoprodol/aspirin/codeine 1 1 QL NoSomatuline Depot 2 2 PA, QL YesSomavert 2 2 PA YesSonata * zaleplon 1 1 QL NoSoolantra * ivermectin cream 1 1 ST, QL NoSoriatane * acitretin 1 1 NoSorilux 3 3 NoSotylize 3 3 NoSovaldi 3 3 PA, QL YesSpectazole * econazole nitrate 1 1 QL NoSpectracef * cefditoren pivoxil 1 1 NoSpiriva, Respimat 2 2 QL No

Updated 9/24/2021


drug?Sporanox * itraconazole 1 1 NoSpritam 3 3 PA, QL NoSprycel 2 2 PA, QL YesSPS (sorbitol free) * sodium polystyrene sulfon/sorb 1 1 NoSPS * sodium polystyrene sulfonate 1 1 NoSPS 50g/200ml enema 3 3 NoSSKI 3 3 NoStadol NS * butorphanol tartrate 1 1 QL NoStalevo * carbidopa/levodopa/entacapone 1 1 NoStarlix * nateglinide 1 1 NoStaxyn * vardenafil hcl 1 1 PA, QL NoSteglatro 3 3 QL NoStelara 45mg, 90mg 2 2 PA, QL YesStelazine * trifluoperazine hcl 1 1 NoStendra 3 3 PA, QL NoStimate 2 2 YesStiolto Respimat 2 2 QL NoStivarga 2 2 PA, QL YesStrattera * atomoxetine hcl 1 1 NoStrensiq 2 2 PA, QL YesStriant 3 3 ST, QL NoStribild 2 2 QL NoStriverdi Respimat 3 3 QL NoStromectol * ivermectin 1 1 NoStrong Iodine * potassium iodide/iodine 1 1 NoSuboxone * buprenorphine hcl/naloxone hcl 1 1 QL NoSuboxone film * buprenorphine hcl/naloxone hcl film 1 1 QL NoSubsys 3 3 PA, QL NoSubutex * buprenorphine hcl 1 1 PA, QL NoSucraid 3 3 PA, QL Yes

Sular * nisoldipine 1Free as

preventiveNo

Sulconazole Nitrate cream and solution 3 3 NoSulfadiazine * sulfadiazine 1 1 NoSulfamylon * mafenide acetate 1 1 NoSulfamylon cream 3 3 NoSumavel DosePro 3 3 ST, QL NoSunosi tablet 3 3 PA, QL NoSuprax * cefixime 1 1 No

Suprax capsule, chew tablet, 500mg/5ml suspension 3 3 No

Suprep 3 3 NoSurmontil * trimipramine maleate 1 1 NoSustiva * efavirenz 1 1 NoSutent * sunitinib 1 1 PA, QL YesSylatron 3 3 QL YesSymbicort 2 2 QL NoSymbyax * olanzapine/fluoxetine hcl 1 1 QL NoSymdeko 2 2 PA, QL YesSymfi* Efavirenz-Lamivu-Tenofov Disop 1 1 QL NoSymfi Lo * Efavirenz-Lamivu-Tenofov Disop 1 1 QL NoSymjepi 2 2 QL NoSymlinpen 3 3 NoSymmetrel * amantadine hcl 1 1 NoSympazan 3 3 PA, QL NoSymproic 3 3 PA, QL NoSymtuza 2 2 QL NoSynalar 0.01% * fluocinolone acetonide 1 1 NoSynalar 0.025% * fluocinolone acetonide 1 1 NoSynarel 2 2 NoSyndros 3 3 NoSynjardy, XR 2 2 QL NoSyprine * trientine hcl, clorique 1 1 PA, QL YesTabloid 2 2 NoTaclonex ointment * calcipotriene/betamethasone 3 3 PA NoTaclonex topical suspension 3 3 PA NoTafinlar 2 2 PA, QL YesTagamet (Rx only) * cimetidine 1 1 No

Updated 9/24/2021


drug?Tagamet liquid (Rx only) * cimetidine hcl 1 1 NoTagrisso 2 2 PA, QL YesTakhzyro 3 3 PA, QL YesTalicia capsule 3 3 QL NoTaltz 3 3 PA, QL YesTalwin NX * pentazocine hcl/naloxone hcl 1 1 QL NoTalzenna 3 3 PA, QL YesTambocor * flecainide acetate 1 1 NoTamiflu * oseltamivir phosphate 1 1 QL No

Tamoxifen * tamoxifen citrateFree as

preventiveFree as

preventivePA, QL No

Tamoxifen * tamoxifen citrate 1 1 QL NoTapazole * methimazole 1 1 NoTarceva* Erlotinib 1 1 PA, QL YesTargretin capsule * bexarotene 1 1 PA, QL YesTargretin gel 3 3 PA Yes

Tarka * trandolapril/verapamil hcl 1Free as

preventiveNo

Tasigna 2 2 PA, QL YesTasmar * tolcapone 1 1 NoTavalisse 3 3 PA, QL Yes

Taytulla* Gemmily capsule/Noresthin-Eth-Estra-Ferrous Fum, Merzee, Taysofy

Free as preventive

Free as preventive

No

Tazorac * tazarotene 1 1 NoTazorac 0.05%; 0.1% gel 2 2 NoTecfidera * Dimethyl Fumarate 1 1 QL YesTechnivie 3 3 PA, QL YesTegretol * carbamazepine 1 1 NoTegretol XR * carbamazepine 1 1 NoTekturna, HCT aliskiren 3 3 NoTemixys 2 2 NoTemodar * temozolomide 1 1 YesTemovate Emollient * clobetasol propionate/emoll 1 1 No

Tenex * guanfacine hcl 1Free as

preventiveNo

Tenoretic * atenolol/chlorthalidone 1Free as

preventiveNo

Tenormin * atenolol 1Free as

preventiveNo

Tenuate * diethylpropion hcl 1Free as

preventiveNo

Terazol- 3, 7 * terconazole 1 1 NoTessalon, Perles * benzonatate 1 1 NoTestim * testosterone 1 1 ST, QL NoTestosterone (Brand) pump 3 3 PA, QL NoTestosterone (Brand) 1% packet 3 3 ST, QL NoTetracycline * tetracycline hcl 1 1 No

Teveten * eprosartan mesylate 1Free as

preventiveNo

Texacort 3 3 NoThalomid 2 2 YesTheo-24 2 2 NoTheophylline anhydrous * theophylline anhydrous 1 1 NoThiola * tiopronin 1 1 PA NoThorazine * chlorpromazine hcl 1 1 NoThyrolar 2 2 No

Tiazac * diltiazem hcl 1Free as

preventiveNo

Tiazac * Tiadylt Er 1 1 NoTibsovo 2 2 PA, QL YesTigan * trimethobenzamide hcl 1 1 NoTiglutik 3 3 PA, QL YesTikosyn * dofetilide 1 1 NoTimoptic Ocudose Timolo Maleate dropperette 1 1 No

Timoptic, XE * timolol maleate 1Free as

preventiveNo

Tindamax * tinidazole 1 1 QL NoTirosint 3 3 No

Updated 9/24/2021


drug?Tirosint-Sol solution 3 3 NoTivicay 2 2 NoTivorbex 3 3 ST, QL NoTobi * tobramycin in 0.225% sod chlor 1 1 QL YesTobi Podhaler 3 3 PA, QL YesTobradex ointment 2 2 NoTobradex ST 3 3 NoTobradex suspension * tobramycin/dexamethasone 1 1 NoTobrex drops * tobramycin 1 1 NoTobrex ointment 3 3 No

Today contraceptive sponge Free as

preventiveFree as

preventiveQL No

Tofranil * imipramine hcl 1 1 NoTofranil-PM * imipramine pamoate 1 1 NoTolak 2 2 QL NoTolectin, DS * tolmetin sodium 1 1 NoTolinase * tolazamide 1 1 NoTopamax, Sprinkle * topiramate 1 1 NoTopicort 0.05% cream, ointment * desoximetasone 1 1 NoTopicort 0.25%; 0.05% gel * desoximetasone 1 1 NoTopiramate ER 3 3 PA, QL No

Toprol XL * metoprolol succinate 1Free as

preventiveNo

Toradol injection * ketorolac tromethamine 1 1 NoToradol tablet * ketorolac tromethamine 1 1 QL NoToujeo, Max Solostar 2 2 NoToviaz 3 3 ST, QL NoTracleer * Bosentan 1 1 PA, QL YesTracleer tablet for suspension 2 2 PA YesTradjenta 2 2 QL NoTramadol hcl ER 3 3 QL NoTransderm-Scop * scopolamine 1 1 NoTranxene T-Tab * clorazepate dipotassium 1 1 NoTravatan Z * Travoprost 1 1 NoTrecator 3 3 NoTrelegy Ellipta 2 2 QL NoTremfya 3 3 PA, QL YesTremfya auto injector 3 3 PA NoTrental * pentoxifylline 1 1 NoTresiba, Flextouch 2 2 NoTretin-X 3 3 NoTrexall 2 2 NoTreximet * sumatriptan succ/naproxen sod 1 1 PA, QL NoTrezix 3 3 QL No

Tribenzor * olmesartan/amlodipin/hcthiazid 1Free as

preventiveQL No

Tricor * fenofibrate nanocrystallized 1Free as

preventiveNo

Triglide 3 3 NoTrikafta 3 3 PA, QL YesTrileptal suspension * oxcarbazepine 1 1 NoTrileptal tablet * oxcarbazepine 1 1 No

Trilevlen * levonorgestrel-ethin estradiolFree as

preventiveFree as

preventiveNo

Trilipix * fenofibric acid (choline) 1Free as

preventiveNo

Trimethoprim * trimethoprim 1 1 NoTrimpex 3 3 No

Tri-Norinyl * norethindrone-ethinyl estradFree as

preventiveFree as

preventiveNo

Trintellix 3 3 ST, QL NoTritocin Kenalog ointment 1 1 NoTriumeq 2 2 QL NoTrokendi XR 3 3 PA, QL NoTrulicity 2 2 QL NoTrusopt * dorzolamide hcl 1 1 NoTrust Natal DHA combo pack 2 2Truvada* Emtricitabine-Tenofovir Disop 1 1 PA, QL No

Updated 9/24/2021


drug?

Truvada 200mg/300mgFree as

preventiveFree as

preventivePA, QL No

Tudorza Pressair 3 3 QL NoTuralio 3 3 NoTussicaps 2 2 QL NoTussionex * hydrocodone/chlorphen p-stirex 1 1 NoTuxarin ER tablet 3 3 NoTuzistra XR 3 3 QL No

Twinrix Free as

preventiveFree as

preventiveQL No

Twynsta * telmisartan/amlodipine 1Free as

preventiveNo

Tyblume 3 3 NoTybost 2 2 QL NoTykerb * Lapatinib 1 1 PA YesTylenol w/codeine * acetaminophen with codeine 1 1 QL NoTylenol w/codeine solution * acetaminophen with codeine 1 1 QL NoTymlos 2 2 PA, QL YesTyvaso 2 2 PA, QL YesTyzine 3 3 NoUceris foam 3 3 ST NoUceris tablet * budesonide 1 1 PA, QL NoUlesfia 3 3 NoUloric * febuxostat 1 1 ST, QL NoUltracet * tramadol hcl/acetaminophen 1 1 QL NoUltram, ER * tramadol hcl 1 1 QL NoUltravate cream, ointment * halobetasol propionate 1 1 No

Univasc * moexipril hcl 1Free as

preventiveNo

Upneeq dropperette 2 2 NoUptravi 2 2 PA, QL YesUrecholine * bethanechol chloride 1 1 NoUrispas * flavoxate hcl 1 1 NoUrocit-K * potassium citrate, potassium citrate ER 1 1 NoUroxatral * alfuzosin hcl 1 1 NoUrso; Forte * ursodiol 1 1 NoUtibron Neohaler 3 3 QL NoVagifem * estradiol 1 1 NoValchlor 3 3 PA, QL YesValcyte * valganciclovir hcl 1 1 NoValisone lotion * betamethasone valerate 1 1 NoValisone ointment * betamethasone valerate 1 1 NoValium * diazepam 1 1 NoValtrex * valacyclovir hcl 1 1 NoVancocin * vancomycin hcl 1 1 NoVantin * cefpodoxime proxetil 1 1 No

Vaqta Free as

preventiveFree as

preventiveQL No

Varenicline Tartrate $2 $2 QL NoVarubi 3 3 PA, QL NoVascepa* Icosapent Ethyl capsule 1 1 PA, QL No

Vaseretic * enalapril/hydrochlorothiazide 1Free as

preventiveNo

Vasocidin * sulfacetamide/prednisolone sp 1 1 No

Vasotec * enalapril maleate 1Free as

preventiveNo

VCF film, gel Free as

preventiveFree as

preventiveQL No

VCF foam * nonoxynol 9Free as

preventiveFree as

preventiveQL No

Vecamyl 3 3 PA, QL NoVectical * calcitriol 1 1 NoVelphoro 3 3 NoVeltassa 2 2 QL NoVemlidy 2 2 QL YesVenclexta 2 2 PA, QL YesVentavis 2 2 PA, QL YesVepesid * etoposide 1 1 No

Updated 9/24/2021


drug?Verdeso 3 3 NoVeregen 3 3 No

Verelan, PM * verapamil hcl 1Free as

preventiveNo

Versacloz 3 3 NoVersed syrup * midazolam hcl 1 1 NoVerzenio 2 2 PA, QL YesVesanoid * tretinoin 1 1 NoVesicare Solifenacin Succinate 1 1 ST, QL NoVfend * voriconazole 1 1 NoViagra * sildenafil citrate 1 1 PA, QL NoViberzi 3 3 PA, QL NoVibramycin * doxycycline hyclate 1 1 NoVibramycin suspension * doxycycline monohydrate 1 1 NoVibramycin syrup 3 3 NoVicoprofen * hydrocodone/ibuprofen 1 1 QL NoVictoza 2 2 QL NoVigamox * moxifloxacin hcl 1 1 NoViibryd, dose pack 3 3 ST, QL NoVimpat 2 2 PA, QL NoViokace 2 2 NoViramune, XR * nevirapine 1 1 NoViread * tenofovir disoproxil fumarate 1 1 NoViread 150mg, 200mg, 250mg tablet; packet 2 2 NoViroptic * trifluridine 1 1 NoVirtussin DAC * pseudoephed/codeine/guaifen 1 1 No

Visken * pindolol 1Free as

preventiveNo

Vistaril * hydroxyzine pamoate 1 1 NoVistogard 2 2 QL YesVitafol Fe Plus 3 3Vitamin K ampule * phytonadione (vit k1) 1 1 NoVitrakvi 3 3 PA, QL YesVivactil * protriptyline hcl 1 1 NoVivlodex * meloxicam 1 1 PA, QL NoVizimpro 2 2 PA, QL YesVogelxo 3 3 ST, QL NoVoltaren gel * diclofenac sodium 1 1 QL NoVoltaren ophthalmic solution * diclofenac sodium 1 1 NoVoltaren tablet * diclofenac sodium 1 1 NoVoltaren-XR * diclofenac sodium 1 1 NoVosevi 3 3 PA, QL YesVosol * acetic acid 1 1 NoVospire ER * albuterol sulfate 1 1 NoVotrient 2 2 PA, QL YesVraylar 3 3 ST, QL NoVusion 3 3 QL NoVyndamax capsule 2 2 No

Vytorin * ezetimibe/simvastatin 1Free as

preventiveQL No

Vyvanse 3 3 QL NoVyzulta 3 3 PA, QL No

Welchol * colesevelam hcl 1Free as

preventiveNo

Wellbutrin, SR, XL * bupropion hcl, burpropion xl 1 1 NoWestab Plus 1 1 NoWestcort * hydrocortisone valerate 1 1 NoWesthroid * thyroid,pork 1 1 NoWinlevi cream 2 2 NoWP Thyroid * thyroid,pork 1 1 NoWP Thyroid 32.5mg, 65mg, 81.25mg, 130mg 3 3 NoXadago 3 3 QL NoXalatan * latanoprost 1 1 NoXalkori 2 2 PA, QL YesXanax, XR * alprazolam 1 1 NoXarelto, starter kit 2 2 PA, QL NoXcopri 3 3Xatmep 3 3 Yes

Updated 9/24/2021


drug?Xeljanz, XR 2 2 PA, QL YesXeloda * capecitabine 1 1 YesXelpros 3 3 PA, QL NoXembify 3 3 PA YesXenazine * tetrabenazine 1 1 PA, QL YesXenical 3 3 NoXenleta tablet 3 3 QL NoXepi 3 3 PA, QL NoXermelo 2 2 PA, QL YesXifaxan 200mg 3 3 NoXifaxan 550mg 3 3 PA, QL NoXigduo XR 2 2 QL NoXiidra 2 2 PA, QL NoXofluza 3 3 QL NoXolair 3 3 PA, QL YesXolegel 3 3 PA, QL NoXopenex HFA 3 3 QL NoXopenex solution * levalbuterol hcl 1 1 NoXospata 3 3 PA, QL YesXpovio tablet 2 2 QL YesXtandi 2 2 PA, QL YesXultophy 100-3.6 2 2 QL NoXuriden 2 2 PA, QL YesXylocaine Viscous Solution (Rx Only) * lidocaine hcl 1 1 NoXyntha Solofuse 2 2 NoXyosted 3 3 PA, QL NoXyrem 3 3 PA, QL YesXyzal * levocetirizine dihydrochloride 1 1 QL No

Yasmin 28 * ethinyl estradiol/drospirenone, zumandimineFree as

preventiveFree as

preventiveNo

Yaz *ethinyl estradiol/drospirenone, Jasmiel, lo-zumandimine

Free as preventive

Free as preventive

No

Zanaflex * tizanidine hcl 1 1 NoZantac (Rx Only) * ranitidine hcl 1 1 NoZarontin * ethosuximide 1 1 No

Zaroxolyn * metolazone 1Free as

preventiveNo

Zarxio 3 3 YesZavesca * miglustat 1 1 PA, QL Yes

Zebeta * bisoprolol fumarate 1Free as

preventiveNo

Zejula 2 2 PA, QL YesZelapar 3 3 QL NoZelboraf 2 2 PA, QL YesZelnorm tablet 3 3 PA, QL NoZembrace SymTouch 3 3 ST, QL NoZemplar * paricalcitol 1 1 NoZenpep 2 2 NoZenzedi * dextroamphetamine sulfate 1 1 NoZepatier 2 2 PA, QL Yes

Zetia * ezetimibe 1Free as

preventiveQL No

Zetonna 3 3 ST, QL No

Ziac * bisoprolol/hydrochlorothiazide 1Free as

preventiveNo

Ziagen * abacavir sulfate 1 1 NoZioptan 3 3 NoZipsor 3 3 PA, QL NoZirgan 2 2 NoZithromax * azithromycin 1 1 No

Zocor * simvastatin 1Free as

preventiveQL No

Zocor* (5mg, 10mg, 20mg, 40mg) * simvastatinFree as

preventiveFree as

preventiveQL No

Zofran * ondansetron hcl 1 1 QL NoZofran ODT * ondansetron 1 1 QL NoZohydro ER * Hydrocodone Bitartrate 1 1 PA, QL NoZolinza 2 2 PA, QL Yes

Updated 9/24/2021


drug?Zoloft * sertraline hcl 1 1 NoZomacton 3 3 PA YesZomig nasal spray 3 3 ST, QL NoZomig, ZMT * zolmitriptan 1 1 QL NoZonalon 30g 3 3 PA, QL NoZonatuss * benzonatate 1 1 NoZonegran * zonisamide 1 1 NoZontivity 3 3 QL NoZorbtive 3 3 PA YesZortress * Everolimius 2 2 YesZorvolex 3 3 PA, QL NoZovirax * acyclovir 1 1 NoZubsolv 2 2 QL NoZutripro * hydrocodone/cpm/pseudoephed 1 1 QL No

Zyban * bupropion hclFree as

preventiveFree as

preventiveQL No

Zyclara * imiquimod cream pack 1 1 PA, QL NoZydelig 2 2 PA, QL YesZyflo 3 3 QL NoZyflo CR * zileuton 1 1 QL NoZykadia 2 2 PA, QL YesZylet 3 3 NoZyloprim * allopurinol 1 1 NoZymaxid * gatifloxacin 1 1 NoZyprexa, Zydis * olanzapine 1 1 NoZyrtec solution (Rx Only) * cetirizine hcl 1 1 NoZyvox * linezolid 1 1 No

Documents

ABC and Choices 3-Tier Rx drug list - MESSA