AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE …...Jan 01, 2021 · codes on the prescription: 1. O09.91- Supervision of high risk pregnancy, 1st Trimester. 2. O09.92- Supervision

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE JANUARY 1, 2021

Drug Class/Drug Name Reference Brand NameBRAND ONLY / Generic Notes

Preferred Drug Status Prior Authorization Type

Step Therapy Requirements

Quantity Limit (QL)

QL Days

ADHD/ANTI-NARCOLEPSY

AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 30 30AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand & Generic PREFERRED DRUG PA Required for Ages < 6 years of age 60 30DEXTROAMPHETAMINE SULFATE TABLETS VARIOUS PREFERRED DRUG PA Required for Ages < 6 years of age 60 30LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE CHEWABLES BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 30 30LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 30 30

DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR FOCALIN XR BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 60 30DEXMETHYLPHENIDATE HCL TABLETS VARIOUS PREFERRED DRUG PA Required for Ages < 6 years of age 60 30METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN PREFERRED DRUG PA Required for Ages < 6 years of age 90 30METHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA 10MG BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 30 30METHYLPHENIDATE HCL CAPSULE 24-HOUR APTENSIO XR BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 30 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE CD VARIOUS PREFERRED DRUG PA Required for Ages < 6 years of age 30 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE VARIOUS PREFERRED DRUG PA Required for Ages < 6 years of age 30 30METHYLPHENIDATE PATCH DAYTRANA BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 30 30METHYLPHENIDATE HCL SOLUTION METHYLIN BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 300 30METHYLPHENIDATE HCL TABLETS VARIOUS PREFERRED DRUG PA Required for Ages < 6 years of age 90 30METHYLPHENIDATE HCL TABLET EXTENDED RELEASE RITALIN LA BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 60 30METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE CONCERTA BRAND ONLY PREFERRED DRUG PA Required for Ages < 6 years of age 60 30

ATOMOXETINE HCL CAPSULES VARIOUS PREFERRED DRUG PA Required for Ages < 6 years of age 30 30

clonidine hcl Catapres PA Required for Ages < 6 years of ageclonidine hcl transdermal patch Catapres Patches PA Required for Ages < 6 years of age 4 28CLONIDINE HCL (ADHD) TABLET 12-HOUR Clonidine ER PREFERRED DRUG PA Required for Ages < 6 years of age 120 30GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER PREFERRED DRUG PA Required for Ages < 6 years of age 30 30guanfacine hcl Tenex PA Required for Ages < 6 years of ageAMINOGLYCOSIDESAMINOGLYCOSIDES

Central Alpha-Agonists

• Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List May Be Available Through Prior Authorization

Amphetamines

Stimulants

Miscellaneous Agents

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Quantity Limit (QL)

QL Days


NEOMYCIN SULFATE TABLETS NEOMYCIN SULFATEINHALED ANTIBIOTICSTOBRAMYCIN NEBULIZED BETHKIS BRAND ONLY PREFERRED DRUG PA RequiredTOBRAMYCIN NEBULIZED KITABIS BRAND ONLY PREFERRED DRUG PA RequiredANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC ANTIMETABOLITESMETHOTREXATE SODIUM TABLETS RHEUMATREXNONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)CELECOXIB CAPSULES CELEBREX PA RequiredDICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XRDICLOFENAC SODIUM TABLET ENTERIC COATED VOLTARENETODOLAC CAPSULES VARIOUSETODOLAC TABLETS VARIOUSFENOPROFEN CALCIUM CAPSULES NALFONFENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUMFLURBIPROFEN TABLETS FLURBIPROFENIBUPROFEN CAPSULES ADVILIBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRINIBUPROFEN SUSPENSION CHILDRENS MOTRINIBUPROFEN TABLETS ADVIL INDOMETHACIN CAPSULES VARIOUSINDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CRINDOMETHACIN SUPPOSITORY INDOCININDOMETHACIN SUSPENSION INDOCINKETOPROFEN CAPSULES ORUDISKETOROLAC TROMETHAMINE TABLETS KETOROLAC TROMETHAMINE 20 30MELOXICAM SUSPENSION MOBICMELOXICAM TABLETS MOBICNABUMETONE TABLETS NABUMETONENAPROXEN SODIUM TABLETS ALEVE. ANAPROXNAPROXEN SUSPENSION NAPROSYN

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Quantity Limit (QL)

QL Days


NAPROXEN TABLETS NAPROSYNOXAPROZIN TABLETS DAYPROPIROXICAM CAPSULES FELDENESULINDAC TABLETS SULINDACPYRIMIDINE SYNTHESIS INHIBITORSLEFLUNOMIDE TABLETS ARAVACYTOKINE & CAM ANTAGONIST AGENTSADALIMUMAB HUMIRA BRAND ONLY PREFERRED DRUG PA RequiredAPREMILAST OTEZLA BRAND ONLY PREFERRED DRUG PA RequiredETANERCEPT ENBREL BRAND ONLY PREFERRED DRUG PA Required

TOFACITINIB CITRATEXELJANZ IMMEDIATE

RELEASE ONLY BRAND ONLY PREFERRED DRUG PA RequiredANALGESICS - NONNARCOTICANALGESIC COMBINATIONSBUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS VARIOUS 120 30BUTALBITAL-ASPIRIN-CAFFEINE TABLETS VARIOUS 120 30ANALGESICS OTHERACETAMINOPHEN CAPSULES VARIOUSACETAMINOPHEN CHEWABLE TABLETS VARIOUSACETAMINOPHEN ELIXIR VARIOUSACETAMINOPHEN LIQUID VARIOUSACETAMINOPHEN SUPPOSITORY FEVERALL INFANTSACETAMINOPHEN SUSPENSION TYLENOL INFANTSSALICYLATESASPIRIN CHEWABLE TABLETS VARIOUSASPIRIN SUPPOSITORY VARIOUSASPIRIN TABLETS VARIOUSDIFLUNISAL TABLETS DIFLUNISALSALSALATE TABLETS DISALCIDANALGESICS - OPIOIDLONG-ACTING OPIOID AGONISTS

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Quantity Limit (QL)

QL Days


FENTANYL PATCH 72-HOUR 12mcg, 25mcg, 50mcg, 75mcg & 100mcgDURAGESIC 12mcg, 25mcg, 50mcg,

75mcg & 100mcg PREFERRED DRUG PA RequiredMORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE RELEASE EMBEDA BRAND ONLY PREFERRED DRUG PA RequiredMORPHINE SULFATE TABLET CONTROLLED RELEASE VARIOUS PREFERRED DRUG PA RequiredOXYCODONE HCL TABLET 12-HOUR ABUSE DETERRANT XTAMPZA ER BRAND ONLY PREFERRED DRUG PA RequiredTRAMADOL HCL TABLETS ER ULTRAM ER PREFERRED DRUG PA RequiredBUPRENORPHINE PATCH WEEKLY BUTRANS BRAND ONLY PREFERRED DRUG PA RequiredSHORT-ACTING OPIOID AGONISTS

HYDROMORPHONE HCL LIQUID DILAUDIDPA Required for > 2 Short Acting Opioid

Medications in a 30-day time period.

HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCLPA Required for > 2 Short Acting Opioid


HYDROMORPHONE HCL TABLETS DILAUDIDPA Required for > 2 Short Acting Opioid


MEPERIDINE HCL TABLETS DEMEROLPA Required for > 2 Short Acting Opioid


MORPHINE SULFATE SOLUTION MORPHINE SULFATEPA Required for > 2 Short Acting Opioid


MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATEPA Required for > 2 Short Acting Opioid


MORPHINE SULFATE TABLETS MORPHINE SULFATEPA Required for > 2 Short Acting Opioid


OXYCODONE HCL CAPSULES OXYCODONE HCLPA Required for > 2 Short Acting Opioid


OXYCODONE HCL CONCENTRATE OXYCODONE HCLPA Required for > 2 Short Acting Opioid


OXYCODONE HCL SOLUTION OXYCODONE HCLPA Required for > 2 Short Acting Opioid


OXYCODONE HCL TABLETS ROXICODONEPA Required for > 2 Short Acting Opioid


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Quantity Limit (QL)

QL Days


TRAMADOL HCL TABLETS ULTRAMPA Required for > 2 Short Acting Opioid

Medications in a 30-day time period.OPIOID COMBINATIONS

ACETAMINOPHEN W/ CODEINE SOLUTION ACETAMINOPHEN/CODEINEPA Required for > 2 Short Acting Opioid


ACETAMINOPHEN W/ CODEINE TABLETS ACETAMINOPHEN/CODEINEPA Required for > 2 Short Acting Opioid


BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES FIORICET/CODEINEPA Required for > 2 Short Acting Opioid


BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES ASCOMP/CODEINEPA Required for > 2 Short Acting Opioid


HYDROCODONE-ACETAMINOPHEN CAPSULES HYDROGESICPA Required for > 2 Short Acting Opioid


HYDROCODONE-ACETAMINOPHEN SOLUTION HYCETPA Required for > 2 Short Acting Opioid


HYDROCODONE-ACETAMINOPHEN TABLETS VERDROCETPA Required for > 2 Short Acting Opioid


HYDROCODONE-IBUPROFEN TABLETS REPREXAINPA Required for > 2 Short Acting Opioid


OXYCODONE W/ ACETAMINOPHEN CAPSULESOXYCODONE/

ACETAMINOPHENPA Required for > 2 Short Acting Opioid


OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICETPA Required for > 2 Short Acting Opioid


OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCETPA Required for > 2 Short Acting Opioid


OXYCODONE-IBUPROFEN TABLETS OXYCODONE/IBUPROFENPA Required for > 2 Short Acting Opioid

Medications in a 30-day time period.ANTIDOTESOPIOID ANTAGONISTSNALOXONE HCL SOLUTION + SYRINGE NALOXONE HCL + SYRINGE PREFERRED DRUGNALOXONE HCL NASAL SPRAY NARCAN NASAL SPRAY PREFERRED DRUG

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Quantity Limit (QL)

QL Days


NALTREXONE HCL TABLETS NALTREXONE HCL PREFERRED DRUGNALTREXONE SUSPENSION VIVITROL PREFERRED DRUGOPIOID AGONISTS

BUPRENORPHINE VARIOUS

PA Required unless the member is pregnant or nursing. The prescriber must note the following ICD-10 codes on the prescription:1. O09.91- Supervision of high risk pregnancy, 1st Trimester.2. O09.92- Supervision of high risk pregnancy, 2nd Trimester.3. O09.93- Supervision of high risk pregnancy, 3rd Trimester.4. O09.91- Supervision of high risk pregnancy- use for Postpartum Nursing Mothers. The first digit of the diagnosis code is the Letter - O and the second is a Zero - 0

BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM SUBOXONE FILM BRAND ONLY PREFERRED DRUG

BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE ORALLY DISINTEGRATING TABLETS VARIOUS

GENERIC FORMULATIONS

ONLYPREFERRED DRUG

BUPRENORPHINE EXTENDED RELEASE INJECTION SUBLOCADE BRAND ONLY PREFERRED DRUG PA Required

METHADONE VARIOUSOnly avaliable at an Opioid Treatment

Program (OTP) provider.MISCELLANEOUS AGENTSACAMPROSATE VARIOUSDISULFIRAM ANTABUSEANDROGENS-ANABOLICANDROGENSDANAZOL CAPSULES DANAZOLFLUOXYMESTERONE TABLETS ANDROXY

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Quantity Limit (QL)

QL Days


TESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA RequiredTESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA RequiredTESTOSTERONE GEL ANDROGEL PA RequiredTESTOSTERONE PATCH ANDRODERM PA RequiredTESTOSTERONE SOLUTION AXIRON PA RequiredANORECTAL AGENTSINTRARECTAL STEROIDSHYDROCORTISONE (INTRARECTAL) ENEMA COLOCORTHYDROCORTISONE ACETATE (INTRARECTAL) FOAM CORTIFOAMRECTAL STEROIDSHYDROCORTISONE (RECTAL) CREAM PROCTOCORTANTHELMINTICSANTHELMINTICSALBENDAZOLE TABLETS ALBENZA PA RequiredIVERMECTIN TABLETS STROMECTOL PA RequiredPRAZIQUANTEL TABLETS BILTRICIDEANTIANGINAL AGENTSANTIANGINALS-OTHERRANOLAZINE TABLET 12-HOUR RANEXA PA RequiredNITRATESISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE DILATRATE SRISOSORBIDE DINITRATE SUBLINGUAL ISOSORBIDE DINITRATEISOSORBIDE DINITRATE TABLETS ISORDIL TITRADOSEISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE ISOSORBIDE DINITRATE ERISOSORBIDE MONONITRATE TABLETS ISOSORBIDE MONONITRATEISOSORBIDE MONONITRATE TABLET 24-HOUR IMDURNITROGLYCERIN CAPSULE CONTROLLED RELEASE NITRO-TIMENITROGLYCERIN OINTMENT NITRO-BIDNITROGLYCERIN PATCH 24-HOUR NITRO-DURNITROGLYCERIN SUBLINGUAL NITROSTATANTIANXIETY AGENTS

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Quantity Limit (QL)

QL Days


ANTIANXIETY AGENTS - MISC.

BUSPIRONE HCL TAB 5 MG BUSPIRONE HCL

PA Required for Ages < 6 years. PA Required for > 1 Anxiolytic Medication in a

30-day time period. 120 30

BUSPIRONE HCL TAB 7.5 MG BUSPIRONE HCL











30-day time period. 60 30HYDROXYZINE HCL SYRUP HYDROXYZINE SYRUP 300 30HYDROXYZINE HCL TABLETS HYDROXYZINE TABLETS 240 30HYDROXYZINE PAMOATE CAPSULES VISTARIL 120 30BENZODIAZEPINES

ALPRAZOLAM CONC 1 MG/ML ALPRAZOLAM INTENSOL



ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG VARIOUSPA Required for Ages < 6 years.

PA Required for > 1 Anxiolytic Medication in a 120 30

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG VARIOUS



ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG VARIOUS



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Quantity Limit (QL)

QL Days


ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG VARIOUS



ALPRAZOLAM TAB 0.25 MG VARIOUS



ALPRAZOLAM TAB 0.5 MG VARIOUS



ALPRAZOLAM TAB 1 MG VARIOUS



ALPRAZOLAM TAB 2 MG VARIOUS



ALPRAZOLAM TAB SR 24HR 0.5 MG VARIOUS



ALPRAZOLAM TAB SR 24HR 1 MG VARIOUS









CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUS



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Quantity Limit (QL)

QL Days








CLONAZEPAM 0.5 MG VARIOUS


30-day time period.120 30

CLONAZEPAM 1.0 MGVARIOUS



CLONAZEPAM 2 MGVARIOUS



CLONAZEPAM ODT 0.125MGVARIOUS



CLONAZEPAM ODT 0.25MGVARIOUS



CLONAZEPAM ODT 0.5 MG VARIOUS



CLONAZEPAM ODT 1MG VARIOUS



CLONAZEPAM ODT 2MG VARIOUS



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Quantity Limit (QL)

QL Days


CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUS



CLORAZEPATE DIPOTASSIUM TAB 3.75 MG VARIOUS



CLORAZEPATE DIPOTASSIUM TAB 7.5 MG VARIOUS



DIAZEPAM CONC 5 MG/ML DIAZEPAM INTENSOL



DIAZEPAM SOLN 1 MG/ML VARIOUS



DIAZEPAM TAB 10 MG VARIOUS









LORAZEPAM CONC 2 MG/ML LORAZEPAM INTENSOL



LORAZEPAM TAB 0.5 MG VARIOUS



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Quantity Limit (QL)

QL Days


LORAZEPAM TAB 1 MG VARIOUS



LORAZEPAM TAB 2 MG VARIOUS



OXAZEPAM CAP 10 MG VARIOUS








30-day time period. 60 30ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-ADISOPYRAMIDE PHOSPHATE CAPSULES NORPACEDISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR NORPACE CRQUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CRQUINIDINE SULFATE TABLETS QUINIDINE SULFATEQUINIDINE SULFATE TABLET CONTROLLED RELEASE QUINIDINE SULFATE ERANTIARRHYTHMICS TYPE I-BMEXILETINE HCL CAPSULES MEXILETINE HCLANTIARRHYTHMICS TYPE I-CFLECAINIDE ACETATE TABLETS TAMBOCORPROPAFENONE HCL CAPSULE 12-HOUR RYTHMOL SRPROPAFENONE HCL TABLETS RYTHMOLANTIARRHYTHMICS TYPE IIIAMIODARONE HCL TABLETS 100MG & 200MG PACERONEDOFETILIDE CAPSULES TIKOSYN PA Required

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Quantity Limit (QL)

QL Days


DRONEDARONE HCL TABLETS MULTAQ PA RequiredANTIASTHMATIC AND BRONCHODILATOR AGENTSANTI-INFLAMMATORY AGENTSCROMOLYN SODIUM NEBULIZER CROMOLYN SODIUMBRONCHODILATORS - ANTICHOLINERGICSACLIDINIUM BROMIDE TUDORZA PRESSAIR PREFERRED DRUGIPRATROPIUM BROMIDE HFA AEROSOL ATROVENT HFA PREFERRED DRUGIPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDE PREFERRED DRUGTIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALER PREFERRED DRUGLEUKOTRIENE MODULATORSMONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR PREFERRED DRUG 30 30MONTELUKAST SODIUM GRANULES SINGULAIR PA IS NOT Required for < 4 Years of Age 30 30MONTELUKAST SODIUM TABLETS SINGULAIR PREFERRED DRUG 30 30STEROID INHALANTSBUDESONIDE (INHALATION) SUSPENSION 0.25MG, 0.50MG & 1.0MG PULMICORT VARIOUS PREFERRED DRUG PA IS NOT Required for < 4 Years of AgeBUDESONIDE INHALATION POWDER PULMICORT FLEXHALER BRAND ONLY PREFERRED DRUGFLUTICASONE PROPIONATE HFA AERO FLOVENT HFA BRAND ONLY PREFERRED DRUGFLUTICASONE PROPIONATE ORAL INHALATION FLOVENT DISKUS Brand Only PREFERRED DRUGMOMETASONE FUROATE (INHALATION) AEPB ASMANEX TWISTHALER PREFERRED DRUGSYMPATHOMIMETICS

ALBUTEROL SULFATE AEROSOL PROAIR HFA- BRAND ONLY BRAND Only PREFERRED DRUGPROAIR IS THE ONLY PREFERRED ALBUTEROL

INHALER ON THE AHCCCS DRUG LIST.ALBUTEROL SULFATE NEBULIZED ALBUTEROL SULFATE PREFERRED DRUGALBUTEROL SULFATE SYRUP ALBUTEROL SULFATE PREFERRED DRUG

BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL SYMBICORT BRAND ONLY PREFERRED DRUG Step Therapy

Patient must have tried one steroid

inhaler: Beclomethasone

Dipropionate, Budesonide, Fluticasone

Propionate, or Mometasone

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Quantity Limit (QL)

QL Days


FLUTICASONE-SALMETEROL ORAL INHALATION ADVAIR DISKUS Brand Only Preferred Drug Step Therapy

Patient must have tried one steriod inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or Mometasone

FLUTICASONE-SALMETEROL AEROSOL ADVAIR HFA BRAND ONLY PREFERRED DRUG Step Therapy





MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL DULERA BRAND ONLY PREFERRED DRUG Step Therapy





IPRATROPIUM-ALBUTEROL AEROSOL COMBIVENT RESPIMAT PREFERRED DRUGIPRATROPIUM-ALBUTEROL SOLUTION DUONEB PREFERRED DRUGSALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED SEREVENT DISKUS PREFERRED DRUG PA RequiredGLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL SOLUTION BEVESPI AEROSPHERE PREFERRED DRUG PA RequiredTIOTROPIUM BROMIDE-OLODATEROL HCL AEROSOL SOLUTION STIOLTO RESPIMAT PREFERRED DRUG PA RequiredSALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED SEREVENT DISKUS PREFERRED DRUG PA RequiredANTICOAGULANTS

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Quantity Limit (QL)

QL Days


COUMARIN ANTICOAGULANTSWARFARIN SODIUM TABLETS VARIOUS PREFERRED DRUGDIRECT FACTOR XA INHIBITORSAPIXABAN TABLETS ELIQUIS BRAND ONLY PREFERRED DRUG 60 30APIXABAN TABLETS STARTER PACK ELIQUIS STARTER PACK BRAND ONLY PREFERRED DRUG 74 365RIVAROXABAN TABLETS XARELTO BRAND ONLY PREFERRED DRUG 60 30RIVAROXABAN TABLETS XARELTO DOSE PACK BRAND ONLY PREFERRED DRUG 51 30HEPARINS AND HEPARINOID-LIKE AGENTSENOXAPARIN SODIUM INJ 100 MG/ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 120 MG/0.8ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 150 MG/ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 30 MG/0.3ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 300 MG/3ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 40 MG/0.4ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 60 MG/0.6ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30ENOXAPARIN SODIUM INJ 80 MG/0.8ML VARIOUS VIAL OR SYRINGE PREFERRED DRUG 60 30HEPARIN (PORCINE) IN SODIUM CHLORIDE SOLUTION HEPARIN SODIUM/NACL 0.9%HEPARIN SOD (PORCINE) IN D5W SOLUTION HEPARIN SODIUM/D5WHEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSH KIT HEPARIN SODIUM LOCK FLUSHHEPARIN SODIUM (PORCINE) LOCK FLUSH SOLUTION HEPARIN LOCK FLUSHTHROMBIN INHIBITORSDABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA BRAND ONLY PREFERRED DRUG 60 30ANTICONVULSANTSANTICONVULSANTS - BENZODIAZEPINESCLOBAZAM SUSPENSION ONFI PA RequiredCLOBAZAM TABLETS ONFI PA Required

CLONAZEPAM TAB 0.5 MG KLONOPIN



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Quantity Limit (QL)

QL Days


CLONAZEPAM TAB 1 MG KLONOPIN



CLONAZEPAM TAB 2 MG KLONOPIN



CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG CLONAZEPAM ODT









CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG CLONAZEPAM ODT



CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG CLONAZEPAM ODT


30-day time period. 60 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIASTAT 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIASTAT 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG DIASTAT 2 30ANTICONVULSANTS - MISC.CARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINECARBAMAZEPINE CAPSULE 12-HOUR CARBATROLCARBAMAZEPINE SUSPENSION TEGRETOLCARBAMAZEPINE TABLETS EPITOLCARBAMAZEPINE CAPSULE 12-HOUR EQUETROCARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XR

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Quantity Limit (QL)

QL Days


GABAPENTIN CAPSULES NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN GRALISE PA RequiredGABAPENTIN TABLETS NEURONTINGABAPENTIN HORIZANT PA RequiredLACOSAMIDE SOLUTION VIMPAT PA RequiredLACOSAMIDE TABLETS VIMPAT PA RequiredLAMOTRIGINE CHEWABLE TABLETS LAMICTAL CHEWABLELAMOTRIGINE TABLETS LAMICTALLAMOTRIGINE TABLET 24-HOUR LAMICTAL XRLAMOTRIGINE ORALLY DISINTEGRATING TABLETS LAMICTAL ODTLEVETIRACETAM SOLUTION KEPPRALEVETIRACETAM TABLETS KEPPRALEVETIRACETAM TABLET 24-HOUR KEPPRA XROXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTALPREGABALIN CAPSULES LYRICA PA RequiredPREGABALIN SOLUTION LYRICA PA RequiredPRIMIDONE TABLETS MYSOLINERUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA RequiredTOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLESTOPIRAMATE TABLETS TOPAMAXZONISAMIDE CAPSULES ZONEGRANCARBAMATESFELBAMATE SUSPENSION FELBATOLFELBAMATE TABLETS FELBATOLGABA MODULATORSTIAGABINE HCL TABLETS GABITRIL PA RequiredHYDANTOINSPHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETS

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Quantity Limit (QL)

QL Days


PHENYTOIN SODIUM EXTENDED CAPSULES DILANTINPHENYTOIN SUSPENSION DILANTIN-125SUCCINIMIDESETHOSUXIMIDE CAPSULES ZARONTINETHOSUXIMIDE SOLUTION ZARONTINVALPROIC ACIDDIVALPROEX SODIUM SPRINKLE CAPSULES DEPAKOTE SPRINKLESDIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ERDIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTEVALPROATE SODIUM SYRUP DEPAKENE+B252VALPROIC ACID CAPSULES DEPAKENEANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

MIRTAZAPINE TABLETS MIRTAZAPINE PA Required for Ages < 6 years of age 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS REMERON SOLTAB PA Required for Ages < 6 years of age 30 30

ESKETAMINE HYDROCHLORIDE SPRAVATO PA Required

BUPROPION HCL TABLETS WELLBUTRIN PA Required for Ages < 6 years of age 120 30BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for Ages < 6 years of age 60 30BUPROPION HCL TABLET 24-HOUR (150MG & 300MG) WELLBUTRIN XL PA Required for Ages < 6 years of age 30 30SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

CITALOPRAM HYDROBROMIDE SOLUTION CELEXAPA Required for Ages < 6 years of age and

greater than 12 years of age 600 30

CITALOPRAM HYDROBROMIDE TABLETS CELEXA PA Required for Ages < 6 years of age

10mg: 6020mg: 3040mg: 30

303030

ESCITALOPRAM OXALATE TABLETS LEXAPRO PA Required for Ages < 6 years of age

5mg: 6010mg: 3020mg: 30

303030

Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

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Quantity Limit (QL)

QL Days


FLUOXETINE HCL CAPSULES ONLY PROZAC PA Required for Ages < 6 years of age

10mg: 6020mg: 12040mg: 60

303030

FLUOXETINE HCL SOLUTION PROZACPA Required for Ages < 6 years of age and

greater than 12 years of age 600 30FLUOXETINE HCL TABLETS - WEEKLY PROZAC WEEKLY PA Required

FLUVOXAMINE MALEATE TABLETS LUVOX PA Required for Ages < 6 years of age

25mg: 6050mg: 180100mg: 90

303030

PAROXETINE HCL TABLETS PAXIL PA Required for Ages < 6 years of age

10mg: 3020mg: 3030mg: 3040mg: 45

30303030

SERTRALINE HCL CONCENTRATE ZOLOFTPA Required for Ages < 6 years of age and

greater than 12 years of age 300 30

SERTRALINE HCL TABLETS ZOLOFT PA Required for Ages < 6 years of age

25mg: 9050mg: 120100mg: 60

303030

SEROTONIN MODULATORS

TRAZODONE HCL TABLETS TRAZODONE HCL PA Required for Ages < 6 years of age

50mg:90100mg:120150mg: 60300mg 30

30303030

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)

DULOXETINE HCL CAPSULE DELAYED RELEASE 20MG, 30MG & 60MGCYMBALTA

20MG, 30MG & 60MG PA Required for Ages < 6 years of age

20mg: 12030mg: 12060mg: 60

303030

VENLAFAXINE HCL CAPSULE CONTROLLED RELEASE EFFEXOR XR PA Required for Ages < 6 years of age

37.5mg: 9075mg: 90

150mg: 30

303030

VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY VENLAFAXINE HCL PA Required for Ages < 6 years of age

25mg: 120 37.5mg: 90 50mg: 9075mg: 150100mg: 90

3030303030

1/28/2021 19





Quantity Limit (QL)

QL Days


TRICYCLIC AGENTSAMITRIPTYLINE HCL TABLETS AMITRIPTYLINE HCL PA Required for Ages < 6 years of ageAMOXAPINE TABLETS VARIOUS PA Required for Ages < 6 years of ageCLOMIPRAMINE HCL CAPSULES ANAFRANIL PA Required for Ages < 6 years of ageDESIPRAMINE HCL TABLETS NORPRAMIN PA Required for Ages < 6 years of ageDOXEPIN HCL CAPSULES DOXEPIN HCL PA Required for Ages < 6 years of age 90 30DOXEPIN HCL CONCENTRATE DOXEPIN HCL PA Required for Ages < 6 years of age 180 30IMIPRAMINE PAMOATE CAPSULES TORFRANIL-PM PA Required for Ages < 6 years of age 30 30IMIPRAMINE HCL TABLETS TOFRANIL PA Required for Ages < 6 years of ageMAPROTILINE HCL VARIOUS PA Required for Ages < 6 years of ageNORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for Ages < 6 years of ageNORTRIPTYLINE HCL SOLUTION NORTRIPTYLINE HCL PA Required for Ages < 6 years of agePROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for Ages < 6 years of ageTRIMIPRAMINE MALEATE SURMONTIL PA Required for Ages < 6 years of ageANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORSACARBOSE TABLETS PRECOSEANTIDIABETIC - AMLYN ANALOGSPRAMLINTIDE ACETATE SOLUTION PEN INJECTION SYMLINPEN 60 PREFERRED DRUG PA RequiredANTIDIABETIC COMBINATIONSGLYBURIDE-METFORMIN HCL TABLETS GLUCOVANCEPIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS METPIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XRSITAGLIPTIN-METFORMIN HCL TABLETS JANUMET PREFERRED DRUG PA RequiredLINAGLIPTIN - METFORMIN TABLETS JENTADUETO PREFERRED DRUG PA RequiredSITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR PREFERRED DRUG PA RequiredBIGUANIDESMETFORMIN HCL TABLETS GLUCOPHAGE

METFORMIN HCL TABLET 24-HOUR (GENERIC OF GLUCOPHAGE XR ONLY- 500MG & 750MG) Various

PA Required for Osmotic and Modified Release Products

DIABETIC OTHER

1/28/2021 20





Quantity Limit (QL)

QL Days


GLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1 30DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSLINAGLIPTIN TABLETS TRADJENTA PREFERRED DRUG PA RequiredEMPAGLIFLOZIN-LINAGLIPTIN TABLETS GLYXAMBI PREFERRED DRUG PA RequiredSAXAGLIPTIN HCL TABLETS ONGLYZA PREFERRED DRUG PA RequiredSAXAGLIPTIN-METFORMIN HCL TABLETS KOMBIGLYZE XR PREFERRED DRUG PA RequiredSITAGLIPTIN PHOSPHATE TABLETS JANUVIA PREFERRED DRUG PA RequiredINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)EXENATIDE SOLUTION PEN INJECTION BYETTA PREFERRED DRUG PA RequiredEXENATIDE PEN BYDUREON PREFERRED DRUG PA RequiredLIRAGLUTIDE SOLUTION PEN INJECTION VICTOZA PREFERRED DRUG PA RequiredDIABETIC MISCELLANEOUS AGENTPRAMLINTIDE SYMLIN PEN PREFERRED DRUG PA RequiredINSULIN SENSITIZING AGENTSPIOGLITAZONE HCL TABLETS ACTOSINSULIN

INSULIN ASPART NOVOLOG BRAND ONLY PREFERRED DRUG INSULIN ASPART NOVOLOG PENFILL BRAND ONLY PREFERRED DRUG INSULIN ASPART NOVOLOG FLEXPEN BRAND ONLY PREFERRED DRUG INSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART NOVOLOG MIX 70/30 BRAND ONLY PREFERRED DRUG INSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART NOVOLOG MIX 70/30 FLEXPEN BRAND ONLY PREFERRED DRUG INSULIN DETEMIR SOLUTION LEVEMIR BRAND ONLY PREFERRED DRUG INSULIN DETEMIR SUSPENSION LEVEMIR FLEXPEN BRAND ONLY PREFERRED DRUG INSULIN GLARGINE SOLUTION LANTUS BRAND ONLY PREFERRED DRUG INSULIN GLARGINE SUSPENSION LANTUS SOLOSTAR BRAND ONLY PREFERRED DRUG INSULIN LISPRO (HUMAN) SOLUTION HUMALOG BRAND ONLY PREFERRED DRUG INSULIN LISPRO (HUMAN) SUSPENSION HUMALOG KWIKPEN BRAND ONLY PREFERRED DRUG INSULIN LISPRO (HUMAN) SOLUTION PEN INJECTION 100/ML HUMALOG JUNIOR KWIKPEN BRAND ONLY PREFERRED DRUG INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 50/50 BRAND ONLY PREFERRED DRUG INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 50/50 KWIKPEN BRAND ONLY PREFERRED DRUG INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 75/25 BRAND ONLY PREFERRED DRUG

1/28/2021 21





Quantity Limit (QL)

QL Days


INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 75/25 KWIKPEN BRAND ONLY PREFERRED DRUG INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N BRAND ONLY PREFERRED DRUG INSULIN REGULAR (HUMAN) SOLUTION PEN INJECTION HUMULIN N KWIKPEN BRAND ONLY PREFERRED DRUG INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION NOVOLIN N BRAND ONLY PREFERRED DRUG INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30 BRAND ONLY PREFERRED DRUG INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30 KWIKPEN BRAND ONLY PREFERRED DRUG INSULIN REGULAR (HUMAN) SOLUTION HUMULIN R U-100 BRAND ONLY PREFERRED DRUG INSULIN REGULAR (HUMAN) SOLUTION NOVOLIN R BRAND ONLY PREFERRED DRUG

INSULIN REGULAR (HUMAN) SOLUTIONHUMULIN R U-500 (CONCENTRATED) BRAND ONLY PREFERRED DRUG PA REQUIRED

INSULIN REGULAR (HUMAN) PENHUMULIN R U-500 PEN

(CONCENTRATED) BRAND ONLY PREFERRED DRUG PA REQUIRED

MEGLITINIDE ANALOGUESNATEGLINIDE TABLETS STARLIXREPAGLINIDE TABLETS PRANDINSGLT2SDAPAGLIFLOZIN PROPANEDIOL FARXIGA PREFERRED DRUG PA RequiredCANAGLIFLOZIN INVOKANA PREFERRED DRUG PA RequiredEMPAGLIFLOZIN JARDIANCE PREFERRED DRUG PA RequiredSULFONYLUREASGLIMEPIRIDE TABLETS AMARYLGLIPIZIDE TABLETS GLUCOTROLGLIPIZIDE TABLET 24-HOUR GLUCATROL XLGLYBURIDE MICRONIZED TABLETS GLYNASEGLYBURIDE TABLETS DIABETAANTIDIARRHEALSANTIPERISTALTIC AGENTSDIPHENOXYLATE W/ ATROPINE LIQUID DIPHENOXYLATE/ATROPINEDIPHENOXYLATE W/ ATROPINE TABLETS LOMOTILLOPERAMIDE HCL CAPSULES LOPERAMIDE HCLLOPERAMIDE HCL CHEWABLE TABLETS IMODIUM A-DLOPERAMIDE HCL LIQUID LOPERAMIDE HCL

1/28/2021 22





Quantity Limit (QL)

QL Days


LOPERAMIDE HCL SUSPENSION IMODIUM A-DLOPERAMIDE HCL TABLETS IMODIUM A-DANTIDOTESOPIOID ANTAGONISTSNALOXONE HCL SOLUTION + SYRINGE NALOXONE HCL + SYRINGE PREFERRED DRUGNALOXONE HCL NASAL SPRAY NARCAN NASAL SPRAY PREFERRED DRUGANTIEMETICS5-HT3 RECEPTOR ANTAGONISTSDOLASETRON MESYLATE TABLETS ANZEMET PA RequiredGRANISETRON HCL SOLUTION VARIOUS PA RequiredGRANISETRON HCL TABLETS VARIOUS PA RequiredONDANSETRON HCL TABLETS ZOFRAN PA Required for tablets > 8mg 30 30ANTIEMETICS MISC.PROCHLORPERAZINE MALEATE TABLETS COMPAZINEPROCHLORPERAZINE SUPPOSITORY COMPAZINESUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTAPREPITANT CAPSULES EMEND 6 21ANTIFUNGALSANTIFUNGAL ORAL AGENTSCLOTRIMAZOLE TROCHE VARIOUSGRISEOFULVIN SUSPENSION VARIOUSGRISEOFULVIN MICROSIZE TABLETS GRIFULVIN VNYSTATIN SUSPENSION NYSTATINNYSTATIN TABLETS NYSTATINTERBINAFINE HCL TABLETS LAMISIL 90 365IMIDAZOLE-RELATED ANTIFUNGALSFLUCONAZOLE SUSPENSION DIFLUCAN 600 30FLUCONAZOLE TABLETS DIFLUCAN 60 30ANTIHISTAMINESANTIHISTAMINES - ALKYLAMINESBROMPHENIRAMINE MALEATE J-TAN PD

1/28/2021 23





Quantity Limit (QL)

QL Days


CHLORPHINERAMINE MALEATE CHLORPHENIRAMINE MALEATEDEXCHLORPHENIRAMINE MALEATE SYRUP DEXCHLORPHENIRAMINE MALEATEANTIHISTAMINES - ETHANOLAMINESCLEMASTINE FUMARATE SYRUP CLEMASTINE FUMARATECLEMASTINE FUMARATE TABLETS CLEMASTINE FUMARATEDIPHENHYDRAMINE HCL CAPSULES VARIOUSDIPHENHYDRAMINE HCL CHEWABLE TABLETS VARIOUSDIPHENHYDRAMINE HCL ELIXIR VARIOUSDIPHENHYDRAMINE HCL LIQUID VARIOUSDIPHENHYDRAMINE HCL SOLUTION VARIOUSDIPHENHYDRAMINE HCL SUSPENSION VARIOUSDIPHENHYDRAMINE HCL SYRUP VARIOUSDIPHENHYDRAMINE HCL TABLETS VARIOUSANTIHISTAMINES - NON-SEDATINGCETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30 30CETIRIZINE HCL CHEWABLE TABLETS VARIOUS 30 30CETIRIZINE HCL SYRUP VARIOUS 150 30CETIRIZINE HCL TABLETS VARIOUS 30 30CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS ZYRTEC ALLERGY 30 30FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS 150 30FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS 30 30FEXOFENADINE HCL ORALLY DISINTEGRATING TABLETS ALLEGRA ALLERGY CHILDRENS 30 30LORATADINE CAPSULES CLARITIN 30 30LORATADINE CHEWABLE TABLETS CLARITIN 30 30LORATADINE SYRUP CLARITIN 150 30LORATADINE TABLETS ALAVERT 30 30LORATADINE ORALLY DISINTEGRATING TABLETS CLARITIN REDITABS 30 30ANTIHISTAMINES - PHENOTHIAZINESPROMETHAZINE HCL SUPPOSITORY PHENERGANPROMETHAZINE HCL TABLETS PROMETHAZINE HCLANTIHISTAMINES - PIPERIDINES

1/28/2021 24





Quantity Limit (QL)

QL Days


CYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCLCYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCLANTIHYPERLIPIDEMICSBILE ACID SEQUESTRANTSCHOLESTYRAMINE LIGHT PACKETS PREVALITECHOLESTYRAMINE LIGHT POWDER PREVALITECHOLESTYRAMINE PACKETS QUESTRANCHOLESTYRAMINE POWDER QUESTRANCOLESTIPOL HCL TABLETS COLESTIDFIBRIC ACID DERIVATIVESFENOFIBRATE MICRONIZED CAPSULES 67MG, 134MG & 200MG VARIOUSFENOFIBRATE TABLETS 48MG, 54MG, 145MG & 160MG VARIOUSFENOFIBRIC ACID TABLETS FIBRICORGEMFIBROZIL TABLETS LOPIDHMG COA REDUCTASE INHIBITORSATORVASTATIN CALCIUM TABLETS LIPITOR PREFERRED DRUG 30 30LOVASTATIN TABLETS MEVACOR PREFERRED DRUG 30 30PRAVASTATIN SODIUM TABLETS PRAVACOL PREFERRED DRUG 30 30ROUVASTATIN TABLETS CRESTOR PREFERRED DRUG 30 30SIMVASTATIN TABLETS ZOCOR PREFERRED DRUG 30 30INTESTINAL CHOLESTEROL ABSORPTION INHIBITORSEZETIMIBE TABLETS ZETIA PREFERRED DRUG PA RequiredNICOTINIC ACID DERIVATIVESNIACIN CAPSULE CONTROLLED RELEASE VARIOUSNIACIN TABLET CONTROLLED RELEASE VARIOUSMISC. NUTRITIONAL SUBSTANCESOMEGA-3 FATTY ACIDS CAPSULES FISH OILOMEGA-3 FATTY ACIDS CAPSULE DELAYED RELEASE FISH OILANTIHYPERTENSIVESACE INHIBITORSBENAZEPRIL HCL TABLETS BENAZEPRIL HCL

1/28/2021 25





Quantity Limit (QL)

QL Days


CAPTOPRIL TABLETS CAPTOPRILENALAPRIL MALEATE SOLUTION EPANEDENALAPRIL MALEATE TABLETS VASOTECFOSINOPRIL SODIUM TABLETS FOSINOPRIL SODIUMLISINOPRIL TABLETS ZESTRILMOEXIPRIL HCL TABLETS UNIVASCPERINDOPRIL ERBUMINE TABLETS ACEONQUINAPRIL HCL TABLETS ACCUPRILRAMIPRIL CAPSULES ALTACETRANDOLAPRIL TABLETS MAVIKANGIOTENSIN II RECEPTOR ANTAGONISTSIRBESARTAN TABLETS AVAPROLOSARTAN POTASSIUM TABLETS COZAARVALSARTAN TABLETS DIOVANANTIADRENERGIC ANTIHYPERTENSIVESCLONIDINE HCL PATCH-WEEKLY CATAPRES-TTS-1 PA Required for Ages < 6 years of age 4 28CLONIDINE HCL TABLETS CATAPRESCLONIDINE HCL (ADHD) TABLET 12-HOUR CLONIDINE ER PA Required for Ages < 6 years of age 120 30DOXAZOSIN MESYLATE TABLETS CARDURAGUANFACINE HCL TABLETS TENEXGUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER PREFERRED DRUG PA Required for Ages < 6 years of age 30 30METHYLDOPA TABLETS METHYLDOPAPRAZOSIN HCL CAPSULES MINIPRESSTERAZOSIN HCL CAPSULES TERAZOSIN HCLANTIHYPERTENSIVE COMBINATIONSATENOLOL & CHLORTHALIDONE TABLETS VARIOUS

CAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETSCAPTOPRIL/

HYDROCHLOROTHIAZIDE

ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETSENALAPRIL MALEATE/

HYDROCHLOROTHIAZIDE

FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETSFOSINOPRIL SODIUM/

HYDROCHLOROTHIAZIDE

1/28/2021 26





Quantity Limit (QL)

QL Days


LISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETICLOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS HYZAARMOEXIPRIL - HYDROCHLOROTHIAZIDE TABLETS UNIRETICQUINAPRIL - HYDROCHLOROTHIAZIDE TABLETS ACCURETICVALSARTAN - HYDROCHLOROTHIAZIDE TABLETS DIOVAN HCTSELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)EPLERENONE TABLETS INSPRA PA RequiredVASODILATORSHYDRALAZINE HCL TABLETS HYDRALAZINE HCLMINOXIDIL TABLETS MINOXIDILANTI-INFECTIVE AGENTS - MISCELLANEOUSANTI-INFECTIVE AGENTS - MISC.VANCOMYCIN HCL CAPSULES VANCOCIN HCL PA Required

VANCOMYCIN HCL SOLUTIONAvailable through a compounding

pharmacy PA RequiredANTI-INFECTIVE MISC. - COMBINATIONSERYTHROMYCIN-SULFISOXAZOLE SUSPENSION E.S.P.SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION SULFATRIM PEDIATRICSULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS BACTRIMLEPROSTATICSDAPSONE TABLETS DAPSONEOXAZOLIDINONESLINEZOLID SUSPENSION ZYVOX PA RequiredLINEZOLID TABLETS ZYVOX PA RequiredANTIMALARIALSANTIMALARIAL COMBINATIONSARTEMETHER-LUMEFANTRINE TABLETS COARTEMATOVAQUONE-PROGUANIL HCL TABLETS MALARONEANTIMALARIALSCHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATEHYDROXYCHLOROQUINE SULFATE TABLETS PLAQUENILPRIMAQUINE PHOSPHATE TABLETS PRIMAQUINE PHOSPHATE

1/28/2021 27





Quantity Limit (QL)

QL Days


QUININE SULFATE CAPSULES QUALAQUINANTIMYCOBACTERIAL AGENTSETHAMBUTOL HCL TABLETS MYAMBUTOLISONIAZID SYRUP ISONIAZIDISONIAZID TABLETS ISONIAZIDPYRAZINAMIDE TABLETS PYRAZINAMIDERIFAMPIN CAPSULES RIFADINONCOLOGY -FEDERALLY REIMBURSABLE ANTINEOPLASTIC AGENTS,NOT LISTED BELOW, ARE AVAILABLE THROUGH PRIOR AUTHORIZATION ANTIMETABOLITESMERCAPTOPURINE TABLETS PURINETHOLMETHOTREXATE SODIUM TABLETS METHOTREXATEANTINEOPLASTIC - HORMONAL AND RELATED AGENTSANASTROZOLE TABLETS ARIMIDEX PA RequiredEXEMESTANE TABLETS AROMASIN PA RequiredFLUTAMIDE CAPSULES FLUTAMIDELEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE KIT LUPRON DEPOT PA RequiredTAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETOREMIFENE CITRATE TABLETS FARESTON PA RequiredANTINEOPLASTIC ENZYME INHIBITORSAXITINIB TABLETS INLYTA PA RequiredCRIZOTINIB CAPSULES XALKORI PA RequiredERLOTINIB HCL TABLETS TARCEVA PA RequiredEVEROLIMUS TABLETS AFINITOR PA RequiredEVEROLIMUS SOLUBLE TABLET AFINITOR DISPERZ PA RequiredGEFITINIB TABLETS IRESSA PA RequiredIBRUTINIB CAPSULES IMBRUVICA PA RequiredIMATINIB MESYLATE TABLETS GLEEVEC PA RequiredLAPATINIB DITOSYLATE TABLETS TYKERB PA RequiredNILOTINIB HCL CAPSULES TASIGNA PA Required

1/28/2021 28





Quantity Limit (QL)

QL Days


PAZOPANIB HCL TABLETS VOTRIENT PA RequiredPONATINIB HCL TABLETS ICLUSIG PA RequiredRUXOLITINIB PHOSPHATE TABLETS JAKAFI PA RequiredSORAFENIB TOSYLATE TABLETS NEXAVAR PA RequiredSUNITINIB MALATE CAPSULES SUTENT PA RequiredVANDETANIB TABLETS CAPRELSA PA RequiredVEMURAFENIB TABLETS ZELBORAF PA RequiredVORINOSTAT CAPSULES ZOLINZA PA RequiredANTINEOPLASTICS - MISC.BEXAROTENE CAPSULES TARGRETIN PA RequiredHYDROXYUREA CAPSULES HYDREAINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-N3 SOLUTION ALFERON N PA RequiredINTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA RequiredPEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA RequiredPROCARBAZINE HCL CAPSULES MATULANETRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of AgeCHEMOTHERAPY RESCUE/ANTIDOTE AGENTSLEUCOVORIN CALCIUM TABLETS LEUCOVORIN CALCIUM PA RequiredMITOTIC INHIBITORSETOPOSIDE CAPSULES ETOPOSIDE PA RequiredANTIPARKINSON AGENTSANTIPARKINSON ANTICHOLINERGICSBENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATETRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCLTRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCLANTIPARKINSON COMT INHIBITORSENTACAPONE TABLETS COMTANANTIPARKINSON DOPAMINERGICSAMANTADINE HCL CAPSULES AMANTADINE HCL

1/28/2021 29





Quantity Limit (QL)

QL Days


AMANTADINE HCL SYRUP AMANTADINE HCLBROMOCRIPTINE MESYLATE CAPSULES PARLODELBROMOCRIPTINE MESYLATE TABLETS PARLODELCARBIDOPA-LEVODOPA TABLETS SINEMETCARBIDOPA-LEVODOPA ER TABLETS VARIOUSPRAMIPEXOLE DIHYDROCHLORIDE TABLETS MIRAPEXROPINIROLE HYDROCHLORIDE TABLETS REQUIPANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS

LITHIUM CARBONATE CAPSULES LITHIUM CARBONATE

PA Required for Ages < 6 years Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric

clinician, a developmental pediatrician or other prescribers as approved by the MCO

Contractors.

LITHIUM CARBONATE TABLETS LITHIUM CARBONATE



Contractors.

LITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBID



Contractors.

1/28/2021 30





Quantity Limit (QL)

QL Days


LITHIUM SOLUTION LITHIUM



Contractors.

ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS

ARIPIPRAZOLE TABLETS ABILIFY PREFERRED DRUG



Contractors. 30 30

CLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO PREFERRED DRUG



Contractors. 150 30

CLOZAPINE TABLETS CLOZARIL PREFERRED DRUG



Contractors. 150 30

ANTIPSYCHOTICS

1/28/2021 31





Quantity Limit (QL)

QL Days


LURASIDONE HCL TABS LATUDA PREFERRED DRUG



Contractors. 30 30

OLANZAPINE ORALLY DISPERSABLE TABLET ZYPREXA ZYDIS PREFERRED DRUG



Contractors.

5mg: 60 10mg: 6015MG: 3020mg: 30

30303030

OLANZAPINE TABLETS ZYPREXA PREFERRED DRUG



Contractors. 30 30

QUETIAPINE FUMARATE TABLETS SEROQUEL PREFERRED DRUG



Contractors. 60 30

RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT PREFERRED DRUG



Contractors. 60 30

1/28/2021 32





Quantity Limit (QL)

QL Days


RISPERIDONE ORAL SOLUTION RISPERDAL PREFERRED DRUG



Contractors. 240 30

RISPERIDONE TABLETS RISPERDAL PREFERRED DRUG



Contractors. 60 30

ZIPRASIDONE HCL CAPSULES GEODON PREFERRED DRUG



Contractors. 60 30ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES

ARIPIPRAZOLE LAUROXIL ARISTADA INITIO PREFERRED DRUG



Contractors. 2 365

ARIPIPRAZOLE LAUROXIL ARISTADA PREFERRED DRUG



Contractors. 1 30

1/28/2021 33





Quantity Limit (QL)

QL Days


ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA PREFERRED DRUG



Contractors. 1 30

PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA PREFERRED DRUG



Contractors. 1 30

PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA PREFERRED DRUG



Contractors. 1 90

RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA PREFERRED DRUG



Contractors. 2 30ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS

1/28/2021 34





Quantity Limit (QL)

QL Days


CHLORPROMAZINE HCL SOLUTION VARIOUS



Contractors.

CHLORPROMAZINE HCL TABLETS VARIOUS



Contractors.

FLUPHENAZINE HCL CONCENTRATE VARIOUS



Contractors.

FLUPHENAZINE HCL ELIXIR VARIOUS



Contractors.

FLUPHENAZINE HCL TABLETS VARIOUS



Contractors.

1/28/2021 35





Quantity Limit (QL)

QL Days


HALOPERIDOL LACTATE CONCENTRATE VARIOUS



Contractors.

HALOPERIDOL TABLETS VARIOUS



Contractors.

LOXAPINE SUCCINATE CAPSULES LOXITANE



Contractors.

PERPHENAZINE TABLETS VARIOUS



Contractors.

PIMOZIDE ORAP



Contractors.

1/28/2021 36





Quantity Limit (QL)

QL Days


THIORIDAZINE HCL TABLETS VARIOUS



Contractors.

THIOTHIXENE CAPSULES VARIOUS



Contractors.

TRIFLUOPERAZINE HCL TABLETS VARIOUS



Contractors.ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS

FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE



Contractors.

HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE 50



Contractors.

1/28/2021 37





Quantity Limit (QL)

QL Days


ANTIVIRALSANTIRETROVIRALSABACAVIR SULFATE SOLUTION ZIAGENABACAVIR SULFATE TABLETS ZIAGENABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOMABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIRABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQATAZANAVIR SULFATE CAPSULES REYATAZATAZANAVIR SULFATE PACK REYATAZATAZANAVIR SULFATE-COBICISTAT TABLETS EVOTAZBICTEGRAVIR-EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS BIKTARVY 30 30COBICISTAT TABLETS TYBOST 30 30DARUNAVIR ETHANOLATE SUSPENSION PREZISTADARUNAVIR ETHANOLATE TABLETS PREZISTADARUNAVIR-COBICISTAT TABLETS PREZCOBIXDELAVIRDINE MESYLATE TABLETS RESCRIPTORDIDANOSINE CAPSULE DELAYED RELEASE VIDEX ECDIDANOSINE SOLUTION VIDEX PEDIATRICDOLUTEGRAVIR SODIUM TABLETS TIVICAYDORAVIRINE TABLETS PIFELTROEFAVIRENZ CAPSULES SUSTIVAEFAVIRENZ TABLETS SUSTIVAEFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLA BRAND ONLYELVITEGRAVIR TABLETS VITEKTAELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILDELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE TABLETS GENVOYAEMTRICITABINE CAPSULES EMTRIVAEMTRICITABINE SOLUTION EMTRIVAEMTRICITABINE-RILPIVIRINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS ODEFSEYEMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS COMPLERAEMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS DESCOVY

1/28/2021 38





Quantity Limit (QL)

QL Days


EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADA BRAND ONLYENFUVIRTIDE SOLUTION FUZEON PA Required 1 30ETRAVIRINE TABLETS INTELENCEFOSAMPRENAVIR CALCIUM SUSPENSION LEXIVAFOSAMPRENAVIR CALCIUM TABLETS LEXIVAINDINAVIR SULFATE CAPSULES CRIXIVANLAMIVUDINE SOLUTION EPIVIRLAMIVUDINE TABLETS EPIVIRLAMIVUDINE-ZIDOVUDINE TABLETS COMBIVIRLOPINAVIR-RITONAVIR SOLUTION KALETRALOPINAVIR-RITONAVIR TABLETS KALETRAMARAVIROC TABLETS SELZENTRY PA RequiredNELFINAVIR MESYLATE TABLETS VIRACEPTNEVIRAPINE SUSPENSION VIRAMUNENEVIRAPINE TABLETS VIRAMUNENEVIRAPINE TABLET 24-HOUR VIRAMUNE XRRALTEGRAVIR POTASSIUM CHEWABLE TABLETS ISENTRESSRALTEGRAVIR POTASSIUM PACK ISENTRESSRALTEGRAVIR POTASSIUM TABLETS ISENTRESSRILPIVIRINE HCL TABLETS EDURANTRITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIRSAQUINAVIR MESYLATE CAPSULES INVIRASESAQUINAVIR MESYLATE TABLETS INVIRASESTAVUDINE CAPSULES ZERITSTAVUDINE SOLUTION ZERITTENOFOVIR DISOPROXIL FUMARATE POWDER VIREADTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREADTIPRANAVIR CAPSULES APTIVUSTIPRANAVIR SOLUTION APTIVUS

1/28/2021 39





Quantity Limit (QL)

QL Days


ZIDOVUDINE CAPSULES RETROVIRZIDOVUDINE SYRUP RETROVIRZIDOVUDINE TABLETS ZIDOVUDINECMV AGENTSCIDOFOVIR IV VISTIDE PA RequiredFOSCARENT SODIUM FOSCAVIR PA RequiredGANCICLOVIR SODIUM CYTOVENE PA RequiredVALGANCICLOVIR HCL SOLUTION VALCYTE PA RequiredVALGANCICLOVIR HCL TABLETS VALCYTE PA RequiredHEPATITIS B AGENTSADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredLAMIVUDINE (HBV) SOLUTION EPIVIR HBVLAMIVUDINE (HBV) TABLETS EPIVIR HBVTELBIVUDINE TABLETS TYZEKA PA RequiredHEPATITIS C AGENTSGLECAPREVIR-PIBRENTASVIR TABLETS MAVYRET PREFERRED DRUG PA RequiredPEGINTERFERON ALFA-2A SOLUTION PEGASYS PREFERRED DRUG PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON PREFERRED DRUG PA RequiredRIBAVIRIN (HEPATITIS C) CAPSULES VARIOUS PREFERRED DRUG PA RequiredRIBAVIRIN (HEPATITIS C) TABLETS VARIOUS PREFERRED DRUG PA Required

SOFOSBUVIR/VELPATASVIR EPCLUSA

AUTHORIZED GENERIC BRAND

ONLY PREFERRED DRUG PA RequiredHERPES AGENTSACYCLOVIR SUSPENSION ZOVIRAXACYCLOVIR TABLETS ZOVIRAXFAMCICLOVIR TABLETS FAMVIR PA RequiredVALACYCLOVIR HCL TABLETS VALTREX PA RequiredINFLUENZA AGENTSOSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20 270

1/28/2021 40





Quantity Limit (QL)

QL Days


OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLURIMANTADINE HYDROCHLORIDE TABLETS FLUMADINEZANAMIVIR AEROSOL POWDER BREATH ACTIVATED RELENZA DISKHALER 40 270ASSORTED CLASSESBLOOD PRODUCTS - IMMUNE GLOBULINSIMMUNE GLOBULIN BIVIGAM (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN

(IV) BRAND ONLY PREFERRED DRUG PA REQUIRED

IMMUNE GLOBULIN FLEBOGFAMMA DIF (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMASTAN S/D (IM) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMMAGARD LIQUID (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMMAGARD S-D LIQUID (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMUNEX-C (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN HIZENTRAL (SUBQ) BRAND ONLY PREFERRED DRUG PA REQUIREDCHELATING AGENTSPENICILLAMINE CAPSULES CUPRIMINEIMMUNOMODULATORSLENALIDOMIDE CAPSULES REVLIMID PA RequiredTHALIDOMIDE CAPSULES THALOMID PA RequiredIMMUNOSUPPRESSIVE AGENTSAZATHIOPRINE TABLETS IMURANCYCLOSPORINE CAPSULES SANDIMMUNECYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAFCYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAFCYCLOSPORINE SOLUTION SANDIMMUNEEVEROLIMUS (IMMUNOSUPRESSANT) TABLETS ZORTRESS PA RequiredMYCOPHENOLATE MOFETIL CAPSULES CELLCEPTMYCOPHENOLATE MOFETIL SUSPENSION CELLCEPTMYCOPHENOLATE MOFETIL TABLETS CELLCEPTSIROLIMUS SOLUTION RAPAMUNESIROLIMUS TABLETS RAPAMUNETACROLIMUS CAPSULES HECORIA

1/28/2021 41





Quantity Limit (QL)

QL Days


TACROLIMUS CAPSULE CONTROLLED RELEASE ASTAGRAF XLPOTASSIUM REMOVING RESINSSODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATESODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEXBETA BLOCKERSALPHA-BETA BLOCKERSCARVEDILOL TABLETS COREGLABETALOL HCL TABLETS TRANDATEBETA BLOCKERS CARDIO-SELECTIVEATENOLOL TABLETS TENORMINATENOLOL/CHLORTHALIDONE VARIOUSBISOPRODOL VARIOUSBISOPRODOL/HCTZ VARIOUSMETOPROLOL TARTRATE TABLETS VARIOUSMETOPROLOL SUCCINATE TABLET XL 24-HOUR VARIOUSMETOPROLOL TARTRATE/HCTZ VARIOUSBETA BLOCKERS NON-SELECTIVE

NADOLOL VARIOUSPA NOT REQUIRED FOR CHILDREN AND ADOLESCENTS UNDER 19 YEARS OF AGE

PROPRANOLOL HCL CAPSULE ER CONTROLLED RELEASE VARIOUSPROPRANOLOL HCL SOLUTION VARIOUSPROPRANOLOL HCL TABLETS VARIOUSPROPRANOLOL / HCTZ VARIOUSSOTALOL HCL TABLETS BETAPACECALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERSAMLODIPINE BESYLATE VARIOUS 30 30DILTIAZEM CAPSULE ER VARIOUSDILTIAZEM TABLETS VARIOUSFELODIPINE TABLET ER 24-HOUR VARIOUS 30 30NIFEDIPINE IR CAPSULES VARIOUSNIFEDIPINE TABLET ER 24-HOUR VARIOUS 30 30

1/28/2021 42





Quantity Limit (QL)

QL Days


VERAPAMIL HCL CAPSULE SR VARIOUS 30 30VERAPAMIL HCL TABLETS VARIOUSVERAPAMIL HCL TABLET CONTROLLED RELEASE VARIOUS 30 30CARDIOTONICSCARDIAC GLYCOSIDESDIGOXIN SOLUTION DIGOXINDIGOXIN TABLETS LANOXINCARDIOVASCULAR AGENTS - MISC.ANGIOTENSTIN RECEPTOR NEPRILYSIN INHIBITORSACUBITRIL / VALSARTAN ENTRESTO PA RequiredPULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGAMBRISENTAN TABLETS LETAIRIS BRAND ONLY PREFERRED DRUG PA RequiredBOSENTAN TABLETS TRACLEER BRAND ONLY PREFERRED DRUG PA RequiredPULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITSILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO BRAND ONLY PREFERRED DRUG PA Required FOR > 12 YEARS OF AGESILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS VARIOUS PREFERRED DRUG PA RequiredTADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA BRAND ONLY PREFERRED DRUG PA RequiredCEPHALOSPORINSCEPHALOSPORINS - 1ST GENERATIONCEFADROXIL CAPSULES CEFADROXILCEFADROXIL SUSPENSION CEFADROXILCEFADROXIL TABLETS CEFADROXILCEPHALEXIN CAPSULES KEFLEXCEPHALEXIN SUSPENSION CEPHALEXINCEPHALEXIN TABLETS CEPHALEXINCEPHALOSPORINS - 2ND GENERATIONCEFACLOR CAPSULES CEFACLORCEFACLOR SUSPENSION CEFACLORCEFPROZIL SUSPENSION CEFPROZILCEFPROZIL TABLETS CEFPROZILCEFUROXIME AXETIL SUSPENSION CEFTIN

1/28/2021 43





Quantity Limit (QL)

QL Days


CEFUROXIME AXETIL TABLETS CEFTINCEPHALOSPORINS - 3RD GENERATIONCEFDINIR CAPSULES CEFDINIRCEFDINIR SUSPENSION CEFDINIRCEFIXIME CAPSULES SUPRAX 1 30CEFIXIME CHEWABLE TABLETS SUPRAX 1 30CEFIXIME SUSPENSION SUPRAX 1 30CEFIXIME TABLETS SUPRAX 1 30CEFPODOXIME PROXETIL SUSPENSION CEFPODOXIME PROXETILCEFPODOXIME PROXETIL TABLETS CEFPODOXIME PROXETILCONTRACEPTIONCOMBINATION CONTRACEPTIVES - ORALDESOGESTREL & ETHINYL ESTRADIOL TABLETS APRIDESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS AZURETTEDESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS CAZIANTDROSPIRENONE-ETHINYL ESTRADIOL TABLETS OCELLAETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS KELNOR 1/35LEVONORGESTREL & ETHINYL ESTRADIOL TABLETS AUBRALEVONORGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ENPRESSE-28LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS AMETHIA LOLEVONORGESTREL & ETHINYL ESTRADIOL (CONTINUOUS) TABLETS AMETHYSTNORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TABLETS JUNEL FE

NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE CHEWABLES MELODETTA 24 FENORETHINDRONE & ETH ESTRADIOL TABLETS BALZIVA NORETHINDRONE & MESTRANOL TABLETS NECON 1/50-28NORETHINDRONE ACET & ETH ESTRA TABLETS GILDESS 1/20NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS ESTROSTEP FE

NORETHIN ACET & ESTRAD-FE TABLETS LOESTRIN FE TAB 1/20NORETHINDRONE-ETH ESTRADIOL (BIPHASIC) TABLETS NECON 10/11-28NORETHINDRONE-ETH ESTRADIOL (TRIPHASIC) TABLETS CYCLAFEM 7/7/7NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEWABLES KAITLIB FE

1/28/2021 44





Quantity Limit (QL)

QL Days


NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ORTHO TRI-CYCLENNORGESTIMATE-ETHINYL ESTRADIOL TABLETS ESTARYLLANORGESTREL & ETHINYL ESTRADIOL TABLETS CRYSELLE-28COMBINATION CONTRACEPTIVES - VAGINALETONOGESTREL-ETHINYL ESTRADIOL RING NUVARING BRAND ONLYCOPPER CONTRACEPTIVES - IUD

COPPER (IUD) PARAGARD Buy and Bill Under Medical BenefitEMERGENCY CONTRACEPTIVES

LEVONORGESTREL (EMERGENCY OC) TABLETS PLAN B ONE-STEP OTC PREFERRED DRUG

LEVONORGESTREL (EMERGENCY OC) TABLETS AFTERA OTC PREFERRED DRUG

LEVONORGESTREL (EMERGENCY OC) TABLETS LEVONORGESTREL OTC PREFERRED DRUG

LEVONORGESTREL (EMERGENCY OC) TABLETS MY CHOICE OTC PREFERRED DRUG

LEVONORGESTREL (EMERGENCY OC) TABLETS MY WAY OTC PREFERRED DRUG

LEVONORGESTREL (EMERGENCY OC) TABLETS NEW DAY OTC PREFERRED DRUG

LEVONORGESTREL (EMERGENCY OC) TABLETS OPTION 2 OTC PREFERRED DRUG

1/28/2021 45





Quantity Limit (QL)

QL Days


LEVONORGESTREL (EMERGENCY OC) TABLETS TAKE ACTION OTC PREFERRED DRUGPROGESTIN CONTRACEPTIVES - IMPLANTS

ETONOGESTREL IMPLANT NEXPLANON PREFERRED DRUGPROGESTIN CONTRACEPTIVES - INJECTABLE

MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) SUSPENSION

CONTRACEPTIVE PROGESTIN CONTRACEPTIVES - IUD

LEVONORGESTREL (IUD) LILETTA Buy and Bill Under Medical Benefit

LEVONORGESTREL (IUD) SKYLA Buy and Bill Under Medical Benefit

LEVONORGESTREL (IUD) MIRENA Buy and Bill Under Medical Benefit

LEVONORGESTREL (IUD) KYLEENA Buy and Bill Under Medical BenefitPROGESTIN CONTRACEPTIVES - ORALNORETHINDRONE (CONTRACEPTIVE) TABLETS CAMILAPROGESTIN CONTRACEPTIVES - TRANSDERMALNORELGESTROMIN-ETHINYL ESTRADIOL PATCH WEEKLY XULANECORTICOSTEROIDSGLUCOCORTICOSTEROIDSDEXAMETHASONE CONCENTRATE DEXAMETHASONE INTENSOLDEXAMETHASONE ELIXIR VARIOUSDEXAMETHASONE SOLUTION DEXAMETHASONEDEXAMETHASONE TABLETS DEXAMETHASONEHYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE) A-HYDROCORT PA RequiredMETHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE) DEPO-MEDROL PA RequiredMETHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE) A-METHAPRED PA RequiredMETHYLPREDNISOLONE TABLETS MEDROLPREDNISOLONE SODIUM PHOSPHATE SOLUTION ORAPREDPREDNISOLONE SODIUM PHOSPHATE ORALLY DISINTEGRATING TABLETS ORAPRED ODTPREDNISOLONE SYRUP PRELONE

1/28/2021 46





Quantity Limit (QL)

QL Days


PREDNISOLONE TABLETS VARIOUSPREDNISONE CONCENTRATE PREDNISONE INTENSOLPREDNISONE SOLUTION PREDNISONEPREDNISONE TABLETS PREDNISONETRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE) KENALOG-10 PA RequiredTRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE) TRIAMCINOLONE PA Required

TRIAMCINOLONE HEXACETONIDE SUSPENSION (INJECTABLE)ARISTOSPAN INTRALESIONAL &

INTRA-ARTICULAR PA RequiredMINERALOCORTICOIDSFLUDROCORTISONE ACETATE TABLETS FLORINEFCOUGH/COLD/ALLERGYANTITUSSIVESBENZONATATE CAPSULES TESSALON PERLESHYDROCODONE W/ HOMATROPINE SYRUP VARIOUS PA Required for < 18 years of age 240 12HYDROCODONE W/ HOMATROPINE TABLETS VARIOUS PA Required for < 18 years of ageCOUGH/COLD/ALLERGY COMBINATIONSBROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID VARIOUSBROMPHENIRAMINE &PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUSBROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE LIQUID/TABLETS VARIOUSCETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS VARIOUSCHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID VARIOUS 480 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION VARIOUS 480 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP VARIOUS 480 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS VARIOUSDEXTROMETHORPHAN-GUAIFENESIN TABLET VARIOUSDEXTROMETHORPHAN-GUAIFENESIN LIQUID VARIOUS 480 30DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DMFEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS 30 30GUAIFENESIN-CODEINE SYRUP ROBITUSSIN AC PA Required for < 18 years of age 240 12LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30 30

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Quantity Limit (QL)

QL Days


LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN LIQUIDROBITUSSIN CHILDRENS COUGH &

COLD CF 480 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLETS VARIOUSPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR VARIOUSPHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN ELIXIR VARIOUS 480 30

PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN LIQUIDDIMETAPP DEXTROMETHORPHAN

COLD & COUGH 480 30PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID VARIOUS 480 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS VARIOUS PA Required for < 6 years agePHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS VARIOUSPHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE-GUAIFENESIN LIQUIDTRIAMINIC CHEST/

NASAL CONGESTION 480 30

PHENYLEPHRINE-GUAIFENESIN SYRUPTRIAMINIC CHEST & NASAL

CONGESTION 480 30PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUSPROMETHAZINE & PHENYLEPHRINE SYRUP PROMETHAZINE/ PHENYLEPHRINE 480 30PROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE PA Required for < 18 years of age 240 12

PROMETHAZINE-DEXTROMETHORPHAN SYRUPPROMETHAZINE/

DEXTROMETHORPHAN 480 30PSEUDOEPHEDRINE W/ CODEINE-GUAIFENESIN SYRUP VARIOUS PA Required for < 18 years of age 240 12EXPECTORANTSGUAIFENESIN LIQUID VARIOUS 480 30GUAIFENESIN SYRUP VARIOUS 480 30GUAIFENESIN TABLETS VARIOUSGUAIFENESIN TABLET 12-HOUR VARIOUSDERMATOLOGICALSACNE PRODUCTS

1/28/2021 48





Quantity Limit (QL)

QL Days


BENZOYL PEROXIDE WASH 5% & 10% VARIOUS

BENZOYL PEROXIDE CLEANSER 6%NEUTROGENA ON-THE-SPOT

ACNE TREATMENTBENZOYL PEROXIDE GEL BENZOYL PEROXIDEBENZOYL PEROXIDE LIQUID PANOXYLBENZOYL PEROXIDE LOTION BP CLEANSING LOTIONBENZOYL PEROXIDE-ERYTHROMYCIN PACK BENZAMYCINPAKCLINDAMYCIN PHOSPHATE (TOPICAL) GEL CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) LOTION CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) SOLUTION CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) SWAB CLEOCIN-TCLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE (REFRIGERATE) CLINDAMY/BENERYTHROMYCIN (ACNE AID) SOLUTION ERYTHROMYCINISOTRETINOIN CAPSULES ABSORICA PA RequiredTRETINOIN CREAM RETIN-A Brand Only PA Required For > 26 Years of AgeTRETINOIN GEL RETIN-A Brand Only PA Required For > 26 Years of AgeANTIBIOTICS - TOPICALBACITRACIN OINTMENT BACIGUENTBACITRACIN ZINC OINTMENT BACITRACINBACITRACIN-POLYMYXIN B OINTMENT POLYSPORINBACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORINGENTAMICIN SULFATE CREAM GENTAMICIN SULFATEGENTAMICIN SULFATE OINTMENT GENTAMICIN SULFATEMUPIROCIN CALCIUM CREAM BACTROBANMUPIROCIN OINTMENT BACTROBANNEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT NEOSPORINANTIFUNGALS - TOPICALBUTENAFINE LOTRIMIN ULTRACICLOPROX CREAM VARIOUSCICLOPROX SOLUTION VARIOUSCLOTRIMAZOLE CREAM (RX & OTC) LOTRIMIN

1/28/2021 49





Quantity Limit (QL)

QL Days


CLOTRIMAZOLE OINTMENT LOTRIMINCLOTRIMAZOLE SOLUTION (OTC) VARIOUSCLOTRIMAZOLE W/ BETAMETHASONE CREAM LOTRISONEKETOCONAZOLE CREAM VARIOUSKETOCONAZOLE SHAMPOO VARIOUSMICONAZOLE NITRATE CREAM VARIOUSMICONAZOLE NITRATE POWDER VARIOUSNYSTATIN CREAM VARIOUSNYSTATIN OINTMENT VARIOUSNYSTATIN POWDER VARIOUSTOLNAFTATE AERO POWDER VARIOUSTOLNAFTATE CREAM VARIOUSTOLNAFTATE POWDER VARIOUSTERBINAFINE CREAM VARIOUSANTIHISTAMINES-TOPICALDIPHENHYDRAMINE HCL CREAM ANTI-ITCH MAXIMUM STRENGTHDIPHENHYDRAMINE HCL GEL BENADRYL ITCH STOPPINGDIPHENHYDRAMINE HCL SOLUTION BENADRYL MAXIMUM STRENGTHANTISEBORRHEIC TOPICAL PRODUCTSSELENIUM SULFIDE LOTION SELSUN SHAMPOOANTIVIRALS - TOPICALDOCOSANOL 10% CREAM ABREVA 15GM 30ACYCLOVIR OINTMENT ZOVIRAXBURN PRODUCTSSILVER SULFADIAZINE CREAM SILVADENECORTICOSTEROIDS - TOPICAL LOW POTENCYFLUOCINOLONE ACETONIDE DERMA-SMOOTH FS BRAND ONLYHYDROCORTISONE CREAM VARIOUSHYDROCORTISONE GEL VARIOUSHYDROCORTISONE LOTION VARIOUSHYDROCORTISONE OINTMENT VARIOUS

1/28/2021 50





Quantity Limit (QL)

QL Days


FLUOCINOLONE 0.01% OIL VARIOUSCORTICOSTEROIDS - TOPICAL MEDIUM POTENCYFLUTICASONE PROPIONATE CREAM VARIOUSFLUTICASONE PROPIONATE OINTMENT VARIOUSMOMETASONE FUROATE CREAM VARIOUSMOMETASONE FUROATE OINTMENT VARIOUSMOMETASONE FUROATE SOLUTION VARIOUSCORTICOSTEROIDS - TOPICAL HIGH POTENCYBETAMETHASONE DIPROPIONATE LOTION VARIOUSBETAMETHASONE DIPROPIONATE/PROPYLENE GLYC. CREAM VARIOUSBETAMETHASONE VALERATE CREAM VARIOUSBETAMETHASONE VALERATE LOTION VARIOUSBETAMETHASONE VALERATE SOLUTION VARIOUSFLUOCINONIDE CREAM VARIOUSFLUOCINONIDE OINTMENT VARIOUSFLUOCINONIDE SOLUTION VARIOUSTRIAMCINOLONE ACETONIDE CREAM VARIOUSTRIAMCINOLONE ACETONIDE LOTION VARIOUSTRIAMCINOLONE ACETONIDE OINTMENT VARIOUSCORTICOSTEROIDS - TOPICAL VERY HIGH POTENCYCLOBETASOL PROPIONATE CREAM VARIOUS 100 30CLOBETASOL PROPIONATE EMOLLIENT VARIOUS 100 30CLOBETASOL PROPIONATE GEL VARIOUS 118 30CLOBETASOL PROPIONATE OINTMENT VARIOUS 100 30CLOBETASOL PROPIONATE SOLUTION VARIOUS 100 30HALOBETASOL PROPIONATE CREAM VARIOUS 100 30HALOBETASOL PROPIONATE OINTMENT VARIOUS 100 30KERATOLYTIC/ANTIMITOTIC AGENTSSALICYLIC ACID CREAM SALACYNSALICYLIC ACID FOAM SALVAXSALICYLIC ACID GEL KERALYT

1/28/2021 51





Quantity Limit (QL)

QL Days


SALICYLIC ACID LIQUID VIRASALSALICYLIC ACID LOTION SALACYNSALICYLIC ACID SHAMPOO SALEXSALICYLIC ACID SOLUTION VARIOUSLOCAL ANESTHETICS - TOPICALLIDOCAINE CREAM 4% ASPERCREME W/LIDOCAINELIDOCAINE HCL GEL 2% GLYDOLIDOCAINE HCL LOTION LIDOCAINE HCL PA RequiredLIDOCAINE OINTMENT LIDOCAINE PA RequiredLIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE HCL SOLUTION VARIOUSLIDOCAINE-PRILOCAINE CREAM EMLATOPICAL - MISC.ALUMINUM CHLORIDE SOLUTION DRYSOLROSACEA TOPICAL AGENTSMETRONIDAZOLE CREAM 0.75% METROCREAMMETRONIDAZOLE GEL 0.75% METROGELMETRONIDAZOLE LOTION METROLOTIONSCABICIDES & PEDICULICIDES TOPICAl AGENTS+A1106CROTAMITON CREAM EURAXCROTAMITON LOTION EURAXIVERMECTIN LOTION SKLICE PA RequiredPERMETHRIN CREAM ACTICINPERMETHRIN 1%, 5% NIX, ELIMITEPERMETHRIN LIQUID NIX CREME RINSEPYRETHRINS-PIPERONYL BUTOXIDE GEL A-200PYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARCPYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDESPINOSAD SUSPENSION NATROBA PA RequiredDIAGNOSTIC PRODUCTSDIAGNOSTIC TESTS

1/28/2021 52





Quantity Limit (QL)

QL Days


BLOOD GLUCOSE MONITORS & STRIPS VARIOUSDIGESTIVE AIDSDIGESTIVE ENZYMESLIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE CREON BRAND ONLY PREFERRED DRUG 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE ZENPEP BRAND ONLY PREFERRED DRUG 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 UNITS PANCRELIPASE 5000 UNITS PREFERRED DRUG 300 30DIURETICSCARBONIC ANHYDRASE INHIBITORSACETAZOLAMIDE CAPSULE 12-HOUR DIAMOXACETAZOLAMIDE TABLETS ACETAZOLAMIDEMETHAZOLAMIDE TABLETS NEPTAZANEDIURETIC COMBINATIONSSPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25LOOP DIURETICSBUMETANIDE TABLETS BUMETANIDEFUROSEMIDE SOLUTION FUROSEMIDEFUROSEMIDE TABLETS LASIXTORSEMIDE TABLETS DEMADEXPOTASSIUM SPARING DIURETICSSPIRONOLACTONE TABLETS ALDACTONETHIAZIDES AND THIAZIDE-LIKE DIURETICSCHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDECHLORTHALIDONE TABLETS CHLORTHALIDONEHYDROCHLOROTHIAZIDE CAPSULES 12.5MG VARIOUSHYDROCHLOROTHIAZIDE TABLETS 25MG & 50MG HYDROCHLOROTHIAZIDEINDAPAMIDE TABLETS INDAPAMIDEMETOLAZONE TABLETS ZAROXOLYNENDOCRINE AND METABOLIC AGENTS - MISC.

1/28/2021 53





Quantity Limit (QL)

QL Days


BONE DENSITY REGULATORSALENDRONATE SODIUM SOLUTION ALENDRONATE SODIUMALENDRONATE SODIUM TABLETS ALENDRONATE SODIUMCALCITONIN (SALMON) SOLUTION FORTICALDENOSUMAB PROLIA PA RequiredIBANDRONATE SODIUM BONIVARALOXIFENE TABLETS VARIOUSTERIPARATIDE (RECOMBINANT) FORTEO PA RequiredGROWTH HORMONESSOMATROPIN SOLUTION NORDITROPIN BRAND ONLY PREFERRED DRUG PA RequiredSOMATROPIN SOLUTION GENOTROPIN BRAND ONLY PREFERRED DRUG PA RequiredHORMONE RECEPTOR MODULATORSRALOXIFENE HCL TABLETS EVISTAINSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)MECASERMIN SOLUTION INCRELEX PA RequiredLHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTSLEUPROLIDE ACETATE (CPP) (3 MONTH) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE (CPP) KIT LUPRON DEPOT-PED PA RequiredMETABOLIC MODIFIERSCINACALCET HCL TABLETS SENSIPAR PA RequiredIDURSULFASE SOLUTION ELAPRASE PA RequiredPOSTERIOR PITUITARY HORMONESDESMOPRESSIN ACETATE REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY SOLUTION VARIOUSDESMOPRESSIN ACETATE TABLETS VARIOUS PA RequiredESTROGENSESTROGEN COMBINATIONSCONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPROESTRADIOL-LEVONORGESTREL PATCH-WEEKLY CLIMARA PATCH

1/28/2021 54





Quantity Limit (QL)

QL Days


ESTROGENSESTERIFIED ESTROGENS TABLETS MENESTESTRADIOL PATCH-TWICE WEEKLY ALORAESTRADIOL PATCH-WEEKLY MENOSTARESTRADIOL TABLETS ESTRACEESTROGENS, CONJUGATED SYNTHETIC A TABLETS CENESTINESTROGENS, CONJUGATED TABLETS PREMARINESTROPIPATE TABLETS ORTHO-ESTFLUOROQUINOLONESFLUOROQUINOLONESCIPROFLOXACIN HCL TABLETS CIPROFLOXACIN HCLLEVOFLOXACIN SOLUTION LEVAQUINLEVOFLOXACIN TABLETS LEVAQUINOFLOXACIN TABLETS OFLOXACINGASTROINTMENTESTINAL AGENTS - MISC.GALLSTONE SOLUBILIZING AGENTSURSODIOL CAPSULES ACTIGALLURSODIOL TABLETS URSO 250GASTROINTMENTESTINAL CHLORIDE CHANNEL ACTIVATORSLUBIPROSTONE CAPSULES AMITIZA PA RequiredGASTROINTMENTESTINAL STIMULANTSMETOCLOPRAMIDE HCL SOLUTION VARIOUSMETOCLOPRAMIDE HCL TABLETS VARIOUSMETOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS VARIOUSINFLAMMATORY BOWEL AGENTSBALSALAZIDE DISODIUM CAPSULES COLAZAL 270 30BALSALAZIDE DISODIUM TABLETS GIAZO 270 30INFLIXIMAB-ABDA RENFLEXIS PA RequiredBUDESONIDE CAPSULES ENTOCORT ECMESALAMINE CAPSULE CONTROLLED RELEASE PENTASA 270 30MESALAMINE ENEMA MESALAMINE 30 30

1/28/2021 55





Quantity Limit (QL)

QL Days


MESALAMINE TABLET ENTERIC COATED ASACOL HD 120 30OLSALAZINE SODIUM CAPSULES DIPENTUM 120 30SULFASALAZINE TABLETS AZULFIDINE 240 30SULFASALAZINE TABLET ENTERIC COATED AZULFIDINE EN-TABLETS 240 30IRRITABLE BOWEL SYNDROME (IBS) AGENTSLINACLOTIDE CAPSULES LINZESS PA RequiredPHOSPHATE BINDER AGENTSCALCIUM ACETATE TABLETS VARIOUS PREFERRED DRUGCALCIUM ACETATE CAPSULES VARIOUS PREFERRED DRUGSEVELAMER CARBONATE RENVELA VARIOUS PREFERRED DRUGGENITOURINARY AGENTS - MISC.INTERSTITIAL CYSTITIS AGENTSPENTOSAN POLYSULFATE SODIUM CAPSULES ELMIRON PA RequiredPROSTATIC HYPERTROPHY AGENTSALFUZOSIN ER VARIOUSDOXAZOSIN MESYLATE VARIOUSDUTASTERIDE VARIOUSFINASTERIDE PROSCARTAMSULOSIN HCL FLOMAXTERAZOSIN VARIOUSURINARY ANALGESICSPHENAZOPYRIDINE HCL TABLETS PYRIDIUMGOUT AGENTSGOUT AGENTSALLOPURINOL TABLETS ZYLOPRIMCOLCHICINE TABLETS VARIOUSFEBUXOSTAT TABLETS ULORIC PA RequiredURICOSURICSPROBENECID TABLETS PROBENECIDHEMATOLOGICAL AGENTS - MISC.PLATELET AGGREGATION INHIBITORS

1/28/2021 56





Quantity Limit (QL)

QL Days


CILOSTAZOL TABLETS PLETALCLOPIDOGREL BISULFATE TABLETS PLAVIXDIPYRIDAMOLE TABLETS PERSANTINETICAGRELOR TABLETS BRILINTA PA RequiredHEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASEELIGLUSTAT TARTRATE CERDELGA (oral) BRAND ONLY PA RequiredIMIGLUCERASE SOLUTION CEREZYME 400 IU (IV) BRAND ONLY PA RequiredTALIGLUCERASE ALFA ELELYSO (IV) BRAND ONLY PA RequiredMIGLUSTAT MIGLUSTAT (AG) (oral) BRAND ONLY PA RequiredVELAGLUCERASE ALFA VPRIV 400 IU BRAND ONLY PA RequiredHEMATOPOIETIC GROWTH FACTORSELTROMBOPAG OLAMINE TABLETS PROMACTA BRAND ONLY PREFERRED DRUG PA RequiredEPOETIN ALFA SOLUTION RETACRIT BRAND ONLY PREFERRED DRUG PA RequiredFILGRASTIM DISPOSABLE SYRINGE NEUPOGEN BRAND ONLY PREFERRED DRUG PA RequiredFILGRASTIM SOLUTION NEUPOGEN BRAND ONLY PREFERRED DRUG PA RequiredPEGFILGRASTIM -JMDB PREFILLED SYRINGE FULPHILA BRAND ONLY PREFERRED DRUG PA RequiredPEGFILGRASTIM PREFILLED SYRINGE UNDENYCA BRAND ONLY PREFERRED DRUG PA RequiredROMIPLOSTIM NPLATE BRAND ONLY PREFERRED DRUG PA RequiredHEMOSTATICSHEMOSTATICS - SYSTEMICAMINOCAPROIC ACID SYRUP AMICARAMINOCAPROIC ACID TABLETS AMICARHYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTBARBITURATE HYPNOTICSPHENOBARBITAL SOLUTION PHENOBARBITALPHENOBARBITAL TABLETS PHENOBARBITAL

NON-BARBITURATE HYPNOTICS

1/28/2021 57





Quantity Limit (QL)

QL Days


ESZOPICLONE LUNESTA VARIOUS PREFERRED DRUGPA Required for Ages <6 years

PA Required for > 1 Hypnotic Drug 30 30

TEMAZEPAM CAPSULES 15MG & 30MG RESTORIL PREFERRED DRUGPA Required for Ages <6 years


ZOLPIDEM TARTRATE TABLETS 5MG AMBIEN PREFERRED DRUGPA Required for Ages <6 years


ZOLPIDEM TARTRATE TABLETS 10MG AMBIEN PREFERRED DRUGPA Required for Ages <6 years

PA Required for > 1 Hypnotic Drug 30 30SELECTIVE MELATONIN RECEPTOR AGONISTS

RAMELTEON TABLETS ROZEREM BRAND ONLY PREFERRED DRUG PA Required for < 6 years of age

Patient must have tried two preferred

agents. 30 30LAXATIVESLAXATIVE COMBINATIONSPEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTELAXATIVES - MISC.LACTULOSE SOLUTION LACTULOSEMACROLIDESAZITHROMYCINAZITHROMYCIN PACKETS ZITHROMAXAZITHROMYCIN SUSPENSION ZITHROMAXAZITHROMYCIN TABLETS ZITHROMAXCLARITHROMYCINCLARITHROMYCIN SUSPENSION CLARITHROMYCINCLARITHROMYCIN TABLETS BIAXINCLARITHROMYCIN TABLET 24-HOUR BIAXIN XLMEDICAL DEVICESCONTRACEPTIVESCONDOMS - FEMALE MISC. FC FEMALE CONDOMCONDOMS - MALE MISC. LIFESTYLES ASSORTED COLORSDIAPHRAGM ARC-SPRING DPRH CAYA

1/28/2021 58





Quantity Limit (QL)

QL Days


DIAPHRAGM COIL SPRING KITORTHO DIAPHRAGM COIL SPRING

KIT 50

DIAPHRAGM FLAT SPRING KITORTHO DIAPHRAGM FLAT SPRING

KIT 55

DIAPHRAGM WIDE SEAL DPRHWIDE-SEAL SILICONE DIAPHRAGM

KIT 60DIAPHRAGMS - OTHER+A1294 OMNIFLEX DIAPHRAGMDIABETIC SUPPLIESBLOOD GLUCOSE MONITORING KIT W/ DEVICE VARIOUSBLOOD GLUCOSE MONITORING DEVICES VARIOUSLANCET DEVICES MISC. VARIOUSLANCETS MISC. VARIOUSDEVICES - MISC.ALCOHOL SWABS PADS ALCOH-GLOVE CONTOURED WIPERESPIRATORY THERAPY SUPPLIES

SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKSMASK VORTEX/

BABY WHIRL DUCKLING 2 365

SPACER/AEROSOL-HOLDING CHAMBERS DEVICEAEROCHAMBER

MINI AEROCHAMBER 2 365MIGRAINE PRODUCTSMIGRAINE COMBINATIONSERGOTAMINE W/ CAFFEINE SUPPOSITORY MIGERGOT 12 30ERGOTAMINE W/ CAFFEINE TABLETS CAFERGOTMIGRAINE PRODUCTS - MONOCLONAL ANTIBODIESFREMANEZUMAB-VFRM SOLUTION AUTOINJECTOR AJOVY Preferred Drug PA Required 1.00 30.00GALCANEZUMAB-GNLM SOLUTION AUTOINJECTOR / PREFILLED SYRINGE / PEN EMGALITY Preferred Drug PA Required

SEROTONIN AGONISTSNARATRIPTAN HCL TABLETS AMERGE PREFERRED DRUG 9 30RIZATRIPTAN BENZOATE ORALLY DISPERSABLE TABLET MAXALT-MLT PREFERRED DRUG 9 30RIZATRIPTAN BENZOATE TABLETS MAXALT PREFERRED DRUG 9 30SUMATRIPTAN NASAL SPRAY IMITREX BRAND ONLY PREFERRED DRUG 6 30

1/28/2021 59





Quantity Limit (QL)

QL Days


SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION AUTO INJECTION IMITREX PREFERRED DRUG 2 30SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION CARTRIDGE IMITREX PREFERRED DRUG 2 30

SUMATRIPTAN SUCCINATE TABLETS IMITREX PREFERRED DRUG 9 30

ZOLMITRIPTAN NASAL SPRAY ZOMIG BRAND ONLY PREFERRED DRUG 6 30

ZOLMITRIPTAN ORALLY DISPERSABLE TABLET ZOMIG ZMT PREFERRED DRUG 9 30ZOLMITRIPTAN TABLETS ZOMIG PREFERRED DRUG 9 30MINERALS & ELECTROLYTESSODIUM FLUORIDE CHEWABLE TABLETS LUDENTSODIUM FLUORIDE LOZG LOZI-FLURSODIUM FLUORIDE SOLUTION FLUOR-A-DAYSODIUM FLUORIDE TABLETS SODIUM FLUORIDEMOUTH/THROAT/DENTAL AGENTSANTI-INFECTIVES - THROATCLOTRIMAZOLE TROC CLOTRIMAZOLESTEROIDS - MOUTH/THROATTRIAMCINOLONE ACETONIDE ORAL PASTE ORALONEMULTIVITAMINSPRENATAL VITAMINSPRENATAL MULTIVITAMINS WITH OR WITHOUT MINERALS W/ FOLATE VARIOUSPRENATAL MULTIVITAMINES WITH MINERAL W/FE-FA VARIOUSMUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTSBACLOFEN TABLETS BACLOFEN

CYCLOBENZAPRINE HCL TABLETS 5MG & 10MG FLEXERILPA Required for dosages other than 5mg and

10mg tabletsMETHOCARBAMOL TABLETS ROBAXINTIZANIDINE HCL TABLETS - 2MG & 4MG ONLY TIZANIDINE HCLDIRECT MUSCLE RELAXANTS

1/28/2021 60





Quantity Limit (QL)

QL Days


DANTROLENE SODIUM CAPSULES DANTRIUMNASAL AGENTS - SYSTEMIC AND TOPICALNASAL ANTIALLERGYAZELASTINE HCL SOLUTION 0.10% ASTELINNASAL ANTICHOLINERGICSIPRATROPIUM BROMIDE SOLUTION ATROVENTNASAL STEROIDSFLUNISOLIDE SOLUTION FLUNISOLIDEFLUTICASONE PROPIONATE SUSPENSION FLONASETRIAMCINOLONE ACETONIDE NASACORT AQSYMPATHOMIMETIC DECONGESTANTSPSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENSPSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINEPSEUDOEPHEDRINE HCL TABLETS SUDAFEDPSEUDOEPHEDRINE HCL TABLET 12-HOUR NASAL DECONGESTANTPSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOUROPHTHALMIC AGENTSOPHTHALMIC - BETA-BLOCKERSBETAXOLOL HCL SOLUTION BETAXOLOL HCLBETAXOLOL HCL SUSPENSION BETOPTIC-SCARTEOLOL HCL SOLUTION CARTEOLOL HCLDORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION COSOPTLEVOBUNOLOL HCL SOLUTION LEVOBUNOLOL HCLMETIPRANOLOL SOLUTION METIPRANOLOLTIMOLOL MALEATE SOLUTION TIMOPTIC-XETIMOLOL MALEATE SOLUTION TIMOPTICOPHTHALMIC - CYCLOPLEGIC MYDRIATICSATROPINE SULFATE OINTMENT ATROPINE SULFATEATROPINE SULFATE SOLUTION ISOPTO ATROPINECYCLOPENTOLATE HCL SOLUTION CYCLOGYLHOMATROPINE HBR SOLUTION ISOPTO HOMATROPINE

1/28/2021 61





Quantity Limit (QL)

QL Days


OPHTHALMIC - MIOTICSPILOCARPINE HCL GEL PILOPINE HSPILOCARPINE HCL SOLUTION ISOPTO CARPINEOPHTHALMIC - ANTI-INFECTIVESBACITRACIN OINTMENT BACITRACIN 3.5GM 7BACITRACIN-POLYMYXIN B OINTMENT POLYCINCIPROFLOXACIN HCL OINTMENT CILOXANCIPROFLOXACIN HCL SOLUTION CILOXANERYTHROMYCIN OINTMENT ILOTYCINGENTAMICIN SULFATE OINTMENT GARAMYCINGENTAMICIN SULFATE SOLUTION GARAMYCINMOXIFLOXACIN HCL SOLUTION VIGAMOXNATAMYCIN SUSPENSION NATACYNNEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT NEO-POLYCINNEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION NEOSPORINOFLOXACIN SOLUTION OCUFLOXPOLYMYXIN B-TRIMETHOPRIM SOLUTION POLYTRIMSULFACETAMIDE SODIUM OINTMENT SULFACETAMIDE SODIUMSULFACETAMIDE SODIUM SOLUTION BLEPH-10TOBRAMYCIN OINTMENT TOBREX 3.5GM 7TOBRAMYCIN SOLUTION TOBREXTRIFLURIDINE SOLUTION VIROPTICOPHTHALMIC - DECONGESTANTSNAPHAZOLINE HCL SOLUTION VASOCLEARNAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-AOPHTHALMIC - IMMUNOMODULATORSCYCLOSPORINE EMULSION RESTASIS PA RequiredOPHTHALMIC - STEROIDSBACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HCDEXAMETHASONE SUSPENSION MAXIDEX

DEXAMETHASONE SODIUM PHOSPHATE SOLUTIONDEXAMETHASONE SODIUM

PHOSPHATE

1/28/2021 62





Quantity Limit (QL)

QL Days


FLUOROMETHOLONE OINTMENT FMLFLUOROMETHOLONE SUSPENSION FML LIQUIFILMGENTAMICIN-PREDNISOLONE ACETATE OINTMENT PRED-G S.O.P.GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION PRED-GNEOMYCIN-POLYMY-DEXAMETH OINTMENT MAXITROLNEOMYCIN-POLYMY-DEXAMETH SUSPENSION MAXITROLPREDNISOLONE ACETATE SUSPENSION PRED MILD

PREDNISOLONE SODIUM PHOSPHATE SOLUTIONPREDNISOLONE SODIUM

PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE OINTMENT BLEPHAMIDE S.O.P.

SULFACETAMIDE SOD-PREDNISOLONE SOLUTION

SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM

PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE SUSPENSION BLEPHAMIDETOBRAMYCIN-DEXAMETHASONE OINTMENT TOBRADEXTOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX STOPHTHALMICS - MISC.BRINZOLAMIDE SUSPENSION AZOPT PA RequiredCROMOLYN SODIUM SOLUTION CROMOLYN SODIUMDICLOFENAC SODIUM SOLUTION DICLOFENAC SODIUMDORZOLAMIDE HCL SOLUTION TRUSOPTFLURBIPROFEN SODIUM SOLUTION OCUFENKETOROLAC TROMETHAMINE SOLUTION ACULAR LSKETOTIFEN FUMARATE SOLUTION ALAWAYOPHTHALMIC - PROSTAGLANDINSLATANOPROST SOLUTION XALATAN 2.5 30TAFLUPROST SOLUTION ZIOPTAN PA RequiredTRAVOPROST SOLUTION TRAVATAN Z PA RequiredOTIC AGENTSOTIC AGENTS - MISCELLANEOUSACETIC ACID SOLUTION ACETIC ACIDOTIC ANTI-INFECTIVES

1/28/2021 63





Quantity Limit (QL)

QL Days


CIPROFLOXACIN SOLUTION VARIOUSOTIC COMBINATIONSANTIPYRINE-BENZOCAINE SOLUTION AURODEXANTIPYRINE-BENZOCAINE-POLYCOSANOL SOLUTION OTIC CARECIPROFLOXACIN-DEXAMETHASONE CIPRODEX BRAND ONLY PREFERRED DRUGNEOMYCIN-POLYMYXIN-HC SOLUTION CORTISPORIN PREFERRED DRUGNEOMYCIN-POLYMYXIN-HC SUSPENSION NEO/POLYMYXIN/HC 5-10000-1 PREFERRED DRUGOTIC STEROIDSHYDROCORTISONE W/ACETIC ACID SOLUTION ACETASOL HCOXYTOCICSOXYTOCICSMETHYLERGONOVINE MALEATE TABLETS METHERGINEPASSIVE IMMUNIZING AGENTSMONOCLONAL ANTIBODIES

PALIVIZUMAB SOLUTION SYNAGISPA Required - if approved the prescriber may

be required to buy and bill a medical claim for the drug

PENICILLINSAMINOPENICILLINSAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLINAMOXICILLIN TABLETS AMOXICILLINAMPICILLIN CAPSULES AMPICILLINAMPICILLIN SUSPENSION AMPICILLINNATURAL PENICILLINSPENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUMPENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUMPENICILLIN COMBINATIONSAMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTINAMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTIN

1/28/2021 64





Quantity Limit (QL)

QL Days


AMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRPENICILLINASE-RESISTANT PENICILLINSDICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUMPROGESTINSPROGESTINSHYDROXYPROGESTERONE CAPROATE OIL MAKENA 250 MG/ML Brand Only PA RequiredHYDROXYPROGESTERONE CAPROATE SOLUTION AUTOINJECTOR MAKENA AUTO INJECTOR Brand Only PA RequiredMEDROXYPROGESTERONE ACETATE TABLETS PROVERANORETHINDRONE ACETATE TABLETS AYGESTINPROGESTERONE MICRONIZED CAPSULES PROMETRIUMPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTANTIDEMENTIA AGENTSDONEPEZIL HYDROCHLORIDE TABLETS ARICEPT PA RequiredDONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TABLETS ARICEPT ODT PA RequiredGALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE RAZADYNE ER PA RequiredGALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA RequiredMEMANTINE HCL SOLUTION NAMENDA PA RequiredMEMANTINE HCL TABLETS NAMENDA PA RequiredRIVASTIGMINE PATCH EXELON PA RequiredRIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredMULTIPLE SCLEROSIS AGENTSFINGOLIMOD HCL CAPSULES GILENYA PA RequiredGLATIRAMER ACETATE 20MG COPAXONE 20mg BRAND ONLY PREFERRED DRUG PA RequiredGLATIRAMER ACETATE 40MG GLATOPA 40MG BRAND ONLY PREFERRED DRUG PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredSMOKING DETERRENTS

BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR BUPROBAN 84-day supply 180

1/28/2021 65





Quantity Limit (QL)

QL Days


NICOTINE INHA NICOTROL INHALER 84-day supply 180

NICOTINE POLACRILEX GUM NICORETTE GUM 84-day supply 180

NICOTINE POLACRILEX LOZENGE COMMIT 84-day supply 180

NICOTINE PATCH NICODERM CQ 84-day supply 180

NICOTINE SOLUTION NICOTROL NS 84-day supply 180

VARENICLINE TARTRATE TABLETS CHANTIX 84-day supply 180RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA RequiredCYSTIC FIBROSIS AGENTSDORNASE ALFA SOLUTION PULMOZYME PA RequiredSULFONAMIDESSULFONAMIDESSULFADIAZINE TABLETS SULFADIAZINETETRACYCLINESTETRACYCLINESDEMECLOCYCLINE HCL TABLETS DEMECLOCYCLINE HCL PA RequiredDOXYCYCLINE HYCLATE CAPSULES - 50MG AND 100MG CAPSULES ONLY VARIOUSDOXYCYCLINE HYCLATE TABLETS - 20MG AND 100MG TABLETS ONLY VARIOUSDOXYCYCLINE MONOHYDRATE - CAPSULES 50MG & 100MG ONLY VARIOUSMINOCYCLINE HCL - 50MG, 75MG & 100MG CAPSULES ONLY MINOCINTHYROID AGENTSANTITHYROID AGENTSMETHIMAZOLE TABLETS TAPAZOLEPROPYLTHIOURACIL TABLETS PROPYLTHIOURACILTHYROID HORMONESLEVOTHYROXINE SODIUM TABLETS LEVO-T

1/28/2021 66





Quantity Limit (QL)

QL Days


LIOTHYRONINE SODIUM TABLETS CYTOMELTHYROID TABLETS ARMOUR THYROIDULCER DRUGSANTISPASMODICSDICYCLOMINE HCL CAPSULES VARIOUSDICYCLOMINE HCL SOLUTION VARIOUSDICYCLOMINE HCL TABLETS VARIOUSGLYCOPYRROLATE SOLUTION VARIOUSGLYCOPYRROLATE TABLETS VARIOUSHYOSCYAMINE SULFATE ELIXIR VARIOUSHYOSCYAMINE SULFATE SOLUTION VARIOUSHYOSCYAMINE SULFATE SUBLINGUAL VARIOUSHYOSCYAMINE SULFATE TABLETS VARIOUSHYOSCYAMINE SULFATE TABLET 12-HOUR VARIOUSHYOSCYAMINE SULFATE CONTROLLED RELEASE TABLET VARIOUSHYOSCYAMINE SULFATE ORALLY DISINTEGRATING TABLETS VARIOUSPROPANTHELINE BROMIDE TABLETS VARIOUSH-2 ANTAGONISTSFAMOTIDINE CHEWABLE TABLETS PEPCID ACFAMOTIDINE SUSPENSION PEPCIDFAMOTIDINE TABLETS PEPCID ACRANITIDINE HCL CAPSULES RANITIDINE HCLRANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQRANITIDINE HCL SYRUP ZANTACRANITIDINE HCL TABLETS ZANTAC 75ANTI-ULCER - MISC.SUCRALFATE TABLETS CARAFATEPROTON PUMP INHIBITORSESOMEPRAZOLE MAGNESIUM PACKETS NEXIUM PREFERRED DRUG PA Required for > 18 Years of Age 30.00 30.00ESOMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE NEXIUM PREFERRED DRUG 60.00 30.00LANSOPRAZOLE CAPSULE DELAYED RELEASE VARIOUS PREFERRED DRUG 60.00 30.00

1/28/2021 67





Quantity Limit (QL)

QL Days


LANSOPRAZOLE ORALLY DISPERSABLE TABLET (ODT) PREVACID SOLUTAB PREFERRED DRUG PA Required for > 18 Years of Age 60.00 30.00OMEPRAZOLE ORAL CAPSULES VARIOUS PREFERRED DRUG 60.00 30.00PANTOPRAZOLE SODIUM PACKETS PROTONIX PREFERRED DRUG PA Required for > 18 Years of Age 30.00 30.00URINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLI)FESOTERODINE FUMARATE TOVIAZ BRAND ONLY PREFERRED DRUGOXYBUTYNIN CHLORIDE SYRUP VARIOUS PREFERRED DRUGOXYBUTYNIN CHLORIDE TABLETS VARIOUS PREFERRED DRUGOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XL PREFERRED DRUGTOLTERODINE TARTRATE CAPSULE CONTROLLED RELEASE DETROL LA BRAND ONLY PREFERRED DRUGTOLTERODINE TARTRATE TABLETS DETROL BRAND ONLY PREFERRED DRUGVAGINAL PRODUCTSSPERMICIDES

NONOXYNOL-9 FOAMVCF VAGINAL CONTRACEPTIVE

FOAMNONOXYNOL-9 GEL SHUR-SEALVAGINAL ANTI-INFECTIVESCLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCINCLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCINCLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMINMETRONIDAZOLE VAGINAL GEL METROGEL-VAGINAL

MICONAZOLE NITRATE VAGINAL MONISTAT 3 COMBINATION

PACKETSMICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3SULFANILAMIDE VAGINAL CREAM AVCVAGINAL ESTROGENSESTRADIOL ACETATE VAGINAL RING FEMRING PA RequiredESTRADIOL VAGINAL RING ESTRINGESTRADIOL VAGINAL TABLETS VAGIFEMESTRADIOL VAGINAL CREAM 0.01% ESTRACE CREAMESTROGENS, CONJUGATED VAGINAL CREAM PREMARIN VAGINAL CREAM PA RequiredVASOPRESSORS

1/28/2021 68





Quantity Limit (QL)

QL Days


ANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE SELF-INJECTABLE 0.15MG AND 0.30MGEPINEPHRINE SELF-INJECTABLE (By

Mylan) Mylan Generic PREFERRED DRUG PA Required for > 2 Per Month 2.00 30.00

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AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE …...Jan 01, 2021 · codes on the prescription: 1. O09.91- Supervision of high risk pregnancy, 1st Trimester. 2. O09.92- Supervision