EOCCO Pharmacy FormularyRefer to the chart below for a list of prescription medications covered by Moda Health. Medications that are new to the market are subject to a review period

EOCCO Pharmacy Formulary Effective 1/1/2021

Medications that are new to the market are not included within your pharmacy benefit until reviewed by the Pharmacy and Therapeutics Committee. Please contact Moda Health Customer Service if you are taking a medication that is new to the market. Please note that this list is subject to change at any time.

Questions?

Call Pharmacy Customer Service at 888-474-8539.

2

How to read your pharmacy formulary

Refer to the chart below for a list of prescription medications covered by Moda Health. Medications that are new to the market are subject to a review period. Please contact us if you are taking a medication that is new to the market.

This document is provided for informational purposes only and is intended as a quick reference. For cost and further details of the coverage, including exclusions, prior authorization requirements, any reduction or limitations and the terms under which the policy may be continued in force, contact your producer or Moda Health.

Key

Bold Italic Font

Brand name medications

Regular Font

Generic medications

Tier 1 Generic retail

Tier 2 Brand retail

Tier 3 Generic specialty

Tier 4 Brand specialty

SP

Speciality medications – Certain prescription medications are defined as specialty products. Specialty medications are often used to treat complex chronic health conditions. Specialty treatments often require special handling techniques, careful administration and a unique ordering process. You must access specialty medications through the exclusive specialty pharmacy. All specialty medications require a prior authorization before they can be dispensed. To enroll with Ardon Health Specialty Pharmacy, call toll-free at 855-425-4085.

PA Prior authorization required – Your healthcare provider must work directly with Moda Health to obtain approval before we can process payment for a specific medication.

ST Step therapy required – You must try one or more “first line” medications before you can get this step therapy medication.

QL Quantity limits – Some medications have limits to how much you can get per prescription or refill.

A Age limits – Some medications are limited to certain ages based on FDA recommendation or plan benefit limitations.

Bold Italic = Brand name; Regular Font = Generic; SP = Specialty medications; PA = Prior authorization required; ST = Step therapy required; QL = Quantity limits; A = Age limits

2021.1 (1/15/2021).

For prior effective dates, please contact EOCCO. 3 eocco.com

Product Name Strength Dosage Tier Restrictions Restriction Details

12 Hour Decongestant 120 mg Tablet Er 1

12 Hour Nasal Decongestant 120 mg Tablet Er 1

1st Tier Unifine Pentips 29 g x1/2"" Dis Needle 1

1st Tier Unifine Pentips 31 g x1/4"" Dis Needle 1

1st Tier Unifine Pentips 31 gx3/16"" Dis Needle 1

1st Tier Unifine Pentips 31 gx5/16"" Dis Needle 1

1st Tier Unifine Pentips 32gx 5/32"" Dis Needle 1

1st Tier Unifine Pentips Plus 31 gx3/16"" Dis Needle 1

1st Tier Unifine Pentips Plus 31 gx5/16"" Dis Needle 1

1st Tier Unifine Pentips Plus 32gx 5/32"" Dis Needle 1

1st Tier Unilet Comfortouch 28 gauge Each 1

1st Tier Unilet Comfortouch 30 gauge Each 1

24hour Allergy 10 mg Tablet 1

2tek Each 1

8 Hour Acetaminophen 650 mg Tablet Er 1

8 Hour Pain Relief 650 mg Tablet Er 1

8hr Arthritis Pain 650 mg Tablet Er 1

8hr Arthritis Pain Relief 650 mg Tablet Er 1

8hr Muscle Aches-Pain 650 mg Tablet Er 1

Abacavir 20 mg/ml Solution 1

Abacavir 300 mg Tablet 1

Abacavir-Lamivudine 600-300mg Tablet 1

Abacavir-Lamivudine-Zidovudine 150-300 mg Tablet 1

Abaneu-Sl 600-600mcg Tab Subl 1

Abiraterone Acetate 250 mg Tablet 3 SP

Abiraterone Acetate 500 mg Tablet 3 SP, PA, QL Limited to 60 tabs per 30 days

Acarbose 100 mg Tablet 1 QL Limited to 90 tabs per 30 days



Accu-Chek Each 1

Accu-Chek Kit 1

Accu-Chek Fastclix Lancet Drum Each 1

Accu-Chek Fastclix Lancing Dev Kit 1

Accu-Chek Guide Control Soln Each 1

Accu-Chek Rapid D 10mmx20cm Each 1

Accu-Chek Rapid D 70cm Each 1

Accu-Chek Rapid D 10 mmx50cm Infus.Set 1


Accu-Chek Rapid D 10mmx100cm Infus.Set 1

Accu-Chek Rapid D 6 mm x50cm Infus.Set 1



2021.1 (1/15/2021).







Accu-Chek Safe-T-Pro 23 gauge Each 1

Accu-Chek Safe-T-Pro Plus 23 gauge Each 1

Accu-Chek Smartview Each 1

Accu-Chek Softclix Each 1

Accu-Chek Softclix Kit 1

Accu-Chek Spirit Each 1

Accu-Chek Tender 13 mmx60cm Infus.Set 1


Accu-Chek Tender 13mmx110cm Infus.Set 1



Accu-Chek Tender 17mmx110cm Infus.Set 1

Accu-Chek Ultraflex 10 mmx60cm Infus.Set 1


Accu-Chek Ultraflex 10mmx110cm Infus.Set 1

Accu-Chek Ultraflex 8 mm x60cm Infus.Set 1

Accu-Chek Ultraflex 8 mm x80cm Infus.Set 1


Accutrend Glucose Each 1

Acebutolol Hcl 200 mg Capsule 1

Acebutolol Hcl 400 mg Capsule 1

Acerola C 500 mg Tab Chew 1

Acerola C 500 mg Wafer 1

Aceso Ag 4"" x 4"" Bandage 1

Acetadryl 500mg-25mg Tablet 1

Acetamin-Caff-Dihydrocodeine 325-30-16 Tablet 1

Acetaminophen 325 mg Capsule 1

Acetaminophen 500 mg Capsule 1

Acetaminophen 80mg/0.8ml Drops Susp 1

Acetaminophen 160 mg/5ml Elixir 1

Acetaminophen 160 mg/5ml Liquid 1

Acetaminophen 500mg/15ml Liquid 1

Acetaminophen 160 mg/5ml Oral Susp 1

Acetaminophen 325/10.15 Oral Susp 1

Acetaminophen 650mg/20.3 Oral Susp 1

Acetaminophen 160 mg/5ml Solution 1

Acetaminophen 325/10.15 Solution 1


2021.1 (1/15/2021).



Acetaminophen 650mg/20.3 Solution 1

Acetaminophen 160 mg Tab Chew 1

Acetaminophen 160 mg Tab Rapdis 1

Acetaminophen 80 mg Tab Rapdis 1

Acetaminophen 325 mg Tablet 1

Acetaminophen 500 mg Tablet 1

Acetaminophen 8 Hour 650 mg Tablet Er 1

Acetaminophen Er 650 mg Tablet Er 1

Acetaminophen Extra Strength 500 mg Tablet 1

Acetaminophen Pm 500mg-25mg Tablet 1

Acetaminophen Pm Xtra Strength 500mg-25mg Tablet 1

Acetaminophen-Codeine 120-12mg/5 Solution 1 QL Limited to 990ml per 30 days

Acetaminophen-Codeine 300mg/12.5 Solution 1 QL Limited to 390ml per 30 days

Acetaminophen-Codeine 300mg-15mg Tablet 1 QL Limited to 360 tabs per 30 days



Acetaminophen-Diphenhydramine 500mg-25mg Tablet 1

Acetazolamide 125 mg Tablet 1

Acetazolamide 250 mg Tablet 1

Acetazolamide Er 500 mg Capsule Er 1

Acetic Acid 2% Solution 1

Acetylcysteine 100 mg/ml Vial 1

Acetylcysteine 200 mg/ml Vial 1

Acid Controller 10 mg Tablet 1

Acid Reducer 20 mg Capsule Dr 1

Acid Reducer 10 mg Tablet 1

Aciphex Sprinkle 10 mg Cap Dr Spr 2 QL Limited to 30 caps per 30 days

Aciphex Sprinkle 5 mg Cap Dr Spr 2

Acthib 10 mcg/0.5 Vial 2

Acti-Lance 17 gauge Each 1



Actimmune 100mcg/0.5 Vial 4 SP, PA

Active Fe 75-1.25 mg Tablet 2

Acuvail 0.45% Droperette 2

Acyclovir 200 mg Capsule 1

Acyclovir 5% Oint. (G) 1

Acyclovir 200 mg/5ml Oral Susp 1

Acyclovir 400 mg Tablet 1

Acyclovir 800 mg Tablet 1

Adacel Tdap 2-2.5-5/.5 Syringe 2


2021.1 (1/15/2021).



Adacel Tdap 2-2.5-5/.5 Vial 2

Adapalene 0.10% Solution 2

Addaprin 200 mg Tablet 1

Added Strength Headache 250-250-65 Tablet 1

Adefovir Dipivoxil 10 mg Tablet 3 SP

Adjustable Lancing Device Each 1

Admelog 100/ml Vial 2 QL Limited to 60ml per 30 days

Admelog Solostar 100/ml Insuln Pen 2 QL Limited to 60ml per 30 days

Adrenalin Chloride 1 mg/ml Solution 2

Adult Aspirin Regimen 81 mg Tablet Dr 1

Adult Low Dose Aspirin Ec 81 mg Tablet Dr 1

Adult Tussin Cough Congest Dm 100-10mg/5 Liquid 1

Adult Tussin Dm 100-10mg/5 Syrup 1

Adult Wal-Tussin Dm 100-10mg/5 Syrup 1

Advair Hfa 115-21mcg Hfa Aer Ad 2 QL Limited to 1 inhaler per 30 days

Advair Hfa 230-21mcg Hfa Aer Ad 2 QL Limited to 1 inhaler per 30 days

Advair Hfa 45-21 mcg Hfa Aer Ad 2 QL Limited to 1 inhaler per 30 days

Advance Plus Intermittent 6 fr Combo. Pkg 1

Advance Plus Intermittent 8fr-14"" Combo. Pkg 1

Advanced Antacid 200-200-20 Oral Susp 1

Advanced Antacid-Antigas 200-200-20 Oral Susp 1

Advanced Antacid-Antigas 400-400-40 Oral Susp 1

Advanced Lancing Device Kit 1

Advanced Travel Lancets 28 gauge Each 1

Advanced Travel Lancets 30 gauge Each 1

Advate 3000 (+/-) Vial 4 SP, PA

Advocate Control Solution Each 1

Advocate Lancet 26 gauge Each 1

Advocate Lancet 30 gauge Each 1

Advocate Lancets 26 gauge Each 1

Advocate Pen Needles 29 g x1/2"" Dis Needle 1

Advocate Pen Needles 31 gx3/16"" Dis Needle 1

Advocate Pen Needles 31 gx5/16"" Dis Needle 1

Advocate Rapid-Safe Each 1

Advocate Redi-Code+ Ctrl Soln Each 1

Advocate Syringes 29 g x1/2"" Disp Syrin 1

Advocate Syringes 30 gx5/16"" Disp Syrin 1

Advocate Syringes 31 gx5/16"" Disp Syrin 1

Aemcolo 194 mg Tablet Dr 2

Aerobika Each 1

Afirmelle 0.1-0.02mg Tablet 1


2021.1 (1/15/2021).



Afluria Quad 2020-2021 60mcg/.5ml Vial 2

Afluria Quad 2020-21 (3yr Up) 60mcg/.5ml Syringe 2

Afluria Quad 2020-21 (6-35mo) 30mcg/0.25 Syringe 2

Afrezza 12 unit Cart Inhal 2


Afrezza 4 unit(90) Cart Inhal 2

Afrezza 4-8-12(60) Cart Inhal 2


Afrezza 8 unit(90) Cart Inhal 2

Aftera 1.5 mg Tablet 1

Agamatrix Control Each 1

Agamatrix Control Solution Each 1

Agamatrix Control Solution n/a Each 1

Ak-Poly-Bac 500-10k/g Oint. (G) 1

Akten 3.50% Gel (Ml) 2

Akynzeo 300-0.5 mg Capsule 2 ST Must try/fail ondansetron or Emend.

Ala-Cort 1% Cream (G) 1

Ala-Quin 3 %-0.5 % Cream (G) 2

Ala-Scalp 2% Lotion 1

Alavert 10 mg Tab Rapdis 1

Albendazole 200 mg Tablet 1

Albuterol Sulfate 5 mg/ml Solution 1

Albuterol Sulfate 2 mg/5 ml Syrup 1

Albuterol Sulfate 4 mg Tab Er 12h 1

Albuterol Sulfate 8 mg Tab Er 12h 1

Albuterol Sulfate 2 mg Tablet 1

Albuterol Sulfate 4 mg Tablet 1

Albuterol Sulfate 0.63mg/3ml Vial-Neb 1

Albuterol Sulfate 1.25mg/3ml Vial-Neb 1

Albuterol Sulfate 2.5 mg/0.5 Vial-Neb 1

Albuterol Sulfate 2.5 mg/3ml Vial-Neb 1

Albuterol Sulfate Hfa 90 mcg Hfa Aer Ad 1 QL Limited to 2 inhalers per 30 days

Alcaine 0.50% Drops 1

Alclometasone Dipropionate 0.05% Cream (G) 1

Alclometasone Dipropionate 0.05% Oint. (G) 1

Alcortin A 2 %-1 %-1% Gel Packet 2

Aldactazide 50 mg-50mg Tablet 2

Alecensa 150 mg Capsule 4 SP, PA, QL Limited to 240 caps per 30 days

Alendronate Sodium 70 mg/75ml Solution 1


2021.1 (1/15/2021).



Alendronate Sodium 10 mg Tablet 1




Aler-Caps 25 mg Capsule 1

Aleve 220 mg Tablet 1

Alfuzosin Hcl Er 10 mg Tab Er 24h 1

Algal Omega-3 Dha 200 mg Capsule 1

Alinia 100 mg/5ml Susp Recon 2

Alka-Seltzer Plus Allergy 25 mg Tablet 1

All Day Allergy 10 mg Tablet 1

All Day Pain Relief 220 mg Tablet 1

All Day Relief 220 mg Tablet 1

Aller-Chlor 4 mg Tablet 1

Allerclear 10 mg Tablet 1

Aller-G-Time 25 mg Tablet 1

Allergy 25 mg Capsule 1

Allergy 12.5mg/5ml Liquid 1

Allergy 25 mg Tablet 1

Allergy 4 mg Tablet 1

Allergy 4-Hour 4 mg Tablet 1

Allergy Medication 25 mg Capsule 1

Allergy Medication 25 mg Tablet 1

Allergy Medicine 25 mg Tablet 1

Allergy Relief 25 mg Capsule 1

Allergy Relief 12.5mg/5ml Liquid 1

Allergy Relief 5 mg/5 ml Solution 1

Allergy Relief 10 mg Tab Rapdis 1

Allergy Relief 10 mg Tablet 1



Allergy-Time 4 mg Tablet 1

Aller-Tec 10 mg Tablet 1

Allopurinol 100 mg Tablet 1

Allopurinol 300 mg Tablet 1

Almacone-2 400-400-40 Oral Susp 1

Alocril 2% Drops 2

Alogliptin 12.5 mg Tablet 1 QL, ST Limited to 30 tabs per 30 days Must try/fail metformin


2021.1 (1/15/2021).



Alogliptin 25 mg Tablet 1 QL, ST Limited to 30 tabs per 30 days Must try/fail metformin

Alogliptin 6.25 mg Tablet 1 QL, ST Limited to 30 tabs per 30 days Must try/fail metformin

Alogliptin-Metformin 12.5-1000 Tablet 1 QL, ST Limited to 30 tabs per 30 days Must try/fail metformin

Alogliptin-Metformin 12.5-500mg Tablet 1 QL, ST Limited to 30 tabs per 30 days Must try/fail metformin

Alomide 0.10% Drops 2

Alophen Pills 5 mg Tablet Dr 1

Alosetron Hcl 0.5 mg Tablet 1

Alosetron Hcl 1 mg Tablet 1

Alrex 0.20% Drops Susp 2

Altabax 1% Oint. (G) 2

Altachlore 5% Drops 1

Altachlore 5% Oint. (G) 1

Altafluor Benox 0.4%-0.25% Drops 1

Altamist 0.65% Spray 1

Altavera 0.15-0.03 Tablet 1

Alternate Site Lancets 26 gauge Each 1

Alternate Site Lancing Device Each 1

Altoprev 20 mg Tab Er 24h 2



Altreno 0.05% Lotion 2

Alum-Mag Hydroxide-Simethicone 200-200-20 Oral Susp 1

Alum-Mag Hydroxide-Simethicone 400-400-40 Oral Susp 1

Alunbrig 30 mg Tablet 4 SP, PA

Alvesco 160 mcg Hfa Aer Ad 2 QL Limited to 2 inhalers per 30 days

Alvesco 80 mcg Hfa Aer Ad 2 QL Limited to 4 inhalers per 30 days

Alyacen 1 mg-35mcg Tablet 1

Alyacen 7 days x 3 Tablet 1

Alyq 20 mg Tablet 1

Amabelz 0.5-0.1 mg Tablet 1

Amabelz 1 mg-0.5mg Tablet 1


2021.1 (1/15/2021).



Amantadine 100 mg Capsule 1

Amantadine 50 mg/5 ml Solution 1

Amantadine 100 mg Tablet 1

Ambrisentan 10 mg Tablet 3 SP

Ambrisentan 5 mg Tablet 3 SP

Amcinonide 0.10% Cream (G) 1

Amcinonide 0.10% Lotion 1

Amethia 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Amethia Lo 100-20(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Amethyst 90-20 mcg Tablet 1

Amiloride Hcl 5 mg Tablet 1

Amiloride-Hydrochlorothiazide 5 mg-50 mg Tablet 1

Aminocaproic Acid 250 mg/ml Solution 1

Amiodarone Hcl 100 mg Tablet 1



Amitiza 24mcg Capsule 2

Amitiza 8 mcg Capsule 2

Amlodipine Besylate 10 mg Tablet 1

Amlodipine Besylate 2.5 mg Tablet 1

Amlodipine Besylate 5 mg Tablet 1

Amlodipine Besylate-Benazepril 10 mg-20mg Capsule 1

Amlodipine Besylate-Benazepril 10 mg-40mg Capsule 1

Amlodipine Besylate-Benazepril 2.5mg-10mg Capsule 1

Amlodipine Besylate-Benazepril 5 mg-10 mg Capsule 1



Amlodipine-Olmesartan 10 mg-20mg Tablet 1

Amlodipine-Olmesartan 10 mg-40mg Tablet 1

Amlodipine-Olmesartan 5 mg-20 mg Tablet 1

Amlodipine-Olmesartan 5 mg-40 mg Tablet 1

Amlodipine-Valsartan 10mg-160mg Tablet 1

Amlodipine-Valsartan 10mg-320mg Tablet 1

Amlodipine-Valsartan 5 mg-160mg Tablet 1

Amlodipine-Valsartan 5 mg-320mg Tablet 1

Amlodipine-Valsartan-Hctz 10-160-25 Tablet 1

Amlodipine-Valsartan-Hctz 10-320-25 Tablet 1

Amlodipine-Valsartan-Hctz 10mg-160mg Tablet 1

Amlodipine-Valsartan-Hctz 5-160-12.5 Tablet 1

Amlodipine-Valsartan-Hctz 5-160-25mg Tablet 1

Ammonium Lactate 12% Cream (G) 1


2021.1 (1/15/2021).



Amnesteem 10 mg Capsule 1 QL Limited to 60 caps per 30 days

Amnesteem 20 mg Capsule 1 QL Limited to 60 caps per 30 days

Amoxicillin 250 mg Capsule 1

Amoxicillin 500 mg Capsule 1

Amoxicillin 125 mg/5ml Susp Recon 1




Amoxicillin 125 mg Tab Chew 1

Amoxicillin 250 mg Tab Chew 1

Amoxicillin 500 mg Tablet 1

Amoxicillin 875 mg Tablet 1

Amoxicillin-Clavulanate Pot Er 1000-62.5 Tab Er 12h 1

Amoxicillin-Clavulanate Potass 200-28.5/5 Susp Recon 1


Amoxicillin-Clavulanate Potass 400-57mg/5 Susp Recon 1


Amoxicillin-Clavulanate Potass 200-28.5mg Tab Chew 1

Amoxicillin-Clavulanate Potass 400-57mg Tab Chew 1

Amoxicillin-Clavulanate Potass 250-125 mg Tablet 1



Amphetamine 1.25 mg/ml Sus Bp 24h 1 QL Limited to 300ml per 30 days

Ampicillin Trihydrate 250 mg Capsule 1

Ampicillin Trihydrate 500 mg Capsule 1

Amyl Nitrite 0.3 ml Ampul 1

Anacaine 10% Oint. (G) 2

Anadrol-50 50 mg Tablet 2 PA

Anagrelide Hcl 0.5 mg Capsule 1

Anagrelide Hcl 1 mg Capsule 1

Analpram Hc 2.5 %-1 % Lotion 2

Anastrozole 1 mg Tablet 1

Androderm 2 mg/24 hr Patch Td24 2 QL Limited to 60 patches per 30 days

Androderm 4 mg/24 hr Patch Td24 2 QL Limited to 30 patches per 30 days

Angeliq 0.25-0.5mg Tablet 2

Angeliq 0.5 mg-1mg Tablet 2

Animi-3 500-1000-1 Capsule 2

Anodyne Lpt 2.5 %-2.5% Kit 1

Antacid 200-200-20 Oral Susp 1


2021.1 (1/15/2021).



Antacid 400-400-40 Oral Susp 1

Antacid 200(500)mg Tab Chew 1

Antacid 215(500)mg Tab Chew 1

Antacid 300mg(750) Tab Chew 1

Antacid 320mg(750) Tab Chew 1

Antacid Calcium 215(500)mg Tab Chew 1

Antacid Extra Strength 300mg(750) Tab Chew 1

Antacid M 200-200-20 Oral Susp 1

Antacid Maximum Strength 400-400-40 Oral Susp 1

Antacid Plus Anti-Gas 200-200-20 Oral Susp 1

Antacid Plus Anti-Gas 400-400-40 Oral Susp 1

Antacid Plus Gas Relief 200-200-20 Oral Susp 1

Antacid Ultra Strength 400(1000) Tab Chew 1

Antacid With Simethicone 400-400-40 Oral Susp 1

Antacid-Antigas 200-200-20 Oral Susp 1

Antacid-Antigas 400-400-40 Oral Susp 1

Antacid-Gas Relief 400-400-40 Oral Susp 1

Antara 30 mg Capsule 2

Antara 90 mg Capsule 2

Antibiotic 3.5-400-5k Oint. (G) 1

Antibiotic 500 unit/g Oint. (G) 1

Anticoagulant Sodium Citrate 4 g/100 ml Solution 1

Anticoagulant Sodium Citrate 4 % (5 ml) Syringe 1

Anti-Diarrheal 262mg/15ml Oral Susp 1

Antifungal Cream 1% Cream (G) 1

Antifungal Cream 2% Cream (G) 1

Anti-Fungal Cream 2% Cream (G) 1

Anti-Itch 1% Cream (G) 1

Antitussive Dm 100-10mg/5 Syrup 1

Apexicon E 0.05% Cream (G) 2

Apligraf Disk 2

Apokyn 10 mg/ml Cartridge 4 SP, PA

Aprepitant 125 mg Capsule 1

Aprepitant 40 mg Capsule 1

Apri 0.15-0.03 Tablet 1

Aptensio Xr 10 mg Csbp 40-60 2 QL Limited to 60 caps per 30 days







2021.1 (1/15/2021).




Aptiom 200 mg Tablet 2 QL Limited to 30 tabs per 30 days




Aptivus 250 mg Capsule 2

Aptivus 100 mg/ml Solution 2

Aqua Glycolic Hc 2% Combo. Pkg 2

Aqua Lance Lancing Device Each 1

Aquoral Spray/Pump 2

Aranelle 7/9/2005 Tablet 1

Aranesp 100mcg/0.5 Syringe 4 SP, PA






Aranesp 40 mcg/0.4 Syringe 4 SP, PA

Aranesp 500 mcg/ml Syringe 4 SP, PA

Aranesp 60 mcg/0.3 Syringe 4 SP, PA

Aranesp 100 mcg/ml Vial 4 SP, PA

Aranesp 150mcg/.75 Vial 4 SP, PA






Arcapta Neohaler 75 mcg Cap W/Dev 2

Argyle Each 1

Armonair Respiclick 232 mcg Aer Pow Ba 2

Armonair Respiclick 55 mcg Aer Pow Ba 2

Arnuity Ellipta 100 mcg Blst W/Dev 2 QL Limited to 1 device per 30 days



Arthritis Pain 650 mg Tablet Er 1

Arthritis Pain Relief 650 mg Tablet Er 1

Arthritis Pain Reliever 650 mg Tablet Er 1

Artificial Tears Drops 1

Artificial Tears 0.1%-0.3% Drops 1

Artificial Tears 0.3%-1% Drops 1

Artificial Tears 0.5%-0.6% Drops 1


2021.1 (1/15/2021).



Artificial Tears 1.40% Drops 1

Artiss 10 ml Syringe 2



Asa-Butalb-Caffeine-Codeine 30-50-325 Capsule 1

Ascomp With Codeine 30-50-325 Capsule 1

Ascorbic Acid 500 mg Tablet 1

Ashlyna 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Asmanex 220mcg 120 Aer Pow Ba 2

Asmanex 220mcg(60) Aer Pow Ba 2

Asmanex Hfa 100 mcg Hfa Aer Ad 2 QL Limited to 1 inhaler per 30 days

Asmanex Hfa 200 mcg Hfa Aer Ad 2 QL Limited to 1 inhaler per 30 days

Aspirin 81 mg Tab Chew 1

Aspirin 325 mg Tablet 1

Aspirin 500 mg Tablet 1

Aspirin Ec 325 mg Tablet Dr 1




Aspirin-Omeprazole 325mg-40mg Tab Ir Dr 1

Aspirin-Omeprazole 81 mg-40mg Tab Ir Dr 1

Aspir-Trin 325 mg Tablet Dr 1

Assure 4 Combo. Pkg 1

Assure Dose Each 1

Assure Haemolance Plus 1.2 mm Each 1

Assure Haemolance Plus 18 gauge Each 1




Assure Id Insulin Safety 29 g x1/2"" Disp Syrin 1

Assure Lance 25 gauge Each 1

Assure Lance 28 gauge Each 1

Assure Lance Plus 21 gauge Each 1



Assure Prism Each 1

Astagraf Xl 0.5 mg Cap Er 24h 2

Astagraf Xl 1 mg Cap Er 24h 2

Astagraf Xl 5 mg Cap Er 24h 2

Astero 4% Gel W/Pump 2

Astringyn 259 mg/g Soln(Gram) 2


2021.1 (1/15/2021).



Atabex Dha 200 200 mg Capsule 1

Atazanavir Sulfate 150 mg Capsule 1



Atenolol 100 mg Tablet 1



Atenolol-Chlorthalidone 100mg-25mg Tablet 1

Atenolol-Chlorthalidone 50 mg-25mg Tablet 1

Athenol 325 mg Tablet 1

Athlete's Foot 1% Cream (G) 1

Atopaderm Cream (G) 2

Atorvastatin Calcium 10 mg Tablet 1




Atovaquone 750 mg/5ml Oral Susp 1

Atovaquone-Proguanil Hcl 250-100 mg Tablet 1

Atovaquone-Proguanil Hcl 62.5-25 mg Tablet 1

Atrapro Dermal Spray 0.00% Spray 2

Atrapro Hydrogel Gel (Gram) 2

Atropine Sulfate 1% Drops 1

Atropine Sulfate 1% Oint. (G) 1

Atrovent Hfa 17mcg Hfa Aer Ad 2

Aubra 0.1-0.02mg Tablet 1

Aubra Eq 0.1-0.02mg Tablet 1

Augmentin 125-31.25/ Susp Recon 2

Aurovela 1.5-0.03mg Tablet 1

Aurovela 1mg-20mcg Tablet 1

Aurovela 24 Fe 1mg-20(24) Tablet 1

Aurovela Fe 1.5-30(21) Tablet 1

Aurovela Fe 1mg-20(21) Tablet 1

Austedo 12 mg Tablet 4 SP, PA, QL Limited to 120 tabs per 30 days



Autoject 2 Insuln Pen 1

Auto-Lancet Mini Each 1

Autolet Impression Kit 1

Autolet Lancing Device Each 1

Autolet Plus Each 1

Autopen Insuln Pen 1


2021.1 (1/15/2021).



Autoshield Duo Pen Needle 30 gx3/16"" Dis Needle 1

Auvi-Q 0.15/0.15 Auto Injct 2 QL Limited to 2 pens per 30 days

Avandia 2 mg Tablet 2

Avandia 4 mg Tablet 2

Aviane 0.1-0.02mg Tablet 1

Avidoxy Dk 100mg-2-30 Kit 2

Avitene Powd Pack 2

Avitene Powder 2

Avitene 35mmx35mm Sheet 2



Avo Cream Emulsn(G) 1

Avonex 30mcg/.5ml Syringekit 4 SP, QL Limited to 1 kit per 28 days

Avonex Pen 30mcg/.5ml Pen Ij Kit 4 SP, QL Limited to 2 syringes per 28 days

Ayr Saline 0.65% Spray 1

Ayuna 0.15-0.03 Tablet 1

Azasan 100 mg Tablet 2

Azasan 75 mg Tablet 2

Azasite 1% Drops 2

Azathioprine 50 mg Tablet 1

Azelastine Hcl 0.05% Drops 1

Azelex 20% Cream (G) 2

Azithromycin 1 g Packet 1

Azithromycin 100 mg/5ml Susp Recon 1

Azithromycin 200 mg/5ml Susp Recon 1

Azithromycin 250 mg Tablet 1



Azurette 21-5 (28) Tablet 1

B-12 500 mcg Tablet 1

B-12 Dots 500 mcg Tablet 1

Bacitracin 500 unit/g Oint. (G) 1

Bacitracin Zinc 500 unit/g Oint. (G) 1

Bacitracin-Polymyxin 500-10k/g Oint. (G) 1

Bacitraycin Plus 500 unit/g Oint. (G) 1

Baclofen 10 mg Tablet 1



Bal-Care Dha Essential 27-1-374mg Cmbpkgdrcp 1

Balcoltra 0.1-0.02mg Tablet 2


2021.1 (1/15/2021).



Balsalazide Disodium 750 mg Capsule 1

Balsam Peru-Castor Oil Oint. (G) 1

Balziva 0.4-0.035 Tablet 1

Ban-Acid 300mg(750) Tab Chew 1

Banophen 25 mg Capsule 1

Banophen 50 mg Capsule 1

Banophen 25 mg Tablet 1

Banzel 400 mg Tablet 2

Baqsimi 3 mg Spray 2

Baraclude 0.05 mg/ml Solution 4 SP

Basaglar Kwikpen U-100 100/ml (3) Insuln Pen 1 QL Limited to 60ml per 30 days

Baxdela 450 mg Tablet 2 QL Limited to 28 tabs per 14 days

Bayer Migraine 250-250-65 Tablet 1

Baza Antifungal 2% Cream (G) 1

Bcg Vaccine (Tice Strain) 50 mg Vial 2

Bd Microtainer Lancets 21 gauge Each 1

Bd Microtainer Lancets 30 gauge Each 1

Bd Ultra-Fine 33 gauge Each 1

Bd Ultra-Fine Ii 30 gauge Each 1

Beconase Aq 42 mcg Spray 2 QL Limited to 1 inhaler per 15 days

Bekyree 21-5 (28) Tablet 1

Belbuca 750 mcg Film 2

Belladonna-Opium 30-16.2 mg Supp.Rect 1

Belladonna-Opium 60-16.2 mg Supp.Rect 1

Belladonna-Phenobarbital 16.2 mg Tablet 1

Benadryl Allergy 25 mg Tablet 1

Benazepril Hcl 10 mg Tablet 1




Benazepril-Hydrochlorothiazide 10-12.5mg Tablet 1

Benazepril-Hydrochlorothiazide 20 mg-25mg Tablet 1

Benazepril-Hydrochlorothiazide 20-12.5 mg Tablet 1

Benazepril-Hydrochlorothiazide 5-6.25mg Tablet 1

Bensal Hp 3% Oint. (G) 2

Benzepro 7% Cleanser 1

Benzhydrocodone-Acetaminophen 4.08-325mg Tablet 1 QL Limited to 360 tabs per 30 days



Benznidazole 100 mg Tablet 1 QL Limited to 360 tabs per 365 days


2021.1 (1/15/2021).



Benznidazole 12.5 mg Tablet 1 QL Limited to 360 tabs per 365 days

Benzodox 30 100mg-4.4% Kit Cl-Tab 2

Benzodox 60 100mg-4.4% Kit Cl-Tab 2

Benzonatate 100 mg Capsule 1



Benzoyl Peroxide 7% Cleanser 1

Benzoyl Peroxide 9.80% Foam 1

Benztropine Mesylate 0.5 mg Tablet 1

Benztropine Mesylate 1 mg Tablet 1

Benztropine Mesylate 2 mg Tablet 1

Bepreve 1.50% Drops 2

Betadine 5% Solution 2

Betamethasone Diprop Augmented 0.05% Cream (G) 1

Betamethasone Diprop Augmented 0.05% Gel (Gram) 1

Betamethasone Diprop Augmented 0.05% Lotion 1

Betamethasone Diprop Augmented 0.05% Oint. (G) 1

Betamethasone Dipropionate 0.05% Cream (G) 1

Betamethasone Dipropionate 0.05% Lotion 1

Betamethasone Dipropionate 0.05% Oint. (G) 1

Betamethasone Valerate 0.10% Cream (G) 1

Betamethasone Valerate 0.10% Lotion 1

Betamethasone Valerate 0.10% Oint. (G) 1

Betasept 4% Liquid 1

Betatemp 160 mg/5ml Oral Susp 1

Betaxolol Hcl 0.50% Drops 1

Betaxolol Hcl 10 mg Tablet 1

Betaxolol Hcl 20 mg Tablet 1

Bethanechol Chloride 10 mg Tablet 1




Bevyxxa 40 mg Capsule 2

Bevyxxa 80 mg Capsule 2

Bexsero 50-50/0.5 Syringe 2

Bicalutamide 50 mg Tablet 1

Bidil 20-37.5mg Tablet 2

Bijuva 1 mg-100mg Capsule 2

Biktarvy 50-200-25 Tablet 2

Bimatoprost 0.03% Drops 1 ST Must try/fail latanoprost drops


2021.1 (1/15/2021).



Binaxnow Covid-19 Ag Card N/A Kit 2

Binosto 70 mg Tablet Eff 2 QL Limited to 4 tabs per 28 days

Biocotron 100-10mg/5 Liquid 1

Bionect 0.20% Cream (G) 2

Bionect 0.20% Gel (Gram) 2

Biothrax 0.5ml/dose Vial 2

Bisacodyl 10 mg Supp.Rect 1

Bisacodyl 5 mg Tablet Dr 1

Bisa-Lax 5 mg Tablet Dr 1

Bismatrol 262mg/15ml Oral Susp 1

Bismatrol 262 mg Tab Chew 1

Bismuth 262 mg Tab Chew 1

Bisoprolol Fumarate 10 mg Tablet 1

Bisoprolol Fumarate 5 mg Tablet 1

Bisoprolol-Hydrochlorothiazide 10-6.25mg Tablet 1

Bisoprolol-Hydrochlorothiazide 2.5-6.25mg Tablet 1

Bisoprolol-Hydrochlorothiazide 5-6.25mg Tablet 1

Bleph-10 10% Drops 1

Blephamide 10 %-0.2 % Drops Susp 2

Blephamide S.O.P. 10 %-0.2 % Oint. (G) 2

Blisovi 24 Fe 1mg-20(24) Tablet 1

Blisovi Fe 1.5-30(21) Tablet 1

Blisovi Fe 1mg-20(21) Tablet 1

Blood Glucose Control Each 1

Blood Lancets 30 gauge Each 1

Blood-Glucose Control Each 1

Bocasal 538 mg Powd Pack 2

Boostrix Tdap 2.5-8-5/.5 Syringe 2

Boostrix Tdap 2.5-8-5/.5 Vial 2

Bosentan 125 mg Tablet 3 SP, PA

Bosentan 62.5 mg Tablet 3 SP, PA

Bosulif 100 mg Tablet 4 SP, PA, QL Limited to 120 tabs per 30 days

Bosulif 500 mg Tablet 4 SP, PA, QL Limited to 30 tabs per 30 days

Boys Training Pants Each 1

Bp 10-1 10 %-1 % Cleanser 1

Bpo 8% Gel (Gram) 1

Breeze 2 Each 1

Breztri Aerosphere 160-9-4.8 Hfa Aer Ad 2 QL Limited to 1 device per 30 days

Briellyn 0.4-0.035 Tablet 1

Brilinta 60 mg Tablet 2

Brimonidine Tartrate 0.15% Drops 1


2021.1 (1/15/2021).



Brimonidine Tartrate 0.20% Drops 1

Bromocriptine Mesylate 5 mg Capsule 1

Bromocriptine Mesylate 2.5 mg Tablet 1

Bromsite 0.08% Drops 2

Bryhali 0.01% Lotion 2

Budesonide 0.25mg/2ml Ampul-Neb 1

Budesonide 0.5 mg/2ml Ampul-Neb 1

Budesonide 1 mg/2 ml Ampul-Neb 1

Budesonide Ec 3 mg Capdr - Er 1

Budesonide Er 9 mg Tabdr - Er 1

Budesonide-Formoterol Fumarate 160-4.5mcg Hfa Aer Ad 1 QL, ST

Limited to 1 inhaler per 30 days Must try/fail at least 1 of the following: FLUTICASONE-SALMETEROL, WIXELA INHUB, OR ADVAIR HFA

Budesonide-Formoterol Fumarate 80-4.5 mcg Hfa Aer Ad 1 QL, ST

Limited to 1 inhaler per 30 days Must try/fail at least 1 of the following: FLUTICASONE-SALMETEROL, WIXELA INHUB, OR ADVAIR HFA

Buffered Aspirin 325 mg Tablet 1

Bufferin 325 mg Tablet 1

Bullseye Mini Safety Lancets 21 gauge Each 1



Bumetanide 0.5 mg Tablet 1

Bumetanide 1 mg Tablet 1

Bumetanide 2 mg Tablet 1

Bunavail 2.1-0.3 mg Film 2

Bunavail 4.2-0.7 mg Film 2

Bunavail 6.3mg-1mg Film 2

Buprenorphine 15 mcg/hr Patch Tdwk 1

Buprenorphine 7.5 mcg/hr Patch Tdwk 1

Buprenorphine Hcl 2 mg Tab Subl 1

Buprenorphine Hcl 8 mg Tab Subl 1

Buprenorphine-Naloxone 12 mg-3 mg Film 1

Buprenorphine-Naloxone 2 mg-0.5mg Film 1

Buprenorphine-Naloxone 4mg-1mg Film 1

Buprenorphine-Naloxone 8 mg-2 mg Film 1

Buprenorphine-Naloxone 2 mg-0.5mg Tab Subl 1

Buprenorphine-Naloxone 8 mg-2 mg Tab Subl 1


2021.1 (1/15/2021).



Bupropion Hcl Sr 150 mg Tab Er 12h 1

Butalb-Acetaminoph-Caff-Codein 50-300-30 Capsule 1 QL Limited to 180 caps per 30 days

Butalb-Caff-Acetaminoph-Codein 50-325-30 Capsule 1 QL Limited to 180 caps per 30 days

Butalbital Compound-Codeine 30-50-325 Capsule 1

Butalbital-Acetaminophen 50mg-325mg Tablet 1

Butalbital-Acetaminophen-Caffe 50-300-40 Capsule 1 QL Limited to 180 caps per 30 days

Butalbital-Acetaminophen-Caffe 50-325-40 Capsule 1

Butalbital-Acetaminophen-Caffe 50-325-40 Tablet 1

Butalbital-Aspirin-Caffeine 50-325-40 Capsule 1

Butalbital-Aspirin-Caffeine 50-325-40 Tablet 1

Butorphanol Tartrate 10 mg/ml Spray 1 QL Limited to 1 package per 15 days

Bystolic 10 mg Tablet 2 QL Limited to 30 tabs per 30 days

Bystolic 2.5 mg Tablet 2 QL Limited to 30 tabs per 30 days



C-500 500 mg Tab Chew 1

C-500 500 mg Tablet 1

Cabergoline 0.5 mg Tablet 1 QL Limited to 16 tabs per 30 days

Cadeau Dha 29-1-150mg Capsule 2

Caffeine Citrate 60 mg/3 ml Solution 1

Calcipotriene 0.01% Cream (G) 1

Calcipotriene 0.01% Oint. (G) 1

Calcipotriene 0.01% Solution 1

Calcitonin-Salmon 200/spray Spray/Pump 1

Calcitriol 0.25 mcg Capsule 1

Calcitriol 0.5 mcg Capsule 1

Calcitriol 1 mcg/ml Solution 1

Calcium 600 mg Tablet 1

Calcium 600-Vit D3 600 mg-200 Tablet 1



Calcium Acetate 667 mg Capsule 1

Calcium Acetate 667 mg Tablet 1

Calcium Antacid 200(500)mg Tab Chew 1

Calcium Antacid 215(500)mg Tab Chew 1

Calcium Antacid 300mg(750) Tab Chew 1

Calcium Antacid 320mg(750) Tab Chew 1

Calcium Antacid 400(1000) Tab Chew 1

Calcium Carbonate 200(500)mg Tab Chew 1

Calcium Carbonate 300mg(750) Tab Chew 1


2021.1 (1/15/2021).



Calcium Carbonate 400(1000) Tab Chew 1

Calcium Citrate 200(950)mg Tablet 1

Calcium Citrate - Vitamin D 315 mg-250 Tablet 1

Calcium Citrate - Vitamin D 315mg-5mcg Tablet 1

Calcium Citrate - Vitamin D3 315 mg-250 Tablet 1

Calcium Citrate-D 315 mg-250 Tablet 1

Calcium Citrate-Vit D 315 mg-250 Tablet 1

Calcium Citrate-Vit D3 315 mg-250 Tablet 1

Calcium Citrate-Vitamin D3 315 mg-250 Tablet 1

Calcium Citrate-Vitamin D3 315mg-5mcg Tablet 1

Calcium Polycarbophil 625 mg Tablet 1

Calcium-Folic Acid Plus D 500-300-1 Wafer 1

Cal-Gest 200(500)mg Tab Chew 1

Calquence 100 mg Capsule 4 SP, PA, QL Limited to 60 caps per 30 days

Cambia 50 mg Powd Pack 2

Camila 0.35 mg Tablet 1

Camrese 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Camrese Lo 100-20(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Candesartan Cilexetil 16 mg Tablet 1 ST

Must try/fail at least two of the following generics: irbesartan, irbesartan/HCTZ, losartan potassium, or losartan/HCTZ







Candesartan-Hydrochlorothiazid 16-12.5mg Tablet 1 ST


Candesartan-Hydrochlorothiazid 32-12.5mg Tablet 1 ST


Candesartan-Hydrochlorothiazid 32mg-25mg Tablet 1 ST



2021.1 (1/15/2021).



Capecitabine 150 mg Tablet 3 SP, PA

Capecitabine 500 mg Tablet 3 SP, PA

Capex Shampoo 0.01% Shampoo 2

Caphosol Solution 2

Capsaicin 0.03% Cream (G) 1

Capsinac 1.5-0.025% Cmb Sol Cr 2

Captopril-Hydrochlorothiazide 25 mg-15mg Tablet 1




Carbamazepine 100 mg/5ml Oral Susp 1

Carbamazepine 100 mg Tab Chew 1

Carbamazepine 200 mg Tablet 1

Carbamazepine Er 100 mg Cpmp 12hr 1



Carbamazepine Er 100 mg Tab Er 12h 1



Carbamoxide 6.50% Drops 1

Carbidopa 25 mg Tablet 1

Carbidopa-Levodopa 10mg-100mg Tab Rapdis 1



Carbidopa-Levodopa 10mg-100mg Tablet 1



Carbidopa-Levodopa Er 25mg-100mg Tablet Er 1

Carbidopa-Levodopa Er 50mg-200mg Tablet Er 1

Carbinoxamine Maleate 4 mg/5 ml Liquid 1

Carbinoxamine Maleate 4 mg Tablet 1

Cardiovid Plus 1000-600mg Capsule 1

Cardizem La 120 mg Tab Er 24h 2

Cardura Xl 4 mg Tab Er 24 2

Cardura Xl 8 mg Tab Er 24 2

Careone Each 1

Caresens Each 1

Caresens 30 gauge Each 1

Caretouch Safety Lancets 26 gauge Each 1

Caretouch Safety Lancets 28 gauge Each 1

Caretouch Twist Lancet 28 gauge Each 1


2021.1 (1/15/2021).





Carisoprodol Compound 200-325 mg Tablet 1

Carisoprodol-Aspirin 200-325 mg Tablet 1

Carisoprodol-Aspirin-Codeine 200-325-16 Tablet 1

Carnitor Sf 100 mg/ml Solution 2

Carrasyn Hydrogel Wound Gel (Gram) 1

Carteolol Hcl 1% Drops 1

Cartia Xt 120 mg Cap Er 24h 1




Carvedilol 12.5 mg Tablet 1

Carvedilol 25 mg Tablet 1



Caya Contoured 65 mm-80mm Diaphragm 1

Caziant 7 days x 3 Tablet 1

C-Clarifying Serum 4 %-10 % Liquid 2

Cefaclor 250 mg Capsule 1

Cefaclor 500 mg Capsule 1

Cefaclor 125 mg/5ml Susp Recon 1



Cefaclor Er 500 mg Tab Er 12h 1

Cefadroxil 500 mg Capsule 1

Cefadroxil 250 mg/5ml Susp Recon 1

Cefadroxil 500 mg/5ml Susp Recon 1

Cefadroxil 1 g Tablet 1

Cefaly Combo. Pkg 1

Cefdinir 300 mg Capsule 1

Cefdinir 125 mg/5ml Susp Recon 1

Cefdinir 250 mg/5ml Susp Recon 1

Cefditoren Pivoxil 200 mg Tablet 1

Cefditoren Pivoxil 400 mg Tablet 1

Cefixime 400 mg Capsule 1

Cefixime 100 mg/5ml Susp Recon 1

Cefixime 200 mg/5ml Susp Recon 1

Cefpodoxime Proxetil 100 mg/5ml Susp Recon 1

Cefpodoxime Proxetil 50 mg/5 ml Susp Recon 1

Cefpodoxime Proxetil 100 mg Tablet 1


2021.1 (1/15/2021).



Cefpodoxime Proxetil 200 mg Tablet 1

Cefprozil 125 mg/5ml Susp Recon 1

Cefprozil 250 mg/5ml Susp Recon 1

Cefprozil 250 mg Tablet 1

Cefprozil 500 mg Tablet 1

Cefuroxime 250 mg Tablet 1

Cefuroxime 500 mg Tablet 1

Celacyn Gel W/Pump 2

Celecoxib 100 mg Capsule 1 QL Limited to 60 caps per 30 days


Celecoxib 400 mg Capsule 1 QL, ST

Limited to 60 caps per 30 days Must try/fail CELECOXIB 50mg, 100mg or 200mg


Cellpad 2""x5.5"" Pad 1

Celontin 300 mg Capsule 2

Centamin 9 mg/15 ml Liquid 1

Centany At 2% Kit 2

Centratex 106 mg-1mg Capsule 2

Centravites 50 Plus Tablet 1

Cephalexin 250 mg Capsule 1



Cephalexin 125 mg/5ml Susp Recon 1

Cephalexin 250 mg/5ml Susp Recon 1

Cephalexin 250 mg Tablet 1

Cephalexin 500 mg Tablet 1

Cerovite Advanced Formula 18mg-0.4mg Tablet 1

Cerovite Senior Tablet 1

Cervidil 10 mg Insert Er 2

Cesamet 1 mg Capsule 2 QL Limited to 30 caps per 30 days

Cetacaine 2%-14%-2% Spray 2

Cetacaine Anesthetic 2%-14%-2% Liquid 2

Cetirizine Hcl 1 mg/ml Solution 1

Cetirizine Hcl 10 mg Tablet 1

Cevimeline Hcl 30 mg Capsule 1

Chantix 0.5 (11)-1 Tab Ds Pk 2

Chantix 0.5 mg Tablet 2

Chantix 1 mg Tablet 2

Charlotte 24 Fe 1mg-20(24) Tab Chew 1


2021.1 (1/15/2021).



Chateal 0.15-0.03 Tablet 1

Chateal Eq 0.15-0.03 Tablet 1

Chemet 100 mg Capsule 2

Child Fever Reducer-Pain Relvr 160 mg/5ml Oral Susp 1

Children's Acetaminophen 160 mg/5ml Liquid 1

Children's Acetaminophen 160 mg/5ml Oral Susp 1

Children's Acetaminophen 80 mg Tab Chew 1

Children's Allergy 12.5mg/5ml Liquid 1

Children's Allergy 5 mg/5 ml Solution 1

Children's Allergy Relief 12.5mg/5ml Liquid 1

Children's Allergy Relief 5 mg/5 ml Solution 1

Children's Allergy Relief 12.5 mg Tab Chew 1

Children's Allergy Relief 12.5 mg Tab Rapdis 1

Children's Aspirin 81 mg Tab Chew 1

Children's Aurodryl Allergy 12.5mg/5ml Liquid 1

Children's Aurophen Pain-Fever 160 mg/5ml Oral Susp 1

Children's Diphenhydramine 12.5mg/5ml Liquid 1

Children's Ferrous Sulfate 15 mg/ml Drops 1

Children's Ibuprofen 100 mg/5ml Oral Susp 1

Children's Iron 15 mg/ml Drops 1

Children's Loratadine 5 mg/5 ml Solution 1

Children's Mapap 80 mg Tab Chew 1

Children's Non-Aspirin 100 mg/ml Drops 1

Children's Non-Aspirin 160 mg/5ml Oral Susp 1

Children's Pain Relief 160 mg/5ml Oral Susp 1

Children's Pain Reliever 160 mg/5ml Oral Susp 1

Children's Pain-Fever 160 mg/5ml Oral Susp 1

Children's Profen Ib 100 mg/5ml Oral Susp 1

Children's Profenib 100 mg/5ml Oral Susp 1

Children's Saline Nasal Spray 0.65% Spray 1

Children's Silapap 160 mg/5ml Liquid 1

Children's Tactinal 80 mg Tab Chew 1

Children's Wal-Dryl Allergy 12.5mg/5ml Liquid 1

Children's Wal-Dryl Allergy 12.5 mg Tab Rapdis 1

Chlordiazepoxide-Clidinium 5 mg-2.5mg Capsule 1

Chlorhexidine Gluconate 0.12% Mouthwash 1

Chlorhist 4 mg Tablet 1

Chloroquine Phosphate 250 mg Tablet 1

Chloroquine Phosphate 500 mg Tablet 1

Chlorothiazide 500 mg Tablet 1

Chlorpheniramine Maleate 4 mg Tablet 1


2021.1 (1/15/2021).



Chlortabs 4 mg Tablet 1

Chlorthalidone 25 mg Tablet 1

Chlorthalidone 50 mg Tablet 1

Chlorzoxazone 500 mg Tablet 1

Choicedm Clarus Control Soln Each 1

Cholbam 250 mg Capsule 4 SP, PA

Cholbam 50 mg Capsule 4 SP, PA

Cholestyramine 4 g Powd Pack 1

Cholestyramine 4 g Powder 1

Cholestyramine Light 4 g Powd Pack 1

Cholestyramine Light 4 g Powder 1

Cicasil 2""x5.5"" Pad 1

Cicatrace Pad 4.7"" x5.7"" Pad 1

Ciclodan 0.77% Combo. Pkg 2

Ciclopirox 0.77% Cream (G) 1

Ciclopirox 0.77% Gel (Gram) 1

Ciclopirox 1% Shampoo 1

Ciclopirox 0.77% Suspension 1

Ciferex 3775 unit Capsule 2

Cifrazol 3775 unit Capsule 2

Cilostazol 100 mg Tablet 1

Cilostazol 50 mg Tablet 1

Ciloxan 0.30% Oint. (G) 2

Cimduo 300-300 mg Tablet 2 QL Limited to 30 tabs per 30 days

Cimetidine 300 mg/5ml Solution 1

Cimetidine 200 mg Tablet 1




Cimzia 400 mg Kit 4 SP, PA, QL Limited to 1 kit per 28 days

Cipro Hc 0.2 %-1 % Drops Susp 2

Ciprofloxacin 250 mg/5ml Sus Mc Rec 1

Ciprofloxacin 500 mg/5ml Sus Mc Rec 1

Ciprofloxacin Hcl 0.20% Droperette 1

Ciprofloxacin Hcl 0.30% Drops 1

Ciprofloxacin Hcl 100 mg Tablet 1




Ciprofloxacin Hcl-Fluocinolone 0.3-0.025% Vial 1 QL Limited to 1 package per 7 days

Citracal + D Maximum 315 mg-250 Tablet 1


2021.1 (1/15/2021).



Citranatal 90 Dha 90-1-300mg Combo. Pkg 2

Citranatal Assure 35-1-50 mg Combo. Pkg 2

Citranatal Dha 27-1-50 mg Combo. Pkg 2

Citranatal Rx 27-1-50 mg Tablet 2

Citrate Of Magnesia Solution 1

Citrate Phosphate Dextrose 2.63 g/100 Solution 1

Citroma Solution 1

Claravis 10 mg Capsule 1 QL Limited to 60 caps per 30 days



Clarinex-D 12 Hour 2.5-120 mg Tbmp 12hr 2

Clarithromycin 125 mg/5ml Susp Recon 1

Clarithromycin 250 mg/5ml Susp Recon 1

Clarithromycin 250 mg Tablet 1

Clarithromycin 500 mg Tablet 1

Clarithromycin Er 500 mg Tab Er 24h 1

Claritin 10 mg Tablet 1

C-Lax Laxative 5 mg Tablet Dr 1

Cleansing Wash 10%-4%-10% Cleanser 1

Clemastine Fumarate 2.68 mg Tablet 1

Clenpiq 10-3.5/160 Solution 2

Cleocin 100 mg Supp.Vag 2

Clever Chek Lancets 30 gauge Each 1

Clever Choice Control Solution Each 1

Clickfine 31 g x1/4"" Dis Needle 1

Clickfine 31 gx5/16"" Dis Needle 1

Clickfine 32gx 5/32"" Dis Needle 1

Climara Pro 45-15/24h Patch Tdwk 2

Clindacin Etz 1% Kit 2

Clindacin Pac 1% Kit 2

Clindamycin Hcl 150 mg Capsule 1



Clindamycin Palmitate Hcl 75 mg/5 ml Soln Recon 1

Clindamycin Pediatric 75 mg/5 ml Soln Recon 1

Clindamycin Phos-Benzoyl Perox 1.2(1)%-5% Gel (Gram) 1

Clindamycin Phosphate 2% Cream/Appl 1

Clindamycin Phosphate 1% Gel (Gram) 1

Clindamycin Phosphate 1% Lotion 1

Clindamycin Phosphate 1% Med. Swab 1

Clindamycin Phosphate 1% Solution 1


2021.1 (1/15/2021).



Clindesse 2% Crm Er (G) 2

Clinpro 5000 1.10% Paste (G) 2 A Excluded for members age 19 or older

Clobetasol Emollient 0.05% Cream (G) 1

Clobetasol Emollient 0.05% Foam 1

Clobetasol Emulsion 0.05% Foam 1

Clobetasol Propionate 0.05% Cream (G) 1

Clobetasol Propionate 0.05% Foam 1

Clobetasol Propionate 0.05% Gel (Gram) 1

Clobetasol Propionate 0.05% Lotion 1

Clobetasol Propionate 0.05% Oint. (G) 1

Clobetasol Propionate 0.05% Shampoo 1

Clobetasol Propionate 0.05% Solution 1

Clobetasol Propionate 0.05% Spray 1

Clodan 0.05% Kt Shm Cln 2

Clonazepam 0.125 mg Tab Rapdis 1



Clonazepam 1 mg Tab Rapdis 1

Clonazepam 2 mg Tab Rapdis 1

Clonazepam 0.5 mg Tablet 1

Clonazepam 1 mg Tablet 1

Clonazepam 2 mg Tablet 1

Clonidine 0.1mg/24hr Patch Tdwk 1 QL Limited to 1 patch per 7 days



Clonidine Hcl 0.1 mg Tablet 1



Clopidogrel 300 mg Tablet 1

Clopidogrel 75 mg Tablet 1

Clotrimazole 1% Cream (G) 1

Clotrimazole 1% Cream/Appl 1

Clotrimazole 1% Solution 1

Clotrimazole 10 mg Troche 1

Clotrimazole-7 1% Cream/Appl 1

Clotrimazole-Betamethasone 1 %-0.05 % Cream (G) 1

Clotrimazole-Betamethasone 1 %-0.05 % Lotion 1

C-Nate Dha 28-1-200mg Capsule 1

Coaguchek Each 1

Coaguchek Xs Each 1


2021.1 (1/15/2021).



Coartem 20mg-120mg Tablet 2

Cocaine Hcl 4% Solution 1

Codeine Sulfate 15 mg Tablet 1



Colchicine 0.6 mg Capsule 1

Colchicine 0.6 mg Tablet 1

Colestid 7.5 g Packet 2

Colestipol Hcl 5 g Granules 1

Colestipol Hcl 5 g Packet 1

Colestipol Hcl 1 g Tablet 1

Color Lancets 21 gauge Each 1

Col-Rite 100 mg Capsule 1

Col-Rite 250 mg Capsule 1

Combipatch .05-.14/24 Patch Tdsw 2

Combipatch .05-.25/24 Patch Tdsw 2

Combivent Respimat 20-100 mcg Mist Inhal 2 QL Limited to 2 inhalers per 30 days

Comfort Ez 21 gauge Each 1



Comfort Ez Insulin Syringe 28gx1/2"" Disp Syrin 1

Comfort Ez Insulin Syringe 29 g x1/2"" Disp Syrin 1

Comfort Ez Insulin Syringe 30 gx5/16"" Disp Syrin 1

Comfort Ez Insulin Syringe 30gx1/2"" Disp Syrin 1

Comfort Ez Insulin Syringe 31 gx5/16"" Disp Syrin 1

Comfort Ez Pen Needle 31 g x1/4"" Dis Needle 1

Comfort Ez Pen Needle 31 gx3/16"" Dis Needle 1


Comfort Ez Pen Needle 32 gx 1/4"" Dis Needle 1



Comfort Ez Pen Needle 32gx 5/32"" Dis Needle 1

Comfort Ez Pen Needle 33 g x1/4"" Dis Needle 1




Comfort Gel 200-200-20 Oral Susp 1

Comfort Gel 400-400-40 Oral Susp 1

Comfort Lancets Each 1

Comfort Pac-Cyclobenzaprine 10 mg Kit 2


2021.1 (1/15/2021).



Comfort Pac-Ibuprofen 800 mg Kit 2

Comfort Pac-Naproxen 500 mg Kit 2

Comfort Pac-Tizanidine 4 mg Kit 2

Complera 200-25-300 Tablet 2 QL Limited to 30 tabs per 30 days

Complete Allergy 25 mg Capsule 1

Complete Allergy 25 mg Tablet 1

Complete Natal Dha 29-1-200mg Combo. Pkg 2

Complete Senior Tablet 1

Completenate 29 mg-1 mg Tab Chew 1

Compoz 25 mg Tablet 1

Compro 25 mg Supp.Rect 1

Conception Kit 1

Constulose 10 g/15 ml Solution 1

Contour Each 1

Contour Next Control Solution Each 1

Contour Next Test Strip Strip 1 QL Limited to 300 strips per 30 days

Contour Test Strip Strip 1 QL Limited to 300 strips per 30 days

Control Solution Each 1

Cool Control Solution Each 1

Cordran 0.03% Cream (G) 2

Cordran 4mcg/sq cm Med. Tape 2

Corlanor 5 mg Tablet 4 SP, PA, QL Limited to 60 tabs per 30 days

Corlanor 7.5 mg Tablet 4 SP, PA, QL Limited to 60 tabs per 30 days

Cortaid 1% Cream (G) 1

Cortifoam 10% Foam/Appl 2

Cortisone 1% Cream (G) 1

Cortisone Acetate 25 mg Tablet 1

Cortisone With Aloe 1% Cream (G) 1

Cortisporin 0.50% Cream (G) 2

Cortisporin 1% Oint. (G) 2

Cortizone-10 1% Cream (G) 1

Cortizone-10 Plus 1% Cream (G) 1

Corvita 1.25-2.5mg Tablet 2

Corvita 150 150-1.25mg Tablet 1

Corvite 1.25-2.5mg Tablet 2

Corvite 150 150 mg-1mg Tablet 2

Corvite Free 1.25-35mg Tablet 2

Cosentyx (2 Syringes) 150 mg/ml Syringe 4 SP, PA, QL Quantity limit varies by indication


2021.1 (1/15/2021).



Cosentyx Pen 150 mg/ml Pen Injctr 4 SP, PA, QL Quantity limit varies by indication

Cosentyx Pen (2 Pens) 150 mg/ml Pen Injctr 4 SP, PA, QL Quantity limit varies by indication

Cosentyx Syringe 150 mg/ml Syringe 4 SP, PA, QL Quantity limit varies by indication

Cotempla Xr-Odt 25.9 mg Tab Rap Bp 2

Cotempla Xr-Odt 8.6 mg Tab Rap Bp 2

Cough Dm 100-10mg/5 Syrup 1

Cough Syrup Dm 100-10mg/5 Syrup 1

Creon 12k-38k-60 Capsule Dr 2

Creon 24-76-120k Capsule Dr 2

Creon 36k-114k Capsule Dr 2

Creon 3-9.5-15k Capsule Dr 2

Creon 6k-19k-30k Capsule Dr 2

Cresemba 186 mg Capsule 2 PA

Crinone 4% Gel/Pf App 2

Crixivan 200 mg Capsule 2

Crixivan 400 mg Capsule 2

Cromolyn Sodium 20 mg/2 ml Ampul-Neb 1

Crotan 10% Lotion 2

Cryselle 0.3-0.03mg Tablet 1

C-Therapy Night Cream 4% Cream (G) 2

Curafil Gel (Gram) 1

Curosurf 120 mg/1.5 Vial 2

Curosurf 240 mg/3ml Vial 2

Cutaquig 16.50% Vial 2 PA, QL Limited to 576ml per 28 days

Cuvitru 1 g/5 ml Vial 4 SP, PA

Cuvitru 10 g/50 ml Vial 2 PA




Cuvposa 1 mg/5 ml Solution 2

Cyclafem 1 mg-35mcg Tablet 1

Cyclafem 7 days x 3 Tablet 1

Cyclobenzaprine Hcl 10 mg Tablet 1

Cyclobenzaprine Hcl 5 mg Tablet 1

Cyclomydril 0.2 %-1 % Drops 2

Cyclopentolate Hcl 0.50% Drops 1

Cyclopentolate Hcl 1% Drops 1

Cyclopentolate Hcl 2% Drops 1

Cyclopentolate-Pe-Tropicamide 1%-1%-2.5% Drops 1


2021.1 (1/15/2021).



Cyclopentolate-Tropicamide-Pe 1%-1%-2.5% Drops 1

Cyclophosphamide 25 mg Capsule 1

Cyclophosphamide 50 mg Capsule 1

Cycloserine 250 mg Capsule 1

Cyclosporine 100 mg Capsule 1

Cyclosporine 25 mg Capsule 1

Cyclosporine Modified 100 mg Capsule 1



Cyclosporine Modified 100 mg/ml Solution 1

Cyproheptadine Hcl 2 mg/5 ml Syrup 1

Cyproheptadine Hcl 4 mg Tablet 1

Cyred 0.15-0.03 Tablet 1

Cyred Eq 0.15-0.03 Tablet 1

Cystadane 1 g/1.7 ml Powder 4 SP, PA

Cytra-2 334-500mg Solution 1

Cytra-3 500-550/5 Solution 1

Cytra-K 1100-334/5 Solution 1

Daily Fiber 0.52g Capsule 1

Daily Fiber 3.4 g/12 g Powder 1

Daily Multiple Vitamin Tablet 1

Daily Value Tablet 1

Daily Vitamin + Iron Tablet 1

Daily Vitamin Formula Tablet 1

Daily Vitamin Formula-Minerals Tablet 1

Daily Vite Tablet 1

Daily Vite With Iron Tablet 1

Danazol 100 mg Capsule 1



Dapsone 100 mg Tablet 1

Dapsone 25 mg Tablet 1

Daptacel Dtap 15-10-5/.5 Vial 2

Dasetta 1 mg-35mcg Tablet 1

Dasetta 7 days x 3 Tablet 1

Daysee 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Daytrana 15mg/9hr Patch Td24 2

Daytrana 20 mg/9 hr Patch Td24 2

Daytrana 30mg/9hr Patch Td24 2

Debacterol 30%-50% Med. Swab 2

Debacterol 30%-50% Solution 2


2021.1 (1/15/2021).



Deblitane 0.35 mg Tablet 1

Debrox 6.50% Drops 1

Decadron 0.5 mg Tablet 1

Decadron 0.75 mg Tablet 1

Decadron 4 mg Tablet 1

Decadron 6 mg Tablet 1

Deep Sea 0.65% Spray 1

Deferasirox 180 mg Gran Pack 3 SP, PA



Deferasirox 125 mg Tab Disper 3 SP



Deferasirox 180 mg Tablet 3 SP



Delstrigo 100-300 mg Tablet 2

Deluo 0.02% Spray 2

Demeclocycline Hcl 150 mg Tablet 1

Demeclocycline Hcl 300 mg Tablet 1

Denavir 1% Cream (G) 2

Denta 5000 Plus 1.10% Cream (G) 1 A Excluded for members age 19 or older

Dentagel 1.10% Gel (Gram) 1 A Excluded for members age 19 or older

Depo-Provera 400 mg/ml Vial 2 QL Limited to 1 injection per 84 days

Depo-Subq Provera 104 104mg/0.65 Syringe 2 QL Limited to 1 injection per 84 days

Dermacinrx Folixapure 5000 unit Tablet 2

Dermacinrx Lexitral 1.5-0.025% Cmb Sol Cr 2

Dermacinrx Purefolix 5000 unit Tablet 2

Dermagraft 2""x3"" Sheet 2

Derm-Silk 2.5""x2"" Pad 1

Dermulcera Oint. (G) 2

Descovy 200mg-25mg Tablet 2

Desloratadine 5 mg Tablet 1

Desogestrel-Ethinyl Estradiol 0.15-0.03 Tablet 1

Desogestr-Eth Estrad Eth Estra 21-5 (28) Tablet 1

Desonate 0.05% Gel (Gram) 2

Desonide 0.05% Cream (G) 1

Desonide 0.05% Gel (Gram) 1


2021.1 (1/15/2021).



Desonide 0.05% Lotion 1

Desonide 0.05% Oint. (G) 1

Desoximetasone 0.05% Cream (G) 1

Desoximetasone 0.25% Cream (G) 1

Desoximetasone 0.05% Gel (Gram) 1

Desoximetasone 0.05% Oint. (G) 1

Desoximetasone 0.25% Oint. (G) 1

Dex4 Glucose 40% Gel (Gram) 1

Dexamethasone 0.5 mg/5ml Elixir 1

Dexamethasone 0.5 mg/5ml Solution 1

Dexamethasone 1.5mg (21) Tab Ds Pk 1



Dexamethasone 0.5 mg Tablet 1


Dexamethasone 1 mg Tablet 1





Dexamethasone Intensol 1 mg/ml Drops 2

Dexamethasone Sodium Phosphate 0.10% Drops 1

Dexchlorpheniramine Maleate 2 mg/5 ml Solution 1

Dexcom G6 (Meter) Each 1 PA, QL Limited to 1 meter per 365 days

Dexcom G6 (Sensor) Each 1 PA, QL Limited to 3 sensors per 30 days

Dexcom G6 (Transmitter) Each 1 PA, QL Limited to 4 transmitters per 365 days

Dexifol 5 mg Tablet 1

Dexilant 30 mg Cap Dr Bp 2 QL Limited to 30 caps per 30 days

Dexmethylphenidate Hcl 10 mg Tablet 1 QL Limited to 60 tabs per 30 days

Dexmethylphenidate Hcl 2.5 mg Tablet 1 QL Limited to 60 tabs per 30 days

Dexmethylphenidate Hcl 5 mg Tablet 1 QL Limited to 60 tabs per 30 days

Dextroamphetamine Sulfate 5 mg/5 ml Solution 1 QL Limited to 1200ml per 30 days

Dextroamphetamine Sulfate 10 mg Tablet 1

Dextroamphetamine Sulfate 5 mg Tablet 1

Dextroamphetamine Sulfate Er 10 mg Capsule Er 1 QL Limited to 120 caps per 30 days



Dextroamphetamine-Amphet Er 10 mg Cap Er 24h 1 QL Limited to 60 caps per 30 days




2021.1 (1/15/2021).






Dextroamphetamine-Amphetamine 10 mg Tablet 1

Dextroamphetamine-Amphetamine 12.5 mg Tablet 1





Dextroamphetamine-Amphetamine 7.5 mg Tablet 1

Diabetic Tussin Dm 100-10mg/5 Liquid 1

Dialyvite 1 mg-100mg Tablet 1

Dialyvite 3000 3mg-15mg Tablet 1

Dialyvite 5000 5 mg Tablet 2

Dialyvite 800 With Iron 29mg-0.8mg Tablet 1

Dialyvite Zinc 1 mg-100mg Tablet 1

Diapers Each 1

Diarrhea Relief 262mg/15ml Oral Susp 1

Diatrue Each 1

Diazepam 12.5-15-20 Kit 1 QL Limited to 1 kit per 30 days

Diazepam 2.5 mg Kit 1 QL Limited to 1 kit per 30 days

Diazepam 5-7.5-10mg Kit 1 QL Limited to 1 kit per 30 days

Diazoxide 50 mg/ml Oral Susp 1 QL Limited to 336ml per 30 days

Diclofenac 35 mg Capsule 1

Diclofenac Potassium 50 mg Tablet 1

Diclofenac Sodium 0.10% Drops 1

Diclofenac Sodium 1% Gel (Gram) 1 QL Limited to 400 grams per 30 days

Diclofenac Sodium 25 mg Tablet Dr 1



Diclofenac Sodium Er 100 mg Tab Er 24h 1

Diclofenac Sodium-Misoprostol 50 mg-200 Tab Ir Dr 1

Diclofenac Sodium-Misoprostol 75 mg-200 Tab Ir Dr 1

Diclofex Dc 1.5-0.025% Cmb Sol Cr 2

Diclofono 1.60% Gel Packet 2

Diclosaicin 1.5-0.025% Cmb Sol Cr 2

Diclotral 1.5-0.025% Cmb Sol Cr 2

Dicloxacillin Sodium 250 mg Capsule 1

Dicloxacillin Sodium 500 mg Capsule 1

Dicyclomine Hcl 10 mg Capsule 1


2021.1 (1/15/2021).



Dicyclomine Hcl 10 mg/5 ml Solution 1

Dicyclomine Hcl 20 mg Tablet 1

Didanosine 250 mg Capsule Dr 1

Didanosine 400 mg Capsule Dr 1

Dificid 40 mg/ml Susp Recon 2 QL, ST

Limited to 136 ml per 10 days Must try/fail oral vancomycin (capsules and solution)

Dificid 200 mg Tablet 2 ST Must try/fail oral vancomycin (capsules and solution)

Diflunisal 500 mg Tablet 1

Digestive Relief 262mg/15ml Oral Susp 1

Digitek 125 mcg Tablet 1

Digitek 250 mcg Tablet 1

Digox 125 mcg Tablet 1

Digox 250 mcg Tablet 1

Digoxin 50 mcg/ml Solution 2

Digoxin 125 mcg Tablet 1

Digoxin 250 mcg Tablet 1

Dilantin 30 mg Capsule 2

Dilatrate-Sr 40 mg Capsule Er 2

Diltiazem 12hr Er 120 mg Cap Er 12h 1



Diltiazem 24hr Er 120 mg Cap Sa 24h 1






Diltiazem 24hr Er (Cd) 120 mg Cap Er 24h 1





Diltiazem 24hr Er (La) 180 mg Tab Er 24h 1





Diltiazem Hcl 120 mg Tablet 1



2021.1 (1/15/2021).





Dilt-Xr 120 mg Cap Er Deg 1



Diluent For Rotarix Syringe 2

Dimethyl Fumarate 120 mg Capsule Dr 3 SP, QL Limited to 60 tabs per 30 days

Dimethyl Fumarate 120-240 mg Capsule Dr 3 SP, QL Limited to 60 tabs per 30 days

Dimethyl Fumarate 240 mg Capsule Dr 3 SP, QL Limited to 60 tabs per 30 days

Diocto 50 mg/5 ml Liquid 1

Diocto 60 mg/15ml Syrup 1

Dioctyl 60 mg/15ml Syrup 1

Diotame 262 mg Tab Chew 1

Dipentum 250 mg Capsule 2

Diphedryl 25 mg Capsule 1

Diphedryl 12.5mg/5ml Liquid 1

Diphedryl Allergy 12.5mg/5ml Liquid 1

Diphen 12.5mg/5ml Elixir 1

Diphen 25 mg Tablet 1

Diphenhist 25 mg Capsule 1

Diphenhydramine Hcl 25 mg Capsule 1

Diphenhydramine Hcl 50 mg Capsule 1

Diphenhydramine Hcl 12.5mg/5ml Elixir 1

Diphenhydramine Hcl 12.5mg/5ml Liquid 1

Diphenhydramine Hcl 12.5mg/5ml Syrup 1

Diphenhydramine Hcl 25 mg Tablet 1

Diphenoxylate-Atropine 2.5-.025/5 Liquid 1

Diphenoxylate-Atropine 2.5-.025mg Tablet 1

Diphtheria-Tetanus Toxoids-Ped 5-25/0.5ml Vial 2

Dipyridamole 25 mg Tablet 1



Disopyramide Phosphate 100 mg Capsule 1

Disopyramide Phosphate 150 mg Capsule 1

Disulfiram 250 mg Tablet 1

Disulfiram 500 mg Tablet 1

Dithol 1.5 %-10 % Combo. Pkg 2

Diuril 250 mg/5ml Oral Susp 2

Divigel 0.25/0.25g Gel Packet 2

Divigel 0.5mg/0.5g Gel Packet 2

Divigel 0.75/0.75g Gel Packet 2


2021.1 (1/15/2021).



Divigel 1 mg/gram Gel Packet 2

Dm2 500 mg Cmbtabstrp 2

Docu Liquid 50 mg/5 ml Liquid 1

Docusate Calcium 240 mg Capsule 1

Docusate Sodium 100 mg Capsule 1

Docusate Sodium 250 mg Capsule 1

Docusate Sodium 50 mg/5 ml Liquid 1

Docusate Sodium 60 mg/15ml Syrup 1

Docuzen 8.6mg-50mg Tablet 1

Dofetilide 500 mcg Capsule 1

Dok 100 mg Capsule 1

Donepezil Hcl 10 mg Tablet 1

Donepezil Hcl 5 mg Tablet 1

Donepezil Hcl Odt 10 mg Tab Rapdis 1

Donepezil Hcl Odt 5 mg Tab Rapdis 1

Donnatal 16.2mg/5ml Elixir 2

Doryx Mpc 120 mg Tablet Dr 2

Dorzolamide Hcl 2% Drops 1

Dorzolamide-Timolol 2 %-0.5 % Droperette 1

Dorzolamide-Timolol 22.3-6.8/1 Drops 1

Dotti .025mg/24h Patch Tdsw 1

Dotti .0375mg/24 Patch Tdsw 1

Dotti .075mg/24h Patch Tdsw 1

Dotti 0.05mg/24h Patch Tdsw 1

Dotti 0.1mg/24hr Patch Tdsw 1

Dover Coated Latex Foley Combo. Pkg 1

Doxazosin Mesylate 1 mg Tablet 1




Doxycycline Hyclate 20 mg Tablet 1

Doxycycline Hyclate 100 mg Tablet Dr 1

Doxycycline Monohydrate 100 mg Capsule 1

Doxycycline Monohydrate 50 mg Capsule 1

Doxycycline Monohydrate 25 mg/5 ml Susp Recon 1

Doxycycline Monohydrate 100 mg Tablet 1



Doxylamine Succ-Pyridoxine Hcl 10 mg-10mg Tablet Dr 1

Drithocreme Hp 1% Cream (G) 2

Dronabinol 2.5 mg Capsule 1 PA


2021.1 (1/15/2021).



Dronabinol 5 mg Capsule 1 PA

Droplet Lancets 30 gauge Each 1

Droplet Lancing Device Each 1

Drospirenone-Ethinyl Estradiol 0.02-3(28) Tablet 1

Drospirenone-Ethinyl Estradiol 0.03mg-3mg Tablet 1

Droxia 200 mg Capsule 2



Dss 250 mg Capsule 1

Dsuvia 30 mcg Tab In App 2

Duaklir Pressair 400-12 mcg Aer Pow Ba 2 QL Limited to 1 inhaler per 30 days

Duavee 0.45-20 mg Tablet 2

Duet Dha 400 25-1-400mg Combo. Pkg 2

Duexis 800-26.6mg Tablet 2

Dulcoease 100 mg Capsule 1

Dulcolax 400 mg/5ml Oral Susp 1

Dulcolax Stool Softener 100 mg Capsule 1

Dulera 100-5 mcg Hfa Aer Ad 2 ST Must try/fail fluticasone/salmeterol, Wixela Inhub or Advair HFA.

Dulera 200-5 mcg Hfa Aer Ad 2 ST Must try/fail fluticasone/salmeterol, Wixela Inhub or Advair HFA.

Dulera 50mcg-5mcg Hfa Aer Ad 2 QL Limited to 1 inhaler per 30 days

Duobrii 0.01-0.045 Lotion 2 QL, ST

Limited to 1 tube per 30 days Must try/fail high potency topical steroid

Dupixent Pen 300 mg/2ml Pen Injctr 4 SP, PA, QL Limited to 1 pen per 28 days

Dupixent Syringe 200mg/1.14 Syringe 4 SP, PA, QL Limited to 2 syringes per 28 days

Dupixent Syringe 300 mg/2ml Syringe 4 SP, PA, QL Limited to 2 syringes per 28 days

Durachol 3775 unit Capsule 2

Durezol 0.05% Drops 2

Durlaza 162.5 mg Cap Er 24h 2

Dutasteride 0.5 mg Capsule 1

Duzallo 200-200 mg Tablet 2

Duzallo 200-300 mg Tablet 2

Dvorah 325-30-16 Tablet 1

Dxevo 1.5 mg(39) Tab Ds Pk 2

Dyna-Hex 4% Liquid 1

E.E.S. 400 400 mg Tablet 1


2021.1 (1/15/2021).



Ear Drops 6.50% Drops 1

Ear Popper Each 1

Ear System 6.50% Drops 1

Ear Wax Removal 6.50% Drops 1

Easy Comfort 30 gauge Each 1

Easy Comfort Insulin Syringe 30 gx5/16"" Disp Syrin 1

Easy Comfort Insulin Syringe 30gx1/2"" Disp Syrin 1

Easy Comfort Pen Needle 31 gx3/16"" Dis Needle 1

Easy Comfort Pen Needle 31 gx5/16"" Dis Needle 1

Easy Plus Ii Each 1

Easy Step Control Solution Each 1

Easy Talk Each 1

Easy Touch 28gx1/2"" Disp Syrin 1

Easy Touch 29 g x1/2"" Disp Syrin 1

Easy Touch 30 gx5/16"" Disp Syrin 1

Easy Touch 30gx1/2"" Disp Syrin 1

Easy Touch 31 gx5/16"" Disp Syrin 1

Easy Touch 21 gauge Each 1







Easy Touch Control Solution Each 1

Easy Touch Insulin Safety 29 g x1/2"" Disp Syrin 1

Easy Touch Insulin Safety 30 gx5/16"" Disp Syrin 1

Easy Touch Insulin Safety 30gx1/2"" Disp Syrin 1

Easy Touch Insulin Syringe 27gx1/2"" Disp Syrin 1

Easy Touch Insulin Syringe 30gx1/2"" Disp Syrin 1

Easy Touch Lancing Device Each 1

Easy Touch Pen Needle 29 g x1/2"" Dis Needle 1

Easy Touch Pen Needle 31 g x1/4"" Dis Needle 1

Easy Touch Pen Needle 31 gx3/16"" Dis Needle 1


Easy Touch Pen Needle 32 gx 1/4"" Dis Needle 1


Easy Trak Each 1

Easy Trak Ii Control Solution Each 1

Easy Twist & Cap Lancets 28 gauge Each 1

Easygluco Plus Control Normal Each 1


2021.1 (1/15/2021).



Easymax Each 1

Easymax 15 Each 1

Easy-Touch Insulin Syringe 31 gx5/16"" Disp Syrin 1

Eazzze The Pain 500mg-25mg Tablet 1

Eclipse Syringe 30gx1/2"" Disp Syrin 1

Ec-Naproxen 375 mg Tablet Dr 1

Ec-Naproxen 500 mg Tablet Dr 1

Econazole Nitrate 1% Cream (G) 1

Econtra Ez 1.5 mg Tablet 1

Econtra One-Step 1.5 mg Tablet 1

Ecotrin 325 mg Tablet Dr 1

Ecoza 1% Foam 2

Ecpirin 325 mg Tablet Dr 1

Ed-Apap 160 mg/5ml Liquid 1

Edarbi 40 mg Tablet 2

Edarbi 80 mg Tablet 2

Edarbyclor 40 mg-25mg Tablet 2

Edarbyclor 40-12.5 mg Tablet 2

Edluar 10 mg Tab Subl 2 QL Limited to 30 tabs per 30 days

Edluar 5 mg Tab Subl 2 QL Limited to 60 tabs per 30 days

Ed-Spaz 0.125 mg Tab Rapdis 1

Edurant 25 mg Tablet 2

Efavirenz 200 mg Capsule 1

Efavirenz 50 mg Capsule 1

Efavirenz 600 mg Tablet 1

Efavirenz-Emtric-Tenofov Disop 600-200mg Tablet 1 QL Limited to 30 tabs per 30 days

Efavirenz-Lamivu-Tenofov Disop 400-300 mg Tablet 1

Efavirenz-Lamivu-Tenofov Disop 600-300mg Tablet 1 QL Limited to 30 tabs per 30 days

Effer-K 20 meq Tablet Eff 2

Effer-K 25 meq Tablet Eff 1

Egaten 250 mg Tablet 2

Electrolyte Solution 1

Element Compact Control Soln Each 1

Element Control Solution Each 1

Elestrin 0.87g Gel Md Pmp 2

Elinest 0.3-0.03mg Tablet 1

Eliquis 5 mg (74) Tab Ds Pk 2

Eliquis 2.5 mg Tablet 2

Eliquis 5 mg Tablet 2

Elite-Ob 50-1.25 mg Tablet 2

Elixophyllin 80 mg/15ml Elixir 1


2021.1 (1/15/2021).



Ella 30 mg Tablet 2

Elmiron 100 mg Capsule 2 QL Limited to 90 caps per 30 days

Eluryng .12-.015mg Vag Ring 1 QL Limited to 1 ring per 21 days

Embrace Each 1

Embrace 30 gauge Each 1

Embrace Evo Each 1

Embrace Glucose Control Soln Each 1

Embrace Pro Each 1

Embrace Talk Control Solution Each 1

Emcyt 140 mg Capsule 4 SP, PA

Emoquette 0.15-0.03 Tablet 1

Emtricitabine 200 mg Capsule 1

Emtricitabine-Tenofovir Disop 200-300 mg Tablet 1 QL Limited to 30 tabs per 30 days

Emtrivav 10 mg/ml Solution 2

Emulsion Sb Emulsn(G) 1

Emverm 100 mg Tab Chew 2

Enalapril Maleate 10 mg Tablet 1

Enalapril Maleate 2.5 mg Tablet 1



Enalapril-Hydrochlorothiazide 10 mg-25mg Tablet 1

Enalapril-Hydrochlorothiazide 5mg-12.5mg Tablet 1

Enbrel 25mg/0.5ml Syringe 4 SP, PA, QL Limited to 8 syringes per 30 days

Enbrel 50mg/ml(1) Syringe 4 SP, PA, QL Limited to 4 syringes per 28 days

Enbrel 25 mg Vial 4 SP, PA, QL Limited to 8 vials per 28 days

Enbrel 25mg/0.5ml Vial 4 SP, PA, QL Limited to 4 vials per 28 days

Enbrel Mini 50mg/ml(1) Cartridge 4 SP, PA, QL Limited to 4 cartridges per 28 days

Enbrel Sureclick 50mg/ml(1) Pen Injctr 4 SP, PA, QL Limited to 4 pens per 28 days

Endo-Avitene 10 mm Sheet 2

Endo-Avitene 5mm Sheet 2

Endocet 10mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Endocet 2.5-325 mg Tablet 1 QL Limited to 360 tabs per 30 days

Endocet 5 mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Endocet 7.5-325 mg Tablet 1 QL Limited to 360 tabs per 30 days

Endur-Acin 250 mg Tablet Er 1



Enema 19g-7g/118 Enema 1

Enema Disposable 19g-7g/118 Enema 1


2021.1 (1/15/2021).



Engerix-B Adult 20 mcg/ml Syringe 2

Engerix-B Adult 20 mcg/ml Vial 2

Engerix-B Pediatric-Adolescent 10 mcg/0.5 Syringe 2

Engerix-B Pediatric-Adolescent 10 mcg/0.5 Vial 2

Enlyte 1.5-8.73mg Cap Ir Dr 2

Enoxaparin Sodium 100 mg/ml Syringe 1

Enoxaparin Sodium 120mg/.8ml Syringe 1

Enoxaparin Sodium 150 mg/ml Syringe 1

Enoxaparin Sodium 30mg/0.3ml Syringe 1




Enoxaparin Sodium 300mg/3ml Vial 1

Enpresse 6/5/2010 Tablet 1

Enskyce 0.15-0.03 Tablet 1

Enstilar 0.005-.064 Foam 2

Entecavir 0.5 mg Tablet 3 SP, PA, QL Limited to 30 tabs per 30 days

Entecavir 1 mg Tablet 3 SP, PA, QL Limited to 30 tabs per 30 days

Enteral Gravity Bag Set-Enfit Each 1

Entresto 24 mg-26mg Tablet 2 QL Limited to 60 tabs per 30 days

Entresto 49 mg-51mg Tablet 2 QL Limited to 60 tabs per 30 days

Entresto 97mg-103mg Tablet 2 QL Limited to 60 tabs per 30 days

Enulose 10 g/15 ml Solution 1

Envarsus Xr 0.75 mg Tab Er 24h 2

Envarsus Xr 1 mg Tab Er 24h 2

Envarsus Xr 4 mg Tab Er 24h 2

Epclusa 200mg-50 mg Tablet 4 SP, PA, QL Limited to 28 tabs per 28 days

Epclusa 400-100 mg Tablet 4 SP, PA, QL Limited to 28 tabs per 28 days

Epiceram Eml Ext Rl 2

Epiduo Forte 0.3 %-2.5% Gel W/Pump 2

Epifoam 1 %-1 % Foam 2

Epinastine Hcl 0.05% Drops 1

Epinephrine 0.15/0.15 Auto Injct 1 QL Limited to 2 pens per 30 days

Epinephrine 0.15mg/0.3 Auto Injct 1 QL Limited to 2 pens per 30 days

Epinephrine 0.3mg/0.3 Auto Injct 1 QL Limited to 2 pens per 30 days

Epitol 200 mg Tablet 1

Epivir Hbv 25 mg/5 ml Solution 4 SP, PA

Epogen 10000/ml Vial 4 SP, PA


Epogen 20000/2ml Vial 4 SP, PA



2021.1 (1/15/2021).





Ergoloid Mesylates 1 mg Tablet 1

Ergomar 2 mg Tab Subl 2

Erleada 60 mg Tablet 4 SP, PA, QL Limited to 120 tabs per 30 days

Erlotinib Hcl 100 mg Tablet 3 SP



Errin 0.35 mg Tablet 1

Ertaczo 2% Cream (G) 2

Ery 2% Med. Swab 1

Ery-Tab 250 mg Tablet Dr 1

Ery-Tab 500 mg Tablet Dr 1

Erythrocin Stearate 250 mg Tablet 1

Erythromycin 250 mg Capsule Dr 1

Erythromycin 2% Gel (Gram) 1

Erythromycin 5 mg/gram Oint. (G) 1

Erythromycin 2% Solution 1

Erythromycin 250 mg Tablet 1

Erythromycin 500 mg Tablet 1

Erythromycin 250 mg Tablet Dr 1



Erythromycin Ethylsuccinate 200 mg/5ml Susp Recon 1

Erythromycin Ethylsuccinate 400 mg/5ml Susp Recon 1

Erythromycin Ethylsuccinate 400 mg Tablet 1

Eskata 40% Sol W/Appl 2

Esomep-Ezs 20 mg Kit Cap Sp 2

Esomeprazole Magnesium 10 mg Suspdr Pkt 1 QL Limited to 30 packets per 30 days



Esomeprazole Strontium 49.3 mg Capsule Dr 1

Estarylla 0.25-0.035 Tablet 1

Estazolam 1 mg Tablet 1

Estazolam 2 mg Tablet 1

Estradiol 0.01% Cream/Appl 1

Estradiol 0.5 mg Tablet 1

Estradiol 1 mg Tablet 1

Estradiol 2 mg Tablet 1


2021.1 (1/15/2021).



Estradiol (Once Weekly) .025mg/24h Patch Tdwk 1

Estradiol (Once Weekly) .0375mg/24 Patch Tdwk 1

Estradiol (Once Weekly) .075mg/24h Patch Tdwk 1

Estradiol (Once Weekly) 0.05mg/24h Patch Tdwk 1

Estradiol (Once Weekly) 0.06mg/24h Patch Tdwk 1

Estradiol (Once Weekly) 0.1mg/24hr Patch Tdwk 1

Estradiol (Twice Weekly) .025mg/24h Patch Tdsw 1

Estradiol (Twice Weekly) .0375mg/24 Patch Tdsw 1

Estradiol (Twice Weekly) .075mg/24h Patch Tdsw 1

Estradiol (Twice Weekly) 0.05mg/24h Patch Tdsw 1

Estradiol (Twice Weekly) 0.1mg/24hr Patch Tdsw 1

Estradiol-Norethindrone Acetat 0.5-0.1 mg Tablet 1

Estradiol-Norethindrone Acetat 1 mg-0.5mg Tablet 1

Estrogel 1.25 g Gel Md Pmp 2 QL Limited to 1 container per 30 days

Estrogen-Methyltestosterone 0.625-1.25 Tablet 1

Estrogen-Methyltestosterone 1.25-2.5mg Tablet 1

Ethambutol Hcl 100 mg Tablet 1

Ethambutol Hcl 400 mg Tablet 1

Ethosuximide 250 mg Capsule 1

Ethosuximide 250 mg/5ml Solution 1

Ethyl Chloride 100% Spray 1

Ethynodiol-Ethinyl Estradiol 1 mg-35mcg Tablet 1

Ethynodiol-Ethinyl Estradiol 1 mg-50mcg Tablet 1

Etidronate Disodium 200 mg Tablet 1

Etodolac 200 mg Capsule 1

Etodolac 300 mg Capsule 1

Etodolac 400 mg Tablet 1

Etodolac 500 mg Tablet 1

Etodolac Er 400 mg Tab Er 24h 1



Etonogestrel-Ethinyl Estradiol .12-.015mg Vag Ring 1 QL Limited to 1 ring per 21 days

Etoposide 50 mg Capsule 3 SP, QL Limited to 20 caps per 30 days

Eurax 10% Cream (G) 2

Eurax 10% Lotion 2

Euthyrox 100 mcg Tablet 1






2021.1 (1/15/2021).









Evac-U-Gen 8.6 mg Tablet 1

Evamist 1.53/spray Spray 2

Evencare Each 1

Evencare G2 Each 1

Evencare G3 Each 1

Evencare Mini Glucose Control Each 1

Evencare Proview Control Soln Each 1

Everolimus 0.25 mg Tablet 1 QL Limited to 60 tabs per 30 days



Everolimus 2.5 mg Tablet 3 SP

Everolimus 5 mg Tablet 3 SP

Everolimus 7.5 mg Tablet 3 SP

Evicel 1 ml Vial 2

Evicel 2 ml Vial 2

Evolution Control Solution Each 1

Evotaz 300-150 mg Tablet 2

Excedrin Migraine 250-250-65 Tablet 1

Exemestane 25 mg Tablet 1 QL Limited to 30 tabs per 30 days

Exoderm 25-1% Lotion 1

Expectorant Dm 100-10mg/5 Syrup 1

Extra Pain Relief 250-250-65 Tablet 1

Extraprin 250-250-65 Tablet 1

Extra-Virt Plus Dha 29-1.25-55 Capsule 1

E-Z Ject Lancets Each 1

Ez Nite Sleep 25 mg Capsule 1

Ez Smart Each 1

Ez Smart Lancets 28 gauge Each 1

Ezetimibe 10 mg Tablet 1

E-Zject Lancets 26 gauge Each 1





Ez-Lets 26 gauge Each 1


2021.1 (1/15/2021).



Fabb 1-2.2-25mg Tablet 1

Factive 320 mg Tablet 2 QL Limited to 7 tabs in 30 days

Falmina 0.1-0.02mg Tablet 1

Famciclovir 125 mg Tablet 1 QL Limited to 60 tabs per 30 days



Famotidine 40mg/5ml Oral Susp 1 ST Must try/fail ranitidine, cimetidine or nizatidine.

Famotidine 10 mg Tablet 1



Farydak 10 mg Capsule 4 SP, PA, QL Limited to 6 caps per 21 days



Fast Relief Laxative 10 mg Supp.Rect 1

Fayosim 0.15mg(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Fe C Plus 100-250-1 Tablet 1

Febuxostat 80 mg Tablet 1 QL Limited to 30 tabs per 30 days

Felbamate 600 mg/5ml Oral Susp 1

Felbamate 400 mg Tablet 1

Felbamate 600 mg Tablet 1

Felodipine Er 10 mg Tab Er 24h 1

Felodipine Er 2.5 mg Tab Er 24h 1

Felodipine Er 5 mg Tab Er 24h 1

Fem Ph 0.9-0.025% Jelly/Appl 2

Femcap 22mm Each 1

Femcap 26mm Each 1

Femcap 30mm Each 1

Femring 0.05mg/24h Vag Ring 2 QL Limited to 84 or 91 days per fill

Femynor 0.25-0.035 Tablet 1

Fenofibrate 130 mg Capsule 1







Fenofibrate 120 mg Tablet 1





2021.1 (1/15/2021).





Fenofibric Acid 135 mg Capsule Dr 1

Fenofibric Acid 45 mg Capsule Dr 1

Fenofibric Acid 105 mg Tablet 1

Fenofibric Acid 35 mg Tablet 1

Fentanyl 100 mcg/hr Patch Td72 1 QL, ST

Limited to 15 patches per 30 days Must try/fail MORPHINE ER TABLETS.





Fentanyl 37.5mcg/hr Patch Td72 1 QL, ST


Fentanyl 50mcg/hr Patch Td72 1 QL, ST




Fentanyl 75mcg/hr Patch Td72 1 QL, ST




Fentanyl Citrate 100 mcg Tablet Eff 1 QL Limited to 90 tabs per 30 days



2021.1 (1/15/2021).






Fentora 100 mcg Tablet Eff 2 QL Limited to 90 tabs per 30 days





Feosol 325(65) mg Tablet 1

Feriva 21-7 75-175-1mg Tablet 2

Ferocon 110-0.5mg Capsule 1

Ferosul 325(65) mg Tablet 1

Ferraplus 90 90-1-50 mg Tablet 1

Ferrex 150 150 mg Capsule 1

Ferrex 150 Forte 150-25-1 Capsule 1

Ferrex 150 Forte Plus 150-25-1 Capsule 1

Ferrex 28 151-200-1 Tablet 1

Ferrocite Plus 106 mg-1mg Tablet 1

Ferro-Time 325(65) mg Tablet 1

Ferrous Sulfate 15 mg/ml Drops 1

Ferrous Sulfate 220 (44)/5 Elixir 1

Ferrous Sulfate 220 (44)/5 Solution 1

Ferrous Sulfate 325(65) mg Tablet 1

Ferrousul 325(65) mg Tablet 1

Fever Reducer-Pain Reliever 160 mg/5ml Oral Susp 1

Feverall 325 mg Supp.Rect 1

Feverall 80 mg Supp.Rect 2

Fexofenadine-Pse Er 180-240mg Tab Er 24h 1 QL Limited to 30 tabs per 30 days

Fiber 0.52g Capsule 1

Fiber 3.4 g/12 g Powder 1

Fiber 3.4 g/7 g Powder 1

Fiber 3.4g/5.8g Powder 1

Fiber 500 mg Tablet 1

Fiber 625 mg Tablet 1

Fiber Lax 625 mg Tablet 1

Fiber Laxative 500 mg Tablet 1

Fiber Laxative 625 mg Tablet 1

Fiber Smooth Powder 1

Fiber Tabs 625 mg Tablet 1

Fiber Therapy 0.52g Capsule 1

Fiber Therapy Powder 1


2021.1 (1/15/2021).



Fiber Therapy 3.4 g/12 g Powder 1

Fiber Therapy 3.4 g/7 g Powder 1

Fiber Therapy 3.4g/5.8g Powder 1

Fiber Therapy 500 mg Tablet 1

Fiber Therapy 625 mg Tablet 1

Fiber-Lax 625 mg Tablet 1

Fifty50 Safety Seal Lancets 30 gauge Each 1

Fifty50 Safety Seal Lancets 32 gauge Each 1

Filtered Extension Set Infus.Set 1

Finacea 15% Foam 2

Finasteride 5 mg Tablet 1

Fine 30 Universal Lancets 30 gauge Each 1

Fingerstix Each 1

Fioricet 50-300-40 Capsule 1 QL Limited to 180 caps per 30 days

First Aid Antibiotic 3.5-400-5k Oint. (G) 1

Firvanq 25 mg/ml Soln Recon 2

Fish Oil 1000 mg Capsule 1

Fish Oil 100-160 mg Capsule 1

Fish Oil 300-1000mg Capsule 1

Fish Oil 300-500 mg Capsule 1



Fish Oil 300-1000mg Capsule Dr 1

Fish Oil 60 mg-90mg Capsule Dr 1

Fish Oil Concentrate 1000 mg Capsule 1

Fish Oil Concentrate 300-1000mg Capsule 1

Fish Oil Omega-3 300-1000mg Capsule 1

Flanax 220 mg Tablet 1

Flarex 0.10% Drops Susp 2

Flavor Chews Antacid 300mg(750) Tab Chew 1

Flavoxate Hcl 100 mg Tablet 1

Flecainide Acetate 100 mg Tablet 1



Flexi-Seal Signal Fms Miscell 1

Flolipid 40mg/5ml Oral Susp 2

Floriva 0.25-400/1 Drops 2 A Excluded for members age 19 or older

Floriva 0.5(1.1)mg Tab Chew 2

Floriva 1mg(2.2mg) Tab Chew 2

Flovent Diskus 100 mcg Blst W/Dev 2


2021.1 (1/15/2021).





Flovent Hfa 110 mcg Aer W/Adap 2



Fluad 2020-2021 45mcg/.5ml Syringe 2

Fluad Quad 2020-2021 60mcg/.5ml Syringe 2

Fluarix Quad 2020-2021 60mcg/.5ml Syringe 2

Flublok Quad 2020-2021 180mcg/0.5 Syringe 2

Flucelvax Quad 2020-2021 60mcg/.5ml Syringe 2

Flucelvax Quad 2020-2021 60mcg/.5ml Vial 2

Fluconazole 10 mg/ml Susp Recon 1

Fluconazole 40 mg/ml Susp Recon 1

Fluconazole 100 mg Tablet 1




Flucytosine 250 mg Capsule 1

Flucytosine 500 mg Capsule 1

Fludrocortisone Acetate 0.1 mg Tablet 1

Flulaval Quad 2020-2021 60mcg/.5ml Syringe 2

Flumist Quad 2020-2021 10e6.5-7.5 Nas Sp Syr 2

Fluocinolone Acetonide 0.01% Cream (G) 1

Fluocinolone Acetonide 0.03% Cream (G) 1

Fluocinolone Acetonide 0.01% Oil 1

Fluocinolone Acetonide 0.03% Oint. (G) 1

Fluocinolone Acetonide 0.01% Solution 1

Fluocinonide 0.05% Cream (G) 1

Fluocinonide 0.05% Gel (Gram) 1

Fluocinonide 0.05% Oint. (G) 1

Fluocinonide 0.05% Solution 1

Fluocinonide-E 0.05% Cream (G) 1

Fluorabon 0.25mg/0.6 Drops 2 A Excluded for members age 19 or older

Fluorescein-Proparacaine 0.5%-0.25% Drops 1

Fluoride 0.25(0.55) Tab Chew 1 A Excluded for members age 19 or older

Fluoride 0.5(1.1)mg Tab Chew 1 A Excluded for members age 19 or older

Fluoride 1mg(2.2mg) Tab Chew 1 A Excluded for members age 19 or older

Fluoridex 1.10% Paste (G) 2 A Excluded for members age 19 or older


2021.1 (1/15/2021).



Fluorometholone 0.10% Drops Susp 1

Fluoroplex 1% Cream (G) 2

Fluorouracil 5% Cream (G) 1

Fluorouracil 2% Solution 1

Fluorouracil 5% Solution 1

Fluovix 0.10% Kit 2

Fluovix Plus 0.10% Kit 2

Flura-Drops 0.25mg/drp Drops 2 A Excluded for members age 19 or older

Flurazepam Hcl 15 mg Capsule 1

Flurazepam Hcl 30 mg Capsule 1

Flurbiprofen 100 mg Tablet 1

Flutamide 125 mg Capsule 1

Fluticasone Propionate 0.05% Cream (G) 1

Fluticasone Propionate 0.01% Oint. (G) 1

Fluticasone Propionate 50 mcg Spray Susp 1 QL Limited to 1 bottle per 30 days

Fluticasone-Salmeterol 232-14 mcg Aer Pow Ba 1

Fluticasone-Salmeterol 55-14 mcg Aer Pow Ba 1

Fluticasone-Salmeterol 100-50 mcg Blst W/Dev 1 QL Limited to 1 device per 30 days



Fluzone High-Dose Quad 2020-21 240mcg/0.7 Syringe 2

Fluzone Quad 2020-2021 60mcg/.5ml Syringe 2

Fluzone Quad 2020-2021 60mcg/.5ml Vial 2

Fml Forte 0.25% Drops Susp 2

Fml S.O.P. 0.10% Oint. (G) 2

Folbee 1-2.5-25mg Tablet 1

Folbee Plus 5 mg Tablet 1

Folbee Plus Cz 5-1.5-25mg Tablet 1

Folbic 2-2.5-25mg Tablet 1

Folet One 38-1-25 mg Capsule 2

Folic Acid 0.8 mg Tablet 1

Folic Acid 1 mg Tablet 1

Folivane-F 125-1-40-3 Capsule 1

Folivane-Ob 85 mg-1 mg Capsule 1

Folivane-Plus 125 mg-1mg Capsule 1

Folplex 2.2 0.5-2.2-25 Tablet 1

Fondaparinux Sodium 10mg/0.8ml Syringe 1

Fondaparinux Sodium 2.5 mg/0.5 Syringe 1

Fondaparinux Sodium 5mg/0.4ml Syringe 1

Fondaparinux Sodium 7.5mg/0.6 Syringe 1


2021.1 (1/15/2021).



Fora Control Solution Each 1

Fora Lancets 30 gauge Each 1

Fora Lancing Device Each 1

Foracare Gdh Each 1

Foracare Lancets 30 gauge Each 1

Foraxa 2%-1%-1.2% Gel (Gram) 2

Fortavit Capsule 2

Forteo 20mcg/dose Pen Injctr 4 SP, PA, QL Limited to 1 syringe per 28 days

Fortiscare Each 1

Fosamax Plus D 70 mg-2800 Tablet 2 QL Limited to 4 tabs per 28 days

Fosamax Plus D 70 mg-5600 Tablet 2 QL Limited to 4 tabs per 28 days

Fosamprenavir Calcium 700 mg Tablet 1

Fosfomycin Tromethamine 3 g Packet 1

Fosinopril Sodium 10 mg Tablet 1



Fosinopril-Hydrochlorothiazide 10-12.5mg Tablet 1

Fosinopril-Hydrochlorothiazide 20-12.5 mg Tablet 1

Fosrenol 1000 mg Powd Pack 2

Fosrenol 750 mg Powd Pack 2

Freestyle Control Solution Each 1

Freestyle Freedom Lite Kit 1

Freestyle Insulinx Each 1

Freestyle Insulinx Strip 1 QL Limited to 300 strips per 30 days

Freestyle Insulinx Test Strips Strip 1 QL Limited to 300 strips per 30 days

Freestyle Lancets 28 gauge Each 1

Freestyle Libre 2 Reader Each 1 PA, QL Limited to 1 reader per 365 days

Freestyle Libre 2 Sensor Kit 1 PA, QL Limited to 2 sensors per 28 days

Freestyle Libre 14 Day Reader Each 1 PA, QL Limited to 1 reader per 365 days

Freestyle Libre 14 Day Sensor Kit 1 PA, QL Limited to 2 sensors per 28 days

Freestyle Lite Meter Kit 1

Freestyle Lite Test Strip Strip 1 QL Limited to 300 strips per 30 days

Freestyle Precision 30 gx5/16"" Disp Syrin 1

Freestyle Precision 31 gx5/16"" Disp Syrin 1

Freestyle Precision Neo Strip 1 QL Limited to 300 strips per 30 days

Freestyle Test Strips Strip 1 QL Limited to 300 strips per 30 days


2021.1 (1/15/2021).



Freestyle Unistik 2 Each 1

Frotek 10% Cream Pack 2

Fruit C-500 500 mg Tab Chew 1

Fungoid-D 1% Cream (G) 1

Furosemide 10 mg/ml Solution 1

Furosemide 40mg/5ml Solution 1

Furosemide 20 mg Tablet 1



Fusion Plus 130-1.25mg Capsule 2

Fyavolv 0.5mg-2.5 Tablet 1

Fyavolv 1mg-5mcg Tablet 1

Fycompa 0.5 mg/ml Oral Susp 2

Fycompa 10 mg Tablet 2






Gabapentin 100 mg Capsule 1



Gabapentin 250 mg/5ml Solution 1

Gabapentin 300 mg/6ml Solution 1

Gabapentin 600 mg Tablet 1

Gabapentin 800 mg Tablet 1

Galantamine Er 16 mg Cap24h Pel 1 QL Limited to 30 caps per 30 days



Galantamine Hbr 12 mg Tablet 1 QL Limited to 60 tabs per 30 days



Galantamine Hydrobromide 4 mg/ml Solution 1

Galzin 25 mg Capsule 2

Galzin 50 mg Capsule 2

Gamastan 15 %-18 % Vial 2 PA

Gamastan S-D 15 %-18 % Vial 2 PA

Gammaked 1 g/10 ml Vial 2

Gammaked 10 g/100ml Vial 2

Gammaked 20 g/200ml Vial 2

Gammaked 5 g/50 ml Vial 2


2021.1 (1/15/2021).



Gamunex-C 1 g/10 ml Vial 2

Gamunex-C 10 g/100ml Vial 2

Gamunex-C 2.5g/25ml Vial 2



Gamunex-C 5 g/50 ml Vial 2

Gardasil 20-40/0.5 Syringe 2

Gardasil 20-40/0.5 Vial 2

Gardasil 9 0.5 ml Syringe 2 A Must be between the age of 9 and 45 years of age.

Gardasil 9 0.5 ml Vial 2 A Must be between the age of 9 and 45 years of age.

Gas Relief 40mg/0.6ml Drops Susp 1

Gas Relief 125 mg Tab Chew 1

Gas Relief 80 mg Tab Chew 1

Gatifloxacin 0.50% Drops 1

Gavilyte-C 240-22.72g Soln Recon 1

Gavilyte-G 236-22.74g Soln Recon 1

Gavilyte-N 420g Soln Recon 1

Ge100 Control Solution Normal Each 1

Gelclair Gel Packet 2

Gelfilm 25x50mm Each 2

Gelfoam 200 Sponge 2

Gelfoam 4 Sponge 2

Gelnique 10% Gel Packet 2 QL Limited to 30 packets per 30 days

Gemfibrozil 600 mg Tablet 1

Genadur Liquid 2

Generlac 10 g/15 ml Solution 1

Gengraf 100 mg Capsule 1

Gengraf 25 mg Capsule 1

Gengraf 100 mg/ml Solution 1

Genotropin 12 mg/ml Cartridge 4 SP, PA

Genotropin 5 mg/ml Cartridge 4 SP, PA

Genotropin 0.2mg/0.25 Syringe 4 SP, PA









2021.1 (1/15/2021).



Genotropin 1mg/0.25ml Syringe 4 SP, PA

Genotropin 2mg/0.25ml Syringe 4 SP, PA

Gentak 0.30% Oint. (G) 1

Gentamicin Sulfate 0.10% Cream (G) 1

Gentamicin Sulfate 0.30% Drops 1

Gentamicin Sulfate 0.10% Oint. (G) 1

Genteal Tears 0.1%-0.3% Drops 1

Gentle Laxative 10 mg Supp.Rect 1

Gentle Laxative 5 mg Tablet Dr 1

Genvoya 150-200-10 Tablet 2

Geri-Dryl 12.5mg/5ml Liquid 1

Geri-Dryl 25 mg Tablet 1

Geri-Hydrolac 12% Cream (G) 1

Geri-Kot 8.6 mg Tablet 1

Geri-Lanta 200-200-20 Oral Susp 1

Geri-Lanta 400-400-40 Oral Susp 1

Geri-Mucil 3.4 g/12 g Powder 1

Geri-Mucil 3.4 g/7 g Powder 1

Geri-Mucil 3.4g/5.8g Powder 1

Geri-Pectate 262mg/15ml Oral Susp 1

Geri-Tussin Dm 100-10mg/5 Liquid 1

Gianvi 0.02-3(28) Tablet 1

Gilenya 0.25 mg Capsule 4 SP, QL Limited to 30 caps per 30 days

Gilenya 0.5 mg Capsule 4 SP, QL Limited to 30 caps per 30 days

Giltuss Diabetic 100-10mg/5 Liquid 1

Giltuss Hbp 100-10mg/5 Liquid 1

Girls Training Pants Each 1

Glatiramer Acetate 20 mg/ml Syringe 3 SP, QL Limited to 30ml per 30 days

Glatiramer Acetate 40 mg/ml Syringe 3 SP, QL Limited to 12 syringes per 28 days

Glatopa 20 mg/ml Syringe 3 SP, QL Limited to 30ml per 30 days

Glatopa 40 mg/ml Syringe 3 SP, QL Limited to 12 syringes per 28 days

Gleostine 10 mg Capsule 4 SP, PA



Glimepiride 1 mg Tablet 1



Glipizide 10 mg Tablet 1

Glipizide 5 mg Tablet 1


2021.1 (1/15/2021).



Glipizide Er 10 mg Tab Er 24 1

Glipizide Er 2.5 mg Tab Er 24 1

Glipizide Er 5 mg Tab Er 24 1

Glipizide Xl 10 mg Tab Er 24 1

Glipizide Xl 2.5 mg Tab Er 24 1

Glipizide Xl 5 mg Tab Er 24 1

Glipizide-Metformin 2.5-250 mg Tablet 1

Glipizide-Metformin 2.5-500 mg Tablet 1

Glipizide-Metformin 5 mg-500mg Tablet 1

Gloperba 0.6mg/5ml Solution 2 QL Limited to 300ml per 30 days

Glucagon Emergency Kit 1 mg Vial 2

Gluco Burst 40% Gel (Gram) 1

Glucocard 01 Control Each 1

Glucocard Expression Each 1

Glucocard Shine Each 1

Glucocom 33 gauge Each 1

Glucocom Control Solution Each 1

Glucocom Lancets 28 gauge Each 1

Glucocom Lancets 30 gauge Each 1

Glucose 4 g Tab Chew 1

Glucose Control Each 1

Glucose Control Solution Each 1

Glucose Gel 40% Gel (Gram) 1

Glutose-15 40% Gel (Gram) 1



Glyburide 1.25 mg Tablet 1

Glyburide 2.5 mg Tablet 1

Glyburide 5 mg Tablet 1

Glyburide Micronized 1.5 mg Tablet 1

Glyburide Micronized 3 mg Tablet 1

Glyburide Micronized 6 mg Tablet 1

Glyburide-Metformin Hcl 1.25-250mg Tablet 1

Glyburide-Metformin Hcl 2.5-500 mg Tablet 1

Glyburide-Metformin Hcl 5 mg-500mg Tablet 1

Glycerin pediatric Supp.Rect 1

Glycopyrrolate 1 mg Tablet 1

Glycopyrrolate 2 mg Tablet 1

Glyxambi 10 mg-5 mg Tablet 2 ST Must try/fail metformin and metformin combinations.


2021.1 (1/15/2021).



Glyxambi 25 mg-5 mg Tablet 2 ST Must try/fail metformin and metformin combinations.

Gojji Glucose Control Solution Each 1

Gojji Lancets 30 gauge Each 1

Golytely 227.1-21.5 Powd Pack 2

Gonitro 400 mcg Powd Pack 2

Goody's Migraine Relief 250-250-65 Tablet 1

Grafix Core 14 mm Sheet 2

Grafix Core 2 cmx 3 cm Sheet 2

Grafix Core 5 cmx 5 cm Sheet 2

Grafix Prime 14 mm Sheet 2

Grafix Prime 2 cmx 3 cm Sheet 2

Grafix Prime 5 cmx 5 cm Sheet 2

Grafix Xc 7.5cmx15cm Sheet 2

Granisetron Hcl 1 mg Tablet 1 QL, ST Limited to 1 tab per 15 days Must try/fail ONDANSETRON.

Granix 300mcg/0.5 Syringe 4 SP, PA, QL Limited to 14 syringes per 28 days

Granix 480mcg/0.8 Syringe 4 SP, PA, QL Limited to 14 syringes per 28 days

Granix 300 mcg/ml Vial 4 SP, PA, QL Limited to 14 vials per 28 days

Granix 480mcg/1.6 Vial 4 SP, PA, QL Limited to 14 vials per 28 days

Grastek 2800 unit Tab Subl 2

Griseofulvin 125 mg/5ml Oral Susp 1 A Prior authorization required for members age 18 or older.

Guaiasorb Dm 100-10mg/5 Liquid 1

Guaifenesin-Dextromethorphan 100-10mg/5 Liquid 1

Guaifenesin-Dextromethorphan 100-10mg/5 Syrup 1

Guanfacine Hcl 1 mg Tablet 1

Guanfacine Hcl 2 mg Tablet 1

Guanidine Hcl 125 mg Tablet 1

Gvoke Hypopen 1-Pack 0.5 mg/0.1 Auto Injct 2

Gvoke Hypopen 1-Pack 1 mg/0.2ml Auto Injct 2

Gvoke Hypopen 2-Pack 0.5 mg/0.1 Auto Injct 2

Gvoke Hypopen 2-Pack 1 mg/0.2ml Auto Injct 2

Gvoke Pfs 1-Pack Syringe 0.5 mg/0.1 Syringe 2

Gvoke Pfs 1-Pack Syringe 1 mg/0.2ml Syringe 2

Gvoke Pfs 2-Pack Syringe 0.5 mg/0.1 Syringe 2

Gvoke Pfs 2-Pack Syringe 1 mg/0.2ml Syringe 2

Gynazole 1 2% Crm/Pf App 2


2021.1 (1/15/2021).



Hailey 1.5-0.03mg Tablet 1

Hailey 24 Fe 1mg-20(24) Tablet 1

Hailey Fe 1.5-30(21) Tablet 1

Hailey Fe 1mg-20(21) Tablet 1

Hair Vitamin Tablet 1

Hair, Skin & Nails Tablet 1

Hair, Skin And Nails Tablet 1

Halcinonide 0.10% Cream (G) 1

Halobetasol Propionate 0.05% Cream (G) 1

Halobetasol Propionate 0.05% Oint. (G) 1

Halog 0.10% Oint. (G) 2

Harmony Control Solution Each 1

Havrix 1440/ml Syringe 2

Havrix 720/0.5ml Syringe 2

Havrix 1440/ml Vial 2

Havrix 720/0.5ml Vial 2

Headache Pain 250-250-65 Tablet 1

Headache Pm 500mg-25mg Tablet 1

Headache Pm Formula 500mg-25mg Tablet 1

Headache Relief 250-250-65 Tablet 1

Healthpro Glucose Control Soln Each 1

Healthy Accents Autolet Each 1

Healthy Accents Unifine Pentip 29 g x1/2"" Dis Needle 1

Healthy Accents Unifine Pentip 31 g x1/4"" Dis Needle 1

Healthy Accents Unifine Pentip 31 gx3/16"" Dis Needle 1

Healthy Accents Unifine Pentip 31 gx5/16"" Dis Needle 1

Healthy Accents Unifine Pentip 32gx 5/32"" Dis Needle 1

Healthy Accents Unilet Lancet 30 gauge Each 1

Healthy Eyes Supervision 14320-226 Capsule 1

Heartburn Prevention 10 mg Tablet 1

Heartburn Relief 10 mg Tablet 1

Heather 0.35 mg Tablet 1

Hemady 20 mg Tablet 2 QL Limited to 8 tabs per 30 days

Hemangeol 4.28 mg/ml Solution 2

Hematinic Plus 106 mg-1mg Tablet 1

Hematinic With Folic Acid 106 mg-1mg Tablet 1

Hematogen 200-250-10 Capsule 1

Hematogen Fa 200-250 mg Capsule 1

Hematogen Forte 460-60mg Capsule 1

Hematron-Af 150-50-1mg Tab Er 24h 2

Hemetab 22-6-1-25 Tablet 1


2021.1 (1/15/2021).



Hemlibra 105 mg/0.7 Vial 4 SP, PA

Hemlibra 150 mg/ml Vial 4 SP, PA

Hemlibra 30 mg/ml Vial 4 SP, PA

Hemlibra 60mg/0.4ml Vial 4 SP, PA

Hepagam B >312/ml Vial 2

Hepagam B >312/ml(5) Vial 2

Heparin Sodium 5000/0.5ml Syringe 3 SP, PA

Heparin Sodium 1000/ml Vial 3 SP, PA

Heparin Sodium 10000/ml Vial 1

Heplisav-B 20 mcg/0.5 Syringe 2

Hiberix 10 mcg/0.5 Vial 2

Hidex 1.5mg (21) Tab Ds Pk 1

Hi-Volume Pumping Chamber Each 1

Hizentra 1 g/5 ml Vial 2




Homatropaire 5% Drops 1

Horizant 300 mg Tablet Er 2

Hpr Foam 2

Hpr Plus Cream (G) 2

Humalog 100/ml Cartridge 2 QL Limited to 60ml per 30 days

Humalog Kwikpen U-200 200/ml (3) Insuln Pen 2 QL Limited to 60ml per 30 days

Humalog Mix 50-50 50-50/ml Vial 2 QL Limited to 60ml per 30 days

Humalog Mix 50-50 Kwikpen 50-50/ml Insuln Pen 2 QL Limited to 60ml per 30 days

Humalog Mix 75-25 75-25/ml Vial 2 QL Limited to 60ml per 30 days

Humatrope 12 mg Cartridge 4 SP, PA



Humatrope 5 mg Vial 4 SP, PA

Humira 10mg/0.2ml Syringekit 4 SP, PA, QL Limited to 2 syringes per 28 days



Humira Pen 40mg/0.8ml Pen Ij Kit 4 SP, PA, QL Limited to 2 pens per 28 days

Humira Pen Crohn's-Uc-Hs 40mg/0.8ml Pen Ij Kit 4 SP, PA, QL Limited to 6 pens per 28 days

Humira Pen Psor-Uveits-Adol Hs 40mg/0.8ml Pen Ij Kit 4 SP, PA, QL Limited to 4 pens per 28 days

Humira(Cf) 10mg/0.1ml Syringekit 4 SP, PA, QL Limited to 2 kits per 28 days




2021.1 (1/15/2021).



Humira(Cf) Pediatric Crohn's 80 mg-40mg Syringekit 4 SP, PA, QL Limited to 2 kits per 28 days

Humira(Cf) Pediatric Crohn's 80mg/0.8ml Syringekit 4 SP, PA, QL Limited to 2 kits per 28 days

Humira(Cf) Pen 40mg/0.4ml Pen Ij Kit 4 SP, PA, QL Limited to 2 kits per 28 days

Humira(Cf) Pen 80mg/0.8ml Pen Ij Kit 4 SP, PA, QL Limited to 3 pens per 28 days

Humira(Cf) Pen Crohn's-Uc-Hs 80mg/0.8ml Pen Ij Kit 4 SP, PA, QL Limited to 3 pens per 28 days

Humulin 70/30 Kwikpen 70-30/ml Insuln Pen 2 QL Limited to 60ml per 30 days

Humulin 70-30 70-30/ml Vial 2 QL Limited to 60ml per 30 days

Humulin N 100/ml Vial 2 QL Limited to 60ml per 30 days

Humulin N Kwikpen 100/ml (3) Insuln Pen 2 QL Limited to 30ml per 28 days

Humulin R 100/ml Vial 2 QL Limited to 60ml per 30 days

Humulin R U-500 500/ml Vial 2 QL Limited to 20ml per 30 days

Humulin R U-500 Kwikpen 500/ml (3) Insuln Pen 2 QL Limited to 18ml per 30 days

Hycamtin 0.25 mg Capsule 2

Hycamtin 1 mg Capsule 2

Hyclodex 0.01% Spray 2

Hydralazine Hcl 10 mg Tablet 1




Hydro 35 35% Foam 2

Hydrochlorothiazide 12.5 mg Capsule 1

Hydrochlorothiazide 12.5 mg Tablet 1

Hydrochlorothiazide 25 mg Tablet 1

Hydrochlorothiazide 50 mg Tablet 1

Hydrocil Instant Powder 1

Hydrocodone-Acetaminophen 7.5-325/15 Solution 1 QL Limited to 2700ml per 30 days

Hydrocodone-Acetaminophen 10mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Hydrocodone-Acetaminophen 2.5-325 mg Tablet 1 QL Limited to 360 tabs per 30 days

Hydrocodone-Acetaminophen 5 mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Hydrocodone-Acetaminophen 7.5-325 mg Tablet 1 QL Limited to 360 tabs per 30 days

Hydrocodone-Ibuprofen 10mg-200mg Tablet 1

Hydrocodone-Ibuprofen 5mg-200mg Tablet 1

Hydrocodone-Ibuprofen 7.5-200 mg Tablet 1

Hydrocortisone 0.50% Cream (G) 1

Hydrocortisone 1% Cream (G) 1

Hydrocortisone 2.50% Cream (G) 1

Hydrocortisone 1% Crm/Pe App 1

Hydrocortisone 2.50% Crm/Pe App 1

Hydrocortisone 100mg/60ml Enema 1

Hydrocortisone 2.50% Lotion 1

Hydrocortisone 0.50% Oint. (G) 1


2021.1 (1/15/2021).



Hydrocortisone 1% Oint. (G) 1

Hydrocortisone 2.50% Oint. (G) 1

Hydrocortisone 10 mg Tablet 1



Hydrocortisone Acetate 25 mg Supp.Rect 1

Hydrocortisone Acetate 30 mg Supp.Rect 1

Hydrocortisone Butyrate 0.10% Cream (G) 1

Hydrocortisone Butyrate 0.10% Oint. (G) 1

Hydrocortisone Butyrate 0.10% Solution 1

Hydrocortisone Valerate 0.20% Cream (G) 1

Hydrocortisone Valerate 0.20% Oint. (G) 1

Hydrocortisone-Acetic Acid 1 %-2 % Drops 1

Hydrocortisone-Aloe 1% Cream (G) 1

Hydrocortisone-Iodoquinol 1 %-1 % Cream (G) 1

Hydrocream 1% Cream (G) 1

Hydrogen Peroxide 3% Solution 1

Hydromorphone Hcl 1 mg/ml Liquid 1

Hydromorphone Hcl 3 mg Supp.Rect 1

Hydromorphone Hcl 2 mg Tablet 1



Hydroxychloroquine Sulfate 200 mg Tablet 1

Hydroxyprogesterone Caproate 250 mg/ml Vial 3 SP, PA

Hydroxyurea 500 mg Capsule 1

Hydroxyzine Hcl 10 mg/5 ml Solution 1

Hydroxyzine Hcl 10 mg Tablet 1



Hydroxyzine Pamoate 100 mg Capsule 1



Hygel 2.50% Gel (Gram) 2

Hylaguard Cream (G) 2

Hylatopic Foam 2

Hylatopicplus Cream (G) 2

Hyoscyamine Sulfate 0.125mg/ml Drops 1

Hyoscyamine Sulfate 125mcg/5ml Elixir 1

Hyoscyamine Sulfate 0.125 mg Tab Rapdis 1

Hyoscyamine Sulfate 0.125 mg Tab Subl 1

Hyoscyamine Sulfate 0.125 mg Tablet 1


2021.1 (1/15/2021).



Hyoscyamine Sulfate Er 0.375 mg Tab Er 12h 1

Hyoscyamine Sulfate Sr 0.375 mg Tab Er 12h 1

Hyperhep B S-D 110/0.5ml Syringe 2

Hyperhep B S-D 220 unit/1 Syringe 2

Hyperhep B S-D 220 unit/1 Vial 2

Hyperhep B S-D 220/ml (5) Vial 2

Hyperrab S-D 150 unit/1 Vial 2

Hyperrho S-D 1500 unit Syringe 2

Hyperrho S-D 250 unit Syringe 2

Hyper-Sal 3.50% Vial-Neb 2

Hypertet S-D 250 unit Syringe 2

Hypolance Kit 1

Hyqvia 10 g/100ml Vial 2 PA

Hyqvia 2.5g/25ml Vial 2 PA



Hyqvia 5 g/50 ml Vial 2 PA

Hyqvia Ig Component 10 g/100ml Vial 2

Hyqvia Ig Component 2.5g/25ml Vial 2



Hyqvia Ig Component 5 g/50 ml Vial 2

Hysingla Er 100 mg Tab Er 24h 2 QL Limited to 30 tabs per 30 days







Ibandronate Sodium 150 mg Tablet 1 QL Limited to 1 tab per 28 days

Ibrance 100 mg Capsule 4 SP, PA, QL Limited to 21 caps per 28 days



Ibrance 100 mg Tablet 4 SP, PA, QL Limited to 21 tabs per 28 days



Ibu 400 mg Tablet 1

Ibu 600 mg Tablet 1

Ibu 800 mg Tablet 1

Ibu-200 200 mg Tablet 1

Ibuprofen 200 mg Capsule 1


2021.1 (1/15/2021).



Ibuprofen 50 mg/1.25 Drops Susp 1

Ibuprofen 100 mg/5ml Oral Susp 1

Ibuprofen 100 mg Tab Chew 1

Ibuprofen 100 mg Tablet 1





Ibuprofen Ib 200 mg Tablet 1

Icar-C Plus 100-250-1 Tablet 1

Icosapent Ethyl 1 G Capsule 1 QL Limited to 120 caps per 30 days

Iferex 150 150 mg Capsule 1

Iferex 150 Forte 150-25-1 Capsule 1

Ilevro 0.30% Drops Susp 2

Iliderm Spray 2

Imatinib Mesylate 100 mg Tablet 3 SP

Imatinib Mesylate 400 mg Tablet 3 SP

Imbruvica 140 mg Capsule 4 SP, PA, QL Limited to 120 caps per 30 days

Imbruvica 70 mg Capsule 4 SP, PA, QL Limited to 30 caps per 30 days

Imbruvica 140 mg Tablet 4 SP, PA, QL Limited to 30 tabs per 30 days




Imogam Rabies-Ht 150 unit/1 Vial 2

Imovax Rabies Vaccine 2.5 unit Vial 2

Impavido 50 mg Capsule 4 SP, PA

Impoyz 0.03% Cream (G) 2

Incassia 0.35 mg Tablet 1

Incontrol Lancing Device Each 1

Incontrol Pen Needle 29 g x1/2"" Dis Needle 1

Incontrol Pen Needle 31 g x1/4"" Dis Needle 1

Incontrol Pen Needle 31 gx3/16"" Dis Needle 1

Incontrol Pen Needle 31 gx5/16"" Dis Needle 1

Incontrol Pen Needle 32gx 5/32"" Dis Needle 1

Incontrol Super Thin Lancets 30 gauge Each 1

Incontrol Ultra Thin Lancets 28 gauge Each 1

Increlex 10 mg/ml Vial 4 SP, PA

Incruse Ellipta 62.5 mcg Blst W/Dev 2 QL Limited to 1 device per 30 days

Indapamide 1.25 mg Tablet 1

Indapamide 2.5 mg Tablet 1

Inderal Xl 120 mg Cap Er 24h 2


2021.1 (1/15/2021).



Inderal Xl 80 mg Cap Er 24h 2

Indocin 25 mg/5 ml Oral Susp 2

Indocin 50 mg Supp.Rect 2

Indomethacin 25 mg Capsule 1

Indomethacin 50 mg Capsule 1

Indomethacin Er 75 mg Capsule Er 1

Infanrix Dtap 25-58-10 Syringe 2

Infanrix Dtap 25-58-10 Vial 2

Infant Fever-Pain Reliever 160 mg/5ml Oral Susp 1

Infant Gas Relief 40mg/0.6ml Drops Susp 1

Infant Pain Relief 160 mg/5ml Oral Susp 1

Infant Pain-Fever 160 mg/5ml Oral Susp 1

Infants' Acetaminophen 160 mg/5ml Oral Susp 1

Infants' Fever-Pain Reliever 160 mg/5ml Oral Susp 1

Infants' Gas Relief 40mg/0.6ml Drops Susp 1

Infants' Pain Relief 160 mg/5ml Oral Susp 1

Infants' Pain Reliever 160 mg/5ml Oral Susp 1

Infants' Pain-Fever 160 mg/5ml Oral Susp 1

Infasurf 35mg/ml Vial 2

Infinity Control Solution Each 1

Infinity Voice Control Soln Each 1

Ingrezza 40 mg Capsule 4 SP, PA, QL Limited to 60 caps per 30 days

Ingrezza 80 mg Capsule 4 SP, PA, QL Limited to 30 caps per 30 days

Ingrezza Initiation Pack 40 mg-80mg Cap Ds Pk 2

Inject Ease Lancets 28 gauge Each 1

Inject Ease Lancets 30 gauge Each 1

Innopran Xl 120 mg Cap Er 24h 2

Innopran Xl 80 mg Cap Er 24h 2

Inova 4 %-5 % Combo. Pkg 2

Inova 8%-5% Combo. Pkg 2

Inova 4-1 1%-4%-5% Combo. Pkg 2

Inova 8-2 2%-8%-5% Combo. Pkg 2

Inset 30 Tubing Each 1

Insta-Glucose 24 g/31 g Gel (Gram) 1

Insuflon 25gx18mm Each 1

Insulin Aspart 100/ml Vial 1 QL Limited to 60ml per 30 days

Insulin Aspart Flexpen 100/ml (3) Insuln Pen 1 QL Limited to 60ml per 30 days

Insulin Aspart Penfill 100/ml Cartridge 1 QL Limited to 60ml per 30 days

Insulin Aspart Prot-Insuln Asp 70-30/ml Insuln Pen 1 QL Limited to 60ml per 30 days

Insulin Aspart Prot-Insuln Asp 70-30/ml Vial 1 QL Limited to 60ml per 30 days

Insulin Lispro 100/ml Vial 1 QL Limited to 60ml per 30 days


2021.1 (1/15/2021).



Insulin Lispro Junior Kwikpen 100/ml Ins Pen Hf 1 QL Limited to 60ml per 30 days

Insulin Lispro Kwikpen U-100 100/ml Insuln Pen 1 QL Limited to 60ml per 30 days

Insulin Lispro Protamine Mix 75-25/ml Insuln Pen 1 QL Limited to 60ml per 30 days

Insulin Pen Needle 29 g x1/2"" Dis Needle 1



Insulin Syringe Disp Syrin 1

Insulin Syringe 25gx1"" Disp Syrin 1

Insulin Syringe 25gx5/8"" Disp Syrin 1



Insulin Syringe 28 gauge Disp Syrin 1


Insulin Syringe 29 g x1/2"" Disp Syrin 1




Insulin Syringe 30 gx5/16"" Disp Syrin 1


Insulin Syringe 31 gx5/16"" Disp Syrin 1

Insupen 29 g x1/2"" Dis Needle 1

Insupen 30 gx5/16"" Dis Needle 1

Insupen 31 g x1/4"" Dis Needle 1


Insupen 32 gx 1/4"" Dis Needle 1


Insupen 32gx 5/32"" Dis Needle 1

Intelence 100 mg Tablet 2



Intron A 10mm unit Vial 4 SP, PA

Intron A 10mm/ml Vial 4 SP, PA



Intron A 6mmunit/ml Vial 4 SP, PA

Introvale 0.15-0.03 Tbdspk 3mo 1

Invacare Lancets 30 gauge Each 1

Inveltys 1% Drops Susp 2

Invirase 500 mg Tablet 2

Inzo Antifungal 2% Cream (G) 1

Iodine 5 %-10 % Solution 1


2021.1 (1/15/2021).



Iodoflex 0.90% Med. Pad 2

Ipol 40-8-32 Vial 2

I-Port Each 1

I-Port Advance Each 1

Ipratropium Bromide 0.2 mg/ml Solution 1

Ipratropium-Albuterol 0.5-3mg/3 Ampul-Neb 1

I-Prin 200 mg Tablet 1

Irbesartan 150 mg Tablet 1



Irbesartan-Hydrochlorothiazide 150-12.5mg Tablet 1

Irbesartan-Hydrochlorothiazide 300-12.5mg Tablet 1

Iressa 250 mg Tablet 4 SP, PA

Iron 325(65) mg Tablet 1

Iron 100 Plus 100-250-1 Tablet 1

Irospan 65-1mg(24) Tablet 2

Isentress 100 mg Powd Pack 2

Isentress 100 mg Tab Chew 2

Isentress 25 mg Tab Chew 2

Isentress 400 mg Tablet 2

Isentress Hd 600 mg Tablet 2

Isibloom 0.15-0.03 Tablet 1

Isoflurane 99.90% Liquid 1

Isoniazid 50 mg/5 ml Solution 1

Isoniazid 100 mg Tablet 1

Isoniazid 300 mg Tablet 1

Isordil 40 mg Tablet 2

Isosorbide Dinitrate 10 mg Tablet 1




Isosorbide Dinitrate Er 40 mg Tablet Er 1

Isosorbide Mononitrate 10 mg Tablet 1

Isosorbide Mononitrate 20 mg Tablet 1

Isosorbide Mononitrate Er 120 mg Tab Er 24h 1



Isotretinoin 10 mg Capsule 1 QL Limited to 60 caps per 30 days



Isoxsuprine Hcl 10 mg Tablet 1


2021.1 (1/15/2021).



Isoxsuprine Hcl 20 mg Tablet 1

Isradipine 2.5 mg Capsule 1

Isradipine 5 mg Capsule 1

Itraconazole 100 mg Capsule 1

Itraconazole 10 mg/ml Solution 1

Ivermectin 0.5% Lotion 1 QL Limited to 117ml per 30 days

Ivermectin 3 mg Tablet 1

I-Vite 1000-60-2 Tablet 1

Jaimiess 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Jantoven 1 mg Tablet 1



Jantoven 2.5 mg Tablet 1





Jantoven 7.5 mg Tablet 1

Jardiance 10 mg Tablet 2 QL, ST

Limited to 30 tabs per 30 days Must try/fail metformin and metformin combinations

Jardiance 25 mg Tablet 2 QL, ST


Jasmiel 0.02-3(28) Tablet 1

Jencycla 0.35 mg Tablet 1

Jinteli 1mg-5mcg Tablet 1

Jolessa 0.15-0.03 Tbdspk 3mo 1

Jornay Pm 100 mg Cpdr Er Sp 2





Juleber 0.15-0.03 Tablet 1

Juluca 50 mg-25mg Tablet 2

Junel 1.5-0.03mg Tablet 1

Junel 1mg-20mcg Tablet 1

Junel Fe 1.5-30(21) Tablet 1

Junel Fe 1mg-20(21) Tablet 1


2021.1 (1/15/2021).



Junel Fe 24 1mg-20(24) Tablet 1

Jynarque 15 mg Tablet 4 SP, PA, QL Limited to 30 tabs per 30 days

Jynarque 15 mg-15mg Tablet Seq 4 SP, PA, QL Limited to 56 tabs per 28 days





Kadian 200 mg Cap Er Pel 2

Kaitlib Fe 0.8-25(24) Tab Chew 1

Kaletra 100mg-25mg Tablet 2

Kaletra 200mg-50mg Tablet 2

Kalliga 0.15-0.03 Tablet 1

Kalydeco 25 mg Gran Pack 4 SP, PA

Kamdoy Spray 2

Kangaroo 924 Safety Screw Each 1

Kangaroo Epump Set Each 1

Kangaroo Gravity Set Each 1

Kaopectate 262mg/15ml Oral Susp 1

Kao-Tin 240 mg Capsule 1

Kapspargo Sprinkle 100 mg Cap Spr 24 2




Karbinal Er 4 mg/5 ml Sus Er 12h 2

Kariva 21-5 (28) Tablet 1

Kedrab 150 unit/1 Vial 2

Kelnor 1-35 1 mg-35mcg Tablet 1

Kelnor 1-50 1 mg-50mcg Tablet 1

Kelotop 4.7"" x5.7"" Pad 1

Kendall Disinfectant Cap Each 1

Kerafoam 30% Foam 2

Kerafoam 42% Foam 2

Keralyt Scalp 6 %-6 % Kt Shm Gel 2

Keramatrix 2"" x 2"" Sheet 2

Keramatrix 4"" x 4"" Sheet 2

Ketoconazole 2% Cream (G) 1

Ketoconazole 2% Shampoo 1

Ketoconazole 200 mg Tablet 1

Ketoprofen 25 mg Capsule 1




2021.1 (1/15/2021).



Ketorolac Tromethamine 0.40% Drops 1

Ketorolac Tromethamine 0.50% Drops 1

Ketorolac Tromethamine 10 mg Tablet 1 QL Limited to 20 tabs per 30 days

Keveyis 50 mg Tablet 4 SP, PA, QL Limited to 120 tabs per 30 days

Kevzara 150mg/1.14 Pen Injctr 4 SP, PA, QL Limited to 2 pens per 28 days

Kevzara 200mg/1.14 Pen Injctr 4 SP, PA, QL Limited to 2 pens per 28 days

Kevzara 150mg/1.14 Syringe 4 SP, PA, QL Limited to 2 pens per 28 days

Kevzara 200mg/1.14 Syringe 4 SP, PA, QL Limited to 2 pens per 28 days

Kinrix 25-25-10 Syringe 2

Kinrix 25-25-10 Vial 2

Kionex 15 g/60 ml Oral Susp 1

Kisqali 200 mg/day Tablet 4 SP, PA, QL Limited to 63 tabs per 28 days



Kisqali Femara Co-Pack 200-2.5 mg Tablet 4 SP, PA, QL Limited to 91 tabs per 28 days



Klor-Con M10 10 meq Tab Er Prt 1



Kogenate Fs 3000 (+/-) Vial 4 SP, PA

Konsyl 3.4 g/12 g Powder 1

Kovaltry 3000 (+/-) Vial 4 SP, PA

K-Pec 262mg/15ml Oral Susp 1

K-Phos No.2 700-305mg Tablet 2

K-Phos Original 500 mg Tablet Sol 2

Kristalose 20 g Packet 2

Kurvelo 0.15-0.03 Tablet 1

Kyleena 17.5mcg/24 Iud 2

Kynmobi 10 mg Film 4 SP, PA

Kynmobi 10-15-20mg Film 4 SP, PA





L.E.T. (Lido-Epineph-Tetra) 4-0.05-0.5 Gel/Pf App 1

Labetalol Hcl 100 mg Tablet 1



Lacrisert 5 mg Insert 2

Lactulose 10 g/15 ml Solution 1


2021.1 (1/15/2021).



Lactulose 20 g/30 ml Solution 1

Lamivudine 10 mg/ml Solution 1

Lamivudine 150 mg Tablet 1

Lamivudine 300 mg Tablet 1

Lamivudine Hbv 100 mg Tablet 3 SP, PA

Lamivudine-Zidovudine 150-300 mg Tablet 1

Lancets Each 1

Lancets 21 gauge Each 1





Lancets Thin 23 gauge Each 1

Lancets Ultra Thin 26 gauge Each 1

Lancing Device Each 1

Lancing Device Kit 1

Lancing System Each 1

Lanoxin 62.5 mcg Tablet 2

Lansoprazol-Amoxicil-Clarithro 30-500-500 Combo. Pkg 1

Lanthanum Carbonate 1000 mg Tab Chew 1

Lapatinib 250 mg Tablet 3 SP, PA

Larin 1.5-0.03mg Tablet 1

Larin 1mg-20mcg Tablet 1

Larin 24 Fe 1mg-20(24) Tablet 1

Larin Fe 1.5-30(21) Tablet 1

Larin Fe 1mg-20(21) Tablet 1

Larissia 0.1-0.02mg Tablet 1

Latanoprost 0.01% Drops 1

Lax Stool Softener With Senna 8.6mg-50mg Tablet 1

Laxa Basic 100 100 mg Capsule 1

Laxacin 8.6mg-50mg Tablet 1

Laxative 5 mg Tablet Dr 1

Laxative Suppository 10 mg Supp.Rect 1

Laxative Suppository pediatric Supp.Rect 1

Layolis Fe 0.8-25(24) Tab Chew 1

Lazanda 100mcg/spr Spray/Pump 2



Leena 7/9/2005 Tablet 1

Leflunomide 10 mg Tablet 1

Leflunomide 20 mg Tablet 1


2021.1 (1/15/2021).



Lenvima 10 mg/day Capsule 4 SP, PA






Lenvima 4 mg Capsule 4 SP, PA


Lessina 0.1-0.02mg Tablet 1

Letrozole 2.5 mg Tablet 1

Leucovorin Calcium 10 mg Tablet 1




Leukeran 2 mg Tablet 4 SP

Leuprolide Acetate 1 mg/0.2ml Kit 3 SP, PA

Leuprolide Acetate 1 mg/0.2ml Vial 3 SP, PA

Levalbuterol Concentrate 1.25mg/0.5 Vial-Neb 1 QL, ST

Limited to 96 vials per 30 days MUST TRY/FAIL ALBUTEROL NEBULIZER SOLUTION.

Levalbuterol Hcl 0.31mg/3ml Vial-Neb 1 QL, ST






Levalbuterol Tartrate Hfa 45 mcg Hfa Aer Ad 1 QL, ST

Limited to 2 inhalers per 30 days MUST TRY/FAIL ALBUTEROL SULFATE HFA (AUTHORIZED GENERIC OF PROAIR OR VENTOLIN)

Levatol 20 mg Tablet 2

Lever Lock Cannula Each 1

Levetiracetam 100 mg/ml Solution 1

Levetiracetam 500 mg/5ml Solution 1

Levetiracetam 1000 mg Tablet 1


2021.1 (1/15/2021).






Levetiracetam Er 500 mg Tab Er 24h 1

Levetiracetam Er 750 mg Tab Er 24h 1

Levobunolol Hcl 0.50% Drops 1

Levocarnitine 100 mg/ml Solution 1

Levocarnitine 330 mg Tablet 1

Levocarnitine Sf 100 mg/ml Solution 1

Levocetirizine Dihydrochloride 2.5 mg/5ml Solution 1 QL Limited to 148ml per 30 days

Levofloxacin 0.50% Drops 1

Levofloxacin 250mg/10ml Solution 1

Levofloxacin 250 mg Tablet 1



Levonest 6/5/2010 Tablet 1

Levonorgestrel 1.5 mg Tablet 1

Levonorgestrel-Eth Estradiol 0.1-0.02mg Tablet 1

Levonorgestrel-Eth Estradiol 0.15-0.03 Tablet 1

Levonorgestrel-Eth Estradiol 6/5/2010 Tablet 1

Levonorgestrel-Eth Estradiol 90-20 mcg Tablet 1

Levonorgestrel-Eth Estradiol 0.15-0.03 Tbdspk 3mo 1

Levonorg-Eth Estrad Eth Estrad 0.15mg(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Levonorg-Eth Estrad Eth Estrad 100-20(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Levonorg-Eth Estrad Eth Estrad 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Levora-28 0.15-0.03 Tablet 1

Levothyroxine Sodium 100 mcg Tablet 1












Levulan 20% Sol W/Appl 2

Lexiva 50 mg/ml Oral Susp 2

Lice Killing 1% Liquid 1


2021.1 (1/15/2021).



Lice Treatment 1% Liquid 1

Lidocaine Hcl 2% Jelly(Ml) 1

Lidocaine Hcl 3% Lotion 1

Lidocaine Hcl 4% Solution 1

Lidocaine Hcl 40 mg/ml Solution 1

Lidocaine-Epinephrin-Tetracain 4-0.05-0.5 Sol/Pf App 1

Lidocaine-Hydrocortisone 3 %-0.5 % Cream (G) 1

Lidocaine-Prilocaine 2.5 %-2.5% Cream (G) 1

Lidocaine-Prilocaine 2.5 %-2.5% Kit 1

Lidopac 5% Kit 2

Lidopin 3.25% Cream (G) 2

Lidopure Patch 5% Combo. Pkg 1

Lidorx 3% Gel W/Pump 2

Lidotrex 2% Gel (Gram) 2

Lidovex 3.75% Cream (G) 2

Liletta 20.1mcg/24 Iud 2

Lillow 0.15-0.03 Tablet 1

Lindane 1% Shampoo 1

Linezolid 100 mg/5ml Susp Recon 1

Linzess 145 mcg Capsule 2 QL Limited to 30 caps per 30 days



Liothyronine Sodium 25 mcg Tablet 1



Lipochol Plus 0.5 mg Tablet 2

Liquid Antacid 200-200-20 Oral Susp 1

Liquid Antacid 400-400-40 Oral Susp 1

Lisinopril 10 mg Tablet 1

Lisinopril 2.5 mg Tablet 1





Lisinopril-Hydrochlorothiazide 10-12.5mg Tablet 1

Lisinopril-Hydrochlorothiazide 20 mg-25mg Tablet 1

Lisinopril-Hydrochlorothiazide 20-12.5 mg Tablet 1

Lite Coat Aspirin 325 mg Tablet 1

Lite Touch 29 g x1/2"" Dis Needle 1

Lite Touch 31 g x1/4"" Dis Needle 1

Lite Touch 31 gx3/16"" Dis Needle 1


2021.1 (1/15/2021).



Lite Touch 31 gx5/16"" Dis Needle 1

Lite Touch 28 gauge Disp Syrin 1



Lite Touch 31 gx5/16"" Disp Syrin 1

Lite Touch Each 1

Lite Touch 28 gauge Each 1



Litetouch Insulin Syringe 29 g x1/2"" Disp Syrin 1

Litetouch Insulin Syringe 30 gx5/16"" Disp Syrin 1

Lithostat 250 mg Tablet 2

Little Remedies Fever-Pain 160 mg/5ml Oral Susp 1

Little Remedies Gas Relief 40mg/0.6ml Drops Susp 1

Little Remedies Stuffy Nose 0.65% Spray 1

Livalo 1 mg Tablet 2 QL Limited to 30 tabs per 30 days



Lo-Dose Aspirin Ec 81 mg Tablet Dr 1

Lojaimiess 100-20(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Long Acting Nasal Decongestant 120 mg Tablet Er 1

Lonhala Magnair Refill 25 mcg/ml Vial-Neb 2

Lonhala Magnair Starter 25 mcg/ml Vial-Neb 2

Lonsurf 15-6.14 mg Tablet 4 SP, PA, QL Limited to 80 tabs per 28 days

Lonsurf 20-8.19 mg Tablet 4 SP, PA, QL Limited to 80 tabs per 28 days

Loperamide 2 mg Capsule 1

Lopinavir-Ritonavir 400-100/5 Solution 1

Lopreeza 1 mg-0.5mg Tablet 1

Loprox 0.77% Kit Ss-Cln 2

Loradamed 10 mg Tablet 1

Loratadine 5 mg/5 ml Solution 1

Loratadine 10 mg Tab Rapdis 1

Loratadine 10 mg Tablet 1

Loratadine Allergy 5 mg/5 ml Solution 1

Lorcet 5 mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Lorcet Hd 10mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Loryna 0.02-3(28) Tablet 1

Losartan Potassium 100 mg Tablet 1



Losartan-Hydrochlorothiazide 100-12.5mg Tablet 1


2021.1 (1/15/2021).



Losartan-Hydrochlorothiazide 100mg-25mg Tablet 1

Losartan-Hydrochlorothiazide 50-12.5 mg Tablet 1

Lotemax 0.50% Drops Gel 2

Lotemax 0.50% Oint. (G) 2

Lotemax Sm 0.38% Drops Gel 2

Loutrex Cream (G) 1

Lovastatin 10 mg Tablet 1



Low Dose Aspirin Ec 81 mg Tablet Dr 1

Low-Ogestrel 0.3-0.03mg Tablet 1

Lo-Zumandimine 0.02-3(28) Tablet 1

Lucemyra 0.18 mg Tablet 2 QL Limited to 224 tabs per 14 days

Luer-Lok Syringe Disp Syrin 1

Lugol's 5 %-10 % Solution 1

Lugol's 5% Solution 1

Lupron Depot 11.25 mg Syringekit 4 SP, PA



Lupron Depot 30 mg Syringekit 4 SP, PA


Lupron Depot (Lupaneta) 11.25 mg Syringekit 4 SP, PA

Lupron Depot (Lupaneta) 3.75 mg Syringekit 4 SP, PA

Lupron Depot-Ped 11.25 mg Kit 4 SP, PA

Lupron Depot-Ped 15 mg Kit 4 SP, PA

Lupron Depot-Ped 7.5 mg Kit 4 SP, PA

Lutera 0.1-0.02mg Tablet 1

Luxamend Cream (G) 2

Lyrica Cr 165 mg Tab Er 24h 2

Lyrica Cr 330 mg Tab Er 24h 2

Lyrica Cr 82.5 mg Tab Er 24h 2

Lysiplex Plus Tablet 2

Lyza 0.35 mg Tablet 1

Maalox Advanced 200-200-20 Oral Susp 1

Macuvex 1-250-200 Capsule 2

Macuzin 1-500-400 Capsule 2

Mafenide Acetate 50 g Packet 1

Mag64 64 mg Tablet Dr 1

Mag-Al Plus 200-200-20 Oral Susp 1

Mag-Al Plus Xs 400-400-40 Oral Susp 1

Magellan Insulin Safety Syrng 29 g x1/2"" Disp Syrin 1


2021.1 (1/15/2021).



Magellan Insulin Safety Syrng 30 gx5/16"" Disp Syrin 1

Magellan Insulin Syringe 30 gx5/16"" Disp Syrin 1

Magic Bullet 10 mg Supp.Rect 1

Maglox 200-200-20 Oral Susp 1

Magnebind 400 Rx 200-400-1 Tablet 1

Magnesium 400 mg Tablet 1

Magnesium Chloride 70 mg Tablet Dr 1

Magnesium Citrate Solution 1

Magnesium Oxide 400 mg Tablet 1

Malathion 0.50% Lotion 1

Mapap 500 mg Tablet 1

Mapap Arthritis Pain 650 mg Tablet Er 1

Marlissa 0.15-0.03 Tablet 1

Marnatal-F 60 mg-1 mg Capsule 1

Masanti 400-400-40 Oral Susp 1

Masophen 325 mg Tablet 1

Masophen 500 mg Tablet 1

Matristem 10cmx 15cm Sheet 2

Matristem 3 cm x7 cm Sheet 2

Matristem 3cm x3.5cm Sheet 2

Matristem 7cm x 10cm Sheet 2

Matristem Micromatrix 100 mg Powder(Ea) 2





Matulane 50 mg Capsule 4 SP

Matzim La 180 mg Tab Er 24h 1





Mavyret 100mg-40mg Tablet 4 SP, PA, QL Limited to 84 tabs in 28 days

Maxepa 500 mg Capsule 1

Maxfe 160mg-1-60 Tablet 2

Maxi-Comfort 28gx1/2"" Disp Syrin 1

Maxidex 0.10% Drops Susp 2

Maxi-Tuss Cd 4-10-10/5 Liquid 2

Maxi-Tuss G 100-10mg/5 Liquid 1

M-Dryl 12.5mg/5ml Liquid 1

Meclizine Hcl 12.5 mg Tablet 1


2021.1 (1/15/2021).



Meclizine Hcl 25 mg Tablet 1

Mediproxen 220 mg Tablet 1

Medisense Combo. Pkg 1

Medisense Each 1

Medisense Control Combo. Pkg 1

Medisense Glucose Ketone Combo. Pkg 1

Medisense Glucose Ketone Contr Each 1

Medisense Thin Lancets 28 gauge Each 1

Medlance Plus 21 gauge Each 1



Medlance Plus Special Blade 0.8 mmx2mm Each 1

Medrol 2 mg Tablet 2

Medroxyprogesterone Acetate 150 mg/ml Syringe 1 QL Limited to 1 injection per 84 days

Medroxyprogesterone Acetate 10 mg Tablet 1

Medroxyprogesterone Acetate 2.5 mg Tablet 1

Medroxyprogesterone Acetate 5 mg Tablet 1

Medroxyprogesterone Acetate 150 mg/ml Vial 1 QL Limited to 1 injection per 84 days

Mefloquine Hcl 250 mg Tablet 1

Mega Multi W-Chelated Minerals Tablet 1

Megestrol Acetate 400mg/10ml Oral Susp 1

Megestrol Acetate 625mg/5ml Oral Susp 1

Megestrol Acetate 20 mg Tablet 1

Megestrol Acetate 40 mg Tablet 1

Melatin 3 mg Tablet 1

Melatonin 3 mg Tab Rapdis 1

Melatonin 3 mg Tablet 1

Melatonin 3 mg-10 mg Tablet 1

Melatonin 3mg-500mcg Tablet 1

Melodetta 24 Fe 1mg-20(24) Tab Chew 1

Meloxicam 5 mg Capsule 1 QL, ST

Limited to 30 caps per 30 days Must try/fail at least one of the following: meloxicam, aspirin, naproxen, ketoprofen, oxaprozin, tolmetin, diclofenac, or sulindac.

Meloxicam 10 mg Capsule 1 QL, ST

Limited to 30 caps per 30 days Must try/fail at least one of the following: meloxicam, aspirin, naproxen, ketoprofen,


2021.1 (1/15/2021).



oxaprozin, tolmetin, diclofenac, or sulindac.

Meloxicam 15 mg Tablet 1

Meloxicam 7.5 mg Tablet 1

Melphalan 2 mg Tablet 3 SP

Memantine Hcl 5 mg-10 mg Tab Ds Pk 1

Menactra 4mcg/0.5ml Vial 2

Menest 0.3 mg Tablet 2




Menostar 14mcg/24hr Patch Tdwk 2

Men's One Daily Tablet 1

Mentax 1% Cream (G) 2

Mentho-Caine 5 %-8 % Kt Oint Sp 2

Menveo A-C-Y-W-135-Dip 10-5/0.5ml Kit 2

Menveo Mena Component 10 mcg/0.5 Vial 2

Menveo Mencyw-135 Component 5mcgx3/0.5 Vial 2

Meperidine Hcl 50 mg/5 ml Solution 1

Meperidine Hcl 100 mg Tablet 1

Meperidine Hcl 50 mg Tablet 1

Mercaptopurine 50 mg Tablet 1

Mesalamine 4 g/60 ml Enema 1

Mesalamine 1000 mg Supp.Rect 1 QL Limited to 30 suppositories per 30 days

Mesalamine 1.2 g Tablet Dr 1 QL Limited to 120 tabs per 30 days

Mesalamine 800 mg Tablet Dr 1 QL Limited to 180 tabs per 30 days

Mesalamine Dr 400 mg Cap(Drtab) 1 QL Limited to 180 caps per 30 days

Mesalamine Er 0.375g Cap Er 24h 1 QL Limited to 120 caps per 30 days

Mesnex 400 mg Tablet 4 SP

Metadate Er 20 mg Tablet Er 1 QL Limited to 90 tabs per 30 days

Metamucil 3.4g/5.8g Powder 1

Metamucil Multihealth Fiber 3.4g/5.8g Powder 2

Metaproterenol Sulfate 10 mg/5 ml Syrup 1

Meter-Check Each 1

Metformin Er Osmotic 500 mg Tab Er 24 1

Metformin Hcl 1000 mg Tablet 1



Metformin Hcl Er 500 mg Tab Er 24h 1

Metformin Hcl Er 750 mg Tab Er 24h 1


2021.1 (1/15/2021).



Methadone Hcl 10 mg/ml Oral Conc 1

Methadone Hcl 10 mg/5 ml Solution 1

Methadone Hcl 5 mg/5 ml Solution 1

Methadone Hcl 10 mg Tablet 1

Methadone Hcl 5 mg Tablet 1

Methadone Hcl 40 mg Tablet Sol 1

Methadone Intensol 10 mg/ml Oral Conc 1

Methadose 40 mg Tablet Sol 1

Methenamine Mandelate 1 g Tablet 1

Methenamine Mandelate 500 mg Tablet 1

Methimazole 10 mg Tablet 1

Methimazole 5 mg Tablet 1

Methitest 10 mg Tablet 2 PA

Methocarbamol 500 mg Tablet 1

Methocarbamol 750 mg Tablet 1

Methotrexate 2.5 mg Tablet 1

Methoxsalen 10 mg Cap Lq Rap 1

Methscopolamine Bromide 2.5 mg Tablet 1

Methscopolamine Bromide 5 mg Tablet 1

Methyldopa 250 mg Tablet 1

Methyldopa 500 mg Tablet 1

Methyldopa-Hydrochlorothiazide 250mg-15mg Tablet 1

Methyldopa-Hydrochlorothiazide 250mg-25mg Tablet 1

Methylergonovine Maleate 0.2 mg Tablet 1

Methylphenidate Er 18 mg Tab Er 24 1 QL Limited to 60 tabs per 30 days





Methylphenidate Er 10 mg Tablet Er 1 QL Limited to 90 tabs per 30 days

Methylphenidate Er 20 mg Tablet Er 1 QL Limited to 90 tabs per 30 days

Methylphenidate Er (La) 10 mg Cpbp 50-50 1 QL Limited to 30 caps per 30 days




Methylphenidate Hcl 10 mg/5 ml Solution 1 QL Limited to 900ml per 30 days

Methylphenidate Hcl 5 mg/5 ml Solution 1 QL Limited to 1800ml per 30 days

Methylphenidate Hcl 10 mg Tab Chew 1

Methylphenidate Hcl 2.5 mg Tab Chew 1

Methylphenidate Hcl 5 mg Tab Chew 1

Methylphenidate Hcl 10 mg Tablet 1


2021.1 (1/15/2021).





Methylphenidate Hcl Cd 10 mg Cpbp 30-70 1 QL Limited to 60 caps per 30 days






Methylphenidate Hcl Er (Cd) 10 mg Cpbp 30-70 1 QL Limited to 60 caps per 30 days






Methylphenidate La 10 mg Cpbp 50-50 1 QL Limited to 30 caps per 30 days





Methylprednisolone 4 mg Tab Ds Pk 1

Methylprednisolone 16 mg Tablet 1




Metipranolol 0.30% Drops 1

Metoclopramide Hcl 10 mg/10ml Solution 1

Metoclopramide Hcl 5 mg/5 ml Solution 1

Metoclopramide Hcl 10 mg Tablet 1

Metoclopramide Hcl 5 mg Tablet 1

Metolazone 10 mg Tablet 1

Metolazone 2.5 mg Tablet 1

Metolazone 5 mg Tablet 1

Metoprolol Succinate 100 mg Tab Er 24h 1




Metoprolol Tartrate 100 mg Tablet 1


Metoprolol Tartrate 37.5 mg Tablet 1




2021.1 (1/15/2021).



Metoprolol-Hydrochlorothiazide 100mg-25mg Tablet 1

Metoprolol-Hydrochlorothiazide 100mg-50mg Tablet 1

Metoprolol-Hydrochlorothiazide 50 mg-25mg Tablet 1

Metronidazole 375 mg Capsule 1

Metronidazole 1% Gel (Gram) 1

Metronidazole 0.75% Gel W/Appl 1

Metronidazole 1% Gel W/Pump 1

Metronidazole 0.75% Lotion 1

Metronidazole 250 mg Tablet 1

Metronidazole 500 mg Tablet 1

Metyrosine 250 mg Capsule 3 SP, PA, QL Limited to 448 caps per 28 days

Mexiletine Hcl 150 mg Capsule 1



Mgo 400 mg Tablet 1

Mi-Acid 200-200-20 Oral Susp 1

Mi-Acid 400-400-40 Oral Susp 1

Mi-Acid 80 mg Tab Chew 1

Mibelas 24 Fe 1mg-20(24) Tab Chew 1

Micatin 2% Cream (G) 1

Miconazole 3 200 mg-2 % Cmb Pf Crm 1

Miconazole 3 200 mg-2 % Kit 1

Miconazole 3 200 mg Supp.Vag 1

Miconazole 7 2% Cream/Appl 1

Miconazole 7 100 mg Supp.Vag 1

Miconazole Nitrate 2% Cream (G) 1

Miconazole Nitrate 2% Cream/Appl 1

Miconazole-7 2% Cream/Appl 1

Micrhogam Ultra-Filtered Plus 250 unit Syringe 2

Micro Thin Lancet 33 gauge Each 1

Micro Thin Lancets 33 gauge Each 1

Microbore Extension Set Infus.Set 1

Microcyn 0.00% Spray 2

Microdot Each 1

Microdot Glucose Gel 40% Gel (Gram) 1

Microgestin 1.5-0.03mg Tablet 1

Microgestin 1mg-20mcg Tablet 1

Microgestin Fe 1.5-30(21) Tablet 1

Microgestin Fe 1mg-20(21) Tablet 1

Microlet Each 1

Microlet 2 Kit 1


2021.1 (1/15/2021).



Microtainer Lancets 1.5 mmx2mm Each 1

Midazolam Hcl 2 mg/ml Syrup 1

Midazolam Hcl 10 mg/10ml Vial 1

Midazolam Hcl 10 mg/2 ml Vial 1



Midazolam Hcl 5 mg/ml Vial 1

Midazolam Hcl 5 mg/ml(1) Vial 1

Mifeprex 200 mg Tablet 2

Migergot 2-100mg Supp.Rect 2

Miglustat 100 mg Capsule 3 SP

Migraine Formula 250-250-65 Tablet 1

Migraine Relief 250-250-65 Tablet 1

Mili 0.25-0.035 Tablet 1

Milk Of Magnesia 400 mg/5ml Oral Susp 1

Millipred 5 mg Tablet 2

Millipred Dp 5 mg (21) Tab Ds Pk 2

Millipred Dp 5 mg (48) Tab Ds Pk 2

Mimvey 1 mg-0.5mg Tablet 1

Mini Lancing Device Each 1

Mini Ultra-Thin Ii 31 gx3/16"" Dis Needle 1

Minitran 0.1mg/hr Patch Td24 1




Minocycline Er 135 mg Cap Er 24h 1

Minocycline Er 90 mg Cap Er 24h 1

Minocycline Hcl 100 mg Capsule 1



Minocycline Hcl 100 mg Tablet 1

Minocycline Hcl 50 mg Tablet 1

Minocycline Hcl Er 65 mg Tab Er 24h 1

Minolira Er 105 mg Tab Bp 24h 2

Minolira Er 135 mg Tab Bp 24h 2

Minoxidil 10 mg Tablet 1

Minoxidil 2.5 mg Tablet 1

Mintox Maximum Strength 400-400-40 Oral Susp 1

Mircera 200mcg/0.3 Syringe 4 SP

Mircera 30 mcg/0.3 Syringe 4 SP

Mircera 50 mcg/0.3 Syringe 4 SP


2021.1 (1/15/2021).



Mirena 20mcg/24hr Iud 2

Mirvaso 0.33% Gel W/Pump 2

Misoprostol 100 mcg Tablet 1

Misoprostol 200 mcg Tablet 1

Mitosol 0.2 mg Kit 2

M-M-R Ii Vaccine 12500/0.5 Vial 2

M-Natal Plus 27 mg-1 mg Tablet 1

Moderna Covid19 Vacc(Unapprov) 100mcg/0.5 Vial 2

Moexipril Hcl 15 mg Tablet 1

Moexipril Hcl 7.5 mg Tablet 1

Mometasone Furoate 0.10% Cream (G) 1

Mometasone Furoate 0.10% Oint. (G) 1

Mometasone Furoate 0.10% Solution 1

Mondoxyne Nl 100 mg Capsule 1

Monistat 3 200 mg-2 % Cmb Pf Crm 2

Monistat 3 200 mg-2 % Kit 2

Monistat 7 2% Cream/Appl 1

Monoject 28 gauge Disp Syrin 1

Monoject Insulin Safety Syrng 29 g x1/2"" Disp Syrin 1

Monoject Insulin Syringe Disp Syrin 1

Monoject Insulin Syringe 25gx5/8"" Disp Syrin 1



Monoject Insulin Syringe 29 g x1/2"" Disp Syrin 1

Monoject Insulin Syringe 30 gx5/16"" Disp Syrin 1

Monoject Insulin Syringe 31 gx5/16"" Disp Syrin 1

Monoject Luer Adapter Iv Accessr 1

Monolet Lancets 21 gauge Each 1

Monolet Thin Lancets 28 gauge Each 1

Mono-Linyah 0.25-0.035 Tablet 1

Monsel's .2-.22g/ml Sol W/Appl 1

Montelukast Sodium 5 mg Tab Chew 1

Montelukast Sodium 10 mg Tablet 1

Morgidox 100 mg Kit 2

Morphine Sulfate 10 mg/5 ml Solution 1

Morphine Sulfate 100 mg/5ml Solution 1

Morphine Sulfate 20 mg/5 ml Solution 1

Morphine Sulfate 10 mg Supp.Rect 1





2021.1 (1/15/2021).



Morphine Sulfate 15 mg Tablet 2




Morphine Sulfate Er 10 mg Cap Er Pel 1



Morphine Sulfate Er 100 mg Tablet Er 1





Motofen 1-0.025mg Tablet 2

Moviprep 7.5-2.691g Powd Pack 2 QL Limited to 1 pack per 1 day

Moxatag 775 mg Tbmp 24hr 2

Moxifloxacin 0.50% Drops Visc 1 QL, ST

Limited to 3ml per 7 days Must try/fail at least 1 of the following: GENERIC CIPROFLOXACIN DROPS, LEVOFLOXACIN DROPS OR OFLOXACIN DROPS.

Moxifloxacin Hcl 400 mg Tablet 1

M-Pap 160 mg/5ml Liquid 1

Mtx Support 0.5 mg-1mg Tablet 1

Mulpleta 3 mg Tablet 4 SP, PA, QL Limited to 21 tabs per 365 days

Multaq 400 mg Tablet 2

Multi-Day Plus Iron 18mg-0.4mg Tablet 1

Multigen Folic 70-150-1mg Tablet 1

Multigen Plus 151-60-1mg Tablet 1

Multihealth Fiber 3.4 g/7 g Powder 1

Multihealth Fiber 3.4g/5.8g Powder 1

Multiple Vitamin Tablet 1

Multiple Vitamins Tablet 1

Multivitamin Tablet 1

Multi-Vitamin Daily Tablet 1

Multi-Vitamin W-Fluoride-Iron 0.25-10/ml Drops 1

Multivitamin With Fluoride 0.25 mg/ml Drops 1

Multivitamin With Fluoride 0.5 mg/ml Drops 1

Multivitamin With Fluoride 0.25 mg Tab Chew 1

Multivitamin With Fluoride 0.5 mg Tab Chew 1

Multivitamin With Fluoride 1 mg Tab Chew 1


2021.1 (1/15/2021).



Multivitamin-Iron-Fluoride 0.25-10/ml Drops 1

Multivitamins Tablet 1

Multivitamins With Iron Tablet 1

Multivitamins With Minerals Tablet 1

Mupirocin 2% Cream (G) 1

Mupirocin 2% Oint. (G) 1

Murine Ear Drops 6.50% Drops 1

Murine Ear Wax Removal System 6.50% Drops 1

Muro-128 5% Drops 1

Muro-128 5% Oint. (G) 1

Mvc-Fluoride 0.25 mg Tab Chew 1

Mvc-Fluoride 0.5 mg Tab Chew 1

Mvc-Fluoride 1 mg Tab Chew 1

Mvw Complete Formultn Multivit 1500-800 Capsule 1

My Choice 1.5 mg Tablet 1

My Way 1.5 mg Tablet 1

Mycophenolate Mofetil 250 mg Capsule 1

Mycophenolate Mofetil 200 mg/ml Susp Recon 1

Mycophenolate Mofetil 500 mg Tablet 1

Mycophenolic Acid 180 mg Tablet Dr 1

Mycophenolic Acid 360 mg Tablet Dr 1

Myelogram Tray Tray 1

Myferon 150 150 mg Capsule 1

Myferon-150 Forte 150-25-1 Capsule 1

Myglucohealth Control Solution Each 1

Myglucohealth Lancets 30 gauge Each 1

Mylanta Maximum Strength 400-400-40 Oral Susp 1

Myleran 2 mg Tablet 4 SP

Mynatal 65 mg-1 mg Capsule 1

Mynatal 90-50-1mg Tablet 1

Mynatal Advance 90-1-50 mg Tablet 1

Mynatal Plus 65 mg-1 mg Tablet 1

Mynatal-Z 65 mg-1 mg Tablet 1

Mynate 90 Plus 90-50-1mg Tablet Er 1

Mynephrocaps 1 mg Capsule 1

Mynephron 1 mg Capsule 1

Myorisan 10 mg Capsule 1 QL Limited to 60 caps per 30 days



Mytesi 125 mg Tablet Dr 2 QL Limited to 60 tabs per 30 days

Nabi-Hb >1560/5ml Vial 2


2021.1 (1/15/2021).



Nabi-Hb >312/ml Vial 2

Nabumetone 500 mg Tablet 1

Nabumetone 750 mg Tablet 1

Nadolol 20 mg Tablet 1



Nadolol-Bendroflumethiazide 80 mg-5 mg Tablet 1

Naftifine Hcl 1% Gel (Gram) 1

Naftin 2% Gel (Gram) 2

Naloxone Hcl 0.4 mg/ml Cartridge 1

Naloxone Hcl 1 mg/ml Syringe 1

Naloxone Hcl 0.4 mg/ml Vial 1

Naltrexone Hcl 50 mg Tablet 1

Namenda Xr 7-14-21-28 Cap24 Dspk 2

Namzaric 14mg-10mg Cap Spr 24 2

Namzaric 21 mg-10mg Cap Spr 24 2

Namzaric 28 mg-10mg Cap Spr 24 2

Namzaric 7 mg-10 mg Cap Spr 24 2

Namzaric 7-10/14-10 Cap24 Dspk 2

Naprelan 750 mg Tbmp 24hr 2

Naproxen 125 mg/5ml Oral Susp 1

Naproxen 250 mg Tablet 1



Naproxen 375 mg Tablet Dr 1

Naproxen 500 mg Tablet Dr 1

Naproxen Sodium 220 mg Tablet 1



Naratriptan Hcl 1 mg Tablet 1 QL Limited to 9 tabs per 30 days

Naratriptan Hcl 2.5 mg Tablet 1 QL Limited to 9 tabs per 30 days

Narcan 4 mg Spray 2

Nasal Decongestant 30 mg Tablet 1

Nasal Decongestant 120 mg Tablet Er 1

Nasal Moisturizing 0.65% Spray 1

Nasal Spray 0.65% Spray 1

Nascobal 500mcg/spr Spray 2

Natacyn 5% Drops Susp 2

Natazia 3-2-1(28) Tablet 2

Nateglinide 120 mg Tablet 1

Nateglinide 60 mg Tablet 1


2021.1 (1/15/2021).



Natesto 5.5/0.122 Gel Md Pmp 2

Natpara 100 mcg Cartridge 4 SP, PA, QL Limited to 2 cartridges per 28 days

Natpara 25mcg/dose Cartridge 4 SP, PA, QL Limited to 2 cartridges per 28 days



Natural Daily Fiber 3.4 g/7 g Powder 1

Natural Daily Fiber 3.4g/5.8g Powder 1

Natural Fiber 0.52g Capsule 1

Natural Fiber 3.4 g/7 g Powder 1

Natural Fiber Laxative 3.4 g/12 g Powder 1

Natural Fiber Powder Powder 1

Natural Laxative 8.6 mg Tablet 1

Natural Vegetable Laxative 8.6 mg Tablet 1

Natural Vegetable Powder Powder 1

Natural Vegetable Powder 3.4 g/12 g Powder 1

Nebupent 300 mg Vial-Neb 2 PA, QL Limited to 1 vial per 30 days

Nebusal 3% Vial-Neb 1

Nebusal 6% Vial-Neb 2

Necon 0.5-0.035 Tablet 1

Needles 31 g x1/4"" Dis Needle 1

Neomycin Sulfate 500 mg Tablet 1

Neomycin-Bacitracin-Poly-Hc 3.5-10k-1 Oint. (G) 1

Neomycin-Bacitracin-Polymyxin 3.5mg-400 Oint. (G) 1

Neomycin-Polymyxin-Dexameth 0.10% Drops Susp 1

Neomycin-Polymyxin-Dexameth 3.5-10k-.1 Oint. (G) 1

Neomycin-Polymyxin-Gramicidin 1.75mg-10k Drops 1

Neomycin-Polymyxin-Hc 3.5-10k-1 Drops Susp 1

Neomycin-Polymyxin-Hc 3.5-10k-10 Drops Susp 1

Neomycin-Polymyxin-Hydrocort 3.5-10k-1 Solution 1

Neo-Polycin 3.5mg-400 Oint. (G) 1

Neo-Polycin Hc 3.5-10k-1 Oint. (G) 1

Neosalus Cream (G) 2

Neosalus Foam 2

Neosalus Lotion 2

Neosalus Cp Cream (G) 2

Neosporin 3.5-400-5k Oint. (G) 1

Neo-Synalar 0.5-0.025% Cream (G) 2

Neo-Tuss 200-30mg/5 Liquid 1


2021.1 (1/15/2021).



Nephplex Rx 1mg-60mg Tablet 1

Nephro-Vite Rx 1mg-60mg Tablet 1

Neria 10mmx110cm Infus.Set 1

Neria 6mmx110cm Infus.Set 1

Neria 8 mmx110cm Infus.Set 1

Neria Multi 10mmx90cm Infus.Set 1

Nestabs Dha 32-1-230mg Combo. Pkg 2

Neuac 1.2(1)%-5% Cmb Cr Gel 2

Neuac 1.2(1)%-5% Gel (Gram) 1

Neupro 1 mg/24 hr Patch Td24 2 QL Limited to 30 patches per 30 days





Neuraptine 10% Cream Pack 2

Neurin-Sl 600-600mcg Tab Subl 1

Nevanac 0.10% Drops Susp 2

Nevirapine 50 mg/5 ml Oral Susp 1

Nevirapine 200 mg Tablet 1

Nevirapine Er 100 mg Tab Er 24h 1 QL Limited to 30 tabs per 30 days

Nevirapine Er 400 mg Tab Er 24h 1 QL Limited to 30 tabs per 30 days

New Day 1.5 mg Tablet 1

Newgen 32 mg-1 mg Tablet 1

Nexa Plus 29-1.25-55 Capsule 2

Nexafed 30 mg Tablet 2

Nexavar 200 mg Tablet 4 SP, PA

Nexium 2.5 mg Suspdr Pkt 2 QL Limited to 30 packs per 30 days

Nexplanon 68 mg Implant 4 SP

Niacin 500 mg Tablet 1

Niacin 250 mg Tablet Er 1



Niacor 500 mg Tablet 1

Nicadan 800-10-100 Tablet 2

Nicardipine Hcl 20 mg Capsule 1

Nicardipine Hcl 30 mg Capsule 1

Nicazel 600-5-500 Tablet 2

Nicomide 0.5-750 mg Tablet 2


2021.1 (1/15/2021).



Nicotine Gum 2 mg Gum 1

Nicotine Gum 4 mg Gum 1

Nicotine Lozenge 2 mg Lozenge 1

Nicotine Lozenge 4 mg Lozenge 1

Nicotine Lozenge 2 mg Lozng Mini 1

Nicotine Lozenge 4 mg Lozng Mini 1

Nicotine Patch 14mg/24hr Patch Td24 1

Nicotine Patch 21 mg/24hr Patch Td24 1

Nicotine Patch 7mg/24hr Patch Td24 1

Nicotrol 10 mg Cartridge 2

Nicotrol Ns 10 mg/ml Spray 2

Nifedipine 10 mg Capsule 1

Nifedipine 20 mg Capsule 1

Nifedipine Er 30 mg Tab Er 24 1



Nifedipine Er 30 mg Tablet Er 1



Night Time Pain Medicine 500mg-25mg Tablet 1

Nighttime Allergy Relief 25 mg Tablet 1

Nighttime Sleep Aid 25 mg Capsule 1

Nighttime Sleep Aid 50 mg Capsule 1

Nighttime Sleep Aid 25 mg Tablet 1

Nighttime Sleep Gel 50 mg Capsule 1

Nighttime Underpants Each 1

Nikki 0.02-3(28) Tablet 1

Nilutamide 150 mg Tablet 3 SP, QL Limited to 60 tabs per 30 days

Nimodipine 30 mg Capsule 1

Nitro-Bid 2% Oint. (G) 2

Nitro-Dur 0.3 mg/hr Patch Td24 2

Nitro-Dur 0.8mg/hr Patch Td24 2

Nitrofurantoin 100 mg Capsule 1



Nitrofurantoin 25 mg/5 ml Oral Susp 1

Nitrofurantoin Mono-Macro 100 mg Capsule 1

Nitroglycerin 0.3 mg Tab Subl 1



Nitroglycerin Patch 0.1mg/hr Patch Td24 1


2021.1 (1/15/2021).






Nivatopic Plus Cream (G) 2

Nivestym 300 mcg/ml Vial 4 SP, PA, QL Limited to 14 vials per 28 days

Nivestym 480mcg/1.6 Vial 4 SP, PA, QL Limited to 14 vials per 28 days

Nizatidine 150 mg Capsule 1

Nizatidine 300 mg Capsule 1

Nizatidine 150mg/10ml Solution 1

Noble Formula Hc 1% Cream (G) 1

Nocdurna 27.7 mcg Tab Rapdis 2

Nocdurna 55.3 mcg Tab Rapdis 2

Noctiva 0.83/spray Spray/Pump 2

Noctiva 1.66/spray Spray/Pump 2

Non-Aspirin 160 mg/5ml Elixir 1

Non-Aspirin 160 mg/5ml Oral Susp 1

Non-Aspirin 80 mg Tab Chew 1

Non-Aspirin 325 mg Tablet 1

Non-Aspirin Extra Strength 500 mg Tablet 1

Non-Aspirin Pain Relief 500 mg Tablet 1

Non-Aspirin Pm 500mg-25mg Tablet 1

Non-Aspirin Sleep Aid 500mg-25mg Tablet 1

Nora-Be 0.35 mg Tablet 1

Norditropin Flexpro 10mg/1.5ml Pen Injctr 4 SP, PA

Norditropin Flexpro 15mg/1.5ml Pen Injctr 4 SP, PA

Norditropin Flexpro 30 mg/3 ml Pen Injctr 4 SP, PA

Norditropin Flexpro 5 mg/1.5ml Pen Injctr 4 SP, PA

Norethindrone 0.35 mg Tablet 1

Norethindrone Ac (Lupaneta) 5 mg Tablet 1

Norethindrone Acetate 5 mg Tablet 1

Norethindrone-Eth Estradiol-Fe 1.5-30(21) Tablet 1

Norethindron-Ethinyl Estradiol 0.5mg-2.5 Tablet 1

Norethindron-Ethinyl Estradiol 1.5-0.03mg Tablet 1

Norethindron-Ethinyl Estradiol 1mg-20mcg Tablet 1

Norethindron-Ethinyl Estradiol 1mg-5mcg Tablet 1

Norethin-Eth Estra-Ferrous Fum 1mg-20(24) Capsule 1

Norethin-Eth Estra-Ferrous Fum 0.8-25(24) Tab Chew 1

Norethin-Eth Estra-Ferrous Fum 1mg-20(24) Tab Chew 1

Norethin-Eth Estra-Ferrous Fum 1mg-20(21) Tablet 1

Norgestimate-Ethinyl Estradiol 0.25-0.035 Tablet 1

Norgestimate-Ethinyl Estradiol 7daysx3 28 Tablet 1


2021.1 (1/15/2021).



Norgestimate-Ethinyl Estradiol 7daysx3 lo Tablet 1

Noritate 1% Cream (G) 2

Norlyda 0.35 mg Tablet 1

Normlgel Ag 0.11% Gel (Gram) 2

Norpace Cr 100 mg Capsule Er 2

Norpace Cr 150 mg Capsule Er 2

Nortemp 160 mg/5ml Oral Susp 1

Nortrel 0.5-0.035 Tablet 1

Nortrel 1 mg-35mcg Tablet 1

Nortrel 7 days x 3 Tablet 1

Norvir 100 mg Powd Pack 2

Norvir 80 mg/ml Solution 2

Nova Max Glucose Control Soln Each 1

Nova Safety Lancets 23 gauge Each 1

Nova Safety Lancets 28 gauge Each 1

Nova Sureflex Each 1

Novamax Plus Glu-Ket Each 1

Novofine 32 32 gx 1/4"" Dis Needle 1

Novofine Autocover 30 gx 1/3"" Dis Needle 1

Novolin 70-30 70-30/ml Vial 2 QL Limited to 60ml per 30 days

Novolin 70-30 Flexpen 70-30/ml Insuln Pen 2 QL Limited to 60ml per 30 days

Novolin N 100/ml Vial 2 QL Limited to 60ml per 30 days

Novolin N Flexpen 100/ml (3) Insuln Pen 2 QL Limited to 30ml per 28 days

Novolin R 100/ml Vial 2 QL Limited to 60ml per 30 days

Novolin R Flexpen 100/ml (3) Insuln Pen 2 QL Limited to 60ml per 30 days

Novopen Echo Insuln Pen 1

Novotwist 32 gx 1/5"" Dis Needle 1

Nucynta 100 mg Tablet 2



Nucynta Er 100 mg Tab Er 12h 2 QL Limited to 60 tabs per 30 days





Nu-Derm Sunfader 4 %-spf 15 Cream (G) 2

Nudroxipak I-800 800mg-.025 Kit Lq-Tab 2

Nuedexta 20 mg-10mg Capsule 2 QL Limited to 60 caps per 30 days

Nu-Iron 150 150 mg Capsule 1

Nu-Mag 71.5 mg Tablet Dr 1

Numbonex 2.75% Lotion 2


2021.1 (1/15/2021).



Numbrino 4% Solution 1

Numoisyn Liquid 2

Numoisyn 0.3 g Lozenge 2

Nutraseb Cream (G) 2

Nutropin Aq Nuspin 10 mg/2 ml Pen Injctr 4 SP, PA



Nuvail 16% Nl Fm Soln 2

Nuvakaan 2.5 %-2.5% Kit 1

Nuvessa 1.30% Gel W/Appl 2

Nyamyc 100000/g Powder 1

Nystatin 100000/g Cream (G) 1

Nystatin 100000/g Oint. (G) 1

Nystatin 100000/ml Oral Susp 1

Nystatin 100000/g Powder 1

Nystatin 500k unit Tablet 1

Nystatin-Triamcinolone 100000-0.1 Cream (G) 1

Nystatin-Triamcinolone 100000-0.1 Oint. (G) 1

Nystop 100000/g Powder 1

Nytol Quickcaps 25 mg Tablet 1

Oasis Ultra 3 cm x7 cm Sheet 1

Oasis Ultra 3cm x3.5cm Sheet 1

Oasis Ultra 5cm x 7cm Sheet 1



Ob Complete 50-1.25 mg Tablet 2

Ob Complete With Dha 30-10-1 mg Capsule 2

Obstetrix Dha 29-1-50 mg Cmbpkgdrcp 1

Obstetrix Ec 29-1-50 mg Tablet Dr 2

Obstetrix One 38-1-25 mg Capsule 2

O-Cal Prenatal 15 mg-1 mg Tablet 1

Ocaliva 10 mg Tablet 4 SP, PA

Ocaliva 5 mg Tablet 4 SP, PA

Ocean 0.65% Spray 1

Ocella 0.03mg-3mg Tablet 1

Octreotide Acetate 100 mcg/ml Ampul 3 SP



Octreotide Acetate 100 mcg/ml Syringe 3 SP, PA




2021.1 (1/15/2021).



Octreotide Acetate 1000mcg/ml Vial 3 SP

Octreotide Acetate 200 mcg/ml Vial 3 SP

Odactra 12 sq-hdm Tab Subl 2

Odefsey 200-25-25 Tablet 2

Ofloxacin 0.30% Drops 1

Ofloxacin 300 mg Tablet 1

Ofloxacin 400 mg Tablet 1

Olmesartan Medoxomil 20 mg Tablet 1



Olmesartan-Hydrochlorothiazide 20-12.5 mg Tablet 1

Olmesartan-Hydrochlorothiazide 40 mg-25mg Tablet 1

Olmesartan-Hydrochlorothiazide 40-12.5 mg Tablet 1

Olumiant 1 mg Tablet 4 SP, PA, QL Limited to 30 tabs per 30 days

Omeclamox-Pak 20(20)-500 Combo. Pkg 2

Omega 3 500-1000mg Capsule 1

Omega-3 Fish Oil 300-1000mg Capsule 1

Omeprazole 10 mg Capsule Dr 1 QL Limited to 30 caps per 30 days

Omeprazole 20 mg Capsule Dr 1

Omeprazole 40 mg Capsule Dr 1

Omeprazole 20 mg Tablet Dr 1 QL Limited to 60 tabs per 30 days

Omeprazole Magnesium 20 mg Capsule Dr 1

Omnitrope 10mg/1.5ml Cartridge 4 SP, PA

Omnitrope 5 mg/1.5ml Cartridge 4 SP, PA

Omnitrope 5.8 mg Vial 4 SP, PA

Omnivex 1-5-50 mg Tablet 1

On Call Express Control Soln Each 1

On Call Lancet 30 gauge Each 1

On Call Lancing Device Each 1

On Call Plus Control Each 1

On Call Plus Lancet 30 gauge Each 1

On Call Plus Lancing Device Each 1

On Call Vivid Control Each 1

Onccor 200-10-10 Tablet 1

Oncovite Tablet 1

Ondansetron Hcl 4 mg/5 ml Solution 1 QL Limited to 150ml per 30 days

Ondansetron Hcl 24 mg Tablet 1 QL Limited to 1 tab per 30 days

Ondansetron Hcl 4 mg Tablet 1 QL Limited to 180 tabs per 30 days

Ondansetron Hcl 8 mg Tablet 1 QL Limited to 90 tabs per 30 days

Ondansetron Odt 4 mg Tab Rapdis 1 QL Limited to 180 tabs per 30 days

Ondansetron Odt 8 mg Tab Rapdis 1 QL Limited to 90 tabs per 30 days


2021.1 (1/15/2021).



One Daily Complete Tablet 1

One Daily Complete 0.4mg-18mg Tablet 1

One Daily Energy Tablet 1

One Daily Essential Tablet 1

One Daily Plus Minerals Tablet 1

One-A-Day Essential Tablet 1

One-A-Day Maximum Formula Tablet 1

One-A-Day Men's 400-300mcg Tablet 1

One-A-Day Teen Advantage 9mg-400mcg Tablet 1

One-Daily Multi-Vitamin Tablet 1

Onetouch Delica 30 gauge Each 1

Onetouch Delica 33 gauge Each 1

Onetouch Delica Kit 1

Onetouch Delica Plus Lancet 30 gauge Each 1

Onetouch Delica Plus Lancet 33 gauge Each 1

Onetouch Lancets Each 1

Onetouch Suresoft 18 gauge Each 1



Onetouch Ultra Control Soln Each 1

Onetouch Verio High Cntrl Soln Each 1

Onetouch Verio Mid Cntrl Soln Each 1

Onexton 1.2%-3.75% Gel (Gram) 2

Onexton 1.2%-3.75% Gel W/Pump 2

On-The-Go 30 gauge Each 1

Opcicon One-Step 1.5 mg Tablet 1

Opsumit 10 mg Tablet 4 SP, PA

Option 2 1.5 mg Tablet 1

Opti-Vitamin 1000-60-2 Tablet 1

Optumrx Each 1

Opurity Multivitamin 30-0.8mg Tab Chew 2

Oracit 640-490mg Solution 2

Oralair 100 ir Tab Subl 2

Oralair 100-300 ir Tab Subl 2

Oralair 300 ir Tab Subl 2

Oralone 0.10% Paste (G) 1

Oralyte Solution 1

Oramagicrx Mouthwash 2

Oravig 50 mg Ma Buc Tab 2

Orencia 50mg/0.4ml Syringe 4 SP, PA, QL Limited to 4 syringes per 28 days


2021.1 (1/15/2021).



Orencia 87.5mg/0.7 Syringe 4 SP, PA, QL Limited to 4 syringes per 28 days

Orencia Clickject 125 mg/ml Auto Injct 4 SP, PA, QL Limited to 4 syringes per 28 days

Orkambi 100-125 mg Gran Pack 4 SP, PA, QL Limited to 60 packs per 30 days

Orkambi 150-188 mg Gran Pack 4 SP, PA, QL Limited to 60 packs per 30 days

Orkambi 100-125 mg Tablet 4 SP, PA

Orkambi 200-125mg Tablet 4 SP, PA

Orphenadrine Citrate Er 100 mg Tablet Er 1

Orsythia 0.1-0.02mg Tablet 1

Ortho Df 3775 unit Capsule 2

Oscimin 0.125 mg Tablet 1

Oscimin Sl 0.125 mg Tab Subl 1

Oscimin Sr 0.375 mg Tab Er 12h 1

Oseltamivir Phosphate 30 mg Capsule 1 QL Limited to 28 caps per 90 day and 1 fill per 120 days

Oseltamivir Phosphate 45 mg Capsule 1 QL Limited to 14 caps per 90 days and 1 fill per 120 days

Oseltamivir Phosphate 75 mg Capsule 1 QL Limited to 14 caps per 90 days and 1 fill per 120 days

Oseltamivir Phosphate 6 mg/ml Susp Recon 1 QL Limited to 120ml per 10 day and 1 fill per 120 days

Osmolex Er 129 mg Tab Bp 24h 2



Osmoprep 1.5 g Tablet 2

Otovel 0.3-0.025% Vial 2 QL Limited to 1 package per 7 days

Ovace Plus 9.80% Lotion 2

Ovace Plus 10% Shampoo 2

Oxandrolone 10 mg Tablet 1

Oxandrolone 2.5 mg Tablet 1

Oxaprozin 600 mg Tablet 1

Oxaydo 5 mg Tablet Orl 2

Oxaydo 7.5 mg Tablet Orl 2

Oxcarbazepine 300 mg/5ml Oral Susp 1

Oxcarbazepine 150 mg Tablet 1



Oxistat 1% Lotion 2

Oxtellar Xr 150 mg Tab Er 24h 2




2021.1 (1/15/2021).



Oxybutynin Chloride 5 mg/5 ml Syrup 1 QL Limited to 600ml per 30 days

Oxybutynin Chloride 5 mg Tablet 1 QL Limited to 120 tabs per 30 days

Oxybutynin Chloride Er 10 mg Tab Er 24 1 QL Limited to 60 tabs per 30 days

Oxybutynin Chloride Er 15 mg Tab Er 24 1

Oxybutynin Chloride Er 5 mg Tab Er 24 1 QL Limited to 30 tabs per 30 days

Oxycodone Hcl 5 mg Capsule 1 QL Limited to 480 caps per 30 days

Oxycodone Hcl 20 mg/ml Oral Conc 1

Oxycodone Hcl 5 mg/5 ml Solution 1 QL Limited to 2400ml per 30 days

Oxycodone Hcl 10 mg Tablet 1 QL Limited to 240 tabs per 30 days





Oxycodone Hcl Er 10 mg Tab Er 12h 1 QL, ST

Limited to 90 tabs per 30 days Must try/fail GENERIC MORPHINE SULFATE ER TABLETS

Oxycodone Hcl Er 20 mg Tab Er 12h 1 QL, ST

Limited to 90 tabs per 30 days Must try/fail GENERIC MORPHINE SULFATE ER TABLETS

Oxycodone Hcl-Aspirin 4.8355-325 Tablet 1

Oxycodone Hcl-Ibuprofen 400 mg-5mg Tablet 1

Oxycodone-Acetaminophen 10mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Oxycodone-Acetaminophen 2.5-325 mg Tablet 1 QL Limited to 360 tabs per 30 days

Oxycodone-Acetaminophen 5 mg-325mg Tablet 1 QL Limited to 360 tabs per 30 days

Oxycodone-Acetaminophen 7.5-325 mg Tablet 1 QL Limited to 360 tabs per 30 days

Oxycontin 15 mg Tab Er 12h 2 QL, ST

Limited to 90 tabs per 30 days MUST TRY/FAIL GENERIC MORPHINE SULFATE ER.

Oxymorphone Hcl 10 mg Tablet 1

Oxymorphone Hcl 5 mg Tablet 1

Oxytrol 3.9mg/24hr Patch Tdsw 2 QL Limited to 10 patches per 30 days

Ozobax 5 mg/5 ml Solution 2 QL Limited to 2400ml per 30 days

Pacerone 100 mg Tablet 1



Pain & Sleep 500mg-25mg Tablet 1

Pain Ease Medium Stream Spray Spray 2

Pain Ease Mist Spray Spray 2


2021.1 (1/15/2021).



Pain Relief 160 mg/5ml Liquid 1

Pain Relief 325 mg Tablet 1

Pain Relief 500 mg Tablet 1

Pain Relief 650 mg Tablet Er 1

Pain Relief Extra Strength 500 mg Tablet 1

Pain Relief Pm 500mg-25mg Tablet 1

Pain Reliever 250-250-65 Tablet 1

Pain Reliever 325 mg Tablet 1

Pain Reliever 500 mg Tablet 1

Pain Reliever 650 mg Tablet Er 1

Pain Reliever Plus 250-250-65 Tablet 1

Pain Reliever Pm 500mg-25mg Tablet 1

Pain-Off 250-250-65 Tablet 1

Pancreaze 10.5-35.5k Capsule Dr 2

Pancreaze 16.8-56.8k Capsule Dr 2

Pancreaze 2.6 k-6.2k Capsule Dr 2

Pancreaze 21 k-54.7k Capsule Dr 2

Pancreaze 4.2k-14.2k Capsule Dr 2

Pandel 0.10% Cream (G) 2

Panretin 0.10% Gel (Gram) 2

Pantoprazole Sodium 40 mg Granpkt Dr 1 QL Limited to 30 packets per 30 days

Pantoprazole Sodium 20 mg Tablet Dr 1 QL Limited to 60 tabs per 30 days

Pantoprazole Sodium 40 mg Tablet Dr 1 QL Limited to 60 tabs per 30 days

Paradigm Silhouette Each 1

Paragard T 380-A 380 sq mm Iud 2

Paremyd 1 %-0.25 % Drops 2

Paricalcitol 1 mcg Capsule 1



Paroex 0.12% Mouthwash 1

Paromomycin Sulfate 250 mg Capsule 1

Paser 4 g Granpkt Dr 2

P-Care K80g 40 mg/ml Kit 2

Pcca Accupen-15 Each 1

P-Col Rite 8.6mg-50mg Tablet 1

Pedia Iron 15 mg/ml Drops 1

Pedia Poly-Vite 750-35/ml Drops 2

Pedia Tri-Vite 750-35/ml Drops 1

Pediacare Fever Reducer 160 mg/5ml Oral Susp 1

Pedia-Lax pediatric Supp.Rect 1


2021.1 (1/15/2021).



Pediarix 10/25/2025 Syringe 2

Pediatric Electrolyte Solution 1

Pediatric Enema 9.5-3.5/59 Enema 1

Pediatric Freezer Pops Solution 1

Pedvaxhib 7.5mcg/0.5 Vial 2

Peg 3350-Electrolyte 420g Soln Recon 1

Peg-3350 And Electrolytes 236-22.74g Soln Recon 1

Peg3350-Sod Sul-Nacl-Kcl-Asb-C 7.5-2.691g Powd Pack 1

Peganone 250 mg Tablet 2

Pegasys 180mcg/0.5 Syringe 4 SP, PA, QL Limited to 2 syringes per 28 days

Pegasys 180mcg/ml Vial 4 SP, PA

Pegintron 50 mcg/0.5 Kit 4 SP, PA

Pen Needle 29 g x1/2"" Dis Needle 1

Pen Needle 30 gx5/16"" Dis Needle 1

Pen Needle 31 g x1/4"" Dis Needle 1



Pen Needles 29 g x1/2"" Dis Needle 1

Pen Needles 31 g x1/4"" Dis Needle 1

Pen Needles 31 gx3/16"" Dis Needle 1

Pen Needles 31 gx5/16"" Dis Needle 1

Pen Needles 32gx 5/32"" Dis Needle 1

Penicillamine 250 mg Tablet 1 QL Limited to 480 tabs per 30 days

Penicillin V Potassium 125 mg/5ml Soln Recon 1

Penicillin V Potassium 250 mg/5ml Soln Recon 1

Penicillin V Potassium 250 mg Tablet 1

Penicillin V Potassium 500 mg Tablet 1

Penlen Spray 2

Pennsaid 20mg/g(2%) Sol Md Pmp 2

Pennsaid 2% Soln Pk(G) 2

Pentacel 15-20-5-10 Kit 2

Pentacel Acthib Component 10 mcg/0.5 Vial 2

Pentacel Dtap-Ipv Component 15-20-20 Vial 2

Pentamidine Isethionate 300 mg Vial-Neb 1 PA, QL Limited to 1 vial per 30 days

Pentasa 250 mg Capsule Er 2

Pentasa 500 mg Capsule Er 2

Pentazocine-Naloxone Hcl 50mg-0.5mg Tablet 1

Pentoxifylline 400 mg Tablet Er 1

Peptic Relief 262 mg Tab Chew 1

Pep-T-Med 262 mg Tab Chew 1


2021.1 (1/15/2021).



Perindopril Erbumine 2 mg Tablet 1



Periogard 0.12% Mouthwash 1

Permethrin 5% Cream (G) 1

Pertzye 24k-86.25k Capsule Dr 2

Pertzye 4000-14375 Capsule Dr 2

Pertzye 8k-28.75k Capsule Dr 2

Pharbechlor 4 mg Tablet 1

Pharbedryl 25 mg Capsule 1

Pharbedryl 50 mg Capsule 1

Pharbetol 325 mg Tablet 1

Pharbetol 500 mg Tablet 1

Phaseal Adapter Each 1

Phaseal Assembly Fixture Each 1

Phaseal Connector Luer Each 1

Phaseal Infusion Each 1

Phaseal Injector Luer Each 1

Phaseal Secondary Set Infus.Set 1

Phaseal Y-Site Each 1

Phenazopyridine Hcl 100 mg Tablet 1

Phenazopyridine Hcl 200 mg Tablet 1

Phenobarbital 100 mg Tablet 1


Phenobarbital 16.2 mg Tablet 1





Phenobarbital 97.2mg Tablet 1

Phenobarbital-Belladonna 16.2mg/5ml Elixir 1

Phenobarbital-Belladonna 16.2mg/5ml Elixir 2

Phenobarbital-Hyosc-Atrop-Scop 16.2mg/5ml Elixir 1

Phenobarbital-Hyosc-Atrop-Scop 16.2 mg Tablet 1

Phenohytro 16.2mg/5ml Elixir 2

Phenohytro 16.2 mg Tablet 2

Phenylephrine Hcl 10% Drops 1

Phenylephrine Hcl 2.50% Drops 1

Phenytoin 100 mg/4ml Oral Susp 1

Phenytoin 125 mg/5ml Oral Susp 1

Phenytoin 50 mg Tab Chew 1


2021.1 (1/15/2021).



Phenytoin Sodium Extended 100 mg Capsule 1



Philith 0.4-0.035 Tablet 1

Phillips' Laxative 100 mg Capsule 1

Phoslyra 667 mg/5ml Solution 2

Phospha 250 Neutral 250 mg Tablet 1

Phosphasal 81.6-10.8 Tablet 2

Phospholine Iodide 0.13% Drops 2

Phosphorous 250 mg Tablet 1

Phospho-Trin 250 Neutral 250 mg Tablet 1

Phytonadione 5 mg Tablet 1

Picato 0.02% Gel (Ea) 2

Picato 0.05% Gel (Ea) 2

Pifeltro 100 mg Tablet 2

Pilocarpine Hcl 1% Drops 1



Pilocarpine Hcl 5 mg Tablet 1

Pilocarpine Hcl 7.5 mg Tablet 1

Pimecrolimus 1% Cream (G) 1

Pimtrea 21-5 (28) Tablet 1

Pindolol 10 mg Tablet 1

Pindolol 5 mg Tablet 1

Pink Bismuth 262mg/15ml Oral Susp 1

Pink Bismuth 262 mg Tab Chew 1

Pioglitazone Hcl 15 mg Tablet 1 QL Limited to 30 tabs per 30 days



Pip Lancet 28 gauge Each 1

Pip Lancet 30 gauge Each 1

Pirmella 1 mg-35mcg Tablet 1

Pirmella 7 days x 3 Tablet 1

Piroxicam 10 mg Capsule 1

Piroxicam 20 mg Capsule 1

Plenvu 140-9-5.2g Powd Pk Sq 2

Plexion 9.8%-4.8% Med. Pad 2

Pneumovax 23 25mcg/0.5 Syringe 2

Pneumovax 23 25mcg/0.5 Vial 2

Pnv-Ferrous Fumarate-Docu-Fa 29-1-25 mg Tablet 1

Podocon-25 25% Liquid 1


2021.1 (1/15/2021).



Podofilox 0.50% Solution 1

Polycin 500-10k/g Oint. (G) 1

Poly-Iron 150 mg Capsule 1

Poly-Iron 150 Forte 150-25-1 Capsule 1

Polymyxin B Sul-Trimethoprim 10000-1/ml Drops 1

Polysaccharide Iron 150 mg Capsule 1

Polytoza 5 cmx14cm Sheet 1

Poly-Vi-Flor 0.25 mg/ml Drps Sp Bp 2

Poly-Vi-Flor 0.25 mg Tab Chew 2

Poly-Vi-Flor 0.5 mg Tab Chew 2

Poly-Vi-Flor 1 mg Tab Chew 2

Poly-Vi-Flor With Iron 0.25-7mg/1 Drps Sp Bp 2

Poly-Vi-Flor With Iron 0.5mg-10mg Tab Chew 2

Polyvinyl Alcohol 1.40% Drops 1

Pomalyst 1 mg Capsule 4 SP, PA, QL Limited to 21 caps per 28 days




Pontocaine 2% Solution 2

Portia 0.15-0.03 Tablet 1

Potass Cit-Sod Cit-Citric Acid 500-550/5 Solution 1

Potassium Chloride 10 meq Capsule Er 1

Potassium Chloride 8 meq Capsule Er 1

Potassium Chloride 20meq/15ml Liquid 1

Potassium Chloride 40meq/15ml Liquid 1

Potassium Chloride 20 meq Packet 1

Potassium Chloride 10 meq Tab Er Prt 1

Potassium Chloride 20 meq Tab Er Prt 1

Potassium Chloride 10 meq Tablet Er 1



Potassium Citrate Er 10 meq Tablet Er 1



Potassium Citrate-Citric Acid 1100-334/5 Solution 1

Pr Benzoyl Peroxide 7% Cleanser 1

Pr Natal 400 29-1-400mg Combo. Pkg 1

Pr Natal 400 Ec 29-1-400mg Cmbpkgdrcp 1

Pr Natal 430 29-1-430mg Combo. Pkg 1

Pr Natal 430 Ec 29-1-430mg Cmbpkgdrcp 1

Pradaxa 110 mg Capsule 2


2021.1 (1/15/2021).





Praluent Pen 150 mg/ml Pen Injctr 4 SP, PA

Praluent Pen 75 mg/ml Pen Injctr 4 SP, PA

Pramipexole Dihydrochloride 0.125 mg Tablet 1




Pramipexole Dihydrochloride 1 mg Tablet 1


Pramipexole Er 0.375 mg Tab Er 24h 1



Pramosone 1 %-1 % Cream (G) 2

Pramosone 1 %-1 % Lotion 2

Pramosone 2.5 %-1 % Lotion 2

Pramosone 1 %-1 % Oint. (G) 2

Prasugrel Hcl 5 mg Tablet 1

Pravastatin Sodium 10 mg Tablet 1




Praziquantel 600 mg Tablet 1

Prazosin Hcl 1 mg Capsule 1



Precision Combo. Pkg 1

Precision Glucose Control Combo. Pkg 1

Precision Xtra Each 1

Precision Xtra Strip 1 QL Limited to 300 strips per 30 days

Pred Mild 0.12% Drops Susp 2

Pred-G 0.3%-1% Drops Susp 2

Pred-G 0.3-0.6% Oint. (G) 2

Prednicarbate 0.10% Cream (G) 1

Prednicarbate 0.10% Oint. (G) 1

Prednisolone 15 mg/5 ml Solution 1

Prednisolone Acetate 1% Drops Susp 1

Prednisolone Acet-Gatiflo-Brom 1 %-0.5 % Drops Susp 1

Prednisolone Sodium Phos Odt 10 mg Tab Rapdis 1

Prednisolone Sodium Phos Odt 15 mg Tab Rapdis 1


2021.1 (1/15/2021).



Prednisolone Sodium Phosphate 1% Drops 1

Prednisolone Sodium Phosphate 15 mg/5 ml Solution 1



Prednisone 5 mg/5 ml Solution 1

Prednisone 10 mg Tab Ds Pk 1

Prednisone 5 mg Tab Ds Pk 1

Prednisone 1 mg Tablet 1


Prednisone 2.5 mg Tablet 1




Prednisone Intensol 5 mg/ml Oral Conc 2

Prefest 1-1-0.09mg Tablet 2

Pregabalin 100 mg Capsule 1 QL Limited to 90 caps per 30 days








Pregabalin 20 mg/ml Solution 1 QL Limited to 900ml per 30 days

Premarin 0.3 mg Tablet 2

Premarin 0.45mg Tablet 2




Premium Omega-3 600-1000mg Capsule 1

Premphase 0.625 (14) Tablet 2

Prempro 0.3-1.5mg Tablet 2

Prempro 0.45-1.5mg Tablet 2

Prempro 0.625-2.5 Tablet 2

Prempro 0.625-5 mg Tablet 2

Prena1 Chew 1.4 mg Tab Ch Bph 1

Prena1 Pearl 30-1.4-200 Cap Ir Dr 1

Prenaissance 29-1.25-55 Capsule 1

Prenaissance Plus 28-1-50 mg Capsule 1

Prenata 29 mg-1 mg Tab Chew 2

Prenatabs Rx 29 mg-1 mg Tablet 1


2021.1 (1/15/2021).



Prenatal 19 29-1-25 mg Tablet 2

Prenatal Dha 200 mg Capsule 1

Prenatal Plus 27 mg-1 mg Tablet 1

Prenatal Plus 29 mg-1 mg Tablet 1

Prenatal Vitamin Plus Low Iron 27 mg-1 mg Tablet 1

Prenatal-U 106.5-1mg Capsule 1

Prenate Chewable 1 mg Tab Chew 2

Prenate Dha 18-1-300mg Capsule 2

Prenate Dha 28-1-300mg Capsule 2

Prenate Elite 20 mg-1 mg Tablet 2

Prenate Elite 26 mg-1 mg Tablet 2

Prenate Enhance 28-1-400mg Capsule 2

Prenate Essential 18-1-300mg Capsule 2

Prenate Essential 29-1-300mg Capsule 2

Prenate Mini 18-1-350mg Capsule 2

Prenate Pixie 10-1-200mg Capsule 2

Prenate Restore 27-1-400mg Capsule 2

Prenate Star 20 mg-1 mg Tablet 2

Preparation H 1% Cream (G) 1

Prepidil 0.5 mg/3 g Gel/Pf App 2

Preplus 27 mg-1 mg Tablet 1

Prepopik 10 mg-12 g Powd Pack 2

Pressure Activated Lancets 21 gauge Each 1

Pressure Activated Lancets 28 gauge Each 1

Prestalia 14mg-10mg Tablet 2

Prestalia 3.5-2.5 mg Tablet 2

Prestalia 7 mg-5 mg Tablet 2

Prevalite 4 g Powd Pack 1

Prevalite 4 g Powder 1

Prevident 0.20% Solution 2 A Excluded for members age 19 or older

Prevident 5000 1.10% Gel (Ml) 2 A Excluded for members age 19 or older

Prevident 5000 Enamel Protect 1.1 %-5 % Paste (Ml) 2 A Excluded for members age 19 or older

Prevident 5000 Sensitive 1.1 %-5 % Paste (Ml) 2 A Excluded for members age 19 or older

Previfem 0.25-0.035 Tablet 1

Prevnar 13 0.5 ml Syringe 2 A Drug excluded for members age 64 or under.

Prezcobix 800-150 mg Tablet 2

Prezista 100 mg/ml Oral Susp 2

Prezista 150 mg Tablet 2


2021.1 (1/15/2021).





Prezista 800 mg Tablet 2 QL Limited to 30 tabs per 30 days

Priftin 150 mg Tablet 2

Prilosec Otc 20 mg Tablet Dr 2 QL, ST

Limited to 30 tabs per 30 days Must try/fail at least two of the following generics: lansoprazole, omeprazole, or pantoprazole

Primaquine 26.3 mg Tablet 2

Primidone 250 mg Tablet 1

Primidone 50 mg Tablet 1

Primsol 50 mg/5 ml Solution 2

Pro Comfort Lancet 31 gauge Each 1

Pro Comfort Lancets 30 gauge Each 1

Pro Comfort Tens Electrode Each 1

Pro Comfort Tens Unit Combo. Pkg 1

Probenecid 500 mg Tablet 1

Probenecid-Colchicine 500-0.5 mg Tablet 1

Pro-Ception Fertility Pak Each 1

Prochlorperazine 25 mg Supp.Rect 1

Prochlorperazine Maleate 10 mg Tablet 1

Prochlorperazine Maleate 5 mg Tablet 1

Procrit 10000/ml Vial 4 SP, PA


Procrit 20000/2ml Vial 4 SP, PA





Proctofoam-Hc 1 %-1 % Foam 2

Procto-Med Hc 2.50% Crm/Pe App 1

Procto-Pak 1% Crm/Pe App 1

Proctosol-Hc 2.50% Crm/Pe App 1

Proctozone-Hc 2.50% Crm/Pe App 1

Prodigy Control Solution Each 1

Prodigy Insulin Syringe 28gx1/2"" Disp Syrin 1

Prodigy Insulin Syringe 31 gx5/16"" Disp Syrin 1

Prodigy Lancets 26 gauge Each 1

Prodigy Lancets 28 gauge Each 1

Prodigy Lancing Device Each 1


2021.1 (1/15/2021).



Prodigy Twist Top Lancet 28 gauge Each 1

Proferrin-Forte 12-1mg Tablet 2

Progesterone 100 mg Capsule 1

Progesterone 200 mg Capsule 1

Prograf 0.2 mg Gran Pack 2

Prograf 1 mg Gran Pack 2

Prolensa 0.07% Drops 2

Promacta 12.5 mg Tablet 4 SP, PA

Promacta 25 mg Tablet 4 SP, PA

Promacta 50 mg Tablet 2

Promacta 75 mg Tablet 4 SP, PA

Promethazine Hcl 12.5 mg Supp.Rect 1

Promethazine Hcl 25 mg Supp.Rect 1

Promethazine Hcl 50 mg Supp.Rect 1

Promethazine Hcl 6.25mg/5ml Syrup 1

Promethazine Hcl 12.5 mg Tablet 1

Promethazine Hcl 25 mg Tablet 1

Promethazine Hcl 50 mg Tablet 1

Promethazine-Phenylephrine 5-6.25mg/5 Syrup 1

Promethegan 12.5 mg Supp.Rect 1

Promethegan 25 mg Supp.Rect 1

Promethegan 50 mg Supp.Rect 1

Promiseb Cream (G) 2

Propafenone Hcl 150 mg Tablet 1



Propafenone Hcl Er 325 mg Cap Er 12h 1

Propantheline Bromide 15 mg Tablet 1

Proparacaine Hcl 0.50% Drops 1

Propranolol Hcl 20 mg/5 ml Solution 1

Propranolol Hcl 40mg/5ml Solution 1

Propranolol Hcl 10 mg Tablet 1





Propranolol Hcl Er 120 mg Cap Sa 24h 1




Propranolol-Hydrochlorothiazid 40 mg-25mg Tablet 1


2021.1 (1/15/2021).



Propranolol-Hydrochlorothiazid 80 mg-25mg Tablet 1

Propylthiouracil 50 mg Tablet 1

Proquad 3-4.3-3 Vial 2

Prosight 5000-60-30 Tablet 1

Prosilk 2""x5.5"" Pad 1

Prosilk Gel Gel (Gram) 2

Prostin E2 Vaginal Suppository 20 mg Supp.Vag 2

Provent Each 1

Pruclair Cream (G) 1

Prumyx Cream (G) 1

Pseudoephedrine Er 120 mg Tablet Er 1

Pseudoephedrine Hcl 30 mg Tablet 1

Pseudoephedrine Hcl 60 mg Tablet 1

Psyllium Fiber 0.52g Capsule 1

Pulmicort Flexhaler 180 mcg Aer Pow Ba 2 QL Limited to 2 inhalers per 30 days

Pulmicort Flexhaler 90 mcg Aer Pow Ba 2 QL Limited to 1 inhaler per 15 days

Pulmozyme 1 mg/ml Solution 4 SP, PA

Pure And Gentle Saline Enema 19g-7g/118 Enema 1

Pure Comfort Lancets 30 gauge Each 1

Pure Comfort Safety Lancets 30 gauge Each 1

Purefe Ob Plus 106 mg-1mg Capsule 1

Purefe Plus 106 mg-1mg Capsule 1

Push Button Safety Lancets 21 gauge Each 1

Push Button Safety Lancets 28 gauge Each 1

Pyrazinamide 500 mg Tablet 1

Pyridostigmine Bromide 60 mg Tablet 1

Pyridostigmine Bromide Er 180 mg Tablet Er 1

Pyridoxine Hcl 25 mg Tablet 1

Pyridoxine Hcl 50 mg Tablet 1

Pfizer Covid19 Vacc (Unapprov) 30 mcg/0.3 Vial 2

Qbrexza 2.40% Towelette 2 PA, QL Limited to 30 towelettes per 30 days

Q-Care Rx 0.12% Kit 1

Q-Cliq Pen (For Natpara) 71.4microl Pen Injctr 1

Qnasl Children 40 mcg Hfa Aer Ad 2

Qtern 10 mg-5 mg Tablet 2 ST Must try/fail metformin and metformin combinations.

Quadracel Dtap-Ipv 15-20-20 Vial 2

Quake Each 1

Quflora 0.25 mg/ml Drops 1


2021.1 (1/15/2021).



Quflora 0.5 mg/ml Drops 1

Quflora 0.25(0.55) Tab Chew 1

Quflora 0.5(1.1)mg Tab Chew 1

Quflora 1mg(2.2mg) Tab Chew 1

Quflora Fe 9.5-.25/ml Drops 1

Quillichew Er 20 mg Tab Cbp24h 2 QL, A

Limited to 90 tabs per 30 days Prior authorization required for members over 12 years of age.





Quillivant Xr 5 mg/ml Su Er Rc24 2 A Prior authorization required for members age 7 or younger and age 13 or older.

Quinapril Hcl 10 mg Tablet 1




Quinapril-Hydrochlorothiazide 10-12.5mg Tablet 1

Quinapril-Hydrochlorothiazide 20 mg-25mg Tablet 1

Quinapril-Hydrochlorothiazide 20-12.5 mg Tablet 1

Quinidine Sulfate 200 mg Tablet 1

Quinidine Sulfate 300 mg Tablet 1

Quinine Sulfate 324 mg Capsule 1

Quinja 1.25%-1% Gel (Gram) 2

Quit 2 2 mg Gum 1

Quit 2 2 mg Lozenge 1

Quit 4 4 mg Gum 1

Quit 4 4 mg Lozenge 1

Qutenza 8% Kit 2

Qvar Redihaler 40 mcg Hfa Aeroba 2

Qvar Redihaler 80 mcg Hfa Aeroba 2

Rabavert 2.5 unit Vial 2

Rabeprazole Sodium 10 mg Cap Dr Spr 1 QL Limited to 30 caps per 30 days

Radiaplexrx Gel (Gram) 2

Radiogardase 0.5 gram Capsule 2


2021.1 (1/15/2021).



Ragwitek 12 unit Tab Subl 2

Raloxifene Hcl 60 mg Tablet 1

Ramipril 1.25 mg Capsule 1

Ramipril 10 mg Capsule 1

Ramipril 2.5 mg Capsule 1

Ramipril 5 mg Capsule 1

Rapport Vacuum Therapy Kit 1

Rasagiline Mesylate 0.5 mg Tablet 1

Rasagiline Mesylate 1 mg Tablet 1

Rate Flow Regulator Iv Set Infus.Set 1

Rayaldee 30 mcg Cap Sa 24h 2 QL Limited to 30 caps per 30 days

Rayos 1 mg Tablet Dr 2



Readylance Safety Lancets 21 gauge Each 1





Recedo Gel (Gram) 2

Reclipsen 0.15-0.03 Tablet 1

Recombivax Hb 10 mcg/ml Syringe 2

Recombivax Hb 5mcg/0.5ml Syringe 2

Recombivax Hb 10 mcg/ml Vial 2

Recombivax Hb 40 mcg/ml Vial 2

Recombivax Hb 5mcg/0.5ml Vial 2

Reconstitube Kit 1

Recothrom 20000 unit Vial 2

Recothrom 5000 unit Vial 2

Refresh Classic 1.4 %-0.6% Droperette 2

Refresh Lacri-Lube 42.5-56.8% Oint. (G) 2

Refresh Liquigel 1% Drp Lq Gel 2

Refuah Plus Glucose Control Each 1

Regenecare 2% Gel (Gram) 2

Regenecare 2% Gel (Ml) 2

Regranex 0.01% Gel (Gram) 2

Relafen Ds 1000 mg Tablet 2 QL Limited to 60 tabs per 30 days

Relagard 0.9-0.025% Jelly/Appl 2

Relenza 5 mg Blst W/Dev 2 QL Limited to 1 inhaler per fill

Reliamed 23 gauge Each 1



2021.1 (1/15/2021).




Reliamed Mini Lancing Device Each 1

Reliamed Safety Seal Lancets 28 gauge Each 1

Reliamed Safety Seal Lancets 30 gauge Each 1

Relion Pen Needles 32gx 5/32"" Dis Needle 1

Relion Thin 26 gauge Each 1

Relizorb Cartridge 1

Remedy Antifungal 2% Cream(Ml) 1

Renal Caps 1 mg Capsule 1

Rena-Vite Rx 1mg-60mg Tablet 1

Reno Caps 1 mg Capsule 1

Repaglinide 0.5 mg Tablet 1 ST Must try/fail metformin.

Repaglinide 1 mg Tablet 1 ST Must try/fail metformin.

Repaglinide 2 mg Tablet 1 ST Must try/fail metformin.

Repatha Pushtronex 420 mg/3.5 Wear Injct 4 SP, PA

Repatha Sureclick 140 mg/ml Pen Injctr 4 SP, PA

Repatha Syringe 140 mg/ml Syringe 4 SP, PA

Req49+ 200mcg-1.5 Tablet 2

Respa A.R. 90-8-0.24 Tab Er 12h 1

Restora Rx 60-1.25 mg Capsule 2

Retacrit 2000/ml Vial 4 SP, PA

Retacrit 3000/ml Vial 4 SP, PA

Retacrit 20000/ml Vial 4 SP, PA, QL Limited to 4 vials per 30 days

Retacrit 20000/2ml Vial 4 SP, PA

Retin-A Micro Pump 0.06% Gel W/Pump 2

Retin-A Micro Pump 0.08% Gel W/Pump 2

Revlimid 10 mg Capsule 4 SP, PA


Revlimid 2.5 mg Capsule 4 SP, PA




Reyataz 50 mg Powd Pack 2

Rhofade 1% Cream (G) 2

Rhogam Ultra-Filtered Plus 1500 unit Syringe 2

Rhophylac 1500/2 ml Syringe 2

Ridaura 3 mg Capsule 2

Rifabutin 150 mg Capsule 1

Rifamate 300-150 mg Capsule 2

Rifampin 150 mg Capsule 1

Rifampin 300 mg Capsule 1


2021.1 (1/15/2021).



Rifater 120-50-300 Tablet 2

Ri-Gel 200-200-20 Oral Susp 1

Ri-Gel Ii 400-400-40 Oral Susp 1

Rightest Control Solution Each 1

Rightest Gc250s Control Soln Each 1

Rightest Gd500 Each 1

Rightest Gl300 Lancets 30 gauge Each 1

Riluzole 50 mg Tablet 3 SP, QL

Rimantadine Hcl 100 mg Tablet 1

Risedronate Sodium 30 mg Tablet 1



Ritonavir 100 mg Tablet 1

Ri-Tussin Dm 100-10mg/5 Syrup 1

Rivastigmine 1.5 mg Capsule 1

Rivastigmine 3 mg Capsule 1

Rivastigmine 4.5 mg Capsule 1

Rivastigmine 6 mg Capsule 1

Rizatriptan 10 mg Tab Rapdis 1 QL Limited to 12 tabs per 30 days

Rizatriptan 5 mg Tab Rapdis 1 QL Limited to 12 tabs per 30 days

Rizatriptan 10 mg Tablet 1 QL Limited to 12 tabs per 30 days

Rizatriptan 5 mg Tablet 1 QL Limited to 12 tabs per 30 days

Robafen Dm Cough 100-10mg/5 Liquid 1

Robafen Dm Cough-Chest Congest 100-10mg/5 Syrup 1

Robafen Dm Peak Cold 100-10mg/5 Liquid 1

Ropinirole Er 2 mg Tab Er 24h 1 ST Must try/fail ropinirole IR.

Ropinirole Er 4 mg Tab Er 24h 1 ST Must try/fail ropinirole IR.

Ropinirole Hcl 0.25 mg Tablet 1

Ropinirole Hcl 0.5 mg Tablet 1

Ropinirole Hcl 1 mg Tablet 1





Rosadan 0.75% Kit Cl-Crm 2

Rosadan 0.75% Kit Cl-Gel 2

Rosanil 10-5%(w/w) Cleanser 2

Rosula 10 %-5 % Med. Pad 1

Rosuvastatin Calcium 10 mg Tablet 1 QL Limited to 30 tabs per 30 days




2021.1 (1/15/2021).




Rotarix 10e6/ml Susp Recon 2

Rotateq 2 ml Solution 2

Rubraca 200 mg Tablet 4 SP, PA, QL Limited to 120 tabs per 30 days

Rubraca 300 mg Tablet 4 SP, PA, QL Limited to 120 tabs per 30 days

Ruzurgi 10 mg Tablet 2 PA, QL Limited to 240 tabs per 30 days

Rydapt 25 mg Capsule 4 SP, PA

Rytary 23.75-95mg Capsule Er 2

Rytary 36.25-145 Capsule Er 2



Safesnap Insulin Syringe 28gx1/2"" Disp Syrin 1

Safesnap Insulin Syringe 29 g x1/2"" Disp Syrin 1

Safesnap Insulin Syringe 30 gx5/16"" Disp Syrin 1

Safetussin Dm 100-10mg/5 Liquid 1

Safety Lancets 21 gauge Each 1



Safety Seal Lancets 28 gauge Each 1

Safety Seal Lancets 30 gauge Each 1

Safetyglide Insulin Syringe 29 g x1/2"" Disp Syrin 1

Safetyglide Insulin Syringe 30 gx5/16"" Disp Syrin 1

Safetyglide Insulin Syringe 31 gx5/16"" Disp Syrin 1

Safetyglide Syringe 27gx5/8"" Disp Syrin 1

Safety-Let 30 gauge Each 1

Saizen 5 mg Vial 4 SP, PA

Saizen 8.8 mg Vial 4 SP, PA

Saizen-Saizenprep 8.8mg/1.51 Cartridge 4 SP, PA

Salicylic Acid 6% Crm Er (G) 1

Salicylic Acid 6% Gel (Gram) 1

Salicylic Acid 6% Lotion 1

Salicylic Acid 6% Lotion Er 1

Salicylic Acid 6% Shampoo 1

Salimez Forte 10% Cream (G) 2

Saline Enema 19g-7g/118 Enema 1

Saline Mist 0.65% Spray 1

Saline Nasal Spray 0.65% Spray 1

Saline Nose Spray 0.65% Spray 1

Salmon Oil-1000 1000-200mg Capsule 1

Salsalate 500 mg Tablet 1

Salsalate 750 mg Tablet 1


2021.1 (1/15/2021).



Salvax Duo Plus 6 %-35 % Foam 2

Samsca 15 mg Tablet 4 SP, PA, QL Limited to 30 tabs per 30 days

Sancuso 3.1mg/24hr Patch Tdwk 2

Sandimmune 100 mg/ml Solution 2

Santyl 250 unit/g Oint. (G) 2

Sapropterin Dihydrochloride 100 mg Powd Pack 3 SP, PA

Sapropterin Dihydrochloride 500 mg Powd Pack 3 SP, PA

Sapropterin Dihydrochloride 100 mg Tablet Sol 3 SP, PA

Savaysa 15 mg Tablet 2



Scalacort Dk 2%-2%-2% Combo. Pkg 2

Scarcinpad 1.57x5.12"" Pad 1

Scarsilk 2""x5.5"" Pad 1

Scarsilk Gel Gel (Gram) 2

Scopolamine 1 mg/3 day Patch Td 3 1 QL Limited to 10 patches per 30 days

Sea-Omega 600-1000mg Capsule 1

Sebuderm Gel (Gram) 2

Seconal Sodium 100 mg Capsule 2

Secura Antifungal 2% Cream (G) 1

Segluromet 2.5-1000mg Tablet 2 QL, ST


Segluromet 2.5-500 mg Tablet 2 QL, ST


Segluromet 7.5-1000mg Tablet 2 QL, ST


Segluromet 7.5-500 mg Tablet 2 QL, ST


Select-Ob 29 mg-1 mg Tab Chew 1

Select-Ob + Dha 29-1-250mg Combo. Pkg 2

Selegiline Hcl 5 mg Capsule 1

Selegiline Hcl 5 mg Tablet 1


2021.1 (1/15/2021).



Selenium Sulfide 2.30% Shampoo 1

Selzentry 20 mg/ml Solution 2

Selzentry 150 mg Tablet 2




Semprex-D 60-8mg Capsule 2

Se-Natal 19 29 mg-1 mg Tab Chew 1

Senexon-S 8.6mg-50mg Tablet 1

Senna 8.6 mg Tablet 1

Senna Lax 8.6 mg Tablet 1

Senna Laxative 8.6 mg Tablet 1

Senna Plus 8.6mg-50mg Tablet 1

Senna-Plus 8.6mg-50mg Tablet 1

Senna-S 8.6mg-50mg Tablet 1

Senna-S Laxative 8.6mg-50mg Tablet 1

Senna-Time S 8.6mg-50mg Tablet 1

Sennosides-Docusate Sodium 8.6mg-50mg Tablet 1

Senokot-S 8.6mg-50mg Tablet 1

Sen-O-Tab 8.6 mg Tablet 1

Sentry 18mg-0.4mg Tablet 1

Serevent Diskus 50 mcg Blst W/Dev 2 QL Limited to 1 inhaler per 15 days

Sernivo 0.05% Spray/Pump 2

Serostim 4 mg Vial 4 SP, PA



Se-Tan Plus 106 mg-1mg Capsule 1

Setlakin 0.15-0.03 Tbdspk 3mo 1

Sevelamer Carbonate 800 mg Tablet 1

Sevelamer Hcl 800 mg Tablet 1

Sevoflurane Liquid 1

Sf 1.10% Gel (Gram) 1 A Excluded for members age 19 or older

Sf 5000 Plus 1.10% Cream (G) 1 A Excluded for members age 19 or older

Shake That Ache 500 mg Tablet 1

Sharobel 0.35 mg Tablet 1

Sharps Collector Each 1

Sharps Container Each 1

Sharps Container n/a Each 1

Shingrix 50 mcg/0.5 Kit 2 QL, A Limited to 2 per lifetime


2021.1 (1/15/2021).



Shingrix Ge Antigen Component 50 mcg Vial 2 QL, A Limited to 2 per lifetime

Shohl's Modified 300-500 mg Solution 2

Siklos 100 mg Tablet 2

Siklos 1000 mg Tablet 2

Silace 50 mg/5 ml Liquid 1

Silace 60 mg/15ml Syrup 1

Siladryl 12.5mg/5ml Liquid 1

Silazone-Ii 0.10% Kit 2

Sildenafil Citrate 10 mg/ml Susp Recon 1

Sildenafil Citrate 20 mg Tablet 1 QL Limited to 90 tabs per 30 days

Silivex 2""x5.5"" Pad 1

Sil-K 2""x5.5"" Pad 1

Siltrex 2""x5.5"" Pad 1

Siltussin Dm 100-10mg/5 Syrup 1

Siltussin Dm Das 100-10mg/5 Liquid 1

Silver Nitrate 0.50% Solution 1

Silver Nitrate 10% Solution 1



Silver Nitrate Applicator 75 %-25 % Stick (Ea) 1

Silver Sulfadiazine 1% Cream (G) 1

Simethicone 40mg/0.6ml Drops Susp 1

Simethicone 125 mg Tab Chew 1

Simethicone 80 mg Tab Chew 1

Simliya 21-5 (28) Tablet 1

Simpesse 150-30(84) Tbdspk 3mo 1 QL Limited to 91 tabs per 91 days

Simply Sleep 25 mg Tablet 1

Simponi 100 mg/ml Pen Injctr 4 SP, PA, QL Limited to 1 syringe per 28 days

Simponi 50mg/0.5ml Pen Injctr 4 SP, PA, QL Limited to 0.5ml per 28 days

Simponi 100 mg/ml Syringe 4 SP, PA, QL Limited to 1 syringe per 28 days

Simponi 50mg/0.5ml Syringe 4 SP, PA, QL Limited to 0.5ml per 28 days

Simvastatin 10 mg Tablet 1


Simvastatin 40 mg Tablet 1 QL Limited to 30 tabs per 30 days


Simvastatin 80 mg Tablet 1 PA, QL Limited to 30 tabs per 30 days

Single-Let Each 1

Sinus 12 Hour 120 mg Tablet Er 1

Sinus 12-Hour 120 mg Tablet Er 1

Sirolimus 0.5 mg Tablet 1

Sirolimus 1 mg Tablet 1


2021.1 (1/15/2021).



Sirolimus 2 mg Tablet 1

Sitavig 50 mg Ma Buc Tab 2

Sivextro 200 mg Tablet 2

Sklice 0.50% Lotion 2

Skyla 14mcg/24hr Iud 2

Skyrizi (2 Syringes) Kit 150mg/1.66 Syringekit 4 SP, PA, QL Limited to 1 kit per 84 days

Sleep Aid 25 mg Capsule 1

Sleep Aid 50 mg Capsule 1

Sleep Aid 25 mg Tablet 1

Sleep Ii 25 mg Tablet 1

Sleep Tablet 25 mg Tablet 1

Sleep Tabs 25 mg Tablet 1

Sleep Time 25 mg Capsule 1

Sleep-Aid 25 mg Capsule 1

Sleeping 50 mg Capsule 1

Smart Sense 33 gauge Each 1

Smart Sense Lancets 21 gauge Each 1

Smart Sense Lancets 26 gauge Each 1

Smartdiabetes Vantage Each 1

Smartest Each 1

Smartest Lancet Each 1

Smooth Antacid 300mg(750) Tab Chew 1

Sodium Bicarbonate 325 mg Tablet 1

Sodium Bicarbonate 650 mg Tablet 1

Sodium Chloride 5% Drops 1

Sodium Chloride 5% Oint. (G) 1

Sodium Chloride 0.90% Vial-Neb 1

Sodium Chloride 10% Vial-Neb 1



Sodium Citrate 4 g/100 ml Solution 1

Sodium Citrate 4 % (3 ml) Syringe 1

Sodium Citrate-Citric Acid 334-500mg Solution 1

Sodium Fluoride 1.10% Cream (G) 1 A Excluded for members age 19 or older

Sodium Fluoride 0.5 mg/ml Drops 1 A Excluded for members age 19 or older

Sodium Fluoride 1.10% Gel (Gram) 1 A Excluded for members age 19 or older

Sodium Fluoride 0.25(0.55) Tab Chew 1 A Excluded for members age 19 or older

Sodium Fluoride 0.5(1.1)mg Tab Chew 1 A Excluded for members age 19 or older


2021.1 (1/15/2021).



Sodium Fluoride 1mg(2.2mg) Tab Chew 1 A Excluded for members age 19 or older

Sodium Fluoride 5000 Plus 1.10% Cream (G) 1 A Excluded for members age 19 or older

Sodium Polystyrene Sulfonate 15 g/60 ml Oral Susp 1

Sodium Polystyrene Sulfonate Powder 1

Sodium Sulfacetamide 10% Cleanser 1

Sodium Sulfacetamide 10% Clnsr Gel 1

Sodium Sulfacetamide 10% Shampoo 1

Sodium Sulfacetamide-Sulfur 10 %-2 % Cleanser 1

Sodium Sulfacetamide-Sulfur 10%-5%-10% Cleanser 1

Sodium Sulfacetamide-Sulfur 10-5%(w/w) Cleanser 1

Sodium Sulfacetamide-Sulfur 9 %-4 % Cleanser 1

Sodium Sulfacetamide-Sulfur 9 %-4.5 % Cleanser 1

Sodium Sulfacetamide-Sulfur 9.8%-4.8% Cleanser 1

Sodium Sulfacetamide-Sulfur 10 %-2 % Cream (G) 1

Sodium Sulfacetamide-Sulfur 10-5%(w/w) Cream (G) 1

Sodium Sulfacetamide-Sulfur 9.8%-4.8% Cream (G) 1

Sodium Sulfacetamide-Sulfur 10-5%(w/v) Lotion 1

Sodium Sulfacetamide-Sulfur 10-5%(w/w) Lotion 1

Sodium Sulfacetamide-Sulfur 9.8%-4.8% Lotion 1

Sodium Sulfacetamide-Sulfur 10 %-4 % Med. Pad 1

Sofia2 Flu-Sars Antigen Fia Kit 1

Sofosbuvir-Velpatasvir 400-100 mg Tablet 3 SP, PA, QL Limited to 28 tabs per 28 days

Soft Touch Each 1

Soft-Glide Saf-Q Infusion Set 12mm x30.5 Infus.Set 1

Soft-Glide Saf-Q Infusion Set 9mmx30.5cm Infus.Set 1

Solifenacin Succinate 10 mg Tablet 1

Solifenacin Succinate 5 mg Tablet 1

Solosec 2 g Grandr Pkt 2 QL Limited to 1 pack per 14 days

Soltamox 20 mg/10ml Solution 2 ST Must try/fail generic tamoxifen citrate.

Solus V2 28 gauge Each 1

Solus V2 Control Solution Each 1

Solus V2 Lancets 30 gauge Each 1

Solus V2 Lancing Device Kit 1

Somavert 10 mg Vial 4 SP, PA





Sominex 25 mg Tablet 1


2021.1 (1/15/2021).



Sonafine Emulsn(G) 1

Soothe 262mg/15ml Oral Susp 1

Soothe 262 mg Tab Chew 1

Soothing Care 1% Cream (G) 1

Soothing Pureway-C 500 mg Tablet 1

Sorbitol-Mannitol 0.54g-2.7g Irrig Soln 1

Sorbugen Nr 100-10mg/5 Liquid 1

Sorine 120 mg Tablet 1




Sotalol 120 mg Tablet 1




Sotalol Af 120 mg Tablet 1



Sotylize 5 mg/ml Solution 2

Spectragel Gel (Gram) 1

Spectravite Advanced Formula 18mg-0.4mg Tablet 1

Spinosad 0.90% Suspension 1

Spiriva 18 mcg Cap W/Dev 2 QL Limited to 30 caps per 30 days

Spiriva Respimat 1.25 mcg Mist Inhal 2 QL Limited to 1 inhaler per 30 days

Spiriva Respimat 2.5 mcg Mist Inhal 2 QL Limited to 1 inhaler per 30 days

Spironolactone 100 mg Tablet 1



Spironolactone-Hctz 25 mg-25mg Tablet 1

Spray And Stretch Spray 2

Sprintec 0.25-0.035 Tablet 1

Spritam 1000 mg Tab Susp 2




Sprycel 100 mg Tablet 4 SP, PA







2021.1 (1/15/2021).



Sps 15 g/60 ml Oral Susp 1

Sronyx 0.1-0.02mg Tablet 1

Ssd 1% Cream (G) 1

Sski 1 g/ml Solution 1

Sss 10-5 10-5%(w/w) Cream (G) 1

Sss 10-5 10 %-5 % Foam 1

St. Joseph Aspirin 81 mg Tab Chew 1

St. Joseph Aspirin Ec 81 mg Tablet Dr 1

Stavudine 15 mg Capsule 1




Steglatro 15 mg Tablet 2 QL, ST


Steglatro 5 mg Tablet 2 QL, ST


Steglujan 15mg-100mg Tablet 2 ST Must try/fail metformin and metformin combinations.

Steglujan 5 mg-100mg Tablet 2 ST Must try/fail metformin and metformin combinations.

Stelara 45mg/0.5ml Syringe 4 SP, PA, QL

Stelara 90 mg/ml Syringe 4 SP, PA, QL

Sterilance Tl 30 gauge Each 1

Sterilance Tl 32 gauge Each 1

Stimulant Laxative Plus 8.6mg-50mg Tablet 1

Stivarga 40 mg Tablet 4 SP, PA, QL Limited to 84 tabs in 28 days

Stomach Relief 262mg/15ml Oral Susp 1

Stomach Relief 262 mg Tab Chew 1

Stomach Relief Original 262mg/15ml Oral Susp 1

Stool Softener 100 mg Capsule 1



Stool Softener 50 mg/5 ml Liquid 1

Stool Softener 60 mg/15ml Syrup 1

Stool Softener-Laxative 8.6mg-50mg Tablet 1

Stool Softener-Stimulant Lax 8.6mg-50mg Tablet 1

Stop Smoking Aid 2 mg Lozenge 1


2021.1 (1/15/2021).



Stop Smoking Aid 4 mg Lozenge 1

Stratactx Gel (Gram) 1

Strataxrt Gel (Gram) 1

Stravix 2 cmx 4 cm Sheet 2

Strensiq 18mg/.45ml Vial 4 SP, PA, QL Limited to 24 vials per 28 days

Strensiq 28mg/0.7ml Vial 4 SP, PA, QL Limited to 24 vials per 28 days

Strensiq 40 mg/ml Vial 4 SP, PA, QL Limited to 24 vials per 28 days

Strensiq 80mg/0.8ml Vial 4 SP, PA, QL Limited to 24 vials per 28 days

Stribild 150-200 mg Tablet 2 QL Limited to 30 tabs per 30 days

Striverdi Respimat 2.5 mcg Mist Inhal 2 QL Limited to 1 inhaler per 30 days

Strong Iodine 5% Solution 1

Subsys 100mcg/spr Spray 2 QL Limited to 120 sprays per 30 days

Subsys 1200 mcg Spray 2 QL Limited to 120 sprays per 30 days



Subsys 400mcg/spr Spray 2 QL Limited to 120 sprays per 30 days



Sucralfate 1 g/10 ml Oral Susp 1

Sucralfate 1 g Tablet 1

Sudafed 12 Hour 120 mg Tablet Er 1

Sudogest 30 mg Tablet 1

Sudogest 60 mg Tablet 1

Sudogest 120 mg Tablet Er 1

Sulfacetamide Sodium 10% Drops 1

Sulfacetamide Sodium 10% Oint. (G) 1

Sulfacetamide Sodium 10% Suspension 1

Sulfacetamide-Prednisolone 10 %-0.23% Drops 1

Sulfadiazine 500 mg Tablet 1

Sulfamethoxazole-Trimethoprim 200-40mg/5 Oral Susp 1

Sulfamethoxazole-Trimethoprim 800-160/20 Oral Susp 1

Sulfamethoxazole-Trimethoprim 400mg-80mg Tablet 1

Sulfamethoxazole-Trimethoprim 800-160 mg Tablet 1

Sulfamylon 8.50% Cream (G) 2

Sulfamylon 50 g Packet 2

Sulfasalazine 500 mg Tablet 1


2021.1 (1/15/2021).



Sulfasalazine Dr 500 mg Tablet Dr 1

Sulfatrim 200-40mg/5 Oral Susp 1

Sulindac 150 mg Tablet 1

Sulindac 200 mg Tablet 1

Sumadan 9 %-4.5 % Kit 2

Sumatriptan 20 mg Spray 1 QL Limited to 6ml per 30 days

Sumatriptan 5 mg Spray 1 QL Limited to 6ml per 30 days

Sumatriptan Succinate 100 mg Tablet 1 QL Limited to 9 tabs per 30 days



Sumaxin Cp 10 %-4 % Kit 2

Super B-50 Complex Capsule 1

Super Calcium 600 mg Tablet 1

Super Multivitamin Tablet 1

Super Thin Lancets Each 1

Super Thin Lancets 28 gauge Each 1

Super Thin Lancets 30 gauge Each 1

Supervite 1000-1-75 Liquid 2

Suphedrin 15 mg/5 ml Liquid 1

Suphedrin 30 mg Tablet 1

Suphedrine 30 mg Tablet 1

Suphedrine 12-Hour 120 mg Tablet Er 1

Suphedrine Sinus Congestion 30 mg Tablet 1

Suprane 100% Liquid 2

Suprax 500 mg/5ml Susp Recon 2

Suprax 100 mg Tab Chew 2

Suprax 200 mg Tab Chew 2

Sure Comfort 29 g x1/2"" Dis Needle 1

Sure Comfort 30 gx5/16"" Dis Needle 1



Sure Comfort 32gx 5/32"" Dis Needle 1

Sure Comfort 28gx1/2"" Disp Syrin 1

Sure Comfort 29 g x1/2"" Disp Syrin 1

Sure Comfort 30 gx5/16"" Disp Syrin 1

Sure Comfort 30gx1/2"" Disp Syrin 1

Sure Comfort 31 gx5/16"" Disp Syrin 1

Sure Comfort Lancets 18 gauge Each 1





2021.1 (1/15/2021).




Sure Comfort Lancing Pen Each 1

Sure Result Dss Premium Pack 1.5-0.025% Cmb Sol Cr 2

Sure-Fine Pen Needles 29 g x1/2"" Dis Needle 1

Sure-Fine Pen Needles 31 gx3/16"" Dis Needle 1

Sure-Fine Pen Needles 31 gx5/16"" Dis Needle 1

Sureflex Each 1

Sureflex Kit 1

Sure-Ject Insulin Syringe 28gx1/2"" Disp Syrin 1

Sure-Ject Insulin Syringe 29 g x1/2"" Disp Syrin 1

Sure-Ject Insulin Syringe 30 gx5/16"" Disp Syrin 1

Sure-Ject Insulin Syringe 31 gx5/16"" Disp Syrin 1

Sure-Lance Each 1

Sure-Lance 26 gauge Each 1



Sure-Pen Each 1

Sure-T Each 1

Sure-Test Easyplus Mini Each 1

Sure-Touch Each 1

Survanta 25 mg/ml Vial 2

Sutent 12.5 mg Capsule 4 SP, PA

Sutent 25 mg Capsule 4 SP, PA

Sutent 37.5 mg Capsule 4 SP, PA

Sutent 50 mg Capsule 4 SP, PA

Suvicort 2 %-1 %-1% Gel (Gram) 2

Syeda 0.03mg-3mg Tablet 1

Sylatron 200 mcg Kit 4 SP, PA

Sylatron 300 mcg Kit 4 SP, PA

Symax Duotab 0.125-0.25 Tab Mphase 2

Symdeko 100-150 mg Tablet Seq 4 SP, PA, QL Limited to 56 tabs per 28 days

Sympazan 10 mg Film 2



Symproic 0.2 mg Tablet 2 QL Limited to 30 tabs per 30 days

Symtuza 800-150 mg Tablet 2

Synagis 100 mg/ml Vial 4 SP, PA

Synagis 50mg/0.5ml Vial 4 SP, PA

Synalar 0.03% Cream (G) 2

Synarel 2 mg/ml Spray 4 SP, PA

Syndros 5 mg/ml Solution 2


2021.1 (1/15/2021).



Synera 70 mg-70mg M.Ht Patch 2

Synribo 3.5 mg Vial 4 SP, PA

Syringe Avitene Powder 2

T.E.D. Anti-Embolism Stocking Each 1

Tab-A-Vite Tablet 1

Tab-A-Vite With Iron Tablet 1

Tabloid 40 mg Tablet 4 SP, QL Limited to 120 tabs per 30 days

Tacrolimus 0.5 mg Capsule 1

Tacrolimus 1 mg Capsule 1

Tacrolimus 5 mg Capsule 1

Tadalafil 20 mg Tablet 1

Take Action 1.5 mg Tablet 1

Taltz Autoinjector 80 mg/ml Auto Injct 4 SP, PA, QL Limited to 3ml per 28 days

Taltz Autoinjector (2 Pack) 80 mg/ml Auto Injct 4 SP, PA, QL Limited to 3ml per 28 days

Taltz Autoinjector (3 Pack) 80 mg/ml Auto Injct 4 SP, PA, QL Limited to 3ml per 28 days

Taltz Syringe 80 mg/ml Syringe 4 SP, PA, QL Limited to 3ml per 28 days

Tamoxifen Citrate 10 mg Tablet 1

Tamoxifen Citrate 20 mg Tablet 1

Tamsulosin Hcl 0.4 mg Capsule 1

Taperdex 1.5 mg(49) Tab Ds Pk 1

Taperdex 1.5mg (21) Tab Ds Pk 1

Taperdex 1.5mg (27) Tab Ds Pk 1

Targretin 1% Gel (Gram) 4 SP, PA

Tarina 24 Fe 1mg-20(24) Tablet 1

Tarina Fe 1mg-20(21) Tablet 1

Tarina Fe 1-20 Eq 1mg-20(21) Tablet 1

Taron Forte 150mg-60-1 Capsule 1

Taron-C Dha 35-1-200mg Capsule 1

Taron-Prex Prenatal 30-1.2-55 Capsule 1

Tasigna 150 mg Capsule 2 SP, PA, QL Limited to 120 caps per 30 days

Tasigna 200 mg Capsule 4 SP, PA

Tasigna 50 mg Capsule 4 SP, PA, QL Limited to 60 caps per 30 days

Taztia Xt 120 mg Cap Sa 24h 1





Td Gold Level 1 Control Sol Each 1



Tdvax 2-2 lf/0.5 Vial 2


2021.1 (1/15/2021).



Techlite Lancets 25 gauge Each 1



Tekturna Hct 150-12.5mg Tablet 2

Tekturna Hct 150mg-25mg Tablet 2

Tekturna Hct 300-12.5mg Tablet 2

Tekturna Hct 300mg-25mg Tablet 2

Telcare 30 gauge Each 1

Telcare Control Solution Each 1

Telmisartan 20 mg Tablet 1



Temazepam 15 mg Capsule 1

Temazepam 30 mg Capsule 1

Temixys 300-300 mg Tablet 2 QL Limited to 30 tabs per 30 days

Temozolomide 100 mg Capsule 3 SP






Tencon 50mg-325mg Tablet 1

Tenivac 5-2/0.5ml Syringe 2

Tenivac 5-2/0.5ml Vial 2

Tenofovir Disoproxil Fumarate 300 mg Tablet 1

Tens 502 Each 1

Tens 504 Each 1

Terazosin Hcl 1 mg Capsule 1




Terbinafine Hcl 250 mg Tablet 1 QL Limited to 30 tabs per 30 days

Terbutaline Sulfate 2.5 mg Tablet 1

Terbutaline Sulfate 5 mg Tablet 1

Terconazole 0.40% Cream/Appl 1 QL Limited to 45 grams per fill

Terconazole 0.80% Cream/Appl 1 QL Limited to 20 grams per fill

Terconazole 80 mg Supp.Vag 1 QL Limited to 3 suppositories per fill

Terrell 99.90% Liquid 1

Tersi Foam 2.25% Foam 2

Terumo Insulin Syringe 27gx1/2"" Disp Syrin 1


2021.1 (1/15/2021).



Terumo Insulin Syringe 28gx1/2"" Disp Syrin 1

Terumo Insulin Syringe 29 g x1/2"" Disp Syrin 1

Terumo Insulin Syringe 30 g x3/8"" Disp Syrin 1

Testopel 75 mg Pellet(Ea) 2

Testosterone 25mg(1%) Gel Packet 1 QL Limited to 30 packets per 30 days

Testosterone Cypionate 100 mg/ml Vial 1 PA

Testosterone Cypionate 200 mg/ml Vial 1 PA

Testosterone Enanthate 200 mg/ml Vial 1 PA

Tetrabenazine 12.5 mg Tablet 1

Tetrabenazine 25 mg Tablet 1

Tetracycline Hcl 250 mg Capsule 1

Tetracycline Hcl 500 mg Capsule 1

Texacort 2.50% Solution 2

Thalomid 100 mg Capsule 4 SP, PA




Theo-24 100 mg Cap Er 24h 2




Theochron 100 mg Tab Er 12h 1



Theophylline 80 mg/15ml Elixir 1

Theophylline 80 mg/15ml Solution 1

Theophylline 400 mg Tab Er 24h 1

Theophylline 600 mg Tab Er 24h 1

Theophylline Anhydrous 300 mg Tab Er 12h 1

Theophylline Anhydrous 450 mg Tab Er 12h 1

Thera 400 mcg Tablet 1

Thera M Plus 9mg-400mcg Tablet 1

Theradex M 27mg-0.4mg Tablet 1

Thera-M 27mg-0.4mg Tablet 1

Thera-M 9mg-400mcg Tablet 1

Therapeutic M 27mg-0.4mg Tablet 1

Therapeutic-M 9mg-400mcg Tablet 1

Thera-Tabs Tablet 1

Thera-Tabs M 27mg-400 Tablet 1

Theratrum Complete 50 Plus Tablet 1


2021.1 (1/15/2021).



Theratrum Complete 50 Plus .4-300-250 Tablet 1

Therems-M 27mg-0.4mg Tablet 1

Thin Lancets Each 1

Thin Lancets 26 gauge Each 1

Thin Lancets 28 gauge Each 1

Thinpro Insulin Syringe 28gx1/2"" Disp Syrin 1

Thinpro Insulin Syringe 29 g x1/2"" Disp Syrin 1

Thinpro Insulin Syringe 30 g x3/8"" Disp Syrin 1

Thinpro Insulin Syringe 31gx3/8"" Disp Syrin 1

Thrivite 19 29-1-25 mg Tablet 2

Thrombi-Gel 10 sq cm Med. Pad 1



Thrombin-Jmi 5000 unit Nas Sp Syr 1

Thrombin-Jmi 20000 unit Spray 1

Thrombin-Jmi 20000 unit Spray Syrn 1

Thrombin-Jmi 5000 unit Spray Syrn 1

Thrombin-Jmi 20000 unit Vial 1

Thrombin-Jmi 5000 unit Vial 1

Thrombi-Pad 3"" x 3"" Med. Pad 1

Thyrolar-1 12.5-50mcg Tablet 2

Thyrolar-1/2 6.25-25mcg Tablet 2

Thyrolar-1/4 3.1-12.5 Tablet 2

Thyrolar-2 25-100 mcg Tablet 2

Thyrolar-3 37.5-150 Tablet 2

Tiadylt Er 120 mg Cap Sa 24h 1






Tiagabine Hcl 12 mg Tablet 1




Ticanase 50mcg-0.9% Kit Sprssp 2

Ticaspray 50mcg-0.9% Kit Sprssp 2

Tilia Fe 5-7-9-7 Tablet 1

Timolol Maleate 0.25% Drops 1

Timolol Maleate 0.50% Drops 1

Timolol Maleate 10 mg Tablet 1


2021.1 (1/15/2021).





Tinidazole 250 mg Tablet 1

Tinidazole 500 mg Tablet 1

Tirosint-Sol 100 mcg/ml Solution 2











Tisseel Vhsd 2 ml Syringe 2

Tisseel Vhsd 4 ml Syringe 2

Tivicay 10 mg Tablet 2 QL Limited to 60 tabs per 30 days

Tivicay 25 mg Tablet 2

Tivicay 50 mg Tablet 2 QL Limited to 60 tabs per 30 days

Tivicay Pd 5 mg Tab Susp 2 QL Limited to 180 tabs per 30 days

Tizanidine Hcl 2 mg Tablet 1

Tizanidine Hcl 4 mg Tablet 1

Tobi Podhaler 28 mg Cap W/Dev 4 SP, PA, QL Limited to 1 fill of 224 caps per 56 days

Tobradex 0.3 %-0.1% Oint. (G) 2

Tobramycin 300 mg/4ml Ampul-Neb 3 SP, PA, QL Limited to 224ml per 28 days

Tobramycin 300 mg/5ml Ampul-Neb 3 SP, PA, QL Limited to 280ml per 30 days

Tobramycin 0.30% Drops 1

Tobramycin-Dexamethasone 0.3 %-0.1% Drops Susp 1

Tobrex 0.30% Oint. (G) 2

Tolak 4% Cream (G) 2

Tolmetin Sodium 400 mg Capsule 1

Tolmetin Sodium 200 mg Tablet 1

Tolmetin Sodium 600 mg Tablet 1

Tolnaftate 1% Cream (G) 1

Tolsura 65 mg Cap Sd Dsp 2

Tolterodine Tartrate 1 mg Tablet 1 QL Limited to 60 tabs per 30 days

Tolterodine Tartrate 2 mg Tablet 1 QL Limited to 60 tabs per 30 days

Tolvaptan 15 mg Tablet 3 SP, PA, QL Limited to 60 tabs per 30 days

Tolvaptan 30 mg Tablet 3 SP, PA, QL Limited to 60 tabs per 30 days


2021.1 (1/15/2021).



Topcare Clickfine 31 g x1/4"" Dis Needle 1

Topcare Clickfine 31 gx5/16"" Dis Needle 1

Topcare Ultra Comfort 29 g x1/2"" Disp Syrin 1

Topcare Ultra Comfort 30 gx5/16"" Disp Syrin 1

Topcare Ultra Comfort 31 gx5/16"" Disp Syrin 1

Topcare Universal1 Lancet 33 gauge Each 1

Topcare Universal1 Thin Lancet Each 1

Topiramate 15 mg Cap Sprink 1

Topiramate 25 mg Cap Sprink 1

Topiramate 100 mg Tablet 1




Topiramate Er 150 mg Cap Spr 24 1

Topiramate Er 200 mg Cap Spr 24 1

Toremifene Citrate 60 mg Tablet 3 SP

Torsemide 10 mg Tablet 1




Total Allergy 25 mg Tablet 1

Tramadol Hcl 100 mg Tablet 1 QL Limited to 120 tabs per 30 days

Tramadol Hcl 50 mg Tablet 1

Tramadol Hcl Er 300 mg Cpbp 17-83 1 QL, ST

Limited to 30 caps per 30 days Must try/fail GENERIC TRAMADOL IR

Tramadol Hcl Er 100 mg Cpbp 25-75 1 QL, ST


Tramadol Hcl Er 100 mg Tab Er 24h 1 QL, ST







2021.1 (1/15/2021).



Tramadol Hcl Er 100 mg Tbmp 24hr 1 QL, ST






Tramadol Hcl-Acetaminophen 37.5-325mg Tablet 1 QL Limited to 180 tabs per 30 days

Trandolapril 1 mg Tablet 1



Trandolapril-Verapamil Er 1mg-240 mg Tab Bp 24h 1

Trandolapril-Verapamil Er 2 mg-180mg Tab Bp 24h 1



Tranexamic Acid 650 mg Tablet 1 QL Limited to 30 tabs per 28 days

Travoprost 0.004% Drops 1 ST Must try/fail latanoprost drops

Trecator 250 mg Tablet 2

Trelegy Ellipta 100-62.5 Blst W/Dev 2 QL, ST Limited to 1 device per 30 days

Trelegy Ellipta 200-62.5 Blst W/Dev 2 QL, ST Limited to 1 device per 30 days

Tremfya 100 mg/ml Auto Injct 4 SP, PA, QL

Tremfya 100 mg/ml Syringe 4 SP, PA, QL

Treprostinil 2.5 mg/ml Vial 3 SP

Tretinoin 10 mg Capsule 1

Tretinoin 0.01% Gel (Gram) 1

Tretinoin 0.05% Gel (Gram) 1

Tretin-X 0.03% Combo. Pkg 2



Tretin-X 0.08% Cream (G) 2

Trexall 10 mg Tablet 2



2021.1 (1/15/2021).




Trexall 7.5 mg Tablet 2

Tri Femynor 7daysx3 28 Tablet 1

Triamcinolone Acetonide 0.03% Cream (G) 1



Triamcinolone Acetonide 0.03% Lotion 1

Triamcinolone Acetonide 0.10% Lotion 1

Triamcinolone Acetonide 0.03% Oint. (G) 1




Triamcinolone Acetonide 0.10% Paste (G) 1

Triamterene 100 mg Capsule 1

Triamterene 50 mg Capsule 1

Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule 1

Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet 1

Triamterene-Hydrochlorothiazid 75 mg-50mg Tablet 1

Trianex 0.05% Oint. (G) 1

Tri-Buffered Aspirin 325 mg Tablet 1

Tricare 27 mg-1 mg Tablet 2

Tri-Chlor 80% Solution 2

Tricon 110-0.5mg Capsule 1

Triderm 0.10% Cream (G) 1

Triderm 0.50% Cream (G) 1

Tri-Estarylla 7daysx3 28 Tablet 1

Trifluridine 1% Drops 1

Trigels-F Forte 460-60mg Capsule 1

Trihexyphenidyl Hcl 2 mg/5 ml Elixir 1

Trihexyphenidyl Hcl 2 mg Tablet 1

Trihexyphenidyl Hcl 5 mg Tablet 1

Tri-Legest Fe 5-7-9-7 Tablet 1

Tri-Linyah 7daysx3 28 Tablet 1

Triloan Ii Suik 40 mg/ml Kit 2

Tri-Lo-Estarylla 7daysx3 lo Tablet 1

Tri-Lo-Marzia 7daysx3 lo Tablet 1

Tri-Lo-Mili 7daysx3 lo Tablet 1

Tri-Lo-Sprintec 7daysx3 lo Tablet 1

Tri-Luma 0.01-.05-4 Cream (G) 2

Trilyte With Flavor Packets 420g Soln Recon 1

Trimethobenzamide Hcl 300 mg Capsule 1


2021.1 (1/15/2021).



Tri-Mili 7daysx3 28 Tablet 1

Triphrocaps 1 mg Capsule 1

Triple Antibiotic 3.5-400-5k Oint Pack 1

Triple Antibiotic 3.5-400-5k Oint. (G) 1

Triple Antibiotic Plus 3.5-10k-10 Oint. (G) 1

Tri-Previfem 7daysx3 28 Tablet 1

Trisodium Citrate Crrt 0.50% Solution 1

Tri-Sprintec 7daysx3 28 Tablet 1

Triumeq 600-50-300 Tablet 2

Triveen-Duo Dha 29-1-400mg Combo. Pkg 1

Triveen-Prx Rnf 26-1.2-55 Capsule 1

Tri-Vi-Flor 0.25 mg/ml Drps Sp Bp 2

Tri-Vi-Flor 0.5 mg/ml Drps Sp Bp 2

Tri-Vitamin With Fluoride 0.25 mg/ml Drops 1

Tri-Vitamin With Fluoride 0.5 mg/ml Drops 1

Tri-Vite With Fluoride 0.25 mg/ml Drops 1

Tri-Vite With Fluoride 0.5 mg/ml Drops 1

Trivora-28 6/5/2010 Tablet 1

Tri-Vylibra 7daysx3 28 Tablet 1

Tri-Vylibra Lo 7daysx3 lo Tablet 1

Trokendi Xr 100 mg Cap Er 24h 2

Trokendi Xr 200 mg Cap Er 24h 2

Tropicamide 0.50% Drops 1

Tropicamide 1% Drops 1

Tropicamide-Cyclopentolate-Pe 1%-1%-2.5% Drops 1

Trospium Chloride 20 mg Tablet 1 QL Limited to 60 tabs per 30 days

Trospium Chloride Er 60 mg Cap Er 24h 1 QL Limited to 30 caps per 30 days

True Comfort Lancet 30 gauge Each 1

True Metrix Each 1

Truecontrol Each 1

Truedraw Each 1

Trueplus Insulin Syringe 28gx1/2"" Disp Syrin 1

Trueplus Insulin Syringe 29 g x1/2"" Disp Syrin 1

Trueplus Insulin Syringe 30 gx5/16"" Disp Syrin 1

Trueplus Insulin Syringe 31 gx5/16"" Disp Syrin 1

Trueplus Lancet 28 gauge Each 1

Trueplus Lancets 26 gauge Each 1




Trulance 3 mg Tablet 2 QL Limited to 30 tabs per 30 days


2021.1 (1/15/2021).



Trulicity 0.75mg/0.5 Pen Injctr 2 QL, ST Limited to 4 pens per 28 days Must try/fail metformin

Trulicity 1.5 mg/0.5 Pen Injctr 2 QL, ST Limited to 4 pens per 28 days Must try/fail metformin

Trulicity 3 mg/0.5ml Pen Injctr 2 QL, ST Limited to 4 pens per 28 days Must try/fail metformin

Trulicity 4.5 mg/0.5 Pen Injctr 2 QL, ST Limited to 4 pens per 28 days Must try/fail metformin

Trumenba 120mcg/0.5 Syringe 2

Truvada 100-150 mg Tablet 2



Tudorza Pressair 400 mcg Aer Pow Ba 2 QL Limited to 1 inhaler per 30 days

Tulana 0.35 mg Tablet 1

Tusnel Diabetic 100-10mg/5 Liquid 1

Tussin Cough 100-10mg/5 Liquid 1

Tussin Dm 100-10mg/5 Liquid 1

Tussin Dm 100-10mg/5 Syrup 1

Tussin Dm Clear 100-10mg/5 Syrup 1

Tussin Dm Cough-Chest Congest 100-10mg/5 Syrup 1

Tuxarin Er 8mg-54.3mg Tab Er 12h 2 QL Limited to 600 tabs per 30 days

Twinrix 720-20/ml Syringe 2

Twist Lancets 30 gauge Each 1

Twist Lancets 32 gauge Each 1

Tybost 150 mg Tablet 2

Tyzine 0.10% Drops 2

Tyzine 0.10% Spray 2

Udamin Sp 1mg-320mg Tablet 2

Udenyca 6 mg/0.6ml Syringe 4 SP, PA, QL Limited to 2 syringes per 28 days

Ulesfia 5% Lotion 2

Ulticare 30gx1/2"" Disp Syrin 1

Ulticare 31 gx5/16"" Disp Syrin 1

Ulticare Pen Needle 29 g x1/2"" Dis Needle 1

Ulticare Pen Needle 31 g x1/4"" Dis Needle 1

Ulticare Pen Needle 31 gx5/16"" Dis Needle 1

Ulticare Pen Needle 32gx 5/32"" Dis Needle 1


2021.1 (1/15/2021).



Ulti-Lance Each 1

Ulti-Lance Kit 1

Ultilet Basic 30 gauge Each 1

Ultilet Classic Each 1

Ultilet Classic 28 gauge Each 1



Ultilet Insulin Syringe 29 g x1/2"" Disp Syrin 1

Ultilet Insulin Syringe 29 gauge Disp Syrin 1

Ultilet Insulin Syringe 30 gx5/16"" Disp Syrin 1

Ultilet Insulin Syringe 31 gx5/16"" Disp Syrin 1

Ultilet Lancets 28 gauge Each 1



Ultilet Pen Needle 29 gauge Dis Needle 1

Ultilet Safety 23 gauge Each 1

Ultra Comfort 28 gauge Disp Syrin 1

Ultra Comfort 28gx1/2"" Disp Syrin 1

Ultra Comfort 29 g x1/2"" Disp Syrin 1



Ultra Comfort 30 gx5/16"" Disp Syrin 1

Ultra Comfort 31 gx5/16"" Disp Syrin 1

Ultra Dm Free & Clear 100-10mg/5 Liquid 1

Ultra Fine Lancets 30 gauge Each 1

Ultra Fresh Pm Oint. (G) 1

Ultra Omega-3 500-1000mg Capsule 1

Ultra Saline 0.65% Spray 1

Ultra Strength Antacid 400(1000) Tab Chew 1

Ultra Thin Lancet 31 gauge Each 1

Ultra Thin Lancets Each 1

Ultra Thin Lancets 28 gauge Each 1




Ultra Thin Plus Each 1

Ultra Thin Plus Lancets 33 gauge Each 1

Ultra Tuss 100-10mg/5 Syrup 1

Ultra-Care Lancets 30 gauge Each 1

Ultra-Fine Mini Pen Needle 31 gx3/16"" Dis Needle 1

Ultra-Fine Nano Pen Needle 32gx 5/32"" Dis Needle 1


2021.1 (1/15/2021).



Ultra-Fine Original Pen Needle 29 g x1/2"" Dis Needle 1

Ultra-Fine Short Pen Needle 31 gx5/16"" Dis Needle 1

Ultralance 26 gauge Each 1

Ultralance 28 gauge Each 1

Ultrasal-Er 28.50% Sol-Filmer 2

Ultra-Thin Ii 29 g x1/2"" Dis Needle 1

Ultra-Thin Ii 31 gx5/16"" Dis Needle 1

Ultra-Thin Ii 29 g x1/2"" Disp Syrin 1

Ultra-Thin Ii 30 gx5/16"" Disp Syrin 1

Ultra-Thin Ii 31 gx5/16"" Disp Syrin 1

Ultra-Thin Ii 28 gauge Each 1

Ultra-Thin Ii 30 gauge Each 1

Ultratlc Lancets Each 1

Ultratrak Each 1

Ultratrak Ultimate Each 1

Ultravate 0.05% Lotion 2

Umecta 40% Foam 1

Unifine Pentips 29 g x1/2"" Dis Needle 1

Unifine Pentips 29 gauge Dis Needle 1

Unifine Pentips 31 g x1/4"" Dis Needle 1

Unifine Pentips 31 gx3/16"" Dis Needle 1

Unifine Pentips 31 gx5/16"" Dis Needle 1

Unifine Pentips 32gx 5/32"" Dis Needle 1

Unifine Pentips Plus 29 g x1/2"" Dis Needle 1

Unifine Pentips Plus 31 g x1/4"" Dis Needle 1

Unifine Pentips Plus 31 gx3/16"" Dis Needle 1

Unifine Pentips Plus 31 gx5/16"" Dis Needle 1

Unifine Pentips Plus 32gx 5/32"" Dis Needle 1

Unilet Comfortouch Each 1

Unilet Comfortouch 26 gauge Each 1

Unilet Excelite Each 1

Unilet Excelite Ii Each 1

Unilet Gp Lancet Each 1

Unilet Lancet 33 gauge Each 1

Unilet Lancets 28 gauge Each 1



Unisom 50 mg Capsule 1

Unistik 2 Kit 1

Unistik 2 Extra Kit 1

Unistik 2 Normal Kit 1


2021.1 (1/15/2021).



Unistik 3 Each 1

Unistik 3 21 gauge Each 1



Unistik 3 Kit 1

Unistik 3 Comfort Kit 1

Unistik 3 Extra 21 gauge Each 1

Unistik 3 Neonatal Kit 1

Unistik Czt 23 gauge Each 1

Unistik Czt 28 gauge Each 1

Unistik Pro 21 gauge Each 1



Unistik Safety 28 gauge Each 1

Unistik Safety 30 gauge Each 1

Unistik Touch 21 gauge Each 1




Unistrip Each 1

Universal 1 21 gauge Each 1




Upneeq 0.10% Droperette 2

Uptravi 200-800mcg Tab Ds Pk 4 SP, PA

Uptravi 1000 mcg Tablet 4 SP, PA








Uramaxin 20% Foam 2

Uramaxin Gt 45% Kt Crm Gel 2

Urea 41% Cream (G) 1




Urea 35% Foam 1


2021.1 (1/15/2021).



Urea 45% Gel (Ml) 1

Urea 40% Lotion 1

Urea 50% Sol/Pf App 1

Uretron D-S 81.6-10.8 Tablet 2

Urimar-T 120-0.12mg Tablet 1

Urin D.S. 81.6-10.8 Tablet 2

Uro-458 81-0.12mg Tablet 1

Uro-Mp 118-10-36 Capsule 1

Uroqid-Acid No.2 500-500 mg Tablet 2

Ursodiol 300 mg Capsule 1

Ursodiol 250 mg Tablet 1

Ursodiol 500 mg Tablet 1

Ustell 120-0.12mg Capsule 1

Valacyclovir 1000 mg Tablet 1

Valacyclovir 500 mg Tablet 1

Valganciclovir Hcl 50 mg/ml Soln Recon 1

Valganciclovir Hcl 450 mg Tablet 1

Valsartan 160 mg Tablet 1




Valsartan-Hydrochlorothiazide 160-12.5mg Tablet 1

Valsartan-Hydrochlorothiazide 160mg-25mg Tablet 1


Valsartan-Hydrochlorothiazide 320mg-25mg Tablet 1


Valtoco 10mg/spray Spray 2 ST Must try/fail midazolam vial with atomizer

Valtoco 15/2 spray Spray 2 ST Must try/fail midazolam vial with atomizer

Valtoco 20/2 spray Spray 2 ST Must try/fail midazolam vial with atomizer

Valtoco 5 mg/spray Spray 2 ST Must try/fail midazolam vial with atomizer

Vanatol Lq 50-325/15 Solution 1

Vanatol S 50-325/15 Solution 1

Vancomycin Hcl 125 mg Capsule 1

Vancomycin Hcl 250 mg Capsule 1

Vancomycin Hcl 50 mg/ml Soln Recon 1 QL Limited to 140ml per 14 days

Vancomycin Hcl 1 g Vial 1


Vancomycin Hcl 250 mg Vial 1


2021.1 (1/15/2021).






Vancomycin Hcl 1 g Vial Port 1

Vancomycin Hcl 500 mg Vial Port 1

Vancomycin Hcl 750 mg Vial Port 1

Vandazole 0.75% Gel W/Appl 2

Vanishpoint 29 g x1/2"" Disp Syrin 1

Vanishpoint 30gx1/2"" Disp Syrin 1

Vanoxide-Hc 5 %-0.5 % Suspension 2

Vapro Plus Intermitt Catheter 14 fr-16 "" Combo. Pkg 1

Vaqta 25/0.5ml Syringe 2

Vaqta 50 unit/ml Syringe 2

Vaqta 25/0.5ml Vial 2

Vaqta 50 unit/ml Vial 2

Varithena Administration Pack Each 1

Varivax Vaccine 1350 unit Vial 2

Varubi 90 mg Tablet 2

Vascepa 0.5 gram Capsule 2 QL Limited to 120 caps per 30 days

Vaseline White Petroleum Oint Pack 1

Vaxchora Active Component 0.4b to 2b Susp Recon 2

Vaxchora Buffer Component Susp Recon 2

Vaxchora Vaccine 0.4b to 2b Susp Recon 2

Vaxelis 15-5-10 Vial 2

V-C Forte 1 mg Capsule 1

Vecamyl 2.5 mg Tablet 2

Vegetable Laxative 8.6 mg Tablet 1

Vegetable Lax-Stool Softener 8.6mg-50mg Tablet 1

Velivet 7 days x 3 Tablet 1

Velphoro 500mg iron Tab Chew 2

Vemlidy 25 mg Tablet 4 SP, QL Limited to 30 tabs per 30 days

Venclexta 10 mg Tablet 4 SP, PA



Venclexta Starting Pack 10-50-100 Tab Ds Pk 4 SP, PA

Venelex Oint Pack 2

Venelex Oint. (G) 2

Veo Insulin Syringe 31gx15/64"" Disp Syrin 1

Verapamil Er 120 mg Cap24h Pel 1




2021.1 (1/15/2021).



Verapamil Er 120 mg Tablet Er 1



Verapamil Er Pm 100 mg Cap24h Pct 1



Verapamil Hcl 360 mg Cap24h Pel 1

Verapamil Hcl 120 mg Tablet 1



Verapamil Sr 120 mg Cap24h Pel 1



Verasens Control Solution Each 1

Verdeso 0.05% Foam 2

Veregen 15% Oint. (G) 2 QL Limited to 1 tube per 30 days

Verzenio 100 mg Tablet 4 SP, PA, QL Limited to 56 tabs per 28 days




Vexasyn 2%-1%-1.2% Gel (Gram) 2

Vibramycin 50 mg/5 ml Syrup 2

Vic-Forte 1 mg Capsule 1

Victoza 2-Pak 0.6 mg/0.1 Pen Injctr 2 QL, ST Limited to 3 pens per 30 days Must try/fail metformin

Victoza 3-Pak 0.6 mg/0.1 Pen Injctr 2 QL, ST Limited to 3 pens per 30 days Must try/fail metformin

Vienva 0.1-0.02mg Tablet 1

Vilamit Mb 118-10-36 Capsule 1

Vimpat 50 mg Tablet 2 QL Limited to 60 tabs per 30 days

Vinate Care 40 mg-1 mg Tab Chew 1

Vinate Dha Rf 27-1.13 mg Capsule 1

Vinate Gt 90-1-50 mg Tablet 1

Vinate Ii 29 mg-1 mg Tablet 1

Vinate One 60 mg-1 mg Tablet 1

Vinate Ultra 90-1-50 mg Tablet 1

Vinate-M 27 mg-1 mg Tablet 1

Viokace 10.4-39.2k Tablet 2

Viokace 20.9-78.3k Tablet 2


2021.1 (1/15/2021).



Viorele 21-5 (28) Tablet 1

Viracept 250 mg Tablet 2

Viracept 625 mg Tablet 2

Viread 40mg/scoop Powder 2

Viread 150 mg Tablet 2



Virt-C Dha 35-1-200mg Capsule 1

Virt-Caps 1 mg Capsule 1

Virt-Fefa Plus 125 mg-1mg Capsule 1

Virt-Gard 1-2.2-25mg Tablet 1

Virt-Nate Dha 28-1-200mg Capsule 1

Virt-Phos 250 Neutral 250 mg Tablet 1

Virtrate-2 334-500mg Solution 1

Virtrate-3 500-550/5 Solution 1

Virtrate-K 1100-334/5 Solution 1

Virtussin Dac 30-10-100 Syrup 1 A Drug excluded for members ages 17 or younger.

Virt-Vite 1-2.5-25mg Tablet 1

Virt-Vite Plus 5 mg Tablet 1

Vit 3 500-0.5-1 Capsule 1

Vitafol Nano 18 mg-1 mg Tablet 1

Vitafol Ultra 29-1-200mg Capsule 2

Vitafol-Ob+Dha 65-1-250mg Combo. Pkg 1

Vitafol-One 29-1-200mg Capsule 2

Vital-D Rx 1750-60-1 Tablet 1

Vitamedmd One Rx 30-1-200mg Capsule 2

Vitamin B Complex Capsule 1

Vitamin B-12 1000 mcg Tablet 1

Vitamin B-12 500 mcg Tablet 1

Vitamin B-6 100 mg Tablet 1



Vitamin C 500 mg Tab Chew 1

Vitamin C 250 mg Tablet 1

Vitamin C 500 mg Tablet 1

Vitamin C 500 mg Wafer 1

Vitamin C With Rose Hips 500 mg Tab Chew 1

Vitamin C With Rose Hips 500 mg Tablet 1

Vitamin D2 1250 mcg Capsule 1

Vitamin E 200 unit Capsule 1


2021.1 (1/15/2021).



Vitamin E 400 unit Capsule 1

Vitamins A,C,D And Fluoride 0.25 mg/ml Drops 1

Vitamins A,C,D And Fluoride 0.5 mg/ml Drops 1

Vitamins For Hair Tablet 1

Vita-Respa 1.3-2.2-25 Tablet 2

Viva Dha 28-1-200mg Capsule 1

Vivaguard Ino Control Solution Each 1

Vivaguard Lancet 30 gauge Each 1

Vivitrol 380 mg Sus Er Rec 4 SP, PA

Volnea 21-5 (28) Tablet 1

Voriconazole 200 mg/5ml Susp Recon 1 QL Limited to 450ml per 30 days

Voriconazole 200 mg Tablet 1 QL Limited to 90 tabs per 30 days

Voriconazole 50 mg Tablet 1 QL Limited to 90 tabs per 30 days

Vosevi 400-100 mg Tablet 4 SP, PA, QL Limited to 28 tabs per 28 days

Votrient 200 mg Tablet 2

Vp-Ch Plus 29-1-50 mg Capsule 1

Vp-Ch-Pnv 30-1-50 mg Capsule 1

Vp-Vite Rx 1mg-60mg Tablet 1

Vtol Lq 50-325/15 Solution 1

Vyfemla 0.4-0.035 Tablet 1

Vylibra 0.25-0.035 Tablet 1

Vyvanse 10 mg Capsule 2 QL, ST Limited to 30 caps per 30 days







Vyvanse 10 mg Tab Chew 2 QL, ST Limited to 30 tabs per 30 days






Wal-Dryl 25 mg Capsule 1

Wal-Dryl Allergy 12.5mg/5ml Liquid 1

Wal-Dryl Allergy 25 mg Tablet 1

Wal-Finate 4 mg Tablet 1

Wal-Itin 5 mg/5 ml Solution 1

Wal-Itin 10 mg Tablet 1

Wal-Mucil 0.52g Capsule 1


2021.1 (1/15/2021).



Wal-Mucil 3.4g/5.8g Powder 1

Wal-Mucil Natural Fiber Lax 3.4 g/12 g Powder 1

Wal-Nadol Pm 500mg-25mg Tablet 1

Wal-Phed 30 mg Tablet 1

Wal-Phed 12 Hour 120 mg Tablet Er 1

Wal-Phed D Er 120 mg Tablet Er 1

Wal-Profen 200 mg Tablet 1

Wal-Proxen 220 mg Tablet 1

Wal-Sleep Z 25 mg Capsule 1

Wal-Sleep Z 25 mg Tab Rapdis 1

Wal-Som 50 mg Capsule 1

Wal-Tussin Dm 100-10mg/5 Syrup 1

Wal-Zyr 10 mg Tablet 1

Warfarin Sodium 1 mg Tablet 1



Warfarin Sodium 2.5 mg Tablet 1





Warfarin Sodium 7.5 mg Tablet 1

Wavesense Control Solution Each 1

Wera 0.5-0.035 Tablet 1

Westab Max 2-2.5-25mg Tablet 1

Westab One 1-2.5-25mg Tablet 1

Wide Seal Diaphragm 60mm Diaphragm 1








Winrho Sdf 1500/1.3ml Vial 2

Winrho Sdf 15000/13ml Vial 2



Wixela Inhub 100-50 mcg Blst W/Dev 1 QL Limited to 1 device per 30 days




2021.1 (1/15/2021).



Women's Gentle Laxative 5 mg Tablet Dr 1

Women's Laxative 5 mg Tablet Dr 1

Wound Matrix 3 cm x7 cm Sheet 1

Wound Matrix 3cm x3.5cm Sheet 1

Wynzora 0.005-.064 Cream (G) 2 QL, ST

Limited to 420 grams per 28 days Must try/fail at least two of the following: Calcipotriene cream/oint, Anthralin cream (Drithocreme Hp), Tazorac 0.05% cream*, Tazorac 0.10% gel*, Fluocinonide cream/gel/oint, Mometasone cream/oint, Fluticasone cream/oint, Betamethasone dipropionate cream/oint, Triamcinolone cream/lotion/oint, Desoximetasone cream/gel/oint, Clobetasol cream/gel/foam/lotion/oint, Desonide cream/lotion/oint, Amcinonide cream/lotion/oint, Halobetasol cream/oint.

Xadago 100 mg Tablet 2

Xadago 50 mg Tablet 2

Xarelto 15 mg-20mg Tab Ds Pk 2 QL Limited to 51 tabs per 30 days

Xarelto 10 mg Tablet 2 QL Limited to 60 tabs per 30 days


Xarelto 2.5 mg Tablet 2


Xatmep 2.5 mg/ml Solution 2

Xclair Cream(Ml) 2

Xelitral 1.5-0.025% Cmb Sol Cr 2

Xeljanz 10 mg Tablet 4 SP, QL Limited to 60 tabs per 30 days

Xeljanz 5 mg Tablet 4 SP, PA, QL Limited to 60 tabs per 30 days

Xeljanz Xr 11 mg Tab Er 24h 4 SP, PA, QL Limited to 30 tabs per 30 days

Xembify 1 g/5 ml Vial 2




Xepi 1% Cream (G) 2

Xerostomia Relief Spray/Pump 2

Xifaxan 200 mg Tablet 2 PA, QL Limited to 9 tablets per 3 days


2021.1 (1/15/2021).



Xifaxan 550 mg Tablet 2 PA, QL Limited to 60 tabs per 30 days

Ximino 135 mg Cap Er 24h 2

Ximino 90 mg Cap Er 24h 2

Xofluza 20 mg Tablet 2

Xofluza 40 mg Tablet 2

Xolegel 2% Gel (Gram) 2

Xpovio 120mg/week Tablet 4 SP

Xpovio 40 mg/week Tablet 4 SP

Xpovio 80 mg/week Tablet 4 SP

Xtampza Er 13.5 mg Cap Spr 12 2 QL Limited to 90 caps per 30 days

Xtampza Er 18 mg Cap Spr 12 2 QL Limited to 90 caps per 30 days




Xulane 150-35/24h Patch Tdwk 1

Xultophy 100-3.6 100-3.6/ml Insuln Pen 2

Xyzbac 1-5-50 mg Tablet 1

Yonsa 125 mg Tablet 2

Yosprala 325mg-40mg Tab Ir Dr 2

Yosprala 81 mg-40mg Tab Ir Dr 2

Yupelri 175mcg/3ml Vial-Neb 2

Zafirlukast 10 mg Tablet 1

Zafirlukast 20 mg Tablet 1

Zaleplon 10 mg Capsule 1 QL Limited to 60 caps per 30 days

Zaleplon 5 mg Capsule 1 QL Limited to 60 caps per 30 days

Zarah 0.03mg-3mg Tablet 1

Zarxio 300mcg/0.5 Syringe 4 SP, QL Limited to 14 syringes per 28 days

Zarxio 480mcg/0.8 Syringe 4 SP, QL Limited to 14 syringes per 28 days

Zebutal 50-325-40 Capsule 1

Zejula 100 mg Capsule 4 SP, PA, QL Limited to 90 caps per 30 days

Zelapar 1.25 mg Tab Rapdis 2

Zenatane 10 mg Capsule 1 QL Limited to 60 caps per 30 days



Zenpep 10-32-42k Capsule Dr 2






2021.1 (1/15/2021).



Zenpep 40-126-168 Capsule Dr 2

Zenpep 5k-17k-24k Capsule Dr 2

Zenzedi 10 mg Tablet 1

Zenzedi 5 mg Tablet 1

Zephrex-D 30 mg Tablet 1

Zetonna 37 mcg Hfa Aer Ad 2 QL Limited to 1 package per 30 days

Zidovudine 100 mg Capsule 1

Zidovudine 10 mg/ml Syrup 1

Zidovudine 300 mg Tablet 1

Ziextenzo 6 mg/0.6ml Syringe 4 SP, PA, QL

Zilxi 1.50% Foam 2

Zinc Oxide 20% Oint. (G) 1

Zinc Sulfate 220(50) mg Capsule 1

Zinc-220 220(50) mg Capsule 1

Zingiber 1.2-40-100 Tablet 1

Zipsor 25 mg Capsule 2

Zirgan 0.15% Gel (Gram) 2

Zithranol 1% Shampoo(G) 2

Zohydro Er 10 mg Cap Er 12h 2 QL, ST Limited to 60 caps per 30 days Must try/fail morphine er tabs





Zolinza 100 mg Capsule 2

Zolmitriptan 5 mg Tablet 1 QL Limited to 6 tabs per 30 days

Zolmitriptan Odt 2.5 mg Tab Rapdis 1 QL Limited to 6 tabs per 30 days

Zolmitriptan Odt 5 mg Tab Rapdis 1 QL Limited to 6 tabs per 30 days

Zolpidem 5mg Tablet 1 QL Limited to 60 tabs per 30 days

Zolpidem Tartrate 10 mg Tablet 1 QL Limited to 30 tabs per 30 days

Zolpidem Tartrate 10mg Tablet 1 QL Limited to 30 tabs per 30 days


2021.1 (1/15/2021).



Zolpidem Tartrate 5 mg Tablet 1 QL Limited to 60 tabs per 30 days

Zolpidem Tartrate 5mg Tablet 1 QL Limited to 60 tabs per 30 days

Zolpidem Tartrate Er 12.5 mg Tab Mphase 1 QL, ST

Limited to 30 tabs per 30 days Must try/fail GENERIC ZOLPIDEM 5MG OR 10MG

Zolpidem Tartrate Er 6.25 mg Tab Mphase 1 QL, ST

Limited to 30 tabs per 30 days Must try/fail GENERIC ZOLPIDEM 5MG OR 10MG

Zolpimist 5 mg/spray Spray/Pump 2 QL Limited to 1 package per 30 days

Zomacton 10 mg Vial 4 SP, PA

Zomacton 5 mg Vial 4 SP, PA

Zomig 2.5 mg Spray 2 QL Limited to 12 single use sprays per 30 days

Zomig 5 mg Spray 2 QL Limited to 1 package per 5 days

Zonisamide 100 mg Capsule 1



Zorbtive 8.8 mg Vial 4 SP, PA

Zortress 1 mg Tablet 2

Zorvolex 18 mg Capsule 2

Zorvolex 35 mg Capsule 2

Zostavax 19400 unit Vial 2 A Excluded for age 59 and under

Zostrix 0.03% Cream (G) 1

Zovia 1-35e 1 mg-35mcg Tablet 1

Z-Sleep 25 mg Capsule 1

Ztlido 1.80% Adh. Patch 2

Zubsolv 0.7-0.18mg Tab Subl 2




Zubsolv 5.7-1.4 mg Tab Subl 2

Zubsolv 8.6-2.1 mg Tab Subl 2

Zumandimine 0.03mg-3mg Tablet 1

Zyclara 3.75% Cream Pack 2

Zyclara 2.50% Crm Md Pmp 2

Zyflo 600 mg Tablet 2

Zykadia 150 mg Tablet 2

Zylet 0.3%-0.5% Drops Susp 2

Zypitamag 2 mg Tablet 2 QL Limited to 30 tabs per 30 days

Zypitamag 4 mg Tablet 2 QL Limited to 30 tabs per 30 days


2021.1 (1/15/2021).



Zyvit 1-5-50 mg Tablet 1

Health plans in Oregon provided by Moda Health Plan, Inc. Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon.

Documents

EOCCO Pharmacy FormularyRefer to the chart below for a list of prescription medications covered by Moda Health. Medications that are new to the market are subject to a review period