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Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs
ABACAVIR SULFATE SOLN 20 MG/ML ABIRATERONE ACETATE TABS 250 MG ABACAVIR SULFATE SOLN 20 MG/ML
ABACAVIR SULFATE TABS 300 MG Abstral 100 mcg sublingual tablet ABACAVIR SULFATE TABS 300 MG
ABACAVIR SULFATE-LAMIVUDINE TABS 600-300 MG acetaminophen 120 mg-codeine 12 mg/5 ABACAVIR SULFATE-LAMIVUDINE TABS 600-300 MG
ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABS 300-150-300 MG acetaminophen 300 mg-codeine 15 mg ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABS 300-150-
ABIRATERONE ACETATE TABS 250 MG acetaminophen 300 mg-codeine 30 mg ABIRATERONE ACETATE TABS 250 MG
ACARBOSE TABS 100 MG acetaminophen 300 mg-codeine 60 mg ACARBOSE TABS 100 MG
ACARBOSE TABS 25 MG
ACTEMRA ACTPEN SOAJ 162 MG/0.9ML
ACARBOSE TABS 25 MG
ACARBOSE TABS 50 MG ACTEMRA SOSY 162 MG/0.9ML ACARBOSE TABS 50 MG
ACETAMINOPHEN SOLN 10 MG/ML ACTHAR GEL 80 UNIT/ML ACETAMINOPHEN SOLN 10 MG/ML
ACETAMINOPHEN-CODEINE #2 TABS 300-15 MG ADLYXIN SOPN 20 MCG/0.2ML ACETAMINOPHEN-CODEINE #2 TABS 300-15 MG
ACETAMINOPHEN-CODEINE #3 TABS 300-30 MG
ADLYXIN STARTER PACK PNKT 10 & 20 MCG/0.2ML
ACETAMINOPHEN-CODEINE #3 TABS 300-30 MG
ACETAMINOPHEN-CODEINE #4 TABS 300-60 MG
AIMOVIG SOAJ 140 MG/ML
ACETAMINOPHEN-CODEINE #4 TABS 300-60 MG
ACETAMINOPHEN-CODEINE SOLN 120-12 MG/5ML AIMOVIG SOAJ 70 MG/ML ACETAMINOPHEN-CODEINE SOLN 120-12 MG/5ML
ACETAZOLAMIDE ER CP12 500 MG AJOVY SOAJ 225 MG/1.5ML ACETAZOLAMIDE ER CP12 500 MG
ACETAZOLAMIDE SODIUM SOLR 500 MG AJOVY SOSY 225 MG/1.5ML ACETAZOLAMIDE SODIUM SOLR 500 MG
ACETAZOLAMIDE TABS 125 MG ALECENSA CAPS 150 MG ACETAZOLAMIDE TABS 125 MG
ACETAZOLAMIDE TABS 250 MG
AMITIZA CAPS 24 MCG
ACETAZOLAMIDE TABS 250 MG
ACETIC ACID SOLN 0.25 % AMITIZA CAPS 8 MCG ACETIC ACID SOLN 0.25 %
ACETIC ACID SOLN 2 % AMPYRA TB12 10 MG ACETIC ACID SOLN 2 %
ACETIC ACID-ALUMINUM ACETATE SOLN 2 % APOKYN 10 mg/mL subcutaneous ACETIC ACID-ALUMINUM ACETATE SOLN 2 %
ACETYLCYSTEINE SOLN 10 %
ARANESP (ALBUMIN FREE) SOLN 100 MCG/ML
ACETYLCYSTEINE SOLN 10 %
ACETYLCYSTEINE SOLN 20 %
ARANESP (ALBUMIN FREE) SOLN 200 MCG/ML
ACETYLCYSTEINE SOLN 20 %
ACITRETIN CAPS 10 MG ARANESP (ALBUMIN FREE) SOLN 25 MCG/MLACITRETIN CAPS 10 MG
ACITRETIN CAPS 17.5 MG ARANESP (ALBUMIN FREE) SOLN 300 MCG/MLACITRETIN CAPS 17.5 MG
ACITRETIN CAPS 25 MG ARANESP (ALBUMIN FREE) SOLN 40 MCG/MLACITRETIN CAPS 25 MG
ACTEMRA ACTPEN SOAJ 162 MG/0.9ML
ARANESP (ALBUMIN FREE) SOLN 60 MCG/ML
ACTEMRA ACTPEN SOAJ 162 MG/0.9ML
ACTEMRA SOSY 162 MG/0.9ML
ARANESP (ALBUMIN FREE) SOSY 10 MCG/0.4ML
ACTEMRA SOSY 162 MG/0.9ML
ACYCLOVIR CAPS 200 MG ARANESP (ALBUMIN FREE) SOSY 100 MCG/0.5MLACYCLOVIR CAPS 200 MG
ACYCLOVIR SODIUM INJ 1000MG ARANESP (ALBUMIN FREE) SOSY 150 MCG/0.3MLACYCLOVIR SODIUM INJ 1000MG
ACYCLOVIR SODIUM INJ 500MG ARANESP (ALBUMIN FREE) SOSY 200 MCG/0.4MLACYCLOVIR SODIUM INJ 500MG
ACYCLOVIR SUSP 200 MG/5ML
ARANESP (ALBUMIN FREE) SOSY 25 MCG/0.42ML
ACYCLOVIR SUSP 200 MG/5ML
ACYCLOVIR TABS 400 MG
ARANESP (ALBUMIN FREE) SOSY 300 MCG/0.6ML
ACYCLOVIR TABS 400 MG
ACYCLOVIR TABS 800 MG ARANESP (ALBUMIN FREE) SOSY 40 MCG/0.4MLACYCLOVIR TABS 800 MG
ADACEL SUSP 5-2-15.5 LF-MCG/0.5 ARANESP (ALBUMIN FREE) SOSY 500 MCG/MLADACEL SUSP 5-2-15.5 LF-MCG/0.
Prescription Drug Formulary
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
ADAGEN SOLN 250 UNIT/ML
ARANESP (ALBUMIN FREE) SOSY 60 MCG/0.3ML
ADAGEN SOLN 250 UNIT/ML
ADAPALENE GEL 0.1 %
Ascomp with Codeine 30 mg-50 mg-
mg-40 mg capsule
ADAPALENE GEL 0.1 %
ADAPALENE GEL 0.3 % AUBAGIO TABS 14 MG ADAPALENE GEL 0.3 %
ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5 % AUBAGIO TABS 7 MG ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5 %
ADEFOVIR DIPIVOXIL TABS 10 MG
Auvi-Q ADEFOVIR DIPIVOXIL TABS 10 MG
ADEMPAS TABS 0.5 MG Auvi-Q 0.15 mg/0.15 mL injection,auto- ADEMPAS TABS 0.5 MG
ADEMPAS TABS 1 MG Auvi-Q 0.3 mg/0.3 mL injection, auto- ADEMPAS TABS 1 MG
ADEMPAS TABS 1.5 MG AVONEX PEN AJKT 30 MCG/0.5ML ADEMPAS TABS 1.5 MG
ADEMPAS TABS 2 MG AVONEX PREFILLED PSKT 30 MCG/0.5ML ADEMPAS TABS 2 MG
ADEMPAS TABS 2.5 MG
benzhydrocodone-acetaminophen ADEMPAS TABS 2.5 MG
ADENOSINE (DIAGNOSTIC) SOLN 3 MG/ML
butalbital 50 mg-acetaminophen 300 mg-
caffeine 40 mg-codeine 30 mg cap
ADENOSINE (DIAGNOSTIC) SOLN 3 MG/ML
ADENOSINE SOLN 12 MG/4ML
butalbital 50 mg-acetaminophen 325 mg-
caffeine 40 mg-codeine 30 mg cap
ADENOSINE SOLN 12 MG/4ML
ADENOSINE SOLN 6 MG/2ML
Butalbital Compound with Codeine 30 mg-
50 mg-325 mg-40 mg capsule
ADENOSINE SOLN 6 MG/2ML
ADRUCIL SOLN 500 MG/10ML butorphanol tartrate 1 mg/mL injection ADRUCIL SOLN 500 MG/10ML
ADULT AEROSOL MASK MISC butorphanol tartrate 10 mg/mL nasal ADVAIR HFA AERO 115-21 MCG/ACT
ADVAIR HFA AERO 115-21 MCG/ACT Butrans 10 mcg/hour transdermal patch ADVAIR HFA AERO 230-21 MCG/ACT
ADVAIR HFA AERO 230-21 MCG/ACT Butrans 15 mcg/hour transdermal patch ADVAIR HFA AERO 45-21 MCG/ACT
ADVAIR HFA AERO 45-21 MCG/ACT Butrans 20 mcg/hour transdermal patch AFIRMELLE TABS 0.1-20 MG-MCG
ADVOCATE CONTROL SOLUTION LIQD LOW Butrans 5 mcg/hour transdermal patch AFTERA TABS 1.5 MG
AEROCHAMBER Z-STAT PLUS MISC Butrans 7.5 mcg/hour transdermal patch AKOVAZ SOLN 50 MG/ML
AEROCHAMBER Z-STAT PLUS/LARGE MISC
Bydureon 2 mg subcutaneous extended
release suspension
AKYNZEO CAPS 300-0.5 MG
AEROCHAMBER Z-STAT PLUS/MEDIUM MISC Bydureon 2 mg/0.65 mL subcutaneous ALAVERT TBDP 10 MG
AEROCHAMBER Z-STAT PLUS/SMALL MISC BYDUREON BCISE AUIJ 2 MG/0.85ML ALBENDAZOLE TABS 200 MG
AEROGEAR ACTION ASTHMA KIT KIT
Byetta 10 mcg/dose(250 mcg/mL)2.4 mL
subcutaneous pen injector
ALBUMIN HUMAN SOLN 25 %
AFIRMELLE TABS 0.1-20 MG-MCG
Byetta 5 mcg/dose (250 mcg/mL)1.2 mL
subcutaneous pen injector
ALBUSTIX STRP
AFTERA TABS 1.5 MG carisoprodol-ASA-codeine 200 mg-325 ALBUTEROL SULFATE HFA AERS 108 (90 Base) MCG/A
AKOVAZ SOLN 50 MG/ML CAYSTON SOLR 75 MG ALBUTEROL SULFATE NEBU (2.5 MG/3ML) 0.083%
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
AMBRISENTAN TABS 5 MG
EMFLAZA TABS 6 MG
AMLODIPINE BESYLATE TABS 10 MG
AMIKACIN SULFATE INJ 500/2ML EMGALITY (300 MG DOSE) SOSY 100 MG/MLAMLODIPINE BESYLATE TABS 2.5 MG
AMIKACIN SULFATE SOLN 1 GM/4ML EMGALITY SOAJ 120 MG/ML AMLODIPINE BESYLATE TABS 5 MG
AMIKACIN SULFATE SOLN 500 MG/2ML EMGALITY SOSY 120 MG/ML AMOXICILLIN CAPS 250 MG
AMILORIDE HCL TABS 5 MG Enbrel AMOXICILLIN CAPS 500 MG
AMILORIDE-HYDROCHLOROTHIAZIDE TABS 5-50 MG
ENBREL MINI SOCT 50 MG/ML
AMOXICILLIN CHEW 125 MG
AMINOCAPROIC ACID TABS 500 MG ENBREL SOLR 25 MG AMOXICILLIN CHEW 250 MG
AMINOPHYLLINE SOLN 25 MG/ML ENBREL SOSY 25 MG/0.5ML AMOXICILLIN SUSR 125 MG/5ML
AMIODARONE HCL SOLN 150 MG/3ML ENBREL SOSY 50 MG/ML AMOXICILLIN SUSR 200 MG/5ML
AMIODARONE HCL TABS 200 MG ENBREL SURECLICK SOAJ 50 MG/ML AMOXICILLIN SUSR 250 MG/5ML
AMLODIPINE BESYLATE TABS 10 MG Endocet 10 mg-325 mg tablet AMOXICILLIN SUSR 400 MG/5ML
AMLODIPINE BESYLATE TABS 2.5 MG Endocet 5 mg-325 mg tablet AMOXICILLIN TABS 500 MG
AMLODIPINE BESYLATE TABS 5 MG Endocet 7.5 mg-325 mg tablet AMOXICILLIN TABS 875 MG
AMOXICILLIN CAPS 250 MG Epclusa AMOXICILLIN-POT CLAVULANATE CHEW 200-28.5 MG
AMOXICILLIN CAPS 500 MG Epclusa 400 mg-100 mg tablet AMOXICILLIN-POT CLAVULANATE CHEW 400-57 MG
AMOXICILLIN CHEW 125 MG
ESBRIET CAPS 267 MG
AMOXICILLIN-POT CLAVULANATE SUSR 200-28.5 MG/
AMOXICILLIN CHEW 250 MG ESBRIET TABS 267 MG AMOXICILLIN-POT CLAVULANATE SUSR 250-62.5 MG/
AMOXICILLIN SUSR 125 MG/5ML ESBRIET TABS 801 MG AMOXICILLIN-POT CLAVULANATE SUSR 400-57 MG/5M
AMOXICILLIN SUSR 200 MG/5ML Exalgo ER 8 mg tablet,extended release AMOXICILLIN-POT CLAVULANATE SUSR 600-42.9 MG/
AMOXICILLIN SUSR 250 MG/5ML Farxiga 10 mg tablet AMOXICILLIN-POT CLAVULANATE TABS 250-125 MG
AMOXICILLIN SUSR 400 MG/5ML Farxiga 5 mg tablet AMOXICILLIN-POT CLAVULANATE TABS 500-125 MG
AMOXICILLIN TABS 500 MG FASENRA PEN SOAJ 30 MG/ML AMOXICILLIN-POT CLAVULANATE TABS 875-125 MG
AMOXICILLIN TABS 875 MG FASENRA SOSY 30 MG/ML AMPHOTERICIN B SOLR 50 MG
AMOXICILLIN-POT CLAVULANATE CHEW 200-28.5 MG fentanyl (PF) 50 mcg/mL injection AMPICILLIN CAP 250MG
AMOXICILLIN-POT CLAVULANATE CHEW 400-57 MG fentanyl 100 mcg/hr transdermal patch AMPICILLIN CAPS 500 MG
AMOXICILLIN-POT CLAVULANATE SUSR 200-28.5 MG/5ML fentanyl 12 mcg/hr transdermal patch AMPICILLIN SODIUM SOLR 1 GM
AMOXICILLIN-POT CLAVULANATE SUSR 250-62.5 MG/5ML fentanyl 25 mcg/hr transdermal patch AMPICILLIN SODIUM SOLR 2 GM
AMOXICILLIN-POT CLAVULANATE SUSR 400-57 MG/5ML fentanyl 37.5 mcg/hour transdermal AMPICILLIN SODIUM SOLR 250 MG
AMOXICILLIN-POT CLAVULANATE SUSR 600-42.9 MG/5ML fentanyl 50 mcg/hr transdermal patch AMPICILLIN SODIUM SOLR 500 MG
AMOXICILLIN-POT CLAVULANATE TABS 250-125 MG fentanyl 62.5 mcg/hour transdermal AMPICILLIN SUSR 125 MG/5ML
AMOXICILLIN-POT CLAVULANATE TABS 500-125 MG fentanyl 75 mcg/hr transdermal patch AMPICILLIN SUSR 250 MG/5ML
AMOXICILLIN-POT CLAVULANATE TABS 875-125 MG fentanyl 87.5 mcg/hour transdermal AMPICILLIN-SULBACTAM SODIUM SOLR 1.5 (1-0.5) GM
AMPHOTERICIN B SOLR 50 MG Fentora 100 mcg buccal tablet, AMPICILLIN-SULBACTAM SODIUM SOLR 3 (2-1) GM
AMPICILLIN CAP 250MG Fentora 200 mcg buccal tablet, AMP-SULBACTA INJ 1.5GM
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
AMPICILLIN CAPS 500 MG
FIRDAPSE TABS 10 MG
AMP-SULBACTA INJ 3GM
AMPICILLIN SODIUM SOLR 1 GM
Genotropin 12 mg/mL (36 unit/mL)
subcutaneous cartridge
ANAGRELIDE HCL CAPS 0.5 MG
AMPICILLIN SODIUM SOLR 2 GM
Genotropin 5 mg/mL (15 unit/mL)
subcutaneous cartridge
ANAGRELIDE HCL CAPS 1 MG
AMPICILLIN SODIUM SOLR 250 MG
Genotropin MiniQuick 0.4 mg/0.25 mL
subcutaneous syringe
ANASTROZOLE TABS 1 MG
AMPICILLIN SODIUM SOLR 500 MG
Genotropin MiniQuick 0.8 mg/0.25 mL
subcutaneous syringe
APREPITANT CAPS 125 MG
AMPICILLIN SUSR 125 MG/5ML
Genotropin MiniQuick 1 mg/0.25 mL
subcutaneous syringe
APREPITANT CAPS 80 MG
AMPICILLIN SUSR 250 MG/5ML
Genotropin MiniQuick 1.6 mg/0.25 mL
subcutaneous syringe
APRI TABS 0.15-30 MG-MCG
AMPICILLIN-SULBACTAM SODIUM SOLR 1.5 (1-0.5) GM
Genotropin MiniQuick 1.8 mg/0.25 mL
subcutaneous syringe
APTIVUS CAPS 250 MG
AMPICILLIN-SULBACTAM SODIUM SOLR 3 (2-1) GM
Genotropin MiniQuick 2 mg/0.25 mL
subcutaneous syringe
APTIVUS SOLN 100 MG/ML
AMP-SULBACTA INJ 1.5GM GILENYA CAPS 0.25 MG AQUASOL A SOLN 15 MG/ML
AMP-SULBACTA INJ 3GM GILENYA CAPS 0.5 MG ARANELLE TABS 0.5/1/0.5-35 MG-MCG
ANAGRELIDE HCL CAPS 0.5 MG GLYXAMBI TABS 10-5 MG ARZOL SILVER NIT APPLICATORS MISC 75-25 %
ANAGRELIDE HCL CAPS 1 MG
GLYXAMBI TABS 25-5 MG
ASCORBIC ACID SOLN 500 MG/ML
ANASTROZOLE TABS 1 MG Guaiatussin AC 10 mg-100 mg/5 mL oral ASCRIPTIN TABS 325 MG
APREPITANT CAPS 125 MG Guaifenesin AC 10 mg-100 mg/5 mL oral ASPIRIN CHEW 81 MG
APREPITANT CAPS 80 MG Harvoni ASPIRIN-DIPYRIDAMOLE ER CP12 25-200 MG
APRI TABS 0.15-30 MG-MCG Harvoni 90 mg-400 mg tablet ATAZANAVIR SULFATE CAPS 150 MG
APTIVUS CAPS 250 MG HARVONI PACK 33.75-150 MG ATAZANAVIR SULFATE CAPS 200 MG
APTIVUS SOLN 100 MG/ML HARVONI PACK 45-200 MG ATAZANAVIR SULFATE CAPS 300 MG
AQUASOL A SOLN 15 MG/ML Humatrope 5 mg (15 unit) solution for ATENOLOL TABS 100 MG
ARANELLE TABS 0.5/1/0.5-35 MG-MCG HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8MLATENOLOL TABS 25 MG
ARZOL SILVER NIT APPLICATORS MISC 75-25 % HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML & 40MG/0.4MLATENOLOL TABS 50 MG
ASCORBIC ACID SOLN 500 MG/ML
HUMIRA PEN PNKT 40 MG/0.4ML
ATENOLOL-CHLORTHALIDONE TABS 100-25 MG
ASCRIPTIN TABS 325 MG HUMIRA PEN PNKT 40 MG/0.8ML ATENOLOL-CHLORTHALIDONE TABS 50-25 MG
ASPIRIN CHEW 81 MG HUMIRA PEN-CD/UC/HS STARTER PNKT 40 MG/0.8MLATORVASTATIN CALCIUM TABS 10 MG
ASPIRIN-DIPYRIDAMOLE ER CP12 25-200 MG HUMIRA PEN-CD/UC/HS STARTER PNKT 80 MG/0.8MLATORVASTATIN CALCIUM TABS 20 MG
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
AZACITIDINE SUSR 100 MG hydromorphone 4 mg tablet AZTREONAM SOLR 2 GM
AZATHIOPRINE TABS 50 MG hydromorphone 8 mg tablet BACIIM SOLR 50000 UNIT
AZELAIC ACID GEL 15 % hydromorphone ER 12 mg tablet,extended BACITRACIN OINT 500 UNIT/GM
AZELASTINE HCL SOLN 0.1 % hydromorphone ER 16 mg tablet,extended BACITRACIN-POLYMYXIN B OINT 500-10000 UNIT/GM
AZITHROMYCIN PACK 1 GM hydromorphone ER 32 mg tablet,extended BACITRA-NEOMYCIN-POLYMYXIN-HC OINT 1 %
AZITHROMYCIN SOLR 500 MG hydromorphone ER 8 mg tablet,extended BACLOFEN TABS 10 MG
AZITHROMYCIN SUSR 100 MG/5ML hydroxychloroquine 200 mg tablet BACLOFEN TABS 20 MG
AZITHROMYCIN SUSR 200 MG/5ML IBRANCE CAPS 100 MG BACTERIOSTATIC WATER(BENZ ALC) SOLN
AZITHROMYCIN TABS 250 MG IBRANCE CAPS 125 MG BALSALAZIDE DISODIUM CAPS 750 MG
AZITHROMYCIN TABS 500 MG IBRANCE CAPS 75 MG BAQSIMI ONE PACK POWD 3 MG/DOSE
AZITHROMYCIN TABS 600 MG IBRANCE TABS 100 MG BARACLUDE SOLN 0.05 MG/ML
AZTREONAM SOLR 1 GM IBRANCE TABS 125 MG BENDEKA SOLN 100 MG/4ML
AZTREONAM SOLR 2 GM IBRANCE TABS 75 MG BENZONATATE CAPS 100 MG
BACIIM SOLR 50000 UNIT Ibudone 5 mg-200 mg tablet BENZTROPINE MESYLATE SOLN 1 MG/ML
BACITRACIN OINT 500 UNIT/GM ibuprofen-oxycodone 400 mg-5 mg tablet BENZTROPINE MESYLATE TABS 0.5 MG
BACITRACIN-POLYMYXIN B OINT 500-10000 UNIT/GM
ILARIS SOLN 150 MG/ML
BENZTROPINE MESYLATE TABS 1 MG
BACITRA-NEOMYCIN-POLYMYXIN-HC OINT 1 % ILUMYA SOSY 100 MG/ML BENZTROPINE MESYLATE TABS 2 MG
BACLOFEN TABS 10 MG IMBRUVICA CAPS 140 MG BETADINE OPHTHALMIC PREP SOLN 5 %
BACLOFEN TABS 20 MG IMBRUVICA CAPS 70 MG BETAMETHASONE DIPROPIONATE AUG CREA 0.05 %
BACTERIOSTATIC WATER(BENZ ALC) SOLN IMBRUVICA TABS 140 MG BETAMETHASONE DIPROPIONATE AUG GEL 0.05 %
BALSALAZIDE DISODIUM CAPS 750 MG IMBRUVICA TABS 280 MG BETAMETHASONE DIPROPIONATE AUG LOTN 0.05 %
BAQSIMI ONE PACK POWD 3 MG/DOSE IMBRUVICA TABS 420 MG BETAMETHASONE DIPROPIONATE AUG OINT 0.05 %
BARACLUDE SOLN 0.05 MG/ML IMBRUVICA TABS 560 MG BETAMETHASONE DIPROPIONATE CREA 0.05 %
BD 10ML LUER-LOK SYRINGE 22G X 1-1/2" MIS 22GX1.5" Increlex 10 mg/mL subcutaneous solution BETAMETHASONE VALERATE CREA 0.1 %
BD 3ML LUER-LOK SYRINGE 21G X 1-1/4" MIS 21GX1.25 INVOKAMET TABS 150-1000 MG BETAMETHASONE VALERATE LOTN 0.1 %
BD 3ML LUER-LOK SYRINGE/22G X 1-1/4" MIS 22GX1.
INVOKAMET TABS 150-500 MG
BETAMETHASONE VALERATE OINT 0.1 %
BD ALLERGY SYRINGE MISC 28G X 1/2" 1 ML INVOKAMET TABS 50-1000 MG BETAXOLOL HCL SOLN 0.5 %
BD AUTOSHIELD DUO MISC 30G X 5 MM INVOKAMET TABS 50-500 MG BETHANECHOL CHLORIDE TABS 10 MG
BD BLUNT FILL NEEDLE MISC 18G X 1-1/2" INVOKAMET XR TB24 150-1000 MG BETHANECHOL CHLORIDE TABS 25 MG
BD DISP NEEDLE MISC 25G X 1" INVOKAMET XR TB24 150-500 MG BETHANECHOL CHLORIDE TABS 5 MG
BD DISP NEEDLES MISC 18G X 1-1/2"
INVOKAMET XR TB24 50-1000 MG
BETHANECHOL CHLORIDE TABS 50 MG
BD DISP NEEDLES MISC 20G X 1" INVOKAMET XR TB24 50-500 MG BEXAROTENE CAPS 75 MG
BD DISP NEEDLES MISC 22G X 1-1/2" Invokana 100 mg tablet BEXSERO SUSY
BD DISP NEEDLES MISC 25G X 5/8" Invokana 300 mg tablet BICALUTAMIDE TABS 50 MG
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
BD DISP NEEDLES MISC 27G X 1/2" Janumet 50 mg-1,000 mg tablet BICILLIN L-A SUSP 1200000 UNIT/2ML
BD DISP NEEDLES MISC 30G X 1/2" Janumet 50 mg-500 mg tablet BICILLIN L-A SUSP 2400000 UNIT/4ML
BD FILTER NEEDLE/5 MICRON MISC Janumet XR 100 mg-1,000 mg BICILLIN L-A SUSP 600000 UNIT/ML
BD HYPODERMIC NEEDLE MISC 18G X 1-1/2" Janumet XR 50 mg-1,000 mg BICNU SOLR 100 MG
BD HYPODERMIC NEEDLE MISC 20G X 1-1/2" Janumet XR 50 mg-500 mg BIKTARVY TABS 50-200-25 MG
BD HYPODERMIC NEEDLE MISC 22G X 1" Januvia 100 mg tablet BIO-D-MULSION FORTE LIQD 50 MCG/0.03ML
BD HYPODERMIC NEEDLE MISC 22G X 1-1/2" Januvia 25 mg tablet BIO-D-MULSION LIQD 10 MCG/0.03ML
BD HYPODERMIC NEEDLE MISC 25G X 1" Januvia 50 mg tablet BISOPROLOL FUMARATE TABS 10 MG
BD HYPODERMIC NEEDLE MISC 25G X 1-1/2" Jardiance 10 mg tablet BISOPROLOL FUMARATE TABS 5 MG
BD HYPODERMIC NEEDLE MISC 25G X 5/8" Jentadueto 2.5 mg-1,000 mg tablet BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 10-6.25 M
BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2" MIS 0.3/28GJentadueto 2.5 mg-500 mg tablet BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 2.5-6.25 M
BD INSULIN SYRINGE MICROFINE MISC 27G X 5/8" 1 ML Jentadueto 2.5 mg-850 mg tablet BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 5-6.25 M
BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2" MIS 0.3/28GJYNARQUE TABS 15 MG BLEOMYCIN SULFATE SOLR 15 UNIT
BD INSULIN SYRINGE MISC 25G X 1" 1 ML JYNARQUE TABS 30 MG BLEOMYCIN SULFATE SOLR 30 UNIT
BD INSULIN SYRINGE MISC 25G X 5/8" 1 ML JYNARQUE TBPK 45 & 15 MG BLEPHAMIDE SUSP 10-0.2 %
BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML
JYNARQUE TBPK 60 & 30 MG
BLISOVI FE 1.5/30 TABS 1.5-30 MG-MCG
BD INSULIN SYRINGE MISC 27G X 1/2" 1 ML JYNARQUE TBPK 90 & 30 MG BLISOVI FE 1/20 TABS 1-20 MG-MCG
BD INSULIN SYRINGE MISC U-100 1 ML Kadian 10 mg capsule,extended release BOSENTAN TABS 125 MG
BD INSULIN SYRINGE U/F MISC 30G X 1/2" 0.3 ML Kadian 20 mg capsule,extended release BOSENTAN TABS 62.5 MG
BD INSULIN SYRINGE U/F MISC 30G X 1/2" 0.5 ML Kadian 30 mg capsule,extended release BOTOX SOLR 100 UNIT
BD INSULIN SYRINGE U/F MISC 30G X 1/2" 1 ML Kadian 50 mg capsule,extended release BRIDION SOLN 200 MG/2ML
BD INSULIN SYRINGE U/F MISC 31G X 5/16" 0.3 ML Kadian 60 mg capsule,extended release BRIDION SOLN 500 MG/5ML
BD INSULIN SYRINGE U/F MISC 31G X 5/16" 0.5 ML Kadian 80 mg capsule,extended release BRILINTA TABS 60 MG
BD INSULIN SYRINGE U/F MISC 31G X 5/16" 1 ML Kaletra 100 mg-25 mg tablet BRILINTA TABS 90 MG
BD INSULIN SYRINGE U-500 MISC 31G X 6MM 0.5 ML KALETRA 100-25 MG TABLET BRIMONIDINE TARTRATE SOLN 0.2 %
BD INTEGRA INSULIN SYRINGE/U-100/1ML/29G X 1/2" MIS 1ML/29GKaletra 200 mg-50 mg tablet BROMOCRIPTINE MESYLATE CAPS 5 MG
BD LANCET ULTRAFINE 30G MISC KALETRA 200-50 MG TABLET BROMOCRIPTINE MESYLATE TABS 2.5 MG
BD LUER-LOK SYRINGE MISC 18G X 1-1/2" 3 ML Kaletra 400 mg-100 mg/5 mL oral BSS SOLN
BD LUER-LOK SYRINGE MISC 20G X 1" 10 ML KALETRA 80 MG-20 MG/ML SOLN BUDESONIDE CPEP 3 MG
BD LUER-LOK SYRINGE MISC 20G X 1" 3 ML KALETRA ORAL SOLUTION 400-100 MG/5MLBUDESONIDE SUSP 0.25 MG/2ML
BD LUER-LOK SYRINGE MISC 20G X 1" 5 ML
KALETRA TABS 100-25 MG
BUDESONIDE SUSP 0.5 MG/2ML
BD LUER-LOK SYRINGE MISC 20G X 1-1/2" 10 ML KALETRA TABS 200-50 MG BUFFERIN LOW DOSE TABS 81 MG
BD LUER-LOK SYRINGE MISC 20G X 1-1/2" 3 ML Kazano 12.5 mg-1,000 mg tablet BUPIVACAINE HCL (PF) SOLN 0.25 %
BD LUER-LOK SYRINGE MISC 20G X 1-1/2" 5 ML Kazano 12.5 mg-500 mg tablet BUPIVACAINE HCL (PF) SOLN 0.5 %
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
BD VEO INSULIN SYR U/F 1/2UNIT MISC 31G X 15/64" 0.3 ML meperidine 100 mg tablet CAPTOPRIL TABS 50 MG
BD VEO INSULIN SYRINGE U/F MISC 31G X 15/64" 0.3 ML meperidine 50 mg tablet CARBIDOPA TABS 25 MG
BD VEO INSULIN SYRINGE U/F MISC 31G X 15/64" 0.5 ML meperidine 50 mg/5 mL oral solution CARBIDOPA-LEVODOPA ER TBCR 25-100 MG
BD VEO INSULIN SYRINGE U/F MISC 31G X 15/64" 1 ML methadone 10 mg tablet CARBIDOPA-LEVODOPA ER TBCR 50-200 MG
BENDEKA SOLN 100 MG/4ML methadone 10 mg/5 mL oral solution CARBIDOPA-LEVODOPA TABS 10-100 MG
BENZONATATE CAPS 100 MG methadone 10 mg/mL oral concentrate CARBIDOPA-LEVODOPA TABS 25-100 MG
BENZTROPINE MESYLATE SOLN 1 MG/ML methadone 5 mg tablet CARBIDOPA-LEVODOPA TABS 25-250 MG
BENZTROPINE MESYLATE TABS 0.5 MG methadone 5 mg/5 mL oral solution CARBOCAINE PRESERVATIVE-FREE SOLN 1 %
BENZTROPINE MESYLATE TABS 1 MG Methadone Intensol 10 mg/mL oral CARBOCAINE PRESERVATIVE-FREE SOLN 1.5 %
BENZTROPINE MESYLATE TABS 2 MG Methadose 10 mg/mL oral concentrate CARBOPLATIN INJ 150MG
BETADINE OPHTHALMIC PREP SOLN 5 %
MIRCERA SOSY 100 MCG/0.3ML
CARBOPLATIN INJ 450MG
BETAMETHASONE DIPROPIONATE AUG CREA 0.05 % MIRCERA SOSY 150 MCG/0.3ML CARBOPLATIN INJ 50MG
BETAMETHASONE DIPROPIONATE AUG GEL 0.05 % MIRCERA SOSY 200 MCG/0.3ML CARBOPLATIN SOLN 150 MG/15ML
BETAMETHASONE DIPROPIONATE AUG LOTN 0.05 % MIRCERA SOSY 30 MCG/0.3ML CARBOPLATIN SOLN 450 MG/45ML
BETAMETHASONE DIPROPIONATE AUG OINT 0.05 % MIRCERA SOSY 50 MCG/0.3ML CARDENE IV SOLN 20-0.86 MG/200ML-%
BETAMETHASONE DIPROPIONATE CREA 0.05 %
MIRCERA SOSY 75 MCG/0.3ML
CARDENE IV SOLN 40-0.83 MG/200ML-%
BETAMETHASONE VALERATE CREA 0.1 % morphine CARTIA XT CP24 120 MG
BETAMETHASONE VALERATE LOTN 0.1 % morphine 10 mg/5 mL oral solution CARTIA XT CP24 180 MG
BETAMETHASONE VALERATE OINT 0.1 % morphine 15 mg immediate release tablet CARTIA XT CP24 240 MG
BETAXOLOL HCL SOLN 0.5 % morphine 20 mg/5 mL (4 mg/mL) oral CARTIA XT CP24 300 MG
BETHANECHOL CHLORIDE TABS 10 MG morphine 30 mg immediate release tablet CARVEDILOL TABS 12.5 MG
BETHANECHOL CHLORIDE TABS 25 MG
morphine concentrate 100 mg/5 mL (
mg/mL) oral solution
CARVEDILOL TABS 25 MG
BETHANECHOL CHLORIDE TABS 5 MG morphine ER 10 mg capsule,extended CARVEDILOL TABS 3.125 MG
BETHANECHOL CHLORIDE TABS 50 MG morphine ER 100 mg tablet,extended CARVEDILOL TABS 6.25 MG
BEXAROTENE CAPS 75 MG morphine ER 15 mg tablet,extended CASPOFUNGIN ACETATE SOLR 70 MG
BEXSERO SUSY morphine ER 20 mg capsule,extended CATHFLO ACTIVASE SOLR 2 MG
BICALUTAMIDE TABS 50 MG morphine ER 200 mg tablet,extended CEFACLOR CAPS 250 MG
BICILLIN L-A SUSP 1200000 UNIT/2ML
morphine ER 30 mg capsule,extended
release 24 hr multiphase
CEFACLOR CAPS 500 MG
BICILLIN L-A SUSP 2400000 UNIT/4ML morphine ER 30 mg tablet,extended CEFACLOR SUSR 125 MG/5ML
BICILLIN L-A SUSP 600000 UNIT/ML morphine ER 60 mg tablet,extended CEFACLOR SUSR 250 MG/5ML
BICNU SOLR 100 MG MOTEGRITY TABS 1 MG CEFACLOR SUSR 375 MG/5ML
BIKTARVY TABS 50-200-25 MG MOTEGRITY TABS 2 MG CEFAZOLIN SODIUM SOLR 1 GM
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
BIO-D-MULSION FORTE LIQD 50 MCG/0.03ML
MOVANTIK TABS 12.5 MG
CEFAZOLIN SODIUM SOLR 10 GM
BIO-D-MULSION LIQD 10 MCG/0.03ML MOVANTIK TABS 25 MG CEFAZOLIN SODIUM-DEXTROSE SOLN 1-4 GM/50ML-%
BISOPROLOL FUMARATE TABS 10 MG MYALEPT SOLR 11.3 MG CEFDINIR CAPS 300 MG
BISOPROLOL FUMARATE TABS 5 MG Nalocet CEFDINIR SUSR 125 MG/5ML
BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 10-6.25 MG Nesina 12.5 mg tablet CEFDINIR SUSR 250 MG/5ML
BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 2.5-6.25 MG Nesina 25 mg tablet CEFEPIME HCL SOLR 1 GM
BISOPROLOL-HYDROCHLOROTHIAZIDE TABS 5-6.25 MG NEXAVAR TABS 200 MG CEFEPIME HCL SOLR 2 GM
BLEOMYCIN SULFATE SOLR 15 UNIT NINLARO CAPS 2.3 MG CEFEPIME-DEXTROSE SOLR 1-5 GM-%(50ML)
BLEOMYCIN SULFATE SOLR 30 UNIT NINLARO CAPS 3 MG CEFEPIME-DEXTROSE SOLR 2-5 GM-%(50ML)
BLEPHAMIDE SUSP 10-0.2 % NINLARO CAPS 4 MG CEFIXIME CAPS 400 MG
BLISOVI FE 1.5/30 TABS 1.5-30 MG-MCG
Norditropin FlexPro 10 mg/1.5 mL (6.
mg/mL) subcutaneous pen injector
CEFIXIME SUSR 100 MG/5ML
BLISOVI FE 1/20 TABS 1-20 MG-MCG
Norditropin FlexPro 15 mg/1.5 mL (
mg/mL) subcutaneous pen injector
CEFIXIME SUSR 200 MG/5ML
BOSENTAN TABS 125 MG
Norditropin FlexPro 5 mg/1.5 mL (3.
mg/mL) subcutaneous pen injector
CEFOTAXIME SODIUM SOLR 1 GM
BOSENTAN TABS 62.5 MG NORVIR 100 MG POWDER PACKET CEFOXITIN SODIUM SOLR 1 GM
BOTOX SOLR 100 UNIT Norvir 100 mg tablet CEFOXITIN SODIUM SOLR 10 GM
BRIDION SOLN 200 MG/2ML Norvir 80 mg/mL oral solution CEFOXITIN SODIUM SOLR 2 GM
BRIDION SOLN 500 MG/5ML NORVIR 80 MG/ML SOLUTION CEFTAZIDIME AND DEXTROSE SOLR 1-5 GM-%(50ML)
BRILINTA TABS 60 MG
NORVIR CAP 100MG
CEFTAZIDIME AND DEXTROSE SOLR 2-5 GM-%(50ML)
BRILINTA TABS 90 MG NORVIR ORAL POWDER PACK 100 MG CEFTIN SUSR 250 MG/5ML
BRIMONIDINE TARTRATE SOLN 0.2 % NORVIR ORAL SOLUTION 80 MG/ML CEFTRIAXONE SODIUM IN DEXTROSE SOLN 20 MG/ML
BROMOCRIPTINE MESYLATE CAPS 5 MG NORVIR PACK 100 MG CEFTRIAXONE SODIUM IN DEXTROSE SOLN 40 MG/ML
BROMOCRIPTINE MESYLATE TABS 2.5 MG NORVIR TABS 100 MG CEFTRIAXONE SODIUM SOLR 1 GM
BSS SOLN
NUCALA SOAJ 100 MG/ML
CEFTRIAXONE SODIUM SOLR 10 GM
BUDESONIDE CPEP 3 MG NUCALA SOLR 100 MG CEFTRIAXONE SODIUM SOLR 2 GM
BUDESONIDE SUSP 0.25 MG/2ML NUCALA SOSY 100 MG/ML CEFTRIAXONE SODIUM SOLR 250 MG
BUDESONIDE SUSP 0.5 MG/2ML Nucynta 100 mg tablet CEFTRIAXONE SODIUM SOLR 500 MG
BUFFERIN LOW DOSE TABS 81 MG Nucynta 50 mg tablet CEFTRIAXONE SODIUM-DEXTROSE SOLR 1-3.74 GM-%(
BUPIVACAINE HCL (PF) SOLN 0.25 % Nucynta 75 mg tablet CEFTRIAXONE SODIUM-DEXTROSE SOLR 2-2.22 GM-%(
BUPIVACAINE HCL (PF) SOLN 0.5 % Nucynta ER 100 mg tablet,extended CEFUROXIME AXETIL SUS 125/5ML
BUPIVACAINE HCL (PF) SOLN 0.75 % Nucynta ER 150 mg tablet,extended CEFUROXIME AXETIL SUS 250/5ML
BUPIVACAINE HCL SOLN 0.5 % Nucynta ER 50 mg tablet,extended release CEFUROXIME AXETIL TABS 250 MG
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
CAPTOPRIL TABS 12.5 MG
OTREXUP SOAJ 22.5 MG/0.4ML
CHLORAMPHENICOL POWD
CAPTOPRIL TABS 25 MG OTREXUP SOAJ 25 MG/0.4ML CHLOROQUINE PHOSPHATE TABS 250 MG
CAPTOPRIL TABS 50 MG oxycodone 15 mg tablet CHLOROQUINE PHOSPHATE TABS 500 MG
CARBIDOPA TABS 25 MG oxycodone 20 mg tablet CHLOROTHIAZIDE TABS 250 MG
CARBIDOPA-LEVODOPA ER TBCR 25-100 MG oxycodone 20 mg/mL oral concentrate CHLOROTHIAZIDE TABS 500 MG
CARBIDOPA-LEVODOPA ER TBCR 50-200 MG oxycodone 30 mg tablet CHLORTHALIDONE TABS 25 MG
CARBIDOPA-LEVODOPA TABS 10-100 MG oxycodone 5 mg capsule CHLORTHALIDONE TABS 50 MG
CARBIDOPA-LEVODOPA TABS 25-100 MG oxycodone 5 mg tablet CHOLESTYRAMINE PACK 4 GM
CARBIDOPA-LEVODOPA TABS 25-250 MG oxycodone 5 mg/5 mL oral solution CHOLESTYRAMINE POWD 4 GM/DOSE
CARBOCAINE PRESERVATIVE-FREE SOLN 1 %
oxycodone ER 10 mg tablet,crush
resistant,extended release 12 hr
CHOLINE MAGNESIUM TRISALICYLATE TAB 1000MG
CARBOCAINE PRESERVATIVE-FREE SOLN 1.5 %
oxycodone ER 15 mg tablet,crush
resistant,extended release 12 hr
CICLOPIROX GEL 0.77 %
CARBOPLATIN INJ 150MG
oxycodone ER 20 mg tablet,crush
resistant,extended release 12 hr
CICLOPIROX OLAMINE CREA 0.77 %
CARBOPLATIN INJ 450MG
oxycodone ER 30 mg tablet,crush
resistant,extended release 12 hr
CILOSTAZOL TABS 100 MG
CARBOPLATIN INJ 50MG
oxycodone ER 40 mg tablet,crush
resistant,extended release 12 hr
CILOSTAZOL TABS 50 MG
CARBOPLATIN SOLN 150 MG/15ML
oxycodone ER 60 mg tablet,crush
resistant,extended release 12 hr
CILOXAN OINT 0.3 %
CARBOPLATIN SOLN 450 MG/45ML
oxycodone ER 80 mg tablet,crush
resistant,extended release 12 hr
CIMDUO TABS 300-300 MG
CARDENE IV SOLN 20-0.86 MG/200ML-% OXYCODONE HCL TABS 10 MG CINACALCET HCL TABS 30 MG
CARDENE IV SOLN 40-0.83 MG/200ML-% oxycodone-acetaminophen 10 mg-325 mg CINACALCET HCL TABS 60 MG
CARTIA XT CP24 120 MG oxycodone-acetaminophen 2.5 mg-325 CINACALCET HCL TABS 90 MG
CARTIA XT CP24 180 MG oxycodone-acetaminophen 5 mg-325 mg CIPROFLOXACIN HCL SOLN 0.3 %
CARTIA XT CP24 240 MG
oxycodone-acetaminophen 5 mg-
mg/5 mL oral solution
CIPROFLOXACIN HCL TABS 100 MG
CARTIA XT CP24 300 MG oxycodone-acetaminophen 7.5 mg-325 CIPROFLOXACIN HCL TABS 250 MG
CARVEDILOL TABS 12.5 MG OxyContin 10 mg tablet,crush CIPROFLOXACIN HCL TABS 500 MG
CARVEDILOL TABS 25 MG OxyContin 15 mg tablet,crush CIPROFLOXACIN HCL TABS 750 MG
CARVEDILOL TABS 3.125 MG OxyContin 20 mg tablet,crush CIPROFLOXACIN IN D5W SOLN 200 MG/100ML
CARVEDILOL TABS 6.25 MG OxyContin 30 mg tablet,crush CIPROFLOXACIN IN D5W SOLN 400 MG/200ML
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
CASPOFUNGIN ACETATE SOLR 70 MG OxyContin 40 mg tablet,crush CIPROFLOXACIN SUSR 250 MG/5ML (5%)
CATHFLO ACTIVASE SOLR 2 MG OxyContin 60 mg tablet,crush CIPROFLOXACIN SUSR 500 MG/5ML (10%)
CEFACLOR CAPS 250 MG OxyContin 80 mg tablet,crush CIPROFLOXACIN-DEXAMETHASONE SUSP 0.3-0.1 %
CEFACLOR CAPS 500 MG oxymorphone 10 mg tablet CISATRACURIUM BESYLATE (PF) SOLN 10 MG/5ML
CEFACLOR SUSR 125 MG/5ML oxymorphone 5 mg tablet CISATRACURIUM BESYLATE (PF) SOLN 200 MG/20ML
CEFACLOR SUSR 250 MG/5ML oxymorphone ER 10 mg tablet,extended CISPLATIN SOLN 100 MG/100ML
CEFACLOR SUSR 375 MG/5ML oxymorphone ER 15 mg tablet,extended CISPLATIN SOLN 200 MG/200ML
CEFAZOLIN SODIUM SOLR 1 GM oxymorphone ER 20 mg tablet,extended CISPLATIN SOLN 50 MG/50ML
CEFAZOLIN SODIUM SOLR 10 GM oxymorphone ER 30 mg tablet,extended CLADRIBINE SOLN 10 MG/10ML
CEFAZOLIN SODIUM-DEXTROSE SOLN 1-4 GM/50ML-% oxymorphone ER 40 mg tablet,extended CLAFORAN INJ 2GM
CEFDINIR CAPS 300 MG oxymorphone ER 5 mg tablet,extended CLARAVIS CAPS 10 MG
CEFDINIR SUSR 125 MG/5ML oxymorphone ER 7.5 mg tablet,extended CLARAVIS CAPS 20 MG
CEFDINIR SUSR 250 MG/5ML Ozempic CLARAVIS CAPS 30 MG
CEFEPIME HCL SOLR 1 GM Plaquenil 200 mg tablet CLARAVIS CAPS 40 MG
CEFEPIME HCL SOLR 2 GM PLEGRIDY SOPN 125 MCG/0.5ML CLARITHROMYCIN SUSR 125 MG/5ML
CEFEPIME-DEXTROSE SOLR 1-5 GM-%(50ML)
PLEGRIDY SOSY 125 MCG/0.5ML
CLARITHROMYCIN SUSR 250 MG/5ML
CEFEPIME-DEXTROSE SOLR 2-5 GM-%(50ML) PLEGRIDY STARTER PACK SOPN 63 & 94 MCG/0.5MLCLARITHROMYCIN TABS 250 MG
CEFIXIME CAPS 400 MG PLEGRIDY STARTER PACK SOSY 63 & 94 MCG/0.5MLCLARITHROMYCIN TABS 500 MG
CEFIXIME SUSR 100 MG/5ML POMALYST CAPS 1 MG CLARITIN CAPS 10 MG
CEFIXIME SUSR 200 MG/5ML POMALYST CAPS 2 MG CLARITIN CHEW 5 MG
CEFOTAXIME SODIUM SOLR 1 GM POMALYST CAPS 3 MG CLARITIN REDITABS TBDP 5 MG
CEFOXITIN SODIUM SOLR 1 GM POMALYST CAPS 4 MG CLEVIPREX EMUL 25 MG/50ML
CEFOXITIN SODIUM SOLR 10 GM PRALUENT SOPN 150 MG/ML CLEVIPREX EMUL 50 MG/100ML
CEFOXITIN SODIUM SOLR 2 GM PRALUENT SOPN 75 MG/ML CLIMARA PTWK 0.025 MG/24HR
CEFTAZIDIME AND DEXTROSE SOLR 1-5 GM-%(50ML) PRALUENT SOSY 150 MG/ML CLIMARA PTWK 0.0375 MG/24HR
CEFTAZIDIME AND DEXTROSE SOLR 2-5 GM-%(50ML)
PRALUENT SOSY 75 MG/ML
CLIMARA PTWK 0.05 MG/24HR
CEFTIN SUSR 250 MG/5ML Prolate CLIMARA PTWK 0.06 MG/24HR
CEFTRIAXONE SODIUM IN DEXTROSE SOLN 20 MG/ML promethazine 6.25 mg-codeine 10 mg/5 CLIMARA PTWK 0.075 MG/24HR
CEFTRIAXONE SODIUM IN DEXTROSE SOLN 40 MG/ML
Promethazine VC-Codeine 6.25 mg-5 mg-
10 mg/5 mL syrup
CLIMARA PTWK 0.1 MG/24HR
CEFTRIAXONE SODIUM SOLR 1 GM
Qtern CLINDAMYCIN HCL CAPS 150 MG
CEFTRIAXONE SODIUM SOLR 10 GM QTERN TABS 10-5 MG CLINDAMYCIN HCL CAPS 300 MG
CEFTRIAXONE SODIUM SOLR 2 GM RASUVO SOAJ 10 MG/0.2ML CLINDAMYCIN PALMITATE HCL SOLR 75 MG/5ML
CEFTRIAXONE SODIUM SOLR 250 MG RASUVO SOAJ 12.5 MG/0.25ML CLINDAMYCIN PHOSPHATE CREA 2 %
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
CHEWABLE VITE/IRON CHILDRENS CHEW 15 MG
RITONAVIR TABS 100 MG
CODEINE SULFATE TABS 60 MG
CHLORAMPHENICOL POWD RoxyBond CODEINE/GUAIFENESIN TAB 10-
CHLOROQUINE PHOSPHATE TABS 250 MG RUZURGI TABS 10 MG COLCHICINE CAPS 0.6 MG
CHLOROQUINE PHOSPHATE TABS 500 MG Rybelsus COLCHICINE TABS 0.6 MG
CHLOROTHIAZIDE TABS 250 MG Saizen 5 mg subcutaneous solution COLESTIPOL HCL TABS 1 GM
CHLOROTHIAZIDE TABS 500 MG
Saizen click.easy 8.8 mg/1.51 mL (final
conc.) subcutaneous cartridge
COLISTIMETHATE SODIUM (CBA) SOLR 150 MG
CHLORTHALIDONE TABS 25 MG Segluromet COLOCORT ENEM 100 MG/60ML
CHLORTHALIDONE TABS 50 MG SEGLUROMET TABS 2.5-1000 MG COLY-MYCIN S SUSP 3.3-3-10-0.5 MG/ML
CHOLESTYRAMINE PACK 4 GM SEGLUROMET TABS 2.5-500 MG COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 MG
CHOLESTYRAMINE POWD 4 GM/DOSE
SEGLUROMET TABS 7.5-1000 MG
COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 MG & 80 M
CHOLINE MAGNESIUM TRISALICYLATE TAB 1000MG SEGLUROMET TABS 7.5-500 MG COMETRIQ (60 MG DAILY DOSE) KIT 20 MG
CICLOPIROX GEL 0.77 % Serostim 4 mg subcutaneous solution COMPLERA TABS 200-25-300 MG
CICLOPIROX OLAMINE CREA 0.77 % SILIQ SOSY 210 MG/1.5ML COMPLETE SENIOR TABS
CILOSTAZOL TABS 100 MG SIMPONI SOAJ 100 MG/ML CONTOUR NEXT TEST STRP
CILOSTAZOL TABS 50 MG
SIMPONI SOAJ 50 MG/0.5ML
CORTISONE ACETATE TABS 25 MG
CILOXAN OINT 0.3 % SIMPONI SOSY 100 MG/ML CORTROSYN SOLR 0.25 MG
CIMDUO TABS 300-300 MG SIMPONI SOSY 50 MG/0.5ML COSENTYX (300 MG DOSE) SOSY 150 MG/ML
CINACALCET HCL TABS 30 MG SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83MLCOSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML
CINACALCET HCL TABS 60 MG SOLIQUA SOPN 100-33 UNT-MCG/ML COSENTYX SENSOREADY PEN SOAJ 150 MG/ML
CINACALCET HCL TABS 90 MG
Sovaldi COSENTYX SOSY 150 MG/ML
CIPROFLOXACIN HCL SOLN 0.3 % Sovaldi 400 mg tablet COSMEGEN SOLR 0.5 MG
CIPROFLOXACIN HCL TABS 100 MG SOVALDI PACK 150 MG COTELLIC TABS 20 MG
CIPROFLOXACIN HCL TABS 250 MG SOVALDI PACK 200 MG CREON CPEP 12000-38000 UNIT
CIPROFLOXACIN HCL TABS 500 MG SPRYCEL TABS 100 MG CREON CPEP 24000-76000 UNIT
CIPROFLOXACIN HCL TABS 750 MG SPRYCEL TABS 140 MG CREON CPEP 3000-9500 UNIT
CIPROFLOXACIN IN D5W SOLN 200 MG/100ML SPRYCEL TABS 20 MG CREON CPEP 36000-114000 UNIT
CIPROFLOXACIN IN D5W SOLN 400 MG/200ML SPRYCEL TABS 50 MG CREON CPEP 6000-19000 UNIT
CIPROFLOXACIN SUSR 250 MG/5ML (5%) SPRYCEL TABS 70 MG CRIXIVAN CAPS 200 MG
CIPROFLOXACIN SUSR 500 MG/5ML (10%) SPRYCEL TABS 80 MG CRIXIVAN CAPS 400 MG
CIPROFLOXACIN-DEXAMETHASONE SUSP 0.3-0.1 %
Steglatro CROMOLYN SODIUM CONC 100 MG/5ML
CISATRACURIUM BESYLATE (PF) SOLN 10 MG/5ML Steglujan CROMOLYN SODIUM NEBU 20 MG/2ML
CISATRACURIUM BESYLATE (PF) SOLN 200 MG/20ML STELARA SOLN 45 MG/0.5ML CROMOLYN SODIUM SOLN 4 %
CISPLATIN SOLN 100 MG/100ML STELARA SOSY 45 MG/0.5ML CYANOCOBALAMIN SOLN 1000 MCG/ML
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
CISPLATIN SOLN 200 MG/200ML
STELARA SOSY 90 MG/ML
CYCLAFEM 1/35 TABS 1-35 MG-MCG
CISPLATIN SOLN 50 MG/50ML Subsys 100 mcg/spray sublingual spray CYCLOBENZAPRINE HCL TABS 10 MG
CLADRIBINE SOLN 10 MG/10ML SYMPROIC TABS 0.2 MG CYCLOBENZAPRINE HCL TABS 5 MG
CLAFORAN INJ 2GM SYNJARDY TABS 12.5-1000 MG CYCLOMYDRIL SOLN 0.2-1 %
CLARAVIS CAPS 10 MG SYNJARDY TABS 12.5-500 MG CYCLOPENTOLATE HCL SOLN 0.5 %
CLARAVIS CAPS 20 MG
SYNJARDY TABS 5-1000 MG
CYCLOPENTOLATE HCL SOLN 1 %
CLARAVIS CAPS 30 MG SYNJARDY TABS 5-500 MG CYCLOPENTOLATE HCL SOLN 2 %
CLARAVIS CAPS 40 MG SYNJARDY XR TB24 10-1000 MG CYCLOPHOSPHAMIDE CAPS 25 MG
CLARITHROMYCIN SUSR 125 MG/5ML SYNJARDY XR TB24 12.5-1000 MG CYCLOPHOSPHAMIDE CAPS 50 MG
CLARITHROMYCIN SUSR 250 MG/5ML SYNJARDY XR TB24 25-1000 MG CYCLOPHOSPHAMIDE SOLR 1 GM
CLARITHROMYCIN TABS 250 MG
SYNJARDY XR TB24 5-1000 MG
CYCLOPHOSPHAMIDE SOLR 2 GM
CLARITHROMYCIN TABS 500 MG TADALAFIL TABS 2.5 MG CYCLOPHOSPHAMIDE SOLR 500 MG
CLARITIN CAPS 10 MG TADALAFIL TABS 5 MG CYCLOSPORINE CAPS 100 MG
CLARITIN CHEW 5 MG TAGRISSO TABS 40 MG CYCLOSPORINE CAPS 25 MG
CLARITIN REDITABS TBDP 5 MG TAGRISSO TABS 80 MG CYPROHEPTADINE HCL SYRP 2 MG/5ML
CLEVIPREX EMUL 25 MG/50ML
TALTZ SOAJ 80 MG/ML
CYPROHEPTADINE HCL TABS 4 MG
CLEVIPREX EMUL 50 MG/100ML TALTZ SOSY 80 MG/ML CYRAMZA SOLN 100 MG/10ML
CLIMARA PTWK 0.025 MG/24HR Tanzeum 30 mg/0.5 mL subcutaneous CYRAMZA SOLN 500 MG/50ML
CLIMARA PTWK 0.0375 MG/24HR Tanzeum 50 mg/0.5 mL subcutaneous CYRED EQ TABS 0.15-30 MG-MCG
CLIMARA PTWK 0.05 MG/24HR TECFIDERA CPDR 120 MG CYTARABINE (PF) SOLN 100 MG/ML
CLIMARA PTWK 0.06 MG/24HR
TECFIDERA CPDR 240 MG
CYTARABINE (PF) SOLN 20 MG/ML
CLIMARA PTWK 0.075 MG/24HR TECFIDERA MISC 120 & 240 MG CYTARABINE INJ 100MG
CLIMARA PTWK 0.1 MG/24HR TECHNIVIE TABS 12.5-75-50 MG CYTARABINE INJ 2GM
CLINDAMYCIN HCL CAPS 150 MG TEGSEDI SOSY 284 MG/1.5ML CYTARABINE INJ 500MG
CLINDAMYCIN HCL CAPS 300 MG Tradjenta 5 mg tablet CYTARABINE SOLN 20 MG/ML
CLINDAMYCIN PALMITATE HCL SOLR 75 MG/5ML
tramadol CYTOVENE SOLR 500 MG
CLINDAMYCIN PHOSPHATE CREA 2 % tramadol 37.5 mg-acetaminophen 325 mg CYTOXAN INJ 1GM
CLINDAMYCIN PHOSPHATE GEL 1 % tramadol 50 mg tablet CYTOXAN INJ 2GM
CLINDAMYCIN PHOSPHATE IN D5W SOLN 300 MG/50ML tramadol ER 100 mg tablet,extended CYTOXAN INJ 500MG
CLINDAMYCIN PHOSPHATE LOTN 1 % tramadol ER 100 mg tablet,extended CYTRA K CRYSTALS PACK 3300-1002 MG
CLINDAMYCIN PHOSPHATE SOLN 1 % tramadol ER 200 mg tablet,extended D3 MAXIMUM STRENGTH LIQD 125 MCG/ML
CLINDAMYCIN PHOSPHATE SOLN 300 MG/2ML tramadol ER 300 mg tablet,extended DACARBAZINE SOLR 200 MG
CLINDAMYCIN PHOSPHATE SOLN 600 MG/4ML tramadol ER 300 mg tablet,extended DANAZOL CAPS 100 MG
CLINDAMYCIN PHOSPHATE SOLN 900 MG/6ML TREMFYA SOPN 100 MG/ML DANAZOL CAPS 200 MG
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
COLESTIPOL HCL TABS 1 GM
XELJANZ TABS 5 MG
DESOXIMETASONE CREA 0.25 %
COLISTIMETHATE SODIUM (CBA) SOLR 150 MG XELJANZ XR TB24 11 MG DESOXIMETASONE OINT 0.25 %
COLOCORT ENEM 100 MG/60ML XELJANZ XR TB24 22 MG DEXAMETHASONE ELIX 0.5 MG/5ML
COLY-MYCIN S SUSP 3.3-3-10-0.5 MG/ML Xigduo XR DEXAMETHASONE INTENSOL CONC 1 MG/ML
COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 MG Xigduo XR 5 mg-1,000 mg tablet,extended DEXAMETHASONE SODIUM PHOSPHATE SOLN 0.1 %
COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 MG & 80 MG
XOLAIR SOLR 150 MG
DEXAMETHASONE SODIUM PHOSPHATE SOLN 10 MG/M
COMETRIQ (60 MG DAILY DOSE) KIT 20 MG XOLAIR SOSY 150 MG/ML DEXAMETHASONE SODIUM PHOSPHATE SOLN 4 MG/M
COMFORT ASSIST INSULIN SYRINGE MISC 30G X 5/16" 1 ML XOLAIR SOSY 75 MG/0.5ML DEXAMETHASONE SOLN 0.5 MG/5ML
COMPLERA TABS 200-25-300 MG XTANDI CAPS 40 MG DEXAMETHASONE TABS 0.5 MG
COMPLETE SENIOR TABS XULTOPHY SOPN 100-3.6 UNIT-MG/ML DEXAMETHASONE TABS 0.75 MG
CONTOUR NEXT TEST STRP
XYREM SOLN 500 MG/ML
DEXAMETHASONE TABS 1 MG
CORTISONE ACETATE TABS 25 MG YONSA TABS 125 MG DEXAMETHASONE TABS 1.5 MG
CORTROSYN SOLR 0.25 MG Zamicet 10 mg-325 mg/15 mL oral DEXAMETHASONE TABS 2 MG
COSENTYX (300 MG DOSE) SOSY 150 MG/ML ZEPATIER TABS 50-100 MG DEXAMETHASONE TABS 4 MG
COSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML ZOMACTON SOLR 10 MG DEXAMETHASONE TABS 6 MG
COSENTYX SENSOREADY PEN SOAJ 150 MG/ML
ZOMACTON SOLR 5 MG
DEXMEDETOMIDINE HCL IN NACL SOLN 80 MCG/20ML
COSENTYX SOSY 150 MG/ML ZORBTIVE SOLR 8.8 MG DEXMEDETOMIDINE HCL SOLN 200 MCG/2ML
COSMEGEN SOLR 0.5 MG Zutripro 5 mg-4 mg-60 mg/5 mL oral DEXRAZOXANE HCL SOLR 250 MG
COTELLIC TABS 20 MG ZYTIGA TABS 250 MG DEXTROSE 10% INJ 10%
CREON CPEP 12000-38000 UNIT ZYTIGA TABS 500 MG DEXTROSE IN LACTATED RINGERS SOLN 5 %
CREON CPEP 24000-76000 UNIT DEXTROSE SOLN 10 %
CREON CPEP 3000-9500 UNIT DEXTROSE SOLN 5 %
CREON CPEP 36000-114000 UNIT DEXTROSE SOLN 50 %
CREON CPEP 6000-19000 UNIT DEXTROSE SOLN 70 %
CRIXIVAN CAPS 200 MG DEXTROSE-NACL SOLN 5-0.2 %
CRIXIVAN CAPS 400 MG DEXTROSE-NACL SOLN 5-0.33 %
CROMOLYN SODIUM CONC 100 MG/5ML DEXTROSE-NACL SOLN 5-0.45 %
CROMOLYN SODIUM NEBU 20 MG/2ML DEXTROSE-NACL SOLN 5-0.9 %
CROMOLYN SODIUM SOLN 4 % DIALYVITE VITAMIN D3 MAX TABS 1.25 MG (50000 UT
CYANOCOBALAMIN SOLN 1000 MCG/ML DIANEAL LOW CALCIUM/1.5% DEX SOLN 344 MOSM/L
CYCLAFEM 1/35 TABS 1-35 MG-MCG DIANEAL LOW CALCIUM/2.5% DEX SOLN 395 MOSM/L
CYCLOBENZAPRINE HCL TABS 10 MG DIANEAL LOW CALCIUM/4.25% DEX SOLN 483 MOSM/
CYCLOBENZAPRINE HCL TABS 5 MG DIANEAL PD-2/1.5% DEXTROSE SOLN 346 MOSM/L
CYCLOMYDRIL SOLN 0.2-1 % DIANEAL PD-2/2.5% DEXTROSE SOLN 396 MOSM/L
Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL
Med/Surg Drugs Med/Surg Drugs Prescription Drug Formulary
CYCLOPENTOLATE HCL SOLN 0.5 % DIANEAL PD-2/4.25% DEXTROSE SOLN 485 MOSM/L
CYCLOPENTOLATE HCL SOLN 1 % DIASTIX STRP
CYCLOPENTOLATE HCL SOLN 2 % DIAZOXIDE SUSP 50 MG/ML
CYCLOPHOSPHAMIDE CAPS 25 MG DICLOFENAC SODIUM SOLN 0.1 %
CYCLOPHOSPHAMIDE CAPS 50 MG DICLOFENAC SODIUM TBEC 25 MG
CYCLOPHOSPHAMIDE SOLR 1 GM DICLOFENAC SODIUM TBEC 50 MG
CYCLOPHOSPHAMIDE SOLR 2 GM DICLOFENAC SODIUM TBEC 75 MG
CYCLOPHOSPHAMIDE SOLR 500 MG DICLOXACILLIN SODIUM CAPS 250 MG
CYCLOSPORINE CAPS 100 MG DICLOXACILLIN SODIUM CAPS 500 MG
CYCLOSPORINE CAPS 25 MG DICYCLOMINE HCL CAPS 10 MG
CYPROHEPTADINE HCL SYRP 2 MG/5ML DICYCLOMINE HCL SOLN 10 MG/5ML
CYPROHEPTADINE HCL TABS 4 MG DICYCLOMINE HCL SOLN 10 MG/ML
CYRAMZA SOLN 100 MG/10ML DICYCLOMINE HCL TABS 20 MG
CYRAMZA SOLN 500 MG/50ML DIDANOSINE CPDR 250 MG
CYRED EQ TABS 0.15-30 MG-MCG DIDANOSINE CPDR 400 MG
CYTARABINE (PF) SOLN 100 MG/ML DIETHYLSTILBESTROL POW
CYTARABINE (PF) SOLN 20 MG/ML DIFFERIN CREA 0.1 %
CYTARABINE INJ 100MG DIFLORASONE DIACETATE OINT 0.05 %
CYTARABINE INJ 2GM DIGOXIN SOLN 0.05 MG/ML
CYTARABINE INJ 500MG DIGOXIN SOLN 0.25 MG/ML
CYTARABINE SOLN 20 MG/ML DIGOXIN TABS 125 MCG
CYTOVENE SOLR 500 MG DIGOXIN TABS 250 MCG
CYTOXAN INJ 1GM DIHYDROERGOTAMINE MESYLATE INJ 1MG/ML
CYTOXAN INJ 2GM DIHYDROERGOTAMINE MESYLATE SOLN 1 MG/ML
CYTOXAN INJ 500MG DILANTIN CAPS 30 MG
CYTRA K CRYSTALS PACK 3300-1002 MG DILTIAZEM HCL ER COATED BEADS CP24 120 MG
D3 MAXIMUM STRENGTH LIQD 125 MCG/ML DILTIAZEM HCL ER COATED BEADS CP24 180 MG
DACARBAZINE SOLR 200 MG DILTIAZEM HCL ER COATED BEADS CP24 240 MG
DANAZOL CAPS 100 MG DILTIAZEM HCL ER COATED BEADS CP24 300 MG
DANAZOL CAPS 200 MG DILTIAZEM HCL ER CP12 120 MG
DANAZOL CAPS 50 MG DILTIAZEM HCL ER CP12 60 MG
DANTROLENE SODIUM CAPS 100 MG DILTIAZEM HCL ER CP12 90 MG
DANTROLENE SODIUM CAPS 25 MG DILTIAZEM HCL POWD
DANTROLENE SODIUM CAPS 50 MG DILTIAZEM HCL SOLN 25 MG/5ML
