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2016 Formulary

Priority Health Choice, Inc.
(Medicaid and Healthy Michigan Plan)
List of covered drugs

Please read: This document contains information about the drugs we cover in this plan.

Important: Priority Health requires the use of an A rated generic drug when one is available.
This list changes frequently. For the most current information, please refer to our drug list at
priorityhealth.com.

Last updated: June 2016

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
1ML ALLERGIST
TRAY
INTRADERMAL
BEVEL 26GX1/2" KIT Covered
ABACAVIR TABS 300MG Not Covered
ABACAVIR
SULFATE/LAMIVUDI
NE/ZIDOVUDINE TABS 300MG; 150MG; 300MG Not Covered
ABILIFY TABS 10MG Not Covered
ABILIFY TABS 30MG Not Covered
ABILIFY SOLN 1MG/ML Not Covered
ABILIFY TABS 15MG Not Covered
ABILIFY TABS 20MG Not Covered
ABILIFY TABS 2MG Not Covered
ABILIFY TABS 5MG Not Covered
ABILIFY DISCMELT TBDP 10MG Not Covered
ABILIFY DISCMELT TBDP 15MG Not Covered
ABILIFY MAINTENA SUSR 300MG Not Covered
ABILIFY MAINTENA SUSR 400MG Not Covered
ABREVA CREA 10% Covered
ABSORICA CAPS 10MG Not Covered
ABSORICA CAPS 40MG Not Covered
ABSORICA CAPS 35MG Not Covered
ABSORICA CAPS 25MG Not Covered
ABSORICA CAPS 20MG Not Covered
ABSORICA CAPS 30MG Not Covered
ABSTRAL SUBL 100MCG Not Covered
ABSTRAL SUBL 200MCG Not Covered
ABSTRAL SUBL 800MCG Not Covered
ABSTRAL SUBL 300MCG Not Covered
ABSTRAL SUBL 600MCG Not Covered
ABSTRAL SUBL 400MCG Not Covered
ACAMPROSATE
CALCIUM DR TBEC 333MG Not Covered
ACANYA GEL 2.5%; 1.2% Not Covered
ACARBOSE TABS 25MG Covered QL
ACARBOSE TABS 100MG Covered QL
ACARBOSE TABS 50MG Covered QL
ACCOLATE TABS 10MG Not Covered
ACCOLATE TABS 20MG Not Covered

ACCU-CHEK
FASTCLIX
LANCETDEVICE KIT KIT Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 1 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
ACCU-CHEK
MULTICLIX LANC ET
DEVICE KIT KIT Covered

ACCU-CHEK
SOFTCLIX
LANCETDEVICE KIT KIT Covered
ACEBUTOLOL HCL CAPS 400MG Covered
ACEBUTOLOL HCL CAPS 200MG Covered
ACEPHEN SUPP 650MG Covered
ACEPHEN SUPP 120MG Covered
ACEPHEN SUPP 325MG Covered
ACETAMINOPHEN SOLN 160MG/5ML Covered
ACETAMINOPHEN TABS 500MG Covered
ACETAMINOPHEN TABS 325MG Covered
ACETAMINOPHEN
ER TBCR 650MG Covered
ACETAMINOPHEN
EXTRA STRENGTH LIQD 500MG/15ML Covered
ACETAMINOPHEN/C
ODEINE TABS 300MG; 15MG Covered QL
ACETAMINOPHEN/C
ODEINE TABS 300MG; 60MG Covered QL
ACETAMINOPHEN/C
ODEINE SOLN 120MG/5ML; 12MG/5ML Covered QL
ACETAMINOPHEN/C
ODEINE SOLN 120MG/5ML; 12MG/5ML Covered QL
ACETAMINOPHEN/C
ODEINE #3 TABS 300MG; 30MG Covered QL
ACETASOL HC SOLN 2%; 1% Not Covered
ACETAZOLAMIDE TABS 125MG Covered
ACETAZOLAMIDE TABS 250MG Covered
ACETAZOLAMIDE
ER CP12 500MG Covered
ACETIC ACID SOLN 2% Covered
ACETIC
ACID/ALUMINUM
ACETATE SOLN 2%; 0 Covered
ACETYLCYSTEINE SOLN 20% Covered
ACETYLCYSTEINE SOLN 10% Covered
ACIPHEX TBEC 20MG Not Covered
ACITRETIN CAPS 17.5MG Covered
ACITRETIN CAPS 10MG Covered
ACITRETIN CAPS 25MG Covered
ACLOVATE CREA 0.05% Not Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 2 of 178

5ML Covered QL AL ADAGEN SOLN 250UNIT/ML Not Covered ADAPALENE GEL 0.5ML.9ML Not Covered ACTHREL SOLR 100MCG Not Covered ACTICIN CREA 5% Not Covered ACTICLATE TABS 75MG Not Covered ACTICLATE TABS 150MG Not Covered ACTIMMUNE SOLN 2000000UNIT/0. 15MG Not Covered ACTOPLUS MET TABS 850MG. 15MG Not Covered ACTOPLUS MET XR TB24 1000MG. 5LF/0.10% Covered AL ADAPALENE LOTN 0.5ML Not Covered ACTIMMUNE SOLN 2000000UNIT/0.45% Not Covered ACYCLOVIR CAPS 200MG Covered QL ACYCLOVIR TABS 400MG Covered QL ACYCLOVIR TABS 800MG Covered QL ACYCLOVIR SUSP 200MG/5ML Covered AL ACYCLOVIR OINT 5% Not Covered QL ACZONE GEL 5% Not Covered QL 15. ACTIVE FE TABS 40UNIT. 4MG. 30MG Not Covered ACTOS TABS 15MG Not Covered ACTOS TABS 30MG Not Covered ACTOS TABS 45MG Not Covered ACULAR SOLN 0. 30MCG.5ML Not Covered 160MG.10% Not Covered AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 3 of 178 . 30MG.5MCG/0. 1MG. 1250MCG. 75MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ACNE MEDICATION LOTN 10% Covered ACNE MEDICATION 10 GEL 10% Covered ACNE MEDICATION 5 GEL 5% Covered ACNE MEDICATION 5 LOTN 5% Covered ACTEMRA SOSY 162MG/0. 2100UNIT. 20MG Covered ACTONEL TABS 30MG Not Covered ACTONEL TABS 5MG Not Covered ACTONEL TABS 35MG Not Covered ACTONEL TABS 150MG Not Covered ACTOPLUS MET TABS 500MG. 15MG Not Covered ACTOPLUS MET XR TB24 1000MG. 20MG. 400UNIT.50% Not Covered ACUVAIL SOLN 0. 4MG.5ML. 20MG. ADACEL SUSP 2LF/0.

10MG. 7. 6.5MG. 1000MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 4 of 178 .25MG.5MG.5MG. 6. 0. 21MCG/ACT Not Covered ADVAIR HFA AERO 115MCG/ACT. 5MG.5MG Covered PA QL ADEMPAS TABS 1MG Covered PA QL ADEMPAS TABS 2.25MG.75MG. 0. 10% Not Covered ADCIRCA TABS 20MG Covered PA QL 1.75MG.25MG Not Covered ADDERALL XR CP24 5MG.25MG. 5MG.10% Covered ST ADAZIN CREA 2%. 7. 0.75MG. 650MG.75MG Not Covered 2. 0.25MG.30% Not Covered ADAPALENE CREA 0.25MG Not Covered 3. 500MG Not Covered ADVICOR TB24 20MG. 0.5MG Covered PA QL ADEMPAS TABS 2MG Covered PA QL ADEMPAS TABS 0. 21MCG/ACT Not Covered ADVAIR HFA AERO 230MCG/ACT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ADAPALENE GEL 0.5MG Covered PA QL ADOXA CAPS 150MG Not Covered ADOXA TABS 50MG Not Covered ADOXA TABS 75MG Not Covered ADOXA TABS 100MG Not Covered 250MCG/DOSE. 3. 2.5MG Not Covered ADEFOVIR DIPIVOXIL TABS 10MG Covered ADEMPAS TABS 1. 2.5MG Not Covered 7.035%. ADVAIR DISKUS AEPB 50MCG/DOSE Not Covered ADVAIR HFA AERO 45MCG/ACT. ADDERALL XR CP24 1. 1.5MG. 0. ADDERALL XR CP24 3.5MG. ADDERALL XR CP24 7. 0. 2%. ADDERALL XR CP24 6. ADVANCED AM/PM MISC 100MG. ADDERALL XR CP24 2.5MG. 3. 1. ADVAIR DISKUS AEPB 50MCG/DOSE Not Covered 500MCG/DOSE.25MG. 5MG Not Covered 6.25MG. 0. 21MCG/ACT Not Covered 0. 50UNIT Covered ADVATE SOLR 1000UNIT Not Covered ADVICOR TB24 20MG. ADVAIR DISKUS AEPB 50MCG/DOSE Not Covered 100MCG/DOSE.

03% Covered ALBENZA TABS 200MG Not Covered QL ALBUMINAR-5 SOLN 5% Not Covered ALBURX SOLN 5% Not Covered ALBUSTIX STRP 0 Not Covered ALBUTEROL SULFATE TABS 2MG Covered ALBUTEROL SULFATE NEBU 0.5MG Not Covered ALAVERT TABS 10MG Covered ALAVERT ALLERGY/SINUS TB12 5MG. 120MG Not Covered ALAWAY SOLN 0. 750MG Not Covered ADVICOR TB24 40MG. 1000MG Not Covered AEROCHAMBER PLUS FLOW-VU MISC Covered QL AEROCHAMBER PLUS FLOW- VU/LARGE MASK MISC Covered QL AEROCHAMBER PLUS FLOW- VU/MASK MISC Covered QL AEROCHAMBER PLUS FLOW- VU/SMALL MASK MISC Covered QL AEROSPAN AERS 80MCG/ACT Covered AFEDITAB CR TB24 30MG Not Covered AFEDITAB CR TB24 60MG Not Covered AFINITOR TABS 5MG Covered PA QL AFINITOR TABS 7.5MG Covered PA QL AFINITOR TABS 10MG Covered PA QL AFINITOR DISPERZ TBSO 5MG Covered PA QL AFINITOR DISPERZ TBSO 2MG Covered PA QL AFINITOR DISPERZ TBSO 3MG Covered PA QL AFLURIA 2015-2016 SUSP 0 Covered AL AFREZZA POWD 0 Not Covered AFREZZA POWD 0 Not Covered AGGRENOX CP12 25MG.5MG Covered PA QL AFINITOR TABS 2. 0. 200MG Not Covered AIMSCO LUBRICATED MISC Covered QL AKYNZEO CAPS 300MG.08% Covered QL ALBUTEROL SULFATE SYRP 2MG/5ML Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 5 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ADVICOR TB24 20MG.

50% Covered ALBUTEROL SULFATE NEBU 0. 2%.25MG/3ML Covered QL ALCALAK CHEW 420MG Covered ALCLOMETASONE DIPROPIONATE OINT 0.05% Not Covered ALCLOMETASONE DIPROPIONATE CREA 0.9MG/5ML Not Covered ALENDRONATE SODIUM TABS 10MG Covered ALENDRONATE SODIUM TABS 5MG Covered ALENDRONATE SODIUM TABS 70MG Covered QL ALENDRONATE SODIUM SOLN 70MG/75ML Not Covered ALENDRONATE SODIUM TABS 40MG Covered ALENDRONATE SODIUM TABS 35MG Covered QL ALER-CAP CAPS 25MG Covered ALEVAZOL OINT 1% Covered ALFUZOSIN HCL ER TB24 10MG Not Covered ALINIA TABS 500MG Not Covered ALINIA SUSR 100MG/5ML Not Covered ALL DAY ALLERGY CHILDRENS CHEW 10MG Covered QL AL ALL DAY ALLERGY CHILDRENS CHEW 5MG Covered QL AL ALL DAY ALLERGY CHILDRENS SOLN 5MG/5ML Covered QL AL ALL DAY RELIEF TABS 220MG Covered ALLEGRA ALLERGY TABS 180MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 6 of 178 . 1% Not Covered ALDARA CREA 5% Not Covered ALDURAZYME SOLN 2.63MG/3ML Covered QL ALBUTEROL SULFATE NEBU 1.05% Not Covered ALCOHOL PREP PADS PADS 70% Covered ALCORTIN A GEL 1%. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ALBUTEROL SULFATE TABS 4MG Covered ALBUTEROL SULFATE NEBU 0.

25MG Covered QL ALMOTRIPTAN MALATE TABS 12. 240MG Not Covered ALLERGY-TIME TABS 4MG Covered ALLOPURINOL TABS 100MG Covered QL ALLOPURINOL TABS 300MG Covered QL ALMACONE DOUBLE 400MG/5ML.5MG/5ML Covered ALLERGY RELIEF TABS 10MG Covered ALLERGY RELIEF TABS 4MG Covered ALLERGY RELIEF FOR KIDS SYRP 5MG/5ML Covered QL AL ALLERGY RELIEF/NASAL DECONGESTANT TB24 10MG.025MG/24HR Not Covered ALORA PTTW 0. 120MG Not Covered ALLEGRA-D 24 HOUR ALLERGY & CONGESTION TB24 180MG. STRENGTH SUSP 40MG/5ML Covered ALMOTRIPTAN MALATE TABS 6.05MG/24HR Not Covered ALORA PTTW 0. 400MG/5ML.5MG Not Covered ALOSETRON HYDROCHLORIDE TABS 1MG Not Covered ALPAWASH OINT 0 Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 7 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ALLEGRA ALLERGY TABS 60MG Covered ALLEGRA ALLERGY CHILDRENS SUSP 30MG/5ML Covered ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TB12 60MG.1MG/24HR Not Covered ALORA PTTW 0.075MG/24HR Not Covered ALOSETRON HYDROCHLORIDE TABS 0.5MG Covered QL ALOMIDE SOLN 0.10% Not Covered ALORA PTTW 0. 240MG Not Covered ALLER-CHLOR SYRP 2MG/5ML Covered ALLER-CHLOR TABS 4MG Covered ALLERGY TABS 4MG Covered ALLERGY TABS 10MG Covered ALLERGY MEDICATION CHILDRENS LIQD 12.

25MG Not Covered AMBIEN CR TBCR 12.15% Not Covered ALPHAGAN P SOLN 0.5MG Not Covered ALPRAZOLAM ER TB24 3MG Not Covered ALPRAZOLAM INTENSOL CONC 1MG/ML Not Covered ALPRAZOLAM ODT TBDP 0.25MG Not Covered ALPRAZOLAM ODT TBDP 1MG Not Covered ALPRAZOLAM ODT TBDP 2MG Not Covered ALPRAZOLAM ODT TBDP 0.10% Not Covered AMCINONIDE CREA 0.15MG Covered ALTOPREV TB24 60MG Not Covered ALTOPREV TB24 40MG Not Covered ALTOPREV TB24 20MG Not Covered ALUMINUM HYDROXIDE SUSP 320MG/5ML Covered ALVESCO AERS 80MCG/ACT Not Covered QL ALVESCO AERS 160MCG/ACT Not Covered QL ALYACEN 1/35 TABS 35MCG.5MG Not Covered AMCINONIDE OINT 0. 0.5MG Not Covered ALPROLIX SOLR 3000UNIT Not Covered ALPROLIX SOLR 500UNIT Not Covered ALPROLIX SOLR 2000UNIT Not Covered ALPROLIX SOLR 1000UNIT Not Covered ALSUMA SOAJ 6MG/0. 7.5MG Not Covered ALPRAZOLAM ER TB24 1MG Not Covered ALPRAZOLAM ER TB24 2MG Not Covered ALPRAZOLAM ER TB24 0.10% Not Covered AMCINONIDE LOTN 0.10% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 8 of 178 .10% Not Covered ALPHANATE/VON WILLEBRAND FACTOR COMPLEX/HUMAN SOLR 500UNIT Not Covered ALPHAQUIN HP CREA 5%.5ML Not Covered ALTABAX OINT 1% Not Covered ALTAVERA TABS 0. 0 Covered AMANTADINE HCL CAPS 100MG Covered QL AMANTADINE HCL SYRP 50MG/5ML Covered QL AMANTADINE HCL TABS 100MG Covered AMBIEN CR TBCR 6. 1MG Covered ALYACEN 7/7/7 TABS 0.5% Not Covered ALPRAZOLAM TABS 1MG Not Covered ALPRAZOLAM TABS 2MG Not Covered ALPRAZOLAM TABS 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ALPHAGAN P SOLN 0.03MG.25MG Not Covered ALPRAZOLAM TABS 0. 4%.

20MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 9 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL AMETHIA TABS 0.5MG Covered QL AMLODIPINE BESYLATE TABS 5MG Covered QL AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 5MG. 10MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 5MG. 50MG Covered QL AMINOCAPROIC ACID SYRP 25% Not Covered AMINOCAPROIC ACID TABS 500MG Not Covered AMIODARONE HCL TABS 200MG Covered AMIODARONE HCL TABS 100MG Covered AMIODARONE HCL TABS 400MG Covered AMITIZA CAPS 24MCG Covered AMITIZA CAPS 8MCG Covered AMITRIPTYLINE HCL TABS 100MG Not Covered AMITRIPTYLINE HCL TABS 50MG Not Covered AMITRIPTYLINE HCL TABS 10MG Not Covered AMITRIPTYLINE HCL TABS 150MG Not Covered AMITRIPTYLINE HCL TABS 25MG Not Covered AMITRIPTYLINE HCL TABS 75MG Not Covered AMLACTIN LOTN 12% Covered AMLACTIN ULTRA CREA Covered AMLODIPINE BESYLATE TABS 10MG Covered QL AMLODIPINE BESYLATE TABS 2. 90MCG Not Covered AMILORIDE HCL TABS 5MG Covered QL AMILORIDE/HYDRO CHLOROTHIAZIDE TABS 5MG. 0 Not Covered AMETHIA LO TABS 0. 80MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 10MG. 0 Not Covered AMETHYST TABS 20MCG.

40MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 10MG. 80MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 5MG. 20MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 2. 20MG Covered QL AMLODIPINE BESYLATE/BENAZE PRIL HYDROCHLORIDE CAPS 5MG. 40MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 2. 10MG Covered QL AMLODIPINE BESYLATE/BENAZE PRIL HYDROCHLORIDE CAPS 5MG.5MG. 40MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 10MG. 10MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 10MG.5MG. 20MG Not Covered AMLODIPINE BESYLATE/ATORVA STATIN CALCIUM TABS 2. 10MG Not Covered AMLODIPINE BESYLATE/BENAZE PRIL HYDROCHLORIDE CAPS 2.5MG. 20MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 10 of 178 . 10MG Covered QL AMLODIPINE BESYLATE/BENAZE PRIL HYDROCHLORIDE CAPS 5MG.5MG. 40MG Covered QL AMLODIPINE BESYLATE/BENAZE PRIL HYDROCHLORIDE CAPS 10MG.

160MG Not Covered AMMONIUM LACTATE CREA 12% Covered QL AMMONIUM LACTATE LOTN 12% Covered QL AMMONUL SOLN 10%. 320MG Not Covered AMLODIPINE/VALSA RTAN/HCTZ TABS 10MG. 40MG Covered QL AMLODIPINE BESYLATE/VALSART AN TABS 5MG. 320MG Not Covered AMLODIPINE BESYLATE/VALSART AN TABS 10MG. 10% Not Covered AMNESTEEM CAPS 40MG Not Covered AMNESTEEM CAPS 20MG Not Covered AMNESTEEM CAPS 10MG Not Covered AMOXAPINE TABS 25MG Not Covered AMOXAPINE TABS 50MG Not Covered AMOXAPINE TABS 100MG Not Covered AMOXAPINE TABS 150MG Not Covered AMOXICILLIN CHEW 250MG Covered AL AMOXICILLIN CAPS 250MG Covered AMOXICILLIN SUSR 250MG/5ML Covered AL AMOXICILLIN TABS 500MG Covered AMOXICILLIN SUSR 400MG/5ML Covered AL AMOXICILLIN TABS 875MG Covered AMOXICILLIN CHEW 125MG Covered AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 11 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL AMLODIPINE BESYLATE/BENAZE PRIL HYDROCHLORIDE CAPS 10MG. 160MG Not Covered AMLODIPINE/VALSA RTAN/HCTZ TABS 5MG. 160MG Not Covered AMLODIPINE/VALSA RTAN/HCTZ TABS 10MG. 160MG Not Covered AMLODIPINE BESYLATE/VALSART AN TABS 10MG. 25MG. 25MG.5MG. 160MG Not Covered AMLODIPINE BESYLATE/VALSART AN TABS 5MG. 160MG Not Covered AMLODIPINE/VALSA RTAN/HCTZ TABS 10MG.5MG. 12. 25MG. 12. 320MG Not Covered AMLODIPINE/VALSA RTAN/HCTZ TABS 5MG.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL AMOXICILLIN SUSR 125MG/5ML Covered AL AMOXICILLIN CAPS 500MG Covered AMOXICILLIN SUSR 200MG/5ML Covered AL AMOXICILLIN ER TB24 775MG Not Covered AMOXICILLIN/CLAVU LANATE POTASSIUM TABS 875MG. 125MG Covered AMOXICILLIN/CLAVU LANATE POTASSIUM ER TB12 1000MG.5MG.9MG/5ML Covered AL AMOXICILLIN/CLAVU LANATE POTASSIUM SUSR 250MG/5ML. 62. TROAMPHETAMINE TABS 7.5MG Not Covered AMPHETAMINE/DEX TROAMPHETAMINE TABS 5MG.5MG.5MG Covered AMPHETAMINE/DEX 2. 5MG. 28. 7.5MG/5ML Covered AL AMOXICILLIN/CLAVU LANATE POTASSIUM SUSR 400MG/5ML. 57MG Covered AL AMOXICILLIN/CLAVU LANATE POTASSIUM SUSR 600MG/5ML. 42. 125MG Covered AMOXICILLIN/CLAVU LANATE POTASSIUM TABS 250MG.5MG.5MG/5ML Covered AL AMOXICILLIN/CLAVU LANATE POTASSIUM TABS 500MG. 57MG/5ML Covered AL AMOXICILLIN/CLAVU LANATE POTASSIUM CHEW 200MG. 2.5MG Covered AL AMOXICILLIN/CLAVU LANATE POTASSIUM CHEW 400MG.5MG.5MG. 5MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 12 of 178 . 7. 2. 5MG. 125MG Covered AMOXICILLIN/CLAVU LANATE POTASSIUM SUSR 200MG/5ML.5MG Not Covered AMPHETAMINE/DEX 7. TROAMPHETAMINE TABS 2.5MG. 28. 62.

1% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 13 of 178 . 1. 5MG. 7. 7.25MG Not Covered AMPHETAMINE/DEX 1.875MG. 3.125MG.125MG.5MG Not Covered AMPHETAMINE/DEX 6. TROAMPHETAMINE TABS 3. 5MG. 3.25MG. 3.75MG. 2.5MG.75MG Not Covered AMPHETAMINE/DEX 1. TROAMPHETAMINE CP24 1. 1. 3. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL AMPHETAMINE/DEX 1. 1.5MG.875MG Not Covered AMPICILLIN CAPS 500MG Covered AMPICILLIN CAPS 250MG Covered AMPICILLIN SUSR 125MG/5ML Covered AL AMPICILLIN SUSR 250MG/5ML Covered AL AMPYRA TB12 10MG Covered PA AMRIX CP24 15MG Not Covered AMRIX CP24 30MG Not Covered AMTURNIDE TABS 150MG. 12. 1% Not Covered ANALPRAM-HC CREA 1%. TROAMPHETAMINE TABS 1.25MG.25MG.75MG.25MG Not Covered AMPHETAMINE/DEX 3.25MG.25MG.25MG Not Covered AMPHETAMINE/DEX 3. 1% Not Covered ANALPRAM-HC CREA 2. 6. 1.5MG Covered ANAGRELIDE HYDROCHLORIDE CAPS 1MG Covered ANALPRAM-HC LOTN 2. 6.5%. TROAMPHETAMINE CP24 2. 5MG. 2. TROAMPHETAMINE CP24 3.75MG. 5MG Not Covered AMPHETAMINE/DEX 7.875MG.25MG.25MG.5%. TROAMPHETAMINE TABS 3.75MG.5MG. 1. TROAMPHETAMINE CP24 6.25MG.5MG.5MG.125MG.5MG Covered QL ANAGRELIDE HYDROCHLORIDE CAPS 0. TROAMPHETAMINE CP24 7.75MG Not Covered AMPHETAMINE/DEX 3.5MG.5MG Not Covered AMPHETAMINE/DEX TROAMPHETAMINE CP24 5MG.25MG.875MG. 1. 3. 3.125MG Not Covered AMPHETAMINE/DEX 2. TROAMPHETAMINE TABS 1.75MG.75MG.

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
ANALPRAM-HC
SINGLES CREA 2.5%; 1% Not Covered
ANALPRAM-HC
SINGLES CREA 1%; 1% Not Covered
ANASPAZ TBDP 0.125MG Not Covered
ANDRODERM PT24 4MG/24HR Not Covered
ANDRODERM PT24 2MG/24HR Not Covered
ANDROGEL GEL 50MG/5GM Not Covered
ANDROGEL GEL 25MG/2.5GM Not Covered
ANDROGEL PUMP GEL 1% Not Covered
ANDROID CAPS 10MG Not Covered

ANIMAS VIBE
INSULIN PUMP/BLUE KIT Not Covered
1000UNIT; 500MCG;
350MG; 35MG; 1MG;
ANIMI-3 CAPS 500MG; 200MG; 12.5MG Covered

ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH Not Covered
ANTABUSE TABS 250MG Not Covered
ANTABUSE TABS 500MG Not Covered
200MG/5ML; 200MG/5ML;
ANTACID SUSP 20MG/5ML Covered
ANTACID CHEW 500MG Covered
ANTACID EXTRA
STRENGTH CHEW 750MG Covered
400MG/5ML; 400MG/5ML;
ANTACID III SUSP 40MG/5ML Covered
ANTACID PLUS ANTI-
GAS RELIEF
MAXIMUM 400MG/5ML; 400MG/5ML;
STRENGTH SUSP 40MG/5ML Covered
ANTARA CAPS 43MG Not Covered
ANTARA CAPS 130MG Not Covered
ANTI-DIARRHEAL TABS 2MG Covered
ANTI-DIARRHEAL CAPS 2MG Covered
ANTI-DIARRHEAL LIQD 1MG/5ML Covered
ANTIFUNGAL CREA 2% Covered
ANTIFUNGAL CREA 1% Covered
ANTI-FUNGAL
POWDER POWD 1% Covered
ANTI-ITCH CREA 2%; 0.1% Covered
ANTIPYRINE/BENZO
CAINE SOLN 5.4%; 1.4% Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 14 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
ANTIPYRINE/BENZO
CAINE SOLN 5.4%; 1.4% Covered
ANUSOL-HC SUPP 25MG Not Covered
APEXICON E CREA 0.05% Not Covered
APHEN TABS 325MG Covered
APIDRA SOLN 100UNIT/ML Covered

APIDRA SOLOSTAR SOPN 100UNIT/ML Covered
APLENZIN TB24 522MG Not Covered
APLENZIN TB24 348MG Not Covered
APRACLONIDINE SOLN 0.50% Covered
APRI TABS 0.15MG; 30MCG Covered
APRISO CP24 0.375GM Covered
APTENSIO XR CP24 15MG Not Covered
APTENSIO XR CP24 40MG Not Covered
APTENSIO XR CP24 10MG Not Covered
APTENSIO XR CP24 50MG Not Covered
APTENSIO XR CP24 20MG Not Covered
APTENSIO XR CP24 30MG Not Covered
APTENSIO XR CP24 60MG Not Covered
APTIOM TABS 800MG Not Covered
APTIOM TABS 600MG Not Covered
APTIOM TABS 200MG Not Covered
APTIOM TABS 400MG Not Covered
APTIVUS CAPS 250MG Not Covered
AQUACEL AG
EXTRA 2" X
2"/HYDROFIBER PADS 0; 1.2% Covered
AQUACEL AG
EXTRA 4" X
5"/HYDROFIBER PADS 0; 1.2% Covered
AQUACEL AG
EXTRA 6" X
6"/HYDROFIBER PADS 0; 1.2% Covered
AQUACEL AG
EXTRA 8" X
12"/HYDROFIBER PADS 0; 1.2% Covered

0; 50MCG; 6MG; 400UNIT;
5MG; 6MCG; 100MCG;
5MG; 350MCG; 0.95MG;
0.85MG; 37.5MCG; 5MG;
35MG; 0.75MG; 50UNIT;
AQUADEKS CHEW 9083.5UNIT; 15MG; 5MG Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 15 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

10MG; 100MCG; 12MG;
800UNIT; 10MG; 12MCG;
200MCG; 10MG; 700MCG;
1.9MG; 1.7MG; 75MCG;
75MG; 1.5MG; 150UNIT;
AQUADEKS CAPS 18167UNIT; 80MG; 10MG Covered

45MG/ML; 3MG/ML;
15MCG/ML; 3MG/ML;
400UNIT/ML; 2MG/ML;
6MG/ML; 400MCG/ML;
0.6MG/ML; 0.6MG/ML;
10MCG/ML; 0.6MG/ML;
50UNIT/ML; 5751UNIT/ML;
AQUADEKS LIQD 15MG/ML; 5MG/ML Not Covered
AQUANIL HC LOTN 1% Covered
ARANELLE TABS 0; 0 Covered
ARANESP ALBUMIN
FREE SOLN 40MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 25MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 200MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOSY 40MCG/0.4ML Covered PA
ARANESP ALBUMIN
FREE SOSY 500MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOSY 60MCG/0.3ML Covered PA
ARANESP ALBUMIN
FREE SOSY 150MCG/0.3ML Covered PA
ARANESP ALBUMIN
FREE SOSY 100MCG/0.5ML Covered PA
ARANESP ALBUMIN
FREE SOSY 200MCG/0.4ML Covered PA
ARANESP ALBUMIN
FREE SOLN 10MCG/0.4ML Covered PA
ARANESP ALBUMIN
FREE SOLN 60MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 100MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 150MCG/0.75ML Covered PA

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 16 of 178

6% Covered ASACOL HD TBEC 800MG Covered QL ASCRIPTIN TABS 0. 200MCG Not Covered ARTHROTEC 75 TBEC 75MG. 200MCG Not Covered ARTIFICIAL TEARS SOLN 1. 0 Not Covered ASMANEX HFA AERO 200MCG/ACT Not Covered ASMANEX HFA AERO 100MCG/ACT Not Covered ASMANEX TWISTHALER 120 METERED DOSES AEPB 220MCG/INH Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 17 of 178 . 0. 0.40% Covered ARTIFICIAL TEARS SOLN 0. 325MG.5%. 0.42ML Covered PA ARCALYST SOLR 220MG Not Covered ARICEPT TABS 5MG Not Covered ARICEPT TABS 23MG Not Covered ARICEPT TABS 10MG Not Covered ARICEPT ODT TBDP 5MG Not Covered ARICEPT ODT TBDP 10MG Not Covered ARIMIDEX TABS 1MG Not Covered ARIPIPRAZOLE TABS 10MG Not Covered ARIPIPRAZOLE TABS 5MG Not Covered ARIPIPRAZOLE TABS 20MG Not Covered ARIPIPRAZOLE TABS 30MG Not Covered ARIPIPRAZOLE TABS 15MG Not Covered ARIPIPRAZOLE TABS 2MG Not Covered ARIPIPRAZOLE ODT TBDP 10MG Not Covered ARIPIPRAZOLE ODT TBDP 15MG Not Covered ARMOUR THYROID TABS 90MG Covered AL ARMOUR THYROID TABS 60MG Covered AL ARMOUR THYROID TABS 15MG Covered AL ARMOUR THYROID TABS 180MG Covered AL ARMOUR THYROID TABS 240MG Covered AL ARMOUR THYROID TABS 30MG Covered AL ARMOUR THYROID TABS 120MG Covered AL ARMOUR THYROID TABS 300MG Covered AL ARNUITY ELLIPTA AEPB 100MCG/ACT Not Covered ARNUITY ELLIPTA AEPB 200MCG/ACT Not Covered AROMASIN TABS 25MG Not Covered ARTHRITIS PAIN RELIEF TBCR 650MG Covered ARTHROTEC 50 TBEC 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ARANESP ALBUMIN FREE SOSY 25MCG/0.

15% Not Covered ASTHMA CHECK METER-ZONE SYSTEM DEVI Covered ASTHMAMENTOR DEVI Covered ATACAND TABS 4MG Not Covered ATACAND TABS 16MG Not Covered ATACAND TABS 32MG Not Covered ATACAND TABS 8MG Not Covered ATACAND HCT TABS 16MG.5MG Not Covered ATACAND HCT TABS 32MG. 16MG Not Covered ASPIR-LOW TBEC 81MG Covered AL ASPIR-TRIN TBEC 325MG Covered ASSESS FULL RANGE PEAK FLOW METER DEVI Covered ASTAGRAF XL CP24 1MG Not Covered ASTAGRAF XL CP24 0. 30MG. 12.4MG.5MG Not Covered ASTAGRAF XL CP24 5MG Not Covered ASTEPRO SOLN 0. 25MG Not Covered ATELVIA TBEC 35MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 18 of 178 . 200MG Covered ASPIRIN-CAFFEINE- DIHYDROCODEINE CAPS 356. 12.5MG Not Covered ATACAND HCT TABS 32MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ASMANEX TWISTHALER 14 METERED DOSES AEPB 220MCG/INH Not Covered ASMANEX TWISTHALER 30 METERED DOSES AEPB 110MCG/INH Not Covered ASMANEX TWISTHALER 30 METERED DOSES AEPB 220MCG/INH Not Covered ASMANEX TWISTHALER 60 METERED DOSES AEPB 220MCG/INH Not Covered ASPIRIN SUPP 300MG Covered ASPIRIN TABS 325MG Covered AL ASPIRIN CHEW 81MG Covered QL AL ASPIRIN SUPP 600MG Covered ASPIRIN TBEC 325MG Covered AL ASPIRIN EC TBEC 325MG Covered AL ASPIRIN EC LOW DOSE TBEC 81MG Covered AL ASPIRIN/DIPYRIDAM OLE CP12 25MG.

05% Not Covered ATRIPLA TABS 600MG.3ML Not Covered AVANDAMET TABS 1000MG.05% Covered AURYXIA TABS 210MG Covered AUVI-Q SOAJ 0.15MG/0. 4MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 19 of 178 .3MG/0. 2MG Not Covered AVANDAMET TABS 500MG. 200MG.05% Covered AUGMENTED BETAMETHASONE DIPROPIONATE GEL 0. 4MG Not Covered AVANDAMET TABS 500MG.15ML Not Covered AUVI-Q SOAJ 0. 25MG Covered ATENOLOL/CHLORT HALIDONE TABS 100MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ATENOLOL TABS 50MG Covered ATENOLOL TABS 100MG Covered ATENOLOL TABS 25MG Covered ATENOLOL/CHLORT HALIDONE TABS 50MG.05% Covered AUGMENTED BETAMETHASONE DIPROPIONATE CREA 0. 25MG Covered ATORVASTATIN CALCIUM TABS 10MG Covered QL ATORVASTATIN CALCIUM TABS 40MG Covered QL ATORVASTATIN CALCIUM TABS 80MG Covered QL ATORVASTATIN CALCIUM TABS 20MG Covered QL ATOVAQUONE SUSP 750MG/5ML Covered ATOVAQUONE/PRO GUANIL HCL TABS 250MG. 300MG Not Covered ATROPINE SULFATE SOLN 1% Covered ATROPINE SULFATE OINT 1% Covered ATROVENT SOLN 0.06% Covered ATROVENT SOLN 0. 100MG Not Covered ATRALIN GEL 0. 2MG Not Covered AVANDAMET TABS 1000MG.03% Covered ATROVENT HFA AERS 17MCG/ACT Covered AUBAGIO TABS 14MG Not Covered AUBAGIO TABS 7MG Not Covered AUGMENTED BETAMETHASONE DIPROPIONATE OINT 0.

3MG. 2GM Not Covered AXERT TABS 12. 60MG. 1MCG. 4MG Covered AVANDARYL TABS 4MG.1MG Covered AVODART CAPS 0. 0 Covered 5MG. 40MG Not Covered AZOR TABS 10MG. 20MG. 50MG. 10. 0.5MG. B COMPLEX CAPS 0.2MG. 60MG Covered B COMPLEX/VITAMIN 300MG.5MG Not Covered AXERT TABS 6. 4MG Covered AVANDIA TABS 2MG Not Covered AVANDIA TABS 4MG Not Covered AVANDIA TABS 8MG Not Covered AVASTIN SOLN 100MG/4ML Not Covered AVASTIN SOLN 400MG/16ML Not Covered AVEED SOLN 750MG/3ML Not Covered AVELOX TABS 400MG Not Covered AVELOX ABC PACK TABS 400MG Not Covered AVIANE TABS 20MCG.05% Covered AZELASTINE HCL SOLN 0. 4MG Covered AVANDARYL TABS 2MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL AVANDARYL TABS 1MG.10% Covered QL AZELASTINE HCL SOLN 0. 15MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 20 of 178 .25MG Not Covered AXIRON SOLN 30MG/ACT Not Covered AZASITE SOLN 1% Not Covered AZATHIOPRINE TABS 50MG Covered QL AZELASTINE HCL SOLN 0. C CAPS 5MG.5MG Not Covered AVONEX KIT 30MCG/VIAL Covered QL AVONEX PSKT 30MCG/0. 3MG.15% Not Covered AZELEX CREA 20% Not Covered AZITHROMYCIN SUSR 100MG/5ML Covered AL AZITHROMYCIN TABS 250MG Covered AZITHROMYCIN SUSR 200MG/5ML Covered AL AZITHROMYCIN TABS 600MG Covered AZITHROMYCIN TABS 500MG Covered AZITHROMYCIN PACK 1GM Covered AZOLEN TINCTURE SOLN 2% Covered AZOR TABS 5MG. 40MG Not Covered AZOR TABS 5MG.5GM. 10MG.5ML Covered QL AVYCAZ SOLR 0. 20MG Not Covered AZOR TABS 10MG.5ML Covered QL AVONEX PEN AJKT 30MCG/0. 20MG Not Covered AZURETTE TABS 0.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL B-1 TABS 100MG Covered BACITRACIN OINT 500UNIT/GM Covered BACITRACIN/NEOMY 400UNIT/GM. 5MG/GM.1MG. 50MCG. 0. 150MCG. 50MG.5MG Covered BACTROBAN CREA 2% Not Covered BACTROBAN OINT 2% Not Covered BACTROBAN NASAL OINT 2% Not Covered 0. 25MG Covered BALSALAZIDE DISODIUM CAPS 750MG Covered BALZIVA TABS 35MCG. BACMIN TABS 30UNIT. 100MG.5MG/5ML Covered BANOPHEN TABS 25MG Covered AL BANOPHEN CAPS 25MG Covered AL BANOPHEN CAPS 50MG Covered AL BANZEL TABS 200MG Not Covered BANZEL TABS 400MG Not Covered BARACLUDE SOLN 0. YXIN B OINT 10000UNIT/GM Covered BACLOFEN TABS 10MG Covered AL BACLOFEN TABS 20MG Covered AL 500MG. 27MG. 3MG. 50MG. 25MG. 5MG. CIN/POLYMYXIN OINT 5000UNIT/GM Covered BACITRACIN/POLYM 500UNIT/GM. 5000UNIT. 50MCG. BALANCED B 25MG. 0.3MG. 22. 25MG. 25MCG. COMPLEX TABS 25MG. 1MG. 25MCG.5MG Not Covered BARACLUDE TABS 1MG Not Covered BAYER ADVANCED ASPIRIN EXTRA STRENGTH TABS 500MG Covered BAYER ASPIRIN TABS 325MG Covered BAYER ASPIRIN TABS 325MG Covered AL BAYER BREEZE 2 TEST DISC DISK Covered BAYER CHEWABLE LOW DOSE CHEW 81MG Covered QL AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 21 of 178 . 20MG. 20MG.4MG Covered BANOPHEN LIQD 12.05MG/ML Not Covered BARACLUDE TABS 0. 25MG. 25MG.

140MG Covered BAZA ANTIFUNGAL CREA 2% Covered 2%. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS STRP 0 Covered QL BAYER CONTOUR NEXT BLOOD GLUCOSE TEST STRP 0 Covered QL BAYER PLUS TABS 500MG.3ML/28G X 1/2" MISC Covered BD INSULIN SYRINGE ULTRAFINE/1ML/30G X 1/2" MISC Covered BD INTEGRA 3ML SYRINGE W/RETRACTING NEEDLE/21G X 1-1/2" MISC Covered BD INTEGRA 3ML SYRINGE W/RETRACTING NEEDLE/25G X 1" MISC Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 22 of 178 . 2MG/ML. 100MG/ML.5ML/28G X 1/2" MISC Covered BD INSULIN SYRINGE MICROFINE/U- 100/0. B-COMPLEX 100 SOLN 100MG/ML Covered BD ECLIPSE SYRINGE/1ML/27GX 1/2" MISC Covered BD ECLIPSE SYRINGE/3ML/23G X 1" MISC Covered BD ECLIPSE SYRINGE/3ML/25GX 5/8" MISC Covered BD INSULIN SYRINGE MICROFINE IV/U- 100/0. 2MG/ML. 2MG/ML.

5" MISC Covered BD INTEGRA SYRINGE/3ML/23G X 1" MISC Covered BD INTEGRA SYRINGE/3ML/25G X 5/8 MISC Covered BD PEN NEEDLE/MINI/ULTRA FINE/31G X 3/16" MISC Covered BD PEN NEEDLE/NANO/ULT RA FINE/32G X 4MM MISC Covered BD PEN NEEDLE/SHORT/ULT RAFINE/31G X 5/16" MISC Covered BD PEN NEEDLE/ULTRAFINE /29GX1/2" 12. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL BD INTEGRA SYRINGE/3ML/22G X 1.5MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 23 of 178 . 12.7MM MISC Covered BD SAFETYGLIDE 21G X 1-1/2" MISC Covered BD SAFETYGLIDE ALLERGY SYRINGE/1ML/27GX 1/2" MISC Covered BEBULIN SOLR 200-1200 UNIT Not Covered BELLADONNA ALKALOIDS & OPIUM SUPP 16.2MG. 60MG Not Covered BELSOMRA TABS 10MG Not Covered BELSOMRA TABS 5MG Not Covered BELSOMRA TABS 15MG Not Covered BELSOMRA TABS 20MG Not Covered BELVIQ TABS 10MG Not Covered BENAZEPRIL HCL TABS 40MG Covered QL BENAZEPRIL HCL TABS 10MG Covered QL BENAZEPRIL HCL TABS 20MG Covered QL BENAZEPRIL HCL TABS 5MG Covered QL BENAZEPRIL HCL/HYDROCHLOR OTHIAZIDE TABS 10MG.

12.10% Covered BETAMETHASONE VALERATE OINT 0. 40MG Not Covered BENICAR HCT TABS 12.5MG.60% Not Covered BETA HC LOTN 1% Covered BETAMETHASONE DIPROPIONATE LOTN 0. 20MG Not Covered BENICAR HCT TABS 12.5MG Not Covered BEPREVE SOLN 1.5MG Not Covered BENAZEPRIL HCL/HYDROCHLOR OTHIAZIDE TABS 5MG. 1% Not Covered BENZONATATE CAPS 100MG Not Covered BENZOYL PEROXIDE GEL 5% Covered BENZOYL PEROXIDE CLEANSER LOTN 6% Covered BENZTROPINE MESYLATE TABS 1MG Not Covered BENZTROPINE MESYLATE TABS 2MG Not Covered BENZTROPINE MESYLATE TABS 0.50% Not Covered BERINERT KIT 500UNIT Not Covered BESIVANCE SUSP 0. 25MG Not Covered BENEFIX SOLR 500UNIT Not Covered BENEFIX SOLR 1000UNIT Not Covered BENEFIX SOLR 250UNIT Not Covered BENEFIX SOLR 2000UNIT Not Covered BENICAR TABS 40MG Not Covered BENICAR TABS 5MG Not Covered BENICAR TABS 20MG Not Covered BENICAR HCT TABS 25MG.5MG.10% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 24 of 178 .05% Not Covered BETAMETHASONE DIPROPIONATE CREA 0. 6. 40MG Not Covered BENZACLIN GEL 5%.05% Covered BETAMETHASONE VALERATE CREA 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL BENAZEPRIL HCL/HYDROCHLOR OTHIAZIDE TABS 20MG.25MG Not Covered BENAZEPRIL HCL/HYDROCHLOR OTHIAZIDE TABS 20MG.

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
BETAMETHASONE
VALERATE LOTN 0.10% Covered
BETASERON KIT 0.3MG Not Covered
BETATEMP
CHILDRENS SUSP 160MG/5ML Covered
BETAXOLOL HCL TABS 10MG Covered
BETAXOLOL HCL SOLN 0.50% Covered
BETAXOLOL HCL TABS 20MG Covered
BETHANECHOL
CHLORIDE TABS 50MG Covered QL
BETHANECHOL
CHLORIDE TABS 25MG Covered QL
BETHANECHOL
CHLORIDE TABS 5MG Covered QL
BETHANECHOL
CHLORIDE TABS 10MG Covered QL
BETHKIS NEBU 300MG/4ML Not Covered
BETOPTIC-S SUSP 0.25% Not Covered
BEXAROTENE CAPS 75MG Covered PA
BEXSERO SUSY 0 Covered QL AL
BEYAZ TABS 3MG; 0.02MG; 0.451MG Not Covered
BICALUTAMIDE TABS 50MG Covered
BIDIL TABS 37.5MG; 20MG Not Covered

BIFERARX TABS 25MCG; 1MG; 6MG; 22MG Covered
BIMATOPROST SOLN 0.03% Not Covered
BINOSTO TBEF 70MG Not Covered
BIO-D-MULSION LIQD 400UNT/0.03ML Covered
BIO-D-MULSION
FORTE LIQD 2000UNT/0.03ML Covered
BION TEARS SOLN 0.1%; 0.3% Covered
BISAC-EVAC SUPP 10MG Covered
BISACODYL EC TBEC 5MG Covered
BISACODYL
LAXATIVE SUPP 10MG Covered
BISMATROL SUSP 262MG/15ML Covered
BISMUTH CHEW 262MG Covered
BISOPROLOL
FUMARATE TABS 5MG Covered
BISOPROLOL
FUMARATE TABS 10MG Covered QL

BISOPROLOL
FUMARATE/HYDRO
CHLOROTHIAZIDE TABS 2.5MG; 6.25MG Covered QL

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 25 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

BISOPROLOL
FUMARATE/HYDRO
CHLOROTHIAZIDE TABS 5MG; 6.25MG Covered

BISOPROLOL
FUMARATE/HYDRO
CHLOROTHIAZIDE TABS 10MG; 6.25MG Covered QL
BLEPHAMIDE SUSP 0.2%; 10% Covered

BLEPHAMIDE S.O.P. OINT 0.2%; 10% Covered
BLINCYTO SOLR 35MCG Not Covered
BONIVA TABS 150MG Not Covered
18.5MCG/0.5ML;
BOOSTRIX SUSP 2.5LF/0.5ML; 5LF/0.5ML Covered QL AL
BOSULIF TABS 100MG Not Covered
BOSULIF TABS 500MG Not Covered
500MCG; 350MG; 35MG;
1MG; 500MG; 200MG;
BP VIT 3 CAPS 12.5MG Covered

0; 0; 1000UNIT; 500MCG;
350MG; 35MG; 1MG;
BP VIT 3 PLUS CAPS 500MG; 200MG; 12.5MG; 0 Covered
BPO GEL 8% Not Covered
BPO GEL 4% Not Covered

BPO CREAMY WASH
COMPLETE PACK KIT 0 Covered QL
BREATHERITE
VALVED MDI
CHAMBER/RIGID DEVI Covered QL
BREATHERITE
W/SMALL MASK MISC Covered QL
BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH Not Covered
BREVICON-28 TABS 35MCG; 0.5MG Covered
BRIELLYN TABS 35MCG; 0.4MG Covered
BRILINTA TABS 90MG Not Covered
BRIMONIDINE
TARTRATE SOLN 0.15% Covered
BRIMONIDINE
TARTRATE SOLN 0.20% Covered
BRINTELLIX TABS 10MG Not Covered
BRINTELLIX TABS 20MG Not Covered
BRINTELLIX TABS 5MG Not Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 26 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
BRISDELLE CAPS 7.5MG Not Covered
BROMFENAC SOLN 0.09% Not Covered
BROMOCRIPTINE
MESYLATE CAPS 5MG Covered
BROMOCRIPTINE
MESYLATE TABS 2.5MG Covered QL
BRONCHO SALINE AERS 0.90% Not Covered
BROVANA NEBU 15MCG/2ML Not Covered AL
BUDEPRION SR TB12 100MG Not Covered
BUDESONIDE SUSP 0.5MG/2ML Covered QL AL
BUDESONIDE SUSP 0.25MG/2ML Covered QL AL
BUDESONIDE SUSP 32MCG/ACT Not Covered
BUDESONIDE SUSP 1MG/2ML Covered QL AL

BUFFERED ASPIRIN TABS 325MG; 0; 0; 0 Covered AL
325MG; 158MG; 34MG;
BUFFERIN TABS 63MG Covered AL
BUFFERIN LOW
DOSE TABS 81MG; 0; 0; 0 Not Covered
BUMETANIDE TABS 1MG Covered
BUMETANIDE TABS 2MG Covered
BUMETANIDE TABS 0.5MG Covered
BUMINATE SOLN 25% Not Covered
BUNAVAIL FILM 6.3MG; 1MG Not Covered
BUNAVAIL FILM 2.1MG; 0.3MG Not Covered
BUNAVAIL FILM 4.2MG; 0.7MG Not Covered
BUPHENYL TABS 500MG Not Covered
BUPHENYL POWD 3GM/TSP Not Covered
BUPRENORPHINE
HCL SUBL 2MG Not Covered
BUPRENORPHINE
HCL SUBL 8MG Not Covered
BUPRENORPHINE
HCL/NALOXONE
HCL SUBL 8MG; 2MG Not Covered
BUPRENORPHINE
HCL/NALOXONE
HCL SUBL 2MG; 0.5MG Not Covered
BUPROBAN TB12 150MG Covered QL
BUPROPION HCL TABS 75MG Not Covered
BUPROPION HCL TABS 100MG Not Covered

BUPROPION HCL SR TB12 150MG Not Covered

BUPROPION HCL SR TB12 200MG Not Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 27 of 178

40MG. 50MG.5MCG/HR Not Covered QL AL BUTRANS PTWK 5MCG/HR Not Covered QL AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 28 of 178 . 50MG. 50MG. 40MG. 50MG. 40MG Covered BUTALBITAL/ACETA MINOPHEN/CAFFEIN E CAPS 300MG. 40MG. 50MG Covered QL AL BUTALBITAL/ACETA MINOPHEN/CAFFEIN E TABS 325MG. 40MG Covered QL AL BUTALBITAL/ACETA MINOPHEN/CAFFEIN 300MG. 40MG Covered QL AL BUTALBITAL/ASPIRI N/CAFFEINE/CODEI 325MG. 40MG Covered QL AL BUTALBITAL/ACETA MINOPHEN/CAFFEIN E TABS 500MG. E/CODEINE CAPS 30MG Covered QL BUTALBITAL/ASPIRI N/CAFFEINE CAPS 325MG. 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL BUPROPION HCL SR TB12 100MG Not Covered BUPROPION HCL XL TB24 150MG Not Covered BUPROPION HCL XL TB24 300MG Not Covered BUSPIRONE HCL TABS 5MG Not Covered BUSPIRONE HCL TABS 30MG Not Covered BUSPIRONE HCL TABS 7.5MG Not Covered BUSPIRONE HCL TABS 10MG Not Covered BUSPIRONE HCL TABS 15MG Not Covered BUTALBITAL/ACETA MINOPHEN TABS 325MG. NE CAPS 30MG Covered QL BUTISOL SODIUM TABS 30MG Not Covered BUTISOL SODIUM TABS 50MG Not Covered BUTISOL SODIUM ELIX 30MG/5ML Not Covered BUTORPHANOL TARTRATE SOLN 10MG/ML Not Covered QL BUTRANS PTWK 10MCG/HR Not Covered QL AL BUTRANS PTWK 20MCG/HR Not Covered QL AL BUTRANS PTWK 7. E/CODEINE CAPS 30MG Not Covered BUTALBITAL/ACETA MINOPHEN/CAFFEIN 325MG. 50MG. 50MG. 40MG Not Covered QL BUTALBITAL/ACETA MINOPHEN/CAFFEIN E CAPS 325MG. 50MG.

5MG Not Covered BYSTOLIC TABS 5MG Not Covered BYSTOLIC TABS 10MG Not Covered CABERGOLINE TABS 0.01% Not Covered CALCITRIOL SOLN 1MCG/ML Covered AL CALCITRIOL CAPS 0.5MG Covered CADUET TABS 2. 10MG Not Covered CADUET TABS 5MG. 10MG Not Covered CADUET TABS 10MG. 0 Not Covered CANDESARTAN CILEXETIL TABS 32MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 29 of 178 .5MCG Covered QL CALCIUM ACETATE CAPS 667MG Covered CALCIUM ACETATE TABS 667MG Covered CALCIUM ANTACID EXTRA STRENGTH CHEW 750MG Covered CALCIUM CARBONATE TABS 1250MG Covered CALCIUM CARBONATE TABS 648MG Covered CALCIUM CARBONATE SUSP 1250MG/5ML Covered CALCIUM CHLORIDE SOLN 10% Covered CALCIUM CITRATE TABS 950MG Covered CAMILA TABS 0.04ML Not Covered BYSTOLIC TABS 2.25MCG Covered QL CALCITRIOL OINT 3MCG/GM Not Covered CALCITRIOL CAPS 0. 0 Not Covered CAMRESE LO TABS 0.01% Covered CALCIPOTRIENE OINT 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL BUTRANS PTWK 15MCG/HR Not Covered QL AL BYDUREON PEN 2MG Not Covered BYDUREON SRER 2MG Not Covered BYETTA SOPN 5MCG/0. 10MG Not Covered CAFFEINE CITRATE SOLN 60MG/3ML Covered AL CALAMINE LOTN 0 Not Covered CALCIFEROL SOLN 8000UNIT/ML Covered CALCIPOTRIENE SOLN 0.5MG.02ML Not Covered BYETTA SOPN 10MCG/0.35MG Covered CAMPRAL TBEC 333MG Not Covered CAMRESE TABS 0.01% Covered CALCITONIN- SALMON SOLN 200UNIT/ACT Covered CALCITRENE OINT 0.01% Covered CALCIPOTRIENE CREA 0.

5MG Not Covered CANDESARTAN CILEXETIL/HYDROC HLOROTHIAZIDE TABS 32MG.03% Covered CAPTOPRIL TABS 12. 25MG Not Covered CANDESARTAN CILEXETIL/HYDROC HLOROTHIAZIDE TABS 16MG.5MG Not Covered CANTIL TABS 25MG Not Covered CAPECITABINE TABS 500MG Covered CAPECITABINE TABS 150MG Covered CAPRELSA TABS 100MG Not Covered CAPRELSA TABS 300MG Not Covered CAPSAICIN CREA 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CANDESARTAN CILEXETIL TABS 16MG Not Covered CANDESARTAN CILEXETIL TABS 8MG Not Covered CANDESARTAN CILEXETIL TABS 4MG Not Covered CANDESARTAN CILEXETIL/HYDROC HLOROTHIAZIDE TABS 32MG. 15MG Not Covered CAPTOPRIL/HYDRO CHLOROTHIAZIDE TABS 25MG. 12.50% Not Covered CARAFATE SUSP 1GM/10ML Not Covered CARBAGLU TABS 200MG Not Covered CARBAMAZEPINE SUSP 100MG/5ML Not Covered CARBAMAZEPINE CHEW 100MG Not Covered CARBAMAZEPINE TABS 200MG Not Covered CARBAMAZEPINE ER TB12 400MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 30 of 178 .5MG Covered CAPTOPRIL TABS 100MG Covered CAPTOPRIL TABS 25MG Covered CAPTOPRIL TABS 50MG Covered CAPTOPRIL/HYDRO CHLOROTHIAZIDE TABS 50MG. 15MG Not Covered CARAC CREA 0. 12. 25MG Not Covered CAPTOPRIL/HYDRO CHLOROTHIAZIDE TABS 50MG. 25MG Not Covered CAPTOPRIL/HYDRO CHLOROTHIAZIDE TABS 25MG.

100MG Covered CARBIDOPA/LEVOD OPA ER TBCR 25MG. 200MG Not Covered CARBIDOPA/LEVOD OPA/ENTACAPONE TABS 31. 100MG Not Covered CARBIDOPA/LEVOD OPA/ENTACAPONE TABS 50MG. 100MG Covered CARBIDOPA/LEVOD OPA TABS 25MG. 200MG. 125MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 31 of 178 . 200MG. 100MG Covered QL CARBIDOPA/LEVOD OPA ODT TBDP 25MG.75MG. 100MG Covered CARBIDOPA/LEVOD OPA ER TBCR 50MG. 250MG Covered CARBIDOPA/LEVOD OPA/ENTACAPONE TABS 12. 250MG Covered CARBIDOPA/LEVOD OPA TABS 25MG. 200MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CARBAMAZEPINE ER TB12 200MG Not Covered CARBAMAZEPINE ER CP12 300MG Not Covered CARBAMAZEPINE ER CP12 100MG Not Covered CARBAMAZEPINE ER TB12 100MG Not Covered CARBAMAZEPINE ER CP12 200MG Not Covered CARBATROL CP12 300MG Not Covered CARBATROL CP12 100MG Not Covered CARBATROL CP12 200MG Not Covered CARBIDOPA TABS 25MG Not Covered CARBIDOPA/LEVOD OPA TABS 10MG. 200MG. 100MG Covered CARBIDOPA/LEVOD OPA ODT TBDP 25MG.5MG.25MG. 50MG Not Covered CARBIDOPA/LEVOD OPA/ENTACAPONE TABS 18. 200MG. 200MG Covered CARBIDOPA/LEVOD OPA ODT TBDP 10MG. 75MG Not Covered CARBIDOPA/LEVOD OPA/ENTACAPONE TABS 25MG.

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 37.5MG; 200MG; 150MG Not Covered
CARBINOXAMINE
MALEATE TABS 4MG Covered
CARBINOXAMINE
MALEATE SOLN 4MG/5ML Covered
500MG; 500MCG; 2MG; 0;
CARDIOTEK-RX TABS 50MG Covered
CARDIZEM CD CP24 120MG Not Covered
CARDIZEM CD CP24 240MG Not Covered
CARDIZEM CD CP24 300MG Not Covered
CARDIZEM CD CP24 360MG Not Covered
CARDIZEM CD CP24 180MG Not Covered
CARDIZEM LA TB24 300MG Not Covered
CARDIZEM LA TB24 360MG Not Covered
CARDIZEM LA TB24 180MG Not Covered
CARDIZEM LA TB24 120MG Not Covered
CARDIZEM LA TB24 240MG Not Covered
CARDIZEM LA TB24 420MG Not Covered
CARISOPRODOL TABS 350MG Not Covered
CARISOPRODOL/AS
PIRIN TABS 325MG; 200MG Not Covered
CARTEOLOL HCL SOLN 1% Covered
CARTIA XT CP24 120MG Not Covered
CARTIA XT CP24 300MG Not Covered
CARTIA XT CP24 180MG Not Covered
CARTIA XT CP24 240MG Not Covered
CARVEDILOL TABS 3.125MG Covered
CARVEDILOL TABS 25MG Covered
CARVEDILOL TABS 12.5MG Covered
CARVEDILOL TABS 6.25MG Covered
CASODEX TABS 50MG Not Covered
CATAPRES TABS 0.2MG Not Covered
CATAPRES TABS 0.3MG Not Covered
CATAPRES TABS 0.1MG Not Covered
CATAPRES-TTS-1 PTWK 0.1MG/24HR Not Covered
CATAPRES-TTS-2 PTWK 0.2MG/24HR Not Covered
CATAPRES-TTS-3 PTWK 0.3MG/24HR Not Covered

120MG; 200MG; 420UNIT;
CAVAN 55MG; 8MCG; 28MG; 1MG;
PRENATAL/EC 20MG; 150MCG; 50MG;
CALCIUM TBEC 3MG; 3MG; 30UNIT; 15MG Covered
CAVERJECT SOLR 20MCG Not Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 32 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
CAVERJECT
IMPULSE KIT 10MCG Not Covered
CAYSTON SOLR 75MG Covered
CAZIANT TABS 0; 0 Covered
CEFACLOR CAPS 500MG Covered
CEFACLOR SUSR 125MG/5ML Covered AL
CEFACLOR SUSR 250MG/5ML Covered AL
CEFACLOR SUSR 375MG/5ML Covered AL
CEFACLOR CAPS 250MG Covered
CEFACLOR ER TB12 500MG Not Covered
CEFADROXIL TABS 1GM Covered
CEFADROXIL CAPS 500MG Covered
CEFADROXIL SUSR 500MG/5ML Covered AL
CEFADROXIL SUSR 250MG/5ML Covered AL
CEFDINIR SUSR 250MG/5ML Covered AL
CEFDINIR CAPS 300MG Covered
CEFDINIR SUSR 125MG/5ML Covered AL
CEFIXIME SUSR 100MG/5ML Covered
CEFIXIME SUSR 200MG/5ML Covered
CEFPODOXIME
PROXETIL SUSR 50MG/5ML Covered AL
CEFPODOXIME
PROXETIL SUSR 100MG/5ML Covered AL
CEFPODOXIME
PROXETIL TABS 100MG Covered
CEFPODOXIME
PROXETIL TABS 200MG Covered
CEFPROZIL SUSR 125MG/5ML Covered AL
CEFPROZIL TABS 250MG Covered
CEFPROZIL SUSR 250MG/5ML Covered AL
CEFPROZIL TABS 500MG Covered
CEFUROXIME
AXETIL TABS 250MG Not Covered
CEFUROXIME
AXETIL TABS 500MG Not Covered
CELEBREX CAPS 400MG Not Covered
CELEBREX CAPS 200MG Not Covered
CELEBREX CAPS 50MG Not Covered
CELEBREX CAPS 100MG Not Covered
CELECOXIB CAPS 400MG Covered PA QL
CELECOXIB CAPS 100MG Covered PA QL
CELECOXIB CAPS 200MG Covered PA QL
CELECOXIB CAPS 50MG Covered PA QL
CELEXA TABS 10MG Not Covered
CELEXA TABS 20MG Not Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 33 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
CELEXA TABS 40MG Not Covered
CELLCEPT SUSR 200MG/ML Not Covered
CELONTIN CAPS 300MG Not Covered
CENTANY OINT 2% Not Covered
10MG; 0.8MG; 15MCG;
106MG; 1MG; 6.9MG;
1.3MG; 30MG; 5MG; 6MG;
CENTRATEX CAPS 200MG; 10MG; 18.2MG Covered
CEPHALEXIN SUSR 250MG/5ML Covered AL
CEPHALEXIN CAPS 500MG Covered
CEPHALEXIN SUSR 125MG/5ML Covered AL
CEPHALEXIN CAPS 250MG Covered
CEPHALEXIN TABS 500MG Not Covered
CEPHALEXIN CAPS 750MG Not Covered
CEPHALEXIN TABS 250MG Not Covered
CEPROTIN SOLR 500UNIT Not Covered
CERDELGA CAPS 84MG Not Covered QL
600MG; 6MG; 2MG;
CEREFOLIN NAC TABS 90.314MG Covered
CERVARIX SUSP 0 Covered QL AL
CESAMET CAPS 1MG Not Covered
CETIRIZINE HCL TABS 5MG Covered
CETIRIZINE HCL CHEW 10MG Covered QL AL
CETIRIZINE HCL TABS 10MG Covered
CETIRIZINE HCL CHEW 5MG Covered QL AL
CETIRIZINE HCL
CHILDRENS
ALLERGY SYRP 1MG/ML Covered QL AL
CETIRIZINE
HCL/PSEUDOEPHED
RINE HCL ER TB12 5MG; 120MG Not Covered
CETRAXAL SOLN 0.20% Not Covered
CHANTIX TABS 1MG Covered QL
CHANTIX TABS 0.5MG Covered QL
CHANTIX
CONTINUING
MONTH PAK TABS 1MG Covered QL

CHANTIX STARTING
MONTH PAK TABS 0 Covered
CHEMET CAPS 100MG Covered
CHEMSTRIP BG LOG
BOOK MISC Covered
CHEMSTRIP-K STRP 0 Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 34 of 178

2.5MG. 10MG Not Covered CHLORHEXIDINE GLUCONATE ORAL RINSE SOLN 0.5MG Not Covered CHLORDIAZEPOXID E/AMITRIPTYLINE TABS 12. 5MG Not Covered CHLORDIAZEPOXID E/AMITRIPTYLINE TABS 25MG.12% Covered QL CHLOROQUINE PHOSPHATE TABS 500MG Covered QL CHLOROQUINE PHOSPHATE TABS 250MG Covered QL CHLOROTHIAZIDE TABS 500MG Covered CHLOROTHIAZIDE TABS 250MG Covered CHLORPROMAZINE HCL SOLN 50MG/2ML Not Covered CHLORPROMAZINE HCL TABS 10MG Not Covered CHLORPROMAZINE HCL TABS 100MG Not Covered CHLORPROMAZINE HCL TABS 50MG Not Covered CHLORPROMAZINE HCL TABS 25MG Not Covered CHLORPROMAZINE HCL TABS 200MG Not Covered CHLORPROPAMIDE TABS 100MG Covered QL AL CHLORPROPAMIDE TABS 250MG Covered QL AL CHLORTHALIDONE TABS 50MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 35 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CHEWABLE ANTACID CHEW 500MG Covered CHILDRENS ASPIRIN CHEW 81MG Covered QL AL CHILDRENS LORATADINE SYRP 5MG/5ML Covered QL AL CHLORDIAZEPOXID E HCL CAPS 25MG Not Covered CHLORDIAZEPOXID E HCL CAPS 5MG Not Covered CHLORDIAZEPOXID E HCL CAPS 10MG Not Covered CHLORDIAZEPOXID E HCL/CLIDINIUM BROMIDE CAPS 5MG.

2%. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CHLORTHALIDONE TABS 100MG Not Covered CHLORTHALIDONE TABS 25MG Covered QL CHLORZOXAZONE TABS 500MG Covered AL CHOLESTYRAMINE POWD 4GM/DOSE Covered QL CHOLESTYRAMINE PACK 4GM Covered CHOLESTYRAMINE LIGHT PACK 4GM Covered CHOLESTYRAMINE LIGHT POWD 4GM/DOSE Covered CHOLINE MAGNESIUM TRISALICYLATE TABS 1000MG Not Covered CHOLINE MAGNESIUM TRISALICYLATE LIQD 500MG/5ML Covered CIALIS TABS 5MG Not Covered CIALIS TABS 10MG Not Covered CIALIS TABS 20MG Not Covered CIALIS TABS 2.5MG Not Covered CICLOPIROX SUSP 0.77% Not Covered CICLOPIROX NAIL LACQUER SOLN 8% Not Covered CICLOPIROX OLAMINE CREA 0. 1% Not Covered CIPRODEX SUSP 0. 0. 0 Not Covered CIPROFLOXACIN HCL TABS 500MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 36 of 178 .1% Covered AL CIPROFLOXACIN SUSR 250MG/5ML Covered AL CIPROFLOXACIN SUSR 500MG/5ML Covered AL CIPROFLOXACIN ER TB24 1000MG.77% Not Covered CILOSTAZOL TABS 100MG Covered QL CILOSTAZOL TABS 50MG Covered QL CIMETIDINE TABS 300MG Covered CIMETIDINE TABS 200MG Covered CIMETIDINE TABS 400MG Covered CIMETIDINE TABS 800MG Covered CIMETIDINE HCL SOLN 300MG/5ML Not Covered CIMZIA KIT 200MG Not Covered CIMZIA KIT 200MG/ML Not Covered CINRYZE SOLR 500UNIT Not Covered CIPRO HC SUSP 0. 0 Not Covered CIPROFLOXACIN ER TB24 500MG.3%.

3MG. 1MG.30% Covered QL CIPROFLOXACIN HCL TABS 100MG Covered CITALOPRAM HYDROBROMIDE TABS 10MG Not Covered CITALOPRAM HYDROBROMIDE SOLN 10MG/5ML Not Covered CITALOPRAM HYDROBROMIDE TABS 20MG Not Covered CITALOPRAM HYDROBROMIDE TABS 40MG Not Covered 120MG. CITRANATAL 90 DHA MISC 25MG Not Covered 120MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CIPROFLOXACIN HCL TABS 250MG Not Covered CIPROFLOXACIN HCL TABS 750MG Covered CIPROFLOXACIN HCL SOLN 0. 400UNIT. 400UNIT. 0 Covered CLARITHROMYCIN TABS 250MG Covered CLARITHROMYCIN TABS 500MG Covered CLARITHROMYCIN SUSR 125MG/5ML Covered AL CLARITHROMYCIN SUSR 250MG/5ML Covered AL CLARITHROMYCIN ER TB24 500MG Not Covered CLARITIN CHEW 5MG Not Covered CLARITIN SYRP 5MG/5ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 37 of 178 . 3. 2MG.4MG. 2MG. 1MG. 20MG. 3MG. 4%. CITRANATAL RX TABS 30UNIT. 90MG. 50MG. 0. 0. 150MCG. 159MG. 27MG. 30UNIT. 0. 3.25GM Not Covered CLARAVIS CAPS 40MG Covered PA QL CLARAVIS CAPS 20MG Covered PA QL CLARAVIS CAPS 10MG Covered PA QL CLARAVIS CAPS 30MG Covered PA QL CLARIFOAM EF FOAM 10%. 25MG Not Covered CITRUS BERGAMOT POWD 250MG/0. 50MG. 20MG. 20MG. 300MG. 124MG. 150MCG. 0. 5% Not Covered CLARIS CLARIFYING WASH EMUL 10%. 0. 20MG.75MG.4MG.

120MG Not Covered CLARITIN-D 24 HOUR TB24 10MG.2% Not Covered CLOBETASOL PROPIONATE OINT 0. 240MG Not Covered CLEMASTINE FUMARATE TABS 2.05% Not Covered CLOBETASOL PROPIONATE FOAM 0. 1% Not Covered CLINDAMYCIN/BENZ OYL PEROXIDE GEL 5%. 240MG Not Covered CLEAR-ATADINE D TB24 10MG.67MG/5ML Covered CLEOCIN PEDIATRIC GRANULES SOLR 75MG/5ML Not Covered CLINDAMYCIN HCL CAPS 150MG Covered CLINDAMYCIN HCL CAPS 300MG Covered CLINDAMYCIN HCL CAPS 75MG Covered CLINDAMYCIN PALMITATE HCL SOLR 75MG/5ML Covered AL CLINDAMYCIN PHOSPHATE LOTN 1% Not Covered CLINDAMYCIN PHOSPHATE SOLN 1% Covered CLINDAMYCIN PHOSPHATE GEL 1% Not Covered CLINDAMYCIN PHOSPHATE CREA 2% Covered CLINDAMYCIN/BENZ OYL PEROXIDE GEL 5%.68MG Covered CLEMASTINE FUMARATE SYRP 0. 1.05% Covered QL CLOBETASOL PROPIONATE SHAM 0.05% Covered PA QL CLOBETASOL PROPIONATE GEL 0.05% Covered PA QL CLOBETASOL PROPIONATE CREA 0.05% Not Covered CLOBETASOL PROPIONATE LOTN 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CLARITIN REDITABS TBDP 5MG Not Covered CLARITIN-D 12 HOUR TB12 5MG.05% Not Covered CLOBETASOL PROPIONATE SOLN 0.05% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 38 of 178 .

2MG/24HR Not Covered CLONIDINE HCL ER TB12 0.5MG Not Covered CLONAZEPAM TABS 1MG Not Covered CLONAZEPAM ODT TBDP 2MG Not Covered CLONAZEPAM ODT TBDP 0.10% Not Covered QL CLOCORTOLONE PIVALATE PUMP CREA 0.75MG Not Covered CLORPRES TABS 15MG.1MG Not Covered CLORPRES TABS 15MG.5MG Not Covered CLONIDINE HCL TABS 0.1MG Covered CLONIDINE HCL TABS 0. 0.5MG Not Covered CLORAZEPATE DIPOTASSIUM TABS 15MG Not Covered CLORAZEPATE DIPOTASSIUM TABS 3. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CLOBETASOL PROPIONATE E CREA 0. 0.125MG Not Covered CLONAZEPAM ODT TBDP 1MG Not Covered CLONAZEPAM ODT TBDP 0.2MG Not Covered CLORPRES TABS 15MG. 0.05% Not Covered CLOBEX LIQD 0.05% Not Covered CLOCORTOLONE PIVALATE CREA 0.10% Not Covered CLODERM CREA 0.3MG Covered CLONIDINE HCL PTWK 0.05% Not Covered CLOBEX LOTN 0.25MG Not Covered CLONAZEPAM ODT TBDP 0.2MG Covered CLONIDINE HCL TABS 0.3MG Not Covered CLOTRIMAZOLE TROC 10MG Covered QL CLOTRIMAZOLE CREA 1% Covered CLOTRIMAZOLE SOLN 1% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 39 of 178 .3MG/24HR Not Covered CLONIDINE HCL PTWK 0.1MG Not Covered CLOPIDOGREL TABS 75MG Covered QL CLORAZEPATE DIPOTASSIUM TABS 7.05% Not Covered CLOBEX SHAM 0.10% Not Covered CLOMIPRAMINE HCL CAPS 25MG Not Covered CLOMIPRAMINE HCL CAPS 50MG Not Covered CLOMIPRAMINE HCL CAPS 75MG Not Covered CLONAZEPAM TABS 2MG Not Covered CLONAZEPAM TABS 0.1MG/24HR Not Covered CLONIDINE HCL PTWK 0.

18MCG/ACT Covered COMBIVENT RESPIMAT AERS 100MCG/ACT.53GM.84GM. PACKS SOLR 5. PACKS SOLR 5. 20MCG/ACT Covered QL COMBIVIR TABS 150MG. 22. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CLOTRIMAZOLE/BET AMETHASONE DIPROPIONATE CREA 0.82GM.36GM.05%. 2. 6. 21.72GM Covered COMBIVENT AERO 103MCG/ACT.5GM Covered COLYTE-FLAVOR 240GM. 1% Not Covered CLOZAPINE TABS 25MG Not Covered CLOZAPINE TABS 50MG Not Covered CLOZAPINE TABS 100MG Not Covered CLOZAPINE ODT TBDP 12. 6.98GM. 300MG Not Covered COMETRIQ KIT 0 Not Covered COMETRIQ KIT 0 Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 40 of 178 .5MG Not Covered CLOZAPINE ODT TBDP 25MG Not Covered CLOZAPINE ODT TBDP 150MG Not Covered CLOZAPINE ODT TBDP 100MG Not Covered CLOZAPINE ODT TBDP 200MG Not Covered CLOZARIL TABS 100MG Not Covered CLOZARIL TABS 25MG Not Covered COAL TAR SOLN 20% Covered CODEINE SULFATE TABS 15MG Covered QL CODEINE SULFATE SOLN 30MG/5ML Covered CODEINE SULFATE TABS 60MG Covered QL CODEINE SULFATE TABS 30MG Covered QL COENZYME Q10 POWD 0 Not Covered COENZYME Q-10 CAPS 100MG Not Covered COLACE CAPS 100MG Covered COLACE CAPS 50MG Covered COLCHICINE TABS 0.72GM.6MG Covered QL COLCRYS TABS 0.1GM.6MG Not Covered COLESTID PACK 5GM Not Covered COLESTID TABS 1GM Not Covered COLESTID GRAN 5GM Not Covered COLESTIPOL HCL TABS 1GM Not Covered COLESTIPOL HCL PACK 5GM Not Covered COLESTIPOL HCL GRAN 5GM Not Covered COLYTE-FLAVOR 227. 2.

35MG. 15MCG. 25MG. 25MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 41 of 178 .25MG. 750UNIT. 10MG.5MG Not Covered CORLOPAM SOLN 10MG/ML Covered CORTANE-B 1MG/ML.05% Not Covered CORDRAN TAPE TAPE 4MCG/SQCM Not Covered COREG CR CP24 40MG Not Covered COREG CR CP24 20MG Not Covered COREG CR CP24 80MG Not Covered COREG CR CP24 10MG Not Covered CORIFACT KIT 1000-1600 UNIT Not Covered CORLANOR TABS 5MG Not Covered CORLANOR TABS 7. 125MCG. 1.4MG. 10MG. 125UNIT. 315UNIT. 70MCG. 5MG. 7MG. 1MG. 75MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL COMETRIQ KIT 20MG Not Covered COMPLERA TABS 200MG. 1. CORVITA TABS 35MG Covered 120MG. 35MG. 20MG. 400UNIT. 1MG. CORVITA 150 TABS 150MG. 8MG Not Covered CONTROLRX CREA 1. 13MG. 300MG Not Covered 120MG. 2. 3. 35MG. COMPLETENATE CHEW 2MG. 10MG/ML. 29MG. 10MG. AQUEOUS SOLN 10MG/ML Not Covered CORTROSYN SOLR 0.25MG Not Covered 375MG.10% Not Covered CONZIP CP24 100MG Not Covered CONZIP CP24 200MG Not Covered CONZIP CP24 300MG Not Covered COPAXONE SOSY 20MG/ML Not Covered COPAXONE SOSY 40MG/ML Not Covered CORDRAN CREA 0.05% Not Covered CORDRAN LOTN 0. 12MCG. 150MCG.25MG. 11UNIT Covered QL AL COMPOZ TABS 50MG Not Covered COMTAN TABS 200MG Not Covered CONCERTA TBCR 36MG Not Covered CONCERTA TBCR 54MG Not Covered CONCERTA TBCR 18MG Not Covered CONCERTA TBCR 27MG Not Covered CONDOMS MISC Covered QL CONSTULOSE SOLN 10GM/15ML Covered CONTRAVE TB12 90MG. 25MG.5MG. 3MG. 1000UNIT.

400MCG. 35MG. 125MG. 10MG. 35MG Covered CORZIDE TABS 5MG. 6000UNIT. 1. 125UNIT. 150MCG. 1. 35MG.25MG.5MG Not Covered COUMADIN TABS 6MG Not Covered COUMADIN TABS 5MG Not Covered COUMADIN TABS 2MG Not Covered COUMADIN TABS 2. 3. 20MCG. 25MG. 1000UNIT. 125UNIT. 15MG. 80MG Not Covered COSENTYX SOSY 150MG/ML Not Covered COSENTYX SENSOREADY PEN SOAJ 150MG/ML Not Covered COUMADIN TABS 4MG Not Covered COUMADIN TABS 1MG Not Covered COUMADIN TABS 10MG Not Covered COUMADIN TABS 7. CORVITE 150 TABS 25MG Covered 120MG.4MG. 5MG. 40MG Not Covered CORZIDE TABS 5MG. 35MG. 500MG. CREON CPEP 9500UNIT Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 42 of 178 . 35MG. 7MG. 10MG. 25MG. 70MCG. CREON CPEP 19000UNIT Covered QL 15000UNIT. 1.25MG. 25MG.5MG. 120MG. 10MG. 70MCG. 400UNIT. CORVITE FE TABS 1MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 375MG. 750UNIT. 35MG. 150MG.25MG Not Covered 30000UNIT. 700MCG. 5MG. 13MG. 75MCG. 2. 300MCG.625MG. 25MG Covered 10MG. 10MG. 35MG. 1MG. 5MG.4MG. 150MCG. CORVITE FREE TABS 125MCG. 315UNIT. 3. 75MCG. 125MCG. 3000UNIT. 35MG. 1MG. 125MCG. 5MG. 15MCG. CORVITE TABS 35MG Covered 100MCG.5MG Not Covered COUMADIN TABS 3MG Not Covered COVARYX HS TABS 0.

3MG Covered CUVPOSA SOLN 1MG/5ML Not Covered CYCLAFEM 1/35 TABS 35MCG. 12000UNIT.2MG/ACT Covered CROMOLYN SODIUM SOLN 4% Covered CROMOLYN SODIUM NEBU 20MG/2ML Covered CRYSELLE-28 TABS 30MCG.5MG Not Covered CYCLOGYL SOLN 2% Not Covered CYCLOPENTOLATE HCL SOLN 1% Not Covered CYCLOPENTOLATE HCL SOLN 2% Not Covered CYCLOPHOSPHAMI DE TABS 50MG Not Covered CYCLOPHOSPHAMI DE CAPS 25MG Covered CYCLOPHOSPHAMI DE CAPS 50MG Covered CYCLOPHOSPHAMI DE TABS 25MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 43 of 178 . 24000UNIT. 1MG Covered CYCLAFEM 7/7/7 TABS 0. CREON CPEP 38000UNIT Covered QL 120000UNIT. 0. 36000UNIT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 180000UNIT. 0 Covered CYCLOBENZAPRINE HCL TABS 10MG Covered AL CYCLOBENZAPRINE HCL TABS 5MG Covered AL CYCLOBENZAPRINE HCL TABS 7. CREON CPEP 114000UNIT Covered QL 60000UNIT. CREON CPEP 76000UNIT Covered QL CRESEMBA CAPS 186MG Not Covered CRESEMBA SOLR 372MG Not Covered CRESTOR TABS 20MG Not Covered CRESTOR TABS 40MG Not Covered CRESTOR TABS 10MG Not Covered CRESTOR TABS 5MG Not Covered CRINONE GEL 4% Not Covered CRINONE GEL 8% Not Covered CRIXIVAN CAPS 400MG Not Covered CRIXIVAN CAPS 200MG Not Covered CROMOLYN SODIUM AERS 5.

1100MG/5ML Not Covered DAKLINZA TABS 60MG Not Covered DAKLINZA TABS 30MG Not Covered DALIRESP TABS 500MCG Not Covered DANAZOL CAPS 100MG Covered DANAZOL CAPS 50MG Covered DANAZOL CAPS 200MG Covered DANTROLENE SODIUM CAPS 50MG Not Covered DANTROLENE SODIUM CAPS 100MG Not Covered DANTROLENE SODIUM CAPS 25MG Not Covered DAPSONE TABS 25MG Covered DAPSONE TABS 100MG Covered DARAPRIM TABS 25MG Covered DASETTA 1/35 TABS 35MCG. 0 Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 44 of 178 . 500MG/5ML Not Covered 334MG/5ML. 1MG Covered DASETTA 7/7/7 TABS 0. 3300MG Not Covered CYTRA-2 SOLN 334MG/5ML.44% Not Covered QL CYTRA K CRYSTALS PACK 1002MG. CYTRA-3 SYRP 500MG/5ML Not Covered CYTRA-K SOLN 334MG/5ML.8MG Not Covered CYCLOSPORINE CAPS 100MG Covered QL CYCLOSPORINE CAPS 25MG QL CYCLOSPORINE MODIFIED CAPS 100MG Covered QL CYCLOSPORINE MODIFIED CAPS 50MG Covered CYCLOSPORINE MODIFIED CAPS 25MG Covered QL CYMBALTA CPEP 60MG Not Covered CYMBALTA CPEP 20MG Not Covered CYMBALTA CPEP 30MG Not Covered CYPROHEPTADINE HCL TABS 4MG Covered AL CYPROHEPTADINE HCL SYRP 2MG/5ML Covered AL CYRAMZA SOLN 500MG/50ML Not Covered CYRAMZA SOLN 100MG/10ML Not Covered CYSTADANE POWD 0 Not Covered CYSTARAN SOLN 0. 550MG/5ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL CYCLOSERINE CAPS 250MG Covered CYCLOSET TABS 0.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DAYSEE TABS 0.01% Not Covered DEBLITANE TABS 0. 0 Not Covered DAYTRANA PTCH 15MG/9HR Not Covered DAYTRANA PTCH 20MG/9HR Not Covered DAYTRANA PTCH 30MG/9HR Not Covered DAYTRANA PTCH 10MG/9HR Not Covered DDAVP SOLN 0.35MG Covered DELZICOL CPDR 400MG Covered DEMECLOCYCLINE HCL TABS 150MG Not Covered DEMECLOCYCLINE HCL TABS 300MG Not Covered DENAVIR CREA 1% Not Covered DENTA 5000 PLUS CREA 1.2MG Covered QL DESMOPRESSIN ACETATE SOLN 0.10% Not Covered DERMATOP CREA 0.01% Not Covered DDAVP SOLN 0.10% Not Covered DERMOTIC OIL 0.01% Not Covered DESIPRAMINE HCL TABS 50MG Not Covered DESIPRAMINE HCL TABS 150MG Not Covered DESIPRAMINE HCL TABS 100MG Not Covered DESIPRAMINE HCL TABS 10MG Not Covered DESIPRAMINE HCL TABS 75MG Not Covered DESIPRAMINE HCL TABS 25MG Not Covered DESMOPRESSIN ACETATE TABS 0.10% Covered AL DEPAKOTE TBEC 500MG Not Covered DEPAKOTE TBEC 250MG Not Covered DEPAKOTE TBEC 125MG Not Covered DEPAKOTE ER TB24 500MG Not Covered DEPAKOTE ER TB24 250MG Not Covered DEPAKOTE SPRINKLES CSDR 125MG Not Covered DEPO-PROVERA CONTRACEPTIVE SUSP 150MG/ML Not Covered DERMA- SMOOTHE/FS BODY OIL 0.01% Not Covered DERMATOP OINT 0.01% Not Covered DERMA- SMOOTHE/FS SCALP OIL 0.10% Covered DENTAGEL GEL 1.01% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 45 of 178 .

05% Not Covered DESOXIMETASONE CREA 0.5MG/5ML Covered DEXAMETHASONE INTENSOL CONC 1MG/ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 46 of 178 .25% Not Covered DESOXIMETASONE GEL 0. 30MCG Covered DESOGESTREL/ETH INYL ESTRADIOL TABS 0.25% Not Covered DESOXIMETASONE CREA 0.5MG Covered DEXAMETHASONE TABS 6MG Covered DEXAMETHASONE TABS 4MG Covered DEXAMETHASONE TABS 0.15MG.1MG Covered QL DESMOPRESSIN ACETATE SOLN 0. 0 Covered DESONIDE LOTN 0.05% Not Covered DESOXYN TABS 5MG Not Covered DESVENLAFAXINE ER TB24 100MG Not Covered DESVENLAFAXINE ER TB24 50MG Not Covered DETROL TABS 1MG Not Covered DETROL TABS 2MG Not Covered DETROL LA CP24 4MG Not Covered DETROL LA CP24 2MG Not Covered DEXAMETHASONE TABS 1MG Covered DEXAMETHASONE TABS 2MG Covered DEXAMETHASONE TABS 1.05% Not Covered DESOXIMETASONE OINT 0.01% Covered DESMOPRESSIN ACETATE SOLN 0.75MG Covered DEXAMETHASONE ELIX 0.5MG/5ML Covered DEXAMETHASONE TABS 0.05% Not Covered DESONIDE OINT 0.01% Covered DESOGESTREL/ETH INYL ESTRADIOL TABS 0.5MG Covered DEXAMETHASONE SOLN 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DESMOPRESSIN ACETATE TABS 0.05% Not Covered DESONIDE CREA 0.

1MG. 30UNIT.5MG Not Covered DEXMETHYLPHENID ATE HCL ER CP24 15MG Not Covered DEXMETHYLPHENID ATE HCL ER CP24 40MG Not Covered DEXMETHYLPHENID ATE HCL ER CP24 5MG Not Covered DEXMETHYLPHENID ATE HCL ER CP24 30MG Not Covered DEXMETHYLPHENID ATE HCL ER CP24 10MG Not Covered DEXMETHYLPHENID ATE HCL ER CP24 20MG Not Covered DEXTROAMPHETAM INE SULFATE TABS 5MG Not Covered DEXTROAMPHETAM INE SULFATE TABS 10MG Not Covered DEXTROAMPHETAM INE SULFATE ER CP24 5MG Not Covered DEXTROAMPHETAM INE SULFATE ER CP24 10MG Not Covered DEXTROAMPHETAM INE SULFATE ER CP24 15MG Not Covered 100MG.5MG Covered 100MG. 50MG. 5MG.7MG. 0. 300MCG. 20MG. 1MG. 25MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 47 of 178 . DIALYVITE TABS 1.7MG. 10MG. 1.7MG. 300MCG. 70MCG.3MG. 20MG. 10MG.10% Covered DEXILANT CPDR 60MG Not Covered DEXILANT CPDR 30MG Not Covered DEXMETHYLPHENID ATE HCL TABS 5MG Not Covered DEXMETHYLPHENID ATE HCL TABS 10MG Not Covered DEXMETHYLPHENID ATE HCL TABS 2. 10MG. DIALYVITE 5000 TABS 1. 10MG. 30UNIT. 3MG. 20MG.5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DEXAMETHASONE SODIUM PHOSPHATE SOLN 0. 1. 0.006MG. 15MG Covered 100MG. 25MG. 2MG. 1. 70MCG.5MG. DIALYVITE 3000 TABS 1.

7MG.7MG.7MG.10% Covered DICLOFENAC SODIUM SOLN 1. 30UNIT. 1.5MG Not Covered DIAZEPAM GEL 20MG Not Covered DIAZEPAM INTENSOL CONC 5MG/ML Not Covered DICLEGIS TBEC 10MG. 1MG. 3MG. 20MG. 15MG Covered 100MG. 800MCG. 10MG. 25MG. DIALYVITE 800/IRON TABS 1.50% Not Covered DICLOFENAC SODIUM GEL 3% Covered QL DICLOFENAC SODIUM DR TBEC 75MG Covered DICLOFENAC SODIUM DR TBEC 25MG Covered DICLOFENAC SODIUM DR TBEC 50MG Covered DICLOFENAC SODIUM ER TB24 100MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 48 of 178 . 300MCG. 10MG. 20MG. 1. SUPREME D TABS 70MCG. 2000UNIT. DIALYVITE/ZINC TABS 1.5MG Not Covered DIASTIX STRP 0 Covered DIAZEPAM SOLN 1MG/ML Not Covered DIAZEPAM TABS 5MG Not Covered DIAZEPAM TABS 10MG Not Covered DIAZEPAM TABS 2MG Not Covered DIAZEPAM GEL 10MG Not Covered DIAZEPAM GEL 2. 300MCG. 10MG. 300MCG. 10MG. 29MG. 20MG. DIALYVITE 1MG. 6MCG. 1. 50MG Covered DIAMOX CP12 500MG Not Covered DIASTAT ACUDIAL GEL 20MG Not Covered DIASTAT ACUDIAL GEL 10MG Not Covered DIASTAT PEDIATRIC GEL 2. 6MCG.5MG Covered 100MG. 1.5MG.5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 60MG. 10MG. 10MG Not Covered DICLOFENAC POTASSIUM TABS 50MG Not Covered DICLOFENAC SODIUM SOLN 0.

30% Not Covered DIFFERIN LOTN 0. 200MCG Not Covered DICLOFENAC SODIUM/MISOPROS TOL TBEC 50MG. 200MCG Not Covered DICLOXACILLIN SODIUM CAPS 250MG Covered DICLOXACILLIN SODIUM CAPS 500MG Covered DICYCLOMINE HCL CAPS 10MG Covered AL DICYCLOMINE HCL SOLN 10MG/5ML Covered AL DICYCLOMINE HCL TABS 20MG Covered AL DIDANOSINE CPDR 125MG Not Covered DIDANOSINE CPDR 200MG Not Covered DIDANOSINE CPDR 250MG Not Covered DIDANOSINE CPDR 400MG Not Covered DIFFERIN GEL 0.10% Not Covered DIFICID TABS 200MG Not Covered DIFLORASONE DIACETATE CREA 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DICLOFENAC SODIUM/MISOPROS TOL TBEC 75MG.05% Not Covered DIFLORASONE DIACETATE OINT 0.05% Not Covered DIFLUNISAL TABS 500MG Not Covered DIGOX TABS 250MCG Not Covered DIGOX TABS 125MCG Not Covered DIHYDROERGOTAMI NE MESYLATE SOLN 4MG/ML Not Covered DILANTIN CAPS 30MG Not Covered DILANTIN INFATABS CHEW 50MG Not Covered DILATRATE SR CPCR 40MG Not Covered DILAUDID LIQD 1MG/ML Not Covered DILT-CD CP24 240MG Covered DILT-CD CP24 180MG Covered DILT-CD CP24 120MG Covered DILT-CD CP24 300MG Covered DILTIAZEM CD CP24 300MG Covered QL DILTIAZEM CD CP24 180MG Covered QL DILTIAZEM CD CP24 240MG Covered QL DILTIAZEM CD CP24 120MG Covered QL DILTIAZEM HCL TABS 60MG Covered QL DILTIAZEM HCL TABS 90MG Covered QL DILTIAZEM HCL TABS 30MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 49 of 178 .

5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DILTIAZEM HCL TABS 120MG Covered QL DILTIAZEM HCL ER CP24 120MG Covered DILTIAZEM HCL ER CP24 300MG Covered DILTIAZEM HCL ER CP24 180MG Covered DILTIAZEM HCL ER CP24 360MG Covered QL DILTIAZEM HCL ER CP24 240MG Covered DILTIAZEM HCL ER CP12 60MG Not Covered DILTIAZEM HCL ER CP24 240MG Covered QL DILTIAZEM HCL ER CP24 180MG Covered QL DILTIAZEM HCL ER TB24 300MG Covered QL DILTIAZEM HCL ER CP24 360MG Not Covered DILTIAZEM HCL ER CP24 120MG Covered QL DILTIAZEM HCL ER CP24 120MG Covered QL DILTIAZEM HCL ER CP24 420MG Covered QL DILTIAZEM HCL ER TB24 180MG Covered QL DILTIAZEM HCL ER CP24 180MG Covered QL DILTIAZEM HCL ER CP24 240MG Covered QL DILTIAZEM HCL ER CP12 120MG Not Covered DILTIAZEM HCL ER CP24 300MG Covered QL DILT-XR CP24 180MG Not Covered DILT-XR CP24 240MG Not Covered DILTZAC CP24 240MG Covered DILTZAC CP24 180MG Covered DILTZAC CP24 120MG Covered DILTZAC CP24 300MG Covered DILTZAC CP24 360MG Covered DIOCTO SYRP 60MG/15ML Covered DIOVAN TABS 160MG Not Covered DIOVAN TABS 80MG Not Covered DIOVAN TABS 320MG Not Covered DIOVAN TABS 40MG Not Covered DIOVAN HCT TABS 12. 160MG Not Covered DIOVAN HCT TABS 12.5MG.5MG. 160MG Not Covered DIOVAN HCT TABS 25MG. 320MG Not Covered DIOVAN HCT TABS 25MG. 320MG Not Covered DIOVAN HCT TABS 12. 80MG Not Covered DIPHENHIST TABS 25MG Covered AL DIPHENHYDRAMINE HCL CAPS 50MG Covered AL DIPHENHYDRAMINE HCL CAPS 25MG Covered AL DIPHENHYDRAMINE HCL TABS 25MG Covered AL DIPHENHYDRAMINE HCL SOLN 50MG/ML Covered AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 50 of 178 .

2.025MG/5ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DIPHENHYDRAMINE HCL ELIX 12. 16.5MG/5ML Covered DIPHENOXYLATE/AT ROPINE TABS 0.1037MG/5ML.6MG Covered DONEPEZIL HCL TBDP 10MG Not Covered AL DONEPEZIL HCL TABS 10MG Covered QL AL DONEPEZIL HCL TABS 5MG Covered QL AL DONEPEZIL HCL TBDP 5MG Not Covered AL DONEPEZIL HCL TABS 23MG Not Covered AL 0.0194MG/5ML. 2.0065MG/5ML Not Covered DORAL TABS 15MG Not Covered DORYX TBEC 150MG Not Covered DORYX TBEC 200MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 51 of 178 .2MG/5ML.05% Not Covered DIPYRIDAMOLE TABS 50MG Covered DIPYRIDAMOLE TABS 75MG Covered QL DIPYRIDAMOLE TABS 25MG Covered QL DISOPYRAMIDE PHOSPHATE CAPS 100MG Covered AL DISOPYRAMIDE PHOSPHATE CAPS 150MG Covered AL DISULFIRAM TABS 250MG Not Covered DISULFIRAM TABS 500MG Not Covered DIURIL SUSP 250MG/5ML Covered AL DIVALPROEX SODIUM CSDR 125MG Not Covered DIVALPROEX SODIUM DR TBEC 125MG Not Covered DIVALPROEX SODIUM DR TBEC 250MG Not Covered DIVALPROEX SODIUM DR TBEC 500MG Not Covered DIVALPROEX SODIUM ER TB24 500MG Not Covered DIVALPROEX SODIUM ER TB24 250MG Not Covered DOC-Q-LAX TABS 50MG. DONNATAL ELIX 0. 0.025MG.5MG/5ML Covered AL DIPHENHYDRAMINE HCL MAXIMUM STRENGTH TABS 50MG Not Covered DIPHENOXYLATE/AT ROPINE LIQD 0. 8.5MG Covered DIPROLENE LOTN 0.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DORYX TBEC 50MG Not Covered DORZOLAMIDE HCL SOLN 2% Covered 500UNIT/GM.5MCG Covered DOXERCALCIFEROL CAPS 1MCG Covered DOXERCALCIFEROL CAPS 2.01% Not Covered DOXAZOSIN TABS 4MG Covered QL DOXAZOSIN MESYLATE TABS 8MG Covered QL DOXAZOSIN MESYLATE TABS 1MG Covered QL DOXAZOSIN MESYLATE TABS 2MG Covered QL DOXEPIN HCL CONC 10MG/ML Not Covered DOXEPIN HCL CAPS 25MG Not Covered DOXEPIN HCL CAPS 50MG Not Covered DOXEPIN HCL CAPS 10MG Not Covered DOXEPIN HCL CAPS 75MG Not Covered DOXEPIN HCL CAPS 100MG Not Covered DOXERCALCIFEROL CAPS 0. DOUBLE ANTIBIOTIC OINT 10000UNIT/GM Covered DOVONEX CREA 0.5MCG Covered DOXERCALCIFEROL SOLN 4MCG/2ML Covered DOXYCYCLINE SUSR 25MG/5ML Covered AL DOXYCYCLINE CAPS 150MG Covered DOXYCYCLINE CAPS 75MG Covered DOXYCYCLINE HYCLATE CAPS 100MG Not Covered DOXYCYCLINE HYCLATE CAPS 50MG Not Covered DOXYCYCLINE HYCLATE TABS 20MG Not Covered DOXYCYCLINE HYCLATE TABS 100MG Not Covered DOXYCYCLINE HYCLATE DR TBEC 100MG Not Covered DOXYCYCLINE HYCLATE DR TBEC 150MG Not Covered DOXYCYCLINE HYCLATE DR TBEC 75MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 52 of 178 .

5MG Covered PA DRONABINOL CAPS 10MG Covered PA DROSPIRENONE/ET HINYL ESTRADIOL TABS 3MG. 665MG. GRANULES SUSR 200MG/5ML Covered AL E-400 CAPS 400UNIT Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 53 of 178 . 1. 3MG Not Covered DRONABINOL CAPS 5MG Covered PA DRONABINOL CAPS 2. 30MG Not Covered DUETACT TABS 4MG. 40MG. 80MEQ.45MG Not Covered DUETACT TABS 2MG. 320MG.2MG Not Covered 140MG.E. 83MG.5GM. 800MG Not Covered DULERA AERO 5MCG/ACT. 30MG Not Covered DUEXIS TABS 26. 2.63MG/ML. 20MG/ML Not Covered DUREZOL EMUL 0. 0.5MG Covered DYLOJECT SOLN 37.S.6MG. DRIPDROP ORS PACK 390MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL DOXYCYCLINE MONOHYDRATE CAPS 50MG Covered DOXYCYCLINE MONOHYDRATE CAPS 100MG Covered DOXYCYCLINE MONOHYDRATE TABS 100MG Not Covered DOXYCYCLINE MONOHYDRATE TABS 75MG Not Covered DOXYCYCLINE MONOHYDRATE TABS 50MG Not Covered DRIPDROP HYDRATION 70MG.03MG Covered DROXIA CAPS 400MG Covered DROXIA CAPS 300MG Covered DROXIA CAPS 200MG Covered DRYSOL SOLN 20% Covered DSS CAPS 100MG Covered DSS CAPS 250MG Covered DUAC GEL 5%. POWDER PACK 190MG. 0. 1.5MG/ML Not Covered E. 100MCG/ACT Covered QL DULERA AERO 5MCG/ACT. 200MCG/ACT Covered QL DULOXETINE HCL CPEP 60MG Not Covered DULOXETINE HCL CPEP 30MG Not Covered DULOXETINE HCL CPEP 20MG Not Covered DUOPA SUSP 4.05% Not Covered DUTASTERIDE CAPS 0.2% Not Covered DUAVEE TABS 20MG.

ELDERCAPS CAPS 4000UNIT. 12. 1.5MG Not Covered EFFEXOR XR CP24 75MG Not Covered EFFIENT TABS 10MG Not Covered EFFIENT TABS 5MG Not Covered ELAPRASE SOLN 6MG/3ML Not Covered 200MG.625MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL EARWAX TREATMENT DROPS SOLN 6. 25MG Not Covered EDECRIN TABS 25MG Not Covered EDLUAR SUBL 10MG Not Covered EDLUAR SUBL 5MG Not Covered EDURANT TABS 25MG Not Covered EEMT HS TABS 0.50% Not Covered EASIVENT MISC Covered QL EC-NAPROSYN TBEC 500MG Not Covered EC-NAPROSYN TBEC 375MG Not Covered ECONAZOLE NITRATE CREA 1% Covered QL ECOTRIN LOW STRENGTH TBEC 81MG Covered AL EDARBI TABS 80MG Not Covered EDARBI TABS 40MG Not Covered EDARBYCLOR TABS 40MG.05% Not Covered ELIDEL CREA 1% Covered PA QL ELIMITE CREA 5% Not Covered ELINEST TABS 30MCG. 5MG.5GM Covered EFFERVESCENT POTASSIUM/CHLORI 0.25MG Not Covered EFFERVESCENT POTASSIUM TBEF 2GM. 1MG. 10MG.5MG Not Covered QL ELIQUIS TABS 5MG Not Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 54 of 178 . DE TBEF 1.91GM. 25MG. 0.5GM. 0. 5MG.5MG Not Covered EDARBYCLOR TABS 40MG.55GM.3MG Covered ELIPHOS TABS 667MG Covered ELIQUIS TABS 2. 2. 10MG. 25UNIT. 2MG. 0. 70MG. 110MG Covered ELELYSO SOLR 200UNIT Not Covered ELESTAT SOLN 0. 400UNIT.5GM Covered EFFEXOR XR CP24 150MG Not Covered EFFEXOR XR CP24 37.

4MG. 2MG Not Covered EMBEDA CPCR 30MG. 1.15MG.5MG Not Covered ENALAPRIL MALEATE TABS 5MG Covered QL ENALAPRIL MALEATE TABS 10MG Covered QL ENALAPRIL MALEATE TABS 2.05% Not Covered EMBEDA CPCR 20MG. 10MG. 20UNIT. 3. ELITE-OB TABS 3. 50MG. 15MG. 10MG.25MG. 0.5MG Covered QL ENALAPRIL MALEATE TABS 20MG Covered QL ENALAPRIL MALEATE/HYDROCH LOROTHIAZIDE TABS 10MG. 2. 2100UNIT.4MG Not Covered EMBEDA CPCR 80MG. 10MG Covered ELLA TABS 30MG Covered ELMIRON CAPS 100MG Covered QL ELOCTATE SOLR 500UNIT Not Covered ELOCTATE SOLR 1500UNIT Not Covered ELOCTATE SOLR 250UNIT Not Covered ELOCTATE SOLR 2000UNIT Not Covered ELOCTATE SOLR 3000UNIT Not Covered ELOCTATE SOLR 750UNIT Not Covered ELOCTATE SOLR 1000UNIT Not Covered EMADINE SOLN 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 120MG. 2MG. 4MG Not Covered EMCYT CAPS 140MG Covered EMEND CAPS 125MG Not Covered QL EMEND CAPS 80MG Not Covered QL EMEND CAPS 40MG Not Covered QL EMEND CAPS 0 Not Covered QL EMOQUETTE TABS 0. 1.8MG Not Covered EMBEDA CPCR 50MG. 15MCG.2MG Not Covered EMBEDA CPCR 100MG. 30MCG Covered EMSAM PT24 9MG/24HR Not Covered EMSAM PT24 6MG/24HR Not Covered EMSAM PT24 12MG/24HR Not Covered EMTRIVA CAPS 200MG Not Covered ENABLEX TB24 15MG Not Covered ENABLEX TB24 7.2MG Not Covered EMBEDA CPCR 60MG. 315UNIT. 1MG. 25MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 55 of 178 .

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ENALAPRIL MALEATE/HYDROCH LOROTHIAZIDE TABS 5MG. 25MCG.5MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 56 of 178 . 5MG. 0 Covered ENSKYCE TABS 0. 3. 25MCG. 2.4ML Covered QL ENOXAPARIN SODIUM SOLN 100MG/ML Covered QL ENPRESSE-28 TABS 0. ENLYTE CAPS 25MCG Not Covered ENOVARX- BACLOFEN CREA 1% Not Covered ENOVARX- CYCLOBENZAPRINE HCL CREA 20MG/GM Not Covered ENOVARX- IBUPROFEN CREA 10% Not Covered ENOVARX- LIDOCAINE HCL CREA 5% Not Covered ENOVARX- NAPROXEN CREA 10% Not Covered ENOVARX- TRAMADOL CREA 5% Not Covered ENOXAPARIN SODIUM SOLN 120MG/0.5MG.6ML Covered QL ENOXAPARIN SODIUM SOLN 40MG/0. 12.3ML Covered QL ENOXAPARIN SODIUM SOLN 80MG/0. 25MCG.8ML Covered QL ENOXAPARIN SODIUM SOLN 150MG/ML Covered QL ENOXAPARIN SODIUM SOLN 60MG/0. 30MCG Covered ENTACAPONE TABS 200MG Not Covered ENTECAVIR TABS 0. 25MCG. 283MG Covered QL ENGERIX-B INJ 10MCG/0.5MG.4MG.15MG. 2.5ML Covered QL AL ENGERIX-B INJ 20MCG/ML Covered QL AL 21MG. 25MCG. 1. 40MG.8ML Covered QL ENOXAPARIN SODIUM SOLN 30MG/0.83MG.5MG Covered QL ENBREL SOLR 25MG Not Covered ENBREL SOSY 50MG/ML Covered PA ENEMEEZ MINI ENEM 283MG Covered QL ENEMEEZ PLUS ENEM 20MG.

5% Not Covered EPIDUO FORTE GEL 0.75MG Not Covered EPANED SOLR 1MG/ML Covered AL EPIDUO GEL 0.05% Not Covered EPINEPHRINE SOAJ 0. 1% Not Covered EPINASTINE HCL SOLN 0.15ML Covered QL EPIPEN 2-PAK SOAJ 0.35MG Covered ERY PADS 2% Not Covered ERYGEL GEL 2% Not Covered ERYPED 400 SUSR 400MG/5ML Not Covered ERYTHROCIN STEARATE TABS 250MG Not Covered ERYTHROMYCIN OINT 5MG/GM Covered ERYTHROMYCIN SOLN 2% Covered ERYTHROMYCIN CPEP 250MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 57 of 178 .3ML Not Covered QL EPIPEN-JR 2-PAK SOAJ 0.1%.15MG/0. 51MG Not Covered ENTRESTO TABS 97MG.5% Not Covered EPIFOAM FOAM 1%.3ML Covered QL EPINEPHRINE SOAJ 0.3ML Covered QL EPITOL TABS 200MG Not Covered EPIVIR TABS 150MG Not Covered EPIVIR TABS 300MG Not Covered EPIVIR SOLN 10MG/ML Not Covered EPIVIR HBV TABS 100MG Not Covered EPLERENONE TABS 25MG Not Covered EPLERENONE TABS 50MG Not Covered EPOGEN SOLN 2000UNIT/ML Covered EPOGEN SOLN 4000UNIT/ML Covered EPOGEN SOLN 3000UNIT/ML Covered EPOGEN SOLN 10000UNIT/ML Covered EPOGEN SOLN 20000UNIT/ML Covered EPZICOM TABS 600MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ENTECAVIR TABS 1MG Covered QL ENTRESTO TABS 24MG. 2. 26MG Not Covered ENTRESTO TABS 49MG.3MG/0.15MG/0. 2.3%.3MG/0. 103MG Not Covered ENULOSE SOLN 10GM/15ML Not Covered ENVARSUS XR TB24 1MG Not Covered ENVARSUS XR TB24 4MG Not Covered ENVARSUS XR TB24 0. 300MG Not Covered EQUETRO CP12 300MG Not Covered EQUETRO CP12 100MG Not Covered EQUETRO CP12 200MG Not Covered ERGOLOID MESYLATES TABS 1MG Not Covered ERIVEDGE CAPS 150MG Covered PA QL ERRIN TABS 0.

600MG/5ML Not Covered ESBRIET CAPS 267MG Not Covered ESCITALOPRAM OXALATE TABS 5MG Not Covered ESCITALOPRAM OXALATE TABS 10MG Not Covered ESCITALOPRAM OXALATE TABS 20MG Not Covered ESCITALOPRAM OXALATE SOLN 5MG/5ML Not Covered ESGIC TABS 325MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ERYTHROMYCIN GEL 2% Not Covered ERYTHROMYCIN BASE TABS 250MG Covered ERYTHROMYCIN BASE TABS 500MG Covered ERYTHROMYCIN ETHYLSUCCINATE TABS 400MG Covered ERYTHROMYCIN/BE NZOYL PEROXIDE GEL 5%.5MCG/24HR Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 58 of 178 .075MG/24HR Covered QL ESTRADIOL TABS 0. 2.25MG Covered ESTAZOLAM TABS 1MG Not Covered ESTAZOLAM TABS 2MG Not Covered ESTERIFIED ESTROGENS/METH YLTESTOSTERONE DS TABS 1. 0.1MG/24HR Covered QL ESTRADIOL PTWK 0.25MG. 1.05MG/24HR Covered QL ESTRADIOL PTWK 37.5MG Covered ESTERIFIED ESTROGENS/METH YLTESTOSTERONE HS TABS 0.3MG Not Covered ESTARYLLA TABS 35MCG. 40MG Covered QL AL ESOMEPRAZOLE STRONTIUM CPDR 49. 3% Covered QL ERYTHROMYCIN/SU LFISOXAZOLE SUSR 200MG/5ML.5MG Covered AL ESTRADIOL TABS 1MG Covered AL ESTRADIOL PTWK 0. 50MG.1MG/GM Covered QL ESTRADIOL TABS 2MG Covered AL ESTRADIOL PTWK 0.625MG. 40MG Covered QL AL ESGIC CAPS 325MG. 50MG.025MG/24HR Covered QL ESTRADIOL PTWK 0.25MG Covered ESTRACE CREA 0.

35MG/1.4MG/0.0375MG/24HR Covered QL ESTRADIOL PTTW 0.75MG Covered AL ESTROPIPATE TABS 1.06MG/24HR Covered QL ESTRADIOL PTTW 0.5MG Covered AL ESTROPIPATE TABS 3MG Covered AL ESZOPICLONE TABS 1MG Not Covered ESZOPICLONE TABS 2MG Not Covered ESZOPICLONE TABS 3MG Not Covered ETHAMBUTOL HCL TABS 100MG Covered ETHAMBUTOL HCL TABS 400MG Covered ETHOSUXIMIDE CAPS 250MG Not Covered ETHOSUXIMIDE SOLN 250MG/5ML Not Covered ETHYL CHLORIDE/MIST AERO 0 Not Covered ETIDRONATE DISODIUM TABS 400MG Covered ETIDRONATE DISODIUM TABS 200MG Covered ETODOLAC CAPS 300MG Not Covered ETODOLAC TABS 400MG Not Covered ETODOLAC CAPS 200MG Not Covered ETODOLAC TABS 500MG Not Covered ETODOLAC ER TB24 400MG Not Covered ETODOLAC ER TB24 500MG Not Covered ETODOLAC ER TB24 600MG Not Covered EVEKEO TABS 5MG Not Covered EVEKEO TABS 10MG Not Covered EVISTA TABS 60MG Not Covered EVOTAZ TABS 300MG.075MG/24HR Covered QL ESTRADIOL PTTW 0.05MG/24HR Covered QL ESTRADIOL PTWK 0.025MG/24HR Covered QL ESTRADIOL/NORET HINDRONE ACETATE TABS 0.74GM Covered ESTRING RING 2MG Not Covered ESTROPIPATE TABS 0. 150MG Not Covered EVZIO SOAJ 0.4ML Not Covered EXALGO T24A 8MG Not Covered EXALGO T24A 16MG Not Covered EXALGO T24A 12MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 59 of 178 .5MG Covered ESTRASORB EMUL 4.1MG Covered ESTRADIOL/NORET HINDRONE ACETATE TABS 1MG. 0.5MG.1MG/24HR Covered QL ESTRADIOL PTTW 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ESTRADIOL PTTW 0. 0.

160MG Not Covered EXFORGE HCT TABS 5MG. 320MG Not Covered EXFORGE TABS 5MG. 2. 160MG Not Covered EXFORGE HCT TABS 10MG. 25MG.5MG Not Covered EXELON CAPS 6MG Not Covered EXELON PT24 9. 320MG Not Covered EXFORGE HCT TABS 10MG. 160MG Not Covered EXFORGE TABS 5MG. 12.5MG.5MG/24HR Not Covered QL AL EXFORGE TABS 10MG.5MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 60 of 178 . 160MG Not Covered EXFORGE TABS 10MG.6MG/24HR Not Covered QL AL EXELON PT24 13.3MG Not Covered EXTINA FOAM 2% Not Covered FABB TABS 1MG.1MG Covered FAMCICLOVIR TABS 250MG Covered QL FAMCICLOVIR TABS 125MG Covered QL FAMCICLOVIR TABS 500MG Covered QL FAMOTIDINE TABS 40MG Covered FAMOTIDINE TABS 20MG Covered FANAPT TABS 2MG Not Covered FANAPT TABS 12MG Not Covered FANAPT TABS 4MG Not Covered FANAPT TABS 10MG Not Covered FANAPT TABS 8MG Not Covered FANAPT TABS 1MG Not Covered FANAPT TABS 6MG Not Covered FANAPT TITRATION PACK TABS 0 Not Covered FANTASY LUBRICATED MISC Covered QL FARXIGA TABS 10MG Covered PA QL FARXIGA TABS 5MG Covered PA QL FARYDAK CAPS 20MG Covered PA QL FARYDAK CAPS 15MG Covered PA QL FARYDAK CAPS 10MG Covered PA QL FAZACLO TBDP 12. 160MG Not Covered EXFORGE HCT TABS 5MG. 25MG Covered FABIOR FOAM 0.5MG. 12. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL EXALGO T24A 32MG Not Covered EXELON CAPS 4.3MG/24HR Not Covered QL AL EXELON CAPS 1.10% Not Covered FABRAZYME SOLR 35MG Not Covered FALMINA TABS 20MCG. 320MG Not Covered EXTAVIA KIT 0.2MG. 25MG. 25MG.5MG Not Covered EXELON CAPS 3MG Not Covered EXELON PT24 4. 160MG Not Covered EXFORGE HCT TABS 10MG. 0.

25MCG.5MG Not Covered FEMCON FE CHEW 35MCG.4MG Covered PA FEMHRT LOW DOSE TABS 2. 0 Covered 250MG.5MG Not Covered FEMRING RING 0.1MG/24HR Not Covered FEMRING RING 0. 1MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FAZACLO TBDP 200MG Not Covered FAZACLO TBDP 25MG Not Covered FAZACLO TBDP 150MG Not Covered FAZACLO TBDP 100MG Not Covered FC FEMALE CONDOM MISC Covered QL FC2 FEMALE CONDOM MISC Covered QL 120MG. FE 90 PLUS TABS 1MG. FE C TAB PLUS TABS 100MG Covered FEIBA NF SOLR 0 Not Covered FELBAMATE SUSP 600MG/5ML Not Covered FELBAMATE TABS 400MG Not Covered FELBAMATE TABS 600MG Not Covered FELBATOL TABS 600MG Not Covered FELBATOL TABS 400MG Not Covered FELBATOL SUSP 600MG/5ML Not Covered FELODIPINE ER TB24 10MG Covered QL FELODIPINE ER TB24 2. 25MCG. 0. 90MG. 12MCG. 50MG. FE C PLUS TABS 100MG Covered 250MG. 0. 0.5MG Covered QL FELODIPINE ER TB24 5MG Covered QL FEMARA TABS 2. 0.5MCG. 1MG.05MG/24HR Not Covered FENOFIBRATE TABS 54MG Covered QL FENOFIBRATE TABS 160MG Covered QL FENOFIBRATE CAPS 130MG Covered FENOFIBRATE CAPS 43MG Covered FENOFIBRATE TABS 48MG Covered QL FENOFIBRATE CAPS 150MG Covered FENOFIBRATE TABS 145MG Covered QL FENOFIBRATE CAPS 50MG Covered FENOFIBRATE MICRONIZED CAPS 134MG Covered QL FENOFIBRATE MICRONIZED CAPS 67MG Covered QL FENOFIBRATE MICRONIZED CAPS 200MG Covered QL FENOFIBRIC ACID TABS 35MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 61 of 178 .

5MCG/HR Not Covered FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 200MCG Not Covered FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 1600MCG Not Covered FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 400MCG Not Covered FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 600MCG Not Covered FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 800MCG Not Covered FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 1200MCG Not Covered FENTORA TABS 600MCG Not Covered FENTORA TABS 800MCG Not Covered FENTORA TABS 100MCG Not Covered FENTORA TABS 400MCG Not Covered FENTORA TABS 200MCG Not Covered FERAHEME SOLN 510MG/17ML Covered FERGON TABS 240MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 62 of 178 .5MCG/HR Not Covered FENTANYL PT72 50MCG/HR Covered QL FENTANYL PT72 87.5MCG/HR Not Covered FENTANYL PT72 62. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FENOFIBRIC ACID TABS 105MG Covered FENOFIBRIC ACID DR CPDR 45MG Covered QL FENOFIBRIC ACID DR CPDR 135MG Covered QL FENOGLIDE TABS 120MG Not Covered FENOGLIDE TABS 40MG Not Covered FENOPROFEN CALCIUM CAPS 400MG Covered FENOPROFEN CALCIUM TABS 600MG Covered FENTANYL PT72 12MCG/HR Covered QL FENTANYL PT72 25MCG/HR Covered QL FENTANYL PT72 100MCG/HR Covered QL FENTANYL PT72 75MCG/HR Covered QL FENTANYL PT72 37.

5MG. FERREX 28 TABS 1MG. 12MCG. 81MG. 0. 50MG. 50MG. FERIVA 21/7 TABS 150MG. 90MG Covered 120MG. 50MG. 400MCG. 60MG. 75MG. 150MG Covered FERRIPROX TABS 500MG Not Covered FERRLECIT SOLN 12. 100MG.3MG. 70MG. 1MG. 10MCG. 75MG. 0. 10MCG. 0. 12MCG. 1MG.9MG.5MG/ML Covered 10MG. 6MG. 300MCG. 15MCG. FERREX 150 PLUS CAPS 0 Covered 140MG. 10MG. 6. 150MG.8MG. 12MCG. 1MG. 1.8MG. 1MG. 10MG Covered 175MG. 30MG. 90MG Covered FERREX 150 CAPS 150MG Covered FERREX 150 FORTE CAPS 25MCG.2MG Covered 60MG. FERIVAFA CAPS 110MG. 50MG. FERROGELS FORTE CAPS 1MG Covered FERROUS GLUCONATE TABS 324MG Covered FERROUS SULFATE TABS 325MG Covered FERROUS SULFATE LIQD 220MG/5ML Covered AL FERROUS SULFATE SOLN 15MG/ML Covered AL FERROUS SULFATE ELIX 220MG/5ML Covered AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 63 of 178 . 150MG Covered FERREX 150 FORTE 60MG. 12MCG. 25MCG. FERROCITE PLUS TABS 200MG. 460MG. 0. FERIVA CAPS 25MG. 110MG. 175MG. 12MCG. 324MG. 50MG Covered 50MG. 1. 0 Covered 75MG. 0. 240MG Covered FEROSUL ELIX 220MG/5ML Covered AL 120MG. FEROCON CAPS 0. 0. PLUS CAPS 50MG. 18. 0. 5MG. 300MCG. 15MCG. 50MG. 0 Covered 600MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 152MG. FERRALET 90 TABS 1MG. FERRAPLUS 90 TABS 1MG.5MG.8MG. 1MG. 0.

2GM/237ML.10% Covered FLAVOXATE HCL TABS 100MG Covered FLECAINIDE ACETATE TABS 150MG Covered FLECAINIDE ACETATE TABS 100MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 64 of 178 . 40MG. 0.15GM/237ML. 50MG.15GM/237ML. 40MG Not Covered 300MG. 240MG Not Covered FIBRICOR TABS 35MG Not Covered FIBRICOR TABS 105MG Not Covered FINACEA GEL 15% Not Covered FINASTERIDE TABS 5MG Covered QL FIORICET CAPS 300MG. FIORICET/CODEINE CAPS 30MG Not Covered FIRAZYR SOLN 30MG/3ML Not Covered FIRST- LANSOPRAZOLE SUSP 3MG/ML Covered 3.6GM/237ML. 1.315GM/237ML Not Covered FIRST- OMEPRAZOLE SUSP 2MG/ML Covered FIRST- TESTOSTERONE OINT 2% Not Covered FIRST- TESTOSTERONE MC COMPOUNDING KIT CREA 2% Not Covered FLAGYL ER TB24 750MG Not Covered FLAREX SUSP 0. 50MG. BLM SUSP 0. FIRST-MOUTHWASH 3. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FERROUS SULFATE SYRP 300MG/5ML Covered AL FETZIMA CP24 80MG Not Covered FETZIMA CP24 120MG Not Covered FETZIMA CP24 20MG Not Covered FETZIMA CP24 40MG Not Covered FETZIMA TITRATION PACK C4PK 0 Not Covered FEXOFENADINE HCL TABS 60MG Covered FEXOFENADINE HCL/PSEUDOEPHED RINE HCL ER TB24 180MG.

3MG. 9. 5MG Not Covered FLOVENT HFA AERO 220MCG/ACT Not Covered FLOVENT HFA AERO 44MCG/ACT Not Covered FLOVENT HFA AERO 110MCG/ACT Not Covered FLOWTUSS SOLN 200MG/5ML. 15MG. 1.5MG.03% Covered FLUOCINOLONE ACETONIDE CREA 0.25MG/ML.8MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FLECAINIDE ACETATE TABS 50MG Covered FLECTOR PTCH 1.03% Not Covered FLUOCINOLONE ACETONIDE CREA 0.5GM/59ML Covered FLEXBUMIN SOLN 25% Not Covered FLOMAX CAPS 0. 40MCG.5GM/59ML.1MG Covered FLULAVAL QUADRIVALENT 2015-2016 SUSP 0 Covered AL FLUMIST QUADRIVALENT SUSP 0 Covered AL FLUNISOLIDE SOLN 0. 0.03% Not Covered FLUOCINOLONE ACETONIDE SOLN 0.5MG. 162MCG.01% Not Covered FLUOCINOLONE ACETONIDE OINT 0. 1MG.4MG Not Covered FLORIVA LIQD 0. FLORIVA CHEW 20UNIT. 400UNIT/ML Not Covered 75MG.01% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 65 of 178 . 1.30% Not Covered FLEET PEDIATRIC ENEM 3. 100MCG. 2. 2000UNIT. 600UNIT. 6MCG. 1.01% Not Covered FLUOCINOLONE ACETONIDE OIL 0.5MG/5ML Not Covered FLUBLOK 2015-2016 SOLN 0 Not Covered FLUCELVAX 2015- 2016 SUSY 0 Not Covered FLUCONAZOLE SUSR 40MG/ML Covered AL FLUCONAZOLE SUSR 10MG/ML Covered AL FLUCONAZOLE TABS 200MG Covered FLUCONAZOLE TABS 150MG Covered FLUCONAZOLE TABS 50MG Covered FLUCONAZOLE TABS 100MG Covered FLUDROCORTISON E ACETATE TABS 0.

01% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 66 of 178 .10% Not Covered FLUOCINONIDE CREA 0.03% Covered FLUTICASONE PROPIONATE SUSP 50MCG/ACT Covered FLUTICASONE PROPIONATE OINT 0.05% Covered QL FLUORIDE CHEW 2.10% Covered AL FLUOROMETHOLON E SUSP 0.05% Covered FLUOCINONIDE-E CREA 0.50% Covered QL FLUOROURACIL CREA 5% Covered FLUOXETINE HCL CAPS 10MG Not Covered FLUOXETINE HCL SOLN 20MG/5ML Not Covered FLUOXETINE HCL CAPS 20MG Not Covered FLUOXETINE HCL TABS 10MG Not Covered FLUOXETINE HCL CAPS 40MG Not Covered FLUOXETINE HCL TABS 20MG Not Covered FLUPHENAZINE HCL TABS 10MG Not Covered FLUPHENAZINE HCL TABS 2.01% Not Covered FLUOCINOLONE ACETONIDE SCALP OIL 0.10% Covered QL FLUOROURACIL SOLN 2% Not Covered FLUOROURACIL SOLN 5% Not Covered FLUOROURACIL CREA 0.2MG Covered QL AL FLUORIDE CHEW 1.5MG Not Covered FLUPHENAZINE HCL TABS 5MG Not Covered FLURAZEPAM HCL CAPS 30MG Not Covered FLURAZEPAM HCL CAPS 15MG Not Covered FLURBIPROFEN TABS 50MG Covered FLURBIPROFEN TABS 100MG Not Covered FLURBIPROFEN SODIUM SOLN 0.05% Not Covered FLUOCINONIDE OINT 0.05% Covered QL FLUOCINONIDE SOLN 0.1MG Covered QL AL FLUORIDEX DAILY DEFENSE ENHANCED WHITENING GEL 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FLUOCINOLONE ACETONIDE BODY OIL 0.01% Not Covered FLUOCINONIDE GEL 0.05% Covered QL FLUOCINONIDE CREA 0.

0. 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FLUTICASONE PROPIONATE CREA 0.10% Covered FML FORTE SUSP 0.05% Not Covered FLUVASTATIN CAPS 40MG Covered QL FLUVASTATIN CAPS 20MG Covered QL FLUVIRIN 2015-2016 SUSP 0 Covered AL FLUVOXAMINE MALEATE TABS 100MG Not Covered FLUVOXAMINE MALEATE TABS 50MG Not Covered FLUVOXAMINE MALEATE TABS 25MG Not Covered FLUVOXAMINE MALEATE ER CP24 100MG Not Covered FLUVOXAMINE MALEATE ER CP24 150MG Not Covered FLUZONE HIGH- DOSE PF 2013-2014 SUSY 0 Covered AL FLUZONE HIGH- DOSE PF 2015-2016 SUSY 0 Covered AL FLUZONE INTRADERMAL SUPN 0 Not Covered FLUZONE PEDIATRIC PF 2013- 2014 SUSY 0 Not Covered FLUZONE PF 2013- 2014 SUSP 0 Covered AL FLUZONE QUADRIVALENT 2014-2015 SUSP 0 Not Covered FLUZONE QUADRIVALENT 2015-2016 SUSP 0 Covered QL AL FLUZONE SPLIT 2013-2014 SUSP 0 Covered AL FLUZONE SPLIT 2015-2016 SUSP 0 Covered QL AL FML OINT 0.25% Covered QL 120MG. FOCALGIN DSS TABS 1MG. 0 Covered FOCALIN XR CP24 5MG Not Covered FOCALIN XR CP24 15MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 67 of 178 . 12MCG. 90MG.

2MG. 1. 25MG Covered FOLBIC RF TABS 2MG.5MG Covered 210MG. FOLET ONE CAPS 15UNIT.5MG. 5MG. 400UNIT. 12MCG. 62. 300UNIT. 1.5MG. 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FOCALIN XR CP24 10MG Not Covered FOCALIN XR CP24 20MG Not Covered FOCALIN XR CP24 25MG Not Covered FOCALIN XR CP24 30MG Not Covered FOCALIN XR CP24 40MG Not Covered FOCALIN XR CP24 35MG Not Covered FOLBEE TABS 1MG. 25MG Covered FOLIC ACID TABS 1MG Covered QL 40MG. FOLET DHA THPK 18UNIT. 20MG. 10MCG.13MG. 1. 20MG Not Covered 500MG. 20MG. 50MG. 20MG. 40MG. 62. 300MCG.5MG Covered 60MG. 2.1MG. 350MG. FOLGARD OS TABS 1.5MG.13MG.5MG. 0. 1MG. 1MG. 38MG.5MG.4MG. 3. 25MG Covered FORADIL AEROLIZER CAPS 12MCG Covered QL FORFIVO XL TB24 450MG Not Covered FORTAMET TB24 500MG Not Covered FORTAMET TB24 1000MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 68 of 178 .5MG. 1.2MG. 1. 2. 250UNIT. 20MG. 3MG. 18MG. 3MG. 50MG. 0. 38MG. 2. 30MG. 0. 7MG. 25MG Covered 60MG.2MG. 35MG Covered FOLTX TABS 2MG. 225MG.5MG. 25MG Covered FOLTANX TABS 3MG.5MG.5MG. 50MG.2 TABS 0. 62. 1MG. 15MG. 0.5MG. 30MG. 300MCG. 10MG. 1MG. FOLIVANE-PLUS CAPS 5MG. 10MG Not Covered 0. 1. 300MCG. 65MCG. 25MG. 2. FOLBEE PLUS CZ TABS 25MG Covered FOLBIC TABS 2MG.5MG Covered FOLGARD RX TABS 1MG. 25MG. FOLIVANE-F CAPS 62. 5MG. 10MG. 2700UNIT.5MG. 12. 25MG Covered 120MG. 100MG. 5MG Covered FOLPLEX 2. 0. 2MG. FOLBEE PLUS TABS 1. 1MG. 15MCG. 250MCG.

5MG. 5MG. 50MG. 25MG. FORTAVIT CAPS 150UNIT. 25MG. 2. 25MG. 25MG.5MG. 75MCG. 200MCG.5MG Not Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 69 of 178 .4ML Covered PA FORTESTA GEL 10MG/ACT Not Covered FORTICAL SOLN 200UNIT/ACT Not Covered FOSAMAX TABS 70MG Not Covered FOSINOPRIL SODIUM TABS 40MG Covered QL FOSINOPRIL SODIUM TABS 10MG Covered QL FOSINOPRIL SODIUM TABS 20MG Covered QL FOSINOPRIL SODIUM/HYDROCHL OROTHIAZIDE TABS 10MG.5MG. 15MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 150MG. 1. 12. 40MG. 1MG. 25MCG. 25MCG. 67.5MG. 25MG. 12. 100MG.5MG Not Covered FOSINOPRIL SODIUM/HYDROCHL OROTHIAZIDE TABS 20MG. 8MG Covered FORTEO SOLN 600MCG/2. 25MG. 25MCG. 5000UNIT. 5MCG. 13MCG. 200UNIT. 0. 25MG. 1MG. 7. 0. 1MG. 2MCG.5MG Not Covered FOSRENOL CHEW 500MG Covered FOSRENOL CHEW 1000MG Covered FOSRENOL CHEW 750MG Covered FOSRENOL PACK 750MG Covered FOSRENOL PACK 1000MG Covered FREEDOM DERMA-D CREA Not Covered FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS STRP 0 Covered QL FREESTYLE LITE TEST STRIPS STRP 0 Covered QL FREESTYLE TEST STRIPS STRP 0 Covered QL FROVA TABS 2. 15MG. 50MCG. 5MG. 25MG.

10MG. 1250MCG. 65MG. FUSION PLUS CAPS 3MG. 12MCG.3ML Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 70 of 178 . 65MG. 10MG. 300MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL FULYZAQ TBEC 125MG Not Covered FURADANTIN SUSP 25MG/5ML Not Covered FUROSEMIDE SOLN 10MG/ML Covered AL FUROSEMIDE TABS 40MG Covered QL FUROSEMIDE SOLN 8MG/ML Covered AL FUROSEMIDE TABS 20MG Covered QL FUROSEMIDE TABS 80MG Covered QL 75MG. 30MG. 6MG. 2MG Covered FYCOMPA TABS 2MG Not Covered FYCOMPA TABS 12MG Not Covered FYCOMPA TABS 6MG Not Covered FYCOMPA TABS 4MG Not Covered FYCOMPA TABS 10MG Not Covered FYCOMPA TABS 8MG Not Covered GABAPENTIN CAPS 300MG Not Covered GABAPENTIN CAPS 400MG Not Covered GABAPENTIN TABS 600MG Not Covered GABAPENTIN SOLN 250MG/5ML Not Covered GABAPENTIN CAPS 100MG Not Covered GABAPENTIN TABS 800MG Not Covered GABITRIL TABS 2MG Not Covered GABITRIL TABS 4MG Not Covered GABITRIL TABS 12MG Not Covered GABITRIL TABS 16MG Not Covered GALANTAMINE HYDROBROMIDE CP24 24MG Not Covered GALANTAMINE HYDROBROMIDE TABS 8MG Not Covered GALANTAMINE HYDROBROMIDE SOLN 4MG/ML Not Covered GALANTAMINE HYDROBROMIDE TABS 4MG Not Covered GALANTAMINE HYDROBROMIDE CP24 16MG Not Covered GALANTAMINE HYDROBROMIDE TABS 12MG Not Covered GALANTAMINE HYDROBROMIDE CP24 8MG Not Covered GARDASIL SUSP 0 Covered QL AL GARDASIL 9 SUSP 0 Covered QL AL GAS RELIEF SUSP 20MG/0.

1. GAVILYTE-C SOLR 5.4MG Covered GILDESS 1. GAVILYTE-H KIT 2.6GM Covered GAVILYTE.30% Covered GEODON CAPS 80MG Not Covered GEODON CAPS 20MG Not Covered GEODON CAPS 40MG Not Covered GEODON SOLR 20MG Not Covered GEODON CAPS 60MG Not Covered GIANVI TABS 3MG. 1.86GM. 1MG Covered GILDESS 24 FE TABS 20MCG.74GM.5/30 TABS 30MCG. GINSENG EDGE CAPS 125MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 71 of 178 . 2.84GM. 5. 420GM. 0.72GM. 0.72GM.5MG Covered GILDESS 1/20 TABS 20MCG.5MG Covered GILDESS FE 1/20 TABS 20MCG. 6. 75MG.97GM. 210GM.74GM Covered 5MG. 75MG. N/FLAVOR PACK SOLR 11. 0. 22.2GM Covered GEMFIBROZIL TABS 600MG Covered QL GENAC TABS 60MG.10% Covered GENTAMICIN SULFATE CREA 0.48GM.10% Covered GENTAMICIN SULFATE OINT 0. 1MG Covered GILDESS FE 1.8MG Covered PA GENERLAC SOLN 10GM/15ML Not Covered GENGRAF SOLN 100MG/ML Not Covered GENGRAF CAPS 25MG Not Covered GENGRAF CAPS 100MG Not Covered GENTAMICIN SULFATE SOLN 0.74GM. 2.5MG Covered GILOTRIF TABS 40MG Not Covered GILOTRIF TABS 20MG Not Covered GILOTRIF TABS 30MG Not Covered 25MG. 6. 1MG Covered GILENYA CAPS 0. 22. 75MG.98GM. 2.86GM.72GM Covered 236GM.5MG Not Covered GENERESS FE CHEW 25MCG. 0. 75MG.02MG Covered GIAZO TABS 1.5/30 TABS 30MCG. GAVILYTE-G SOLR 5. 10MG. 50MG. 1. 5. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL GAS-X PREVENTION CAPS 0 Not Covered GATTEX KIT 5MG Not Covered 240GM.30% Covered GENTAMICIN SULFATE OINT 0.1GM Not Covered GILDAGIA TABS 35MCG.

25MG Covered QL GLYBURIDE MICRONIZED TABS 6MG Covered QL GLYBURIDE MICRONIZED TABS 3MG Covered QL GLYBURIDE MICRONIZED TABS 1.5MG.5MG Covered QL GLYBURIDE/METFO RMIN HCL TABS 2.25MG.5MG. 250MG Covered GLIPIZIDE/METFOR MIN HCL TABS 2.5MG Covered QL GLIPIZIDE ER TB24 10MG Covered QL GLIPIZIDE XL TB24 10MG Covered QL GLIPIZIDE XL TB24 2.25MG. 500MG Not Covered GLUCOVANCE TABS 2. 500MG Covered GLUCAGEN HYPOKIT SOLR 1MG Covered GLUCAGON EMERGENCY KIT KIT 1MG Covered GLUCAGON HCL DIAGNOSTIC SOLR 1MG Not Covered GLUCOVANCE TABS 1.5MG Covered QL GLYBURIDE TABS 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL GLASSIA SOLN 1000MG/50ML Not Covered GLATOPA SOSY 20MG/ML Covered PA GLEEVEC TABS 100MG Not Covered GLEEVEC TABS 400MG Not Covered GLIMEPIRIDE TABS 4MG Covered QL GLIMEPIRIDE TABS 2MG Covered QL GLIMEPIRIDE TABS 1MG Covered QL GLIPIZIDE TABS 10MG Covered QL GLIPIZIDE TABS 5MG Covered QL GLIPIZIDE ER TB24 5MG Covered QL GLIPIZIDE ER TB24 2.5MG. 500MG Covered QL GLYBURIDE/METFO RMIN HCL TABS 1. 500MG Not Covered GLUMETZA TB24 500MG Not Covered GLYBURIDE TABS 5MG Covered QL GLYBURIDE TABS 2. 250MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 72 of 178 . 250MG Not Covered GLUCOVANCE TABS 5MG.5MG.5MG Covered QL GLIPIZIDE XL TB24 5MG Covered QL GLIPIZIDE/METFOR MIN HCL TABS 2. 500MG Covered GLIPIZIDE/METFOR MIN HCL TABS 5MG.

GOLYTELY SOLR 5.86GM. ACTHAR GEL 80UNIT/ML Not Covered HALAVEN SOLN 1MG/2ML Not Covered HALOBETASOL PROPIONATE OINT 0.12MG/GM Not Covered GRASTEK SUBL 2800BAU Not Covered GRIFULVIN V TABS 500MG Not Covered GRISEOFULVIN MICROSIZE SUSP 125MG/5ML Covered GRISEOFULVIN MICROSIZE TABS 500MG Not Covered GRIS-PEG TABS 250MG Not Covered GRIS-PEG TABS 125MG Not Covered GUANFACINE ER TB24 1MG Not Covered GUANFACINE ER TB24 2MG Not Covered GUANFACINE ER TB24 3MG Not Covered GUANFACINE ER TB24 4MG Not Covered GUANFACINE HCL TABS 2MG Covered QL GUANFACINE HCL TABS 1MG Covered QL H.5ML Not Covered 788MG/GM.53GM.05% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 73 of 178 .1GM. 2.74GM Covered 227.5GM Covered GOODSENSE ALL DAY ALLERGY TABS 10MG Covered GRALISE TABS 300MG Not Covered GRALISE TABS 600MG Not Covered GRALISE STARTER MISC 0 Not Covered GRANISETRON HCL TABS 1MG Covered QL GRANIX SOSY 480MCG/0. 5MG Not Covered QL 236GM. 2.82GM.8ML Not Covered GRANIX SOSY 300MCG/0.97GM.05% Covered HALOBETASOL PROPIONATE CREA 0.36GM. 6. 500MG Covered QL GLYCOPHOS SOLN 1MMOLE/ML Covered GLYCOPYRROLATE TABS 2MG Covered GLYCOPYRROLATE TABS 1MG Covered GLYXAMBI TABS 10MG. 87MG/GM. GRANULEX AERS 0. 6. 5MG Not Covered QL GLYXAMBI TABS 25MG. 22. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL GLYBURIDE/METFO RMIN HCL TABS 5MG. 21. GOLYTELY SOLR 5.74GM.P.

5MG. 1. S TABS 200MG. 1MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 74 of 178 . 6MG. 15MCG.5MCG Covered HECTOROL SOLN 2MCG/ML Covered HECTOROL SOLN 4MCG/2ML Covered HECTOROL CAPS 1MCG Covered HELIXATE FS KIT 2000UNIT Not Covered HEMANGEOL SOLN 4. 324MG. 200MG. 2MG/5ML. FORTE CAPS 1MG Covered 25MCG/5ML. 150MCG. 10MCG. 5MG. 10MG. 0. 50MG.2MG Covered 250MG. 5MG/5ML. 30UNIT Covered HEMETAB TABS 25MCG. 1MG. 6. HEMATOGEN CAPS 100MG Covered 250MG. 18. HEMAX TABS 150MG.3MG/5ML Covered 500MG. HEMATOGEN FA CAPS 1MG Covered HEMATOGEN 60MG. HEMATRON LIQD 10MG/5ML. 200MG. 3MG. 150MCG. 10MG/5ML.8MG. 1MG. 22MG Covered 10MG.3MG. 6MG. 30MG. 100MG/5ML.5ML Covered QL AL HEATHER TABS 0. 30UNIT Covered 500MG. 2MG/5ML. 50MG. 2.3MG. 1MG. HEMOCYTE PLUS CAPS 200MG. 10MG. 10MCG. 15MCG.9MG. 30MG. 10MCG. 460MG. 6MG. 3MG.8MG.35MG Covered HECTOROL CAPS 0.2MG Covered HEMOCYTE-F TABS 324MG. 60MCG. VITAMINS/MINERAL 1.5MG Not Covered HALOPERIDOL TABS 2MG Not Covered HALOPERIDOL TABS 5MG Not Covered HALOPERIDOL TABS 1MG Not Covered HARVONI TABS 90MG.8MG/5ML. 0. 60MCG. 6. 18. 400MG Not Covered HAVRIX SUSP 1440ELU/ML Covered QL AL HAVRIX SUSP 720ELU/0.9MG. HEMATRON-AF TABS 150MG.10% Not Covered HALOPERIDOL TABS 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL HALOG CREA 0. HEMATINIC PLUS 106MG.10% Not Covered HALOG OINT 0. 0. 1MG. 10MG/5ML. 1MG.5MCG Covered HECTOROL CAPS 2.28MG/ML Covered AL 10MG.

50UNIT/ML Covered HUMALOG MIX 50/50 KWIKPEN SUPN 50UNIT/ML. 70UNIT/ML Covered HUMULIN 70/30 PEN SUPN 30UNIT/ML.5MG/5ML Not Covered HOMATROPAIRE SOLN 5% Not Covered HORIZANT TBCR 600MG Not Covered HORIZANT TBCR 300MG Not Covered HUMALOG SOLN 100UNIT/ML Covered HUMALOG SOCT 100UNIT/ML Covered QL HUMALOG KWIKPEN SOPN 100UNIT/ML Covered QL HUMALOG KWIKPEN SOPN 200UNIT/ML Covered HUMALOG MIX 50/50 SUSP 50UNIT/ML.8ML Covered PA HUMIRA PEN- CROHNS DISEASESTARTER PNKT 40MG/0.5MG/15ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 75 of 178 .8ML Covered PA HUMULIN 70/30 SUSP 30UNIT/ML. 7. HISTEX-AC SYRP 2. 75UNIT/ML Covered QL HUMATE-P SOLR 250UNIT.25MG Covered QL HYCAMTIN CAPS 1MG Covered QL HYCET SOLN 325MG/15ML. 10MG/5ML.8ML Covered PA HUMIRA PEN PNKT 40MG/0. 600UNIT Not Covered HUMIRA PSKT 40MG/0. 70UNIT/ML Covered QL HUMULIN N SUSP 100UNIT/ML Covered HUMULIN N KWIKPEN SUPN 100UNIT/ML Covered QL HUMULIN R SOLN 100UNIT/ML Covered HUMULIN R U-500 (CONCENTRATED) SOLN 500UNIT/ML Covered HYCAMTIN CAPS 0. 75UNIT/ML Covered HUMALOG MIX 75/25 KWIKPEN SUPN 25UNIT/ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL HEMOFIL M SOLR 401-800 UNIT Not Covered HEPARIN SODIUM SOLN 1000UNIT/ML Not Covered HEPARIN SODIUM SOLN 5000UNIT/ML Covered HEPARIN SODIUM SOLN 10000UNIT/ML Covered HEPSERA TABS 10MG Not Covered HETLIOZ CAPS 20MG Not Covered HEXALEN CAPS 50MG Covered 10MG/5ML. 50UNIT/ML Covered HUMALOG MIX 75/25 SUSP 25UNIT/ML.

7. 10MG Not Covered HYDROCODONE BITARTRATE/ACETA MINOPHEN SOLN 325MG/15ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 200MG/5ML.5MG Not Covered HYDROCODONE BITARTRATE/ACETA MINOPHEN SOLN 217MG/10ML.5MG Covered QL HYDROCHLOROTHI AZIDE TABS 25MG Covered QL HYDROCHLOROTHI AZIDE TABS 50MG Covered QL HYDROCHLOROTHI AZIDE TABS 12. 5MG/10ML Covered QL HYDROCODONE BITARTRATE/ACETA MINOPHEN SOLN 108MG/5ML. 2. 10MG Covered HYDROCODONE BITARTRATE/CHLOR PHENIRAMINE 4MG/5ML. MALEATE/PSE SOLN 60MG/5ML Not Covered HYDROCODONE POLISTIREX/CHLOR PHENIRAMINE POLISTIREX SUER 8MG/5ML. 5MG/5ML. 7.5MG/15ML Covered QL HYDROCODONE BITARTRATE/ACETA MINOPHEN TABS 300MG. 2.5MG/5ML. 5MG Not Covered HYDROCODONE BITARTRATE/ACETA MINOPHEN TABS 300MG. 10MG/5ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 76 of 178 .5MG Covered HYDROCODONE BITARTRATE/ACETA MINOPHEN TABS 300MG.5MG/5ML Covered QL HYDROCODONE BITARTRATE/ACETA MINOPHEN TABS 750MG. HYCOFENIX SOLN 30MG/5ML Not Covered HYDRALAZINE HCL TABS 25MG Covered QL HYDRALAZINE HCL TABS 10MG Covered QL HYDRALAZINE HCL TABS 50MG Covered QL HYDRALAZINE HCL TABS 100MG Covered QL HYDRALAZINE HCL SOLN 20MG/ML HYDREA CAPS 500MG Not Covered HYDROCHLOROTHI AZIDE CAPS 12.

10MG Covered QL HYDROCODONE/AC ETAMINOPHEN TABS 500MG. 7.5MG Covered HYDROCODONE/AC ETAMINOPHEN TABS 325MG.5MG/15ML Covered QL HYDROCODONE/IBU PROFEN TABS 7. 5MG Covered QL HYDROCODONE/AC ETAMINOPHEN TABS 500MG.5MG.50% Covered HYDROCORTISONE TABS 10MG Covered HYDROCORTISONE OINT 1% Covered HYDROCORTISONE LOTN 2. 10MG Covered HYDROCODONE/AC ETAMINOPHEN SOLN 500MG/15ML. 7.5MG Covered HYDROCODONE/AC ETAMINOPHEN TABS 325MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL HYDROCODONE/AC ETAMINOPHEN TABS 750MG. 200MG Not Covered HYDROCORTISONE TABS 20MG Covered HYDROCORTISONE OINT 2. 10MG Covered HYDROCODONE/AC ETAMINOPHEN TABS 500MG. 7. 7.50% Covered HYDROCORTISONE TABS 5MG Covered HYDROCORTISONE ENEM 100MG/60ML Not Covered HYDROCORTISONE LOTN 1% Covered HYDROCORTISONE ACETATE SUPP 25MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 77 of 178 .5MG Covered HYDROCODONE/AC ETAMINOPHEN TABS 650MG. 5MG Covered HYDROCODONE/AC ETAMINOPHEN TABS 325MG.50% Covered HYDROCORTISONE CREA 1% Covered HYDROCORTISONE CREA 2. 7.5MG Covered QL HYDROCODONE/AC ETAMINOPHEN TABS 650MG.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL HYDROCORTISONE ACETATE/PRAMOXI NE CREA 2. 1% Covered HYDROFERA BLUE FOAM DRESSING PADS Not Covered HYDROMORPHONE HCL TABS 8MG Not Covered HYDROMORPHONE HCL TABS 4MG Covered QL HYDROMORPHONE HCL TABS 2MG Covered QL HYDROMORPHONE HCL SUPP 3MG Covered QL HYDROMORPHONE HCL LIQD 1MG/ML Covered QL HYDROMORPHONE HCL ER T24A 12MG Not Covered HYDROMORPHONE HCL ER T24A 16MG Not Covered HYDROMORPHONE HCL ER T24A 8MG Not Covered HYDROMORPHONE HCL ER T24A 32MG Not Covered HYDROQUINONE CREA 4% Not Covered HYDROXYCHLOROQ UINE SULFATE TABS 200MG Covered HYDROXYUREA CAPS 500MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 78 of 178 .10% Not Covered HYDROCORTISONE BUTYRATE OINT 0.20% Not Covered HYDROCORTISONE/ ACETIC ACID SOLN 2%.10% Not Covered HYDROCORTISONE BUTYRATE SOLN 0. 1% Not Covered HYDROCORTISONE ACETATE/PRAMOXI NE CREA 1%.5%. 1% Not Covered HYDROCORTISONE BUTYRATE CREA 0.20% Covered HYDROCORTISONE VALERATE OINT 0.10% Not Covered HYDROCORTISONE VALERATE CREA 0.

1% Covered HYSINGLA ER T24A 30MG Not Covered HYSINGLA ER T24A 120MG Not Covered HYSINGLA ER T24A 40MG Not Covered HYSINGLA ER T24A 100MG Not Covered HYSINGLA ER T24A 20MG Not Covered HYSINGLA ER T24A 60MG Not Covered HYSINGLA ER T24A 80MG Not Covered IBANDRONATE SODIUM TABS 150MG Covered IBRANCE CAPS 100MG Not Covered IBRANCE CAPS 75MG Not Covered IBRANCE CAPS 125MG Not Covered IBUPROFEN TABS 800MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 79 of 178 .125MG/5ML Covered AL HYOSCYAMINE SULFATE SUBL 0.375MG Covered AL HYPERCARE SOLN 20% Not Covered HYPER-SAL NEBU 7% Not Covered HYPOLANCE AST LANCING KIT KIT Covered HYPOTEARS SOLN 1%. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL HYDROXYZINE HCL TABS 50MG Covered AL HYDROXYZINE HCL SYRP 10MG/5ML Covered AL HYDROXYZINE HCL TABS 25MG Covered AL HYDROXYZINE HCL TABS 10MG Covered AL HYDROXYZINE PAMOATE CAPS 50MG Covered AL HYDROXYZINE PAMOATE CAPS 25MG Covered AL HYDROXYZINE PAMOATE CAPS 100MG Covered AL HYOMAX-SL SUBL 0.125MG Covered HYOSCYAMINE SULFATE ELIX 0.125MG Covered AL HYOSCYAMINE SULFATE TBDP 0.125MG Covered AL HYOSCYAMINE SULFATE SOLN 0.125MG/ML Covered AL HYOSCYAMINE SULFATE TABS 0.125MG Covered AL HYOSCYAMINE SULFATE ER TB12 0.

3. ICAR-C PLUS TABS 100MG Covered ICLUSIG TABS 15MG Not Covered ICLUSIG TABS 45MG Not Covered IFEREX 150 FORTE CAPS 25MCG. 400UNIT.4MG. 25MCG. 30MG. 20MG. 25MG Covered QL AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 80 of 178 .19MG Not Covered IMBRUVICA CAPS 140MG Not Covered IMIPRAMINE HCL TABS 10MG Not Covered IMIPRAMINE HCL TABS 25MG Not Covered IMIQUIMOD CREA 5% Covered IMITREX SOLN 20MG/ACT Not Covered IMITREX SOLN 5MG/ACT Not Covered IMITREX TABS 25MG Not Covered IMITREX SOLN 6MG/0.V. 12MCG. INATAL ADVANCE TABS 30UNIT. 1MG.5UNIT/ML Covered AL 120MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL IBUPROFEN TABS 600MG Covered IBUPROFEN TABS 400MG Covered IBUPROFEN SUSP 100MG/5ML Covered IBUPROFEN TABS 200MG Covered 250MG.) INJ 2. 20MG. 150MG Covered ILARIS SOLR 180MG Not Covered ILEVRO SUSP 0. 200MG. 50MG.5ML Not Covered IMITREX STATDOSE REFILL SOCT 6MG/0. 2MG.5ML Not Covered IMITREX STATDOSE SYSTEM SOAJ 6MG/0.5ML Not Covered IMITREX STATDOSE SYSTEM SOAJ 4MG/0.5ML Not Covered IMITREX TABS 100MG Not Covered IMITREX TABS 50MG Not Covered IMITREX STATDOSE REFILL SOCT 4MG/0. 90MG. 1MG.C. 2700UNIT.D. 3MG. 1MG.5ML Not Covered IMOVAX RABIES (H.30% Not Covered ILUVIEN IMPL 0.

INTEGRA F CAPS 3MG. 20MG. 200MG. 20MG. 2700UNIT.5MG Covered QL INDAPAMIDE TABS 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 120MG. 10UNIT/5ML. 150MCG/5ML.5MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 81 of 178 .5MG. 5MCG/5ML. INATAL GT TABS 10UNIT.4MG. 60MCG/5ML. 62. 29MG. 90MG. 0.25MG Covered QL INDOMETHACIN CAPS 50MG Covered AL INDOMETHACIN CAPS 25MG Covered AL INDOMETHACIN ER CPCR 75MG Covered AL 104MG. 200MG. 30MCG. 50MG. 20MG. 90MG. 200UNIT/5ML. 265MG. 6MG/5ML. 3MG. 50MG. INATAL ULTRA TABS 30UNIT. 3MG. 15MG/5ML.5MCG/INH Covered AL INDAPAMIDE TABS 2. 40MG/5ML. INFUVITE ADULT INJ 3300UNIT/5ML Covered INJECTAFER SOLN 750MG/15ML Covered INLYTA TABS 1MG Not Covered INLYTA TABS 5MG Not Covered INNOPRAN XL CP24 80MG Not Covered INNOPRAN XL CP24 120MG Not Covered INSPRA TABS 25MG Not Covered INSPRA TABS 50MG Not Covered 40MG. 25MG Covered QL AL INCIVEK TABS 375MG Not Covered INCRUSE ELLIPTA AEPB 62. 2MG. 3. 1000MCG. 600MCG/5ML. 6MG/5ML. 400UNIT. 15MG Covered QL AL 120MG. 0. 2700UNIT. 3. INFANATE BALANCE CAPS 30UNIT Not Covered INFED SOLN 50MG/ML Covered 200MG/5ML. 50MG. 12MCG. 20MG. 30MG. 12MCG. 1MG. 400UNIT. 1MG. 25MG. 62. 3. 150MCG. 400UNIT. 1MG.4MG.6MG/5ML. 6MG. 2MG.

75ML Not Covered INVEGA TRINZA SUSP 819MG/2. INTEGRA PLUS CAPS 25MG.315ML Not Covered INVIRASE TABS 500MG Not Covered INVIRASE CAPS 200MG Not Covered INVOKAMET TABS 50MG. 1000MG Covered PA QL INVOKAMET TABS 150MG. 1000MG Covered PA QL INVOKANA TABS 300MG Covered QL INVOKANA TABS 100MG Covered QL IPECAC SYRP 0 Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 82 of 178 . 500MG Covered PA QL INVOKAMET TABS 50MG.625ML Not Covered INVEGA TRINZA SUSP 273MG/0. 10MCG.25ML Not Covered INVEGA SUSTENNA SUSP 156MG/ML Not Covered INVEGA SUSTENNA SUSP 234MG/1.15MG Covered INTUNIV TB24 3MG Not Covered INTUNIV TB24 2MG Not Covered INTUNIV TB24 1MG Not Covered INTUNIV TB24 4MG Not Covered INVANZ SOLR 1GM Not Covered INVEGA TB24 9MG Not Covered INVEGA TB24 3MG Not Covered INVEGA TB24 6MG Not Covered INVEGA SUSTENNA SUSP 78MG/0.75ML Not Covered INVEGA SUSTENNA SUSP 39MG/0.5ML Not Covered INVEGA TRINZA SUSP 546MG/1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 210MG. 20MG. 62. 1000MCG. 0. 300MCG.5ML Not Covered INVEGA SUSTENNA SUSP 117MG/0.875ML Not Covered INVEGA TRINZA SUSP 410MG/1. 5MG. 500MG Covered PA QL INVOKAMET TABS 150MG.03MG. 5MG Covered INTELENCE TABS 100MG Not Covered INTELENCE TABS 200MG Not Covered INTELENCE TABS 25MG Not Covered INTERMEZZO SUBL 3.5MG Not Covered INTERMEZZO SUBL 1.75MG Not Covered INTRON A SOLN 10MU/ML Covered INTRON A SOLN 6000000UNIT/ML Covered INTRON A W/DILUENT SOLR 50MU Covered INTRON A W/DILUENT SOLR 18MU Covered INTRON A W/DILUENT SOLR 10MU Covered INTROVALE TABS 0. 62.5MG.5MG. 7MG.

5MG/3ML Covered QL IRBESARTAN TABS 75MG Covered QL IRBESARTAN TABS 300MG Covered QL IRBESARTAN TABS 150MG Covered QL IRBESARTAN/HYDR OCHLOROTHIAZIDE TABS 12. 65MG Not Covered ISONIAZID TABS 100MG Covered ISONIAZID TABS 300MG Covered ISONIAZID SYRP 50MG/5ML Covered ISOPROPYL ALCOHOL WIPES MISC 70% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 83 of 178 . 1MG. 100MG.5MG/3ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL IPOL INACTIVATED IPV INJ 0 Covered QL AL IPRATROPIUM BROMIDE SOLN 0. 25MG. 20MG. 5MG Covered ISENTRESS TABS 400MG Not Covered ISOMETHEPTENE/C AFFEINE/ACETAMIN OPHEN TABS 500MG.5MG. 130MG Not Covered ISOMETHEPTENE/DI CHLORALPHENAZO NE/ACETAMINOPHE N CAPS 325MG. 30MG. IRON 100 PLUS TABS 100MG Covered AL IRON SUPPLEMENT CHILDRENS SOLN 15MG/ML Covered AL 300MCG. 150MG Covered QL IRBESARTAN/HYDR OCHLOROTHIAZIDE TABS 12. 65MG. 0.02% Covered IPRATROPIUM BROMIDE SOLN 0.5MG. 100MG. 100MG.06% Covered QL IPRATROPIUM BROMIDE/ALBUTER OL SULFATE SOLN 2. 1000MCG. 7MG.03% Covered QL IPRATROPIUM BROMIDE SOLN 0. 300MG Covered QL IRENKA CPEP 40MG Not Covered IRESSA TABS 250MG Not Covered 250MG. IROSPAN 24/6 MISC 150MG. 25MCG. 0. 5MG. 155MG. 65MG. 10MCG.

25% Covered ISOSORBIDE DINITRATE TABS 20MG Covered ISOSORBIDE DINITRATE TABS 10MG Covered ISOSORBIDE DINITRATE TABS 30MG Covered ISOSORBIDE DINITRATE TABS 5MG Covered ISOSORBIDE DINITRATE ER TBCR 40MG Covered ISOSORBIDE MONONITRATE TABS 20MG Covered ISOSORBIDE MONONITRATE TABS 10MG Covered ISOSORBIDE MONONITRATE ER TB24 120MG Covered QL ISOSORBIDE MONONITRATE ER TB24 30MG Covered QL ISOSORBIDE MONONITRATE ER TB24 60MG Covered QL ISRADIPINE CAPS 2. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ISOPTO HOMATROPINE SOLN 2% Covered ISOPTO HYOSCINE SOLN 0.5MG Covered QL ISRADIPINE CAPS 5MG Covered QL ITRACONAZOLE CAPS 100MG Covered QL IVERMECTIN TABS 3MG Not Covered QL IXEMPRA KIT SOLR 15MG Not Covered IXEMPRA KIT SOLR 45MG Not Covered IXINITY SOLR 500UNIT Not Covered IXINITY SOLR 1000UNIT Not Covered IXINITY SOLR 1500UNIT Not Covered JADENU TABS 180MG Not Covered JADENU TABS 90MG Not Covered JADENU TABS 360MG Not Covered JAKAFI TABS 10MG Covered PA QL JAKAFI TABS 25MG Covered PA QL JAKAFI TABS 15MG Covered PA QL JAKAFI TABS 5MG Covered PA QL JAKAFI TABS 20MG Covered PA QL JANTOVEN TABS 3MG Not Covered JANTOVEN TABS 2.5MG Not Covered JANTOVEN TABS 5MG Not Covered JANTOVEN TABS 1MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 84 of 178 .

50MG Covered PA QL JANUMET XR TB24 1000MG. 50MG Covered PA QL JANUMET TABS 1000MG.5MG Covered JUNEL FE 1/20 TABS 20MCG. 1. 75MG. 1000MG Covered PA JENTADUETO TABS 2.5/30 TABS 30MCG. 100MG Covered PA QL JANUMET XR TB24 500MG.5/30 TABS 30MCG.15MG Covered JOLIVETTE TABS 0.1MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 85 of 178 .5MG. 500MG Covered PA JINTELI TABS 5MCG.5MG. 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL JANTOVEN TABS 6MG Not Covered JANTOVEN TABS 7. 1MG Covered JUXTAPID CAPS 20MG Not Covered JUXTAPID CAPS 5MG Not Covered JUXTAPID CAPS 60MG Not Covered JUXTAPID CAPS 10MG Not Covered JUXTAPID CAPS 40MG Not Covered JUXTAPID CAPS 30MG Not Covered KADIAN CP24 100MG Not Covered KADIAN CP24 30MG Not Covered KADIAN CP24 20MG Not Covered KADIAN CP24 80MG Not Covered KADIAN CP24 50MG Not Covered KADIAN CP24 60MG Not Covered KALBITOR SOLN 10MG/ML Not Covered KALETRA TABS 200MG.5MG. 50MG Covered PA QL JANUVIA TABS 50MG Covered PA QL JANUVIA TABS 25MG Covered PA QL JANUVIA TABS 100MG Covered PA QL JARDIANCE TABS 10MG Not Covered JARDIANCE TABS 25MG Not Covered JENCYCLA TABS 0.5MG Not Covered JANTOVEN TABS 2MG Not Covered JANTOVEN TABS 4MG Not Covered JANTOVEN TABS 10MG Not Covered JANUMET TABS 500MG.35MG Covered JUBLIA SOLN 10% Not Covered JUNEL 1.35MG Covered JENTADUETO TABS 2. 75MG.5MG Covered JUNEL 1/20 TABS 20MCG. 50MG Covered PA QL JANUMET XR TB24 1000MG. 1MG Covered JUNEL FE 1. 50MG Not Covered KALYDECO TABS 150MG Not Covered KALYDECO PACK 50MG Not Covered KALYDECO PACK 75MG Not Covered KAPVAY TB12 0. 0. 850MG Covered PA JENTADUETO TABS 2. 1MG Not Covered JOLESSA TABS 0.03MG.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL KARBINAL ER SUER 4MG/5ML Not Covered KARIVA TABS 0. 1000MG Not Covered KAZANO TABS 12. 0 Covered KAYEXALATE POWD 0 Covered KAZANO TABS 12.67ML Not Covered KIONEX SUSP 15GM/60ML Covered KIONEX POWD 0 Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 86 of 178 . 1MG Covered KENALOG AERS 0.5MG. 500MG Not Covered K-EFFERVESCENT TBEF 25MEQ Covered KEFLEX CAPS 750MG Not Covered KELNOR 1/35 TABS 35MCG.50% Covered QL KETOROLAC TROMETHAMINE TABS 10MG Covered AL KETOSTIX STRP 0 Covered KEVEYIS TABS 50MG Not Covered KHEDEZLA TB24 100MG Not Covered KIMONO LUBRICATED MISC Covered QL KIMONO MICRO THIN MISC Covered QL KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC Covered QL KINERET SOSY 100MG/0.147MG/GM Not Covered KEPPRA TABS 1000MG Not Covered KEPPRA SOLN 100MG/ML Not Covered KEPPRA TABS 750MG Not Covered KEPPRA TABS 500MG Not Covered KEPPRA TABS 250MG Not Covered KEPPRA XR TB24 750MG Not Covered KEPPRA XR TB24 500MG Not Covered KERYDIN SOLN 5% Not Covered KETEK TABS 400MG Not Covered KETEK TABS 300MG Not Covered KETOCONAZOLE TABS 200MG Covered QL KETOCONAZOLE CREA 2% Covered QL KETOCONAZOLE FOAM 2% Covered QL KETOCONAZOLE SHAM 2% Covered KETODAN FOAM 2% Covered QL KETOPROFEN CAPS 50MG Covered KETOPROFEN CAPS 75MG Covered KETOPROFEN ER CP24 200MG Not Covered KETOROLAC TROMETHAMINE SOLN 0.5MG.

3500UNIT/30GM Not Covered LACTULOSE SOLN 10GM/15ML Covered LAMICTAL TABS 25MG Not Covered LAMICTAL TABS 150MG Not Covered LAMICTAL CHEW 2MG Not Covered LAMICTAL TABS 100MG Not Covered LAMICTAL TABS 200MG Not Covered LAMICTAL CHEWABLE DISPERSIBLE CHEW 5MG Not Covered LAMICTAL CHEWABLE DISPERSIBLE CHEW 25MG Not Covered LAMICTAL ODT TBDP 25MG Not Covered LAMICTAL ODT TBDP 100MG Not Covered LAMICTAL ODT TBDP 200MG Not Covered LAMICTAL ODT TBDP 50MG Not Covered LAMICTAL ODT KIT 0 Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 87 of 178 . 5MG Not Covered KORLYM TABS 300MG Not Covered K-PHOS TABS 500MG Covered K-PHOS NO 2 TABS 305MG. 2. 0. 5MG Not Covered KOMBIGLYZE XR TB24 1000MG. 700MG Covered KRISTALOSE PACK 10GM Covered KRISTALOSE PACK 20GM Covered K-TAB TBCR 10MEQ Not Covered KURVELO TABS 0.03MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL KITABIS PAK NEBU 300MG/5ML Not Covered KLOR-CON M10 TBCR 10MEQ Not Covered KLOR-CON M15 TBCR 15MEQ Not Covered KLOR-CON M20 TBCR 20MEQ Not Covered KOATE-DVI SOLR 500UNIT Not Covered KOGENATE FS KIT 500UNIT Not Covered KOGENATE FS BIO- SET KIT 250UNIT Not Covered KOMBIGLYZE XR TB24 500MG.5MG Not Covered KOMBIGLYZE XR TB24 1000MG.15MG Covered KUVAN TBSO 100MG Not Covered KUVAN PACK 100MG Not Covered KYNAMRO SOSY 200MG/ML Not Covered KYPROLIS SOLR 60MG Not Covered LABETALOL HCL TABS 100MG Covered LABETALOL HCL TABS 200MG Covered LABETALOL HCL TABS 300MG Covered LACTASE ENZYME FAST ACTING TABS 9000UNIT Not Covered LACTIC ACID E CREA 10%.

5MCG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 88 of 178 . 300MG Not Covered LAMOTRIGINE CHEW 25MG Not Covered LAMOTRIGINE TABS 25MG Not Covered LAMOTRIGINE TABS 100MG Not Covered LAMOTRIGINE CHEW 5MG Not Covered LAMOTRIGINE TABS 200MG Not Covered LAMOTRIGINE TABS 150MG Not Covered LAMOTRIGINE ER TB24 300MG Not Covered LAMOTRIGINE ER TB24 200MG Not Covered LAMOTRIGINE ER TB24 25MG Not Covered LAMOTRIGINE ER TB24 250MG Not Covered LAMOTRIGINE ER TB24 100MG Not Covered LAMOTRIGINE ER TB24 50MG Not Covered LAMOTRIGINE ODT TBDP 200MG Not Covered LAMOTRIGINE ODT TBDP 25MG Not Covered LAMOTRIGINE ODT TBDP 100MG Not Covered LAMOTRIGINE ODT TBDP 50MG Not Covered LANCETS MISC Covered LANOXIN TABS 187. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT 0 Not Covered LAMICTAL STARTER/TAKING CARBAMAZEPINE/N OT TAKING VALPROATE KIT 0 Not Covered LAMICTAL STARTER/TAKING VALPROATE KIT 25MG Not Covered LAMICTAL XR TB24 100MG Not Covered LAMICTAL XR TB24 50MG Not Covered LAMICTAL XR TB24 250MG Not Covered LAMICTAL XR TB24 200MG Not Covered LAMICTAL XR KIT 0 Not Covered LAMICTAL XR TB24 300MG Not Covered LAMICTAL XR TB24 25MG Not Covered LAMISIL AT CREA 1% Not Covered LAMIVUDINE TABS 300MG Not Covered LAMIVUDINE TABS 100MG Covered LAMIVUDINE TABS 150MG Not Covered LAMIVUDINE SOLN 10MG/ML Not Covered LAMIVUDINE/ZIDOV UDINE TABS 150MG.5MCG Not Covered LANOXIN TABS 62.

75MG. 0. 1MG Covered LATANOPROST SOLN 0.5/30 TABS 30MCG. 30MG Not Covered LANTUS SOLN 100UNIT/ML Covered LANTUS SOLOSTAR SOPN 100UNIT/ML Covered QL LARIN 1. 500MG.01% Covered LATUDA TABS 80MG Not Covered LATUDA TABS 20MG Not Covered LATUDA TABS 60MG Not Covered LATUDA TABS 40MG Not Covered LAXATIVE SUPP 10MG Covered LAZANDA SOLN 100MCG/ACT Not Covered LEENA TABS 0. 0 Covered LEFLUNOMIDE TABS 10MG Covered QL LEFLUNOMIDE TABS 20MG Covered QL LEMTRADA SOLN 12MG/1. 75MG.2ML Not Covered LENVIMA 10MG DAILY DOSE CPPK 10MG Not Covered LENVIMA 14MG DAILY DOSE CPPK 0 Not Covered LENVIMA 20MG DAILY DOSE CPPK 10MG Not Covered LENVIMA 24MG DAILY DOSE CPPK 0 Not Covered LESCOL CAPS 20MG Not Covered LESCOL CAPS 40MG Not Covered LESCOL XL TB24 80MG Not Covered LESSINA TABS 20MCG.5/30 TABS 30MCG.1MG Covered LETAIRIS TABS 5MG Covered PA QL LETAIRIS TABS 10MG Covered PA QL LETROZOLE TABS 2. 1. 1MG Covered LARIN FE 1. 1.5MG Covered AL LEUCOVORIN CALCIUM TABS 5MG Covered LEUCOVORIN CALCIUM TABS 25MG Covered LEUCOVORIN CALCIUM TABS 10MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 89 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LANSOPRAZOLE CPDR 30MG Covered QL LANSOPRAZOLE CPDR 15MG Covered LANSOPRAZOLE/AM OXICILLIN/CLARITH ROMYCIN MISC 500MG.5MG Covered LARIN 1/20 TABS 20MCG.5MG Covered LARIN FE 1/20 TABS 20MCG.

25MG/0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LEUCOVORIN CALCIUM TABS 15MG Covered LEUKERAN TABS 2MG Covered LEVALBUTEROL NEBU 1. POWDER TABS 90.25% Covered LEVOBUNOLOL HCL SOLN 0.25MG/3ML Not Covered LEVALBUTEROL HCL NEBU 0.31MG/3ML Not Covered LEVALBUTEROL HCL NEBU 1.5ML Not Covered LEVALBUTEROL HCL NEBU 0.50% Covered LEVOCARNITINE SOLN 1GM/10ML Not Covered LEVOCETIRIZINE DIHYDROCHLORIDE TABS 5MG Not Covered LEVOFLOXACIN TABS 250MG Not Covered LEVOFLOXACIN SOLN 25MG/ML Not Covered LEVOFLOXACIN TABS 500MG Not Covered LEVOFLOXACIN TABS 750MG Not Covered LEVOFLOXACIN SOLN 0.314MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 90 of 178 .63MG/3ML Not Covered LEVATOL TABS 20MG Not Covered LEVEMIR SOLN 100UNIT/ML Not Covered LEVEMIR FLEXTOUCH SOPN 100UNIT/ML Not Covered LEVETIRACETAM TABS 500MG Not Covered LEVETIRACETAM TABS 750MG Not Covered LEVETIRACETAM TABS 250MG Not Covered LEVETIRACETAM SOLN 100MG/ML Not Covered LEVETIRACETAM ER TB24 500MG Not Covered LEVETIRACETAM ER TB24 750MG Not Covered LEVITRA TABS 20MG Not Covered LEVITRA TABS 10MG Not Covered LEVITRA TABS 2. 6MG.50% Covered LEVOMEFOLATE CALCIUM/ACETYLC YSTEINE/MECOBAL AMIN/ALGAL 600MG. 2MG.5MG Not Covered LEVITRA TABS 5MG Not Covered LEVOBUNOLOL HCL SOLN 0.

75MG Covered LEVONORGESTREL TABS 1. 0.15MG Covered LEVONORGESTREL/ ETHINYL ESTRADIOL TABS 20MCG.1MG Covered LEVORA 0. 0 Covered LEVONORGESTREL TABS 0. 2MG.314MG Covered LEVONEST TABS 0. 0. 90MCG Covered LEVONORGESTREL/ ETHINYL ESTRADIOL TABS 0. 0.15MG Covered LEVOTHYROXINE SODIUM TABS 137MCG Covered AL LEVOTHYROXINE SODIUM TABS 75MCG Covered LEVOTHYROXINE SODIUM TABS 112MCG Not Covered LEVOTHYROXINE SODIUM TABS 175MCG Not Covered LEVOTHYROXINE SODIUM TABS 25MCG Not Covered LEVOTHYROXINE SODIUM TABS 50MCG Covered LEVOTHYROXINE SODIUM TABS 125MCG Not Covered LEVOTHYROXINE SODIUM SOLR 500MCG Not Covered LEVOTHYROXINE SODIUM TABS 150MCG Not Covered LEVOTHYROXINE SODIUM TABS 300MCG Covered LEVOTHYROXINE SODIUM TABS 88MCG Covered AL LEVOTHYROXINE SODIUM TABS 100MCG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 91 of 178 . BALAMIN/ALGAL CAPS 90.15/30-28 TABS 30MCG. 35MG.03MG.5MG Covered LEVONORGESTREL AND ETHINYL ESTRADIOL TABS 20MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LEVOMEFOLATE CALCIUM/PYRIDOXA L-5 PHOSPHATE/MECO 3MG.

6MCG/DAY Not Covered LINDANE SHAM 1% Covered LINDANE LOTN 1% Covered LINEZOLID TABS 600MG Covered PA LINZESS CAPS 145MCG Not Covered LINZESS CAPS 290MCG Not Covered LIOTHYRONINE SODIUM TABS 25MCG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 92 of 178 .5% Covered QL LIDODERM PTCH 5% Not Covered LIDOPIN CREA 3% Not Covered LILETTA IUD 18. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LEVOTHYROXINE SODIUM TABS 200MCG Not Covered LEVOTHYROXINE SODIUM SOLR 100MCG Not Covered LEVOTHYROXINE SODIUM SOLR 200MCG Not Covered LEVOXYL TABS 50MCG Covered LEVOXYL TABS 100MCG Not Covered LEVOXYL TABS 137MCG Not Covered LEVOXYL TABS 200MCG Not Covered LEVOXYL TABS 25MCG Not Covered LEVOXYL TABS 112MCG Not Covered LEVOXYL TABS 125MCG Not Covered LEVOXYL TABS 75MCG Covered LEVOXYL TABS 88MCG Covered AL LEVOXYL TABS 150MCG Not Covered LEVOXYL TABS 175MCG Not Covered LEXAPRO TABS 5MG Not Covered LEXAPRO TABS 20MG Not Covered LEXAPRO SOLN 5MG/5ML Not Covered LEXAPRO TABS 10MG Not Covered LEXIVA TABS 700MG Not Covered LEXIVA SUSP 50MG/ML Not Covered LIALDA TBEC 1.5%.2GM Not Covered LICIDE SHAM 4%.33% Not Covered LIDOCAINE PTCH 5% Not Covered LIDOCAINE CREA 3% Not Covered LIDOCAINE OINT 5% Not Covered LIDOCAINE HCL SOLN 4% Not Covered LIDOCAINE HCL JELLY GEL 2% Covered LIDOCAINE VISCOUS SOLN 2% Covered LIDOCAINE/PRILOC AINE CREA 2. 0. 2.

5MG. 10MG Not Covered LIPTRUZET TABS 20MG. 10MG Not Covered LIPTRUZET TABS 10MG. 20MG Covered QL LITHIUM SOLN 8MEQ/5ML Not Covered LITHIUM CARBONATE CAPS 300MG Not Covered LITHIUM CARBONATE CAPS 600MG Not Covered LITHIUM CARBONATE CAPS 150MG Not Covered LITHIUM CARBONATE ER TBCR 450MG Not Covered LITHIUM CARBONATE ER TBCR 300MG Not Covered LITHOSTAT TABS 250MG Not Covered LIVALO TABS 2MG Not Covered LIVALO TABS 1MG Not Covered LIVALO TABS 4MG Not Covered LIVIXIL PAK KIT 2. 20MG Covered QL LISINOPRIL/HYDRO CHLOROTHIAZIDE TABS 12. 10MG Not Covered LISINOPRIL TABS 10MG Covered QL LISINOPRIL TABS 30MG Covered QL LISINOPRIL TABS 5MG Covered QL LISINOPRIL TABS 20MG Covered QL LISINOPRIL TABS 2.5MG. 2. 10MG Covered QL LISINOPRIL/HYDRO CHLOROTHIAZIDE TABS 12.5MG Covered QL LISINOPRIL TABS 40MG Covered QL LISINOPRIL/HYDRO CHLOROTHIAZIDE TABS 25MG. 10MG Not Covered LIPTRUZET TABS 40MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LIOTHYRONINE SODIUM TABS 50MCG Not Covered LIOTHYRONINE SODIUM TABS 5MCG Not Covered LIPITOR TABS 10MG Not Covered LIPITOR TABS 40MG Not Covered LIPITOR TABS 20MG Not Covered LIPITOR TABS 80MG Not Covered LIPOFEN CAPS 150MG Not Covered LIPOFEN CAPS 50MG Not Covered LIPTRUZET TABS 80MG.5%.5% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 93 of 178 .

1MG Covered LODOSYN TABS 25MG Not Covered LOESTRIN 1/20-21 TABS 20MCG. 25MG Covered LO LOESTRIN FE TABS 10MCG. 1MG Covered LOMUSTINE CAPS 100MG Covered LOMUSTINE CAPS 10MG Covered LOMUSTINE CAPS 40MG Covered LONSURF TABS 6.14MG. 120MG Not Covered LORATADINE-D 24HR TB24 10MG.02MG Covered LORZONE TABS 375MG Not Covered LORZONE TABS 750MG Not Covered LOSARTAN POTASSIUM TABS 25MG Covered QL LOSARTAN POTASSIUM TABS 50MG Covered QL LOSARTAN POTASSIUM TABS 100MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 94 of 178 . 6MG. 75MG. 1.5MG Not Covered LORAZEPAM TABS 1MG Not Covered LORAZEPAM INTENSOL CONC 2MG/ML Not Covered LORYNA TABS 3MG. 2MG Covered LMTHF/PYRIDOXINE HCL/CYANOCOBALA MIN TABS 2MG. CA ME-CBL NAC TABS 90.314MG Covered L-METHYL-MC NAC TABS 600MG. 15MG Not Covered LONSURF TABS 8. 20MG Not Covered LOPERAMIDE HCL CAPS 2MG Covered LORATADINE TABS 10MG Covered LORATADINE CHILDRENS SOLN 5MG/5ML Covered QL AL LORATADINE HIVES RELIEF SOLN 5MG/5ML Covered QL AL LORATADINE-D 12HR TB12 5MG. 240MG Not Covered LORAZEPAM TABS 2MG Not Covered LORAZEPAM TABS 0. 2MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL L-METHYL-B6-B12 TABS 3MG. 0. 35MG Covered L-METHYLFOLATE 600MG.13MG. 1MG Covered LOFIBRA CAPS 200MG Not Covered LOFIBRA TABS 160MG Not Covered LOFIBRA CAPS 134MG Not Covered LOFIBRA CAPS 67MG Not Covered LOMEDIA 24 FE TABS 20MCG.19MG. 2MG. 75MG. 6MG.

100MG Covered QL LOSARTAN POTASSIUM/HYDRO CHLOROTHIAZIDE TABS 12. 1GM Not Covered LOVENOX SOLN 40MG/0. 465MG.8ML Not Covered LOVENOX SOLN 100MG/ML Not Covered LOVENOX SOLN 30MG/0.4ML Not Covered LOVENOX SOLN 80MG/0.8ML Not Covered LOVENOX SOLN 150MG/ML Not Covered LOW-OGESTREL TABS 30MCG. 50MG Covered QL LOSEASONIQUE TABS 0. 0 Not Covered LOTEMAX OINT 0.3ML Not Covered LOVENOX SOLN 60MG/0. 40MG Not Covered LOTREL CAPS 10MG.50% Not Covered LOTREL CAPS 5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LOSARTAN POTASSIUM/HYDRO CHLOROTHIAZIDE TABS 12.50% Not Covered LOTEMAX SUSP 0.3MG Covered LOXAPINE CAPS 50MG Not Covered LOXAPINE SUCCINATE CAPS 5MG Not Covered LOXAPINE SUCCINATE CAPS 25MG Not Covered LOXAPINE SUCCINATE CAPS 10MG Not Covered LOXAPINE SUCCINATE CAPS 50MG Not Covered LOXITANE CAPS 5MG Not Covered LUMIGAN SOLN 0.5MG Not Covered LOTRONEX TABS 1MG Not Covered LOVASTATIN TABS 40MG Covered QL LOVASTATIN TABS 20MG Covered QL LOVASTATIN TABS 10MG Covered QL LOVAZA CAPS 375MG.50% Not Covered LOTEMAX GEL 0. 40MG Not Covered LOTRONEX TABS 0.5MG.6ML Not Covered LOVENOX SOLN 120MG/0.5MG. 100MG Covered QL LOSARTAN POTASSIUM/HYDRO CHLOROTHIAZIDE TABS 25MG. 0.01% Not Covered LUMIZYME SOLR 50MG Not Covered LUNESTA TABS 3MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 95 of 178 .

5MG Not Covered LUPRON DEPOT- PED KIT 15MG Not Covered LURIDE SOLN 0. 15MG/10ML. 60MCG/10ML.5MG Not Covered LUPRON DEPOT KIT 3.6MG/10ML.1MG Covered LUVOX CR CP24 100MG Not Covered LUVOX CR CP24 150MG Not Covered LUZU CREA 1% Not Covered LYNPARZA CAPS 50MG Not Covered LYRICA CAPS 200MG Not Covered LYRICA CAPS 300MG Not Covered LYRICA CAPS 25MG Not Covered LYRICA CAPS 75MG Not Covered LYRICA CAPS 100MG Not Covered LYRICA SOLN 20MG/ML Not Covered LYRICA CAPS 50MG Not Covered LYRICA CAPS 150MG Not Covered LYRICA CAPS 225MG Not Covered LYSTEDA TABS 650MG Not Covered 200MG/10ML. M.5MG/ML Covered AL LUSTRA-AF CREA 0. 6MG/10ML. 5MCG/10ML. 40MG/10ML.V. 6MG/10ML.I. 150MCG/10ML. 0 Not Covered LUSTRA-ULTRA CREA 4% Not Covered LUTERA TABS 20MCG.75MG Not Covered LUPRON DEPOT KIT 30MG Not Covered LUPRON DEPOT KIT 22. 5MCG/10ML. 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL LUNESTA TABS 1MG Not Covered LUNESTA TABS 2MG Not Covered LUPANETA PACK KIT 3. 5MG Not Covered LUPRON DEPOT KIT 7. 5MG Not Covered LUPANETA PACK KIT 11. 1MG/10ML Covered MACA CAPS 500MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 96 of 178 .75MG.25MG Not Covered LUPRON DEPOT KIT 45MG Not Covered LUPRON DEPOT- PED KIT 11. 600MCG/10ML.25MG. 3. ADULT INJ 10MG/10ML.25MG Not Covered LUPRON DEPOT- PED KIT 7.5MG Not Covered LUPRON DEPOT KIT 11. 4%.

50% Covered QL MAPROTILINE HCL TABS 25MG Not Covered MAPROTILINE HCL TABS 50MG Not Covered MAPROTILINE HCL TABS 75MG Not Covered MARGESIC CAPS 325MG. 160MG. MAXARON FORTE TABS 1.5MG Covered MECLIZINE HCL TABS 25MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 97 of 178 . 40MG Covered QL AL MARLISSA TABS 0.1%. 250MCG Covered 100MG.15MG Covered MARPLAN TABS 10MG Not Covered MARQIBO SUSP 5MG/31ML Not Covered MARTEN-TAB TABS 325MG. 0. 0. 10MG/ML Covered MAKENA OIL 250MG/ML Not Covered MALARONE TABS 250MG. 1MG. 0. 1MG. MAXFE TABS 6. 70MG. 3. 5MG. 80MG. 150MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MACRODANTIN CAPS 25MG Not Covered QL 250MG. MACUVEX CAPS 200UNIT. 1MG.5MG.13MG. MAXITROL SUSP 10000UNIT/ML Not Covered MAXX LUBRICATED MISC Covered QL MCT OIL OIL 0 Covered MECLIZINE HCL TABS 12. 1MG. 100MG Not Covered MALATHION LOTN 0.5MG/ML. 400MG Covered MAGNESIUM CHLORIDE SOLN 200MG/ML Covered MAGNESIUM OXIDE TABS 400MG Covered MAGNESIUM SULFATE SOLN 50% Covered MAGNESIUM SULFATE IN D5W SOLN 5%. 0. 200MG Not Covered MAGNEBIND 400 TABS 200MG. 40MG Not Covered MAGNEBIND 200 TABS 450MG. 60MCG. 1MG. 50MG. 12MG Covered 0. 50MG Covered QL AL MATULANE CAPS 50MG Covered MATZIM LA TB24 420MG Not Covered MATZIM LA TB24 240MG Not Covered MATZIM LA TB24 300MG Not Covered MATZIM LA TB24 360MG Not Covered MAXALT TABS 5MG Not Covered MAXALT TABS 10MG Not Covered MAXALT-MLT TBDP 10MG Not Covered MAXALT-MLT TBDP 5MG Not Covered 200MG.03MG. 50MG.

625MG Covered QL MENEST TABS 0.5MG Not Covered MELOXICAM TABS 7.5MG Covered MEDROXYPROGEST ERONE ACETATE TABS 10MG Covered MEDROXYPROGEST ERONE ACETATE SUSP 150MG/ML Not Covered MEFENAMIC ACID CAPS 250MG Not Covered MEFLOQUINE HCL TABS 250MG Covered MEGACE ES SUSP 625MG/5ML Not Covered MEGESTROL ACETATE TABS 40MG Covered MEGESTROL ACETATE SUSP 40MG/ML Covered MEGESTROL ACETATE TABS 20MG Covered MEKINIST TABS 2MG Not Covered MEKINIST TABS 0.3MG Covered QL MENEST TABS 1.5MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 98 of 178 .5MG/5ML Not Covered MELPAQUE HP CREA 4% Not Covered MEMANTINE HCL TABS 5MG Covered QL AL MEMANTINE HCL TABS 10MG Covered QL AL MEMANTINE HCL TITRATION PAK TABS 0 Covered QL AL MEMANTINE HYDROCHLORIDE SOLN 2MG/ML Not Covered QL AL MENACTRA INJ 0 Covered QL AL MENEST TABS 0.5MG Covered QL MELOXICAM TABS 15MG Covered QL MELOXICAM SUSP 7.25MG Covered QL MENEST TABS 2. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MEDICAL PROVIDER EZ FLU SHOT 2013- 2014 KIT 0 Not Covered MEDICAL PROVIDER EZ FLU SHOT 2015- 2016 PSKT 0 Not Covered MEDROL TABS 8MG Not Covered MEDROXYPROGEST ERONE ACETATE TABS 5MG Covered MEDROXYPROGEST ERONE ACETATE TABS 2.

RF TABS 90. 2MG.30% Covered METAPROTERENOL SULFATE SYRP 10MG/5ML Not Covered METAPROTERENOL SULFATE TABS 20MG Covered METAPROTERENOL SULFATE TABS 10MG Covered METAXALONE TABS 800MG Not Covered METFORMIN HCL TABS 850MG Covered QL METFORMIN HCL TABS 500MG Covered QL METFORMIN HCL TABS 1000MG Covered QL METFORMIN HCL ER TB24 750MG Covered METFORMIN HCL ER TB24 500MG Covered METFORMIN HCL ER TB24 1000MG Not Covered METFORMIN HCL ER TB24 500MG Not Covered METHADONE HCL TABS 5MG Covered QL METHADONE HCL SOLN 5MG/5ML Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 99 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MENOMUNE- A/C/Y/W-135 INJ 0 Covered QL AL MENVEO SOLR 0 Covered QL AL MEPERIDINE HCL SOLN 50MG/5ML Covered QL AL MEPERIDINE HCL TABS 50MG Covered QL AL MEPERIDINE HCL TABS 100MG Covered QL AL MEPHYTON TABS 5MG Not Covered MEPROBAMATE TABS 400MG Not Covered MEPROBAMATE TABS 200MG Not Covered MEPRON SUSP 750MG/5ML Not Covered MERCAPTOPURINE TABS 50MG Covered MESALAMINE ENEM 4GM Covered MESNEX TABS 400MG Covered MESTINON TABS 60MG Not Covered METADATE CD CPCR 40MG Not Covered METADATE CD CPCR 30MG Not Covered METADATE CD CPCR 50MG Not Covered METADATE CD CPCR 60MG Not Covered METADATE CD CPCR 10MG Not Covered METADATE CD CPCR 20MG Not Covered METAFOLBIC PLUS TABS 600MG. 2MG Covered METAFOLBIC PLUS 600MG. 6MG. 6MG.314MG Covered METAMUCIL POWD 28.

5MG Not Covered METHYLIN SOLN 5MG/5ML Not Covered METHYLIN CHEW 5MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 100 of 178 . 250MG Covered METHYLERGONOVI NE MALEATE TABS 0.5GM Covered METHIMAZOLE TABS 5MG Covered METHIMAZOLE TABS 10MG Covered METHOCARBAMOL TABS 750MG Covered AL METHOCARBAMOL TABS 500MG Covered AL METHOTREXATE TABS 2. 250MG Covered METHYLDOPA/HYDR OCHLOROTHIAZIDE TABS 15MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL METHADONE HCL SOLN 10MG/5ML Covered QL METHADONE HCL CONC 10MG/ML Covered QL METHADONE HCL TBSO 40MG Covered QL METHADONE HCL TABS 10MG Covered QL METHADOSE CONC 10MG/ML Not Covered METHAMPHETAMIN E HCL TABS 5MG Not Covered METHAZOLAMIDE TABS 25MG Covered METHAZOLAMIDE TABS 50MG Covered METHENAMINE HIPPURATE TABS 1GM Covered METHENAMINE MANDELATE TABS 1GM Covered METHENAMINE MANDELATE TABS 0.2MG Covered AL METHYLIN CHEW 10MG Not Covered METHYLIN CHEW 2.5MG Not Covered QL METHSCOPOLAMIN E BROMIDE TABS 5MG Not Covered METHYCLOTHIAZID E TABS 5MG Covered METHYLDOPA TABS 250MG Covered AL METHYLDOPA TABS 500MG Covered AL METHYLDOPA/HYDR OCHLOROTHIAZIDE TABS 25MG.5MG Covered METHOTREXATE SODIUM SOLR 1GM Not Covered METHOTREXATE SODIUM SOLN 200MG/8ML Covered METHOXSALEN CAPS 10MG Not Covered METHSCOPOLAMIN E BROMIDE TABS 2.

2.25MG.625MG.25MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 101 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL METHYLIN SOLN 10MG/5ML Not Covered METHYLPHENIDATE HCL TABS 5MG Not Covered METHYLPHENIDATE HCL TABS 10MG Not Covered METHYLPHENIDATE HCL TABS 20MG Not Covered METHYLPHENIDATE HCL CD CPCR 10MG Not Covered METHYLPHENIDATE HCL CD CPCR 20MG Not Covered METHYLPHENIDATE HCL CD CPCR 50MG Not Covered METHYLPHENIDATE HCL CD CPCR 40MG Not Covered METHYLPHENIDATE HCL CD CPCR 60MG Not Covered METHYLPHENIDATE HCL CD CPCR 30MG Not Covered METHYLPHENIDATE HCL ER TBCR 36MG Not Covered METHYLPHENIDATE HCL ER TBCR 54MG Not Covered METHYLPHENIDATE HCL ER TBCR 18MG Not Covered METHYLPHENIDATE HCL ER TBCR 27MG Not Covered METHYLPHENIDATE HCL SR TBCR 20MG Not Covered METHYLPREDNISOL ONE TABS 16MG Covered METHYLPREDNISOL ONE TABS 32MG Covered METHYLPREDNISOL ONE TABS 4MG Covered METHYLPREDNISOL ONE TABS 8MG Covered METHYLPREDNISOL ONE DOSE PACK TBPK 4MG Covered METHYLTESTOSTE RONE/ESTERIFIED ESTROGENS TABS 1. 1.5MG Not Covered METHYLTESTOSTE RONE/ESTERIFIED ESTROGENS HS TABS 0.

75% Not Covered METRONIDAZOLE GEL 1% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 102 of 178 . 50MG Not Covered METOPROLOL/HYD ROCHLOROTHIAZID E TABS 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL METIPRANOLOL SOLN 0.30% Covered METOCLOPRAMIDE HCL TABS 10MG Covered METOCLOPRAMIDE HCL TABS 5MG Covered METOCLOPRAMIDE HCL SOLN 5MG/5ML Covered METOCLOPRAMIDE ODT TBDP 5MG Not Covered METOCLOPRAMIDE ODT TBDP 10MG Covered METOLAZONE TABS 2.5MG Covered QL METOLAZONE TABS 5MG Covered QL METOLAZONE TABS 10MG Covered QL METOPROLOL SUCCINATE ER TB24 25MG Covered QL METOPROLOL SUCCINATE ER TB24 100MG Covered QL METOPROLOL SUCCINATE ER TB24 200MG Covered QL METOPROLOL SUCCINATE ER TB24 50MG Covered QL METOPROLOL TARTRATE TABS 25MG Covered QL METOPROLOL TARTRATE TABS 50MG Covered QL METOPROLOL TARTRATE TABS 100MG Covered QL METOPROLOL/HYD ROCHLOROTHIAZID E TABS 25MG. 100MG Not Covered METOZOLV ODT TBDP 5MG Not Covered METOZOLV ODT TBDP 10MG Not Covered METROGEL GEL 1% Not Covered METRONIDAZOLE TABS 250MG Covered METRONIDAZOLE TABS 500MG Covered METRONIDAZOLE CREA 0.75% Not Covered METRONIDAZOLE LOTN 0. 100MG Not Covered METOPROLOL/HYD ROCHLOROTHIAZID E TABS 25MG.

1MG Covered MICROGESTIN FE TABS 20MCG.4MG/HR Not Covered MINIVELLE PTTW 0.75% Not Covered METRONIDAZOLE CAPS 375MG Not Covered METRONIDAZOLE VAGINAL GEL 0. 75MG.2MG/HR Not Covered MINITRAN PT24 0. 0. 250MG. 0. MINERIN LOTN 0. 1MG Covered PA MINERAL OIL OIL 0 Covered 0.0375MG/24HR Not Covered MINIVELLE PTTW 0. 1MG Covered MICROGESTIN FE 1.1MG/24HR Not Covered MINIVELLE PTTW 0.5/30 TABS 30MCG.5MG Not Covered MIDODRINE HCL TABS 5MG Covered QL MIDODRINE HCL TABS 2. 0. 0. 65MG Covered MIGRANAL SOLN 4MG/ML Not Covered MINASTRIN 24 FE CHEW 20MCG.05MG/24HR Not Covered MINOCYCLINE HCL CAPS 100MG Not Covered MINOCYCLINE HCL CAPS 50MG Not Covered MINOCYCLINE HCL TABS 100MG Not Covered MINOCYCLINE HCL TABS 75MG Not Covered MINOCYCLINE HCL CAPS 75MG Not Covered MINOCYCLINE HCL TABS 50MG Not Covered MINOXIDIL TABS 10MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 103 of 178 .5MG Covered MICROGESTIN 1/20 TABS 20MCG. 0 Not Covered MINI WRIGHT PEAK FLOW METER DEVI Covered QL MINITRAN PT24 0.5/30 TABS 30MCG. 0. 0.5MG Covered QL MIDODRINE HCL TABS 10MG Covered QL MIGERGOT SUPP 100MG. 0. 2MG Not Covered MIGRAINE FORMULA TABS 250MG. 75MG.6MG/HR Not Covered MINITRAN PT24 0. 1.5MG Covered MICROZIDE CAPS 12.1MG/HR Not Covered MINITRAN PT24 0. 0. 0. 0.75% Not Covered MEXILETINE HCL CAPS 200MG Covered MEXILETINE HCL CAPS 250MG Covered MEXILETINE HCL CAPS 150MG Covered MICONAZOLE 3 SUPP 200MG Covered MICONAZOLE NITRATE SUPP 100MG Covered MICROGESTIN 1.075MG/24HR Not Covered MINIVELLE PTTW 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL METRONIDAZOLE GEL 0. 75MG. 1.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MINOXIDIL TABS 2.5MG Covered MOEXIPRIL HCL TABS 15MG Not Covered MOEXIPRIL HCL TABS 7. 0.25MG Not Covered MIRAPEX TABS 1.3ML Not Covered MIRCERA SOSY 200MCG/0.5MG. 7.33% Not Covered MISOPROSTOL TABS 100MCG Covered QL MISOPROSTOL TABS 200MCG Covered QL MITIGARE CAPS 0.10% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 104 of 178 .6MG Not Covered M-M-R II INJ 0. 15MG Not Covered MOEXIPRIL/HYDRO CHLOROTHIAZIDE TABS 12.125MG Not Covered MIRAPEX TABS 0.5MG Not Covered MIRAPEX TABS 0.5MG Covered MIRALAX POWD 0 Covered MIRAPEX TABS 0.5MG Not Covered MOEXIPRIL/HYDRO CHLOROTHIAZIDE TABS 12.10% Covered MOMETASONE FUROATE SOLN 0.5MG.75MG Not Covered MIRAPEX TABS 1MG Not Covered MIRAPEX TABS 0.10% Covered MOMETASONE FUROATE OINT 0.5MG Not Covered MIRAPEX ER TB24 1.5MG Not Covered MIRCERA SOSY 75MCG/0.3ML Not Covered MIRCERA SOSY 50MCG/0.5MG Not Covered MOEXIPRIL/HYDRO CHLOROTHIAZIDE TABS 25MG. 15MG Not Covered MOMETASONE FUROATE CREA 0. 0 Covered QL AL MODAFINIL TABS 100MG Not Covered MODAFINIL TABS 200MG Not Covered MODICON TABS 35MCG.375MG Not Covered MIRAPEX ER TB24 4.75MG Not Covered MIRAPEX ER TB24 3MG Not Covered MIRAPEX ER TB24 0.3ML Not Covered MIRCERA SOSY 100MCG/0.5MG Not Covered MIRAPEX ER TB24 0.3ML Not Covered MIRTAZAPINE TABS 30MG Not Covered MIRTAZAPINE TABS 45MG Not Covered MIRTAZAPINE TABS 15MG Not Covered MIRTAZAPINE ODT TBDP 15MG Not Covered MIRTAZAPINE ODT TBDP 30MG Not Covered MIRTAZAPINE ODT TBDP 45MG Not Covered MIRVASO GEL 0. 0.

50% Covered MONONESSA TABS 35MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MONISTAT 1-DAY OINT 6.25MG Covered MONONINE SOLR 250UNIT Not Covered MONONINE SOLR 1000UNIT Not Covered MONONINE SOLR 500UNIT Not Covered MONOVISC SOSY 88MG/4ML Not Covered MONTELUKAST SODIUM CHEW 4MG Covered QL AL MONTELUKAST SODIUM PACK 4MG Covered QL AL MONTELUKAST SODIUM TABS 10MG Covered QL AL MONTELUKAST SODIUM CHEW 5MG Covered QL AL MONUROL PACK 5.631GM Not Covered MORPHINE SULFATE SOLN 10MG/5ML Covered QL MORPHINE SULFATE SOLN 20MG/5ML Covered QL MORPHINE SULFATE TABS 15MG Covered QL MORPHINE SULFATE SUPP 5MG Not Covered MORPHINE SULFATE SUPP 30MG Not Covered MORPHINE SULFATE SUPP 20MG Not Covered MORPHINE SULFATE SUPP 10MG Not Covered MORPHINE SULFATE SOLN 100MG/5ML Covered QL MORPHINE SULFATE TABS 30MG Covered QL MORPHINE SULFATE ER TBCR 15MG Covered QL MORPHINE SULFATE ER TBCR 30MG Covered QL MORPHINE SULFATE ER TBCR 60MG Covered QL MORPHINE SULFATE ER TBCR 200MG Covered QL MORPHINE SULFATE ER CP24 20MG Not Covered MORPHINE SULFATE ER CP24 50MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 105 of 178 . 0.

10MCG.5GM Covered MOXATAG TB24 775MG Not Covered MOXEZA SOLN 0. 75MG Covered 150MG. 0. 10MCG. 7.5MG/ML. VIT/FLUORIDE SOLN 5UNIT/ML. 70MG.4MG/ML. 0. 0. 0.50% Not Covered MOXIFLOXACIN HCL TABS 400MG Not Covered MOXIFLOXACIN HCL SOLN 400MG/250ML Not Covered MULTAQ TABS 400MG Not Covered 150MG.7GM. MULTIGEN TABS 50MG. 2MCG/ML. 1. 101MG. 75MG Covered 60MG. 1MG.691GM.5MG/ML.015GM. MULTIGEN PLUS TABS 50MG. 100GM.9GM. 2MG. 50MG Covered 35MG/ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MORPHINE SULFATE ER CP24 80MG Not Covered MORPHINE SULFATE ER CP24 100MG Not Covered MORPHINE SULFATE ER CP24 75MG Not Covered MORPHINE SULFATE ER CP24 45MG Not Covered MORPHINE SULFATE ER TBCR 100MG Covered QL MORPHINE SULFATE ER CP24 120MG Not Covered MORPHINE SULFATE ER CP24 90MG Not Covered MORPHINE SULFATE ER CP24 60MG Not Covered MORPHINE SULFATE ER CP24 30MG Not Covered MOVANTIK TABS 25MG Not Covered MOVANTIK TABS 12. 10MCG.8MG. 2. MOVIPREP SOLR 5. MULTI. 2MG. MULTIGEN FOLIC TABS 70MG. 400UNIT/ML. 1500UNIT/ML Not Covered AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 106 of 178 . 0.6MG/ML. 8MG/ML.5MG Not Covered 4. 1MG.

1. 0.25MG/ML.5MCG. 4. 1500UNIT/ML Not Covered AL 35MG/ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 35MG/ML.05MG. 400UNIT.5MG. 2500UNIT Covered 60MG. 0. 0. 5000UNIT. 400UNIT/ML.25MG/ML. 8MG/ML. 0. 2500UNIT Covered 60MG. 1. 13. 15UNIT Covered 60MG. MULTIVITAMIN WITH 1MG.6MG/ML. 1. 1MG.25MG. 1.5MG.05MG. 13. VIT/IRON/FLUORIDE SOLN 5UNIT/ML.5MCG. 10MG/ML.5MG Covered QL AL MYALEPT SOLR 11.2MG. 50MG. 4. 50MCG. 0. ORIDE CHEW 15UNIT. 0. 0.2MG. 50MG. 400UNIT. 2MCG/ML. MULTIVITAMINS/FLU 1.5MG. 20MG. 0.4MG/ML.5MG/ML. 150MCG. MULTIVITAMINS/FLU 1. FLUORIDE CHEW 400UNIT.05MG.4MG/ML. 1500UNIT/ML Not Covered AL 60MG. VIT/FLUORIDE SOLN 5UNIT/ML. MULTIVITAMINS/FLU 1. 400UNIT/ML. MULTI. ORIDE CHEW 15UNIT. 4. 1. 0.3MG. 13.3MG. 1.3MG.5MG/ML.3MG.5MCG. 3MG. 1.05MG. 0.05MG. 0. 0. 400UNIT. 1. M-VIT TABS 30UNIT. MULTI. 13. 0. 1.5MG. 25MG.05MG.05MG. 0. 2500UNIT. 2500UNIT Not Covered AL MUPIROCIN CREA 2% Not Covered MUPIROCIN OINT 2% Covered QL MUSE PLLT 125MCG Not Covered 500MG. 5MG. 22. 27MG.5MG.5MCG. 1MG.05MG. 50MCG.6MG/ML. 20MG.3MG Not Covered MYCOPHENOLATE MOFETIL TABS 500MG Covered MYCOPHENOLATE MOFETIL SUSR 200MG/ML Covered AL MYCOPHENOLATE MOFETIL CAPS 250MG Covered QL MYCOPHENOLIC ACID DR TBEC 180MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 107 of 178 . 0.2MG. 4. ORIDE CHEW 15UNIT. 25MG.2MG.1MG. 100MG. 8MG/ML.

30UNIT. 20MG. 2MG. 17MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MYCOPHENOLIC ACID DR TBEC 360MG Covered MYFERON 150 FORTE CAPS 25MCG. 20MG. 400UNIT. 1MG. 65MCG.84MG. 400UNIT. 150MG Covered MYFORTIC TBEC 180MG Not Covered MYFORTIC TBEC 360MG Not Covered MYLERAN TABS 2MG Covered 120MG. 1MG. 3MG.7MG. 2MG. 12MCG. 1MG. ULTRACAPLET TABS 25MG Covered QL AL 70MG. 0.4MG. 4000UNIT. 10MG. 30UNIT.6MG. 65MG. 150MCG. 12MCG. 20MG. 1. MYNATAL PLUS TABS 25MG Covered QL AL 120MG. 0.15MG. 200MG. 1MG. 1. 10MG. 3. 6MCG. 175MCG. 20MG. 20MG. 12MCG. 50MG. 100MG.2MCG. 20MG. 2MG. 90MG. 2. 20MG. 1MG.5MG. 5MG. 2700UNIT. MYNATAL-Z TABS 10UNIT. 15MG Covered QL AL 120MG. 90MG. 2. 150MCG. 2MG. 200MG. 1MG. 4000UNIT. 3. 400UNIT. 400UNIT.4MG. 25MG Covered QL AL 120MG. 65MG. 20MG. 400UNIT. 0. 1. MYNATAL ADVANCE TABS 30UNIT. 200MG. MYNATAL 3MG. 2700UNIT.2MG. 1MG. 90MG. 200MG. 12MCG. MYNATE 90 PLUS TBCR 25MG Covered QL AL 100MG. 50MG. 1. 11MG.4MG.5MG Covered MYORISAN CAPS 10MG Not Covered MYORISAN CAPS 20MG Not Covered MYORISAN CAPS 40MG Not Covered MYOZYME SOLR 50MG Not Covered MYRBETRIQ TB24 50MG Not Covered MYRBETRIQ TB24 25MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 108 of 178 . MYNEPHROCAPS CAPS 1. 4000UNIT. 3. 50MG. 30MG. 3MG. 3MG. 250MG.

80MG Not Covered NAFTIFINE HCL CREA 1% Not Covered QL NAFTIN CREA 2% Not Covered NAFTIN CREA 1% Not Covered NAFTIN GEL 1% Not Covered NAFTIN GEL 2% Not Covered NAGLAZYME SOLN 1MG/ML Not Covered NALTREXONE HCL TABS 50MG Not Covered NAMENDA SOLN 10MG/5ML Not Covered NAMENDA TABS 5MG Not Covered NAMENDA TABS 10MG Not Covered NAMENDA TITRATION PAK TABS 0 Not Covered NAMENDA XR CP24 7MG Not Covered QL AL NAMENDA XR CP24 14MG Not Covered QL AL NAMENDA XR CP24 21MG Not Covered QL AL NAMENDA XR CP24 28MG Not Covered QL AL NAMENDA XR TITRATION PACK CP24 0 Not Covered QL AL NAMZARIC CP24 10MG.10% Covered NAPRELAN TB24 375MG Not Covered NAPRELAN TB24 750MG Not Covered NAPRELAN TB24 500MG Not Covered NAPROXEN TABS 375MG Not Covered NAPROXEN TABS 500MG Not Covered NAPROXEN SUSP 125MG/5ML Covered NAPROXEN TABS 250MG Not Covered NAPROXEN DR TBEC 375MG Covered NAPROXEN DR TBEC 500MG Covered NAPROXEN SODIUM TABS 275MG Not Covered NAPROXEN SODIUM TABS 550MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 109 of 178 . 0 Covered NABUMETONE TABS 500MG Covered QL NABUMETONE TABS 750MG Covered QL NADOLOL TABS 20MG Covered NADOLOL TABS 80MG Covered NADOLOL TABS 40MG Covered NADOLOL/BENDROF LUMETHIAZIDE TABS 5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL MYZILRA TABS 0. 14MG Not Covered NAMZARIC CP24 10MG. 40MG Not Covered NADOLOL/BENDROF LUMETHIAZIDE TABS 5MG. 28MG Not Covered NAPHAZOLINE HCL SOLN 0.

5 TABS 162.75MG Covered AL NATURE-THROID TABS 32. 0 Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 110 of 178 .25MG Covered AL NATURE-THROID TABS 48. 1MG Covered NECON 10/11-28 TABS 35MCG. 5% Not Covered NEBUPENT SOLR 300MG Not Covered NECON 0.5MG Covered QL NARDIL TABS 15MG Not Covered NASACORT ALLERGY 24HR AERO 55MCG/ACT Covered NASONEX SUSP 50MCG/ACT Not Covered NATACYN SUSP 5% Not Covered NATAZIA TABS 0.90% Not Covered AL NATURAL FIBER THERAPY POWD 48.5MG Covered AL NAVA-SC CREA 4%. 0 Not Covered NATEGLINIDE TABS 60MG Covered QL NATEGLINIDE TABS 120MG Covered QL NATESTO GEL 5.5%.5/35-28 TABS 35MCG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NAPROXEN SODIUM ER TB24 500MG Not Covered NARATRIPTAN HCL TABS 1MG Covered QL NARATRIPTAN HCL TABS 2.75MG Covered AL NATURE-THROID TABS 81.57% Covered NATURAL FIBER THERAPY POWD 30.5MG Covered NECON 1/35 TABS 35MCG.90% Covered NATURE-THROID TABS 195MG Covered AL NATURE-THROID TABS 97.5MG Covered AL NATURE-THROID TABS 65MG Covered AL NATURE-THROID NT- 2. 7. 1MG Covered NECON 1/50-28 TABS 50MCG.5MG/ACT Not Covered NATPARA CART 75MCG Not Covered NATPARA CART 50MCG Not Covered NATPARA CART 25MCG Not Covered NATPARA CART 100MCG Not Covered NATROBA SUSP 0.25MG Covered AL NATURE-THROID TABS 130MG Covered AL NATURE-THROID TABS 16. 0 Covered NECON 7/7/7 TABS 0. 0.5MG Covered AL NATURE-THROID TABS 260MG Covered AL NATURE-THROID TABS 325MG Covered AL NATURE-THROID TABS 146.25MG Covered AL NATURE-THROID TABS 113.

1.4MG. 150MCG.4MG. 1%. 3. 1. 3. 3. 20MG. 1. 6MCG.1%. 1MG. 3.5MG/GM.1%. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 0.5MG/ML. 5MCG. 0. CIN/POLYMYXIN OINT 10000UNIT/GM Covered NEOMYCIN/POLYMY XIN/BACITRACIN/HY 400UNIT/GM. 60MCG. 27MG.025MG/ML. XIN/HC SOLN 10000UNIT/ML Covered NEOMYCIN/POLYMY XIN/HYDROCORTIS 1%. DROCORTISONE OINT 10000UNIT/GM Not Covered NEOMYCIN/POLYMY XIN/DEXAMETHASO 0. 3. NEPHPLEX RX TABS 1. 220MCG. 0. ONE SUSP 10000UNIT/ML Covered NEORAL CAPS 100MG Not Covered NEORAL SOLN 100MG/ML Not Covered NEORAL CAPS 25MG Not Covered 60MG.5MG Covered 100MG. 12. NE OINT 10000UNIT/GM Covered NEOMYCIN/POLYMY 0. 1. 10MG. 6MG. 18MG. 1.5MG/ML. 110MG. 85MG.7MG. 300MCG.5MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 111 of 178 . NEEVO DHA CAPS 1. 5MG/GM. 1MG. NEPHROCAPS CAPS 1. 5MG.5MG.7MG.5%. 20MG.13MG. 60MG. 1MG.5MG/ML. 10MG. NE SUSP 10000UNIT/ML Covered NEOMYCIN/POLYMY XIN/DEXAMETHASO 0.75MG/ML. 10MG. ONE SUSP 10000UNIT/ML Covered NEOMYCIN/POLYMY XIN/HYDROCORTIS 1%.5MG/ML. 15MG Not Covered NEFAZODONE HCL TABS 100MG Not Covered NEFAZODONE HCL TABS 250MG Not Covered NEFAZODONE HCL TABS 150MG Not Covered NEFAZODONE HCL TABS 200MG Not Covered NEFAZODONE HCL TABS 50MG Not Covered NEOMYCIN SULFATE TABS 500MG Covered NEOMYCIN/BACITRA 400UNIT/GM. 25MG. XIN/GRAMICIDIN SOLN 10000UNIT/ML Not Covered NEOMYCIN/POLYMY 1%.

180MG. 1.25MG Not Covered NESINA TABS 12. NEPHRO-VITE RX TABS 1. 150MCG. NEPHRON FA TABS 1.5ML Covered PA NEUPOGEN SOSY 480MCG/0. 55MG. 20MG. NESTABS ABC MISC 10MG Not Covered NEUAC GEL 5%. 450UNIT. 1. 300MCG.6ML Not Covered NEUPOGEN SOSY 300MCG/0. 30UNIT. 10MG. 1. 10MG. 1750UNIT. 100MCG. 10MG.5MG Covered NESINA TABS 25MG Not Covered NESINA TABS 6. 1MG. 3MG. 32MG. 5MG. 300MCG.5MG Not Covered 200MG. 200MG. NEPHROCAPS QT TBDP 1. 50MG.6ML Not Covered NEUMEGA SOLR 5MG Not Covered NEUPOGEN SOLN 480MCG/1. 10MG. 10MCG.7MG.8ML Not Covered NEUPOGEN SOLN 300MCG/ML Covered PA NEUPRO PT24 4MG/24HR Not Covered NEUPRO PT24 3MG/24HR Not Covered NEUPRO PT24 1MG/24HR Not Covered NEUPRO PT24 8MG/24HR Not Covered NEUPRO PT24 2MG/24HR Not Covered NEUPRO PT24 6MG/24HR Not Covered NEURONTIN SOLN 250MG/5ML Not Covered NEVANAC SUSP 0.2% Not Covered NEUAC KIT KIT 5%.5MG Covered 60MG. 6MCG. 3MG. 6MCG.7MG. 20MG. 1. 75MG. 1MG.5MG Covered 40MG.10% Not Covered NEVIRAPINE TABS 200MG Not Covered NEVIRAPINE SUSP 50MG/5ML Not Covered NEVIRAPINE ER TB24 400MG Not Covered NEVIRAPINE ER TB24 100MG Not Covered NEXAVAR TABS 200MG Not Covered NEXIUM CPDR 20MG Not Covered NEXIUM CPDR 40MG Not Covered NEXIUM 24HR CPDR 20MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 112 of 178 . 120MG. 6MCG.7MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 100MG. 1.2% Not Covered NEULASTA SOSY 6MG/0. 1MG. 20MG. 20MG. 1MG. 10MG. 120MG.

500MCG.5MG.5MG Covered NIACIN TABS 100MG Covered NIACIN TABS 500MG Covered NIACIN ER CPCR 500MG Covered NIACIN ER TBCR 750MG Covered QL NIACIN ER TBCR 500MG Covered QL NIACIN ER TBCR 1000MG Covered QL NIACINAMIDE TABS 100MG Covered NIACINAMIDE TABS 500MG Covered NIACINAMIDE/AZELA IC AC/ TURMER/FA/B6/ZINC 0. 0. 500MCG. 0. 0. 12MG Covered 1. 12MG Covered NIACOR TABS 500MG Not Covered NIASPAN TBCR 1000MG Not Covered NIASPAN TBCR 750MG Not Covered NIASPAN TBCR 500MG Not Covered 50MG. 2MG. 750MG. 1. 20MG Covered NICARDIPINE HCL CAPS 20MG Covered QL NICARDIPINE HCL CAPS 30MG Covered QL 5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NEXT CHOICE ONE DOSE TABS 1. 8MG. 0. 5MG. NICAZEL TABS 600MG. 800MG. 0. 10MG Covered 0. 100MG. 5MG. 2MG. NICADAN TABS 10MG. 500MCG.5MG. 2MG. OX/COPPER TABS 0. NICAZEL FORTE TABS 8MG. 500MCG. 500MCG. NICOMIDE TABS 25MG Covered NICOTINE PT24 7MG/24HR Covered NICOTINE PT24 14MG/24HR Covered NICOTINE PT24 21MG/24HR Covered NICOTINE POLACRILEX GUM 4MG Covered NICOTINE POLACRILEX LOZG 4MG Covered NICOTINE POLACRILEX LOZG 2MG Covered NICOTINE POLACRILEX GUM 2MG Covered NICOTROL INHALER INHA 10MG Covered NICOTROL NS SOLN 10MG/ML Covered NIFEDIAC CC TB24 30MG Not Covered NIFEDIAC CC TB24 60MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 113 of 178 .

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NIFEDIAC CC TB24 90MG Not Covered NIFEDICAL XL TB24 60MG Not Covered NIFEDICAL XL TB24 30MG Not Covered NIFEDIPINE CAPS 10MG Covered QL AL NIFEDIPINE CAPS 20MG Covered QL AL NIFEDIPINE ER TB24 90MG Covered QL NIFEDIPINE ER TB24 30MG Covered QL NIFEDIPINE ER TB24 30MG Covered QL NIFEDIPINE ER TB24 90MG Covered QL NIFEDIPINE ER TB24 60MG Covered QL NIFEDIPINE ER TB24 60MG Covered QL NIGHTTIME SLEEP AID TABS 50MG Covered NIGHTTIME SLEEP AID TABS 25MG Not Covered NIKKI TABS 3MG.5MG Not Covered NISOLDIPINE TB24 34MG Not Covered NISOLDIPINE TB24 20MG Not Covered NISOLDIPINE TB24 17MG Not Covered NISOLDIPINE TB24 30MG Not Covered NISOLDIPINE ER TB24 25.5MG Not Covered NITROGLYCERIN TRANSDERMAL PT24 0. 0.1MG/HR Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 114 of 178 .5MG Not Covered NITROGLYCERIN ER CPCR 2.5MG Not Covered NISOLDIPINE TB24 40MG Not Covered NISOLDIPINE TB24 8.5MG Not Covered NITRO-BID OINT 2% Covered NITROFURANTOIN SUSP 25MG/5ML Covered AL NITROFURANTOIN MACROCRYSTALS CAPS 50MG Covered QL AL NITROFURANTOIN MACROCRYSTALS CAPS 100MG Covered QL AL NITROFURANTOIN MONOHYDRATE/MA CROCRYSTALS CAPS 100MG Covered QL AL NITROGLYCERIN ER CPCR 9MG Not Covered NITROGLYCERIN ER CPCR 6.25MG Not Covered NIRAVAM TBDP 2MG Not Covered NIRAVAM TBDP 1MG Not Covered NIRAVAM TBDP 0.02MG Covered NIMODIPINE CAPS 30MG Covered QL NIRAVAM TBDP 0.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NITROGLYCERIN TRANSDERMAL PT24 0.6MG/HR Covered QL NITROGLYCERIN TRANSDERMAL PT24 0.4MG/SPRAY Not Covered NITROSTAT SUBL 0.6MG Covered NITRO-TIME CPCR 9MG Not Covered NITRO-TIME CPCR 2. 0. 1MG Covered NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS 20MCG. 75MG.2MG/HR Covered QL NITROGLYCERIN TRANSDERMAL PT24 0. 100MG.5MG Not Covered NIVA-FOL TABS 2MG.35MG Covered NORDITROPIN FLEXPRO SOLN 15MG/1.4MG Covered NITROSTAT SUBL 0. 2.5ML Covered PA NORDITROPIN FLEXPRO SOLN 10MG/1.5ML Covered PA NORDITROPIN NORDIFLEX PEN SOLN 30MG/3ML Covered PA NORETHINDRONE & ETHINYL ESTRADIOL FERROUS FUMARATE CHEW 25MCG.5MG Covered QL NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS 5MCG.5ML Covered PA NORDITROPIN FLEXPRO SOLN 5MG/1. 65MG Not Covered NORA-BE TABS 0.4MG/HR Covered QL NITROLINGUAL PUMPSPRAY SOLN 0.5MG. 1MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 115 of 178 . 25MG Covered NIZATIDINE SOLN 15MG/ML Not Covered NODOLOR CAPS 325MG. 0.5MG Not Covered NITRO-TIME CPCR 6. 0.3MG Covered NITROSTAT SUBL 0.5MCG.8MG Covered NORETHINDRONE ACETATE TABS 5MG Covered QL NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS 2.

75MG. 0 Covered NORGESTIMATE/ET HINYL ESTRADIOL TABS 35MCG.5MG Covered NORTREL 1/35 TABS 35MCG. 1MG Covered NORGESTIMATE/ET HINYL ESTRADIOL TABS 0. 1% Not Covered NOVOEIGHT SOLR 250UNIT Not Covered NOVOEIGHT SOLR 3000UNIT Not Covered NOVOEIGHT SOLR 500UNIT Not Covered NOVOEIGHT SOLR 2000UNIT Not Covered NOVOEIGHT SOLR 1000UNIT Not Covered NOVOEIGHT SOLR 1500UNIT Not Covered NOVOLIN 70/30 SUSP 30UNIT/ML. 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERRO US FUMARATE TABS 20MCG.5/35 (28) TABS 35MCG. 1MG Covered NORTREL 7/7/7 TABS 0. 0. 2%.25MG Covered NORTHERA CAPS 300MG Not Covered NORTHERA CAPS 100MG Not Covered NORTHERA CAPS 200MG Not Covered NORTREL 0. 0 Covered NORTRIPTYLINE HCL CAPS 50MG Not Covered NORTRIPTYLINE HCL CAPS 10MG Not Covered NORTRIPTYLINE HCL CAPS 75MG Not Covered NORTRIPTYLINE HCL CAPS 25MG Not Covered NORVIR CAPS 100MG Not Covered NOVACORT GEL 1%. 75MG. 70UNIT/ML Covered NOVOLIN N SUSP 100UNIT/ML Covered NOVOLIN R SOLN 100UNIT/ML Covered NOVOLOG SOLN 100UNIT/ML Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 116 of 178 . 0 Covered NORGESTIMATE/ET HINYL ESTRADIOL TABS 0. 1MG Covered NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERRO US FUMARATE TABS 20MCG.

72GM.2GM Covered NUQUIN HP CREA 3%. NUTRICAP TABS 33. 80MCG. 25MCG. 5. 5MG. 1MG. 17MG.12MG/24HR Covered QL NUVESSA GEL 1. 200UNIT.30% Not Covered NUVIGIL TABS 250MG Not Covered NUVIGIL TABS 150MG Not Covered NUVIGIL TABS 50MG Not Covered NYMALIZE SOLN 60MG/20ML Not Covered NYSTATIN TABS 500000UNIT Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 117 of 178 . 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NOVOLOG FLEXPEN SOPN 100UNIT/ML Covered QL NOVOLOG MIX 70/30 SUSP 30UNIT/ML. 150MCG. 6000UNIT. 18MG Covered NUTROPIN AQ NUSPIN 10 SOLN 10MG/2ML Not Covered NUTROPIN AQ PEN SOLN 10MG/2ML Not Covered 0. 18MG. 400UNIT. NUVARING RING 0. 10MG.015MG/24HR.48GM. 2MG.125MG Not Covered NULYTELY/FLAVOR 420GM. 4%. 70UNIT/ML Covered NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN 30UNIT/ML. 2%. 10MG Not Covered NULEV TBDP 0. 25MCG. 1.5MCG. 2MG. 25MCG. 70UNIT/ML Covered QL NOVOLOG PENFILL SOCT 100UNIT/ML Covered QL NOVOSEVEN RT SOLR 5MG Not Covered NOXAFIL TBEC 100MG Not Covered NOXAFIL SUSP 40MG/ML Not Covered NUCYNTA TABS 75MG Not Covered NUCYNTA TABS 50MG Not Covered NUCYNTA TABS 100MG Not Covered NUCYNTA ER TB12 250MG Not Covered NUCYNTA ER TB12 50MG Not Covered NUCYNTA ER TB12 200MG Not Covered NUCYNTA ER TB12 100MG Not Covered NUCYNTA ER TB12 150MG Not Covered NUEDEXTA CAPS 20MG. 25MCG. 15MG. 10MG. 20MG. PACKS SOLR 11. 8% Not Covered 150MG.

5MG. 15MCG. 25MG. 1MG.25MG. 3MG. 2100UNIT.5MG/5ML Not Covered 120MG.03MG Covered OCTREOTIDE ACETATE SOLN 50MCG/ML Covered OCTREOTIDE ACETATE SOLN 100MCG/ML Covered OCTREOTIDE ACETATE SOLN 500MCG/ML Not Covered OCTREOTIDE ACETATE SOLN 1000MCG/ML Covered OCTREOTIDE ACETATE SOLN 200MCG/ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 118 of 178 . 2. 1MG.4MG. 30MG. 20UNIT. 1MG. 315UNIT. 30MG. 18UNIT.4MG. 10MG. 20MG. 0. 2MG. 15MG Covered QL AL OCELLA TABS 3MG. OB-NATAL ONE CAPS 330MG. OB COMPLETE TABS 3. 25MG Covered QL AL 90MG. 50MG. 2700UNIT. 12MCG. 30UNIT Covered OBREDON SOLN 200MG/5ML. 10MG. 7MG. 200MG. 29MG. 150MCG. 3. 0. 50MG. 65MCG. 2MG. 15MG. 20MG. 4MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL NYSTATIN SUSP 100000UNIT/ML Covered QL NYSTATIN POWD 0 Not Covered NYSTATIN CREA 100000UNIT/GM Covered NYSTATIN OINT 100000UNIT/GM Covered NYSTATIN POWD 100000UNIT/GM Covered QL NYSTOP POWD 100000UNIT/GM Not Covered NYTOL TABS 25MG Not Covered NYTOL MAXIMUM STRENGTH TABS 50MG Not Covered 120MG. 40MG. 260MG. 170UNIT. 25MG. OBSTETRIX EC TABS 3MG. 1. 400UNIT. 20MG. O-CAL FA TABS 2500UNIT. 400UNIT. 1MG. 100MG. 30MG. 10MG Covered 150MG. 27MG. 3MG. 12MCG. 30UNIT. 40MG.

1MG. 5MG. 40MG Not Covered ODOMZO CAPS 200MG Not Covered OFEV CAPS 100MG Not Covered OFEV CAPS 150MG Not Covered OFLOXACIN TABS 300MG Covered OFLOXACIN SOLN 0. 1100MG Not Covered OMNARIS SUSP 50MCG/ACT Not Covered OMNITROPE SOLN 5MG/1. 6MG Not Covered OLOPATADINE HCL SOLN 0.5MG Not Covered OLANZAPINE TABS 5MG Not Covered OLANZAPINE TABS 10MG Not Covered OLANZAPINE SOLR 10MG Not Covered OLANZAPINE TABS 20MG Not Covered OLANZAPINE TABS 2. 12MG Not Covered OLANZAPINE/FLUOX ETINE CAPS 25MG. 1MG. 465MG. 3MG Not Covered OLANZAPINE/FLUOX ETINE CAPS 25MG. 6MG Not Covered OLANZAPINE/FLUOX ETINE CAPS 50MG. OCUVEL CAPS 200UNIT.5MG Not Covered OLANZAPINE TABS 15MG Not Covered OLANZAPINE ODT TBDP 5MG Not Covered OLANZAPINE ODT TBDP 20MG Not Covered OLANZAPINE ODT TBDP 10MG Not Covered OLANZAPINE ODT TBDP 15MG Not Covered OLANZAPINE/FLUOX ETINE CAPS 50MG. 12MG Not Covered OLANZAPINE/FLUOX ETINE CAPS 25MG. 0. 1GM Covered PA OMEPRAZOLE CPDR 40MG Covered QL OMEPRAZOLE TBEC 20MG Covered QL OMEPRAZOLE CPDR 10MG Covered QL OMEPRAZOLE CPDR 20MG Covered QL OMEPRAZOLE/SODI UM BICARBONATE CAPS 20MG.60% Not Covered OLYSIO CAPS 150MG Not Covered OMEGA-3-ACID ETHYL ESTERS CAPS 375MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 250MG.5MG.5MG Covered OLANZAPINE TABS 7.30% Covered OFLOXACIN TABS 400MG Covered OGESTREL TABS 50MCG. 0.5ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 119 of 178 .

5MG/ML Not Covered ONFI TABS 10MG Not Covered ONFI TABS 20MG Not Covered ONGLYZA TABS 5MG Not Covered ONGLYZA TABS 2.5MG Not Covered OPANA TABS 10MG Not Covered OPANA TABS 5MG Not Covered OPANA ER (CRUSH RESISTANT) T12A 20MG Not Covered OPANA ER (CRUSH RESISTANT) T12A 10MG Not Covered OPANA ER (CRUSH RESISTANT) T12A 30MG Not Covered OPANA ER (CRUSH RESISTANT) T12A 40MG Not Covered OPANA ER (CRUSH RESISTANT) T12A 5MG Not Covered OPDIVO SOLN 40MG/4ML Not Covered OPDIVO SOLN 100MG/10ML Not Covered OPERAND POVIDONE/IODINE GEL 10% Not Covered OPIUM TINCTURE TINC 1% Not Covered OPSUMIT TABS 10MG Not Covered OPTICHAMBER ADVANTAGE MISC Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 120 of 178 . 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL OMONTYS SOLN 10MG/ML Covered OMONTYS SOLN 20MG/2ML Covered ONDANSETRON HCL SOLN 4MG/5ML Covered QL AL ONDANSETRON HCL TABS 4MG Covered QL ONDANSETRON HCL TABS 24MG Covered QL ONDANSETRON HCL TABS 8MG Covered QL ONDANSETRON ODT TBDP 4MG Covered QL ONDANSETRON ODT TBDP 8MG Covered QL ONEXTON GEL 3.75%.2% Not Covered ONFI SUSP 2.

30MG. 0 Not Covered ORAP TABS 1MG Not Covered ORAP TABS 2MG Not Covered ORENITRAM TBCR 0. 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL OPTICHAMBER ADVANTAGE/LARGE MASK MISC Covered QL OPTICHAMBER ADVANTAGE/MEDIU M FACE MASK MISC Covered QL OPTICHAMBER ADVANTAGE/SMALL FACE MASK MISC Covered QL OPTICHAMBER FACE MASK/LARGE MISC Covered QL OPTICHAMBER FACE MASK/MEDIUM MISC Covered QL OPTICHAMBER FACE MASK/SMALL MISC Covered QL OPTI-CLEAR SOLN 0. 200MG Not Covered ORPHENADRINE CITRATE ER TB12 100MG Covered QL AL ORPHENADRINE/AS A/CAFFEINE TABS 385MG. 0.5MG Not Covered ORFADIN CAPS 2MG Not Covered ORFADIN CAPS 10MG Not Covered ORFADIN CAPS 5MG Not Covered ORKAMBI TABS 125MG. 25MG Covered ORSYTHIA TABS 20MCG. 0.05% Covered OPTIVAR SOLN 0.05% Not Covered ORALAIR SUBL 0.125MG Not Covered ORENITRAM TBCR 0.1MG Covered ORTHO DIAPHRAGM COIL SPRING KIT 100 KIT Not Covered ORTHO DIAPHRAGM COIL SPRING KIT 105 KIT Not Covered ORTHO DIAPHRAGM COIL SPRING KIT 50 KIT Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 121 of 178 . 0.25MG Not Covered ORENITRAM TBCR 1MG Not Covered ORENITRAM TBCR 2.

5MG. 30MG Not Covered OSMOPREP TABS 0.102GM Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 122 of 178 .35MG Covered ORTHO TRI-CYCLEN TABS 0. 15MG Not Covered OSENI TABS 25MG. 30MG Not Covered OSENI TABS 25MG. 15MG Not Covered OSENI TABS 12. 1. 0 Covered ORTHO TRI-CYCLEN LO TABS 0.5MG.398GM.375MG Not Covered OSENI TABS 25MG. ORTHO EVRA PTWK 150MCG/24HR Not Covered ORTHO MICRONOR TABS 0. 45MG Not Covered OSENI TABS 12. 45MG Not Covered OSENI TABS 12. 1MG Covered OSCIMIN SR TB12 0. 0 Covered ORTHO-NOVUM 1/35 TABS 35MCG.5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ORTHO DIAPHRAGM FLAT SPRING KIT 55 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 60 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 65 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 70 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 75 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 80 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 85 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 90 KIT Not Covered ORTHO DIAPHRAGM FLAT SPRING KIT 95 KIT Not Covered 35MCG/24HR.

4MG Covered OXAPROZIN TABS 600MG Not Covered OXAZEPAM CAPS 15MG Not Covered OXAZEPAM CAPS 10MG Not Covered OXAZEPAM CAPS 30MG Not Covered OXCARBAZEPINE TABS 150MG Not Covered OXCARBAZEPINE TABS 600MG Not Covered OXCARBAZEPINE TABS 300MG Not Covered OXCARBAZEPINE SUSP 300MG/5ML Not Covered OXSORALEN ULTRA CAPS 10MG Not Covered OXTELLAR XR TB24 150MG Not Covered OXTELLAR XR TB24 600MG Not Covered OXTELLAR XR TB24 300MG Not Covered OXYBUTYNIN CHLORIDE SYRP 5MG/5ML Covered QL OXYBUTYNIN CHLORIDE TABS 5MG Covered QL OXYBUTYNIN CHLORIDE ER TB24 10MG Covered QL OXYBUTYNIN CHLORIDE ER TB24 15MG Covered QL OXYBUTYNIN CHLORIDE ER TB24 5MG Covered QL OXYCODONE HCL TABS 30MG Not Covered OXYCODONE HCL CONC 100MG/5ML Not Covered OXYCODONE HCL CAPS 5MG Covered OXYCODONE HCL TABS 5MG Covered QL OXYCODONE HCL TABS 15MG Not Covered OXYCODONE HCL TABS 10MG Not Covered OXYCODONE HCL SOLN 5MG/5ML Covered OXYCODONE HCL ER T12A 10MG Not Covered OXYCODONE HCL ER T12A 20MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 123 of 178 .4ML Not Covered OTREXUP SOAJ 15MG/0.4ML Not Covered OVACE PLUS WASH LIQD 10% Not Covered OVACE WASH LIQD 10% Not Covered OVCON-35 TABS 35MCG.4ML Not Covered OTREXUP SOAJ 25MG/0.4ML Not Covered OTREXUP SOAJ 10MG/0. 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL OSPHENA TABS 60MG Not Covered OTEZLA TABS 30MG Not Covered OTREXUP SOAJ 20MG/0.

5MG Not Covered OXYCODONE/ACET AMINOPHEN TABS 650MG.5MG Not Covered OXYMORPHONE HYDROCHLORIDE ER TB12 15MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 124 of 178 . 4. 5MG Covered OXYCODONE/ASPIR IN TABS 325MG. 10MG Covered OXYCODONE/ACET AMINOPHEN CAPS 500MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL OXYCODONE HCL ER T12A 40MG Not Covered OXYCODONE HCL ER T12A 80MG Not Covered OXYCODONE/ACET AMINOPHEN TABS 500MG. 10MG Covered QL OXYCODONE/ACET AMINOPHEN TABS 325MG. 7. 2.5MG Covered OXYCODONE/ACET AMINOPHEN TABS 325MG. 7.5MG Covered QL OXYCODONE/ACET AMINOPHEN TABS 325MG. 5MG Covered QL OXYCODONE/ACET AMINOPHEN TABS 325MG.835MG Not Covered OXYCONTIN T12A 15MG Not Covered OXYCONTIN T12A 20MG Not Covered OXYCONTIN T12A 60MG Not Covered OXYCONTIN T12A 10MG Not Covered OXYCONTIN T12A 40MG Not Covered OXYCONTIN T12A 80MG Not Covered OXYCONTIN T12A 30MG Not Covered OXYMORPHONE HYDROCHLORIDE TABS 5MG Not Covered OXYMORPHONE HYDROCHLORIDE TABS 10MG Not Covered OXYMORPHONE HYDROCHLORIDE ER TB12 30MG Not Covered OXYMORPHONE HYDROCHLORIDE ER TB12 20MG Not Covered OXYMORPHONE HYDROCHLORIDE ER TB12 7.

100MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 125 of 178 . PANCRELIPASE CPEP 17000UNIT Covered PANHEMATIN SOLR 313MG Not Covered PANTOPRAZOLE SODIUM TBEC 20MG Covered QL PANTOPRAZOLE SODIUM TBEC 40MG Covered QL PARCOPA TBDP 25MG.5MG Not Covered PALIPERIDONE ER TB24 9MG Not Covered PALIPERIDONE ER TB24 3MG Not Covered PALIPERIDONE ER TB24 6MG Not Covered 70000UNIT. 100MG Not Covered PARCOPA TBDP 10MG. 10500UNIT. 125UNIT Covered PACERONE TABS 200MG Not Covered PACERONE TABS 400MG Not Covered PACERONE TABS 100MG Not Covered PAIN & FEVER TABS 325MG Covered PALIPERIDONE ER TB24 1. 5000UNIT. 16800UNIT. PANCREAZE CPEP 10000UNIT Covered 43750UNIT. PANCREAZE CPEP 25000UNIT Covered 27000UNIT. 250MG Not Covered PARCOPA TBDP 25MG. 21000UNIT. 4200UNIT. 0 Covered OYSTER SHELL/VITAMIN D TABS 600MG. PANCREAZE CPEP 37000UNIT Covered 17500UNIT. 500MG Covered OYSTER SHELL CALCIUM/VITAMIN D TABS 250MG. PANCREAZE CPEP 40000UNIT Covered 61000UNIT. 125UNIT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL OXYMORPHONE HYDROCHLORIDE ER TB12 10MG Not Covered OXYMORPHONE HYDROCHLORIDE ER TB12 5MG Not Covered OXYMORPHONE HYDROCHLORIDE ER TB12 40MG Not Covered OYSTER SHELL CALCIUM TABS 500MG Covered OYSTER SHELL CALCIUM/VITAMIN D TABS 200UNIT.

20MEQ/L. 30MEQ/L.97GM.60% Not Covered PATANOL SOLN 0.86GM. 2.5MG Not Covered PATANASE SOLN 0.5MG Not Covered PAXIL CR TB24 37.5ML Not Covered PEGASYS SOLN 180MCG/ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 126 of 178 . 22.84GM.5MG Not Covered PAZEO SOLN 0.98GM.74GM. 6. S SOLR 5. 6. 22.5MG Not Covered PAROXETINE HCL ER TB24 37. 2. S SOLR 5.72GM.10% Not Covered PAXIL TABS 10MG Not Covered PAXIL TABS 40MG Not Covered PAXIL TABS 20MG Not Covered PAXIL TABS 30MG Not Covered PAXIL SUSP 10MG/5ML Not Covered PAXIL CR TB24 25MG Not Covered PAXIL CR TB24 12. ELECTROLYTE SOLN 45MEQ/L Covered PEDIPAK THPK 8%. 20% Not Covered PEG 3350 POWD 0 Covered PEG 3350/ELECTROLYTE 240GM. PEDIATRIC 25GM/L.70% Not Covered PEAK FLOW METER DEVI Covered QL 35MEQ/L.72GM Covered PEG- 3350/ELECTROLYTE 236GM.74GM Covered PEGANONE TABS 250MG Not Covered PEGASYS KIT 180MCG/0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PARICALCITOL SOLN 5MCG/ML Covered PARICALCITOL SOLN 2MCG/ML Covered PARICALCITOL CAPS 4MCG Covered PARICALCITOL CAPS 2MCG Covered PARICALCITOL CAPS 1MCG Covered PAROMOMYCIN SULFATE CAPS 250MG Covered PAROXETINE HCL TABS 30MG Not Covered PAROXETINE HCL TABS 40MG Not Covered PAROXETINE HCL TABS 20MG Not Covered PAROXETINE HCL TABS 10MG Not Covered PAROXETINE HCL ER TB24 25MG Not Covered PAROXETINE HCL ER TB24 12.

PEG-PREP KIT 2. 25MG Covered PENTAZOCINE/NAL OXONE HCL TABS 0.5ML Not Covered PEG-INTRON KIT 150MCG/0.50% Not Covered PENNSAID SOLN 2% Not Covered PENTASA CPCR 250MG Covered ST QL PENTASA CPCR 500MG Covered ST QL PENTAZOCINE/ACE TAMINOPHEN TABS 650MG.6GM Covered PENICILLIN V POTASSIUM TABS 250MG Covered PENICILLIN V POTASSIUM TABS 500MG Covered PENICILLIN V POTASSIUM SOLR 125MG/5ML Covered AL PENICILLIN V POTASSIUM SOLR 250MG/5ML Covered AL PENLET II AUTOMATIC BLOODSAMPLER KIT Covered PENNSAID SOLN 1.86GM. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PEGASYS PROCLICK SOLN 180MCG/0.5ML Not Covered PEGASYS PROCLICK SOLN 135MCG/0. 50MG Covered QL PENTOXIFYLLINE ER TBCR 400MG Covered PERFOROMIST NEBU 20MCG/2ML Not Covered PERINDOPRIL ERBUMINE TABS 8MG Not Covered PERINDOPRIL ERBUMINE TABS 4MG Covered QL PERINDOPRIL ERBUMINE TABS 2MG Covered QL PERJETA SOLN 420MG/14ML Not Covered PERMETHRIN CREA 5% Covered PERMETHRIN LOTN 1% Covered PERPHENAZINE TABS 8MG Not Covered PERPHENAZINE TABS 4MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 127 of 178 .5ML Not Covered 5MG.5MG. 210GM.74GM. 0. 5.5ML Not Covered PEG-INTRON KIT 50MCG/0.5ML Not Covered PEG-INTRON KIT 120MCG/0.5ML Not Covered PEG-INTRON KIT 80MCG/0.

8MG Not Covered PHENOBARBITAL TABS 97. 2MG Not Covered PERPHENAZINE/AMI TRIPTYLINE TABS 25MG.4MG Not Covered PHENTERMINE HCL CAPS 15MG Not Covered PHENTERMINE HCL CAPS 30MG Not Covered PHENTERMINE HCL TABS 37. 4MG Not Covered PERPHENAZINE/AMI TRIPTYLINE TABS 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PERPHENAZINE/AMI TRIPTYLINE TABS 10MG. 2MG Not Covered PEXEVA TABS 20MG Not Covered PEXEVA TABS 10MG Not Covered PEXEVA TABS 40MG Not Covered PEXEVA TABS 30MG Not Covered PHENADOZ SUPP 25MG Not Covered PHENAZOPYRIDINE HCL TABS 100MG Covered PHENAZOPYRIDINE HCL TABS 200MG Covered PHENELZINE SULFATE TABS 15MG Not Covered PHENOBARBITAL TABS 30MG Not Covered PHENOBARBITAL TABS 15MG Not Covered PHENOBARBITAL TABS 60MG Not Covered PHENOBARBITAL TABS 64.50% Covered PHENYLEPHRINE HCL SOLN 10% Not Covered PHENYTEK CAPS 200MG Not Covered PHENYTEK CAPS 300MG Not Covered PHENYTOIN SUSP 125MG/5ML Not Covered PHENYTOIN CHEW 50MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 128 of 178 .2MG Not Covered PHENOBARBITAL ELIX 20MG/5ML Not Covered PHENOBARBITAL TABS 100MG Not Covered PHENOBARBITAL TABS 16.2MG Not Covered PHENOBARBITAL TABS 32. 4MG Not Covered PERPHENAZINE/AMI TRIPTYLINE TABS 25MG. 4MG Not Covered PERPHENAZINE/AMI TRIPTYLINE TABS 10MG.5MG Not Covered PHENYLEPHRINE HCL SOLN 2.

5MG Not Covered PILOCARPINE HYDROCHLORIDE TABS 5MG Covered PIMOZIDE TABS 2MG Not Covered PIMOZIDE TABS 1MG Not Covered PIMTREA TABS 0.02% Not Covered PICATO GEL 0.4MG Covered PHOSLO CAPS 667MG Covered PHOSLYRA SOLN 667MG/5ML Covered PHOSPHOLINE IODIDE SOLR 0. 1MG Covered PIRMELLA 7/7/7 TABS 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PHENYTOIN SODIUM EXTENDED CAPS 100MG Not Covered PHILITH TABS 35MCG.5MG Not Covered PLASBUMIN-25 SOLN 25% Not Covered PLASMANATE SOLN 5% Not Covered PLAVIX TABS 75MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 129 of 178 .13% Covered PICATO GEL 0. 0.05% Not Covered PILOCARPINE HCL SOLN 1% Covered PILOCARPINE HCL SOLN 4% Covered PILOCARPINE HCL SOLN 2% Covered PILOCARPINE HCL TABS 7. 30MG Not Covered PIOGLITAZONE HCL- GLIMEPIRIDE TABS 2MG. 15MG Not Covered PIOGLITAZONE HCL/METFORMIN HCL TABS 850MG. 30MG Not Covered PIRMELLA 1/35 TABS 35MCG. 0 Covered PIROXICAM CAPS 20MG Not Covered PIROXICAM CAPS 10MG Not Covered PLAN B ONE-STEP TABS 1. 0 Covered PINDOLOL TABS 10MG Covered PINDOLOL TABS 5MG Covered PIOGLITAZONE HCL TABS 30MG Covered QL PIOGLITAZONE HCL TABS 15MG Covered QL PIOGLITAZONE HCL TABS 45MG Covered QL PIOGLITAZONE HCL/METFORMIN HCL TABS 500MG. 15MG Not Covered PIOGLITAZONE HCL- GLIMEPIRIDE TABS 4MG.

29MG. 1100UNIT. 2MG.1% Not Covered POMALYST CAPS 3MG Covered PA POMALYST CAPS 4MG Covered PA POMALYST CAPS 2MG Covered PA POMALYST CAPS 1MG Covered PA PONSTEL CAPS 250MG Not Covered PORTIA-28 TABS 0.5ML Not Covered PLEGRIDY STARTER PACK SOPN 0 Not Covered PNEUMOVAX 23 INJ 25MCG/0. 20MG.8MG. 2MG. 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PLEGRIDY SOPN 125MCG/0. PNV PRENATAL 3MG. 1MG.50% Covered POLYETHYLENE GLYCOL 3350 POWD 0 Covered POLY-IRON 150 FORTE CAPS 25MCG. 0. 200MG.03MG. 1. 150MG Covered POLYTRIM SOLN 10000UNIT/ML. 20MG. 10MG. 35MG Covered PODOFILOX SOLN 0. 1MG. 2MG.5MG. 12MCG. 15MG. 400UNIT. 22MG. 1000UNIT. 5MG. PNV-FIRST CAPS 20UNIT. PLUS MULTIVITAMIN TABS 4000UNIT. 1MG. 2.6MG. 200MG.84MG. 150MCG.5ML Covered QL AL 120MG. 0. 12MCG. 1. 27MG. 1.15MG Covered POTABA CAPS 500MG Covered POTASSIUM CHLORIDE SOLN 10% Covered POTASSIUM CHLORIDE SOLN 20% Covered POTASSIUM CHLORIDE PACK 20MEQ Covered POTASSIUM CHLORIDE ER TBCR 20MEQ Covered POTASSIUM CHLORIDE ER CPCR 10MEQ Covered POTASSIUM CHLORIDE ER TBCR 8MEQ Covered POTASSIUM CHLORIDE ER TBCR 10MEQ Covered POTASSIUM CHLORIDE ER CPCR 8MEQ Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 130 of 178 . 25MG Covered QL AL 30MG. 25MG Covered PODIAPN CAPS 300MG.

1100MG/5ML Covered POTASSIUM CITRATE-CITRIC ACID CRYSTALS PACK 1002MG.25MG Covered QL PRAMIPEXOLE DIHYDROCHLORIDE TABS 1MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 131 of 178 .50% Covered POVIDONE-IODINE SWAB 10% Covered POVIDONE-IODINE OINT 10% Covered PRADAXA CAPS 150MG Not Covered QL PRADAXA CAPS 75MG Not Covered QL PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.125MG Covered QL PRAMIPEXOLE DIHYDROCHLORIDE TABS 1.75MG Covered QL PRAMIPEXOLE DIHYDROCHLORIDE TABS 0. 224MG/ML Covered POTASSIUM PHOSPHATE SOLN 236MG/ML.5MG Covered QL PRAMIPEXOLE DIHYDROCHLORIDE TABS 0. 224MG/ML Covered POTIGA TABS 200MG Not Covered POTIGA TABS 300MG Not Covered POTIGA TABS 50MG Not Covered POTIGA TABS 400MG Not Covered POVIDONE-IODINE SOLN 10% Covered POVIDONE-IODINE SWAB 7. 224MG/ML Covered POTASSIUM PHOSPHATE SOLN 236MG/ML. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL POTASSIUM CHLORIDE ER TBCR 10MEQ Covered POTASSIUM CHLORIDE SR TBCR 8MEQ Covered POTASSIUM CITRATE ER TBCR 1080MG Covered POTASSIUM CITRATE ER TBCR 540MG Covered POTASSIUM CITRATE/CITRIC ACID SOLN 334MG/5ML. 3300MG Covered POTASSIUM PHOSPHATE SOLN 236MG/ML.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.5MG Not Covered PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 0.5MG Not Covered PRANDIN TABS 1MG Not Covered PRAVASTATIN SODIUM TABS 20MG Covered QL PRAVASTATIN SODIUM TABS 10MG Covered QL PRAVASTATIN SODIUM TABS 40MG Covered QL PRAVASTATIN SODIUM TABS 80MG Covered QL PRAZOSIN HCL CAPS 2MG Covered QL PRAZOSIN HCL CAPS 1MG Covered QL PRAZOSIN HCL CAPS 5MG Covered QL PRECOSE TABS 100MG Not Covered PRECOSE TABS 25MG Not Covered PRECOSE TABS 50MG Not Covered PRED MILD SUSP 0.5%. 1% Not Covered PRAMOSONE OINT 1%. 1% Not Covered PRAMOSONE OINT 2.5MG Covered QL PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 1.75MG Not Covered PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 4.375MG Not Covered PRAMOSONE CREA 2.3%.5%. 1% Not Covered PRAMOSONE LOTN 2. 1% Not Covered PRANDIMET TABS 500MG.5%.5MG Covered PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 3MG Covered PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 0. 1MG Not Covered PRANDIN TABS 2MG Not Covered PRANDIN TABS 0.12% Covered PRED-G SUSP 0. 1% Not Covered PRAMOSONE CREA 1%. 1% Not Covered PRAMOSONE LOTN 1%. 2MG Not Covered PRANDIMET TABS 500MG. 1% Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 132 of 178 .

17MG. 12MCG.5MG Covered QL PREMPRO TABS 0.5MG Covered 25MG.9MG Covered QL AL PREMARIN TABS 0.625MG Covered QL AL PREMARIN TABS 0.5MG Covered QL PREMPRO TABS 0. 0.625MG.3MG.5MG Covered QL PREMPRO TABS 0. 1MG.6% Not Covered PREDNICARBATE CREA 0.625MG/GM Covered AL PREMARIN TABS 0. 10MG. 2. 6MG. 400UNIT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL PRED-G S. 1. 10UNIT. 30MCG. 200MG.625MG.10% Not Covered PREDNICARBATE OINT 0. PREFERAOB ONE CAPS 15MG Not Covered PREMARIN TABS 0. 175MCG.45MG.625MG.25MG Covered QL AL PREMIUM CONDOMS LUBRICATED MISC Covered QL PREMPHASE TABS 0.45MG Covered QL AL PREMARIN CREA 0.O.P.3MG Covered QL AL PREMARIN TABS 1. 22MG. 5MG Covered QL PREMPRO TABS 0. 50MG. 5MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 133 of 178 .3%. OINT 0.10% Not Covered PREDNISOLONE SOLN 15MG/5ML Covered PREDNISOLONE ACETATE SUSP 1% Not Covered PREDNISOLONE SODIUM PHOSPHATE SOLN 15MG/5ML Covered PREDNISOLONE SODIUM PHOSPHATE SOLN 5MG/5ML Covered PREDNISOLONE SODIUM PHOSPHATE SOLN 1% Covered PREDNISONE TABS 20MG Covered PREDNISONE TABS 50MG Covered PREDNISONE TABS 10MG Covered PREDNISONE TABS 5MG Covered PREDNISONE SOLN 5MG/5ML Covered PREDNISONE TABS 1MG Covered PREDNISONE TABS 2. 1.

PRENATAL LOW 3MG. PRENATAL AD TABS 30UNIT. 15MG. PRENAFIRST TABS 4000UNIT. 29MG. 7MG. 400UNIT. 1. 400UNIT. 29MG. PRENATAL 19 CHEW 3MG. 17MG. 20MG. 20MG. 200MG. 15MG. 20MG. 150MCG. 3MG. 3MG. 400UNIT. 1MG. 30UNIT. 2. 200MG. 3MG. 1MG. 1MG. 3MG. 200MG. 0. 3MG. 20MG. 2MG. 12MCG. 1MG. 1000UNIT. 3MG. 22UNIT. 8MCG.4MG. 0. 3MG. 200MG. IRON TABS 4000UNIT. 7MG. 15MG Covered 120MG. 0. 30MG. 4000UNIT. 0. PRENATAL TABS 25MG Covered QL AL 100MG. 8MCG. 4000UNIT. 800MCG. 30UNIT. 3MG. 7MG. 12MCG. 200MG.8MG. 400UNIT.84MG. 2700UNIT. 3MG. 27MG. 10MG. 20MG. 30UNIT. 8MCG. 400UNIT.7MG. 4000UNIT. PRENATABS RX TABS 30UNIT. 8MCG. 30UNIT.6MG. 0. 12MCG. 30UNIT. 1. 3. 1MG. 90MG. 1MG. 12MCG. 3MG. 150MCG. PRENATABS FA TABS 400UNIT. 2MG. 29MG. 150MCG. PRENATAL 19 TABS 20MG Not Covered 100MG. 1MG. 1. 3MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 120MG. 20MG. 3MG. 15MG Covered 120MG. 50MG. 200MG. 200MG. 15MG Covered 120MG. 25MG Covered QL AL 120MG. 20MG. 1000UNIT. 20MG. 30MCG. 29MG. 20MG Covered QL AL 120MG. 100MG. 20MG. 28MG. 25MG Covered QL AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 134 of 178 . 400UNIT. 400UNIT. 3MG. 25MG. 3MG. 200MG.

6MG. 20MG. 1. 30UNIT. 11MG. 22UNIT. 0. 3. 29MG. 12MCG. 15MCG. 22MG. 1. 2MG. 1. 5MG. 10MG. 0. 0. 25MG. VITAMINS TABS 25MG Covered QL AL 100MG. 400UNIT.7MG.3MG. 4000UNIT. 200MG. PRENATAL 27MG.5MG. 7MG Not Covered PRESTALIA TABS 10MG. 22MG. 27MG. 8MCG. 27MG. 200MG. 200MG. 150MG. 400UNIT.84MG. 200MG. 3.5MG Not Covered PRESTALIA TABS 5MG. 25MG Covered QL AL 10MG. IRON TABS 4000UNIT. 12MCG. 4MCG. PRENATAL 1. 2.6MG.8MG. 1MG. 14MG Not Covered PREVACID CPDR 15MG Not Covered PREVACID CPDR 30MG Not Covered PREVACID 24HR CPDR 15MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 135 of 178 . 1. 0.8MG. 18MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 100MG. 106. 1MG. 1. 0. 10MG.8MG. 75MG. 20MG. 10MG. 400UNIT. 200MG. 800MCG. 1MG. 25MG Covered QL AL 120MG.5MG. 4MCG. 1MG. 25MG Covered AL 120MG. 12MCG. 1. 18MG. 3MG. 12MCG. 2. PRENATAL PLUS 3MG.5GM. 400MCG. 10MG Covered PRESTALIA TABS 2. 60MG.84MG. 2.7MG. PRENATAL 1. 6MG. PRENATAL MULTI 1. PRENATAL PLUS TABS 4000UNIT. 0. 28MG. 20MG. 200MG. 20MG. LOW IRON TABS 4000UNIT. 200MG. VITAMINS PLUS 3MG.7MG. 2MG. 28MG. 0.6MG.5MG. 400UNIT. 2MG.84MG. PRENATE AM TABS 500MG Covered AL PREPOPIK PACK 12GM. 1. 11UNIT. 30MG. 228MG. 800MCG. VITAMINS TABS 25MG Covered 120MG.5MG. 4000UNIT. 600MCG. +DHA CAPS 4000UNIT. 400UNIT. 25MG Covered QL AL 120MG. 400UNIT. PRENATAL-U CAPS 10MG Covered QL AL 200MG.

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
PREVACID
SOLUTAB TBDP 15MG Not Covered
PREVACID
SOLUTAB TBDP 30MG Not Covered
PREVALITE POWD 4GM/DOSE Not Covered
PREVALITE PACK 4GM Not Covered
PREVIDENT 5000
PLUS CREA 1.10% Covered
PREVIDENT
FLUORIDE GEL 1.10% Covered AL
PREVIFEM TABS 35MCG; 0.25MG Covered
PREVNAR 13 SUSP 0 Covered QL AL
PREVPAC MISC 500MG; 500MG; 30MG Not Covered
PREZCOBIX TABS 150MG; 800MG Not Covered
PREZISTA TABS 600MG Not Covered
PREZISTA TABS 75MG Not Covered
PREZISTA TABS 150MG Not Covered
PREZISTA TABS 800MG Not Covered
PRILOSEC OTC TBEC 20MG Covered QL
PRIMAQUINE
PHOSPHATE TABS 26.3MG Covered
PRIMIDONE TABS 250MG Not Covered
PRIMIDONE TABS 50MG Not Covered
PRISTIQ TB24 50MG Not Covered
PRISTIQ TB24 100MG Not Covered
PRISTIQ TB24 25MG Not Covered
PRIVIGEN SOLN 20GM/200ML Not Covered
PRIVIGEN SOLN 5GM/50ML Not Covered
PRIVIGEN SOLN 10GM/100ML Not Covered
PRIVIGEN SOLN 40GM/400ML Not Covered
PROAIR HFA AERS 108MCG/ACT Covered
PROAIR
RESPICLICK AEPB 108MCG/ACT Not Covered
PROBENECID TABS 500MG Covered
PROBENECID/COLC
HICINE TABS 0.5MG; 500MG Covered
PROCHLORPERAZIN
E SUPP 25MG Covered
PROCHLORPERAZIN
E MALEATE TABS 5MG Covered QL
PROCHLORPERAZIN
E MALEATE TABS 10MG Covered QL
PROCRIT SOLN 40000UNIT/ML Covered
PROCRIT SOLN 2000UNIT/ML Covered
PROCRIT SOLN 3000UNIT/ML Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 136 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL
PROCRIT SOLN 10000UNIT/ML Covered
PROCRIT SOLN 20000UNIT/ML Covered
PROCRIT SOLN 4000UNIT/ML Covered
PROCTOFOAM HC FOAM 1%; 1% Not Covered
PROCTOSOL HC CREA 2.50% Not Covered
PROCYSBI CPDR 25MG Not Covered
PROCYSBI CPDR 75MG Not Covered

PROFERRIN-FORTE TABS 1MG; 12MG Covered
PROGESTERONE CAPS 100MG Covered QL
PROGESTERONE CAPS 200MG Covered QL
PROLENSA SOLN 0.07% Not Covered
PROMACTA TABS 25MG Not Covered
PROMACTA TABS 50MG Not Covered
PROMETHAZINE
HCL SUPP 25MG Covered AL
PROMETHAZINE
HCL SUPP 12.5MG Covered AL
PROMETHAZINE
HCL TABS 25MG Covered AL
PROMETHAZINE
HCL TABS 12.5MG Covered AL
PROMETHAZINE
HCL SUPP 50MG Covered AL
PROMETHAZINE
HCL TABS 50MG Covered AL
PROMETHAZINE
HCL PLAIN SYRP 6.25MG/5ML Covered AL
PROMETHAZINE VC
PLAIN SYRP 5MG/5ML; 6.25MG/5ML Not Covered
PROMETHEGAN SUPP 50MG Not Covered

PROPAFENONE HCL TABS 225MG Covered

PROPAFENONE HCL TABS 150MG Covered

PROPAFENONE HCL TABS 300MG Covered
PROPANTHELINE
BROMIDE TABS 15MG Not Covered
PROPARACAINE
HCL SOLN 0.50% Covered

PROPRANOLOL HCL SOLN 20MG/5ML Covered

PROPRANOLOL HCL TABS 10MG Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 137 of 178

Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

PROPRANOLOL HCL TABS 80MG Covered

PROPRANOLOL HCL SOLN 40MG/5ML Covered

PROPRANOLOL HCL TABS 20MG Covered

PROPRANOLOL HCL TABS 40MG Covered

PROPRANOLOL HCL TABS 60MG Covered
PROPRANOLOL HCL
ER CP24 60MG Covered QL
PROPRANOLOL HCL
ER CP24 120MG Covered QL
PROPRANOLOL HCL
ER CP24 160MG Covered QL
PROPRANOLOL HCL
ER CP24 80MG Covered QL
PROPRANOLOL/HYD
ROCHLOROTHIAZID
E TABS 25MG; 40MG Not Covered
PROPRANOLOL/HYD
ROCHLOROTHIAZID
E TABS 25MG; 80MG Not Covered
PROPYLTHIOURACI
L TABS 50MG Covered
500MG; 10MG; 50MCG;
80MG; 0; 15MG; 25MG;
30MG; 1MG; 100MCG;
25MG; 1MG; 25MG; 32MG;
2MG; 10MCG; 20MG;
60MG; 15MG; 15MG;
10MCG; 15MG; 100UNIT;
PROTECTIRON TABS 5MG Covered
PROTOPIC OINT 0.03% Not Covered
PROTOPIC OINT 0.10% Not Covered
PROTRIPTYLINE
HCL TABS 10MG Not Covered
PROTRIPTYLINE
HCL TABS 5MG Not Covered
PROVENTIL HFA AERS 108MCG/ACT Covered

PA-Prior Authorization QL-Quantity Limit
ST-Step Therapy AL-Age Limit Page 138 of 178

03MG. 1MG. 69MG Not Covered QSYMIA CP24 7.5MG. 1.75MG. 1MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 300MCG. 20MG. 6MG. 400UNIT. 115.25MG. 23MG Not Covered QUALAQUIN CAPS 324MG Not Covered QUARTETTE TABS 0.25MG. 5MG.8ML Covered QSYMIA CP24 15MG. 16MG/5ML Not Covered PYRILAMINE- PHENYLEPHRINE SUSP 5MG/5ML. 125MG. 46MG Not Covered QSYMIA CP24 3. PLUS CAPS 18. PROVIDA OB CAPS 10MG Not Covered PROVIGIL TABS 100MG Not Covered PROVIGIL TABS 200MG Not Covered PROZAC CAPS 10MG Not Covered PROZAC CAPS 40MG Not Covered PROZAC CAPS 20MG Not Covered PROZAC WEEKLY CPDR 90MG Not Covered PULMICORT SUSP 1MG/2ML Not Covered PULMICORT FLEXHALER AEPB 90MCG/ACT Covered PULMICORT FLEXHALER AEPB 180MCG/ACT Covered PULMOZYME SOLN 1MG/ML Covered PA 10MG. 1. 10MG. 20MG. 200MG. 12MCG. 0.2MG Covered PURIXAN SUSP 2000MG/100ML Not Covered PYLERA CAPS 140MG. 162MG. 0 Not Covered QUASENSE TABS 0. 25MG. 16MG/5ML Covered QNASL AERS 80MCG/ACT Not Covered QNASL CHILDRENS AERS 40MCG/ACT Not Covered Q-PAP INFANTS SOLN 80MG/0. 20MG. 125MG Not Covered PYRAZINAMIDE TABS 500MG Covered PYRIDOSTIGMINE BROMIDE TABS 60MG Not Covered PYRIL D SUSP 5MG/5ML. 10MG. 2. 30MG. 30MG.15MG Covered QUDEXY XR CS24 150MG Not Covered QUDEXY XR CS24 50MG Not Covered QUDEXY XR CS24 200MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 139 of 178 .8MG. 15MCG. 92MG Not Covered QSYMIA CP24 11.3MG.2MG. 3.5MG. 0. PUREVIT DUALFE 6MG.5MG. 60MG.

5MG.5MG Covered QL RAMIPRIL CAPS 1.5MG.25MG Covered QL RAMIPRIL CAPS 5MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 140 of 178 . 20MG Not Covered QUINIDINE GLUCONATE CR TBCR 324MG Not Covered QUINIDINE SULFATE TABS 200MG Covered QUINIDINE SULFATE TABS 300MG Covered QUINIDINE SULFATE ER TBCR 300MG Covered QVAR AERS 40MCG/ACT Covered QVAR AERS 80MCG/ACT Covered RABAVERT SUSR 0 Covered AL RABEPRAZOLE SODIUM TBEC 20MG Not Covered RAGWITEK SUBL 12AMB A 1-U Not Covered RALOXIFENE HYDROCHLORIDE TABS 60MG Covered AL RAMIPRIL CAPS 10MG Covered QL RAMIPRIL CAPS 2. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL QUDEXY XR CS24 25MG Not Covered QUDEXY XR CS24 100MG Not Covered QUETIAPINE FUMARATE TABS 25MG Not Covered QUETIAPINE FUMARATE TABS 400MG Not Covered QUETIAPINE FUMARATE TABS 200MG Not Covered QUETIAPINE FUMARATE TABS 300MG Not Covered QUETIAPINE FUMARATE TABS 50MG Not Covered QUETIAPINE FUMARATE TABS 100MG Not Covered QUILLIVANT XR SUSR 25MG/5ML Not Covered QUINAPRIL HCL TABS 10MG Covered QL QUINAPRIL HCL TABS 5MG Covered QL QUINAPRIL HCL TABS 20MG Covered QL QUINAPRIL HCL TABS 40MG Covered QL QUINAPRIL/HYDROC HLOROTHIAZIDE TABS 25MG. 20MG Not Covered QUINAPRIL/HYDROC HLOROTHIAZIDE TABS 12. 10MG Not Covered QUINAPRIL/HYDROC HLOROTHIAZIDE TABS 12.

6ML Not Covered RASUVO SOAJ 10MG/0. 30MCG Covered RECOMBINATE SOLR 401-800 UNIT Not Covered RECOMBIVAX HB SUSP 40MCG/ML Covered QL AL RECOMBIVAX HB SUSP 5MCG/0.2ML Not Covered RASUVO SOAJ 17.45ML Not Covered RASUVO SOAJ 12.4ML Not Covered RASUVO SOAJ 22.5ML Not Covered REBIF REBIDOSE TITRATION PACK SOAJ 0 Not Covered REBIF TITRATION PACK SOSY 0 Not Covered QL RECLIPSEN TABS 0.5ML Not Covered QL REBIF REBIDOSE SOAJ 22MCG/0.5MG Not Covered RAPIVAB SOLN 200MG/20ML Not Covered RASUVO SOAJ 7.25ML Not Covered RASUVO SOAJ 15MG/0.5ML Covered QL AL RECOMBIVAX HB SUSP 10MCG/ML Covered QL AL RECTIV OINT 0.5MG/0.5ML Not Covered REBIF REBIDOSE SOAJ 44MCG/0.15MG.55ML Not Covered RASUVO SOAJ 30MG/0.5MG/0.5MG/0.15ML Not Covered RASUVO SOAJ 20MG/0.40% Not Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 141 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL RANEXA TB12 1000MG Covered RANEXA TB12 500MG Covered RANITIDINE HCL CAPS 150MG Covered RANITIDINE HCL CAPS 300MG Covered RANITIDINE HCL TABS 300MG Covered RANITIDINE HCL SYRP 75MG/5ML Covered QL RANITIDINE HCL TABS 150MG Covered RAPAFLO CAPS 4MG Not Covered RAPAFLO CAPS 8MG Not Covered RAPAMUNE TABS 1MG Not Covered RAPAMUNE TABS 2MG Not Covered RAPAMUNE SOLN 1MG/ML Not Covered RAPAMUNE TABS 0.35ML Not Covered RASUVO SOAJ 25MG/0.5ML Not Covered RAVICTI LIQD 1.5MG/0.3ML Not Covered RASUVO SOAJ 27.1GM/ML Not Covered RAYOS TBEC 5MG Not Covered RAYOS TBEC 1MG Not Covered RAYOS TBEC 2MG Not Covered RAZADYNE ER CP24 24MG Not Covered RAZADYNE ER CP24 8MG Not Covered RAZADYNE ER CP24 16MG Not Covered REBIF SOSY 44MCG/0.5ML Not Covered QL REBIF SOSY 22MCG/0.5MG/0.

5MG Covered RENVELA TABS 800MG Covered PA QL REPAGLINIDE TABS 1MG Covered QL REPAGLINIDE TABS 2MG Covered QL REPAGLINIDE TABS 0. 1.7MG.25MG Not Covered RESERPINE TABS 0.1MG Not Covered RESTASIS EMUL 0.6ML Not Covered RELPAX TABS 20MG Not Covered QL RELPAX TABS 40MG Not Covered QL RENAGEL TABS 800MG Covered RENAGEL TABS 400MG Covered 100MG. 10MG.05% Not Covered RESTORIL CAPS 7. 1. 6MCG. 10MG. 300MCG. 20MG.6ML Not Covered RELISTOR SOLN 12MG/0. RENA-VITE RX TABS 1. RENAL CAPS 1. 10MG. 1MG.01% Not Covered RELENZA DISKHALER AEPB 5MG/BLISTER Covered AL RELISTOR KIT 12MG/0.25MG Not Covered REQUIP TABS 3MG Not Covered REQUIP TABS 0.5MG Not Covered RETIN-A MICRO PUMP GEL 0.5MG Not Covered RESTORIL CAPS 22.08% Not Covered RETROVIR CAPS 100MG Not Covered REVATIO TABS 20MG Not Covered REVATIO SUSR 10MG/ML Not Covered REVESTA CAPS 5750UNIT.5MG Not Covered REQUIP TABS 5MG Not Covered REQUIP XL TB24 2MG Not Covered REQUIP XL TB24 12MG Not Covered REQUIP XL TB24 8MG Not Covered RESCRIPTOR TABS 100MG Not Covered RESCRIPTOR TABS 200MG Not Covered RESERPINE TABS 0.7MG. 6MCG.5MG Covered QL REQUIP TABS 1MG Not Covered REQUIP TABS 2MG Not Covered REQUIP TABS 4MG Not Covered REQUIP TABS 0. 1MG Not Covered REVIA TABS 50MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 142 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL REFISSA CREA 0. 1MG.5MG Covered 60MG. 5MG. 150MCG. 20MG.05% Not Covered REGLAN TABS 10MG Covered REGRANEX GEL 0.

5MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 143 of 178 .5MG Not Covered RISPERDAL TABS 4MG Not Covered RISPERDAL TABS 1MG Not Covered RISPERDAL TABS 2MG Not Covered RISPERDAL CONSTA SUSR 37. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL REVLIMID CAPS 25MG Covered QL REVLIMID CAPS 2.25MG Not Covered REXULTI TABS 2MG Not Covered REXULTI TABS 3MG Not Covered REYATAZ CAPS 200MG Not Covered REYATAZ CAPS 300MG Not Covered REYATAZ CAPS 150MG Not Covered REZIRA SOLN 5MG/5ML.5MG Covered REVLIMID CAPS 5MG Covered QL REVLIMID CAPS 10MG Covered QL REVLIMID CAPS 15MG Covered QL REXULTI TABS 1MG Not Covered REXULTI TABS 4MG Not Covered REXULTI TABS 0.25MG Not Covered RISPERDAL TABS 0. 60MG/5ML Not Covered RHINOCORT AQUA SUSP 32MCG/ACT Not Covered RIASTAP SOLR 0 Not Covered RIAX FOAM 5.50% Not Covered RIBAVIRIN TABS 200MG Not Covered RIBAVIRIN CAPS 200MG Not Covered RIFABUTIN CAPS 150MG Covered RIFAMPIN CAPS 150MG Not Covered RIFAMPIN CAPS 300MG Not Covered RILUTEK TABS 50MG Not Covered RILUZOLE TABS 50MG Not Covered QL RIMANTADINE HCL TABS 100MG Covered RISEDRONATE SODIUM TABS 150MG Not Covered RISEDRONATE SODIUM TABS 35MG Not Covered RISEDRONATE SODIUM TABS 5MG Not Covered RISEDRONATE SODIUM TABS 30MG Not Covered RISEDRONATE SODIUM DR TBEC 35MG Not Covered RISPERDAL TABS 3MG Not Covered RISPERDAL TABS 0.5MG Not Covered REXULTI TABS 0.50% Not Covered RIAX FOAM 9.

5MG Not Covered RISPERDAL M-TAB TBDP 2MG Not Covered RISPERDAL M-TAB TBDP 4MG Not Covered RISPERIDONE TABS 0.5MG Covered AL RIVASTIGMINE TARTRATE CAPS 6MG Covered AL RIVASTIGMINE TRANSDERMAL SYSTEM PT24 13.5MG Not Covered RISPERDAL M-TAB TBDP 1MG Not Covered RISPERDAL M-TAB TBDP 3MG Not Covered RISPERDAL M-TAB TBDP 0.25MG Not Covered RISPERIDONE TABS 4MG Not Covered RISPERIDONE TABS 0.5MG Covered AL RIVASTIGMINE TARTRATE CAPS 3MG Covered AL RIVASTIGMINE TARTRATE CAPS 1.5MG Not Covered RISPERIDONE M- TAB TBDP 3MG Not Covered RITALIN LA CP24 10MG Not Covered RITALIN LA CP24 30MG Not Covered RITALIN LA CP24 20MG Not Covered RITALIN LA CP24 40MG Not Covered RITALIN LA CP24 60MG Not Covered RIVASTIGMINE TARTRATE CAPS 4.5MG Not Covered RISPERIDONE TABS 1MG Not Covered RISPERIDONE TABS 2MG Not Covered RISPERIDONE SOLN 1MG/ML Not Covered RISPERIDONE TABS 3MG Not Covered RISPERIDONE M- TAB TBDP 4MG Not Covered RISPERIDONE M- TAB TBDP 2MG Not Covered RISPERIDONE M- TAB TBDP 1MG Not Covered RISPERIDONE M- TAB TBDP 0.3MG/24HR Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 144 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL RISPERDAL CONSTA SUSR 50MG Not Covered RISPERDAL CONSTA SUSR 25MG Not Covered RISPERDAL CONSTA SUSR 12.

25MG.5MG Covered QL ROPINIROLE HCL TABS 5MG Covered QL ROPINIROLE HCL TABS 3MG Covered QL ROPINIROLE HCL TABS 4MG Covered QL ROSUVASTATIN CALCIUM TABS 5MG Not Covered ROSUVASTATIN CALCIUM TABS 10MG Not Covered ROSUVASTATIN CALCIUM TABS 20MG Not Covered ROSUVASTATIN CALCIUM TABS 40MG Not Covered ROWASA KIT 4GM Not Covered ROXICET TABS 325MG.6MG/24HR Covered QL RIVASTIGMINE TRANSDERMAL SYSTEM PT24 9. 5MG Covered QL ROZEREM TABS 8MG Not Covered RUCONEST SOLR 2100UNIT Not Covered RYTARY CPCR 61. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL RIVASTIGMINE TRANSDERMAL SYSTEM PT24 4. 245MG Not Covered RYTARY CPCR 48.75MG.25MG. 145MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 145 of 178 .25MG Covered QL ROPINIROLE HCL TABS 0.5MG/24HR Covered QL RIXUBIS SOLR 250UNIT Not Covered RIXUBIS SOLR 2000UNIT Not Covered RIXUBIS SOLR 500UNIT Not Covered RIXUBIS SOLR 3000UNIT Not Covered RIXUBIS SOLR 1000UNIT Not Covered RIZATRIPTAN BENZOATE TABS 10MG Covered QL RIZATRIPTAN BENZOATE TABS 5MG Covered QL RIZATRIPTAN BENZOATE ODT TBDP 5MG Covered QL RIZATRIPTAN BENZOATE ODT TBDP 10MG Covered QL ROPINIROLE ER TB24 8MG Not Covered ROPINIROLE ER TB24 2MG Not Covered ROPINIROLE ER TB24 12MG Not Covered ROPINIROLE ER TB24 4MG Not Covered ROPINIROLE HCL TABS 1MG Covered QL ROPINIROLE HCL TABS 2MG Covered QL ROPINIROLE HCL TABS 0. 195MG Not Covered RYTARY CPCR 36.

75MG.5MG Not Covered SAVAYSA TABS 15MG Not Covered SAVAYSA TABS 30MG Not Covered SAVAYSA TABS 60MG Not Covered SAVELLA TABS 100MG Not Covered SAVELLA TABS 25MG Not Covered SAVELLA TABS 50MG Not Covered SAVELLA TABS 12.5MG Not Covered SAVELLA TITRATION PACK MISC 0 Not Covered SAXENDA SOPN 18MG/3ML Not Covered SECONAL CAPS 100MG Not Covered SELECT-LITE DEVICE/LANCETS KIT Covered SELEGILINE HCL TABS 5MG Not Covered SELEGILINE HCL CAPS 5MG Not Covered SELENIUM SULFIDE LOTN 2. 95MG Not Covered SABRIL PACK 500MG Not Covered SABRIL TABS 500MG Not Covered SAFYRAL TABS 3MG. 0.03MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL RYTARY CPCR 23. 0.50% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 146 of 178 .451MG Covered SALEX SHAM 6% Not Covered SALEX CREAM KIT 6% Not Covered SALEX LOTION KIT 6% Not Covered SALICYLIC ACID SHAM 6% Not Covered SALICYLIC ACID LOTN 6% Not Covered SALICYLIC ACID CREA 6% Not Covered SALICYLIC ACID CREAM KIT 6% Not Covered SALICYLIC ACID LOTION KIT 6% Not Covered SALSALATE TABS 500MG Not Covered SALSALATE TABS 750MG Not Covered SAMSCA TABS 30MG Not Covered SAMSCA TABS 15MG Not Covered SANCTURA TABS 20MG Not Covered SANCUSO PTCH 3.1MG/24HR Not Covered QL SANDOSTATIN SOLN 50MCG/ML Not Covered SANDOSTATIN SOLN 200MCG/ML Not Covered SANDOSTATIN SOLN 100MCG/ML Not Covered SANTYL OINT 250UNIT/GM Covered SAPHRIS SUBL 5MG Not Covered SAPHRIS SUBL 10MG Not Covered SAPHRIS SUBL 2.

10% Covered SHAROBEL TABS 0.2MG Covered SEVELAMER CARBONATE TABS 800MG Covered QL SF GEL 1.8MG. 10MG. 1MG. SE-TAN PLUS CAPS 18.6MG Covered SENSIPAR TABS 30MG Covered PA QL SENSIPAR TABS 90MG Covered PA QL SENSIPAR TABS 60MG Covered PA QL SEREVENT DISKUS AEPB 50MCG/DOSE Covered QL SEROMYCIN CAPS 250MG Not Covered SEROQUEL TABS 25MG Not Covered SEROQUEL TABS 100MG Not Covered SEROQUEL TABS 300MG Not Covered SEROQUEL TABS 200MG Not Covered SEROQUEL TABS 50MG Not Covered SEROQUEL XR TB24 400MG Not Covered SEROQUEL XR TB24 300MG Not Covered SEROQUEL XR TB24 200MG Not Covered SEROQUEL XR TB24 50MG Not Covered SEROQUEL XR TB24 150MG Not Covered SERTRALINE HCL TABS 25MG Not Covered SERTRALINE HCL CONC 20MG/ML Not Covered SERTRALINE HCL TABS 50MG Not Covered SERTRALINE HCL TABS 100MG Not Covered 10MG. 0. 8.3MG/ML Not Covered SIGNIFOR SOLN 0.10% Covered AL SF 5000 PLUS CREA 1. 1. 5MG. 0 Covered SELRX SHAM 0.9MG/ML Not Covered SIGNIFOR LAR SUSR 40MG Not Covered SIGNIFOR LAR SUSR 20MG Not Covered SIGNIFOR LAR SUSR 60MG Not Covered SILDENAFIL TABS 20MG Covered PA PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 147 of 178 .6MG Covered SENNA PLUS TABS 50MG.25%. 0 Not Covered SELZENTRY TABS 150MG Not Covered SELZENTRY TABS 300MG Not Covered SENNA TABS 8. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL SELENIUM SULFIDE SHAM 0. 6MG.2MG. 162MG.3%. 15MCG. 30MG. 2. 115.6MG Covered SENNA LAXATIVE TABS 8.3MG. 2. 200MG.6MG/ML Not Covered SIGNIFOR SOLN 0.35MG Covered SIGNIFOR SOLN 0.

5% Not Covered SIMBRINZA SUSP 0. 75MG/GM. 1%.038%.2%. 20MG Not Covered SIMCOR TB24 1000MG. 50MG/GM Not Covered SLEEP-TABS TABS 25MG Not Covered SM ASPIRIN TABS 325MG Covered AL SMOOTH LAX POWD 0 Covered SODIUM CHLORIDE NEBU 7% Covered SODIUM CHLORIDE NEBU 0. 500MG/5ML Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 148 of 178 . 20MG Not Covered SIMETHICONE CHEW 80MG Covered SIMPLE SYRUP SYRP 0 Covered SIMPLY SLEEP TABS 25MG Not Covered SIMPONI SOSY 50MG/0. 20MG Not Covered SIMCOR TB24 750MG.5ML Not Covered SIMPONI ARIA SOLN 50MG/4ML Not Covered SIMVASTATIN TABS 40MG Covered QL SIMVASTATIN TABS 10MG Covered QL SIMVASTATIN TABS 80MG Covered QL SIMVASTATIN TABS 5MG Covered QL SIMVASTATIN TABS 20MG Covered QL SINGULAIR TABS 10MG Not Covered SINGULAIR PACK 4MG Not Covered SINGULAIR CHEW 5MG Not Covered SINGULAIR CHEW 4MG Not Covered SIROLIMUS TABS 0. 1% Not Covered SIMCOR TB24 500MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL SILENOR TABS 3MG Not Covered SILENOR TABS 6MG Not Covered SILVADENE CREA 1% Not Covered SILVER SULFADIAZINE CREA 1% Not Covered SILVERA PAIN RELIEF PTCH 0.90% Covered SODIUM CITRATE GRAN 0 Covered SODIUM CITRATE/CITRIC ACID SOLN 334MG/5ML.5MG Covered SIROLIMUS TABS 1MG Covered SIROLIMUS TABS 2MG Covered SIRTURO TABS 100MG Not Covered SITAVIG TABS 50MG Not Covered SIVEXTRO TABS 200MG Not Covered SKIN BLEACHING/SUNSC REEN CREA 4%.

5MG/ML Covered SODIUM FLUORIDE CHEW 0.25MG Covered AL SODIUM FLUORIDE CHEW 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL SODIUM FERRIC GLUCONATE COMPLEX/SUCROS E SOLN 12.5MG Covered QL AL SODIUM FLUORIDE CHEW 1MG Covered QL AL SODIUM FLUORIDE SOLN 0.3ML Not Covered SOMATULINE DEPOT SOLN 120MG/0.5ML Not Covered SOMINEX TABS 25MG Not Covered SOMINEX MAXIMUM STRENGTH TABS 50MG Not Covered SONATA CAPS 10MG Not Covered SONATA CAPS 5MG Not Covered SOOLANTRA CREA 1% Not Covered SORBITOL SOLN 70% Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 149 of 178 .2ML Not Covered SOMATULINE DEPOT SOLN 90MG/0.5MG/ML Covered QL AL SODIUM PHENYLBUTYRATE POWD 3GM/TSP Not Covered SODIUM PHOSPHATE SOLN 3MMOLE/ML Covered SODIUM POLYSTYRENE SULFONATE SUSP 15GM/60ML Covered SODIUM POLYSTYRENE SULFONATE POWD 0 Covered SODIUM POLYSTYRENE SULFONATE SUSP 50GM/200ML Covered SODIUM SULFACETAMIDE SOLN 10% Covered SODIUM SULFACETAMIDE WASH LIQD 10% Not Covered SOLARAZE GEL 3% Not Covered SOLIRIS SOLN 10MG/ML Not Covered SOMATULINE DEPOT SOLN 60MG/0.

25MG. 200MG. 25MG Covered QL SPRINTEC 28 TABS 35MCG. 125MG Not Covered STALEVO 150 TABS 37. 0. 150MG Not Covered STALEVO 200 TABS 50MG. 100MG Not Covered STALEVO 125 TABS 31.5MG Not Covered SORINE TABS 80MG Not Covered SORINE TABS 240MG Not Covered SORINE TABS 120MG Not Covered SORINE TABS 160MG Not Covered SOTALOL HCL TABS 120MG Covered QL SOTALOL HCL TABS 80MG Covered QL SOTALOL HCL TABS 240MG Covered QL SOTALOL HCL TABS 160MG Covered QL SOTALOL HCL (AF) TABS 160MG Covered SOTALOL HCL (AF) TABS 120MG Covered SOTALOL HCL (AF) TABS 80MG Covered SOTYLIZE SOLN 5MG/ML Not Covered SOVALDI TABS 400MG Not Covered SPECTRACEF TABS 400MG Not Covered SPECTRACEF TABS 200MG Not Covered SPINOSAD SUSP 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL SORIATANE CAPS 25MG Not Covered SORIATANE CAPS 10MG Not Covered SORIATANE CAPS 17.5MCG/ACT Covered QL AL SPIRONOLACTONE TABS 100MG Covered QL SPIRONOLACTONE TABS 25MG Covered QL SPIRONOLACTONE TABS 50MG Covered QL SPIRONOLACTONE/ HYDROCHLOROTHI AZIDE TABS 25MG.5MG.25MG Covered SPRIX SOLN 15.75MG/SPRAY Not Covered SPRYCEL TABS 70MG Not Covered SPRYCEL TABS 20MG Not Covered SPRYCEL TABS 50MG Not Covered SPRYCEL TABS 100MG Not Covered SPS SUSP 15GM/60ML Covered SRONYX TABS 20MCG.90% Not Covered SPIRIVA HANDIHALER CAPS 18MCG Covered QL SPIRIVA RESPIMAT AERS 2. 200MG. 200MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 150 of 178 . 0. 200MG. 200MG.1MG Covered SSD CREA 1% Not Covered SSKI SOLN 1GM/ML Not Covered STALEVO 100 TABS 25MG.

200MG.75MG.5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL STALEVO 50 TABS 12. 200MG.5MCG/ACT Not Covered STIVARGA TABS 40MG Not Covered STOOL SOFTENER CAPS 100MG Covered STOOL SOFTENER LAXATIVE DC CAPS 240MG Covered STRATTERA CAPS 60MG Not Covered STRATTERA CAPS 10MG Not Covered STRATTERA CAPS 40MG Not Covered STRATTERA CAPS 80MG Not Covered STRATTERA CAPS 18MG Not Covered STRATTERA CAPS 100MG Not Covered STRATTERA CAPS 25MG Not Covered 150MG. 150MG.5ML Not Covered STELARA SOSY 90MG/ML Not Covered STENDRA TABS 50MG Not Covered STENDRA TABS 200MG Not Covered STENDRA TABS 100MG Not Covered STIMATE SOLN 1. STRIBILD TABS 300MG Not Covered STRIVERDI RESPIMAT AERS 2.5MG/ML Covered QL STIMULANT LAXATIVE TBEC 5MG Covered STIOLTO RESPIMAT AERS 2. 50MG Not Covered STALEVO 75 TABS 18.5MCG/ACT. 200MG. 2.5MCG/ACT Not Covered STROMECTOL TABS 3MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 151 of 178 . 75MG Not Covered STARLIX TABS 60MG Not Covered STARLIX TABS 120MG Not Covered STAVUDINE CAPS 15MG Not Covered STAVUDINE CAPS 40MG Not Covered STAVUDINE CAPS 30MG Not Covered STAVUDINE SOLR 1MG/ML Not Covered STAVUDINE CAPS 20MG Not Covered STAVZOR CPDR 125MG Not Covered STAVZOR CPDR 250MG Not Covered STAVZOR CPDR 500MG Not Covered STAXYN TBDP 10MG Not Covered STELARA SOSY 45MG/0.

100MCG. 1MG. 0. 2MG Not Covered SUBOXONE FILM 12MG.5MG Not Covered SUBOXONE FILM 8MG. SUCLEAR KIT 17. 50MCG.13GM/180ML. 0.6GM/180ML. 10MG. 15MG Covered 15MG. 25MG. 15MG. 0. 50MCG.23%. 5. 25MG. 2. 5MG. 80MG Covered SULFAMETHOXAZO LE/TRIMETHOPRIM SUSP 200MG/5ML. 3.74GM. 0. 20MG. 60UNIT. 1000UNIT. 1MG Not Covered 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 500MG. 25MG.5GM/180ML Covered SUCRAID SOLN 8500UNIT/ML Not Covered SUCRALFATE TABS 1GM Covered QL SUCRALFATE SUSP 1GM/10ML Not Covered SULFACETAMIDE SODIUM SOLN 10% Covered SULFACETAMIDE SODIUM OINT 10% Covered SULFACETAMIDE SODIUM/PREDNISO LONE SODIUM PHOSPHATE SOLN 0.1MG. 20MG. 3MG.8MG. STROVITE ONE TABS 25MG Covered SUBOXONE FILM 2MG. STROVITE FORTE TABS 3000UNIT.15MG.5MG. 5MG. 100UNIT. 1. 10% Covered SULFAMETHOXAZO LE/TRIMETHOPRIM SUSP 200MG/5ML. 100MG. 50MG. 40MG/5ML Not Covered SULFAMETHOXAZO LE/TRIMETHOPRIM TABS 400MG. 50MCG. 1. 3MG Not Covered SUBOXONE FILM 4MG. 20MG. 50MG.6GM. 25MCG. 3000UNIT. 0.5MG. 25MG.86GM. 50MCG. 100MCG. 40MG/5ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 152 of 178 . 210GM. 300MG. 1000UNIT.

Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL SULFAMETHOXAZO LE/TRIMETHOPRIM DS TABS 800MG. 100MG. SUPERVITE EC TBEC 100UNIT. 29MG Covered SUPRAX SUSR 200MG/5ML Not Covered SUPRAX SUSR 100MG/5ML Not Covered SUPRAX CHEW 100MG Not Covered SUPRAX CHEW 200MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 153 of 178 . 1MG/15ML. 6MCG. 20MG/15ML. 1MG. 10MG/15ML. 10MG/15ML.5ML Not Covered 25MCG/15ML. 2700UNIT.5ML Not Covered SUMAVEL DOSEPRO SOTJ 6MG/0.5ML Covered QL SUMATRIPTAN SUCCINATE REFILL SOCT 6MG/0. 100MG/15ML. 5MG.5ML Covered QL SUMAVEL DOSEPRO SOTJ 4MG/0. 20MG. SUPERVITE LIQD 75MG/15ML Covered 400MG. 1000MG/15ML. 10MG.5ML Covered QL SUMATRIPTAN SUCCINATE REFILL SOCT 4MG/0. 400UNIT. 160MG Covered SULFASALAZINE TABS 500MG Not Covered SULFASALAZINE TBEC 500MG Covered SULINDAC TABS 200MG Covered SULINDAC TABS 150MG Covered SUMATRIPTAN SOLN 20MG/ACT Not Covered QL SUMATRIPTAN SOLN 5MG/ACT Not Covered SUMATRIPTAN SUCCINATE TABS 25MG Covered QL SUMATRIPTAN SUCCINATE TABS 50MG Covered QL SUMATRIPTAN SUCCINATE TABS 100MG Covered QL SUMATRIPTAN SUCCINATE SOAJ 6MG/0.5ML Covered QL SUMATRIPTAN SUCCINATE SOAJ 4MG/0. 6MG.5ML Covered QL SUMATRIPTAN SUCCINATE SOLN 6MG/0. 2MG/15ML.

5MG Covered TACROLIMUS OINT 0.5GM/180ML Covered SURMONTIL CAPS 50MG Not Covered SURMONTIL CAPS 100MG Not Covered SURMONTIL CAPS 25MG Not Covered SUSTIVA CAPS 50MG Not Covered SUSTIVA CAPS 200MG Not Covered SUSTIVA TABS 600MG Not Covered SUTENT CAPS 50MG Not Covered SUTENT CAPS 37. 0.7ML Not Covered SYMLINPEN 60 SOPN 1500MCG/1.03% Covered TACROLIMUS CAPS 0.375MG Not Covered SYMBICORT AERO 80MCG/ACT. 1000MG Not Covered SYNJARDY TABS 5MG. 3MG Not Covered SYMBYAX CAPS 25MG.005% Not Covered TACROLIMUS CAPS 1MG Covered TACROLIMUS OINT 0.5ML Not Covered SYNALGOS-DC CAPS 356. 4.5MG.5MCG/ACT Covered 160MCG/ACT. 500MG Not Covered SYNRIBO SOLR 3. 6MG Not Covered SYMLINPEN 120 SOPN 2700MCG/2. 12MG Not Covered SYMBYAX CAPS 25MG.03MG Covered SYLATRON KIT 200MCG Not Covered SYLATRON KIT 600MCG Not Covered SYLATRON KIT 300MCG Not Covered SYMAX DUOTAB TBCR 0.5MG Not Covered TABLOID TABS 40MG Covered TACLONEX SUSP 0.5MG Not Covered SUTENT CAPS 25MG Not Covered SYEDA TABS 3MG. 1000MG Not Covered SYNJARDY TABS 12. SYMBICORT AERO 4. SUPREP BOWEL 3. 30MG.4MG.5MG.5MG Not Covered SUTENT CAPS 12. 500MG Not Covered SYNJARDY TABS 5MG.13GM/180ML.5MCG/ACT Covered SYMBYAX CAPS 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL SUPRAX SUSR 500MG/5ML Covered SUPRAX CAPS 400MG Covered 1.6GM/180ML.10% Covered TACROLIMUS CAPS 5MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 154 of 178 . 0. 6MG Not Covered SYMBYAX CAPS 50MG. 12MG Not Covered SYMBYAX CAPS 25MG. PREP SOLN 17. 16MG Not Covered SYNAREL SOLN 2MG/ML Not Covered SYNJARDY TABS 12.064%.

240MG Not Covered TARKA TBCR 2MG. 72. 38MG.82ML. 240MG Not Covered 60MG.82ML. 115. TBC AERS 0. 5MG.2MG. 0.8MG. 0. 2MG. 6MG. 1.82ML Not Covered TECFIDERA CPDR 240MG Covered PA QL TECFIDERA CPDR 120MG Covered PA QL TECFIDERA STARTER PACK MISC 0 Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 155 of 178 . 2MG.8MG. 12. 300MCG. 80MG. 25MCG. 200MG. 1MG. 180MG Not Covered TARKA TBCR 1MG. 310MG. 25MG. 156MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TAFINLAR CAPS 50MG Not Covered TAFINLAR CAPS 75MG Not Covered TAMIFLU CAPS 45MG Covered QL TAMIFLU CAPS 30MG Covered QL TAMIFLU SUSR 6MG/ML Covered QL AL TAMIFLU CAPS 75MG Covered QL TAMOXIFEN CITRATE TABS 10MG Covered QL TAMOXIFEN CITRATE TABS 20MG Covered QL TAMSULOSIN HCL CAPS 0. 10MG. TARON FORTE CAPS 1MG.3MG. 1.5MCG. 0. 53. 200MG. TANDEM PLUS CAPS 18. 162MG. 15MCG.4MG Covered QL 10MG. TARON-C DHA CAPS 10MG Not Covered TASIGNA CAPS 200MG Not Covered TASIGNA CAPS 150MG Not Covered TASMAR TABS 100MG Not Covered 650MG/0. 3MG. 39MG.5MG. 5MG. 1MG.5MG/0. 240MG Not Covered TARKA TBCR 4MG.1MG/0.2MG Covered TANZEUM PEN 50MG Covered PA QL TANZEUM PEN 30MG Covered PA QL TARCEVA TABS 100MG Not Covered TARCEVA TABS 150MG Not Covered TARCEVA TABS 25MG Not Covered TARGRETIN CAPS 75MG Covered PA TARGRETIN GEL 1% Not Covered TARKA TBCR 2MG. 5MG. 70MG Covered 25MG. 30MG.

25MG Covered PA QL TEMAZEPAM CAPS 15MG Not Covered TEMAZEPAM CAPS 30MG Not Covered TEMAZEPAM CAPS 22. 75MG. 12.5MG Covered TERCONAZOLE SUPP 80MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 156 of 178 . 10MG Not Covered TEKAMLO TABS 150MG.80% Covered TERAZOSIN HCL CAPS 1MG Covered QL TERAZOSIN HCL CAPS 2MG Covered QL TERAZOSIN HCL CAPS 5MG Covered TERAZOSIN HCL CAPS 10MG Covered QL TERBINAFINE HCL TABS 250MG Covered QL TERBINAFINE HCL CREA 1% Not Covered TERBUTALINE SULFATE TABS 5MG Covered TERBUTALINE SULFATE TABS 2. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TECHNIVIE TABS 12.5MG Covered PA QL TEKTURNA HCT TABS 150MG. 25MG Covered PA QL TEKTURNA HCT TABS 300MG. 5MG Not Covered TEKTURNA TABS 150MG Covered PA QL TEKTURNA TABS 300MG Covered PA QL TEKTURNA HCT TABS 300MG. 5MG Not Covered TEKAMLO TABS 300MG. 5LFU Covered AL TERAZOL 3 CREA 0. 50MG Not Covered TEFLARO SOLR 600MG Not Covered TEFLARO SOLR 400MG Not Covered TEGRETOL-XR TB12 100MG Not Covered TEGRETOL-XR TB12 400MG Not Covered TEGRETOL-XR TB12 200MG Not Covered TEKAMLO TABS 300MG. 10MG Not Covered TEKAMLO TABS 150MG.5MG Covered PA QL TEKTURNA HCT TABS 150MG. 12. 50MG Covered QL AL TENIVAC INJ 2LFU.5MG Not Covered TEMODAR CAPS 20MG Not Covered TEMODAR CAPS 5MG Not Covered TEMODAR CAPS 140MG Not Covered TEMODAR CAPS 250MG Not Covered TEMODAR CAPS 180MG Not Covered TEMODAR CAPS 100MG Not Covered TEMOZOLOMIDE CAPS 5MG Not Covered TEMOZOLOMIDE CAPS 140MG Not Covered TEMOZOLOMIDE CAPS 20MG Not Covered TEMOZOLOMIDE CAPS 180MG Not Covered TEMOZOLOMIDE CAPS 100MG Not Covered TEMOZOLOMIDE CAPS 250MG Not Covered TENCON TABS 325MG.5MG.

5ML Covered AL TETRABENAZINE TABS 25MG Covered QL TETRABENAZINE TABS 12.5ML.5MG Covered QL TETRACYCLINE HCL CAPS 250MG Covered AL TETRACYCLINE HCL CAPS 500MG Covered AL TETRA-FORMULA NIGHTTIME SLEEP AID TABS 50MG Not Covered TETRIX KIT 0. 0.5GM Not Covered TESTOSTERONE GEL 1% Not Covered TESTOSTERONE CYPIONATE SOLN 200MG/ML Covered TESTOSTERONE CYPIONATE SOLN 100MG/ML Covered TESTOSTERONE PUMP GEL 1% Not Covered TESTRED CAPS 10MG Not Covered TETANUS/DIPHTHE RIA TOXOIDS- ADSORBED ADULT SUSP 2LF/0. 2LF/0.80% Covered TERCONAZOLE CREA 0. 0. 0 Not Covered TH SLEEP AID TABS 25MG Not Covered THALOMID CAPS 50MG Not Covered THALOMID CAPS 100MG Not Covered THALOMID CAPS 150MG Not Covered THALOMID CAPS 200MG Not Covered THEOPHYLLINE SOLN 80MG/15ML Covered THEOPHYLLINE ER TB12 300MG Not Covered THEOPHYLLINE ER TB12 200MG Not Covered THEOPHYLLINE ER TB12 100MG Not Covered THEOPHYLLINE ER TB12 450MG Covered THEOPHYLLINE ER TB24 400MG Covered THEOPHYLLINE ER TB24 600MG Covered THIAMINE HCL TABS 100MG Covered THIOLA TABS 100MG Not Covered THIORIDAZINE HCL TABS 10MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 157 of 178 . 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TERCONAZOLE CREA 0.40% Covered TESSALON PERLES CAPS 100MG Not Covered TESTIM GEL 1% Not Covered TESTONE CIK KIT 200MG/ML Not Covered TESTOPEL PLLT 75MG Not Covered TESTOSTERONE GEL 25MG/2.

2.2MG. 25MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 158 of 178 .25% Not Covered TINDAMAX TABS 500MG Not Covered TINDAMAX TABS 250MG Not Covered TINIDAZOLE TABS 500MG Not Covered TINIDAZOLE TABS 250MG Not Covered TIROSINT CAPS 13MCG Not Covered TIROSINT CAPS 25MCG Not Covered TIROSINT CAPS 88MCG Not Covered TIROSINT CAPS 100MCG Not Covered TIROSINT CAPS 50MCG Not Covered TIROSINT CAPS 75MCG Not Covered TIROSINT CAPS 112MCG Not Covered TIROSINT CAPS 150MCG Not Covered TIROSINT CAPS 125MCG Not Covered TIROSINT CAPS 137MCG Not Covered TIVICAY TABS 50MG Not Covered TIVORBEX CAPS 40MG Not Covered TIVORBEX CAPS 20MG Not Covered TIZANIDINE HCL TABS 2MG Covered AL TIZANIDINE HCL TABS 4MG Covered AL TIZANIDINE HCL CAPS 2MG Not Covered TIZANIDINE HCL CAPS 4MG Not Covered TIZANIDINE HCL CAPS 6MG Not Covered TL GARD RX TABS 1MG. 1MG Covered TIMOLOL MALEATE TABS 10MG Covered TIMOLOL MALEATE SOLN 0.25% Not Covered TIMOLOL MALEATE SOLN 0. 75MG.50% Not Covered TIMOLOL MALEATE TABS 5MG Covered TIMOLOL MALEATE TABS 20MG Covered TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL THIORIDAZINE HCL TABS 25MG Not Covered THIORIDAZINE HCL TABS 50MG Not Covered THIORIDAZINE HCL TABS 100MG Not Covered THIOTHIXENE CAPS 2MG Not Covered THIOTHIXENE CAPS 5MG Not Covered THIOTHIXENE CAPS 10MG Not Covered THROMBATE III W/10 ML STERILE WATER SOLR 500UNIT Not Covered TICLOPIDINE HCL TABS 250MG Not Covered TILIA FE TABS 0.50% Not Covered TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0.

4MG. 60MCG. 3MG. 30UNIT Covered TOBI NEBU 300MG/5ML Not Covered TOBI PODHALER CAPS 28MG Covered PA TOBRADEX SUSP 0. 100MCG.5MG Covered 75MG. 1. 50MG. 45MG. 300MCG. 150MCG.1%. 300UNIT. 15MCG. 110MG.30% Not Covered TOFRANIL-PM CAPS 125MG Not Covered TOFRANIL-PM CAPS 100MG Not Covered TOLAZAMIDE TABS 250MG Covered TOLAZAMIDE TABS 500MG Covered TOLBUTAMIDE TABS 500MG Covered TOLCAPONE TABS 100MG Not Covered TOLMETIN SODIUM TABS 600MG Not Covered TOLMETIN SODIUM TABS 200MG Not Covered TOLNAFTATE SOLN 1% Not Covered TOLNAFTATE 1% ANTIFUNGAL CREA 1% Covered TOLTERODINE TARTRATE TABS 2MG Covered QL TOLTERODINE TARTRATE TABS 1MG Covered QL TOLTERODINE TARTRATE ER CP24 4MG Covered QL TOLTERODINE TARTRATE ER CP24 2MG Covered QL TOPAMAX TABS 25MG Not Covered TOPAMAX TABS 200MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 159 of 178 .3% Not Covered TOBRADEX OINT 0. 2MG. TL G-FOL OS TABS 12. 10MG Covered 500MG. 800UNIT. 0.1%. 1MG.1%.3% Covered TOBRAMYCIN NEBU 300MG/5ML Not Covered TOBRAMYCIN SULFATE SOLN 0. 240MG Covered 60MG. 20MG. TL ICON CAPS 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 1. 25MG. 250MCG. TL-CARE DHA CAPS 30UNIT.1MG. 100MG. 215MG.3% Not Covered TOBREX OINT 0. 27MG.5MG. 0. TL-HEM 150 TABS 150MG. 500MG.5MG.30% Not Covered TOBRAMYCIN/DEXA METHASONE SUSP 0. 1MG. 3MG. 500MG. 3. 25MG. 0.

5MG Covered PA QL TRADJENTA TABS 5MG Covered PA QL TRAMADOL HCL TABS 50MG Covered QL TRAMADOL HCL ER TB24 200MG Not Covered QL TRAMADOL HCL ER TB24 100MG Not Covered QL TRAMADOL HCL ER TB24 300MG Not Covered QL TRAMADOL HYDROCHLORIDE/A CETAMINOPHEN TABS 325MG. 50MG. 37. 10MG.5MG Not Covered QL TRANDOLAPRIL TABS 1MG Covered QL TRANDOLAPRIL TABS 2MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 160 of 178 . 15MG Covered TOUJEO SOLOSTAR SOPN 300UNIT/ML Covered TOVIAZ TB24 4MG Not Covered TOVIAZ TB24 8MG Not Covered TOXICOLOGY SALIVA COLLECTION KIT KIT 600MG Not Covered TRACLEER TABS 125MG Covered PA QL TRACLEER TABS 62. TOTAL B/C TABS 5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TOPAMAX TABS 50MG Not Covered TOPAMAX TABS 100MG Not Covered TOPAMAX SPRINKLE CPSP 25MG Not Covered TOPAMAX SPRINKLE CPSP 15MG Not Covered TOPIRAMATE TABS 25MG Not Covered TOPIRAMATE TABS 50MG Not Covered TOPIRAMATE CPSP 15MG Not Covered TOPIRAMATE TABS 100MG Not Covered TOPIRAMATE TABS 200MG Not Covered TOPIRAMATE CPSP 25MG Not Covered TOPIRAMATE ER CS24 25MG Not Covered TOPIRAMATE ER CS24 100MG Not Covered TOPIRAMATE ER CS24 200MG Not Covered TOPIRAMATE ER CS24 50MG Not Covered TOPIRAMATE ER CS24 150MG Not Covered TORSEMIDE TABS 20MG Covered QL TORSEMIDE TABS 5MG Covered QL TORSEMIDE TABS 10MG Covered QL TORSEMIDE TABS 100MG Covered QL 300MG. 10MG.

0. 0. 0.04% Not Covered TRETIN-X KIT 0.05% Covered AL TRETINOIN GEL 0.05% Not Covered TRETIN-X KIT 0.10% Not Covered TRETINOIN MICROSPHERE PUMP GEL 0. 0. 16MG Not Covered QL TREZIX CAPS 356. 30MG. 85MG Not Covered TREZIX CAPS 320.03% Covered AL TRETINOIN CAPS 10MG Covered PA TRETINOIN CREA 0. 0.00% Not Covered TRAVOPROST SOLN 0.4MG. 0. 16MG Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 161 of 178 .04% Not Covered TRETINOIN MICROSPHERE GEL 0.00% Covered TRAZODONE HCL TABS 300MG Not Covered TRAZODONE HCL TABS 50MG Not Covered TRAZODONE HCL TABS 100MG Not Covered TRAZODONE HCL TABS 150MG Not Covered TREANDA SOLR 100MG Not Covered TRECATOR TABS 250MG Covered TRETINOIN CREA 0.1% Not Covered TRETTEN SOLR 2000-3125 UNIT Not Covered TREXIMET TABS 500MG. 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TRANDOLAPRIL TABS 4MG Covered QL TRANDOLAPRIL/VER APAMIL HCL ER TBCR 4MG.10% Not Covered TRETINOIN MICROSPHERE PUMP GEL 0.05% Not Covered TRETINOIN MICROSPHERE GEL 0.03% Covered AL TRETINOIN GEL 0.10% Covered AL TRETINOIN CREA 0. 240MG Not Covered TRANDOLAPRIL/VER APAMIL HCL ER TBCR 1MG.5MG. 30MG.01% Covered AL TRETINOIN EMOLLIENT CREA 0. 0. 240MG Not Covered TRANDOLAPRIL/VER APAMIL HCL ER TBCR 2MG. 0. 0. 240MG Not Covered TRANDOLAPRIL/VER APAMIL HCL ER TBCR 2MG. 180MG Not Covered TRANEXAMIC ACID TABS 650MG Not Covered TRANYLCYPROMINE SULFATE TABS 10MG Not Covered TRAVATAN Z SOLN 0.

03% Covered TRIAMCINOLONE ACETONIDE LOTN 0.10% Covered TRIAMCINOLONE ACETONIDE CREA 0.25MG Not Covered TRIBENZOR TABS 10MG.10% Covered TRIAMCINOLONE ACETONIDE CREA 0. 50MG Covered TRIAZOLAM TABS 0. 40MG Not Covered TRIBENZOR TABS 5MG. 37. 20MG Not Covered TRIBENZOR TABS 5MG. 0 Covered AL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 162 of 178 .125MG Not Covered TRIAZOLAM TABS 0. 12.10% Covered TRIAMTERENE/HYD ROCHLOROTHIAZID E TABS 25MG. 40MG Not Covered TRI-BUFFERED ASPIRIN TABS 325MG.03% Covered TRIAMCINOLONE ACETONIDE OINT 0.10% Not Covered TRIAMCINOLONE ACETONIDE LOTN 0. 40MG Not Covered TRIBENZOR TABS 10MG. 40MG Not Covered TRIBENZOR TABS 5MG.147MG/GM Not Covered TRIAMCINOLONE ACETONIDE AERO 55MCG/ACT Covered TRIAMCINOLONE IN ORABASE PSTE 0.50% Covered TRIAMCINOLONE ACETONIDE AERS 0. 12.5MG Covered TRIAMTERENE/HYD ROCHLOROTHIAZID E CAPS 25MG.5MG Covered TRIAMTERENE/HYD ROCHLOROTHIAZID E TABS 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TRIAMCINOLONE ACETONIDE CREA 0. 0.03% Covered TRIAMCINOLONE ACETONIDE OINT 0.5MG.50% Covered TRIAMCINOLONE ACETONIDE OINT 0. 25MG.5MG. 0.5MG. 75MG Covered TRIAMTERENE/HYD ROCHLOROTHIAZID E CAPS 25MG. 37. 25MG. 12.

1. 27MG.6MG.6MG. 1MG. 27MG. 27MG.4MG/ML Not Covered TRI-LEGEST FE TABS 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 100MG.4MG. 10MG Not Covered 334MG/5ML. 550MG/5ML. 10MCG. TRICARE TABS 10MG Covered 100MG.6MG. 240MG Covered TRICOR TABS 48MG Not Covered TRICOR TABS 145MG Not Covered TRI-ESTARYLLA TABS 0.5MG. 30UNIT. 400UNIT. 2MG. 500MG. 3. 75MG. 1MG. 20MG. 0 Covered TRIFLUOPERAZINE HCL TABS 5MG Not Covered TRIFLUOPERAZINE HCL TABS 2MG Not Covered TRIFLUOPERAZINE HCL TABS 1MG Not Covered TRIFLUOPERAZINE HCL TABS 10MG Not Covered TRIFLURIDINE SOLN 1% Covered 60MG. 25MG. 45MG. DHA ONE CAPS 30UNIT. 800UNIT. 33. TRICON CAPS 0. 200MG. 15MCG. 10MCG.1MG. 1.1MG. 20MG. 1MG Covered TRILEPTAL TABS 300MG Not Covered TRILEPTAL SUSP 300MG/5ML Not Covered TRILEPTAL TABS 150MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 163 of 178 . 200MG. 20MG. 2MG.6MG. 3. 0. 215MG. 3. COMPLEAT MISC 10MG Not Covered 60MG. 12MCG.2MG. 12MCG. 1MG. TRIGELS-F FORTE CAPS 1MG Covered TRIHEXYPHENIDYL HCL TABS 5MG Not Covered TRIHEXYPHENIDYL HCL TABS 2MG Not Covered TRIHEXYPHENIDYL HCL ELIX 0. 1. 30UNIT. 135MG. 300MCG. 100MCG. 3MG. 110MG. TRICARE PRENATAL 1.8MG. TRICITRATES SOLN 500MG/5ML Not Covered 75MG. 71. 2MG. TRICARE PRENATAL 25MG. 151MG.

5MG. 400UNIT/ML.75MG/0. 1500UNIT/ML Not Covered AL 35MG/ML. 1500UNIT/ML Not Covered AL TRIVORA-28 TABS 0.5MG/0. 1. 0 Covered 100MG. 50MG. 0 Covered TRIZIVIR TABS 300MG. 20MG. TRILYTE SOLR 11.2GM Covered TRIMETHOBENZAMI DE HCL SOLN 100MG/ML Covered TRIMETHOBENZAMI DE HCL CAPS 300MG Not Covered TRIMETHOPRIM TABS 100MG Covered TRINESSA TABS 0. 5.50% Covered TROSPIUM CHLORIDE TABS 20MG Covered QL TROSPIUM CHLORIDE ER CP24 60MG Not Covered TRUETRACK TEST STRP 0 Not Covered TRULICITY SOPN 0.5MG/ML. TRI-VIT/FLUORIDE SOLN 0.25MG/ML. 400UNIT/ML. 300MG Not Covered 35MG/ML.48GM. 300MG Not Covered TROKENDI XR CP24 200MG Not Covered TROKENDI XR CP24 100MG Not Covered TROKENDI XR CP24 50MG Not Covered TROKENDI XR CP24 25MG Not Covered TROPICAMIDE SOLN 1% Covered TROPICAMIDE SOLN 0.72GM. 0 Covered TRINESSA LO TABS 0. 10MG. 150MG. TRIPHROCAPS CAPS 1.5ML Not Covered TRUMENBA SUSY 0 Covered QL AL TRUSOPT SOLN 2% Not Covered TRUSTEX NON- LUBRICATED MISC Covered QL PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 164 of 178 . 0 Covered TRI-LO-SPRINTEC TABS 0.7MG. 1.5MG Covered TRI-PREVIFEM TABS 0.5ML Not Covered TRULICITY SOPN 1. TRI-VIT/FLUORIDE SOLN 0. 0 Covered 420GM. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TRILEPTAL TABS 600MG Not Covered TRILIPIX CPDR 45MG Not Covered TRILIPIX CPDR 135MG Not Covered TRI-LO-ESTARYLLA TABS 0. 1MG. 6MCG. 0 Covered TRI-SPRINTEC TABS 0. 0 Covered TRIUMEQ TABS 600MG. 150MCG.

400UNIT. 0. 20MG. 20MG. 12.5MG Covered ULESFIA LOTN 5% Not Covered ULORIC TABS 40MG Covered PA QL ULORIC TABS 80MG Covered PA 120MG. 14. 3MG. 0.5MG. 2MG. 50MG. 80MG Not Covered TWYNSTA TABS 10MG.8MG/5ML. ULTRA TABS TABS 30UNIT. 320MG. 200MG.5MG Not Covered ULTRAM TABS 50MG Not Covered ULTRAM ER TB24 200MG Not Covered ULTRAM ER TB24 300MG Not Covered ULTRAM ER TB24 100MG Not Covered 27600UNIT.5MG. 150MCG. 25MG Not Covered ULTRACET TABS 325MG. 300MG Not Covered TUDORZA PRESSAIR AEPB 400MCG/ACT Covered TUSSIN SYRP 100MG/5ML Not Covered TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER 8MG/5ML. 3.7MG/5ML Not Covered TWINRIX SUSP 720ELU/ML. 37. 0. 10MG/5ML Not Covered TUZISTRA XR SUER 2. 1000MCG. 40MG Not Covered TWYNSTA TABS 5MG. 80MG Not Covered TWYNSTA TABS 10MG. 40MG Not Covered TYBOST TABS 150MG Not Covered TYKERB TABS 250MG Not Covered TYSABRI CONC 300MG/15ML Not Covered TYVASO SOLN 0. 100MCG.4MG. 75UNIT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL TRUSTEX/RIA LUBRICATED MISC Covered QL TRUSTEX/RIA NON- LUBRICATED MISC Covered QL TRUVADA TABS 200MG. 2700UNIT. 0. 90MCG. 13800UNIT.6MG/ML Not Covered TYZEKA TABS 600MG Not Covered UCERIS TB24 9MG Not Covered UCERIS FOAM 2MG/ACT Not Covered QL 250MCG. 2. 17MG. ULTRESA CPEP 27600UNIT Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 165 of 178 . 20MCG/ML Covered QL AL TWYNSTA TABS 5MG. 1MG. UDAMIN SP TABS 7. 12MCG.

5MG. 160MG Covered VALSARTAN/HYDRO CHLOROTHIAZIDE TABS 12.5MG/5ML Not Covered UREA LOTN 40% Not Covered UREA CREA 40% Not Covered UREA GEL 40% Not Covered URELIEF PLUS TABS 15MG.5MG. 0. 150MG Not Covered UROXATRAL TB24 10MG Not Covered URSODIOL CAPS 300MG Covered QL URSODIOL TABS 500MG Not Covered URSODIOL TABS 250MG Not Covered UTOPIC CREA 41% Not Covered VALACYCLOVIR HCL TABS 500MG Covered QL VALACYCLOVIR HCL TABS 1GM Covered QL VALCHLOR GEL 0. 20700UNIT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 41400UNIT. ULTRESA CPEP 41400UNIT Not Covered 46000UNIT. 320MG Not Covered VALSARTAN/HYDRO CHLOROTHIAZIDE TABS 25MG. 160MG Covered VALSARTAN/HYDRO CHLOROTHIAZIDE TABS 12. ULTRESA CPEP 46000UNIT Not Covered UNITHROID TABS 50MCG Covered UNITUXIN SOLN 17.02% Not Covered VALCYTE TABS 450MG Not Covered VALGANCICLOVIR TABS 450MG Covered PA QL VALPROIC ACID CAPS 250MG Not Covered VALPROIC ACID SOLN 250MG/5ML Not Covered VALSARTAN TABS 40MG Covered VALSARTAN TABS 320MG Covered VALSARTAN TABS 160MG Covered VALSARTAN TABS 80MG Covered VALSARTAN/HYDRO CHLOROTHIAZIDE TABS 25MG.3MG. 80MG Covered VALTREX TABS 1GM Not Covered VALTREX TABS 500MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 166 of 178 . 23000UNIT. 320MG Not Covered VALSARTAN/HYDRO CHLOROTHIAZIDE TABS 12.5MG.

10MG. 10MCG.5MG Not Covered VENLAFAXINE HCL TABS 50MG Not Covered VENLAFAXINE HCL TABS 25MG Not Covered VENLAFAXINE HCL ER TB24 150MG Not Covered VENLAFAXINE HCL ER TB24 75MG Not Covered VENLAFAXINE HCL ER CP24 37. 5MG. 80MG Covered VCF VAGINAL CONTRACEPTIVE FOAM FOAM 12. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL VALVED HOLDING CHAMBER DEVI Covered QL VANCOMYCIN HCL SOLR 5000MG Covered VANCOMYCIN HCL SOLR 10GM Covered VANCOMYCIN HCL SOLR 1000MG Not Covered VANCOMYCIN HCL CAPS 125MG Not Covered VANCOMYCIN HCL CAPS 250MG Not Covered VANCOMYCIN HCL SOLR 750MG Covered VANCOMYCIN HCL SOLR 500MG Not Covered VANDAZOLE GEL 0.50% Not Covered VECAMYL TABS 2. 70MG.5MG Not Covered VECTICAL OINT 3MCG/GM Not Covered VELCADE SOLR 3.10% Not Covered VAQTA SUSP 50UNIT/ML Covered QL AL VAQTA SUSP 25UNIT/0. 1MG.5MG Not Covered VENLAFAXINE HCL ER CP24 75MG Not Covered VENLAFAXINE HCL ER TB24 225MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 167 of 178 . 87MG/GM.5MG Not Covered VELIVET TABS 0. 25MG. V-C FORTE CAPS 8000UNIT. 4MG.75% Not Covered VANOS CREA 0. 10MG. VASOLEX OINT 90UNIT/GM Not Covered 150MG. 2MG. 50UNIT. 0 Covered VELPHORO CHEW 500MG Covered VENLAFAXINE HCL TABS 100MG Not Covered VENLAFAXINE HCL TABS 75MG Not Covered VENLAFAXINE HCL TABS 37.5ML Covered QL AL VARIZIG SOLR 125UNIT Not Covered VASCEPA CAPS 1GM Not Covered 788MG/GM.

0.5MCG/SPRAY Not Covered VERAPAMIL HCL TABS 80MG Covered VERAPAMIL HCL TABS 40MG Covered VERAPAMIL HCL TABS 120MG Covered VERAPAMIL HCL ER TBCR 240MG Covered QL VERAPAMIL HCL ER TBCR 180MG Covered QL VERAPAMIL HCL ER TBCR 120MG Covered QL VERAPAMIL HCL ER CP24 100MG Covered QL VERAPAMIL HCL ER CP24 200MG Covered QL VERAPAMIL HCL ER CP24 300MG Covered QL VERAPAMIL HCL ER CP24 180MG Covered QL VERAPAMIL HCL ER CP24 240MG Covered QL VERAPAMIL HCL ER CP24 120MG Covered QL VERAPAMIL HCL SR CP24 360MG Not Covered VERDESO FOAM 0.02MG Covered VFEND TABS 200MG Not Covered VFEND SUSR 40MG/ML Not Covered VFEND TABS 50MG Not Covered VFEND IV SOLR 200MG Not Covered V-GO 20 KIT Covered V-GO 30 KIT Covered V-GO 40 KIT Covered VIAGRA TABS 25MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 168 of 178 .5MG Not Covered VENOFER SOLN 20MG/ML Covered VENTAVIS SOLN 10MCG/ML Not Covered VENTOLIN HFA AERS 108MCG/ACT Covered VERAMYST SUSP 27. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL VENLAFAXINE HCL ER CP24 150MG Not Covered VENLAFAXINE HCL ER TB24 37.05% Not Covered VEREGEN OINT 15% Not Covered VERSACLOZ SUSP 50MG/ML Not Covered VESICARE TABS 5MG Not Covered VESICARE TABS 10MG Not Covered VESTURA TABS 3MG.

5MG.4MG. VIEKIRA PAK TBPK 50MG Not Covered VIGAMOX SOLN 0. 150MG. 7. 2MG. 3. 1MG. 75MG. 20MG. VINATE DHA RF CAPS 1.4MG. 400UNIT. 27MG. 12. 1MG. 4MG. 3000UNIT. 25MG. 500MG Not Covered VIMPAT TABS 50MG Not Covered VIMPAT TABS 150MG Not Covered VIMPAT TABS 200MG Not Covered VIMPAT TABS 100MG Not Covered 120MG. 2. 15MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 169 of 178 . 1. 80MG Covered VICODIN TABS 300MG. 18MG. 375MG Not Covered VIMOVO TBEC 20MG. 12MCG. 5MCG.13MG. 30UNIT. VINATE AZ TABS 15MG Covered 0. 8MG. 60MCG. 220MCG. 25MG. 50UNIT. 5MG Not Covered VICODIN ES TABS 300MG.50% Covered QL VIIBRYD TABS 10MG Not Covered VIIBRYD TABS 20MG Not Covered VIIBRYD TABS 40MG Not Covered VIIBRYD KIT 0 Not Covered VIMIZIM SOLN 5MG/5ML Not Covered VIMOVO TBEC 20MG. 110MG. 10MCG. 1MG. 27MG. 60MG.5MG Not Covered VICODIN HP TABS 300MG. 0. 3MG. 10MG. 70MG. 30MG. 10MG Not Covered VICTOZA SOPN 18MG/3ML Covered PA VICTRELIS CAPS 200MG Not Covered VIDEX EC CPDR 200MG Not Covered VIDEX EC CPDR 125MG Not Covered VIDEX EC CPDR 400MG Not Covered VIDEX EC CPDR 250MG Not Covered 250MG.5MG. 30MCG.5MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL VIAGRA TABS 50MG Not Covered VIAGRA TABS 100MG Not Covered VIBRAMYCIN SUSR 25MG/5ML Not Covered 150MG. VIC-FORTE CAPS 8000UNIT. 75MG. 10MG. 85MG. 1. 5MG.

1MG.5MCG. 100MG. 150MCG. 1. 5MG. 25MG Covered QL AL 80MG. 5000UNIT.9MG. 30MCG. 30MG. 200MG. 7MG. 90MG. 2.2MG. 15MG Covered QL AL 10MG. VIOKACE TABS 78300UNIT Not Covered 39150UNIT. 6.5MG. VINATE ULTRA TABS 30UNIT. 3. 30MG. 25MG Covered QL AL 78300UNIT. 15MCG. 400UNIT. 4000UNIT. 20MG.4MG. 400UNIT. 30MCG. 50MG. 20MG. 17MG. 1MG. 3MG. 2MG. 0. 200MG. 20MCG. 0. 12MCG. 162MG. 2MG.3MG. 150MCG. 25MCG. 0. 5MG. 3MG. 1MG. 10440UNIT.2MG Covered 120MG.6MG. 2700UNIT. VINATE IC CAPS 18. 3MG. 15UNIT. 10MG. VINATE GT TABS 10UNIT. 200MG. VIOKACE TABS 39150UNIT Not Covered VIORELE TABS 0. 400UNIT. 20MG. 25MCG. 3. 1. 20MG. 90MG. 27MG. 0. 20880UNIT. 10MG. 0.4MG.03MG.4MG.8MG. 60MG. 12MCG. 0 Covered VIRACEPT TABS 250MG Not Covered VIRACEPT TABS 625MG Not Covered VIRAMUNE TABS 200MG Not Covered VIRAMUNE SUSP 50MG/5ML Not Covered VIRAMUNE XR TB24 400MG Not Covered VIRAMUNE XR TB24 100MG Not Covered VIREAD TABS 300MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 170 of 178 . 25MG. 1MG. 3. 2700UNIT. 3MG. 20MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 120MG. 12MCG. 115. VINATE M TABS 30UNIT. 200MG. 50MG. 6MG. 200MG. 400UNIT. 4MG. 1. 2MG. VINATE ONE TABS 25MG Covered 120MG. 1MG. 10MG. 6MG.

39MG. 3MG.6MG. 2700UNIT. 6MG. 1100UNIT.5MG. 6MCG. 1MG.5MG. 2MG.6MG. 18MG. 6000UNIT. 20MG.8MG. 1MG. 12. 25MG Covered 60MG.7MG. 2. 15MG.1MG. 2MG. 300MCG. 5MCG.5MCG. 2. 1MG. 5MG. 50MG. 2MG. 1. 25MG. 1750UNIT. 1.6MG. 12MCG. 65MCG.5MG. VITAL-D RX TABS 12.8MG.5MG Covered VITAMIN B-1 TABS 50MG Covered VITAMIN B-1 TABS 250MG Covered VITAMIN D CAPS 50000UNIT Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 171 of 178 . 125MG. VIRT-C DHA CAPS 10MG Not Covered 100MG. VITAFOL-PN TABS 4000UNIT.6MG. 12MCG. 25MG Not Covered 30MG. 20MG. 1. VITAFOL-NANO TABS 2. VIRT-VITE PLUS TABS 1. 30UNIT. 2. 150MCG.8MG. 25MG. 300MCG. 1. 18MG. VITAFOL TABS 400UNIT. 1MG. 1. 156MG. 2. 100MG. 10MG. 200MG. VITAFOL-ONE CAPS 20UNIT. 20MG. 150MCG. 30UNIT Covered 1000UNIT. 0.5MG. 1MG. 1. 1.5MG Not Covered 70MG. 12MCG. VIRT-CAPS CAPS 1. 1000UNIT. 2. 10MG. 15MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL 25MG. 25MG Not Covered 60MG. 310MG.5MG. 20MG. 1MG.8MG. 125MG.5MG Covered VIRT-VITE TABS 1MG. 65MG.8MG. 2. 29MG. 2MG. 300MCG. 1. 5MG. 15MG. 0. 0. 1.5MG. 25MG Covered VIRT-VITE FORTE TABS 2MG.7MG. 5MG. VITAFOL-OB TABS 30UNIT.5MG. 38MG. 400UNIT. 10MG.5MG. 1MG.5MG. 1.5MG Covered 60MG. 10MG. 400UNIT. 53. 5MCG. 25MG. 65MG. 1MG. 1. 200MG. 65MG.4MG. 1. 15MG Not Covered 60MG. 150MCG. 5MG. 1.

10MG. 30MG. 20MG. 400UNIT.05MG/24HR Not Covered VIVITROL SUSR 380MG Not Covered VIVOTIF CPDR 0 Not Covered VOGELXO GEL 50MG/5GM Not Covered VOGELXO PUMP GEL 1% Not Covered 60MG. 1. 4000UNIT. 22MG.8MG.2MG. 2MG. 30UNIT.0375MG/24HR Not Covered VIVELLE-DOT PTTW 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL VITAMIN D TABS 2000UNIT Covered VITAMIN D3 LIQD 400UNIT/ML Covered VITAMIN D3 CAPS 2000UNIT Covered VITAMIN E CAPS 1000UNIT Covered VITAMIN E CAPS 200UNIT Covered VITAMIN E CREA 1000UNIT Covered VITAMIN E CAPS 100UNIT Covered VITAMINS 35MG/ML. 0. 200MG. 3000UNIT. 25MG Covered VITEKTA TABS 150MG Not Covered VITEKTA TABS 85MG Not Covered VITUZ SOLN 4MG/5ML. 28MG. 30MCG.025MG/24HR Not Covered VIVELLE-DOT PTTW 0.5MG Not Covered VITA-RESPA TABS 1. 300MCG. 25MG. 400UNIT/ML. 3MG. 12MCG.3MG. 7MG. 2. 0. 2MG. 200MG. 7. VITAPEARL CPCR 1. 29MG. 10MG. 8MCG. 100MG. VOL-TAB RX TABS 15MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 172 of 178 . 1. 200MG. 25MG. 25MG. 3MG. 4MG. 8MCG. 3MG. 20MG. 6MCG. 150MCG.7MG.5MG Covered 120MG. 1500UNIT/ML Covered QL 30MG. 150MCG. 30UNIT.4MG. 20MG. 1.25MG/ML. 400UNIT. 1MG. 400UNIT.1MG/24HR Not Covered VIVELLE-DOT PTTW 0. VOL-NATE TABS 25MG Covered 120MG. 1MG. VOL-CARE RX TABS 1.075MG/24HR Not Covered VIVELLE-DOT PTTW 0. 1MG. 10MG. 5MG/5ML Not Covered VIVACTIL TABS 10MG Not Covered VIVACTIL TABS 5MG Not Covered VIVELLE-DOT PTTW 0.7MG. 20MG. 3MG. A/C/D/FLUORIDE SOLN 0. 300MCG.

175MCG. 10UNIT. 17MG.4MG Covered VYTONE CREA 0.5MG Covered WARFARIN SODIUM TABS 10MG Covered WARFARIN SODIUM TABS 4MG Covered WARFARIN SODIUM TABS 1MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 173 of 178 . 5MG. 1. 0. 400UNIT. 200MG.5MG. 40MG Not Covered VYTORIN TABS 10MG. 81. 1MG. 10MG Not Covered VYTORIN TABS 10MG. 12MCG.25%. 22MG. 10MG. 20MG Not Covered VYTORIN TABS 10MG.35%. 6MG. 30MCG. 1. 50MG. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL VOLTAREN GEL 1% Not Covered VORICONAZOLE SOLR 200MG Not Covered VORICONAZOLE SUSR 40MG/ML Not Covered VORICONAZOLE TABS 50MG Not Covered QL VORICONAZOLE TABS 200MG Not Covered QL VOTRIENT TABS 200MG Not Covered 25MG. 15% Not Covered VYFEMLA TABS 35MCG. VP-ZEL TABS 600MG. 1% Not Covered VYTORIN TABS 10MG.9%. 500MCG. 80MG Not Covered VYVANSE CAPS 30MG Not Covered VYVANSE CAPS 50MG Not Covered VYVANSE CAPS 20MG Not Covered VYVANSE CAPS 40MG Not Covered VYVANSE CAPS 70MG Not Covered VYVANSE CAPS 60MG Not Covered VYVANSE CAPS 10MG Not Covered WARFARIN SODIUM TABS 2.5MG Covered WARFARIN SODIUM TABS 6MG Covered WARFARIN SODIUM TABS 5MG Covered WARFARIN SODIUM TABS 2MG Covered WARFARIN SODIUM TABS 7. 10MG Covered VUSION OINT 0. VP-HEME ONE CAPS 15MG Not Covered VPRIV SOLR 400UNIT Not Covered 5MG.

500MG Not Covered XIGDUO XR TB24 10MG. 1000MG Not Covered XOFIGO SOLN 30MCCI/ML Not Covered XOLAIR SOLR 150MG Not Covered XOPENEX NEBU 1. 7.5MG Not Covered XELJANZ TABS 5MG Not Covered XELODA TABS 500MG Not Covered XELODA TABS 150MG Not Covered XENAZINE TABS 12. 1000MG Not Covered XIGDUO XR TB24 10MG.01% Not Covered XALKORI CAPS 200MG Not Covered XALKORI CAPS 250MG Not Covered XARELTO TABS 20MG Covered PA QL AL XARELTO TABS 15MG Covered PA QL AL XARELTO TABS 10MG Covered PA QL AL XARELTO STARTER PACK TBPK 0 Not Covered QL AL XARTEMIS XR TBCR 325MG. 500MG Not Covered XIGDUO XR TB24 5MG.31MG/3ML Not Covered XOPENEX CONCENTRATE NEBU 1. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL WARFARIN SODIUM TABS 3MG Covered WELLBUTRIN XL TB24 150MG Not Covered WERA TABS 35MCG. 0.5MG Not Covered XALATAN SOLN 0.25MG/0.25% Not Covered XERESE CREA 5%.5ML Not Covered XOPENEX HFA AERO 45MCG/ACT Not Covered XTANDI CAPS 40MG Covered PA QL 35MCG/24HR.5MG Covered WESTHROID TABS 130MG Not Covered WESTHROID TABS 32. 1% Not Covered XGEVA SOLN 120MG/1.7ML Not Covered XIFAXAN TABS 200MG Not Covered QL AL XIFAXAN TABS 550MG Not Covered QL AL XIGDUO XR TB24 5MG.63MG/3ML Not Covered XOPENEX NEBU 0. XULANE PTWK 150MCG/24HR Covered QL XYNTHA KIT 1000UNIT Not Covered XYREM SOLN 500MG/ML Not Covered XYZAL TABS 5MG Not Covered YASMIN 28 TABS 3MG.25MG/3ML Not Covered XOPENEX NEBU 0. 0.5MG Not Covered XENAZINE TABS 25MG Not Covered XENICAL CAPS 120MG Not Covered XERAC AC SOLN 6.03MG Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 174 of 178 .

8ML Covered ZAVESCA CAPS 100MG Not Covered ZEBUTAL CAPS 325MG. ZENPEP CPEP 17000UNIT Covered 136000UNIT. 1100MG Not Covered ZEGERID PACK 40MG. ZENPEP CPEP 51000UNIT Covered 16000UNIT. 40MG Covered QL AL ZECUITY PTCH 6. 1100MG Not Covered ZELBORAF TABS 240MG Not Covered ZEMPLAR CAPS 2MCG Covered ZEMPLAR CAPS 4MCG Not Covered ZEMPLAR CAPS 1MCG Covered ZEMPLAR SOLN 5MCG/ML Covered ZEMPLAR SOLN 2MCG/ML Covered ZENATANE CAPS 20MG Not Covered ZENATANE CAPS 10MG Not Covered ZENATANE CAPS 40MG Not Covered ZENCHENT TABS 35MCG.03MG Covered ZARXIO SOSY 300MCG/0. 0.5ML Covered ZARXIO SOSY 480MCG/0. 0. 10000UNIT. ZENPEP CPEP 10000UNIT Covered 109000UNIT. 25000UNIT. ZENPEP CPEP 85000UNIT Covered ZENZEDI TABS 2. ZENPEP CPEP 34000UNIT Covered 82000UNIT. 1680MG Not Covered ZEGERID CAPS 20MG. ZENPEP CPEP 68000UNIT Covered 27000UNIT. 50MG. 15000UNIT. 1680MG Not Covered ZEGERID OTC CAPS 20MG. 20000UNIT. 1100MG Not Covered ZEGERID CAPS 40MG.5MG Not Covered ZENZEDI TABS 10MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 175 of 178 . 3000UNIT. 5000UNIT. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ZAFIRLUKAST TABS 10MG Not Covered ZAFIRLUKAST TABS 20MG Not Covered ZALEPLON CAPS 10MG Not Covered ZALEPLON CAPS 5MG Not Covered ZALTRAP SOLN 200MG/8ML Not Covered ZALTRAP SOLN 100MG/4ML Not Covered ZANAFLEX CAPS 2MG Not Covered ZANAFLEX CAPS 4MG Not Covered ZANAFLEX CAPS 6MG Not Covered ZANAFLEX TABS 4MG Not Covered ZARAH TABS 3MG.5MG/4HR Not Covered ZEGERID PACK 20MG.4MG Covered 55000UNIT.

20% Not Covered ZMAX SUSR 2GM Not Covered ZOHYDRO ER CP12 50MG Not Covered ZOHYDRO ER CP12 15MG Not Covered ZOHYDRO ER CP12 20MG Not Covered ZOHYDRO ER CP12 30MG Not Covered ZOHYDRO ER CP12 40MG Not Covered ZOHYDRO ER CP12 10MG Not Covered ZOLINZA CAPS 100MG Covered PA ZOLMITRIPTAN TABS 2.2MG/2ML Not Covered ZEVALIN Y-90 KIT 3.2%.5MG Covered QL ZOLMITRIPTAN ODT TBDP 5MG Covered QL ZOLOFT TABS 50MG Not Covered ZOLOFT CONC 20MG/ML Not Covered ZOLOFT TABS 25MG Not Covered ZOLOFT TABS 100MG Not Covered ZOLPIDEM TARTRATE TABS 10MG Not Covered ZOLPIDEM TARTRATE TABS 5MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 176 of 178 . 0.025% Not Covered ZIDOVUDINE CAPS 100MG Not Covered ZIOPTAN SOLN 0.015MG/ML Not Covered ZIPRASIDONE HCL CAPS 80MG Not Covered ZIPRASIDONE HCL CAPS 60MG Not Covered ZIPRASIDONE HCL CAPS 20MG Not Covered ZIPRASIDONE HCL CAPS 40MG Not Covered ZIPSOR CAPS 25MG Not Covered ZITHRANOL-RR CREA 1.5GM Not Covered ZERIT CAPS 30MG Not Covered ZERIT CAPS 15MG Not Covered ZERIT CAPS 40MG Not Covered ZERIT CAPS 20MG Not Covered ZETIA TABS 10MG Covered QL ZEVALIN IN-111 KIT 3.2MG/2ML Not Covered ZIAGEN TABS 300MG Not Covered ZIANA GEL 1.5MG Covered QL ZOLMITRIPTAN TABS 5MG Covered QL ZOLMITRIPTAN ODT TBDP 2.5MG Not Covered ZENZEDI TABS 20MG Not Covered ZENZEDI TABS 30MG Not Covered ZERBAXA SOLR 1GM. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ZENZEDI TABS 5MG Not Covered ZENZEDI TABS 15MG Not Covered ZENZEDI TABS 7. 0.

4MG Not Covered ZUBSOLV SUBL 1.5MG Not Covered ZOMIG NASAL SPRAY SOLN 5MG Not Covered ZOMIG ZMT TBDP 5MG Not Covered ZOMIG ZMT TBDP 2. 2.75MG Not Covered QL ZORTRESS TABS 0.5MG Not Covered ZOLPIDEM TARTRATE ER TBCR 6.5%.5MG Not Covered QL ZORTRESS TABS 0. 1MG Covered ZOVIRAX CREA 5% Not Covered ZOVIRAX SUSP 200MG/5ML Not Covered ZOVIRAX CAPS 200MG Not Covered ZOVIRAX OINT 5% Not Covered ZOVIRAX TABS 800MG Not Covered ZOVIRAX TABS 400MG Not Covered ZUBSOLV SUBL 5. 0. 5MG/5ML.65ML Covered QL AL ZOVIA 1/35E TABS 35MCG.36MG Not Covered ZUBSOLV SUBL 8.6MG. 0.1MG Not Covered ZUPLENZ FILM 4MG Not Covered ZUPLENZ FILM 8MG Not Covered 4MG/5ML.08MG Not Covered ZORTRESS TABS 0. Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ZOLPIDEM TARTRATE ER TBCR 12.5MG Not Covered ZYPREXA TABS 20MG Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 177 of 178 .4MG. 1.25MG Not Covered QL ZORVOLEX CAPS 18MG Not Covered ZORVOLEX CAPS 35MG Not Covered ZOSTAVAX SOLR 19400UNT/0.5MG Not Covered ZONISAMIDE CAPS 25MG Not Covered ZONISAMIDE CAPS 100MG Not Covered ZONISAMIDE CAPS 50MG Not Covered ZONTIVITY TABS 2.75% Not Covered ZYDELIG TABS 150MG Not Covered ZYDELIG TABS 100MG Not Covered ZYFLO CR TB12 600MG Not Covered ZYKADIA CAPS 150MG Not Covered ZYLET SUSP 0. ZUTRIPRO SOLN 60MG/5ML Not Covered ZYCLARA CREA 3. 1MG Covered ZOVIA 1/50E TABS 50MCG.25MG Not Covered ZOLPIMIST SOLN 5MG/ACT Not Covered ZOMIG TABS 5MG Not Covered ZOMIG TABS 2.50% Not Covered ZYPREXA TABS 2.7MG.3% Not Covered ZYMAXID SOLN 0.

5MG Not Covered ZYPREXA TABS 15MG Not Covered ZYPREXA RELPREVV SUSR 300MG Not Covered ZYPREXA RELPREVV SUSR 405MG Not Covered ZYPREXA RELPREVV SUSR 210MG Not Covered ZYPREXA ZYDIS TBDP 20MG Not Covered ZYPREXA ZYDIS TBDP 10MG Not Covered ZYPREXA ZYDIS TBDP 5MG Not Covered ZYRTEC ALLERGY TABS 10MG Covered ZYRTEC CHILDRENS ALLERGY SYRP 5MG/5ML Not Covered ZYRTEC CHILDRENS ALLERGY CHEW 5MG Not Covered ZYRTEC CHILDRENS ALLERGY CHEW 10MG Not Covered ZYRTEC-D ALLERGY/CONGEST ION TB12 5MG. 120MG Not Covered ZYTIGA TABS 250MG Covered PA QL ZYVOX TABS 600MG Not Covered ZYVOX SUSR 100MG/5ML Not Covered PA-Prior Authorization QL-Quantity Limit ST-Step Therapy AL-Age Limit Page 178 of 178 . Medication Coverage Level Restrictions Label Name Dose Form Strength Coverage Level PA ST QL AL ZYPREXA TABS 10MG Not Covered ZYPREXA TABS 5MG Not Covered ZYPREXA TABS 7.

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